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27,124
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34651
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Discharge summary
|
report
|
Admission Date: [**2121-9-4**] Discharge Date: [**2121-9-8**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
abdominal pain radiating to back with a pulsatile
abdominal mass
Major Surgical or Invasive Procedure:
EVAR AAA
History of Present Illness:
87 yo M with known 9cm AAA had previously refused Tx presented
on
[**9-4**] with abdominal pain radiating to back with a pulsatile
abdominal mass. Patient presented to [**Hospital **] hospital where C-
CT showed leaking abdominal aortic aneurysm with maximum AP and
transverse Diameter of 9.6 and 9cm respectively. Pt was med
flighted to [**Hospital1 18**] where he was met in the ED and found to have
stable vital signs and mentating well. He was immediately taken
for a CTA which showed:
1. Leaking abdominal aortic aneurysm with extensive stranding in
the
retroperitoneum adjacent to the aneurysm compatible with
hematoma. No active
extravasation of contrast is seen. Reduced flow within the
abdominal aorta as
evidenced by dilatation of the right atrium and ventricle and
absence of
intravenous contrast within the aorta distal to the aneurysm on
media
postcontrast images.
2. Extensive colonic diverticula without evidence for acute
diverticulitis.
3. Subcentimeter lesion in the left hepatic lobe incompletely
characterized
on this study.
4. Adequate opacification of the renal arteries, SMA and celiac
artery. The
[**Female First Name (un) 899**] is not clearly visualized.
5. Coronary artery and aortic valvular calcifications
Past Medical History:
CHF EF 15%
Afib
CAD
left inguinal hernia s/P repair
Social History:
Lives with wife.
Family History:
N/C
Physical Exam:
Upon discharge:
Pt is alert, oriented in NAD
99.2 83 Afib 100/56 16 98% RA
PERRL, moist mucus membranes, no JVD
RRR no m/r/g
CTAB
soft NT/ND + BS
Extremies: B/L extremities warm and dry, groins benign.
Pulses:
Fem [**Doctor Last Name **] DP PT
Rt 2+ 2+ 1+ mono
Lt 2+ 2+ 1+ mono
Pertinent Results:
[**2121-9-8**] 06:10AM BLOOD Hct-28.6*
[**2121-9-7**] 03:00AM BLOOD Hct-27.9*
[**2121-9-6**] 11:36AM BLOOD WBC-9.6 RBC-3.25* Hgb-9.3* Hct-27.2*
MCV-84 MCH-28.5 MCHC-34.0 RDW-16.2* Plt Ct-157
[**2121-9-6**] 04:05AM BLOOD WBC-10.0 RBC-3.30* Hgb-9.2* Hct-27.3*
MCV-83 MCH-27.8 MCHC-33.6 RDW-16.1* Plt Ct-156
[**2121-9-5**] 11:33PM BLOOD Hct-25.0*
[**2121-9-5**] 01:25AM BLOOD WBC-9.5 RBC-3.62* Hgb-9.9* Hct-30.2*
MCV-84 MCH-27.3 MCHC-32.7 RDW-15.2 Plt Ct-174
[**2121-9-4**] 08:47PM BLOOD Hct-32.2*
[**2121-9-4**] 06:43PM BLOOD Hct-30.5*
[**2121-9-4**] 04:26PM BLOOD WBC-9.4 RBC-3.39*# Hgb-9.4*# Hct-29.0*#
MCV-85 MCH-27.6 MCHC-32.4 RDW-15.3 Plt Ct-147*
[**2121-9-6**] 11:36AM BLOOD Plt Ct-157
[**2121-9-6**] 04:05AM BLOOD Plt Ct-156
[**2121-9-6**] 04:05AM BLOOD PT-18.9* PTT-33.5 INR(PT)-1.7*
[**2121-9-5**] 01:25AM BLOOD Plt Ct-174
[**2121-9-5**] 01:25AM BLOOD PT-20.6* PTT-32.7 INR(PT)-1.9*
[**2121-9-4**] 08:47PM BLOOD PT-22.7* PTT-33.6 INR(PT)-2.2*
[**2121-9-4**] 04:26PM BLOOD PT-22.9* PTT-39.2* INR(PT)-2.2*
[**2121-9-8**] 06:10AM BLOOD UreaN-33* Creat-1.3* K-4.2
[**2121-9-7**] 03:00AM BLOOD Glucose-122* UreaN-30* Creat-1.3* Na-133
K-4.4 Cl-98 HCO3-27 AnGap-12
[**2121-9-6**] 04:05AM BLOOD Glucose-127* UreaN-28* Creat-1.4* Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
[**2121-9-5**] 11:33PM BLOOD Glucose-117* UreaN-28* Creat-1.3* Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
[**2121-9-5**] 01:25AM BLOOD Glucose-127* UreaN-31* Creat-1.3* Na-138
K-4.3 Cl-103 HCO3-26 AnGap-13
[**2121-9-4**] 04:26PM BLOOD Glucose-156* UreaN-32* Creat-1.2 Na-138
K-3.7 Cl-103 HCO3-25 AnGap-14
[**2121-9-4**] 11:45AM BLOOD Glucose-96 UreaN-29* Creat-0.9 Na-143
K-2.9 Cl-117* HCO3-16*
[**2121-9-5**] 11:33PM BLOOD Calcium-8.1* Phos-2.8 Mg-2.3
[**2121-9-5**] 02:22PM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
ECG Study Date of [**2121-9-4**] 3:35:12 PM
Baseline artifact. Atrial fibrillation. Variable ventricular
response.
There is a single wider beat which is probably ventricular in
origin.
Intraventricular conduction delay. Left bundle-branch block.
ST-T wave
abnormalities. No previous tracing available for comparison.
Clinical
correlation is suggested.
[**2121-9-4**] CTA PELVIS W&W/O C & RE
Final Report
INDICATION: 87-year-old male with AAA.
COMPARISONS: None.
TECHNIQUE: MDCT axial images were obtained from the lung bases
through the
pubic symphysis following administration of 130 ml of
intravenous Optiray
contrast. Delayed images through the abdomen were also acquired.
No pre-contrast images were obtained. Multiplanar
reconstructions were
performed.
CT ABDOMEN WITH IV CONTRAST: Extensive calcifications are seen
within the
coronary arteries and aortic valve. The heart size appears
enlarged with
distention of the right atrium and ventricle consistent with
right heart
strain. A 1.1 x 0.8 cm hypodensity in the left hepatic lobe
(3:41) is
incompletely characterized. There is no biliary ductal
dilatation. The
gallbladder, spleen and adrenal glands appear normal. The
pancreas is
atrophic without mass. There are numerous colonic diverticula
without
evidence for acute diverticulitis. Small mesenteric and
retroperitoneal lymph nodes do not meet criteria for pathologic
enlargement.
There is an abdominal aortic aneurysm which originates
approximately 4.6 cm distal to the lower most right renal artery
and courses in length 14 cm to the bifurcation. The maximal
outside dimensions of the aortic aneurysm are 10.0 x 9.1 cm. The
aneurysm contains extensive intramural thrombus with
heterogeneous attenuation consistent with acute on chronic
components with a maximal internal luminal diameter of
approximately 5.6 x 5.1 cm (5:16). The wall of the aneurysm is
calcified with no definite break in the wall identified. There
is a moderate amount of stranding and intermediate attenuation
(45 [**Doctor Last Name **]) in the retroperitoneum adjacent to the aneurysm, which
does not show an increase of attenuation values on the delayed
images, compatible with periaortic hematoma. Findings are most
consistent with a leaking aneurysm with surrounding hematoma,
with no evidence of active extravasation. No dissection flap is
seen. The common iliac arteries are heavily calcified and
tortuous, measuring 1.1 cm on the right and 1.6 cm on the left.
A saccular aneurysm measuring 2 cm is noted within the proximal
right common iliac artery (5:41). Flow within the abdominal
aorta is reduced given that intravenous contrast is not seen
within the distal aorta on immediate postcontrast images. There
is adequate opacification of the celiac and superior mesenteric
artery. The inferior mesenteric artery is not visualized.
Bilateral renal arteries opacify appropriately with symmetric
enhancement of both kidneys. There are multiple renal
hypodensities, the largest consistent with cysts and others too
small to characterize. There is no free intraperitoneal air.
CT PELVIS WITH IV CONTRAST: There are numerous sigmoid
diverticula without
evidence for acute diverticulitis. The distal ureters, urinary
bladder,
rectum, prostate and seminal vesicles are unremarkable. There is
no free
pelvic fluid or air. No inguinal or pelvic lymphadenopathy is
identified.
OSSEOUS STRUCTURES: There are no osseous findings suspicious for
malignancy.
IMPRESSION:
1. Leaking abdominal aortic aneurysm with extensive stranding in
the
retroperitoneum adjacent to the aneurysm compatible with
hematoma. No active extravasation of contrast is seen. Reduced
flow within the abdominal aorta as evidenced by dilatation of
the right atrium and ventricle and absence of intravenous
contrast within the aorta distal to the aneurysm on media
postcontrast images.
2. Extensive colonic diverticula without evidence for acute
diverticulitis.
3. Subcentimeter lesion in the left hepatic lobe incompletely
characterized on this study.
4. Adequate opacification of the renal arteries, SMA and celiac
artery. The [**Female First Name (un) 899**] is not clearly visualized.
5. Coronary artery and aortic valvular calcifications.
Findings were reviewed with Dr. [**Last Name (STitle) **] the surgical staff
immediately upon completion of the study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2121-9-4**] 2:33 PM
Brief Hospital Course:
87 yo M with known 9cm AAA had who previously refused Tx
presented [**Hospital **] hospital on [**9-4**] with abdominal pain radiating
to back with a pulsatile
abdominal mass. He had a CT showed leaking abdominal aortic
aneurysm with maximum AP and transverse Diameter of 9.6 and 9cm
respectively. Patient was transferred via med flight to [**Hospital1 18**]
same day where he was met in the ED and found to have
stable vital signs and mentating well. He was immediately taken
for a CTA which showed:
1. Leaking abdominal aortic aneurysm with extensive stranding in
the retroperitoneum adjacent to the aneurysm compatible with
hematoma. No active extravasation of contrast is seen. Reduced
flow within the
abdominal aorta as evidenced by dilatation of the right atrium
and ventricle and
absence of intravenous contrast within the aorta distal to the
aneurysm on
media postcontrast images.
2. Extensive colonic diverticula without evidence for acute
diverticulitis.
3. Subcentimeter lesion in the left hepatic lobe incompletely
characterized on this study.
4. Adequate opacification of the renal arteries, SMA and celiac
artery. The [**Female First Name (un) 899**] is not clearly visualized.
5. Coronary artery and aortic valvular calcifications
Patient was admitted to Vascular Surgery/Dr. [**Last Name (STitle) **] service/
taken to the angio suite and underwent EVAR. Patient tolerated
procedure very well. Patient was recovered in the ICU,
extubated. Post-op, transfused with total 3 units FFP.
POD1 [**2121-9-5**] Patient remains in Afib controlled rate, PCA for
pain control, electrolytes repleted. Transferred to [**Hospital Ward Name **] 5 VICU.
Transfused with 1 unit PRBCs for HCT 25 -> 27.3 post
transfusion.
POD2 [**2121-9-6**] Patient c/o CP given Nitro SL and EKG done, showing
Afib with controlled rate. CP resolved. Lasix started.
OOB/ambulate, Physical therapy consult.
POD3 [**2121-9-7**] Chest X-ray - showed no CHF, Lasix held for
borderline BP, made floor status, foley d/c'd, noted to have
scrotal edema. No further CP episoded. PhysicaL Therapy cleared
to go home.
POD4 [**2121-9-8**] Discharged to home in good condition, will FU with
his PCP/cardiologist tomorrow, Lasix and Lisinopril is on hold
until he is seen by Cardiologist.
Medications on Admission:
Digoxin, Lasix 20", Lisinopril 5', Coreg 2", Coumadin 2.5"
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ruptured AAA
afib
CRI
EF 15-20%
CAD s/p MI
Prostate Ca
V Tach
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? 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
?????? Call and schedule an appointment to be seen in [**4-27**] weeks for
post procedure check and CTA
What to report to office:
?????? 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 or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
* We did not resume your Lasix and Lisinopril, when you go to
see your Cardiologist Dr. [**First Name (STitle) **], he will determine if you still
need these medication.
Followup Instructions:
[**Name (NI) **] [**Name (NI) **] (pts Cardiologist) Phone ([**Telephone/Fax (1) **] Date/Time:
[**2121-9-9**] 11:30 AM
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2121-10-6**] 12:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2121-10-6**] 11:30
Completed by:[**2121-9-8**]
|
[
"428.0",
"427.31",
"424.1",
"562.10",
"608.86",
"440.20",
"442.2",
"441.3",
"412",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.71",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
11635, 11641
|
8513, 10778
|
324, 335
|
11748, 11755
|
2059, 8490
|
14533, 14946
|
1728, 1733
|
10888, 11612
|
11662, 11727
|
10804, 10865
|
11779, 13782
|
13808, 14510
|
1748, 1748
|
220, 286
|
1765, 2040
|
363, 1602
|
1624, 1678
|
1694, 1712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,084
| 194,201
|
49496
|
Discharge summary
|
report
|
Admission Date: [**2138-11-3**] Discharge Date: [**2138-11-17**]
Date of Birth: [**2087-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2138-11-5**]: ORIF Lt femur fracture
[**2138-11-5**]: IVC filter
[**2138-11-6**]: Trach/PEG
History of Present Illness:
51M brought into [**Hospital1 18**] ED as trauma after car vs. firetruck; was
en route to fire station b/c he had CP, SOB & abd pain when he
lost consciousness and struck fire truck; GCS [**10-9**], intubated
on scene
Past Medical History:
PMH: bipolar d/o, HTN
.
PSH: ex-lap for GSW ~30y ago, b/l inguinal hernia repair,
umbilical hernia repair, ?L4-L5 discectomy
.
[**Last Name (un) 1724**]: paxil, lamictal, xanax, ritalin, tramadol prn, ibuprofen
Social History:
Lives alone. Not working, on disability. +Smoker. No history of
EtOH.
Family History:
Non-contributory
Physical Exam:
Upon admission:
O: T:95.4 BP: 104/56 HR: 75 R: 11 O2Sats: 100%
Gen: Intubated but able to follow commands
HEENT: Pupils: 3->2mm EOMs
Neck: Pain to palpation posteriorly
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated but able to follow commands
appropriately when sedation lightened.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 0 0 0 0 0 0 0 0 0 0 0
L 0 0 0 0 0 0 0 0 0 0 0
Sensation: Unable to feel touch, pinprick, temperature or
vibration below C5.
Reflexes: B T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Propioception impaired
Toes downgoing bilaterally
Pertinent Results:
Admission Lab values:
[**2138-11-3**] 10:45AM WBC-20.6* RBC-3.03* HGB-8.5* HCT-25.9* MCV-85
MCH-28.1 MCHC-33.0 RDW-14.8
[**2138-11-3**] 10:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2138-11-3**] 10:45AM PT-19.5* PTT-27.9 INR(PT)-1.8*
[**2138-11-3**] 10:45AM cTropnT-<0.01
[**2138-11-3**] 10:45AM CK-MB-4
[**2138-11-3**] 10:45AM ALT(SGPT)-33 AST(SGOT)-96* CK(CPK)-261* ALK
PHOS-78 TOT BILI-0.3
[**2138-11-3**] 10:45AM CALCIUM-7.0* PHOSPHATE-4.0 MAGNESIUM-1.8
[**2138-11-3**] 10:45AM CORTISOL-26.6*
[**2138-11-3**] 12:19PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2138-11-3**] 10:55AM TYPE-ART PO2-399* PCO2-56* PH-7.24* TOTAL
CO2-25 BASE XS--4 INTUBATED-INTUBATED
[**2138-11-3**] 12:19PM URINE HOURS-RANDOM
IMAGING:
[**2138-11-3**] xray pelvis: Acute extensively comminuted L femoral fx
involving L GT to mid distal diaphysis. L iliac fx of
indeterminate acuity. Ill-defined trabeculae in medial prox
tibial metaphysis, w/out discrete lucent fx line or cortical
interruption.
[**2138-11-3**] CT head: No acute ICH. Sinus/mastoid opacity.
[**2138-11-3**] CT c-spine: Possible tiny avulsion of C3 inf endplate.
[**2138-11-3**] CT BLE, pelvis - Extensively comminuted fx of L femur
extending from trochanter to below femoral stem prosthesis. Mod
volume hemoperitoneum likely [**12-30**] liver lac. No active bleeding.
R anterolat rib fx involving 5th-7th ribs w/small amt adj gas.
Bibasilar lung consolidation likely 2o atelectasis. No PE or
acute aortic dissection.
[**2138-11-3**] TEE: mild LVH, EF >60%
[**2138-11-3**] MR [**Name13 (STitle) **]: Acute fx involving ant inf C3 vertebral
body w/
assoc ligamentous injury to ant longitudinal ligament as well as
the interspinous ligaments. Cord contusion from C3-C5. Severe
canal stenosis from C3-C6-C7 from spondylotic change.
[**2138-11-4**] CXR: Some opacification @L base w/poor definition of
costophrenic angle c/w atelectasis and effusion. The hump-like
appearance @L costophrenic angle: possibile pulmonary embolus
w/infarction.
[**11-5**] [**Last Name (un) 103564**]: clot in R femoral, CFV, GSV and clot in L GSV but L
common v patent.
[**11-6**] CXR: Worsening bibasilar opacities likely [**12-30**] atelect and
pleural effusion, although aspiration possible.
[**11-7**] CXR: Stable appearances with moderately large b/l pleural
effusions and atelectasis.
[**11-7**] CT abd: Incr atelectasis @lung bases. Stable
hemoperitoneum, w/
fluid around liver & in pelvis. No fluid collection w/in liver
or abscess. Mesenteric stranding, can be seen w/mesenteric
contusion. No active hemorrhage. Fat density in R common femoral
vein, common iliac, may represent fat embolus given history but
below IVC filter. Unchanged rib fx, s/p ORIF L femur.
[**11-8**] CXR: b/l pleural effusions, subsegmental atelectasis on
RLL & atelectasis or consolidation in the retrocardiac area
[**11-9**] CXR: R retrocardiac opacity unchanged, incr pulm edema & L
sided collapse.
[**11-10**] CXR: interval development of pulmonary edema, R>L. LLL,
LUL atelectasis.
[**11-11**] CXR: Stable.
[**11-12**] CXR: Continued pleural effusions, atelectasis
[**11-13**] CXR: Mild pulmonary edema is stable.
[**11-14**] CXR: Stable, lrg retrocardiac atelectasis, almost complete
collapse LLL; Sm B pleural effusions L>R, mild fluid overload.
[**11-15**] CXR: stable
[**11-16**] CXR: L pleural effusion with atelectasis L > R
Brief Hospital Course:
The patient was run as a trauma stat in the [**Hospital1 18**] per ATLS
protocol. The decision was made to obtain complete CT imaging of
his head, neck, torso, and Lt femur. He was then transferred to
the trauma surgery ICU where upon lightening of sedation he was
noted to have no neurological function below the C5 level.
Despite negative CT Cspine studies, the decision was made to
obtain an MRI of this cervical spine.
His [**Hospital **] hospital course is summarized by systems:
Neuro: Patient suffered a cord contusion at C3-5 level. He was
evaluated by neurosurgery and found to be a non-operative
candidate and the decision was made to keep him in a [**Location (un) 2848**] J
cspine collar at least 6 weeks at which point an MRI will be
repeated. He gradually regained the ability to move his toes
([**3-2**]), ankles ([**1-30**]), and knees ([**1-2**]), as well as use some grasp
function of his hands bilaterally, although this exam waxes and
wanes. The patient's home Paxil was restarted upon resumption of
PO intake, but the patient refused restarting of his other
neuro/psychiatric meds (for BPD, etc.). A nicotine patch was
implemented. Trazodone was used prn for sleep
CV: The patient was hypotensive and bradycardic upon admission,
consistent with neurogenic shock. neosynephrine was used as a
pressor to increase SVR and maintain adequate BP, in addition to
an initially aggressive resuscitation period. The patient was
switched to midodrine PO and weaned off neosynephrine. He has
remained hemodynamically stable throughout his ICU course.
Resp: The patient was given a spontaneous breathing trial
multiple times over the first 72 hours of admission. Although he
was able to produce tidal volumes of >700 on his own, he
fatigued easily. The level of injury and his need for long-term
intubation led to the patient receiving a tracheostomy on
[**2138-11-6**] (trauma day 3). He remains on a PSV. He has undergone
several bronchoscopies for foul-smelling sputum in the setting
of fevers. Sputum cultures and BAL specimens, however, have not
identified a causative pathogen. Although a CT angiogram of the
chest was negative for PE at the time of admission (pt was 2
weeks postop from a Lt distal femur fracture repair and
suspicion of pulmonary embolism as mechanism of presenting chest
pain, SOB was highly suspected at time of presentation to
[**Hospital1 18**]), a CXR on [**11-4**] showed evidence of PE/infarction of the Lt
lower lobe. An IVC filter was placed on [**11-5**] to prevent further
PE in a quadriplegic patient with traumatic contraindications
for anticoagulation.
GI: the patient was gradually started on tube feeds and advanced
to goal. His abdomen was intermittently distended and standard
bowel regimens were utilized to achieve bowel movements.
Additionally, methylnaltrexone was used to stimulate bowel
movements. The patient has always tolerated his tube feeds well
without nausea/vomiting or high residuals.
GU: Foley catheter was placed in the trauma bay. Multiple
negative urine cultures obtained during temperature spikes.
Adequate urine output and creatinine throughout his
hospitalization. The patient was deemed to be edematous and
fluid overloaded and gentle diuresis was begun on HD 8 with the
goal to restore euvolemia, keeping in mind the patient's
neurogenic shock and need for increased intravascular volume.
Heme: the patient's hematocrits were monitored closely over the
first 72 hours after trauma given his liver laceration. They
remained stable. An IVC filter was placed on [**2138-11-5**] at the time
of his orthopedic repair given his high likelihood of PE and
imaging that showed a Rt common femoral DVT. Pneumoboots were
used at all times. Regular turning to prevent DVTs was
performed. Anticoagulation with Lovenox/Coumadin was initiated
for treatment of his DVT, with a goal INR of [**12-31**]. He has
required only intermittent blood transfusions, 2units total
since the initial 72 hours of his trauma. His INR was very slow
to increase and was only 1.1 on [**2138-11-15**] despite increasing
doses of Coumadin over the prior 7 days. Hematology was
consulted who recommended increasing by 2.5-5mg daily over the
following several days, continuing the Lovenox, and maximizing
nutritional status. He is currently receiving Coumadin 20 mg
with last INR 1.1 at 3:39 a.m. on [**11-17**].
Endocrine: tight glycemic control was maintained on a regular
insulin sliding scale. No other endocrine issues.
Infectious Disease: the patient was intermittently febrile
throughout his hospital course, as high as 103 degrees on
multiple occasions. No sources of infection were found: sputum,
BAL, urine, blood, indwelling catheters, pressure ulcers, sinus
infections, wound infections, etc. His Rt common femoral DVT is
believed to be the likely source of his intermittent infections.
He was twice started on empiric antibiotics after spiking
temperatures but these were discontinued after negative
microbiology results. He has been afebrile for several days at
the time of discharge.
MSK: Pt underwent ORIF of Left femur fracture on [**2138-11-5**] - 3
locking plates, cerclage x 8. Pt is to f/u in 2 weeks with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP, call [**Telephone/Fax (1) 103565**] for appointment.
He was evaluated by Physical and Occupational therapy and is
being recommended for acute rehab stay after hospital discharge.
Medications on Admission:
paxil, lamictal, xanax, ritalin, tramadol prn, ibuprofen
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-29**]
Puffs Inhalation Q4H (every 4 hours).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Ibuprofen 100 mg/5 mL Suspension Sig: Six Hundred (600) mg PO
Q8H (every 8 hours) as needed for fevers.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
9. Enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred-Ten (110)
mg Subcutaneous Q12H (every 12 hours).
10. Warfarin 1 mg Tablet Sig: MD to order Tablet PO DAILY
(Daily): goal INR [**12-31**].
11. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. Acetaminophen 160 mg/5 mL Solution Sig: 1000 (1000) mg PO
Q6H (every 6 hours) as needed for fever.
15. Insulin Regular Human 100 unit/mL Solution Sig: insulin
units Injection ASDIR (AS DIRECTED).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: do not exceed 4 g
acetaminophen in 24 hours.
17. Midodrine 2.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for yeast.
19. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
20. Haloperidol 0.5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for agitation, anxiety.
21. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for anxiety.
22. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN breakthrough
pain
Hold for RR<12
23. Ondansetron 4 mg IV Q8H:PRN nausea
24. Warfarin 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
25. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
26. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C3-5 fracture cord contusion with quadriplegia
Grade II liver laceraction
Right 5-7th anterolateral rib fractures
Right common femoral DVT
s/p trach/PEG [**2138-11-6**]
s/p ORIF Lt femur fracture/IVC filter [**2138-11-5**]
Discharge Condition:
Stable
Mental Status:Clear and coherent - able to answer questions
Level of Consciousness:Alert and interactive, difficulty
speaking d/t trach
Activity Status:Bedbound
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 continue medications as prescribed.
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 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:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 103565**]
(orthopedic surgery)
Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Trauma surgery; call
[**Telephone/Fax (1) 600**] for an appointment.
Follow up with Neurosurgery in 4 weeks; call [**Telephone/Fax (1) 1669**] for an
appointment.
Completed by:[**2138-12-6**]
|
[
"V43.64",
"807.03",
"868.03",
"958.4",
"E816.0",
"518.81",
"453.41",
"599.0",
"401.9",
"820.22",
"997.31",
"806.01",
"296.80",
"864.05",
"821.01",
"415.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"31.1",
"33.24",
"38.93",
"96.6",
"38.7",
"43.11",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
13552, 13622
|
5343, 10770
|
338, 434
|
13889, 13896
|
1874, 2969
|
15667, 16068
|
1020, 1038
|
10878, 13529
|
13643, 13868
|
10796, 10855
|
14083, 15147
|
15163, 15644
|
1053, 1055
|
275, 300
|
462, 681
|
2978, 5320
|
1069, 1343
|
13910, 14059
|
703, 916
|
932, 1004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,419
| 143,882
|
11858
|
Discharge summary
|
report
|
Admission Date: [**2150-9-23**] Discharge Date: [**2150-9-26**]
Date of Birth: [**2075-7-10**] Sex: M
Service: MEDICINE
Allergies:
Tetanus
Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2150-9-25**] EGD (upper endoscopy)
History of Present Illness:
75M with hx afib on coumadin, cholecystectomy for gangrenous GB
performed in [**Month (only) 205**] in [**State 108**]. Had been admitted to [**Hospital3 **]
[**2150-9-12**] for syncope with ERC performed Tuesday with
sphincterotomy. Since then had low bp, feeling light headed with
standing. p/w hypotension and syncopal events over the past few
days. Had cholecystecomy for gangrenous GB done in [**Month (only) 205**] in
[**State **]. Was in [**Hospital3 **] on the 8th for syncope and had an
ERCP for ?stone last Tuesday with spincterotomy, had syncopized
. Since then has had low bp, feelign lightheaded when standing,
melanotic stools over last couple of days. On coumadin for afib.
In the ED Initially triggered for hypotension BPs 80-90 guaic
positive, got 3U FFP, 1U PRBC, 3L U.Vanc/cipro.flagyll. BPs are
90/57. ERCP consulted with plan for Endoscopy/ERCP in am.
On arrival to the MICU he was noted to be hypotensivee to the
80s systolic, asymptomatic
Past Medical History:
1. Paroxysmal atrial fibrillation (related to hyperthyroidism)
2. Hypertension
3. Diabetes c/b neuropathy and mild renal insufficiency
4. Hypothyroidism (s/p resection [**2098**] and radioactive iodine
ablation [**2128**]).
5. Prostate Ca - monitored; neg Bx [**2146**], PSA 1.5.
6. Subdural hematoma - post-trauma, s/p drainage (~[**2142**])
7. Morbid obesity - s/p gastric banding [**7-11**]
8. Mitral regurgitation (mild echo [**2144**])
9. Left knee replacement [**1-11**]
10. Depression
11. Anxiety
12. Coronary artery disease (s/p CABG [**8-13**] LIMA to LAD, rSVT to
PDA, OM1, OM2)
13. Non-Hodgkins Lymphoma (tx in FL [**2149**])
14. Renal cysts
15. Retrohepatic cyst on CT (asymptomatic)
Social History:
Up North he lives in an in-law apartment above the garage of his
daughter's home. He comes up 3-4x/year for about a month. He
very much enjoys his independence in [**State 108**] where he has a
condominum in [**Location (un) 20338**] on the golf course.
Family History:
Parents are both deceased. (Father: 88,
peripheral vascular disease); (Mother - 61, congestive heart
failure). He has 1 brother (65, rheumatoid arthritis) and 3
children (a daughter with bipolar disorder).
Physical Exam:
Admission exam
T: 97.9 P: 73 BP: 100/61 RR: 12 99% RA
General: Alert, oriented, no acute distress, pale
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Discharge Exam:
T: AF, HDS, satting well on RA
General: Alert, oriented, no acute distress, pale
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no HSM
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait normal
Pertinent Results:
ADMISSION LABS:
[**2150-9-23**] 04:45PM BLOOD WBC-10.3 RBC-2.96*# Hgb-9.4*# Hct-28.3*#
MCV-96 MCH-31.9 MCHC-33.3 RDW-15.9* Plt Ct-300
[**2150-9-23**] 08:15PM BLOOD WBC-7.7 RBC-2.49* Hgb-8.0* Hct-23.8*
MCV-96 MCH-32.1* MCHC-33.6 RDW-16.0* Plt Ct-244
[**2150-9-23**] 04:45PM BLOOD Neuts-82.1* Lymphs-14.3* Monos-3.0
Eos-0.3 Baso-0.3
[**2150-9-23**] 04:45PM BLOOD PT-24.8* PTT-33.9 INR(PT)-2.4*
[**2150-9-23**] 04:45PM BLOOD Glucose-162* UreaN-44* Creat-2.0* Na-137
K-4.9 Cl-100 HCO3-27 AnGap-15
[**2150-9-23**] 04:45PM BLOOD ALT-40 AST-33 LD(LDH)-117 AlkPhos-95
TotBili-0.2
[**2150-9-23**] 04:45PM BLOOD Lipase-53
[**2150-9-23**] 04:45PM BLOOD cTropnT-0.03*
[**2150-9-24**] 03:07AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6
[**2150-9-23**] 04:45PM BLOOD Albumin-4.2 Iron-74
[**2150-9-23**] 04:45PM BLOOD calTIBC-376 Hapto-143 Ferritn-82 TRF-289
[**2150-9-23**] 08:28PM BLOOD Lactate-1.5
PERTINENT RESULTS:
Hematocrit
[**2150-9-23**] 08:15PM BLOOD Hct-23.8*
[**2150-9-24**] 03:07AM BLOOD Hct-25.8*
[**2150-9-24**] 02:26PM BLOOD Hct-31.4*
[**2150-9-25**] 07:30PM BLOOD Hct-37.0*
[**2150-9-26**] 06:10AM BLOOD Hct-33.6*
Creatinine
[**2150-9-23**] 04:45PM BLOOD Creat-2.0*
[**2150-9-23**] 08:15PM BLOOD Creat-1.8*
[**2150-9-24**] 03:07AM BLOOD Creat-1.6*
[**2150-9-25**] 07:55AM BLOOD Creat-1.2
[**2150-9-26**] 06:10AM BLOOD Creat-1.2
CT abdomen/pelvis:
FINDINGS:
ABDOMEN: The visualized lung bases are clear. The liver
demonstrates minimal pneumobilia within the left lobe. Arising
from the caudate lobe of the liver is a hypodense rounded
exophytic mass that
measures 4.3 AP x 6.1 TV x 10.7 cc (2:25 and 601b:40). It
exerts minimal mass effect on the adjacent liver parenchyma and
duodenum. There is no surrounding inflammation. Its appearance
is similar in the axial plane to prior study from [**2149-1-8**].
Clips are present in the gallbladder fossa. Spleen is normal in
size.
Pancreas and adrenal glands show no masses or nodules. The
small and large bowel shows no evidence of obstruction or wall
edema. Neither kidney shows evidence of hydronephrosis.
Multiple circumscribed hypodense structures arise from the
kidney which consist of simple fluid, the largest of which
measures 4.5 cm in diameter in upper pole of the right kidney.
There is no free air, free fluid, or lymphadenopathy.
PELVIS: The bladder and prostate appear unremarkable. The
prostate measures 3.1 x 5.2 cm in the axial plane (2:76). There
is no free fluid or lymphadenopathy.
Minimal degenerative disc disease is present in the lumbar
spine. Otherwise, there is no aggressive-appearing lytic or
sclerotic lesion.
IMPRESSION:
1. Status post cholecystectomy and gastric banding without
evidence of free air or free fluid.
2. Portocaval mass as described above; evaluation with
contrast-enhanced CT may be considered once the patient's renal
function improves.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT (TTE):
[**2150-9-24**] at 10:01:00 AM
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
TR Gradient (+ RA = PASP): 21 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2144-10-2**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Low normal LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Aortic valve not well seen.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Suboptimal image quality - poor apical views.
CONCLUSIONS:
The left atrium is elongated. The right atrium is moderately
dilated. 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 low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. The mitral valve leaflets are mildly
thickened. 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: Suboptimal image quality. No clinically significant
pericardial effusion. Low normal global left ventricular
systolic function. No clinically significant valvular
regurgitation or stenosis. Normal pulmonary artery systolic
pressure.
Compared with the prior study (images reviewed) of [**2144-10-2**],
mild pulmonary artery systolic hypertension is no longer
appreciated. Due to the suboptimal image quality on the current
study a comprehensive comparison of all other parameters could
not be made.
EGD ([**2150-9-25**]):
Indications: 75 yo with recent ERCP/sphx had melena and upper
GIbleed
FINDINGS:
Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Mucosa: Normal mucosa was noted. Cold forceps biopsies were
performed for histology to evaluate for H.pylori.
Duodenum:
Excavated Lesions A single cratered 2 cm ulcer was found in the
posterior duodenal bulb. No active bleeding was noted.
Other Duodenoscope was introduced and the site of previous
sphincterotomy. There was clear bile draining from the
sphincterotomy. No bleeding was noted.
IMPRESSION:
Normal mucosa in the esophagus
Normal mucosa in the stomach (biopsy)
Ulcer in the posterior duodenal bulb
Duodenoscope was introduced and the site of previous
sphincterotomy. There was clear bile draining from the
sphincterotomy. No bleeding was noted.
Otherwise normal EGD to third part of the duodenum
RECOMMENDATIONS:
Clears when awake and advance diet as tolerated.
Protonix 40 mg orally twice a day.
Await pathology for H.pylori. Treat if positive for H.pylori.
Repeat EGD in 4 weeks to document healing of duodenal ulcer. If
ulcer is persistent then obtain biopsies to rule out malignancy.
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and
the ERCP fellow. The patient's reconciled home medication list
is appended to this report. EBL = zero. Final diagnosis as
above. Specimens as above.
DISCHARGE LABS:
[**2150-9-26**] 06:10AM BLOOD WBC-10.3# RBC-3.63* Hgb-11.7* Hct-33.6*
MCV-93 MCH-32.1* MCHC-34.6 RDW-16.6* Plt Ct-220
[**2150-9-26**] 06:10AM BLOOD PT-11.8 PTT-27.3 INR(PT)-1.1
[**2150-9-26**] 06:10AM BLOOD Glucose-129* UreaN-17 Creat-1.2 Na-144
K-4.3 Cl-109* HCO3-26 AnGap-13
Brief Hospital Course:
ASSESSMENT:
75 year old male with hx CAD s/p CABG, Afib on warfarin, PR
prolongation s/p CCY and more recently ERCP with sphincterotomy
for 1.5cm CBD stone, now presenting with syncope and
hypotension, likely secondary to GI bleed.
BRIEF HOSPITAL COURSE BY PROBLEM:
ACTIVE ISSUES:
# GI bleed: He was initially admitted to the ICU with concern
for active upper GI bleeding with evidence of a HCT drop and
melena. The ERCP service was consulted and recommended
consulting the GI service for upper endoscopy before attempting
a repeat ERCP. While awaiting this study, he received the
following infusions: 6L NS IV, 4 units pRBCs, 1 units FFP, and
10mg vitamin K in order to reverse an INR of 2.4. Due to a prior
history of a transfusion reaction, he was pre -treated with
diphenhydramine and transfused at a slower rate. His hematocrit
was followed closely and continued to trend up over the course
of his MICU stay so he was transferred to the floor. Had EGD
with side viewing scope which showed cratered ulcer at Duodenal
bulb. Biopsies were taken, GI rec'd: 1. following up in 4 weeks
for rescope to evaluate for healing of ulcer; 2. if H Pylori
positive, will need treatment; 3. continue PPi.
.
# Hypotension: Due to a presumed ongoing GI bleed, he was
admitted to the MICU for observation of his hypotension without
tachycardia. He was felt to be hypovolemic from the GI bleed and
was resuscitated as above. He did not appear to be septic. His
blood pressure remained stable throughout his MICU stay.
# Bradycardia/Syncope- His EKGs were initially concerning for a
high-degree AV block, but review of the EKGs with the Cardiology
service revealed atrial flutter with variable conduction
(usually 3:1) as well as known PR prolongation. TTE was done
and showed stable EF and no effusion. Troponins trended
downward. EP consulted who felt no acute intervention was
needed.
# Atrial fibrillation/flutter: INR was supratherapeutic in
setting of coumadin at presentation .Patient appears to have
slow atrial flutter, per EP, and does not require EP
intervention at this time. Reversed with FFP and 10 vitamin K
for EGD. Patient was instructed to restart coumadinon [**2150-9-28**] if
no signs of bleeding/melena. Plans to have INR drawn the week of
[**2150-9-28**] with results sent to his nurse at his anticoagulation
lcinic in FL. They will manage his dosing from there.
INACTIVE ISSUES:
# CAD s/p CABG: Patient was w/o chest pain throughout. Troponins
negative. No evidence of active/acute ischemia on EKG. Home
statin was continued.
# Portacaval lesion: First noted on CT in [**2149**]. Appears stable.
Being followed by PCP in [**Name9 (PRE) 108**] with MRI and surgical referral.
# Diabetes: On metformin, saxaglipitin and Januvia at Home. He
was given insulin sliding scale while in house.
# Hypothyroidism (s/p thyroidectomy): Patient was maintined on
home dose of levothyroxine. No issues while in house.
TRANSITIONAL ISSUES
- Full code
- f/u pending EGD biopsies
- f/u H Pylori, treat if positive
- Repeat EGD in 4 weeks to evaluate healing and rule out
malignancy
- Re-initiation of coumadin on [**2150-9-28**] - goal INR [**2-6**]
- Continued workup of portocaval mass
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Clonazepam 2 mg PO QHS
2. Levothyroxine Sodium 150 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Onglyza *NF* (saxagliptin) unknown Oral daily
6. Tamsulosin 0.4 mg PO HS
7. Rosuvastatin Calcium 30 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. Escitalopram Oxalate 20 mg PO DAILY
10. Warfarin 7.5 mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
Please restart this on [**2150-9-28**] only if you have no signs of
bleeding or dark stool
2. Clonazepam 2 mg PO QHS
3. Escitalopram Oxalate 20 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Onglyza *NF* (saxagliptin) 0 ORAL DAILY
7. Rosuvastatin Calcium 30 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
11. Warfarin 7.5 mg PO DAILY16
Please restart this on [**2150-9-28**] only if you have no signs of
bleeding or dark stool. Modify dose as directed by RN at
[**Hospital 197**] Clinic
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Acute blood loss anemia
GI bleed
Atrial fibrillation/flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 19219**],
It was a pleasure taking care of you during your
hospitalization. You were admitted with passing out and low
blood pressures. You were found to have a low blood count and
blood in your stool. You were given blood transfusions and your
blood count remained stable. You had an upper endoscopy which
showed a large ulcer in your intestines which was not actively
bleeding, but we believe this was the source of your bleeding.
You will need a repeat endoscopy in 4 weeks to recheck the ulcer
to make sure it is healing. We also were holding your aspirin
and coumadin because of this bleeding. You may restart these
medications on Monday [**9-28**] if you are still feeling well and
have no signs of bleeding or dark stools.
Your lap band was deflated by our Bariatric Surgeons in order to
have the EGD. They said this can be reinflated by your regular
Bariatric doctors. Please call your surgeon to schedule an
appointment to follow up on this.
You were also noted to have a slow heart rate at times. You
were seen by our electrophysiologists (heart rhythm
specialists). They felt this was a benign rhythm and did not
require treatment. They suggested you follow up with your usual
cardiologist.
Followup Instructions:
Dr. [**Last Name (STitle) 37424**]
[**2150-10-7**]
9:30AM
Department: CARDIAC SERVICES
When: THURSDAY [**2150-12-24**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], 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
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2151-5-25**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2150-9-29**]
|
[
"V15.82",
"276.52",
"426.0",
"250.40",
"285.1",
"427.31",
"532.40",
"593.9",
"V45.81",
"V58.61",
"250.60",
"V45.86",
"357.2",
"V10.46",
"202.80",
"300.4",
"427.32",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
15206, 15212
|
10753, 10992
|
278, 318
|
15336, 15336
|
4712, 10435
|
16755, 17472
|
2335, 2545
|
14463, 15183
|
15233, 15315
|
13979, 14440
|
15487, 16732
|
10451, 10730
|
2560, 3193
|
3209, 3795
|
230, 240
|
11037, 13137
|
11021, 11021
|
346, 1314
|
13155, 13953
|
3830, 4692
|
15351, 15463
|
1336, 2046
|
2062, 2319
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,275
| 163,294
|
48438+59091
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-10-12**] Discharge Date: [**2103-11-16**]
Date of Birth: [**2033-9-7**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Opioid Analgesics
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Lumbar puncture.
History of Present Illness:
70 yo ho Hep C, DM2, CAD s/p CABG, PPM, hyperchol, HTN and
polysubstance abuse including etoh and narcotics brought in by
EMS after being found at home confused with a clonidine patch on
by his VNA. Neurology was consulted upon presentation to the ED
and their exam at that time was notable for severe inattention
and word finding difficulty with phonemic paraphrasias but exam
was otherwise nonfocal and there were no signs of aphasia.
Additional assessment of patient's mental status was confounded
by his severe inattention. There was no ophthalmoplegia to
suggest a Wernicke's encephalopathy however patient did seem to
confabulate at times suggesting possible Korsakoff's syndrome.
He was noted to have bilateral dysmetria likely associated with
chronic alcohol use. Neuro impression at that time was that
deficits were most c/w a delirium related to a toxic metabolic
infectious etiology, but could not exclude seizure activity or
post-ictal confusion.
.
CT was obtained in the ED on [**10-11**] which showed no bleed nor
edema, but neuro felt that, given his vascular risk factors, it
would be reasonable to evaluate for interval change after 3 days
with a noncontrast head CT.
.
Because of severe agitation, he required 4 point leather
restraints he received 6mg ativan and 15mg of Haldol in ED and
was transferred to the MICU.
Past Medical History:
-Coronary artery disease status post coronary artery bypass
graft [**12/2091**], status post failed percutaneous transluminal
coronary angioplasty in [**2098-6-2**] secondary to tortuous
vessels-->1. Native two vessel coronary artery disease. 2.
Unsuccessful attempt at intervention on mid-RCA stenosis.
-Status post pacer placement for bradycardia [**2097-7-3**]
-Status post atrial flutter ablation in [**2097-6-2**]
-Hypertension.
-Hyperlipidemia.
-Anemia.
-Dyspepsia.
-Syncope.
-Cirrhosis with a positive Hepatitis C virus.
-Type II diabetes mellitus.
-80% vertebral artery stenosis.
-Severe restless legs.
-Depression and bipolar disorder.
-Hypothyroidism.
Social History:
Lives [**Location 6409**] in a senior housing project. Long h/o EtOH
dependence but sober for "many years" after AA, although
endorses occasional beer, last drink he reports a few months
ago. Has experienced one withdrawal seizure in past. Heavy use
of amphetamines in [**2055**]. H/o abusing morphone, dissolved it and
injected it. Off narcotics after several detoxs. Quit tob in
[**2085**].
Family History:
[**Name (NI) **] father died at age 69 from a myocardial infarction and
patient's mother died at age 86 and did have cardiac
arrhythmias.
Physical Exam:
T-95.4 BP-97/40 HR-62 RR- O2Sat 95%RA
Gen: Elderly gentleman in NAD, requesting sleeping pill. Alert
and oriented to person, place and date [**2103-10-4**] although
thinks it's the 5th.
HEENT: EOMI, no nystagmus appreciated, moist oral mucosa, PERRL
Neck: supple, no carotid or vertebral bruit.
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs although distant
heart sounds
Lung: fine bibasilar rales L>R
aBd: Obese, +BS soft, non tender not distended, no rebound,
unable to appreciated ascites nor HSM but difficult given
habitus
Ext: trace edema, no asterixis
Neuro: Not displaying confabulation currently. CN II-XII intact.
MS [**4-7**]. Toes downgoing. + dyetria b/l w/ finger to nose and heel
to shin.
Pertinent Results:
ADMISSION LABS:
================
14.4
3.7 >-------< 100
41.6
MCV 90 Neuts 63.8 Lymphs 24.9 Monos 7.4 Eos 3.5 Baso 0.2
PT 13.4 PTT 27.3 INR 1.2
Lactate 1.7
138 102 21
----|----|-----< 224
5.0 23 1.4
.
Ca 9.9 Phosphate 4.6 Mg 1.7
ALT 44 AST 75 Alk Phos 71 Amylase 35 Total bili 1.0 Lipase
18 Alb 4.5
Serum Tox: negative
UA: 500 protein, 100 glucose
.
STUDIES:
========
CHEST (PA & LAT) [**2103-10-11**]
IMPRESSION: No acute cardiopulmonary disease.
.
CT HEAD W/O CONTRAST [**2103-10-11**]
IMPRESSION:
1. No evidence of intracranial hemorrhage or edema.
2. Sinus mucosal disease with near complete interval
opacification of the left side of the sphenoid sinus.
Of note, MRI with diffusion-weighted imaging is most sensitive
for acute ischemia.
.
EKG [**2103-10-11**]
Sinus rhythm. The P-R interval is prolonged. There are Q waves
in the
inferior leads consistent with prior myocardial infarction.
Diffuse
non-specific ST-T wave changes. Compared to the prior tracing
ST-T wave
changes are more diffuse and atrial bigeminy is no longer
present.
.
CHEST PORT. LINE PLACEMENT [**2103-10-12**]
Portable AP chest radiograph compared to [**2103-10-11**]. The
right subclavian line was inserted with its tip projecting at
the level of low SVC. There is no pneumothorax, apical hematoma
or other complications. The heart size is mildly enlarged but
unchanged as well as there is no change in the stable appearance
of the mediastinum. The overall lung volumes have decreased
compared to the previous study with subsequent increased _____
of the pulmonary vasculature with no pulmonary edema
demonstrated. The pacemaker leads terminate in right atrium and
right ventricle, unchanged. There is no pleural effusion or
pneumothorax.
.
CSF [**2103-10-15**]
NEGATIVE FOR MALIGNANT CELLS.
.
CT HEAD W/O CONTRAST [**2103-10-14**]
IMPRESSION: No acute intracranial process. No interval changes
since [**2103-10-11**].
.
EEG [**2103-10-14**]
IMPRESSION: This is an abnormal routine EEG due to the slow and
disorganized background with bursts of generalized slowing
suggestive of
an encephalopathic process. Infection, metabolic disturbances,
and
medications are among the most frequent causes of
encephalopathy. No
clear epileptiform features or electrographic seizures were seen
during
the recording.
.
EKG [**2103-10-16**]
Atrial fibrillation and ventricular paced rhythm. Intermittent
intrinsic
A-V conduction. Compared to the prior tracing of [**2103-10-14**] no
diagnostic
interim change.
TRACING #1
.
VIDEO OROPHARYNGEAL SWALLOW [**2103-10-17**]
IMPRESSION:
1. Moderate oral and pharyngeal dysphagia, with mild delay in
swallow initiation and reduced laryngeal valve closure.
2. Silent aspiration with ineffective cued coughs
.
EKG [**2103-10-17**]
Atrial fibrillation and ventricular paced rhythm and more
frequent intrinsic A-V conduction. Compared to the prior tracing
of [**2103-10-16**] no diagnostic interim change.
TRACING #2
.
EEG [**2103-10-24**]
IMPRESSION: Abnormal EEG due to the slow and disorganized
background.
This indicates a widespread encephalopathy. Medications,
metabolic
disturbances, and infection are among the most common causes.
There
were no areas of persistent focal slowing, and there were no
epileptiform features.
.
CT HEAD W/O CONTRAST [**2103-10-26**]
IMPRESSION: No significant change since [**2103-10-14**] with no acute
intracranial abnormalities.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2103-10-26**]
IMPRESSION: No ascites.
.
EKG [**2103-10-26**]
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to tracing of [**2103-10-18**] all the beats are ventricular
paced.
.
Brief Hospital Course:
Mr. [**Known lastname 1356**] is a 70 y/o male with CAD, DM, HTN, Hep C cirrhosis,
p/w mental status change is setting of possible substance abuse
at home, hospital course c/b prolonged delirium.
.
# Delirium: The patient presented after initially found at home
in a state of confusion by his VNA. Neurology was consulted upon
presentation to the ED and their exam at that time was notable
for severe inattention and word finding difficulty with phonemic
paraphrasias but exam was otherwise nonfocal and there were no
signs of aphasia. He was noted to have bilateral dysmetria
likely associated with chronic alcohol use. Neuro impression at
that time was that deficits were most c/w a delirium related to
a toxic metabolic infectious etiology. CT was obtained in the ED
on [**10-11**] which showed no bleed nor edema. Pt received Ativan and
Haldol in ED and transferred to the MICU. In the MICU, he was
continued on CIWA protocol w/ standing valium out of concern for
possible postictal state as well as etoh withdrawal. Haldol was
discontinued [**1-5**] to prolonging QTc (reportedly 470s at longest).
Urine and serum tox were +only for benzos, which he had been
receiving. Infectious workup included CXR which did not reveal
infiltrate, UA which showed rare bacteria, but no pyuria, and
blood cultures which have shown NGTD. B12 and Folate wnl.
Additionally, an LP was performed which had no RBCs nor WBCs,
normal glucose, but did show elevated protein; gram stain of CSF
showed no PMNs. RPR and VDRL were sent and were unrevealing. He
was subsequently called out to the floor for further evaluation
and management of his delirium.
.
On the floor ([**10-14**]) a repeat Contrast CT was done which showed
no change from the previous on [**10-11**], an EEG done showed no
evidence of seizure activity. Since that time, his neurologic
status slowly began to improve. Once patient able to communicate
better, he admitted to taking valium at home. Psychiatry also
consulted and felt that the patients delirium was likely
secondary to his valium overdose and that this would take time
for the medication to clear his system. Patient was started on
standing Haldol for agitation and had a 1:1 sitter for some time
while on the floor. On [**10-22**] he was persistantly agitated and we
noted some resting hand tremor and rigidity as well as a concern
for a wide based gait. This was felt to be secondary to the
Haldol. His medications were changed to Zyprexa. Given the
delirium did not appear to be improving and was still waxing and
[**Doctor Last Name 688**]; neurology was re-consulted. Neurology felt there was
some concern for Wernicke's Encephalopathy that would take a
long period of time to clear. He was started on IV Thiamine x 5
daysof which he completed 4 before being changed to po thiamine,
which was continued thoughout. Also in the differential for the
patient's presentation were stroke and ? silent MI. However,
repeat head CT was unchanged, and numerous cardiac workups were
unrevealing. Given his history of Hep C, the diagnosis of
hepatic encephalopathy was considered as an etiology for his
delirium. He was placed on standing TID lactulose. Hepatology
was consulted who felt that this clinical picture was unlikely
due to hepatic encephalopathy, but they recommended continuing
lactulose and starting rifaxamin. An abdominal U/S was negative
for ascites or a cirrhotic liver. After being on lactulose and
rifaximin for some time, these meds did not appear to be
affecting his mental status, and they were discontinued. In
terms of less likely diagnoses, an HIV test to rule out HIV
encephalopathy was negative, and a urine porphobilinogen to rule
out acute intermittent porphyria was also negative. Psychiatry
suggested the possibility of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 309**] Body dementia due to his
mild Parkinsonian features. An acetylcholinesterase inhibitor
was added on the day of d/c. Pre-Aricept mini mental state exam
was 17.
.
[**Known firstname **] has continued to demonstrate marked improvement and
awareness throughout his floor stay. We provided his with
non-prescription glasses, as he does wear these at home.
However, if possible his home prescription should be pursued as
an outpatient. He did complain of insomnia and responded best to
a combination of standing mirtazipine and prn ambien (needed
often). His major concern was anxiety and a desire to go home to
pay rent and take care of his cat. Occupational therapy
recommended rehab for continued cognitive therapy, and
psychiatry confirmed his capacity to decide to go to rehab.
.
# CAD: Patient was initially found to have an elevation of his
troponins which was concerning given known underlying CAD
(unable to intervene on mid RCA lesion in [**2097**]; PMIBI in [**2098**]
showed fixed, no reversible defects). Troponin was elevated on
presentation at 0.12, peaked at 0.20 on [**10-12**] and was trending
down to 0.16 on [**10-13**]. CKs were up, but MB was normal and MB
Index were negative throughout. EKGs were without significant
ST/TW changes from old dated [**2100**]. Patient was markedly
hypertensive on presentation and in the ICU to 240s/120s per
report so it was felt that the troponins may have risen
secondary to subendocardial ischemia in the setting of
hypertension. On the floor he had one episode of CP where an EKG
was again done which showed a slight ST depression. Cardiac
enzymes were negative at that time. The patient's blood pressure
was elevated during this episode and again it was felt that this
EKG change (which resolved 1 hour later on subsequent EKG) as
likely secondary to subendocardial ischemia from hypertension.
His blood pressure medications were uptitrated. His atenolol
was increased to 100mg daily. He was continued on the aspirin.
In addition, patient had several episodes of chest pain on the
floor. It should be mentioned that they were highly inconsistent
and occured during his delirium. Once his MS cleared there were
no complaints of CP. When his prior medical records were
reviewed, it became clear that he has presented innumerably to
the ED with CP, with numerous negative workups. A specific CP
protocol was in effect per his outpatient cardiologist. This was
to administer 0.5" of nitro paste or a nitro patch. This worked
very well on the floor. He also responded to maalox or tums when
it seemed that his CP was not of a cardiac etiology.
.
# Rhythm: Patient has a pacer. His EKG showed paced rhythm with
underlying afib vs flutter. He would occasionally go from normal
sinus rhythm to a.fibb/flutter. Patient is s/p a.flutter
ablation in past. Electrophysiology saw the patient and felt he
was paced appropriately. They recommended follow up in three
months as an outpatient.
.
# HTN: Patient was hypertensive when he was on the floor (out of
MICU). His BP meds were intially held in the ICU but restarted.
He was continued on his verapamil, enalapril and HCTZ. His
atenolol was titrated up as well as his verapamil. His
lisinopril was also increased, and by the time of discharge he
had excellent antihypertensive control with BPs largely in the
120-130s.
.
# Cirrhosis: Patient has a history of +hep C and heavy etoh hx.
Not followed in our system for this so status largely unknown. A
viral load was sent and was 77,000. No h/o GI bleed, no h/o
ascites, no clear h/o hepatic encephalopathy. Has stable, very
mild transaminitis with a normal bilirubin. INR only mildly
elevated to 1.2, albumin normal at 4.2. Patient will need
outpatient follow up with a hepatologist for further management.
Liver was consulted for possible hepatic encephalopathy as part
of his delirium, who felt that this did not appear to be hepatic
encephaloapthy. Ammonia levels were checked and were not
elevated. Lactulose was started, but eventually d/c'ed due to
ineffectiveness.
.
# Pancytopenia: Chronic. Likely represents BM suppressive or
infiltrative process and thrombocytopenia consistent with liver
disease. It was felt that it may be [**1-5**] direct etoh bone marrow
toxicity.
.
# Rash - [**Known firstname **] developed a rash on his upper extremities while
on a number of new medicines. the rash was felt to be a
medication reaction, and began to improve after several meds
were discontinued, including laculose/rifaximin/seroquel. It is
non-prurutic and continues to clear at time of discharge.
.
# Chronic Kidney Disease: No labs in our system since [**2100**], last
creatinine was isolated elevation to 1.3 (all those prior were
normal). Given time lapse since labs and known htn, it is
unclear whether he has chronic renal insufficiency secondary to
hypertension. Patients creatinine increased while on the floor;
felt to be secondary to dehdyration and a FENA<1. Pt received
IVF with improvement in his creatinine. Once [**Known firstname 2979**] mental
status cleared, he was able to hydrate himself and eat
accordingly and his renal function remained normal.
.
# Positive urine culture: UA on admission with rare bacteria but
0 WBC, urine Culture grew Klebsiella pneumoniae. Repeat again w/
neg nitrites, neg leukesterase, NO WBCs, rare bacteria and
0-2squams. Urine culture showed now growth. This was not treated
with any antibiotics. A repeat urine culture was equivocal with
moderate growth of enterococcus and he completed a 10-day course
of ampicllin switched to amoxicillin with a negative
confirmatory culture at the end of his treatment.
.
# DM: Patient had refractory diabetes and required a large
amount of insulin which was titrated upwards during his stay. At
discharge, his requirements were 60 units [**Known firstname 8472**] qHS, 10 units
humulog tid with meals, and a humulog sliding scale for extra
coverage. The night prior to d/c his [**Known firstname **] was mistakenly not
administered, hence his AM FSG was quite elevated at 400. He
received his [**Known firstname **] this AM. Throughout the day prior, FSGs were
99 to 116. On the night of discharge, please administer his
[**Known firstname **] at 3AM and move backwards by 3 hour increments until it
is once again administered at 9PM (usual HS).
.
# Hypothyroidism: TSH slightly elevated to 6.2, but in setting
of acute illness. FT4 wnl. A repeat TSH was within normal
limits. He was continued on home Synthroid.
.
# FEN: Patient had several video speech and swallow studies
because there was a concern for aspiration risk. They suggested
silent aspiration, but that that the patient could tolerate a
honey thickened liquids and pureed solids.1:1 supervision during
meals for feeding. Pills were crushed with purees. No straws.
.
# ? Heparin induced thrombocytopenia: his platelets dropped
quite suddenly during the course of his hospital stay. His
heparin was stopped and a HIT antibody was quivocal. A serotonin
release assay was sent and results were pending at time of
discharge. He received no heparin products but was quite
ambulatory ancd active during his floor stay.
.
# The patient was hypernatremic to 147 on occasion. 1/2 NS was
given with resolution.
.
# [**Known firstname **] was full code throughout
Medications on Admission:
1. ASPIRIN 325MG PO daily
2. ATENOLOL 50 MG daily
3. Catapres-TTS-3 0.3 mg/24hr; 1patch transdermal one time per
week
4. ENALAPRIL 20MG PO bid
5. HYDROCHLOROTHIAZIDE 25 mg daily
6. [**Name (NI) 8472**] unclear amount of units
7. Humalog sliding scale 60-65 units per OMR and [**Last Name (un) **] Note
8. LOTRIMIN 1% 1 application [**Hospital1 **] as needed for prn itching
9. MIRTAZAPINE 60 mg Po daily
10. NEURONTIN 600 mg tid-qid PRN:pain (total nte 2400 mg/day)
11. VERAPAMIL 80 MG PO daily
12. DESIPRAMINE 20 PO QHS
13. LEVOTHYROXINE 25 micrograms po daily
14. Tramadol 50mg po q 8hrs
15. Lunesta 25po q day
16. Uroxatral 10mg po daily
17. Actaplus MET 15mg/850 [**Hospital1 **]
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
SC Subcutaneous at bedtime.
14. Humalog 100 unit/mL Solution Sig: Ten (10) units SC
Subcutaneous with meals.
15. Humalog 100 unit/mL Solution Sig: sliding scale per sliding
scale Subcutaneous four times a day.
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
18. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
19. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
20. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
21. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8221**] - [**Location (un) 583**]
Discharge Diagnosis:
Delirium secondary to valium overdose
Enterococcal UTI
Pancytopenia
Hepatitis C
Diabetes type II
CAD
HTN
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital because you were found to be
confused and unresponsive by your visiting nurse. You were
initially admitted to the ICU. You received medications to
control the agitation.
.
You also developed confusion while in the hospital and you had
an extensive workup to determine the cause of this. We did not
find any abnormalities on head CT or any evidence of a heart
attack. It was felt that your confusion was likely
multifactorial including an overdose of Valium, dehydration and
a urinary tract infection.
.
You were evaluated by neurology and psychiatry. There was
concern that you might have some changes in your memory related
to long term alcohol use. You were started on Thiamine
supplements. Many of your medications were also stopped at is
was felt that they may have been contributing to your confusion.
.
You should keep all your medical appointments. You should take
all your medications as prescribed.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, abdominal pain, worst headaches of your life, black
stools or any other concerning symptoms.
Followup Instructions:
Please call and make an appointment with your PCP, [**Name10 (NameIs) **]
[**Last Name (STitle) 101993**].
.
Please follow up with your psychiatrist.
.
You should follow up with Behavioral neurology after discharge.
An appointment has been set up for you with DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 259**]
Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2103-12-28**] 9:00. He is located in
[**Hospital Ward Name 860**] [**Doctor Last Name **], [**Location (un) **], [**Apartment Address(1) **].
Name: [**Known lastname **],[**Known firstname **] J Unit No: [**Numeric Identifier 16446**]
Admission Date: [**2103-10-12**] Discharge Date: [**2103-11-16**]
Date of Birth: [**2033-9-7**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Opioid Analgesics
Attending:[**First Name3 (LF) 417**]
Addendum:
Pt's discharge was delayed for 1 day due to heavy snowfall on
afternoon of d/c. It was noted that his blood sugars were
running high so prior to discharge his [**First Name3 (LF) 16447**] was increased to
66 units qHS, and his Humulog with meals was increased to 12
units tid with meals.
Chief Complaint:
found down, confused
Major Surgical or Invasive Procedure:
Lumbar puncture
PICC placement
History of Present Illness:
70 yo ho Hep C, DM2, CAD s/p CABG, PPM, hyperchol, HTN and
polysubstance abuse including etoh and narcotics brought in by
EMS after being found at home confused with a clonidine patch on
by his VNA. Neurology was consulted upon presentation to the ED
and their exam at that time was notable for severe inattention
and word finding difficulty with phonemic paraphrasias but exam
was otherwise nonfocal and there were no signs of aphasia.
Additional assessment of patient's mental status was confounded
by his severe inattention. There was no ophthalmoplegia to
suggest a Wernicke's encephalopathy however patient did seem to
confabulate at times suggesting possible Korsakoff's syndrome.
He was noted to have bilateral dysmetria likely associated with
chronic alcohol use. Neuro impression at that time was that
deficits were most c/w a delirium related to a toxic metabolic
infectious etiology, but could not exclude seizure activity or
post-ictal confusion.
.
CT was obtained in the ED on [**10-11**] which showed no bleed nor
edema, but neuro felt that, given his vascular risk factors, it
would be reasonable to evaluate for interval change after 3 days
with a noncontrast head CT.
.
Because of severe agitation, he required 4 point leather
restraints he received 6mg ativan and 15mg of Haldol in ED and
was transferred to the MICU.
Past Medical History:
-Coronary artery disease status post coronary artery bypass
graft [**12/2091**], status post failed percutaneous transluminal
coronary angioplasty in [**2098-6-2**] secondary to tortuous
vessels-->1. Native two vessel coronary artery disease. 2.
Unsuccessful attempt at intervention on mid-RCA stenosis.
-Status post pacer placement for bradycardia [**2097-7-3**]
-Status post atrial flutter ablation in [**2097-6-2**]
-Hypertension.
-Hyperlipidemia.
-Anemia.
-Dyspepsia.
-Syncope.
-Cirrhosis with a positive Hepatitis C virus.
-Type II diabetes mellitus.
-80% vertebral artery stenosis.
-Severe restless legs.
-Depression and bipolar disorder.
-Hypothyroidism.
Social History:
Lives [**Location 3957**] in a senior housing project. Long h/o EtOH
dependence but sober for "many years" after AA, although
endorses occasional beer, last drink he reports a few months
ago. Has experienced one withdrawal seizure in past. Heavy use
of amphetamines in [**2055**]. H/o abusing morphone, dissolved it and
injected it. Off narcotics after several detoxs. Quit tob in
[**2085**].
Family History:
[**Name (NI) **] father died at age 69 from a myocardial infarction and
patient's mother died at age 86 and did have cardiac
arrhythmias.
Physical Exam:
T-95.4 BP-97/40 HR-62 RR- O2Sat 95%RA
Gen: Elderly gentleman in NAD, requesting sleeping pill. Alert
and oriented to person, place and date [**2103-10-4**] although
thinks it's the 5th.
HEENT: EOMI, no nystagmus appreciated, moist oral mucosa, PERRL
Neck: supple, no carotid or vertebral bruit.
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs although distant
heart sounds
Lung: fine bibasilar rales L>R
aBd: Obese, +BS soft, non tender not distended, no rebound,
unable to appreciated ascites nor HSM but difficult given
habitus
Ext: trace edema, no asterixis
Neuro: Not displaying confabulation currently. CN II-XII intact.
MS [**4-7**]. Toes downgoing. + dyetria b/l w/ finger to nose and heel
to shin
Pertinent Results:
ADMISSION LABS:
================
14.4
3.7 >-------< 100
41.6
MCV 90 Neuts 63.8 Lymphs 24.9 Monos 7.4 Eos 3.5 Baso 0.2
PT 13.4 PTT 27.3 INR 1.2
Lactate 1.7
138 102 21
----|----|-----< 224
5.0 23 1.4
.
Ca 9.9 Phosphate 4.6 Mg 1.7
ALT 44 AST 75 Alk Phos 71 Amylase 35 Total bili 1.0 Lipase
18 Alb 4.5
Serum Tox: negative
UA: 500 protein, 100 glucose
.
STUDIES:
========
CHEST (PA & LAT) [**2103-10-11**]
IMPRESSION: No acute cardiopulmonary disease.
.
CT HEAD W/O CONTRAST [**2103-10-11**]
IMPRESSION:
1. No evidence of intracranial hemorrhage or edema.
2. Sinus mucosal disease with near complete interval
opacification of the left side of the sphenoid sinus.
Of note, MRI with diffusion-weighted imaging is most sensitive
for acute ischemia.
.
EKG [**2103-10-11**]
Sinus rhythm. The P-R interval is prolonged. There are Q waves
in the
inferior leads consistent with prior myocardial infarction.
Diffuse
non-specific ST-T wave changes. Compared to the prior tracing
ST-T wave
changes are more diffuse and atrial bigeminy is no longer
present.
.
CHEST PORT. LINE PLACEMENT [**2103-10-12**]
Portable AP chest radiograph compared to [**2103-10-11**]. The
right subclavian line was inserted with its tip projecting at
the level of low SVC. There is no pneumothorax, apical hematoma
or other complications. The heart size is mildly enlarged but
unchanged as well as there is no change in the stable appearance
of the mediastinum. The overall lung volumes have decreased
compared to the previous study with subsequent increased _____
of the pulmonary vasculature with no pulmonary edema
demonstrated. The pacemaker leads terminate in right atrium and
right ventricle, unchanged. There is no pleural effusion or
pneumothorax.
.
CSF [**2103-10-15**]
NEGATIVE FOR MALIGNANT CELLS.
.
CT HEAD W/O CONTRAST [**2103-10-14**]
IMPRESSION: No acute intracranial process. No interval changes
since [**2103-10-11**].
.
EEG [**2103-10-14**]
IMPRESSION: This is an abnormal routine EEG due to the slow and
disorganized background with bursts of generalized slowing
suggestive of
an encephalopathic process. Infection, metabolic disturbances,
and
medications are among the most frequent causes of
encephalopathy. No
clear epileptiform features or electrographic seizures were seen
during
the recording.
.
EKG [**2103-10-16**]
Atrial fibrillation and ventricular paced rhythm. Intermittent
intrinsic
A-V conduction. Compared to the prior tracing of [**2103-10-14**] no
diagnostic
interim change.
TRACING #1
.
VIDEO OROPHARYNGEAL SWALLOW [**2103-10-17**]
IMPRESSION:
1. Moderate oral and pharyngeal dysphagia, with mild delay in
swallow initiation and reduced laryngeal valve closure.
2. Silent aspiration with ineffective cued coughs
.
EKG [**2103-10-17**]
Atrial fibrillation and ventricular paced rhythm and more
frequent intrinsic A-V conduction. Compared to the prior tracing
of [**2103-10-16**] no diagnostic interim change.
TRACING #2
.
EEG [**2103-10-24**]
IMPRESSION: Abnormal EEG due to the slow and disorganized
background.
This indicates a widespread encephalopathy. Medications,
metabolic
disturbances, and infection are among the most common causes.
There
were no areas of persistent focal slowing, and there were no
epileptiform features.
.
CT HEAD W/O CONTRAST [**2103-10-26**]
IMPRESSION: No significant change since [**2103-10-14**] with no acute
intracranial abnormalities.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2103-10-26**]
IMPRESSION: No ascites.
.
EKG [**2103-10-26**]
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to tracing of [**2103-10-18**] all the beats are ventricular
paced.
.
Brief Hospital Course:
Mr. [**Known lastname 2861**] is a 70 y/o male with CAD, DM, HTN, Hep C cirrhosis,
p/w mental status change is setting of possible substance abuse
at home, hospital course c/b prolonged delirium.
.
# Delirium: The patient presented after initially found at home
in a state of confusion by his VNA. Neurology was consulted upon
presentation to the ED and their exam at that time was notable
for severe inattention and word finding difficulty with phonemic
paraphrasias but exam was otherwise nonfocal and there were no
signs of aphasia. He was noted to have bilateral dysmetria
likely associated with chronic alcohol use. Neuro impression at
that time was that deficits were most c/w a delirium related to
a toxic metabolic infectious etiology. CT was obtained in the ED
on [**10-11**] which showed no bleed nor edema. Pt received Ativan and
Haldol in ED and transferred to the MICU. In the MICU, he was
continued on CIWA protocol w/ standing valium out of concern for
possible postictal state as well as etoh withdrawal. Haldol was
discontinued [**1-5**] to prolonging QTc (reportedly 470s at longest).
Urine and serum tox were +only for benzos, which he had been
receiving. Infectious workup included CXR which did not reveal
infiltrate, UA which showed rare bacteria, but no pyuria, and
blood cultures which have shown NGTD. B12 and Folate wnl.
Additionally, an LP was performed which had no RBCs nor WBCs,
normal glucose, but did show elevated protein; gram stain of CSF
showed no PMNs. RPR and VDRL were sent and were unrevealing. He
was subsequently called out to the floor for further evaluation
and management of his delirium.
.
On the floor ([**10-14**]) a repeat Contrast CT was done which showed
no change from the previous on [**10-11**], an EEG done showed no
evidence of seizure activity. Since that time, his neurologic
status slowly began to improve. Once patient able to communicate
better, he admitted to taking valium at home. Psychiatry also
consulted and felt that the patients delirium was likely
secondary to his valium overdose and that this would take time
for the medication to clear his system. Patient was started on
standing Haldol for agitation and had a 1:1 sitter for some time
while on the floor. On [**10-22**] he was persistantly agitated and we
noted some resting hand tremor and rigidity as well as a concern
for a wide based gait. This was felt to be secondary to the
Haldol. His medications were changed to Zyprexa. Given the
delirium did not appear to be improving and was still waxing and
[**Doctor Last Name 2364**]; neurology was re-consulted. Neurology felt there was
some concern for Wernicke's Encephalopathy that would take a
long period of time to clear. He was started on IV Thiamine x 5
daysof which he completed 4 before being changed to po thiamine,
which was continued thoughout. Also in the differential for the
patient's presentation were stroke and ? silent MI. However,
repeat head CT was unchanged, and numerous cardiac workups were
unrevealing. Given his history of Hep C, the diagnosis of
hepatic encephalopathy was considered as an etiology for his
delirium. He was placed on standing TID lactulose. Hepatology
was consulted who felt that this clinical picture was unlikely
due to hepatic encephalopathy, but they recommended continuing
lactulose and starting rifaxamin. An abdominal U/S was negative
for ascites or a cirrhotic liver. After being on lactulose and
rifaximin for some time, these meds did not appear to be
affecting his mental status, and they were discontinued. In
terms of less likely diagnoses, an HIV test to rule out HIV
encephalopathy was negative, and a urine porphobilinogen to rule
out acute intermittent porphyria was also negative. Psychiatry
suggested the possibility of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16448**] Body dementia due to his
mild Parkinsonian features. An acetylcholinesterase inhibitor
was added on the day of d/c. Pre-Aricept mini mental state exam
was 17.
.
[**Known firstname **] has continued to demonstrate marked improvement and
awareness throughout his floor stay. We provided his with
non-prescription glasses, as he does wear these at home.
However, if possible his home prescription should be pursued as
an outpatient. He did complain of insomnia and responded best to
a combination of standing mirtazipine and prn ambien (needed
often). His major concern was anxiety and a desire to go home to
pay rent and take care of his cat. Occupational therapy
recommended rehab for continued cognitive therapy, and
psychiatry confirmed his capacity to decide to go to rehab.
.
# CAD: Patient was initially found to have an elevation of his
troponins which was concerning given known underlying CAD
(unable to intervene on mid RCA lesion in [**2097**]; PMIBI in [**2098**]
showed fixed, no reversible defects). Troponin was elevated on
presentation at 0.12, peaked at 0.20 on [**10-12**] and was trending
down to 0.16 on [**10-13**]. CKs were up, but MB was normal and MB
Index were negative throughout. EKGs were without significant
ST/TW changes from old dated [**2100**]. Patient was markedly
hypertensive on presentation and in the ICU to 240s/120s per
report so it was felt that the troponins may have risen
secondary to subendocardial ischemia in the setting of
hypertension. On the floor he had one episode of CP where an EKG
was again done which showed a slight ST depression. Cardiac
enzymes were negative at that time. The patient's blood pressure
was elevated during this episode and again it was felt that this
EKG change (which resolved 1 hour later on subsequent EKG) as
likely secondary to subendocardial ischemia from hypertension.
His blood pressure medications were uptitrated. His atenolol
was increased to 100mg daily. He was continued on the aspirin.
In addition, patient had several episodes of chest pain on the
floor. It should be mentioned that they were highly inconsistent
and occured during his delirium. Once his MS cleared there were
no complaints of CP. When his prior medical records were
reviewed, it became clear that he has presented innumerably to
the ED with CP, with numerous negative workups. A specific CP
protocol was in effect per his outpatient cardiologist. This was
to administer 0.5" of nitro paste or a nitro patch. This worked
very well on the floor. He also responded to maalox or tums when
it seemed that his CP was not of a cardiac etiology.
.
# Rhythm: Patient has a pacer. His EKG showed paced rhythm with
underlying afib vs flutter. He would occasionally go from normal
sinus rhythm to a.fibb/flutter. Patient is s/p a.flutter
ablation in past. Electrophysiology saw the patient and felt he
was paced appropriately. They recommended follow up in three
months as an outpatient.
.
# HTN: Patient was hypertensive when he was on the floor (out of
MICU). His BP meds were intially held in the ICU but restarted.
He was continued on his verapamil, enalapril and HCTZ. His
atenolol was titrated up as well as his verapamil. His
lisinopril was also increased, and by the time of discharge he
had excellent antihypertensive control with BPs largely in the
120-130s.
.
# Cirrhosis: Patient has a history of +hep C and heavy etoh hx.
Not followed in our system for this so status largely unknown. A
viral load was sent and was 77,000. No h/o GI bleed, no h/o
ascites, no clear h/o hepatic encephalopathy. Has stable, very
mild transaminitis with a normal bilirubin. INR only mildly
elevated to 1.2, albumin normal at 4.2. Patient will need
outpatient follow up with a hepatologist for further management.
Liver was consulted for possible hepatic encephalopathy as part
of his delirium, who felt that this did not appear to be hepatic
encephaloapthy. Ammonia levels were checked and were not
elevated. Lactulose was started, but eventually d/c'ed due to
ineffectiveness.
.
# Pancytopenia: Chronic. Likely represents BM suppressive or
infiltrative process and thrombocytopenia consistent with liver
disease. It was felt that it may be [**1-5**] direct etoh bone marrow
toxicity.
.
# Rash - [**Known firstname **] developed a rash on his upper extremities while
on a number of new medicines. the rash was felt to be a
medication reaction, and began to improve after several meds
were discontinued, including laculose/rifaximin/seroquel. It is
non-prurutic and continues to clear at time of discharge.
.
# Chronic Kidney Disease: No labs in our system since [**2100**], last
creatinine was isolated elevation to 1.3 (all those prior were
normal). Given time lapse since labs and known htn, it is
unclear whether he has chronic renal insufficiency secondary to
hypertension. Patients creatinine increased while on the floor;
felt to be secondary to dehdyration and a FENA<1. Pt received
IVF with improvement in his creatinine. Once [**Known firstname 16449**] mental
status cleared, he was able to hydrate himself and eat
accordingly and his renal function remained normal.
.
# Positive urine culture: UA on admission with rare bacteria but
0 WBC, urine Culture grew Klebsiella pneumoniae. Repeat again w/
neg nitrites, neg leukesterase, NO WBCs, rare bacteria and
0-2squams. Urine culture showed now growth. This was not treated
with any antibiotics. A repeat urine culture was equivocal with
moderate growth of enterococcus and he completed a 10-day course
of ampicllin switched to amoxicillin with a negative
confirmatory culture at the end of his treatment.
.
# DM: Patient had refractory diabetes and required a large
amount of insulin which was titrated upwards during his stay. At
discharge, his requirements were 66 units [**Known firstname 16447**] qHS, 12 units
humulog tid with meals, and a humulog sliding scale for extra
coverage.
.
# Hypothyroidism: TSH slightly elevated to 6.2, but in setting
of acute illness. FT4 wnl. A repeat TSH was within normal
limits. He was continued on home Synthroid.
.
# FEN: Patient had several video speech and swallow studies
because there was a concern for aspiration risk. They suggested
silent aspiration, but that that the patient could tolerate a
honey thickened liquids and pureed solids.1:1 supervision during
meals for feeding. Pills were crushed with purees. No straws.
.
# ? Heparin induced thrombocytopenia: his platelets dropped
quite suddenly during the course of his hospital stay. His
heparin was stopped and a HIT antibody was quivocal. A serotonin
release assay was sent and results were pending at time of
discharge. He received no heparin products but was quite
ambulatory ancd active during his floor stay.
.
# The patient was hypernatremic to 147 on occasion. 1/2 NS was
given with resolution.
.
# [**Known firstname **] was full code throughout
Medications on Admission:
1. ASPIRIN 325MG PO daily
2. ATENOLOL 50 MG daily
3. Catapres-TTS-3 0.3 mg/24hr; 1patch transdermal one time per
week
4. ENALAPRIL 20MG PO bid
5. HYDROCHLOROTHIAZIDE 25 mg daily
6. [**Name (NI) 16447**] unclear amount of units
7. Humalog sliding scale 60-65 units per OMR and [**Last Name (un) 616**] Note
8. LOTRIMIN 1% 1 application [**Hospital1 **] as needed for prn itching
9. MIRTAZAPINE 60 mg Po daily
10. NEURONTIN 600 mg tid-qid PRN:pain (total nte 2400 mg/day)
11. VERAPAMIL 80 MG PO daily
12. DESIPRAMINE 20 PO QHS
13. LEVOTHYROXINE 25 micrograms po daily
14. Tramadol 50mg po q 8hrs
15. Lunesta 25po q day
16. Uroxatral 10mg po daily
17. Actaplus MET 15mg/850 [**Hospital1 **]
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Insulin Glargine 100 unit/mL Solution Sig: Sixty Six (66)
units SC Subcutaneous at bedtime.
14. Humalog 100 unit/mL Solution Sig: Twelve (12) units SC
Subcutaneous with meals.
15. Humalog 100 unit/mL Solution Sig: sliding scale per sliding
scale Subcutaneous four times a day.
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
18. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
19. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
20. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
21. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 10238**] - [**Location (un) 177**]
Discharge Diagnosis:
Delirium secondary to valium overdose
Enterococcal UTI
Pancytopenia
Hepatitis C
Diabetes type II
CAD
HTN
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital because you were found to be
confused and unresponsive by your visiting nurse. You were
initially admitted to the ICU. You received medications to
control the agitation.
.
You also developed confusion while in the hospital and you had
an extensive workup to determine the cause of this. We did not
find any abnormalities on head CT or any evidence of a heart
attack. It was felt that your confusion was likely
multifactorial including an overdose of Valium, dehydration and
a urinary tract infection.
.
You were evaluated by neurology and psychiatry. There was
concern that you might have some changes in your memory related
to long term alcohol use. You were started on Thiamine
supplements. Many of your medications were also stopped at is
was felt that they may have been contributing to your confusion.
.
You should keep all your medical appointments. You should take
all your medications as prescribed.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, abdominal pain, worst headaches of your life, black
stools or any other concerning symptoms.
Followup Instructions:
You have an appointment to see your new PCP:
[**Name Initial (NameIs) **]: [**Name10 (NameIs) 16450**] [**Name11 (NameIs) 16451**], MD Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2103-12-27**]
3:30. She is located on the [**Hospital Ward Name 600**] at the [**Hospital 112**] clinic. When
you come to the appointment please have your insurance card with
you!
.
Please follow up with your psychiatrist.
.
You should follow up with Behavioral neurology after discharge.
An appointment has been set up for you with DR. [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) 571**]
Phone:[**Telephone/Fax (1) 810**] Date/Time:[**2103-12-28**] 9:00. He is located in
[**Hospital Ward Name 8742**] [**Doctor Last Name **], [**Location (un) 457**], [**Apartment Address(1) 16452**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**] MD [**MD Number(1) 425**]
Completed by:[**2103-11-16**]
|
[
"V45.01",
"070.54",
"584.9",
"276.0",
"599.0",
"585.9",
"263.9",
"284.1",
"969.4",
"403.90",
"E853.2",
"041.04",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
44077, 44151
|
30797, 41533
|
23704, 23737
|
44300, 44310
|
27097, 27097
|
45535, 46463
|
26215, 26354
|
42272, 44054
|
44172, 44279
|
41559, 42249
|
44334, 45512
|
26369, 27078
|
23644, 23666
|
23765, 25104
|
27113, 30774
|
25126, 25789
|
25805, 26199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,277
| 161,558
|
35323
|
Discharge summary
|
report
|
Admission Date: [**2187-8-21**] Discharge Date: [**2187-11-9**]
Date of Birth: [**2141-8-1**] Sex: M
Service: SURGERY
Allergies:
Azithromycin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
elevated LFTs noted on outpatient follow-up
Major Surgical or Invasive Procedure:
[**2187-8-23**]: ERCP
[**2187-8-27**]: ERCP
History of Present Illness:
46M with fulminant hepatic failure c/b HRS likely secondary
to Hepatitis E, s/p ABO mismatch OLTx with splenectomy [**4-/2187**]
complicated by bleeding requiring exploratory laparotomy and
washout, splenic fluid collection requiring drainage x 2 and
decubitus ulcers. Notably had a recent episode of biopsy-proven
acute rejection one month ago, treated with prednisone taper.
Patient is re-admitted today for concern of continually elevated
LFTs for the past few weeks. He underwent ERCP four days ago
([**2187-8-17**]) which showed mismatch in the caliber of the native and
transplanted bile ducts; a stent was placed across the
anastomosis. Also noted on ERCP were multiple areas of
stricturing and dilation of the intrahepatic biliary system with
small bile leaks "concerning for cholangitis".
Since that time the patient reports he has not been feeling
well,
with poor appetite, low PO intake, subjective fevers/chills, and
fatigue. He reports a temperature at home of 100.2 today, and
he
states that he has felt quite thirsty and has been drinking a
lot
of water. His blood sugars have been poorly controlled in the
high 200s recently.
He denies abdominal pain, nausea/vomiting, changes in his normal
bowel or bladder habits, or other symptoms on ROS.
Past Medical History:
Liver transplant [**2187-4-26**] secondary to Hepatitis E
mild liver rejection [**2187-7-11**] treated with steroids
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use
Social History:
Divorced, 3 children. Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
H/o alcohol abuse. Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice. Remote
history of vicodin and percocet abuse. Remote history of
marijuana and cocaine use. Remote history of using supplements
from GNC. No IVDU, risky sexual behavior or tattoos. No sick
contacts. [**Name (NI) **] foreign travel.
Family History:
No liver disease.
Physical Exam:
VS 98.6 98 149/101 20 100RA
Gen: NAD
HEENT: sclerae anicteric
CV: RRR
Chest: CTAB
Abd: S/NT/ND, well-healed liver txp scar
Ext: WWP, no C/C/E
Skin: trace jaundice
Pertinent Results:
[**2187-8-21**] 08:20PM BLOOD WBC-15.2* RBC-3.34* Hgb-10.4* Hct-33.2*
MCV-99* MCH-31.2 MCHC-31.5 RDW-15.4 Plt Ct-344
[**2187-8-21**] 08:20PM BLOOD PT-10.5 PTT-21.6* INR(PT)-0.9
[**2187-8-21**] 08:20PM BLOOD Glucose-124* UreaN-40* Creat-2.3* Na-137
K-3.9 Cl-103 HCO3-20* AnGap-18
[**2187-8-21**] 08:20PM BLOOD ALT-77* AST-196* LD(LDH)-275*
AlkPhos-953* TotBili-5.6*
[**2187-8-21**] 08:20PM BLOOD Albumin-4.2 Calcium-10.7* Phos-2.8 Mg-1.6
[**2187-8-22**] 05:25AM BLOOD tacroFK-10.5
Brief Hospital Course:
On [**2187-8-21**] he presented with rising LFTs and general malaise. He
was admitted to Transplant Surgery Service and was given IV
hydration for rising creatinine. CT scan demonstrated no
evidence for hepatic abscess and interval resolution of
subhepatic fluid collection. Blood cultures on [**8-22**] were
positive for pansensitive E.coli. Vanco and zosyn were started.
This was later changed to IV meropenum, micafungin, flagyl were
started. On [**8-27**], ERCP was performd noting focal areas of
biliary leaks and native and donor CBD mismatch followed by
stenting. Findings were suggestive of ischemia.
On [**8-30**], liver duplex revealed 2 hypoechoic lesions within the
right hepatic lobe concerning for abscesses or bilomas with
interval development of intrahepatic biliary ductal dilatation.
Extrahepatic bile ducts could not be assessed. CT showed
biliomas. Broadspectrum antibiotics were continued (flagyl,
cipro, fluc). WBC count continued to increase as high as 35
without fevers. Panculturing was done. Cultures remained
negative. LFTs especially alk phos continued to rise as high as
1800 and t.bili up to 75. He became very jaundiced and pruritic.
Ursodiol was started. In addition to worsening liver function,
he developed ARF on CRF. This increased his acidosis and
pruritus. Phosphate binders were used to lower the phosphate.
Intermittent IV fluid and bicarb were administered for acidosis
and increasing creatinine. Nephrology followed closely agreeing
with Transplant Surgery that a kidney transplant was necessary.
Given progression of liver and kidney dysfunction, he was
relisted for a liver and kidney transplant.
He remained hospitalized while awaiting re-transplant. During
this time, he continued to have poor appetite and inconsistent
caloric intake necessitating TPN then post pyloric tube feeds.
Anemia was treated with ~ weekly PRBC. Of note, stool was guaiac
positive, but EGD did not reveal active bleed, just portal
hypertensive gastropathy. Colonostopy [**10-22**] was done showing
Grade 2 internal hemorrhoids. Hemolysis w/u was negative. On
[**10-17**], blood cultures were sent via the picc line. These were
During this wait time, he remained on low dose prograf,
prednisone. On [**2187-10-23**], a liver and kidney became available.
Donor was HBV core positive. Donation was accepted and he was
taken to the OR by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Induction immunosuppression was administered (cellcept
and solumedrol)as well as HBIG during the anhepatic phase.
Please refer to operative notes for complete details. Two 19
[**Doctor Last Name 406**] drains were placed in the abdomen -one behind the right
lobe of the liver and one behind the porta hepatis. A 3rd drain
was place near the kidney which made urine.
Postop, he was transferred to the SICU for management. Urine
output increased and creatinine trended down. LFTs initially
increased then trended down. Sedation was weaned off and he was
extubated. Initially, he was very agitated due to pruritus. This
was treated with vistaril, benadryl, and ursodiol. Agitation
resolved. Diet was advanced. He was transferred out of the SICU
on postop day 3. Hepatitis B immune globulin (5000units per
dose)was administered for 5 days postop as well as on postop day
7 and 14. This will continue per protocol at home. HBSAb titers
remained >450 and HBSAg was negative. Daily Lamivudine was
started per protocol for HBV prophylaxis.
On [**10-27**], he was hypotensive when oob. Hct dropped to 18. He was
transferred back to the SICU where an EGD revealed a few
serpigenous shallow non-bleeding ulcers were found in the
duodenal bulb. One visible vessel was noted in the duodenal
bulb. The vessel was clipped x1 and injected with 4 ml of
epinephrine at the base. CMV viral load was negative. IV
protonix drip was given. The drip was subsequently changed to
[**Hospital1 **] protonix. Feeding tube was not replaced. Once stable, he
returned to the med-[**Doctor First Name **] unit where he continued to make
progress with his diet, activity and understanding of
medications.
The lateral JP was removed. The medial JP appeared bilious. On
[**11-3**], ERCP was done showing the common bile duct, common hepatic
duct, right and left hepatic ducts, and biliary radicles were
filled with contrast and well visualized. The course and caliber
of the structures were normal with no evidence of extravasation.
No stricture was seen at the native and donor duct anastomosis.
Intra-procedure discussion with Dr. [**First Name (STitle) **] occured. Given
findings- decison made not to place biliary stent. LFTs
improved postop ercp. Ursodiol continued. Recommendations
included repeat ERCP in 8 weeks with f/u HIDA post ERCP.
The medial JP appeared bilious and averaged 130-200cc/day. The
renal JP output continued to average 150-200cc of clear yellow
fluid. The renal JP fluid was sent for creatinine that was 1.1.
PT worked with him extensively noting progress with strength,
balance and endurance. He was declared safe for discharge home
with a cane. Nutrition followed noting kcal intake of 2000kcals.
He was able to take in supplements tid.
On [**11-9**], he was feeling well with LFTs trending down (ast 12,
alt 14, alk phos 183 and tbili 1.9. Creatinine was 1.2.
Immunosuppression consisted of cellcept 1gram [**Hospital1 **], steroids were
tapered to 20mg qd and prograf 2mg [**Hospital1 **] as trough levels
stabilized at 9.2.
He was discharged to home with VNA services. He demonstrated
good understanding of his meds. He was taught how to empty and
record JP outputs. VNA was to administered scheduled HBIG doses.
Of note, he should have f/u of his TSH which was low (0.085 and
0.6) with T4 4.4/4.7 and T3 68/73.
He was discharged home on broad spectrum antibiotics (flagyl,
Linezolid and cipro)which were to continue until follow-up. Of
note, cipro interacts with fluconazole causing prolonged QT
interval. QT interval was acceptable. Weekly outpatient ekg/QT
interval f/u should occur as long as he is on cipro and
fluconazole.
ekg [**11-14**] to check qt interval
Medications on Admission:
- Prograf 2.5mg PO BID
- Cellcept 500mg PO QID
- Prednisone 20mg PO qAM
- Valcyte 450mg PO qAM
- Fluconazole 400mg PO qAM
- Protonix 40mg PO BID
- Colace 100mg PO BID
- Ursodiol 300mg PO TID
- Ferrous Sulfate 325mg PO BID
- Caltrate / Vit D 600/400mg PO BID
- Metoprolol 50mg PO TID
- Dapsone 100mg PO daily
- Ambien 5mg PO qHS prn sleep
- ISS
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
follow transplant clinic taper.
Disp:*120 Tablet(s)* Refills:*2*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
10. 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*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*63 Tablet(s)* Refills:*0*
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
Disp:*2 bottles* Refills:*2*
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*42 Tablet(s)* Refills:*0*
16. Hepatitis B Immun Glob-Maltose >312 unit/mL (5 mL) Solution
Sig: Five (5) ML Intramuscular ONCE (Once) for 2 doses: give IM
on [**11-13**] and [**11-20**].
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
biliary ischemia s/p liver transplant
ARF on CRF
malnutrition
VRE, rectal swab
UTI
DM
Duodenal ulcer
GI bleed
anemia
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
jaundice, abdominal distension, increased drain output, incision
redness/bleeding/drainage, decreased urine output, weight gain
of 3 pounds in a day, leg edema or blood sugars persistently
>200 or too low
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-15**]
8:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-22**]
8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-11-29**]
10:00
Completed by:[**2187-11-9**]
|
[
"790.7",
"996.82",
"698.9",
"584.9",
"263.9",
"599.0",
"276.2",
"568.0",
"041.4",
"537.89",
"585.6",
"250.00",
"285.9",
"532.30",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"51.87",
"51.10",
"99.15",
"54.59",
"50.59",
"96.6",
"44.43",
"55.69",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11675, 11738
|
3092, 9340
|
315, 360
|
11899, 11906
|
2588, 3069
|
12301, 12755
|
2365, 2384
|
9748, 11652
|
11759, 11878
|
9366, 9725
|
11930, 12278
|
2399, 2569
|
231, 277
|
388, 1656
|
1678, 1850
|
1866, 2349
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,838
| 124,601
|
27495
|
Discharge summary
|
report
|
Admission Date: [**2121-3-12**] Discharge Date: [**2121-3-21**]
Date of Birth: [**2042-3-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
ERCP, percutaneous drain placement by IR
History of Present Illness:
78 yo F with h/o DM, HTN, and cholecystectomy presented to
[**Hospital3 3583**] on [**2121-3-10**] with hypotension (SBP 80's) initially
improved with IVF's, RUQ pain, anorexia, loose stools, and
jaundice x3 days. CT abd at [**Hospital3 3583**] revealed a
gallstone occluding CBD. They were unable to perform ERCP at
OSH given h/o gastric bypass. She was started on Ancef. She
was noted to have ARF thought to be secondary to prerenal
azotemia given decreased po intake.
.
She was to be transferred to [**Hospital1 18**] on [**2121-3-12**] for ERCP, however,
she became hypotensive to the 50's on the evening of [**2121-3-11**].
She was started on Neo 10 mg and Vasopressin 0.4 units through
PIV's and transferred to the ICU at [**Hospital3 3583**]. She spiked
a temp to 102.5. She was given a dose of Zosyn. Her finger
stick was found to 58; she was given 1 amp of D50. A left
femoral central line was placed by the surgical service under
sterile conditions. A right fem line was attempted. She
received ~ 3 liters of Normal Saline.
.
She was transferred emergently by [**Location (un) **] to [**Hospital1 18**] for ERCP
and further management of presumed sepsis secondary to
cholangitis. She was intubated for airway protection prior to
the flight. CXR reported as ETT in good position, lung fields
clear. ABG prior to intubation: 7.35/35/55.
.
Currently she is intubated and sedated. Her son is present to
answer questions. He reports a gradual decline in her function
and a 20 lb wt loss over the last month. She has had increasing
confusion, intermittent RUQ pain and bowel/bladder incontinence.
Of note, she presented to an OSH in [**2120-8-8**] with RUQ pain; at
that time she was noted to have elevated LFT's; U/S revealed
fattly liver. Her LFT's subsequently resolved.
Past Medical History:
- NIDDM
- HTN
- hypercholestreolemia
- s/p cholecystectomy [**59**] yrs ago
- OA
- osteoporosis
- s/p gastric bypass for obesity ~30 yrs ago by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- B12 deficiency anemia
- s/p total hysterectomy
- h/o abnormal LFT's with abd U/S sig for fatty liver in [**Month (only) **]
[**2119**]; LFT's subsequently improved
Social History:
Lives alone, however, son dispenses meds and does shopping, home
health aide to assist with bathing and laundry 2x/wk, and meals
on wheels daily. Has life line. Son, [**Name (NI) 3065**], involved in her
care (h[**Telephone/Fax (1) 67267**], c[**Telephone/Fax (1) 67268**], w[**Telephone/Fax (1) 67269**]). Pt does not
leave her house often. She has a h/o poor hygiene and leaving
food out around the house. Denies Tob, EtOH, or Illicit drug
use. Widowed since [**2103**]. Husband was a urologist.
Family History:
Mother died at age 86 of colon cancer. Father died in his 70's
secondary to complications from DM. She has 2 healthy children.
Physical Exam:
On Admission:
Tm 102.5 Tc 97.8 BP 105/51 HR 58 RR 16 Sat 97%
I/O (from [**Hospital1 46**]) 3585/1490
Vent: AC Vt 650/RR set 10, breathing at 16/PEEP 5/50% FiO2
Neo and Vasopressin turned off upon arrival; started Levophed
0.075 mcg/min
Gen: intubated, sedated
HENNT: icteric, pupils ~2 mm minimally reactive to light
CV: RRR, nl S1S2, No M/R/G
Lungs: CTAB
Abd: soft, NT/ND, +BS, No HSM
Ext: warm, no edema, strong DP/PT pulses bilaterally
Skin: no rash, jaundiced, mulitple excoriations over upper and
lower extremeties
Pertinent Results:
[**2121-3-12**] 04:10AM BLOOD WBC-43.8* RBC-3.87* Hgb-11.3* Hct-33.9*
MCV-88 MCH-29.3 MCHC-33.5 RDW-14.5 Plt Ct-208
[**2121-3-21**] 06:10AM BLOOD WBC-14.3* RBC-3.75* Hgb-10.8* Hct-33.3*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.5 Plt Ct-293
[**2121-3-12**] 04:10AM BLOOD Neuts-97.2* Lymphs-1.4* Monos-1.3* Eos-0
Baso-0.1
[**2121-3-20**] 05:50AM BLOOD Neuts-78.9* Lymphs-11.4* Monos-3.5
Eos-6.0* Baso-0.2
[**2121-3-12**] 04:10AM BLOOD PT-16.1* PTT-32.2 INR(PT)-1.5*
[**2121-3-12**] 04:10AM BLOOD Plt Ct-208
[**2121-3-21**] 06:10AM BLOOD Plt Ct-293
[**2121-3-19**] 10:50AM BLOOD PT-11.7 PTT-24.7 INR(PT)-1.0
[**2121-3-12**] 04:10AM BLOOD Fibrino-626* D-Dimer-6412*
[**2121-3-12**] 05:20AM BLOOD FDP-10-40
[**2121-3-12**] 04:10AM BLOOD Glucose-246* UreaN-44* Creat-2.2* Na-130*
K-3.3 Cl-101 HCO3-17* AnGap-15
[**2121-3-21**] 09:30AM BLOOD Glucose-325* UreaN-18 Creat-0.8 Na-135
K-4.4 Cl-106 HCO3-18* AnGap-15
[**2121-3-12**] 01:31PM BLOOD CK(CPK)-396*
[**2121-3-13**] 04:00AM BLOOD ALT-47* AST-87* AlkPhos-417* Amylase-93
TotBili-2.8*
[**2121-3-14**] 05:20AM BLOOD ALT-35 AST-54* LD(LDH)-179 AlkPhos-399*
Amylase-110* TotBili-2.7*
[**2121-3-15**] 08:10AM BLOOD ALT-28 AST-34 LD(LDH)-188 AlkPhos-439*
Amylase-103* TotBili-3.4*
[**2121-3-16**] 07:45AM BLOOD ALT-26 AST-31 AlkPhos-477* Amylase-117*
TotBili-2.7*
[**2121-3-17**] 05:55AM BLOOD ALT-30 AST-32 AlkPhos-526* Amylase-134*
TotBili-2.4*
[**2121-3-18**] 05:40AM BLOOD ALT-50* AST-45* AlkPhos-586* Amylase-128*
TotBili-2.2*
[**2121-3-19**] 10:50AM BLOOD ALT-76* AST-60* AlkPhos-498* Amylase-82
TotBili-2.3*
[**2121-3-20**] 05:50AM BLOOD ALT-59* AST-37 AlkPhos-386* Amylase-77
TotBili-1.6*
[**2121-3-21**] 06:10AM BLOOD ALT-51* AST-34 AlkPhos-440* TotBili-1.5
[**2121-3-21**] 09:30AM BLOOD Amylase-75
[**2121-3-12**] 04:10AM BLOOD Lipase-490*
[**2121-3-21**] 09:30AM BLOOD Lipase-101*
[**2121-3-12**] 04:10AM BLOOD CK-MB-4 cTropnT-<0.01
[**2121-3-12**] 01:31PM BLOOD CK-MB-4 cTropnT-<0.01
[**2121-3-20**] 05:50AM BLOOD Lipase-72*
[**2121-3-19**] 10:50AM BLOOD Lipase-85*
[**2121-3-12**] 04:10AM BLOOD Albumin-2.6* Calcium-7.2* Phos-3.7 Mg-2.0
[**2121-3-21**] 09:30AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.6
[**2121-3-12**] 04:10AM BLOOD Hapto-234*
[**2121-3-12**] 01:31PM BLOOD Hapto-246*
[**2121-3-12**] 01:31PM BLOOD Cortsol-88.5*
[**2121-3-12**] 02:06PM BLOOD Cortsol-99.8*
[**2121-3-12**] 02:48PM BLOOD Cortsol-112.8*
[**2121-3-12**] 06:29AM BLOOD Type-[**Last Name (un) **] Temp-36.6 Rates-[**3-17**] Tidal V-650
PEEP-5 FiO2-50 pO2-42* pCO2-36 pH-7.31* calHCO3-19* Base XS--7
-ASSIST/CON Intubat-INTUBATED
[**2121-3-13**] 12:37PM BLOOD Glucose-49* Lactate-0.9 Na-143 K-3.2*
Cl-113* calHCO3-20*
[**2121-3-13**] 12:37PM BLOOD freeCa-1.17
==================
STUDIES:
[**2121-3-12**] ERCP
ERCP: A single spot fluoroscopic image was obtained without a
radiologist present demonstrating surgical clips and suture
material in the left upper quadrant. A nasogastric tube is noted
within the stomach. There is contrast within the transverse
colon from prior study. By report, cannulation of the bile duct
was not possible
.
PTC [**2121-3-12**]
IMPRESSION: Percutaneous transhepatic cholangiography
demonstrates dilated intra- and extra-hepatic bile ducts with
findings of a large calculus in the distal common bile duct.
A 10-French internal-external biliary drainage catheter was
placed via the right-sided bile ducts and has been left to
straight bag drainage.
Further definitive management of the biliary obstruction will be
performed once the cholangitis has settled with biliary drainage
and antibiotic treatment.
.
CXR [**2121-3-12**]
FINDINGS: Compared with the study at 3:33 a.m. the same day, the
ETT has been withdrawn slightly and now projects approximately 2
cm above the carina.
The lungs appear somewhat clearer than previously, probably due
to the lack of respiratory motion artifact on the current study.
.
CXR [**2121-3-12**]
IMPRESSION:
1) Tip of an endotracheal tube located 1 cm above the level of
the carina. The tube should be retracted approximately 3 cm for
optimal positioning.
2) Tortuous appearance of the thoracic aorta which could be
better evaluated with a PA and lateral chest radiograph.
.
CXR [**2121-3-14**]
IMPRESSION: Slight worsening of left lower lobe consolidation.
No pneumothorax.
.
MRA [**2121-3-15**]
IMPRESSION: No evidence of high-grade stenosis or occlusion in
the arteries of anterior or posterior circulation
.
CT head [**2121-3-15**]
IMPRESSION: Chronic watershed infarction in the right frontal
lobe. No significant associated mass effect. No evidence of
acute intracranial hemorrhage.
.
BILIARY STONE REMOVAL [**2121-3-18**]
IMPRESSION:
1. Pullback cholangiogram demonstrated obstruction at the distal
common bile which could be a long area of fibrous stricture or
the possibility of a small tumor of the pancreatic head.
2. Balloon dilatation of the obstructed common bile duct with 8
mm cutting balloon and 10 mm regular balloons.
3. 10-French external-internal biliary drainage catheter was
placed with the pigtail locked in the small bowel loop. The
catheter was connected with an external drainage bag.
.
CT ABDOMEN [**2121-3-19**]
IMPRESSION:
1. No evidence of a pancreatic mass.
2. Status post percutaneous biliary drainage with a catheter
extending into the duodenum. No intrahepatic biliary ductal
dilatation.
3. Obliteration of the portal vein in segments II and an
adjacent portion of segment IV with increased arterial perfusion
of the affected segments.
4. Borderline enlarged periportal lymph nodes, which may be
reactive.
5. Left adrenal gland fullness.
6. Small bilateral pleural effusions with bibasilar atelectasis.
.
ULTRASOUND RUQ WITH DOPPLER [**2121-3-20**]
IMPRESSION: No demonstrable flow in left portal vein consistent
with thrombus.
.
Brief Hospital Course:
Ms [**Known lastname **] is a 78 yo F with DM, HTN, s/p cholecystectomy who
was transferred by [**Location (un) **] from [**Hospital3 3583**]
intubated/sedated for ERCP and further management of sepsis
secondary to cholangitis. She was treated with Levophed for
hypotension, and fluid resuscitated. She was also continued on
Zosyn, with the plan to complete a full course of antibiotics
for cholangitis. The following morning she had an attempted ERCP
which could not be completed secondary to her prior bariatric
surgery. Therefore she underwent a PTC, with successful
placement of an internal/external drain. A large stone was
thought to be seen in the CBD which was later determined to be a
stricture. The pt quickly stabilized, was weaned off pressors,
and extubated without complication over the next 2 days. After
extubated and removal of sedation she was quite confused, and
was noted to have some asymmetry at her mouth. It was unclear if
this was new. An MRI was ordered, and it showed chronic right
frontal watershed infarct and moderate changes of small vessel
disease and brain atrophy. There was no evidence of mass effect
or midline shift and no evidence of acute or chronic hemorrhage.
The pt's mental status gradually came back to baseline and her
facial asymmetry resolved. Prior to her discharge from the ICU,
peripheral lines were placed, and the central femoral line
placed under sterile conditions at the outside hospital was
removed. During her time in the ICU her cultures from [**Hospital1 3325**] also grew pan-sensitive E Coli. She was continued on
Zosyn and her bile cultures grew gram negative rods,
enterococcus and viridans streptococci. She was maintained on IV
Zosyn and was transitioned to oral Levofloxacin to complete a 10
day course (to end [**2121-3-31**]). The pt's blood cultures were
negative. The pt underwent an interventional radiology guided
dilatation of CBD stenosis also had a percutaneous drain placed
in the common bile duct (as mentioned above). The drain will
stay in place for 4-6 weeks at which point pt will be
reevaluated by a cholangoigram (scheduled already) to determine
timing for removal of drainage by interventional radiology. The
pt was noted to have portal vein thrombosis for which she will
need work-up by her primary care physician.
.
Sepsis:
The pt was noted to have leukocytosis and fever (on admission)
secondary to acute cholangitis. She was treated with IV Zosyn
and transitioned to PO Levofloxacin to complete a 10 day course
(to end [**2121-3-31**]). Her blood cultures (2 sets) were negative. The
pt remained afebrile and her percutaneous drain (mentioned
above) in the bile duct continued to drain about 1.5 liters
daily. The bile drain was plugged prior to the pt's discharge
and will need to stay plugged until the pt's appointment with
interventional radiology on [**2121-4-23**]; at that time pt will be
reevaluated to see if restenosis has occurred. In the event of
restenosis, the pt will need another stricture dilatation. The
interventional radiology team (Dr. [**First Name8 (NamePattern2) 6339**] [**Last Name (NamePattern1) 19420**] or Dr. [**First Name (STitle) **]
[**Name (STitle) **]) at [**Hospital3 **] should be notified if the pt has
recurrence of abdominal pain, worsening levels of liver enzymes
(especially total bilirubin), rising white cell count or fever.
The IR team can be reached at phone# [**Telephone/Fax (1) 53981**].
.
GI:
The pt was noted to have acute cholangitis in the setting of CBD
stenosis. The GI team was unable to perform a successful ERCP
due to a previous gastric bypass procedure. The pt underwent a
10-French internal-external biliary drainage catheter placement
for drainage for dilated bile ducts. She underwent a CT abdomen
that showed no pancreatic mass or tumor.
.
Left portal vein thrombus:
The pt underwent a CT abdomen which showed portal vein
obliteration in segment II and an adjacent portion of segment
IV, with associated increased arterial perfusion of these
segments. A duplex ultrasound confirmed left portal vein
thrombosis. These findings were discussed with the pt's PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], and it was decided that he will initiate an out-patient
workup for the thrombosis.
.
Neuro:
The pt was noted (in ICU) to have facial asymmetry. However, the
chronicity of this asymmetry was unknown. The pt's head MRI was
significant for no acute strokes, however it did indicate a
chronic right frontal watershed infarct, moderate changes of
small vessel disease and brain atrophy and no evidence of
high-grade stenosis or occlusion in the arteries of anterior or
posterior circulation.
.
CV:
The pt has a history of hypertension and hypercholesterolemia
but no known CAD. Her ECG on admission showed no acute evidence
of ischemia and her cardiac enzymes ruled out an acute MI. Pt
was maintained on Captopril during the hospitalization and was
transitioned back to her home regimen of Lisinopril on
discharge.
.
Anemia:
The pt was noted to have a hematocrit drop from 40 to 33 with
IVF hydration in the ICU. Her baseline hematocrit is unknown.
The pt was noted to have no evidence of bleeding and her
hematocrit remained stable in the low 30s. The pt will likely
benefit from an out-patient workup of her anemia and will likely
need to be scheduled for a colonoscopy by her PCP.
.
Renal:
(Baseline unknown). The pt was noted to have acute renal failure
on admission (Cr 2.2) which resolved with hydration and
treatment of acute cholangitis. The pt sustained minor Foley
trauma when she accidentally pulled out her Foley (with bulb
inflated) while trying to get back into bed from chair. The
Foley was replaced and continued to drain normally. The foley
should eventually removed prior to discharge from rehab.
.
Endocrine:
The pt has a history of diabetes for which she was maintained on
a regular insulin sliding scale.
.
FEN:
The pt was maintained on a low fat diet and her electrolytes
were repleted as needed.
.
Prophylaxis: The pt was maintained on prophylaxis with SC
heparin and proton pump inhibitor.
.
Code: Full
.
Communication: Son, [**Name (NI) 3065**] [**Name (NI) **], is power of attorney
(h[**Telephone/Fax (1) 67267**], c[**Telephone/Fax (1) 67268**], w[**Telephone/Fax (1) 67269**])
Medications on Admission:
Home Meds (confirmed with son):
- [**Name (NI) **] 20 daily
- Lisinopril 40 daily
- Glyburide 40 daily
- Fosamax 70 weekly
- HCTZ 25 daily
- B12 1000 mcg daily
- Ca supplements
- Centrum Silver
- Tylenol prn
- ASA prn
.
Transfer Meds:
- Ancef x3 doses (start date [**2121-3-10**])
- Zosyn x1 dose [**2121-3-11**]
- ativan prn for sedation
- Neosynephrine gtt
- Vasopressin gtt
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: NOT to exceed 3 grams daily.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
6. Glyburide 5 mg Tablet Sig: Eight (8) Tablet PO once a day:
home dose: 40mg daily of Glyburide.
7. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Outpatient [**Name (NI) **] Work
Pt to have INR checked every 2 days and Coumadin uptitrated
until therapeutic INR (2 to 3) reached.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 doses: Start date: [**2121-3-21**]
End date: [**2121-3-31**].
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<100.
11. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. CALCIUM 600 + D 600-125 mg-unit Tablet Sig: One (1) Tablet
PO TID with meals: Do NOT give at the same time as
Levofloxacin!.
13. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
14. [**Month/Day/Year **] 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**]
Discharge Diagnosis:
Primary:
Acute cholangitis with placement of (temporary) percutaneous
drain
Left portal vein thrombosis
.
Secondary:
- NIDDM
- HTN
- hypercholestreolemia
- s/p cholecystectomy [**59**] yrs ago
- OA
- osteoporosis
- s/p gastric bypass for obesity ~30 yrs ago by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- B12 deficiency anemia
- s/p total hysterectomy
- h/o abnormal LFT's with abd U/S sig for fatty liver in [**Month (only) **]
[**2119**]; LFT's subsequently improved
Discharge Condition:
Stable
Discharge Instructions:
Please report to the nearest emergency department if you have
fever, worsening abdominal pain, nausea, vomiting, diarrhea,
lightheadedness, loss of consciousness and increased itching.
.
There has been a change in your medications.
.
Your will need to follow-up with the appointments arranged for
your. Your tube draining the bile will need to stay in place for
4-6 weeks at which point you will need to be re-evaluated to see
if the tube can come out.
.
You were noted to have a clot in one of your liver veins. Your
PCP will do further workup of this clotting.
.
You were noted to have anemia for which you will need to ask
your PCP to schedule you for a colonoscopy as an out-patient.
.
You have been started on a 10 day course of Levofloxacin (to end
[**2121-3-31**]) for your bile infection. If you have fever, chills or
abdominal pain you should call #[**Telephone/Fax (1) 53981**] and ask to speak
with any of the interventional radiologists.
Followup Instructions:
***REHAB WILL NEED TO ARRANGE FOR PATIENT TO BE TRANSPORTED TO
HER APPOINTMENT IN A BLS AMBULANCE ****
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Date/Time: [**2121-4-2**] at 3:00pm
Location: [**Street Address(2) 67270**], [**Location (un) 3320**], [**Numeric Identifier 40624**]. Phone:
[**Telephone/Fax (1) 13266**] Fax: [**Telephone/Fax (1) 67271**].
.
You have been scheduled for a CHOLANGIOGRAM. Date/Time: [**2121-4-23**]
at 7:00am. Location: report to Daycare on [**Hospital Ward Name 121**] building [**Location (un) **]. Call the physician's assistant [**Telephone/Fax (1) 6747**] with any
questions.
Phone: [**Telephone/Fax (1) 9387**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2121-3-21**]
|
[
"275.2",
"V12.59",
"276.50",
"294.8",
"995.92",
"V45.3",
"867.0",
"452",
"239.0",
"E928.9",
"576.1",
"518.81",
"401.9",
"281.1",
"250.00",
"038.9",
"584.9",
"785.52",
"041.04",
"577.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"51.98",
"87.51",
"99.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
17715, 17822
|
9599, 15874
|
326, 368
|
18363, 18372
|
3832, 9576
|
19372, 20241
|
3134, 3264
|
16301, 17692
|
17843, 18342
|
15900, 16278
|
18396, 19349
|
3279, 3279
|
275, 288
|
396, 2193
|
3293, 3813
|
2215, 2597
|
2613, 3118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,552
| 143,632
|
47004
|
Discharge summary
|
report
|
Admission Date: [**2134-7-18**] Discharge Date: [**2134-7-22**]
Date of Birth: [**2071-6-8**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Compazine / Vistaril
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 63 M with PMH EtOH abuse, multiple admissions for EtOH
withdrawal (most recently discharged [**2134-7-7**]), Chronic HCV,
Hepatitis B, h/o hematemesis, thought likely to be [**Doctor First Name **]-[**Doctor Last Name **]
tear, Hypertension, Depression/anxiety, Panic disorder with
agoraphobia, GERD s/p Enteryx procedure and chronic LBP p/w s/s
alcohol withdrawal. Last drink [**7-18**] at noon. Pt admits to
h/o seizures and hallucinations but not DT's during prior
withdrawals. He reports that he doesn't feel safe at home
because he has been having arguments with his landlord. Denied
any injuries or pain.
Past Medical History:
- EtOH abuse, with multiple admissions for EtOH withdrawal (most
recently [**3-/2134**])
- Chronic HCV, genotype 2, followed by Dr. [**Last Name (STitle) **]; since
[**2126**] has had undetectable viral loads after successful treatment
with interferon and ribavarin
- Past admission for hematemesis, thought likely to be
[**Doctor First Name **]-[**Doctor Last Name **] tear, endoscopy was unremarkable
- Hypertension
- Hepatitis B cAb positive
- prior IVDU with prior methadone maintenance
- depression/anxiety - reports does not tolerate SSRIs
- panic disorder with agoraphobia
- GERD s/p [**5-19**] Enteryx procedure
- chronic LBP, inactive
- tobacco use
- prior patellofemoral syndrome R knee
- s/p medial meniscectomy [**10-19**] R knee
- s/p inguinal hernia repair [**2132-6-3**]
Social History:
Reports that he had quit smoking but then started again several
weeks ago. Now smoking 1ppd. Long hx of EtOH (since age 13 per
[**Month/Day/Year **]). Currently drinking 1 liter of vodka a day, last drink was
Saturday AM. Remote cocaine, heroin, barbituate use ([**2113**]);
denies current illicit drug use.
Family History:
Father died at age 33 from malignant hypertension, mother with
depression but otherwise healthy, currently living in nursing
home. One daughter died of ovarian cancer. Multiple other family
members with ETOH abuse on both sides of family (cousin, sister,
uncle, aunt, father).
Physical Exam:
ADMISSION EXAM:
Vitals: 96, 170/100, 81, 22, 100% on 5L
General: Alert, oriented, no acute distress, slighly tremulous,
not diaphoretic.
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: Supple, JVP not elevated, no LAD.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
GU: No foley.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Skin: Several spider angiomas on chest. No rashes or lesions.
Neuro: A&Ox3, CNs II-XII intact, strength and sensation grossly
intact. Tremulous but no asterixis.
DISCHARGE EXAM:
VS: 98.9, 138/95, 81, 24, 96% RA
GEN: AAOx3, NAD sitting on edge of hospital bed eating breakfast
HEENT: EOMI, MMM
CVS: RRR no m/r/g, S1, S2
PULM: CTAB
Abd: soft, NT, ND, NABS
Ext: 2+ pulses, no edema
Skin: sun-damaged, mottled skin on legs, with facial erythema
(unchanged from previous exams). No rashes or lesions
Psych: calm, friendly. Makes light of situation. "Lady friend"
[**Doctor First Name **] has come to visit him at hospital and this makes patient
feel better. Agrees to contacting AA upon leaving hospital and
following up with outpatient psych
Neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat. Could
not elicit patellar reflexes, brachiorad and biceps 1+
bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2134-7-18**] 07:30PM BLOOD WBC-5.2 RBC-4.87 Hgb-14.5 Hct-42.7 MCV-88
MCH-29.7 MCHC-33.9 RDW-16.2* Plt Ct-178
[**2134-7-18**] 07:30PM BLOOD Neuts-51.5 Lymphs-40.8 Monos-3.0 Eos-3.6
Baso-1.1
[**2134-7-18**] 07:30PM BLOOD Glucose-135* UreaN-7 Creat-0.9 Na-149*
K-3.6 Cl-111* HCO3-25 AnGap-17
[**2134-7-18**] 07:30PM BLOOD cTropnT-<0.01
[**2134-7-19**] 06:30AM BLOOD Calcium-7.3* Phos-2.4* Mg-1.2*
[**2134-7-18**] 07:30PM BLOOD ASA-NEG Ethanol-221* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2134-7-18**] 04:46PM BLOOD Glucose-88
DISCHARGE LABS:
[**2134-7-21**] 06:25AM BLOOD WBC-4.8 RBC-4.62 Hgb-14.2 Hct-41.2 MCV-89
MCH-30.8 MCHC-34.6 RDW-16.0* Plt Ct-135*
[**2134-7-21**] 05:13PM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-139
K-4.3 Cl-104 HCO3-29 AnGap-10
[**2134-7-21**] 05:13PM BLOOD Calcium-9.2 Phos-2.9 Mg-1.6
IMAGES:
[**2134-7-18**] CXR: No acute cardiopulmonary process.
[**2134-7-21**] CXR: Patient is rotated to the right obscuring much of
the right lower lung. The imaged portions of the lungs are clear
and there is no pleural effusion. Heart size is normal. Thoracic
aorta is tortuous, and mildly enlarged. There is no pleural
abnormality.
Brief Hospital Course:
63 year old man with a longstanding history of alcoholism and
multiple recent admissions for alcohol withdrawal who presents
requesting alcohol detox after he was found to be intoxicated.
# EtOH withdrawal - pt came to ED intoxicated (EtOH = 221) and
was admitted to medicine floor. Pt had hallucinations in the ED
but no seizures throughout admission. Pt was treated with IV
diazepam and ondansetron because of his poor po tolerance. His
initial requirement was 20mg IV q2h, but over the next 48 hours
this was tapered to oral diazepam 10mg q2h and finally to oral
diazepam 5mg q3h upon discharge. This course has been similar
to his previous admissions. He received two banana bags on Day
1, but was transitioned to po thiamine and folate on Day 2. He
was discharged with a regimen of thiamine, folate, and
multivitamin with plans to follow up with his PCP (Dr. [**Last Name (STitle) 5717**] in
2 weeks. He was encouraged to abstain from alcohol and attend
AA meetings.
# Social concerns - pt expressed anxiety and sadness over his
social situation during the admission. Pt has been living in
public housing and has been illegally housing a "lady friend"
who had invited over guests who were using illicit drugs. He
stated that police had been called and that he was now going to
be evicted. SW was called during admission and contact was made
with the patient's outpatient psychologist, Dr. [**First Name (STitle) 26079**]. Per his
PCP, [**Name10 (NameIs) 9278**] issues have been ongoing and are being addressed by
outside social workers and should not hold up his discharge.
The patient was encouraged to contact his social worker ([**Name (NI) 76209**]
[**Name (NI) 14323**]) upon discharge to help him sort out his social
situation.
# HTN - patient was continued on his home HTN medication. His
BP was initially elevated but improved with diazepam and
cessation of withdrawal.
Medications on Admission:
- omeprazole 20 mg PO DAILY
- lisinopril-hydrochlorothiazide 10-12.5 mg One Tablet PO DAILY
- thiamine HCl 100 mg PO DAILY
- multivitamin 1 tab PO DAILY
- folic acid 1 mg PO DAILY
- nicotine 14 mg/24 hr Patch 1 patch TD DAILY
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril-hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Alcohol Withdrawal
Secondary Diagnoses:
alcohol abuse
Hepatitis C
Hepatitis B
hypertension
panic disorder
anxiety
GERD
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:
Mr. [**Known lastname 99662**],
You came to the hospital because you were having alcohol
withdrawal. We treated you for withdrawal and then you went
home. You should abstain from alcohol in the future, follow up
with your psychologist and PCP, [**Name10 (NameIs) **] attend AA meetings
regularly.
No changes were made to your medications.
Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**] in one week:
Thursday, [**7-29**] at 12:40pm
Name: [**Last Name (LF) 5717**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Please also attend your local AA chapter meetings for alcohol
support. You may also call [**First Name4 (NamePattern1) 76209**] [**Last Name (NamePattern1) 14323**] for assistance with
your social concerns.
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,093
| 119,224
|
36802
|
Discharge summary
|
report
|
Admission Date: [**2118-9-24**] Discharge Date: [**2118-9-28**]
Date of Birth: [**2043-9-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name13 (STitle) 13469**] is a 68 year old gentleman with DM 2, seizure
disorder, dCHF, HTN, and neuropathy discharged yesterday after
completing an 11 day course of vancomycin for a LLL MRSA
pneumonia admitted for hypotension. The patient reports that
after discharge yesterday, he spent the night at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**]
shelter. This morning, he reports feeling as if he was
"falling," that he "couldn't control his steps," and that his
"body short-circuited." Then then saw an EMS at [**Location (un) 86**] Common,
at which point he was noted to have a SBP 70s and was
transported to [**Hospital1 18**].
In the [**Hospital1 18**] ED, VS 98.4 80/47 64 20 96%RA. He received 500 cc
- 3L IVF without improvement in BP, and so a RIJ CVL was placed
and levophed was started. He was then admitted to the MICU for
further management. Labs were notable for an acetaminophen
level of 14, creatinine of 3.2 from 1.1 yesterday, and a lactate
of 2.4 decreased to 1.6 after 3L IVF.
.
Currently, he states that his shortness of breath is stable. He
also endorses an increased cough since discharge that is
non-productive. Denies CP, f/c/s, n/v/d, abd pain, HA,
palpitations. States that his disequilibirum symptoms have
since resolved.
.
ROS: Also endorses orthostasis and decreased UOP over the past
day. As above, otherwise negative.
Past Medical History:
1. Seizure history - describes as "[**Doctor Last Name 11332**] mal" but was previously
described as "tonic-clonic" with bilateral arm shaking, no LOC.
Was on Trileptal in the past, but was weaned off due to
associated hyponatremia, now on Keppra. Followed by Dr. [**First Name (STitle) 3322**]
[**Name (STitle) **] (EEG negative 2/[**2118**]).
2. Headaches - taken multiple narcotics in the past to
treat this, in addition to advil and tylenol. It was described
in prior notes as starting on the left side of his head and
radiating anteriorly and down his back. He also has had
documented left face pain.
3. Type II DM
4. Peripheral neuropathy
5. Hypertension
6. Hypercholesterolemia
7. Diastolic Dysfunction (EF 60-70% on recent echo with LVH)
8. GERD
9. Depression/Anxiety
10. Lumbar spinal stenosis w/ history C3/C7 fractures
11. Degenerative joint disease
12. Neurogenic bladder
13. s/p left cataract surgery
[**23**]. Vitamin B12 deficiency
15. Atypical CP (last MIBI negative [**4-18**])
16. Hyponatremia (baseline 128-131)
17. h/o multiple falls due to multifactorial gait ataxia, also
followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]
18. 8-mm thecal mass, stable over several years, consistent with
nerve sheath tumor.
19. Likely prior left temporal infarct (per atrophy on head MRI)
Social History:
Lives alone. Retired, previously worked for the telephone
company. EtOH - 2 glasses wine/night (2 bottles a week). Tobacco
- None current (for 20+ pack years). Denies IV, illicit, or
herbal drug use.
Family History:
None contributory
Physical Exam:
VS: 96.9 83 107/43 16 99%3L nc
Gen: Somnalent, no apparent distress
HEENT: Right temporal hematoma with dried blood in left EAC.
Perrl, eomi, sclerae anicteric, MMM, OP clear without lesions
exudate or erythema. neck supple without LAD.
CV: Nl S1+S2, II/VI systolic murmur at RUSB radiating to
carotids.
Pulm: Bibasilar rales (R>L)
Abd: S/NT/ND +bs
Ext: 1+ lower edema. 2+ dp/pt bilaterally.
Neuro: AOx3, CN II-XII intact. Gait not assessed.
Pertinent Results:
[**2118-9-24**] 04:33PM CK(CPK)-632*
[**2118-9-24**] 04:33PM CK-MB-15* MB INDX-2.4 cTropnT-0.01
[**2118-9-24**] 07:58AM LACTATE-1.6 K+-4.8
[**2118-9-24**] 07:45AM GLUCOSE-121* UREA N-8 CREAT-0.6 SODIUM-129*
POTASSIUM-6.7* CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
[**2118-9-24**] 07:45AM ALT(SGPT)-53* AST(SGOT)-119* CK(CPK)-829* ALK
PHOS-56 TOT BILI-0.9
[**2118-9-24**] 07:45AM LIPASE-27
[**2118-9-24**] 07:45AM CK-MB-25* MB INDX-3.0 cTropnT-0.03*
[**2118-9-24**] 07:45AM ALBUMIN-4.1 CALCIUM-8.0* PHOSPHATE-3.0
MAGNESIUM-1.7
[**2118-9-24**] 07:45AM TSH-0.40
[**2118-9-24**] 07:45AM WBC-7.5 RBC-3.22* HGB-12.3 HCT-34.9* MCV-109*
MCH-38.3* MCHC-35.3* RDW-13.2
[**2118-9-24**] 07:45AM PLT COUNT-212
[**2118-9-24**] 05:30AM GLUCOSE-148* UREA N-7 CREAT-0.5 SODIUM-132*
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-21* ANION GAP-18
[**2118-9-24**] 05:30AM ASA-NEG ETHANOL-15* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-9-24**] 05:30AM GLUCOSE-148* UREA N-7 CREAT-0.5 SODIUM-132*
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-21* ANION GAP-18
[**2118-9-24**] 05:30AM URINE HOURS-RANDOM
[**2118-9-24**] 05:30AM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2118-9-25**] 03:22AM BLOOD WBC-4.8 RBC-2.99* Hgb-11.0* Hct-32.6*
MCV-109* MCH-36.9* MCHC-33.8 RDW-12.5 Plt Ct-170
[**2118-9-24**] 07:45AM BLOOD WBC-7.5 RBC-3.22* Hgb-12.3 Hct-34.9*
MCV-109* MCH-38.3* MCHC-35.3* RDW-13.2 Plt Ct-212
[**2118-9-24**] 05:30AM BLOOD Neuts-90.6* Lymphs-5.7* Monos-2.8 Eos-0.4
Baso-0.4
[**2118-9-25**] 03:22AM BLOOD Plt Ct-170
[**2118-9-24**] 05:30AM BLOOD PT-11.7 PTT-24.8 INR(PT)-1.0
[**2118-9-25**] 03:22AM BLOOD Glucose-104 UreaN-6 Creat-0.6 Na-137
K-3.5 Cl-103 HCO3-24 AnGap-14
[**2118-9-25**] 12:10AM BLOOD CK(CPK)-503*
[**2118-9-25**] 12:10AM BLOOD CK-MB-10 MB Indx-2.0 cTropnT-<0.01
[**2118-9-25**] 03:22AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9
[**2118-9-24**] 07:58AM BLOOD Lactate-1.6 K-4.8
Brief Hospital Course:
# Epidural Hematoma - Head CT showed right temporal epidural
hematoma and right parietal subdural hematoma. Per neurosurgery,
no surgical or other intervention was required. Neurosurgery
recommended conservative management. Serial head CT's showed
stable hematoma. Initially, the patient had persistent nausea
and vomiting concerning for elevated ICP; however, this resolved
in the MICU. Once on the floor, the patient remained
neurologically stable. She was discharged on hospital day 5.
She is to follow-up in 4 weeks with neurosurgery for repeat
imaging. Also, per neurosurgery recommendations, she is not to
have any anticoagulation (including aspirin) until they have
evaluated her in 4 weeks.
.
# Fall - Unclear whether this was a syncopal event,
dysequilibirium in setting of benzodiazepine/barbituate/alcohol
use, or mechanical fall. The patient does have a a murmur on
exam that is being followed by a cardiologist at [**Hospital1 **]
consistent with AS, but she denies any history of syncope,
dyspnea, or exertional angina and cardiac enzymes were negative.
The patient also reports having had 2 glasses of wine on the
night of her fall, and she had barbituates on tox screen, likely
from primidone. Given her new O2 requirement and possible
syncopal episode with a CXR finding of LLL effusion, there was
some concern for a PE. However, a CT angiogram showed small
bilateral pleural effusions and LLL opacity but no PE.
Furthermore, echocardiogram and telemetry revealed no potential
causes for syncope. The patient should follow-up with her PCP
for further [**Name9 (PRE) 8019**] of possible causes of fall or syncope.
.
# Hypoxia - Thought most likely related to aspiration event or
pulmonary edema. It was decided to not start the patient on
antibiotics but to continue to monitor her O2 saturation. She
did not have further episodes of oxygen desaturation on the
floor.
.
# Leg Fracture - Foot films showed fracture of the distal right
fibula. The patient was evaluated by orthopedics and was fitted
with an aircast boot on the right leg.
.
# HTN - The patient was continued on her pindolol and
lisinopril.
.
# Alcohol Use - On admission, the patient was started on valium
PRN with a CIWA scale in case of alcohol withdrawal. However,
per MICU report, the patient did not required any of this valium
in the unit. The CIWA protocol was discontinued when the
patient arrived on the medical floor.
.
# Tremors - The patient's primidone was held.
.
# Anxiety - The patient's citalopram was continued.
.
# Gout - The patient indomethacin was held.
Medications on Admission:
Colace 100 mg po bid
Keppra 1000 mg po bid
Metoprolol 12.5 mg po bid
ASA 81 mg daily
Oxybutynin 5 mg po bid
Trazodone 100 mg po qhs
Citalopram 20 mg daily
Isosorbide mononitrate SR 60 mg daily
Cyanocobalamin 100 mc daily
Amlodipine 5 mg daily
Percocet 5-325 mg 1-2 tablets Q4H prn
Gabapentin 1200 mg po bid
Pantoprazole 40 mg daily
NTG SL prn
Simvastatin 80 mg daily
Lisinopril 10 mg daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Pindolol 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia for 1 doses.
Disp:*15 Tablet(s)* Refills:*0*
6. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary:
- right temporal epidural hematoma,
- right parietal subdural hematoma
- right fibular fracture
- Vitamin B12 deficiency
.
Secondary:
- hypertension
- anxiety
Discharge Condition:
Hemodynamically stable, Ambulating well with immobilization boot
on R foot.
Discharge Instructions:
- You came to the hospital after you fell down the stairs. We
think this fall was due to starting primadone, taking ativan,
and drinking alcohol. A CT scan of your head showed you had an
Epidural and a Subdural Hematoma, which are collections of blood
in your skull, around your brain. You were followed in the ICU
by the neurosurgery service and multiple repeat scans showed no
change in the size of these hematomas. You should NOT take
anticoagulation medicines including aspirin, coumadin, warfarin,
heparin, lovenox, or plavix unless you talk with your
neurosurgeon first.
- You also have a hairline fracture of your right ankle and will
need to wear an immobilizing air cast at all times.
- A blood test showed your Vitamin B12 level was very low and
you will need to take supplements. Please discuss this with
your PCP and please try to stop drinking alcohol as this can
lower your B12 levels.
- Again, we feel this fall was due to a combination of
medications and alcohol. Cardiac telemetry monitoring and an
ECHO showed no reason for you to have fainting spells.
Additionally, a CT scan of your chest showed NO clots in your
lungs.
Medication changes:
- Please STOP taking indomethacin, aspirin, and primadone
- Please stop taking ativan
- You may take trazodone for sleep, but DO NOT drink alcohol if
you take this medication.
- You may take Senna and docusate over the counter if you have
constipation
Please call your PCP or return to the ED if you have increasing
headaches, any of the symptoms described below, chest pain,
shortness of breath or any other concerns.
General Instructions for Epidural and Subdural Hematomas
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you are to start on any blood thinning medications such as
Coumadin or Warfarin please call the neurosurgery office to make
sure that an adequate time has passed since your head bleed so
that you are safe to begin this medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 931**]
Specialty: PCP
Date and time: Thursday, [**10-6**] @11:15
Location: [**Street Address(2) 83158**]., [**Location (un) 1110**]
Phone number: [**Telephone/Fax (1) 35022**]
Appointment #2
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Neurosurgery
Phone number: [**Telephone/Fax (1) 3231**]
Special instructions if applicable: Patient was scheduled for a
repeat CT scan for [**2118-10-30**] @ 11:00am at [**Hospital 47**]
[**Hospital 1281**] Hospital. [**Location (un) 3230**] (Dr.[**Initials (NamePattern4) 9399**] [**Last Name (NamePattern4) **] will mail a copy of
the directions to patient's home.) If you need to reschedule the
appointment, please call Central Scheduling [**Telephone/Fax (1) 83159**].
Within a day or two after the CT scan, Dr. [**First Name (STitle) **] will call the
patient to discuss the results and the need for any further
follow up. If patient doesn't hear from Dr. [**First Name (STitle) **] please call his
office 3 days after CT scan for follow up @ [**Telephone/Fax (1) 3231**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
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9505, 9564
|
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|
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|
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|
3094, 3295
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,835
| 141,286
|
50009
|
Discharge summary
|
report
|
Admission Date: [**2193-8-17**] Discharge Date: [**2193-8-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"severe metabolic acidosis with concern for DKA."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F with diabetes, Parkinson's disease, dementia, urinary
retention and overflow incontinence, initially presenting on
[**2193-8-17**] for altered mental status. In the ED, she was noted to
be febrile, with lactate 3.7 and signficant pyuria. She was
admitted to medicine, and was intially treated for UTI with
vancomycin and cefepime. MICU is now consulted for metabolic
acidosis.
.
Upon evaluation by MICU team while on medicine floor, the
patient was lying in bed with a normal blood pressure and heart
rate. She was tachypneic, oriented only to self. ABG 7.38/25/92,
with lactate 4.0 (from 1.8 yesterday). The patient's fingerstick
was >400 this morning. Urine ketones 150. WBC has been rising
since admission. Of note, the patient was admitted for DKA from
[**Date range (1) 104414**]. Review of prior micro data reveals a history of
MRSA but not of ESBL organisms. Blood and urine cultures from
this admission were pending. Per floor team, patient also has
stage II decubitus ulcer. She had been having frequent but small
volume diarrhea.
.
Review of systems is unobtainable due to the patient's mental
status.
Past Medical History:
- Parkinson's disease
- Dementia
- Gastroesophageal reflux disease.
- History of peptic ulcer disease.
- Gastroparesis.
- Irritable bowel syndrome with constipation predominance.
- Lactose intolerance.
- Hemorrhoids.
- HTN
- Hyperlipidemia
- Hypothyroidism
- anemia (on aranesp)
- Diabetes Mellitus
- Right breast cancer in [**2170**].
- Spinal stenosis.
- Depression.
- Osteoporosis
- Urinary retention & overflow incontinence
Social History:
Social History: Lives at [**Location 10140**]. Uses a wheelchair, no
longer walking. Feeds self. Transfers to toilet on own. Prior
approximate 20 pack-year smoking history but not currentl. No
ETOH. Daughter very involved in her care though lives in
[**State 7080**]. Daughter's Cell is [**Telephone/Fax (1) 104415**] and office
number in [**State **] is [**Telephone/Fax (1) 104416**]. Pt is DNR/DNI
.
Family History:
Sister with DM.
Physical Exam:
On Admission to MICU:
Vital signs: T 98.9 BP 141/93 HR 80 RR 36 Sat 99%/2L
General: Sleepy but arousable. Able to state name. Follows
simple commands.
Neck: JVP not elevated.
HEENT: Anicteric sclerae.
Resp: Tachypneic. CTAB.
CV: RRR. No M/G/R.
Abd: +BS. Soft. NT/ND. No R/G.
Ext: Warm and well-perfused. Trace LUE and left pedal edema.
Neuro: Sleepy but arousable. Oriented only to self (can state
first name only). Left pupil dilated.
On Discharge:
Vital signs:
General: Sleepy but arousable. Able to state name, but not aware
of place or time. Follows simple commands.
Neck: JVP not elevated.
HEENT: Anicteric sclerae. Does not follow finger with eye
Resp: Tachypneic. CTAB.
CV: RRR. No M/G/R.
Abd: +BS. Soft. NT/ND. No masses.
Ext: Warm and well-perfused. Trace left pedal edema.
Neuro: Sleepy but arousable. Oriented only to self. Left pupil
dilated. Repeats same words and phrases but can be interrupted.
Pertinent Results:
On Admission:
.
[**2193-8-17**] 07:35PM BLOOD WBC-11.9*# RBC-2.86* Hgb-9.0* Hct-26.2*
MCV-92 MCH-31.6 MCHC-34.6 RDW-15.0 Plt Ct-419
[**2193-8-17**] 07:35PM BLOOD Neuts-84.4* Lymphs-11.9* Monos-3.2
Eos-0.2 Baso-0.3
[**2193-8-18**] 09:00AM BLOOD PT-10.7 PTT-16.9* INR(PT)-0.9
[**2193-8-17**] 07:35PM BLOOD Glucose-376* UreaN-47* Creat-1.6* Na-137
K-4.9 Cl-97 HCO3-25 AnGap-20
[**2193-8-18**] 08:40AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.5*
[**2193-8-17**] 09:13PM BLOOD Lactate-3.7*
.
Lactate Trend:
[**2193-8-17**] 09:13PM BLOOD Lactate-3.7*
[**2193-8-17**] 11:37PM BLOOD Lactate-2.2*
[**2193-8-18**] 03:16AM BLOOD Lactate-4.3*
[**2193-8-18**] 09:31AM BLOOD Lactate-1.8
[**2193-8-19**] 09:48AM BLOOD Lactate-4.0*
[**2193-8-19**] 01:12PM BLOOD Lactate-4.3*
[**2193-8-20**] 11:01AM BLOOD Lactate-1.3
.
Transfer Labs:
[**2193-8-20**] 03:58AM BLOOD WBC-15.2* RBC-3.37*# Hgb-10.3*#
Hct-30.1*# MCV-89 MCH-30.6 MCHC-34.3 RDW-15.2 Plt Ct-317
[**2193-8-19**] 06:35AM BLOOD Neuts-89.0* Lymphs-8.1* Monos-2.6 Eos-0.1
Baso-0.2
[**2193-8-20**] 03:58AM BLOOD Plt Ct-317
[**2193-8-20**] 03:58AM BLOOD Glucose-107* UreaN-21* Creat-0.8 Na-140
K-4.2 Cl-109* HCO3-21* AnGap-14
[**2193-8-20**] 03:58AM BLOOD Calcium-8.3* Phos-3.4# Mg-2.0
[**2193-8-19**] 08:03PM BLOOD Vanco-5.0*
.
On Discharge:
[**2193-8-27**] 08:05AM BLOOD WBC-11.3* RBC-3.24* Hgb-9.8* Hct-29.7*
MCV-92 MCH-30.2 MCHC-32.9 RDW-15.0 Plt Ct-577*
[**2193-8-27**] 08:05AM BLOOD Glucose-301* UreaN-37* Creat-0.9 Na-142
K-4.2 Cl-103 HCO3-27 AnGap-16
.
Culture Data:
Urine [**8-18**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
Blood [**2104-8-17**]: No growth
Blood 8/24: No growth to date
Stool [**8-21**]: NO SALMONELLA OR SHIGELLA FOUND. NO CAMPYLOBACTER
FOUND. NO OVA AND PARASITES SEEN. NO VIBRIO FOUND. NO YERSINIA
FOUND. NO E.COLI 0157:H7 FOUND. FECES POSITIVE FOR C. DIFFICILE
TOXIN BY EIA.
.
Imaging:
-[**8-17**] CT Head: 1. No acute intracranial hemorrhage. No acute
intracranial pathologic process. 2. Marked global atrophy with
severe chronic microvascular ischemia, progressed from 4 years
ago. 3. Moderate fluid in the left sphenoid sinus.
-[**Date range (1) 104417**] CXR: No acute Cardio-Pulm; PICC line and NG tube
properly placed
-[**8-19**] CXR Heterogeneous opacification which developed in the
right
lung since [**8-17**] is still present raising possibility of
right lower lobe pneumonia particularly aspiration. Small right
pleural
effusion is new or newly apparent.
-[**8-21**] LLE US: Limited study with no evidence of DVT in the left
lower
extremity.
-[**8-21**] LUE US: Limited study with no evidence of DVT in the left
upper
extremity.
-[**8-23**] EKG: Multifocal atrial tachycardia. Left axis deviation.
Right bundle-branch block with left anterior fascicular block.
-[**2110-8-25**] KUB: Large uterine calcifications, status post left hip
replacement. Moderate scoliosis of the lumbar spine. Gas in the
rectum and parts of the sigmoid as well as the descending colon
suggestive of some ileus. No evidence of free air. No
pathological air-fluid levels. No pathologic intestinal
distention.
Brief Hospital Course:
This is a [**Age over 90 **] year old female with Parkinson's disease, dementia,
DM, anemia, urinary retention & overflow incontinence who
intially presented with altered mental status found to be in
DKA. Precipitant was initially thought to be UTI given patient's
grossly positive urinalysis. Patient's course was complicated by
pneumonia and C.diff infection.
.
ACTIVE ISSUES BY PROBLEM:
.
#Diabetic ketoacidosis: Precipitant was likely multiple
infections as below. Patient has history of DKA during prior
admission also in the setting of urosepsis. She was fluid
resuscitated, was placed on insulin drip at 4 units/hr, received
D5 NS until resolution of DKA. Lytes were checked Q2hrs and
repleted accordingly. After resucitation she was volume
overloaded and required 10mg IV Lasix which she responded with
brisk UOP. Patient's gap closed and her ketosis and lactic
acidosis improved. Patient was discharged to hospice with NPH
[**Hospital1 **] only.
.
#Urinary Tract Infection: Patient's urinalysis was grossly
positive on admission, though culture data could not be obtained
to confirm this. This was thought to be the likely contributing
precipitant of patient's diabetic ketoacidosis. Patient was
started on vancomycin and cefepime due to her stay in [**Hospital1 1501**]. She
completed 9 days of treatment and had been afebrile for several
days before discharge to hospice.
.
#Hospital-acquired pneumonia: Patient's chest x-ray on [**8-19**]
showed signs of new right-sided pneumonia. DDx included
aspiration PNA versus hospital-acquired. Patient was tachypneic,
mildly febrile and with persistent leukocytosis but otherwise
asymptomatic with no cough or sputum production. Patient's
cefepime was re-dosed to treat for pneumonia and she completed 9
days of treatment. She was also treated with vancomycin for 9
days. She was discharged to hospice with the understanding that
she will continue to aspirate.
.
#Clostridium Difficile infection: Patient was noted to have
loose stools on transfer from the ICU. Stool was positive for C
diff toxin so patient was started on flagyl for a 14 day course
with the last day being [**9-5**]. KUB was obtained on [**8-24**]
showing only some mild ileus but no signs of megacolon. At the
time of discharge, she was having normal stools.
.
#Dysphagia: Patient passed her video swallow one month ago but
was initially unable to pass evaluation here. Likely due to
declining Parkinson's and dementia. Nutrition was maintained
with nasogastric tube feeds while an inpatient. However, after
discussions with the family, it was decided that placement of a
PEG tube would not be consistent with her goals of care. She
was allowed to eat thickened liquids and pureed solids and to
take her meds PO. The family understands that she will likely
continue to aspirate and so they also decided to transfer her to
hospice care to avoid further readmissions. Palliative care
team was consulted and they recommended that her medications be
changed to PO upon discharge to hospice.
.
#Hypertension: Pt's blood pressures reflected isolated systolic
hypertension only, with peaking SBP approximately 170. Since
this is related to age and has a minimal cardiovascular risk for
a patient on hospice care, she was maintained on her metoprolol
25 mg TID but not amlodipine 2.5 mg daily. Her simvastatin was
discontinued.
.
#Tachycardia: Patient's rate was irregular, tachycardic and
suggestive of a wandering atrial pacemaker. Patient had two
brief episodes of atrial fibrillation on hospital day 8 in the
setting of hypoglycemia and possible hypovolemia. She
spontaneously converted back to sinus rhythm and her metoprolol
was increased to TID with some improvement of her heart rate.
.
CHRONIC ISSUES BY PROBLEM:
#Parkinson's disease: Stable, with chronic muscle rigidity.
Patient's carbidopa/levadopa was increased from [**Hospital1 **] to tid
dosing.
.
#Hypothyroidism: Stable. Patient continued on levothyroxine in
the hospital but not on discharge.
.
#GERD: Stable. Patient continued on omeprazole at discharge for
comfort
.
#Glaucoma: Stable. Patient continued on dorzolamide drops to
left eye
.
#Depression: Stable. Patient continued on lexapro
.
#HL: Stable. Discontinued simvastatin due to lack of risk factor
modification benefit
.
#Anemia: Likely of chronic disease. Patient's aranesp injections
were held while inpatient.
.
#DM2: Admitted for DKA. On insulin gtt with Q1H fingersticks
until DKA resolved. Her sugars were difficult to control on the
floor but [**Last Name (un) **] was consulted to assist. She was discharged on
sliding scale, if issues with hyperglycemia may require
[**Name6 (MD) 104418**] with MD.
.
Transitional Issues:
- patient has a foley due to long-standing urinary incontinence
and muscle rigidity from parkinson's, this should be monitored
- patient was discharged to hospice and her medications were
adjusted to promote comfort per the recommendations of the
palliative care team and the wishes of the family
Medications on Admission:
(Per Nursing Home Records)
levothyroxine 50mcg
omeprazole 40mg
MVI
Miralax
Cranberry pills
Vitron C 125mg
carbidopa/levadopa 25/100 [**Hospital1 **]
Calcitriol 0.25 MCG 1 cap daily
Dorzolamide Hcl 2% Eye drops left eye TID
APAP 650 [**Hospital1 **] prn pain
metoprolol 25 mg [**Hospital1 **]
colace
artificial tears
amlodipine 2.5mg QD
Simvastatin 20mg QD
Lexapro 20mg daily
Procrit [**2181**] mg qwk
Insulin NPH
Insulin humalog (complex sliding scale outlined in Nursing home
chart)
Discharge Medications:
1. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day): Left eye.
[**Year (4 digits) **]:*1 bottle* Refills:*5*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
[**Year (4 digits) **]:*90 Tablet(s)* Refills:*5*
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
grams PO once a day as needed for constipation: mix with 4 oz
H2O.
[**Year (4 digits) **]:*30 pkt* Refills:*5*
4. docusate calcium 240 mg Capsule Sig: One (1) Capsule PO once
a day as needed for constipation.
[**Year (4 digits) **]:*30 Capsule(s)* Refills:*5*
5. Artificial Tears Drops Sig: Two (2) drops Ophthalmic
three times a day.
[**Year (4 digits) **]:*1 bottle* Refills:*5*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO TID prn as needed
for edema/ shortness of breath.
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*5*
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Last day is [**2193-9-5**].
[**Month/Day/Year **]:*21 Tablet(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*5*
9. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*5*
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Month/Day/Year **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*5*
11. Lomotil 2.5-0.025 mg Tablet Sig: 1-2 Tablets PO twice a day
as needed for diarrhea.
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*5*
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day: Please hold for SBP < 100 or HR < 50.
[**Month/Day/Year **]:*90 Tablet(s)* Refills:*5*
13. insulin regular human 100 unit/mL Solution Sig: as dir units
Injection twice a day: Check FBS [**Hospital1 **], then:
150-200 = 2 U, 201-250 = 4 U, 251-300 = 6 U, 301-350 = 8 U,
351-400 = 10 U, > 400 = [**Name8 (MD) 138**] MD.
[**Last Name (Titles) **]:*2 vials* Refills:*5*
14. Parcopa 25-100 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO three times a day.
[**Last Name (Titles) **]:*90 Tablet, Rapid Dissolve(s)* Refills:*5*
15. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
One (1) mL PO prn as needed for pain: Written script given.
Discharge Disposition:
Expired
Facility:
[**Hospital 13054**] Hospice
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Delirium secondary to infections below
Healthcare associated pneumonia
C. difficile associated diarrhea
Urinary tract infection
.
SECONDARY DIAGNOSES:
Parkinson's disease
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the hospital because you were disoriented
at the [**Hospital3 **] facility. We found evidence of a urinary
tract infection as well as a pneumonia and an infection in your
intestines. You were treated for all these infections with
antibiotics and your mental status improved.
.
We think that the pneumonia was caused by food and saliva
entering the lungs instead of your stomach when you
swallow--this is called aspiration. Unfortunately, this is a
common result of Parkinson's and dementia and is unlikely to get
better. After discussions with your family, it was decided that
you should be able to continue eating for your own comfort
although you will likely aspirate further.
.
The intestinal infection was called C. diff diarrhea and is
common in people who are hospitalized or who live in [**Hospital 4382**] facilities. To prevent re-infection, it is important to
wash your hands and that your caregivers also wash their hands
every single time.
.
The following changes were made to your medications:
- Please follow the directions of the hospice nurse [**First Name (Titles) **] [**Last Name (Titles) 67695**]s. Your medications which did not promote comfort
were discontinued but you were continued on your parkinson's
medications and antidepressants.
.
It is very important that you keep all of your follow-up
appointments as listed below. It was a pleasure taking care of
you in the hospital!
Followup Instructions:
Can be managed by hospice coordinators
|
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[
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,361
| 142,724
|
14002+56500
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-7-5**] Discharge Date: [**2112-7-12**]
Date of Birth: [**2030-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Decreasing exercise tolerance; exertional angina
Major Surgical or Invasive Procedure:
[**2112-7-5**] Redo sternotomy and aortic valve replacement(27-mm St.
[**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] Epic tissue)
History of Present Illness:
This 82 year old white male underwent coronary bypass in [**2097**]
and subsequent stenting in [**5-10**]. He has a history of aortic
stenosis followed by echocardiograms. He was referred for
surgical evaluation and admitted now for surgery.
Past Medical History:
Aortic stenosis
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
[**2097**]
s/p coronary stenting
Hypertnesion
s/p gastrointestinal bleed
Nephrolithiasis
Dyslipidemia
Psoriasis
Arthritis
s/p Coronary Artery Bypass Graft x 5 [**2097**]
s/p appendectomy
s/p cervical laminectomy
s/p lumbar laminectomy
s/p tonsillectomy
s/p hernia repair
Social History:
Race:Caucasian
Last Dental Exam:dental clearance in office chart
Lives with:wife
Occupation:retired-telephone worker
Tobacco:none
ETOH:none x40yrs
rec Drugs: none
Family History:
sibling died of MI at 58
Physical Exam:
admission:
Pulse: 63 Resp: O2 sat: 99% RA
B/P Right: Left: 158/65
Height: 70" Weight: 180
General:NAD;occ. cough
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x];anicteric sclera
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur:[**3-8**] blowing murmur radiates
to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: None
Varicosities: minimal bilat; right saphenectomy scars groin to
ankle well-healed
Neuro: Grossly intact;nonfocal exam; moves BUE [**3-7**] strengths;
BLE
[**4-6**] strengths
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 : murmur transmits bilat. carotids
Pertinent Results:
[**2112-7-6**] Echo: PREBYPASS: There is mild symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF=70%). Right ventricular chamber size and free wall
motion are normal.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Moderate to severe (3+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-5**]+) mitral regurgitation is seen. There is mild tricuspid
regurgitation. There is no pericardial effusion. POSTBYPASS: The
patient is on infusions of phenylephrine and epinephrine and is
A-paced at a rate of 80 bpm. Left ventricular systolic function
is borderline hyperdynamic. There are no regional wall motion
abnormalities. The bioprosthetic aortic valve is well-seated,
with a trace amount of central aortic insufficiency. The
post-replacement aortic valve peak gradient is 19 mmHg. Mitral
regurgitation has improved to mild (1+). Aortic contours are
normal.
[**2112-7-8**] 03:57AM BLOOD WBC-7.5 RBC-3.20* Hgb-9.9* Hct-28.5*
MCV-89 MCH-30.9 MCHC-34.7 RDW-15.0 Plt Ct-69*
[**2112-7-5**] 02:00PM BLOOD WBC-8.3# RBC-2.35*# Hgb-7.3*# Hct-21.8*#
MCV-93 MCH-30.9 MCHC-33.3 RDW-13.9 Plt Ct-137*
[**2112-7-10**] 05:41AM BLOOD Glucose-105* UreaN-23* Creat-0.8 Na-133
K-3.8 Cl-97 HCO3-27 AnGap-13
[**2112-7-8**] 02:31PM BLOOD Na-133 K-4.2 Cl-97
[**2112-7-5**] 03:34PM BLOOD UreaN-14 Creat-0.8 Na-142 K-4.1 Cl-112*
HCO3-23 AnGap-11
INR [**2112-7-12**] 2.0 (2 mg couamdin)
INR [**2112-7-11**] 1.8 ( 1mg coumadin)
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit after undergoing
preoperative work-up as an outpatient. On [**7-5**] he was brought
directly to the Operating Room where he underwent a
redo-sternotomy and aortic valve replacement. Please see
operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. CTs
and pacing wirtes were removed per protocols. Beta blockers and
diuretics were instituted postoperatively for rate control and
diuresis. Coumadin was resumed due to the presence of bare
metal stents placed previously.
Physical Therapy worked with him for mobility and strength. He
made good progress but was not conditioned enough to return
directly home, so rehabilitation screening was done and he was
discharged to [**Hospital **] Health Center for rehabilitation.
Discharge medications and restrictions were as outlined in the
summary elsewhere. Wound were clean and healing well. The INR
goal was 2-2.5 for afib and bare metal stents. Of note, he has
had a history of GIB from ASA- please giuaic stools.
Medications on Admission:
Azithromycin (Z-pack -completes [**6-23**])
Tessalon Perles
MVI daily
Vit. C 500 mg daily
Vitamin E 400 units daily
nexium 40 mg [**Hospital1 **]
dovonex 0.005% one appl. daily
taclonex 0.064%-0.005% one appl. daily
HCTZ 25 mg daily
welchol 1250 mg [**Hospital1 **]
niaspan ER 500 mg QHS
ASA 81 mg daily
ramipril 10 mg daily
toprol XL 25 mg daily
Clobetasol 0.05% one applic daily
Metronidaze ? dose
Desonide 0.05% one appl.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
5. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two tablets twice daily for two weeks, then one
twice daily for two weeks, then one daily.
Disp:*100 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for psoriasis.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Ramipril 10 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
13. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR goal 2-2.5.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Center
Discharge Diagnosis:
Aortic stenosis
s/p Redo sternotomy and aortic valve replacement
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 5
s/p coronary stents
Hypertnesion
h/o gastrointestinal bleed
Nephrolithiasis
Dyslipidemia
Psoriasis
Arthritis
s/p appendectomy
s/p cervical laminectomy
s/p lumbar laminectomy
s/p tonsillectomy
s/p hernia repair
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral medications.
Incisions:
Sternal - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2112-8-11**] at
1:00PM
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 40756**]in [**12-5**] weeks
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2912**] in [**12-5**] weeks
The first INR to be drawn on [**2112-7-13**]. Goal INR is 2-2.5 for bare
metal stents and afib.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2112-7-12**] Name: [**Known lastname **],[**Known firstname **] J Unit No: [**Numeric Identifier 7564**]
Admission Date: [**2112-7-5**] Discharge Date: [**2112-7-12**]
Date of Birth: [**2030-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Mr. [**Known lastname 7565**] Welchol and Niaspan were resumed for
hyperlipidemia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 7566**] Health Center
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2112-7-12**]
|
[
"427.31",
"790.92",
"272.4",
"401.9",
"V45.82",
"414.00",
"287.5",
"424.1",
"V45.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"99.04",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9807, 9990
|
3918, 5105
|
368, 527
|
7658, 7841
|
2278, 3895
|
8594, 9784
|
1366, 1392
|
5580, 7199
|
7299, 7637
|
5131, 5557
|
7865, 8571
|
1407, 2259
|
280, 330
|
555, 799
|
821, 1170
|
1186, 1350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,013
| 149,256
|
46316+58895
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-1-22**] Discharge Date: [**2124-2-29**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
male with coronary artery disease, peripheral vascular
disease, diastolic congestive heart failure, and diabetes
mellitus who was admitted from a nursing home with change in
mental status times seven days.
A head computed tomography was negative. The working
diagnosis was congestive heart failure. The patient was
initially admitted to the floor; however, the floor team
asked the Medical Intensive Care Unit to evaluate for hypoxia
and/or respiratory distress. On evaluation, the patient was
agonally breathing and unresponsive. Arterial blood gas
revealed a pH of 7.28, PCO2 was 87, PO2 was 70% on 100%
nonrebreather. The code team was called for emergency
intubation. A left subclavian line was placed. Dopamine was
started for hypotension in the 60s/palpation. Dark mucous
plugs were suctioned after endotracheal tube placement. A
chest x-ray revealed new left lung whiteout. An emergent
bronchoscopy was performed and successfully suctioned copious
amounts of mucous plugs from the left airway. A repeat chest
x-ray showed significant re-expansion.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post left anterior
descending artery stent in [**2119**]. Catheterization in [**2123-8-5**] revealing 2-vessel disease.
2. Peripheral vascular disease; status post aortobifemoral
bypass, status post femoral-femoral bypass.
3. Ischemic colitis in [**2123-11-5**].
4. Hypertension.
5. Left renal artery stenosis of 100%.
6. Hyperlipidemia.
7. Congestive heart failure; diastolic function with an
ejection fraction 50% to 55%.
8. Nephrolithiasis.
9. Diabetes mellitus.
10. Atrial fibrillation.
11. Adjustment disorder.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg p.o. q.h.s.
2. Coumadin 2 mg p.o. every Tuesday and Friday.
3. Lasix 20 mg p.o. q.d.
4. Lopressor 12.5 mg p.o. b.i.d.
5. Loperamide as needed.
6. Regular insulin sliding-scale.
7. Aspirin 81 mg p.o. q.d.
8. Protonix 40 mg p.o. q.d.
9. Flagyl 500 mg p.o. t.i.d.
10. Levaquin 500 mg p.o. q.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 99.5, blood pressure
was 101/70, heart rate was 100, oxygen saturation was 100%.
In general, intubated and sedated elderly male, frail and
cachectic. Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light,
edematous. Cardiovascular examination revealed was
irregularly irregular second heart sound and second heart
sound. No murmurs. Pulmonary examination was clear to
auscultation anteriorly. No wheezes. The abdomen was soft
and nondistended. Extremity examination revealed 2+ pitting
edema bilaterally. Neurologic examination revealed intubated
and sedated.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed white blood cell count was 19.3 (with
85 neutrophils, 11 bands, and 3 lymphocytes), hematocrit was
29.4, and platelets were 263. INR was 4.2 and partial
thromboplastin time was 32.5. Chemistry-7 revealed sodium
was 140, potassium was 4.9, chloride was 100, bicarbonate was
33, blood urea nitrogen was 57, creatinine was 1.5, and blood
glucose was 160. ALT was 15, AST was 29, alkaline
phosphatase was 155, and total bilirubin was 0.4. Creatine
kinase was 58. Troponin was 1.1. Urinalysis revealed
positive nitrites, greater than 50 red blood cells, 11 to 20
white blood cells, many bacteria. Calcium was 7.3, magnesium
was 2.1, and phosphate was 7.3.
RADIOLOGY/IMAGING: Electrocardiogram revealed atrial
fibrillation at 91, normal axis, and normal intervals. Q
wave in V3 and V6. 1-mm ST elevations in V1 and V2. ST
depressions in V5 and V6. T wave inversions in II, III, and
aVF.
A chest x-ray #1 initially revealed pulmonary edema with
bilateral effusions. Chest x-ray #2 revealed left lung
whiteout/collapse, left mediastinal shift. Chest x-ray #3
revealed left lung re-expansion, endotracheal tube and
subclavian lines in satisfactory position.
A head computed tomography revealed no acute bleeding.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY SYSTEM: The patient was seen with copious
secretions and episodes of mucous plugs which were
effectively suctioned. Also with bilateral pleural
effusions. A diagnostic tap was performed of transudative
effusion. Flexible bronchoscopies were performed and
secretions were suctioned.
The patient was initially extubated on [**2124-1-26**]. The
patient was reintubated on [**2-1**] for ventilatory failure
with respiratory distress, acidosis, hypercapnia.
On [**1-29**], a thoracentesis was performed and 1400 cc were
removed with 132 glucose, 1.1 protein, LDH 97, albumin 0.4.
Transudative and negative for malignant cells or organisms.
Due to pulmonary effusions with secretions, the patient was
unable to be re-extubated. A tracheostomy tube was placed on
[**2124-2-3**], and the patient tolerated pressure support
which was weaned as tolerated according to oxygen
saturations. On [**2-13**], .................... was placed.
At the time of discharge, the patient required pressure
support of 10 with a positive end-expiratory pressure of 5
during the day, and at night pressure support of 15 with a
positive end-expiratory pressure of 5. He was discharged to
pulmonary rehabilitation to continue to be weaned.
2. GASTROINTESTINAL ISSUES: The patient has a history of
ischemic colitis. Beginning on the first week of admission,
he began to bleed bright red/melanotic stool and was
transfused as needed for maintaining a hematocrit above 30.
Gastroenterology was consulted, and an upper endoscopy was
negative for a source of bleeding. A red blood cell bleeding
scan was done which was negative. Vascular Surgery was
consulted as was General Surgery. Ultimately, his bleeding
slowed down on [**2-1**].
Then on [**2-3**], he had a colonoscopy performed for
diagnostic purposes which revealed ischemic colitis up to the
level of the splenic flexure; however, the colonoscope could
not be further advanced. He continued without bleeding, and
a percutaneous endoscopic gastrostomy tube was placed on
[**2-4**], and tube feeds were initiated on [**2-5**], and
he began with more bright red blood per rectum. He received
a total 23 units of packed red blood cells to maintain a
hematocrit of greater than 30.
Surgery was consulted again initially wanted to take him to
the operating room for a subtotal colectomy. However,
heparin-induced thrombocytopenia antibodies were sent and
returned positive. Hematology was consulted. At this time,
platelets were 87, and Hematology recommended delaying the
surgery until his platelets began to rise. All heparin
products were discontinued at this time.
On [**2-11**], his bleeding ceased, and his platelets rose.
Surgery (Dr. [**Last Name (STitle) **] opted that given that he was no longer
bleeding, they would not take him to the operating room. He
was started again on tube feeds and tolerated then well
without any gross bleeding. His hematocrit remained stable.
He continued with guaiac-positive stools, but no active
copious bleeding. He was also continued on lansoprazole per
percutaneous endoscopic gastrostomy tube b.i.d. The plan was
to continue supportive management unless he begins to bleed
copiously again; at which time, Surgery should be consulted
again to consider performing a subtotal colectomy.
3. INFECTIOUS DISEASE ISSUES: The patient initially had a
urinary tract infection with enterococcus and Citrobacter
which was treated with Zosyn for 7/7 days. Then, for
ischemic colitis he was continued on Zosyn; however, this was
discontinued after a 2-week course.
He was admitted with a large sacral decubitus ulcer. The
Plastic Service was consulted and initially suggested
wet-to-dry dressing changes; however, they were consulted
again on [**2-4**] and debrided it; revealing a stage IV
ulcer.
On [**2-16**], his sputum returned methicillin-resistant
Staphylococcus aureus positive, and precautions were
initiated.
Then, on [**2-20**], he became septic with
methicillin-resistant Staphylococcus aureus in his blood, and
his left subclavian line was discontinued and revealed
methicillin-resistant Staphylococcus aureus at the tip of the
catheter. He was given vancomycin and improved. It was felt
to be secondary to methicillin-resistant Staphylococcus
aureus line sepsis. Surveillance cultures were pending at
this time.
4. CARDIOVASCULAR SYSTEM: (a) Coronary artery disease:
The patient with a history of coronary artery disease who had
chest pain in the setting of his gastrointestinal bleed. He
was ruled out for a myocardial infarction with a slightly
elevated troponin of 0.6. He was not started on heparin
secondary to the bleed.
He was continued on Lopressor 12.5 mg p.o. b.i.d. which was
discontinued secondary to hypotension. He was switched to
Lopressor 5 mg intravenously q.6h. which he tolerated well.
Then on [**2-23**], he was restarted on Lopressor 12.5 mg
p.o. b.i.d. which he tolerated well.
(b) Atrial fibrillation: The patient with rapid atrial
fibrillation despite being on Lopressor. His heart rate
remained elevated in the 120s to 140s range. As his digoxin
was initially discontinued, it was restarted on [**2-22**],
and his heart rate improved minimally. He was not
anticoagulated because of his ischemic colitis and
gastrointestinal bleed.
(c) Congestive heart failure: The patient with diastolic
dyspnea; per echocardiogram. He was continued on a beta
blocker. An ACE inhibitor was not added secondary to acute
renal failure.
5. HEMATOLOGIC ISSUES: The patient with heparin-induced
thrombocytopenia antibody positive. All heparin was held as
of [**2124-2-9**]. His platelets improved to the 140s, and
the patient had no signs of thrombosis. Prophylaxis with
pneumatic boots only. He was transfused as needed for a
hematocrit of less than 30. After his active
gastrointestinal bleed, he was transfused 23 units of packed
red blood cells during the length of his stay.
6. ENDOCRINE SYSTEM: The patient received a regular insulin
sliding-scale as well as insulin in his total parenteral
nutrition for a goal blood sugar between 80 and 120 with good
control.
7. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient failed
a swallow study when he was extubated on [**1-26**]. A
percutaneous endoscopic gastrostomy tube was placed on
[**2-4**]. Tube feeds were initially held due to bleed, and
he was continued on total parenteral nutrition. Then tube
feeds were restarted on [**2-16**] and were advanced as
tolerated, per Nutrition Service recommendations. Total
parenteral nutrition was decreased as tolerated.
8. NEUROLOGIC ISSUES: The patient with a history of
depression. Initially, the family refused medications, but
on [**2-6**] agreed starting treatment. He was started on
Celexa on [**2-6**] at 10 mg p.o. q.h.s. This was held on
[**2-16**] because he began to be lethargic; however, the
etiology of the lethargy turned out to be the line sepsis, so
his Celexa was restarted on [**2-22**].
9. DISPOSITION/PLAN: The patient to be discharged to
pulmonary rehabilitation. The plan was for the patient to
return home once he is successfully weaned to trach mask.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge to rehabilitation.
DISCHARGE DIAGNOSES:
1. Ischemic colitis.
2. Respiratory failure secondary to mucous plugs.
3. Urinary tract infection.
4. Decubitus ulcer; stage IV.
5. Rapid atrial fibrillation.
6. Sepsis; resolved (from methicillin-resistant
Staphylococcus aureus line infection).
7. Heparin-induced thrombocytopenia antibody positive.
8. Diabetes mellitus.
9. Hypoalimentation with albumin of 1.4.
10. Depression.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding-scale.
2. Lansoprazole 30 mg p.o. b.i.d.
3. Albuterol/ipratropium 1 to 2 puffs inhaled q.6h.
4. .................... one-half strength one application
topically t.i.d. to coccyx and ankle.
5. Vancomycin 1 g intravenously q.12h.
6. Metoprolol 12.5 mg p.o. b.i.d.
7. Digoxin 0.125 mg p.o. q.d.
8. Fentanyl 25 mcg intravenously q.12h. as needed;
premedicate with dressing changes.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2124-2-23**] 14:20
T: [**2124-2-23**] 14:30
JOB#: [**Job Number **]
Name: [**Known lastname 8870**], [**Known firstname 448**] Unit No: [**Numeric Identifier 15703**]
Admission Date: [**2124-1-22**] Discharge Date: [**2124-2-29**]
Date of Birth: [**2043-2-14**] Sex: M
Service:
Patient was discharged on [**2124-2-29**] to a rehabilitation
facility.
MEDICATIONS: Previous discharge summary.
DR.[**Last Name (STitle) 72**],[**First Name3 (LF) 73**] 12-761
Dictated By:[**Last Name (NamePattern1) 1464**]
MEDQUIST36
D: [**2124-4-1**] 20:15
T: [**2124-4-3**] 06:35
JOB#: [**Job Number **]
|
[
"707.0",
"578.9",
"599.0",
"584.9",
"428.0",
"557.0",
"518.84",
"287.4",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"34.91",
"99.15",
"45.13",
"96.71",
"45.23",
"96.04",
"96.72",
"43.11",
"96.05",
"86.22",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11536, 11935
|
11961, 13236
|
1832, 4221
|
4255, 11414
|
11429, 11514
|
112, 1210
|
1233, 1805
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,945
| 135,903
|
54312
|
Discharge summary
|
report
|
Admission Date: [**2104-1-3**] Discharge Date: [**2104-1-22**]
Date of Birth: [**2026-4-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pioglitazone
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Shortness of breath, ? lung abscess
Major Surgical or Invasive Procedure:
Flexible bronchoscopy, right thoracotomy,
decortication, open lung biopsy, intercostal muscle flap,
pericardial window and biopsy, mediastinal lymph node
sampling.
History of Present Illness:
his is a 77 year old male with hospital admission starting on
[**2104-1-3**] with an extensive course. Per records patient had a
diagnosis of lung abcess in [**2103-10-29**] without improvement in
course and since that time have undergone biopsy and been
diagnosed with poorly differentiated cancer. He underwent a
pigtail catheter placement into the pleural space, as well as a
pigtail catheter placed into a lung abscess in attempts to allow
this infection to resolve.
Past Medical History:
AVR/ pacemaker
HTN
COPD
CHF
DM2
Osteoarthritis
Afib
Neuropathy
BPH
Dyslipidemia
CAD
NSCLC
Physical Exam:
Deceased
Pertinent Results:
[**2104-1-21**] 01:44AM BLOOD WBC-12.3* RBC-2.90* Hgb-8.4* Hct-25.8*
MCV-89 MCH-29.1 MCHC-32.8 RDW-15.8* Plt Ct-401
[**2104-1-20**] 09:21PM BLOOD WBC-11.2* RBC-2.73* Hgb-8.1* Hct-25.0*
MCV-92 MCH-29.6 MCHC-32.3 RDW-16.2* Plt Ct-415
[**2104-1-4**] 05:35AM BLOOD WBC-10.2 RBC-3.51* Hgb-10.4* Hct-31.8*
MCV-90 MCH-29.5 MCHC-32.6 RDW-16.0* Plt Ct-355
[**2104-1-3**] 10:05PM BLOOD WBC-8.5 RBC-3.62* Hgb-10.5* Hct-32.6*
MCV-90 MCH-28.9 MCHC-32.1 RDW-15.9* Plt Ct-349
[**2104-1-21**] 01:44AM BLOOD Plt Ct-401
[**2104-1-10**] 10:35AM BLOOD PT-15.2* PTT-33.1 INR(PT)-1.4*
[**2104-1-21**] 01:44AM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-142
K-3.7 Cl-101 HCO3-34* AnGap-11RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2104-1-4**] 12:49 AM
CT CHEST W/CONTRAST
Reason: h/o lung abscess
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with
REASON FOR THIS EXAMINATION:
h/o lung abscess
CONTRAINDICATIONS for IV CONTRAST: None.
ADDENDUM: Proximal to the fluid-filled cavity of the right
middle lobe the middle lobe bronchus approximately 1 cm from its
origin, with intrinsic and some extrinsic component. The
collection splays the right upper lobe anterior segment
subsegmental bronchi at its superior margin (not the medial and
lateral segmental bronchi of the right middle lobe as stated in
the body of the report).
INDICATION: History of lung abscess.
COMPARISON: There are no prior CT exams or radiographs for
comparison.
TECHNIQUE: Contiguous axial images through the chest were
obtained following the administration of 80 cc of Optiray
contrast IV. Coronal reformatted images were generated.
CT OF THE CHEST WITH CONTRAST: A 6.7 x 5.8 cm fluid-filled
cavity in the right middle lobe containing small, non-dependent
air bubbles, has a wall less than one cm thick, smooth
internally, and moderately irregular externally. It splays the
medial and lateral segmental bronchi of the right middle lobe,
displaces the right major fissure posteriorly and reaches the
lateral costal pleural surface but shows no sign of extending
into the chest wall.
There is a small right hydropneumothorax, despite a pleural
catheter in place, and at least one small loculation in the
medial mid right chest at the level of the carina. A small
rounded area of atelectasis or consolidation in the posterior
right lower lobe (2A:50) is 20 mm wide. There is a small simple
left effusion, with associated atelectasis. The central airways
are patent to the subsegmental level, except for retained
secretions in the mid trachea.
There is no pericardial effusion. Moderate cardiomegaly involves
all [**Doctor Last Name 1754**]. An RV pacemaker and aortic valve prosthesis are
present. The mitral annulus is heavily calcified. Coronary
arteries are also heavily calcified. The ascending aorta is
midly dilated, 4.9 cm in diameter. The pulmonary arteries are
enlarged, with the right pulmonary artery measuring 31 mm,
suggesting pulmonary hypertension. A right PICC terminates in
the SVC. Multiple borderline paratracheal nodes measuring up to
10 mm are seen.
Several notable findings are seen in the soft tissues, including
a right thyroid nodule measuring 3.3 x 2.8 cm. There is a 4.3 x
4.2 cm rounded lesion of the posterior right upper back
subcutaneous tissue is not fully characterized but may be a
sebaceous cyst. There is asymmetric enlargement of the left
breast tissue, of undetermined significance.
The exam was not tailored for subdiaphragmatic diagnosis.
Central biliary prominence is seen. A calcified granuloma is in
the right lobe of the liver posteriorly. Enlarged celiac nodes
measure up to 13 mm.
There are no bone findings concerning for malignancy. There are
degenerative changes of the thoracic spine.
IMPRESSION:
1. Right middle lobe lung abscess, less likely cavitating
neoplasm. abutting the lateral costal pleural margin, accessible
to percutaneous aspiration.
2. Small, partially loculated right hydropneumothorax, pleural
catheter in place.
3. Mediastinal and celiac axis lymphadenopathy.
4. 3cm right thyroid nodule. Further evaluation with thyroid
ultrasound recommended.
5. 4.3-cm subcutaneous lesion, right upper back, possible cyst,
but best evaluated clinically.
6. Cardiomegaly, mitral annulus and coronary artery
calcifications, enlarged ascending aorta, aortic valve
replacement, and probably pulmonary hypertension.
The right middle lobe abscess or neoplasm was discussed with Dr.
[**Last Name (STitle) 41455**] on the afternoon of [**2104-1-4**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2104-1-9**] 1:53 PM
RADIOLOGY Final Report
THORACOSTOMY TUBE INSERTION [**2104-1-9**] 10:59 AM
THORACOSTOMY TUBE INSERTION; CT GUIDANCE DRAINAGE
Reason: place pigtail catheter in right pleural abcess.
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with right pleural fluid collection
REASON FOR THIS EXAMINATION:
place pigtail catheter in right pleural abcess.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Right hemithoracic fluid collection requiring
drainage.
COMPARISONS: Chest CT dated [**2104-1-4**].
PROCEDURE: After explaining potential risks, benefits and
alternatives of the procedure to the [**Hospital 228**] healthcare proxy,
verbal consent was obtained. All questions were answered.
Patient identity was confirmed using three identifiers. A
qualified nurse was present to administer 1 mg of Versed and 50
mcg of fentanyl over 30 minutes, with continuous monitoring.
Limited images of the chest were obtained with the patient in
the left posterior oblique position for localization purposes
only. Images confirm the presence of a heterogeneous collection
with a thick rind in the right middle lobe along the major
fissure, with at least one air locule. A small loculated right
hydropneumothorax is again noted, perhaps slightly increased in
size, with a posterior pigtail catheter in stable position.
Pacemaker leads, sternotomy wires, extensive coronary artery and
mitral annular calcifications are seen in addition to an aortic
valve prosthesis. The heart remains enlarged. Left lower lobe
atelectasis appears mild.
The right lower axilla was marked, prepared and draped in the
usual sterile fashion and 1% lidocaine was used for local
anesthesia. Using CT guidance and trocar technique, a 10 French
catheter was inserted directly into the collection and
approximately 35 cc of purulent hemorrhagic fluid was aspirated,
a portion of which was sent to microbiology. The pigtail was
then formed and the catheter was secured to the skin. Adequate
hemostasis was achieved and there were no immediate
complications. Dr. [**First Name (STitle) **] [**Name (STitle) **] was an essential participant
in the procedure. Limited post-procedure images revealed slight
interval decrease in the collection size.
IMPRESSION:
1. Patient status post CT-guided 10 French catheter placement
into a right middle lobe fluid collection without immediate
complication.
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] for failure to resolve lung
infection. He underwent CT guided drainage of lung abscess.
However, he failed to resolve infection and continued to have
significant leukocytosis and fevers. He was taken to the
operating room on [**1-15**] for more definitive treatment. At the
time of the procedure, frozen section pathology of the lung and
pericardium revealed stage IV squamous disease. This lesion was
not resectable. Chest tubes were placed and the patient was
taken to the recovery room.
Over the next several days, he was extubated and chest tubes
were sequentially removed. On POD4 he developed worsening
shortness of breathing and had an episode of desaturation. He
was transferred to the ICU for closer monitoring.
Given the patient's poor prognosis and his wished to have no
further intervention. The patient was made comfortable and
supportive care was withdrawn. He passed on [**2104-1-22**] with his
family at the bedside.
Discharge Disposition:
Expired
Discharge Diagnosis:
Lung cancer
Discharge Condition:
Deceased
Completed by:[**2104-1-24**]
|
[
"V42.2",
"600.00",
"996.62",
"496",
"427.31",
"250.00",
"518.81",
"E879.8",
"272.8",
"585.9",
"511.8",
"403.90",
"162.4",
"E849.7",
"513.0",
"414.01",
"451.84",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"83.82",
"37.24",
"33.23",
"99.15",
"34.04",
"34.51",
"40.11",
"33.93",
"38.93",
"33.28",
"33.27",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
9365, 9374
|
8360, 9342
|
313, 479
|
9429, 9468
|
1139, 1955
|
6189, 6241
|
9395, 9408
|
1110, 1120
|
238, 275
|
6270, 8337
|
507, 980
|
1002, 1095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,664
| 172,211
|
51175
|
Discharge summary
|
report
|
Admission Date: [**2200-3-1**] Discharge Date: [**2200-3-5**]
Date of Birth: [**2132-5-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
bleeding trach, clogged g tube
Major Surgical or Invasive Procedure:
Video Swallow [**2200-3-3**]: The oral phase was predominantly normal,
with slight prolongation of mastication. In the pharyngeal
phase, all initiation was normal, though there was difficulty
maintaining laryngeal valve and airway closure, incomplete
epiglottic deflection. Additionally, there was a residue noted
within the vallecula and piriform sinuses. Barium tablet,
swallowed with a puree bolus, seen passing freely through the
esophagus and pharynx into the stomach. Aspiration is noted with
nectar thick liquids, without spontaneous cough. Acute cough was
effective in eliminating the aspirate. Aspiration also occurred
with thin liquids.
IMPRESSION:
Trace aspiration as described above.
History of Present Illness:
67 year-old gentleman with a history of HIV (last CD4 273,
VL<50), DM type 2, CAD s/p CABG and RCA stent, PVD, CRI, GERD,
CHF, TIA and history of large cell lymphoma s/p chemotherapy in
[**2189**], who presents 2 days after dischrge after long
hospitalization for prolonged respiratory failure secondary to
pneumonia and aspiration with clogged PEG tube and possible
BRBPR. Per wife, they did not like the facility they were
because of poor nursing ratio and not getting appropriate
attention. Here he denies any symptoms, feels fine without any
abdominal pain, shortness of breath, fevers, chills, except for
some tenderness of RLE area or erythema. Was doing well on trach
collar for last 9hrs until started becoming more hypertensive
and anxious, but off his meds today.
Past Medical History:
1. HIV, diagnosed in [**2185**]. Last CD4 273, VL<50 on [**2200-12-30**].
Patient has history of KS, CMV esophagitis. Source of
transmission unknown.
2. CAD, s/p 2-vessel CABG in [**2194**] and RCA stent in 10/[**2198**].
Patent stents on last cath in 10/[**2198**].
3. Diastolic CHF
4. History of large cell lymphoma (liver and periaortic Lymph
nodes) s/p 6 rounds of chemotherapy in [**2189**]
5. Peripheral vascular disease.
6. DM type 2
7. Hypertension
8. GERD
9. CRI with history of hyperkalemia. Baseline creatinine
variable. Last 0.8 in 11/[**2199**].
10. History of TIA [**4-/2199**] with left hemiplegia that resolved.
11. Status post anterior disc excision and fusion C7-Ti in [**2189**].
12. h/o resp failure requiring intubation [**7-7**] (x7 days) with
"double PNA" and resp failure in [**State 33977**] in [**5-7**]
13. Probable HIV encephalopathy
Social History:
He lives with his wife in [**Name (NI) 1562**]. He is a lifelong non-smoker.
No EtOH consumption and no history of illicit drug use. + flu
shot this year.
Family History:
Sister died of CAD and CVA
Brother has h/o CAD
Mother has h/o CAD
Physical Exam:
PE:
VS: T99.1 P92 BP 176/58 R 20 Sat 93% on PS 5/5/50% FiO2
GEN aao, nad
HEENT PERRL, MMM, +trach in place
CHEST CTAB occasional crackles at bases and wheezes throughout
CV RRR no murmurs
ABD soft NT/ND, +PEG tube in place, +ecchymosis LLQ, guiaic
negative
EXT no edema, 2+DPs bilaterally, +area of ecchymosis of left
anterior tibial bone
*
Pertinent Results:
[**2200-3-1**] 06:00PM GLUCOSE-100 UREA N-42* CREAT-1.4* SODIUM-144
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-24 ANION GAP-16
[**2200-3-1**] 06:00PM WBC-11.8* RBC-3.15* HGB-9.6* HCT-28.7* MCV-91
MCH-30.6 MCHC-33.5 RDW-16.0*
[**2200-3-1**] 06:00PM NEUTS-74.1* LYMPHS-18.5 MONOS-3.1 EOS-3.7
BASOS-0.6
[**2200-3-1**] 06:00PM PLT COUNT-324
[**2200-3-1**] 06:00PM PT-13.6 PTT-28.8 INR(PT)-1.2
[**3-1**] CXR:
FINDINGS:
There is a tracheostomy tube, which appears to be in appropriate
position. The patient is status post median sternotomy and CABG.
The patient is status post anterior cervical fusion.
The cardiac, mediastinal and hilar contours are unchanged when
compared to prior study. There are again noted diffuse bilateral
alveolar and interstitial opacities, consistent with the
clinical diagnosis of ARDS. There is no significant change when
compared to the prior study.
IMPRESSION:
1) Overall stable appearance of the chest with alveolar and
interstitial opacities, consistent with the clinical diagnosis
of ARDS.
2) Right pleural effusion appears to be stable.
[**3-1**] RLE Dopplers
LEFT LOWER EXTREMITY DOPPLER ULTRASOUND: The left common
femoral, greater saphenous, superficial femoral, and popliteal
veins were interrogated and reveal normal compressibility, color
flow, waveforms, and augmentation/respiratory variation. No
intraluminal thrombus is identified.
Brief Hospital Course:
For further history on this patient, please also see attached
discharge summary from recent previous admission.
67 yo M with HIV, CAD s/p CABG and PTCA, CHF, DM type 2, here
after recent hospitalization for resp failure secondary to pna
here with possible BRBPR and clogged PEG tube.
*
1. Respiratory failure: prolonged wean last admission requiring
tracheostomy, also remains NPO as concern for aspiration as well
as source of resp failure. Based on CXR unchanged bilateral
opacities- cont trach with vent support as needed and wean as
tolerated at Rehab.
Patient was continued on pressure support at 5/5 and trach
collar as tolerated. He was on trach collar for the last four
days of this admission without switching to PS.
Patient had completed 10 day courses of Levaquin/zosyn/Vanc last
admission and has been stable from infectious standpoint and no
growth on cultures. No new antibiotics were started on this
admission.
*
2. BRBPR: on exam here consistent with guiaic negative stools,
but +internal hemorrhoids- likely source of bleed. Hct 28 this
admission but has been stable at this- all of last admission.
Iron studies last admission consistent with iron deficiency and
chronic disease and likely HAART. Patient was started on iron
for presumed iron deficiency. Patient was started on epogen for
HIV related bone marrow toxicity as well as renal insufficiency.
*
3. Clogged PEG tube: PEG was not clogged here on exam--
restarted tube feeds with flushes without problems during his
stay.
*
4. Diastolic Dysfunction: Last echo [**2200-2-8**] with LVEF>55%.
Patient was slightly fluid overloaded on exam and hypertensive
but had not received his medications. Continued his regular dose
of lasix/hypertensive meds ofmetoprolol, isordil, hydral,
norvasc and lasix
*
5. Chronic Renal Failure: since last admission now with new
baseline of 1.5 which was stable on this admission. We continued
to hold ace as hx of hyperkalemia in this setting in past.
*
6. Anemia: Likely combined with iron deficiency and chronic
disease. Started on iron and epogen this admission. Patient had
multiple ct scans on last admission to look for a source of the
bleed and all were negative. Did not require blood transfusion.
*
7. CAD: CAD s/p CABG s/p PTCA [**10-6**]. Patient had no anginal
symptoms. He was continued on asa/[**Year (2 digits) 4532**]/statin/betablocker. No
ace b/c of hyperkalmeia.
*
8. DMII- Continue NPH/SSI. [**Month (only) 116**] need adjustment as patient begins
regular diet.
*
9. HIV: Stable on HAART and Bactrim.
*
10. Superficial thrombophlebitis: Pt. got supportive care with
warm compresses. LENIS were negative.
*
10a. Anxiety: Stable on klonopin/ativan.
*
11. FEN: TFs were continued via PEG.
Video Swallow [**3-4**]:
RECOMMENDATIONS:
1.Initiate a po diet consistency of soft solids, thin
liquids. PO meds may be given whole with purees (ie,
applesauce, pudding, yogurt).
2.Maintain aspiration precautions, as follows:
a.Sit upright for meals.
b.Take a sip from the cup or straw.
c.Tuck your chin to your chest and swallow 3 times
d.For each bite and sip, swallow 3 times.
e.Alternate between taking bites & sips.
3.Follow up speech therapy at rehab for dysphagia
management and potential trach weaning.
TFs were stopped and patient ate two meals prior to discharge.
*
12. Ppx: Heparin SC TID, lansoprazole, bowel regimen.
*
13. Code: Full
*
14. [**Name (NI) **] wife
*
15. Access: PIV
Medications on Admission:
MEDS:
Paxil 20mg qd
Bactrim 1SS tab QOD
alanzapine 5mg qhs and [**Hospital1 **] prn
albuterol and ipratropium MDIs
lamivudine 100mg qd
abacavir 300mg [**Hospital1 **]
nevirapine 200mg [**Hospital1 **]
indinavir 1000mg q8hr
acetamenaphen 325-650mg prn
lansoprazole 30mg qd
miconazole powder qid prn
artificial tears prn
amlodopine 10mg qd
lasix 40mg qd
isordil 30mg tid
hydralazine 100mg q8hrs
metoprolol 100mg tid
NPH 20units [**Hospital1 **]/RISS
klonopin 0.5mg [**Hospital1 **]
ativan 1mg q4hrs prn
nitroglycerin paste q4-6hrs prn
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QOD ().
3. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
6. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Abacavir Sulfate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Indinavir Sulfate 200 mg Capsule Sig: Five (5) Capsule PO Q8H
(every 8 hours).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
13. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
14. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
19. Hydralazine HCl 25 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
20. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
21. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
23. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection TID (3 times a day).
24. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
25. Epoetin Alfa 3,000 unit/mL Solution Sig: Two (2) mL
Injection QMOWEFR (Monday -Wednesday-Friday).
26. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
27. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
28. Insulin
20 NPH AM and 20 NPH PM
Regular Insulin Sliding Scale:
150-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Good
Discharge Instructions:
Continue all meds as prescribed.
Followup Instructions:
The PCP at the rehab facility
Completed by:[**2200-3-5**]
|
[
"519.02",
"V45.82",
"428.0",
"455.5",
"428.30",
"536.42",
"042",
"280.8",
"443.9",
"530.81",
"729.81",
"V58.67",
"250.00",
"V45.81",
"285.29",
"V10.79",
"518.83",
"300.00",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11322, 11434
|
4774, 8274
|
343, 1043
|
11498, 11504
|
3365, 4751
|
11585, 11645
|
2921, 2988
|
8858, 11299
|
11455, 11477
|
8300, 8835
|
11528, 11562
|
3003, 3346
|
273, 305
|
1071, 1846
|
1868, 2732
|
2748, 2905
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,232
| 114,017
|
22936
|
Discharge summary
|
report
|
Admission Date: [**2173-4-17**] Discharge Date: [**2173-4-21**]
Date of Birth: [**2136-1-13**] Sex: M
Service: MEDICINE
Allergies:
Toradol
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37M initially presented to [**Hospital 3494**] hosp with abdominal pain,
nausea, vomiting,polyuria and polydypsia x 1 night after an
alcoholic binge. pH was 7.14 AG 23 FSG 300s. Pt recieved 5 units
SC insulin and sent to [**Hospital1 18**].
*
In our [**Name (NI) **] pt got 3L NS and D51/2NS + 40KCl at 200 cc/h. got
dilaudid 1mg ativan 1mg and valium 10mg IV. AG=28. Admitted to
[**Hospital Unit Name 153**] for ketoacidosis.
Past Medical History:
DM II
chronic pancreatitis
EtOH abuse states he drinks 3 pints of liquor a day
h/o afib (sinus currently)
bipolar disorder
Social History:
Longstanding alcoholism. Has been drinking > 1 quart vodka
daily. (-) tobacco, denies other illicit substances. Currently
homeless.
Family History:
(+) diabetes
reports pancreatitis in father, mother, and siblings
Physical Exam:
98.2 110s 138/58 18 95%2L
tremulous, flushed, nad
smells of etoh
rr tachy
ctab
s, nd, epigastric ttp, no rebound, no guarding
no edema
nonfocal
Pertinent Results:
Admission Labs:
--------------
*
CBC- WBC-20.3 RBC-4.62 HGB-13.7 HCT-40.4 MCV-87 PLT 265
*
DIFF- NEUTS-89.0* LYMPHS-5.8* MONOS-5.0 EOS-0 BASOS-0.2
*
CHEMISTRIES: GLUCOSE-328* UREA N-12 CREAT-1.0 SODIUM-139
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-11* ALBUMIN-4.4; Anion
Gap=18
*
ACETONE-SMALL
*
ALT(SGPT)-204* AST(SGOT)-118* ALK PHOS-116 AMYLASE-86 TOT
BILI-0.4 LIPASE 11
*
U/A: BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-[**2-6**]* WBC-0
BACTERIA-NONE YEAST-NONE EPI-0
*
Urine Tox: pending
*
SERUM TOX: ASA-NEG ETHANOL-72* ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
*
EKG: Sinus Tach; No ischemic changes
*
Radiologic Studies:
-------------------
CXR- negative for infiltrate
CT abdomen- negative for pseduocyst, necrosis, stranding of
pancreas. mild inflammatory stranding around duodenum which may
be consistent with duodenitis or ulcer.
EGD:
*
Micro Data:
-----------
[**4-17**] Urine Culture- NGTD
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2173-4-21**]):
NEGATIVE BY EIA.
Brief Hospital Course:
1) Ketoacidosis: Initially presented from OSH with anion gap
metabolic acidosis and abdominal pain. On admission here he was
found to have an AG of 28 with a blood sugar of 328 and was
admitted to the ICU for insulin gtt. His anion gap was felt
secondary to ETOH ketoacidosis. CXR and urinalysis were negative
for infectious source and EKG showed no ischemic changes. He was
placed briefly on insulin drip and had quick resolution of his
gap over the next six hours, with anion gap normalizing to 11.
Of note, his serum acetone was "small" and his serum osms were
within normal limits. His max blood sugars were in the 300's by
fingerstick. He was fluid hydrated with a total of 7 liters NS
and was then transitioned to 1/2 NS for maintenance. He was
placed back on his home regimen of insulin, which was 20 units
glargine and sliding scale insulin. He had no mental status
changes throughout his course and his electrolytes were repleted
as needed. He had no noted ectopy by telemetry monitoring.
2) Chronic Pancreatitis: His initial abdominal pain was of
unclear etiology. It was suspected that there may have been a
component of abdominal pain secondary to his DKA, but that his
primary pain was from his chronic pancreatitis. An abdominal CT
was performed to rule out complicated pancreatitis. This showed
atrophic pancreatitis without pseudocyst, stranding or necrosis.
His pancreatic enzymes were within normal limits. He was given
dilaudid prn for pain and was kept NPO until he was able to
tolerate PO's, then given percocet, and discharged on tylenol
not to exceed 2 grams daily.
3) ETOH abuse: He presented with evidence of mild withdrawl
symptoms including diaphoresis, tremor and tachycardia. He had
no HD instability and no seizure activity or visual
hallucinations. He had no mental status change to suggest DT's.
He was placed on valium CIWA scale and only required 10mg IV
valium overnight. Therefore he was tapered to a PO regimen of
5mg Daily + 5mg every 4 hours for CIWA scale, then the daily
valium was discontinued. He was also given supplemental thiamine
and folate. The social worker attempted to secure resources but
was only able to set hium up with a shelter bed at [**Hospital1 **],
from which he will hopefully gain access to an inpatient
program.
4) Transaminitis: Suspected secondary to ETOH abuse although his
AST/ALT pattern is not in the usual 2:1 pattern. CT abdomen
showed no evidence of liver or gall-bladder disease, therefore
U/S was not felt indicated at this time. Hepatitis serologies
were checked and showed hepatitis C so he should be limited to 2
grams daily of tylenol. He could be considered for hepatology
follow up.
5) Gastritis: There was noted duodenal stranding by abdominal CT
of unclear significance. However, he got a EGD which showed
gastritis but no duodenitis which could be from alcohol use. He
was continued on a PPI. Hematocrit was monitored and was stable
over his hospital course. He should call for the EGD biopsy
results in [**12-6**] weeks as instructed below.
6) Psych: The patient has a history of bipolar disorder. His
lithium level was less than 0.2 when checked after three days of
300 mg po bid. He was continued on lithium that was converted to
his regular dose of 300 mg TID at discharge.
7) Renal cyst - He was incidentally found to have a renal cyst,
and follow up ultrasound is recommended preiodically to make
sure it is not changing in appearance.
Medications on Admission:
glargine 20 QHS
zoloft 150 QD
lithium 300 mg tid
lopressor 50 mg po BID
humulin R SS
Discharge Medications:
1. Sertraline HCl 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
[**Date Range **]:*90 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Date Range **]:*60 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
[**Date Range **]:*30 Cap(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: or as directed by your PCP.
[**Name Initial (NameIs) **]:*1 bottle* Refills:*5*
8. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO
three times a day: please have your psychiatrist follow your
level.
[**Name Initial (NameIs) **]:*90 Capsule(s)* Refills:*2*
9. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: as directed unit
Subcutaneous four times a day: Please use sliding scale as
follows:
161-200 3 units
201-240 6 units
241-280 9 units
281-320 12 units
321-350 15 units
Check blood sugar 2-4 times daily.
[**Name Initial (NameIs) **]:*1 bottle* Refills:*10*
11. One Touch Ultra Test Strip Sig: One (1) strip Miscell.
four times a day.
[**Name Initial (NameIs) **]:*1 box* Refills:*12*
12. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscell. four times a day.
[**Name Initial (NameIs) **]:*1 box* Refills:*10*
13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
not to exceed 6 pills daily.
[**Name Initial (NameIs) **]:*50 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Chronic Alcohol Abuse with alcoholic ketoacidosis
Secondary:
2) Alcohol Withdrawal
3) Chronic Pancreatitis and chronic abdominal pain
4) Diabetes II, insulin-requiring
5) Gastritis - likely chemical, H pylori ab pending
6) Mild anemia
7) Renal Cyst - ultrasound follow-up recommended
8) Hepatitis C with abnormal LFTs
9) Hypertension
10) history of atrial fibrillation
11) Bipolar Disorder
Discharge Condition:
stable, with slight abdominal pain controlled with medications
Discharge Instructions:
Please take all medications as prescribed.
Please go directly to the the [**Last Name (un) 2224**] Shelter.
Please report to your primary care physician or go to the
emergency room with any chest pain, shortness of breath, nausea,
vomiting, tremors, altered mental status, diarrhea, bright red
blood per rectum.
Followup Instructions:
You have a follow up appointment with the following doctor:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-5-5**] 3:00
a) your new diagnosis of hepatitis C infection
b) the renal cyst that requires follow-up ultrasound to further
clarify
c) a referral to psychiatry and social services for ongoing care
of your depression and bipolar disorder
d) follow-up on your H. pylori testing (one reason you may
suffer from abdominal pain)
Please call Dr. [**Last Name (STitle) 7307**] at [**Telephone/Fax (1) 11048**] in 1 week for the
results of your biopsy and H. Pylori test.
|
[
"291.81",
"296.7",
"303.91",
"V60.0",
"577.1",
"276.2",
"250.10",
"535.40",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
7913, 7919
|
2376, 5809
|
271, 277
|
8366, 8430
|
1296, 1296
|
8792, 9497
|
1045, 1113
|
5944, 7890
|
7940, 8345
|
5835, 5921
|
8454, 8769
|
1128, 1277
|
228, 233
|
305, 733
|
1312, 2353
|
755, 879
|
895, 1029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,515
| 100,485
|
7064
|
Discharge summary
|
report
|
Admission Date: [**2171-7-22**] Discharge Date: [**2171-7-26**]
Date of Birth: [**2109-2-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Percocet / Tetanus / Latex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
[**2171-7-22**] s/p Coronary artery bypass graft surgery (left internal
mammary artery > left anterior descending, saphenous vein graft
> obtuse marginal 1, saphenous vein graft > obtuse marginal 2)
History of Present Illness:
62 year old female being scheduled for distal SFA to below knee
popliteal artery bypass to relieve her symptoms with Dr [**Last Name (STitle) 3407**]
and developed episode of chest heaviness approximately 2-1/2
weeks ago. This occurred while sleeping and lasted for a couple
of days and resolved spontaneously.
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:
noncontributory
Physical Exam:
Pulse: 85 Resp: 22 O2 sat: 95 RA
B/P Right: 127/68
Height:5'3" Weight:149 lbs/68 kgs
General:
Skin: Dry [x] intact [x], 3 inch long well-healed incision along
midline of anterior chest wall from skin cancer removal
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally anteriorly[x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2171-7-22**] 07:47AM HGB-14.2 calcHCT-43
[**2171-7-22**] 07:47AM GLUCOSE-204* LACTATE-2.4* NA+-138 K+-4.2
CL--108
[**2171-7-22**] 11:24AM PT-14.0* PTT-33.9 INR(PT)-1.2*
[**2171-7-22**] 11:24AM WBC-5.6 RBC-2.76*# HGB-8.8*# HCT-24.1*#
MCV-87 MCH-31.9 MCHC-36.6* RDW-13.4
[**2171-7-22**] 11:24AM GLUCOSE-175* LACTATE-2.6* NA+-137 K+-4.1
CL--110
[**2171-7-25**] 04:49AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.4* Hct-28.3*
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.6 Plt Ct-183
[**2171-7-25**] 04:49AM BLOOD Glucose-174* UreaN-16 Creat-0.6 Na-135
K-3.7 Cl-101 HCO3-26 AnGap-12
Intra-operative Echo [**2171-7-22**]
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is low normal (LVEF 50%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. Trivial mitral
regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions includingphenylephrine and is in
sinus rhythm.
1. Biventricular function is unchanged.
2. Aortic contours appear intact post decannulation
3. Other findings are unchanged
[**Known lastname **],[**Known firstname **] [**Medical Record Number 26365**] F 62 [**2109-2-28**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2171-7-24**] 7:45
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2171-7-24**] 7:45 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 26366**]
Reason: s/p ct removal ? ptx
Final Report
FINDINGS: In comparison with study of [**7-22**], there has been
removal of all the monitoring and supportive devices except for
the left subclavian catheter.
Specifically, no evidence of pneumothorax. Mild bibasilar
atelectatic changes
persist.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: WED [**2171-7-24**] 11:40 AM
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
and underwent coronary artery bypass graft surgery. See
operative report for further details. In summary she had CABG x3
with LIMA-LAD,SVG-OM1, SVG-OM2. Her bypass time was 73 minutes
with a crossclamp of 58 minutes. She tolerated the operation
well and was transferred to the CVICU in stable condition. She
received vancomycin for perioperative antibiotics. In the
intensive care unit she was weaned from sedation, awoke
neurologically intact and extubated without complications. On
post operative day one she was started on beta blockers and
diuretics and transferred to the floor. Physical therapy worked
with her on strength and mobility. On post operative day two her
chest tubes were removed. Her epicardial wires were removed the
following day. She was gently diuresed toward her pre-operative
weight. Her activity level gradually advanced and by
post-operative day four she was discharged to home with the
approval Dr. [**Last Name (STitle) 914**]. All follow-up appointments were advised
per cardiac surgery protocol.
Medications on Admission:
metformin 1000 mg twice a day
glipizide 5 mg twice a day
simvastatin 80 mg daily
Synthroid 125 mcg daily
Ativan p.r.n.
Bupropion 150 mg daily
clotrimazole 0.05 mg apply to the foot
aspirin 81 mg daily
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for to foot .
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p CABG
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.
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] (cardiac surgeon) in 4 weeks ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) in 1 week - please call for appointment
Dr [**Last Name (STitle) **] (cardiology) in [**1-8**] weeks - please call for
appointment
Wound check [**Hospital Ward Name 121**] 6 in 2 weeks as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2171-7-26**]
|
[
"V45.72",
"414.01",
"V10.83",
"250.00",
"244.9",
"733.90",
"300.4",
"272.4",
"401.9",
"V13.01",
"305.1",
"518.0",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"38.93",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7275, 7333
|
4389, 5488
|
322, 523
|
7640, 7647
|
2086, 4366
|
8158, 8622
|
1309, 1326
|
5739, 7252
|
7354, 7619
|
5514, 5716
|
7671, 8135
|
1341, 2067
|
267, 284
|
551, 864
|
886, 1118
|
1134, 1293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,171
| 115,583
|
8544+55954
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-2-12**] Discharge Date: [**2197-2-24**]
Date of Birth: [**2128-5-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 68 year-old female seen in ED for bilateral eye swelling
yesterday and slit lamp exam revealed right keratitis.
Ophthomology recommended Ciprofloxacin and Viroptic drops and
follow up in clinic in the next 2 days. She was sent home and
her PCP was called by daughter reporting ongoing weakness,
fatigue and inability for patient to care for herself. She was
referred back to ED for admission. Of note, her blood sugar was
>300. At this time, she notes progressive weight loss over the
past month, increased fatigue such that she spends > 50% of her
day in bed, and decreased appetite. She denies any recent
fevers, chills, chest pain, abdominal pain, changes in bowel and
bladder habits. She does note occasional red blood on her
stools that is unchanged from her usual hemorrhoids. She also
notes loose watery stools since her colon surgery in [**Month (only) **].
.
Past Medical History:
asthma
s/p whipple procedure
s/p ventral hernia repair
Social History:
The patient is widowed and is the mother of five
healthy children. She lives in [**Hospital1 189**], [**State 350**]. She is a
former high school teacher who retired in [**2189**]. She has never
smoked tobacco and does not use alcohol.
Family History:
Family history includes a remarkable number of carcinomas on her
maternal side. Her mother apparently died of cervical cancer and
may have had a history of colon cancer as well. Her maternal
grandmother died of breast cancer at the age of 36. Several
maternal aunts, uncles, and [**Name2 (NI) 12232**] have been diagnosed with
lung, pancreatic, and bone cancer.
Physical Exam:
PE:
Vitals: Temperature:97.2 Pulse:104 Blood Pressure:103/76
Respiratory Rate:16 Oxygen Saturation:100% on room air
General: Lying in bed in no acute distress with eyes closed
HEENT: Erythematous eyelids with crusting on lashes. Patient is
unable to open her eyes. Bilateral conjunctiva are injected.
Pupils equal and reactive, dry mucouse membranes.
Cardiac: Regular rate and rhythm without murmurs, rubs, or
gallops.
Pulmonary: Clear to auscultation bilaterally
Abdomen: Normoactive bowel sounds, soft, nontender,
nondistended, well-healed midline scar.
Extremities: Warm and well perfused without edema or cyanosis,
2+ dorsalis pedis pulses bilaterally.
.
Pertinent Results:
Imaging:
1. Orbit CT ([**2-11**]): Unremarkable exam
2. Head CT ([**2-11**]): No bleed or masses.
Brief Hospital Course:
INITIAL ASSESSEMENT AND PLAN ON ADMISSION: 68 year-old female
with pancreatic cancer and colon cancer admitted with keratitis
and hyperglycemia.
1. Keratitis: She was seen in the ED yesterday with blurry
vision and eye swelling. A slit lap exam showed keratitis.
Visual acuity was intact. She was sent home on ciporfloxacin
ointments and viroptic. Continue ciprofloxacin and viroptic for
now.
2. Hyperglycemia: She was noted to have sugars in the 300s
yesterday. She had no evidence of DKA. Her blood surgars have
been elevated above 180s for the past several years. Her
hyperglycemia is likely secondary to pancreatic insufficiency
after Whipple. Cover her with an insulin sliding scale for now.
3. Coagulopathy: She has elevate PT and PTT. Given her history
of decreased appetite and poor po intake over the past several
weeks, her coagulopathy could be secondary to vitamin K
deficiency. Treat with 3 doses of vitamin K.
4. Colon cancer: She recently completed cycle 1 of FOLFOX. She
is followed by Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) 13933**].
5. Anemia: She has had recent hematocrits in the low 30s;
however, on admission her hematocrit is 38. She may be
hemoconcentrated.
MICU COURSE: The patient was transferred to the MICU service
with hypotension and gram negative sepsis. She was treated with
IV fluid resuscitation and started on pressors, as well as
antibiotics to cover the gram negative rods. Urine culture and
blood cx eventually grew out E. coli, sesntitive to Cipro as
well as meropenem, so the meropenem was discontinued and cipro
was begun. She developed DIC and was transfused with pRBCs,
platelets, and FFP. She was maintained on [**1-20**] pressors for
several days. She also developed renal failure and renal team
was consulted for dialysis. After a discussion with family
goals of care were changed to comfort measures and patient
expired [**2197-2-24**].
Medications on Admission:
...
Discharge Medications:
none
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Bacteremia
Sepsis
Keratitis
Diabetes mellitus
Coagulopathy
Mucositis
Colon cancer
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2197-2-27**] Name: [**Known lastname 5251**],[**Known firstname 471**] Unit No: [**Numeric Identifier 5252**]
Admission Date: [**2197-2-12**] Discharge Date: [**2197-2-24**]
Date of Birth: [**2128-5-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1225**]
Addendum:
Detailed MICU Course:
85 yo woman c pancreatic cancer and R colon cancer s/p
hemicolectomy and FOLFOX, neutropenic found to be hypothermic
and obtunded on the floor transferred to MICU with GN sepsis.
.
#) Respiratory failure / ARDS - Patient was intubated for
respiratory distress/failure in setting of Septic shock. She
had a Left retrocardiac opacity initially and was started on
antibiotics for PNA. She was maintained on mechanical
ventilation during her course. As her sepsis and DIC progressed
she required higher PEEP and FiO2. She had signs of ARDS and was
maintained on ARDS net low tidal volume ventilation. Esophageal
ballon was used at one point to measure pleural pressure and
revealed that with PEEP ~18 her transpulmonary pressures were 0.
She remained on mechanical ventilation thereafter with higher
PEEP.
.
#) Septic shock: Patient was hypotensive and hypothermic after
transfer and a central line was placed for acess and cvp
monitoring. Soon after her transfer [**1-21**] blood cx bottles were
positive for Gram negative rods (later speciated as E. coli).
She was started on meropenam and vancomycin initilly for broad
coverage and was switched over to vancomycin after sensitivities
returned. The most likely sourse of gram negative sepsis was
pna vs. uti. Urine culture later grew out klebsiella and E.
coli. She was maintained on sepsis protocol with goal CVP>12,
MAP>65. She was initially started on levophed, vasopressin and
neosynephrine (in that order). Neo was weaned off at times
briefly but for most of the time she required atleast 2 pressors
to keep her MAP>65. She also developed DIC (see below). Random
Crotisol was drawn and was 32. She was given hydrocortisone and
fludrocortisone.
.
# DIC - Patient had pancytopenia most likely secondary to
chemotherapy. She also developed DIC, likely secondary to
sepsis. INR was as high as 5 one day after admission. She
received platelets, prbc and ffp to maintain plt >20k and >50k
if bleeding. She received altogether 21 units of FFP, 8 units
of platlets and 4 units of PRBC over her 6 day MICU course.
.
#Acute renal failure: On admission creatinine was 0.6 on
transfer to MICU. OVer the next several days patients
creatinine started going up to 2.1 on last day. She also became
oliguric. Lasix was tried with little success and renal service
was consulted for Dialysis recommendations. Several goals of
care covnersations were held with the family and dialysis was
held off initially. She was started on lasix gtt and was also
given diuril for diuresis. She had a good response to lasix gtt
and dialysis was held off. However evening of [**2197-2-23**] pt became
hypotensive on 3 pressors and lasix gtt was stopped.
.
#FEN: OG tube was placed and patient was given nutrition via
tube feeds.
...........
[**2197-2-23**] during the course of the day patient became more
hypotensive and required 3 pressors. Serial ABGs showed
worsening hypoxemia and Acidosis she was given Bicarb and
pressors were increased. After a family discussion AM of [**2-24**],
pressors and ventilator were withdrawn and goals were directed
towards comfort measures. She expired AM of [**2197-2-24**].
Discharge Disposition:
Home with Service
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1226**] MD [**Last Name (un) 1227**]
Completed by:[**2197-2-28**]
|
[
"287.5",
"038.42",
"286.6",
"263.9",
"370.9",
"153.8",
"284.8",
"518.81",
"995.92",
"785.52",
"584.9",
"V10.09",
"251.3",
"599.0",
"528.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.6",
"34.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8632, 8651
|
2780, 2809
|
328, 334
|
8672, 8681
|
2658, 2757
|
8737, 8907
|
1593, 1958
|
4761, 4767
|
4830, 4914
|
4733, 4738
|
8705, 8714
|
1973, 2639
|
275, 290
|
362, 1244
|
2824, 4707
|
1266, 1322
|
1339, 1577
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,898
| 194,859
|
41061
|
Discharge summary
|
report
|
Admission Date: [**2163-2-15**] Discharge Date: [**2163-3-25**]
Date of Birth: [**2098-1-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Thoracoabdominal aortic aneurysm,
infrarenal abdominal aortic aneurysm involving the common
iliac arteries.
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Repair of thoracoabdominal aortic aneurysm using partial
right heart bypass and a 24 mm multi branch Vascutek
graft with separate branches to the celiac artery,
superior mesenteric artery as well as left and right
renal arteries.
2. Repair of aortoiliac aneurysm with partial right heart
bypass using a 22 x 11 mm bifurcated Dacron graft.
PROCEDURE: Exploratory laparotomy, left colectomy and
temporary closure of abdomen.
Drainage of multiple liters of enteric contents.
PROCEDURE PERFORMED: Exploratory laparotomy, proctectomy,
kocherizing of the duodenum. Removal of intra-abdominal
sponges and temporary abdominal closure.
PROCEDURE PERFORMED: Exploratory laparotomy, Vicryl mesh
abdominal wall closure, colostomy and placement of
gastrostomy tube.
Procedure: Tracheostomy
PROCEDURE PERFORMED: Left subclavian PermaCath.
PROCEDURE PERFORMED: Split-thickness skin graft to abdominal
wall, right and left anterior thigh donor sites.
History of Present Illness:
This patient is a 65-year-old gentleman with a
abdominal aortic aneurysm which on CT scan was found to
involve the entire visceral segment of his abdominal aorta,
his iliac arteries and extended into the distal portion of
the descending thoracic aorta. Maximum dimensions of the
aneurysm were nearly 8 cm in the abdomen and close to 6 mm in
the visceral segment. There were large iliac aneurysms as
well. Due to the extent of the aneurysm, it was felt that a
thoracoabdominal approach using partial right heart bypass
was the best way to correct this problem. I might add that CT
scan also showed a suggestion of an inflammatory component to
the aneurysm in the aorta. Prior to the surgery the patient
understood the risks of surgeries, especially the potential
risk of paraplegia, and agreed to proceed. Because of the
complex nature of this operation, requiring the expertise of
both a vascular and cardiac surgeon, and the use of
cardiopulmonary bypass, I asked Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] from
cardiac surgery to be my co-surgeon for this procedure.
Past Medical History:
PAST MEDICAL HISTORY: HTN, Inc chol, pos smoker, COPD,
osteoarthritis Homocystine, increase PSA
PAST SURGICAL HISTORY: s/p prostate bx - [P]
Social History:
SOCIAL HISTORY: NA. Pos smoker, pet dog, married with children,
wine distrubuter, retired a yr ago
Family History:
FAMILY HISTORY: father and Uncle pos AAA
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAM
Vital Signs: Temp: 98 RR: 12 Pulse: 88 BP: 136/72
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Ulnar: P. Brachial: P.
LUE Radial: P. Ulnar: P. Brachial: P.
RLE Femoral: P. DP: D. PT: D.
LLE Femoral: P. DP: D. PT: D.
Pertinent Results:
[**2163-2-15**] 04:44PM BLOOD WBC-21.3*# RBC-2.50*# Hgb-7.9*#
Hct-23.4*# MCV-93 MCH-31.5 MCHC-33.7 RDW-14.7 Plt Ct-244
[**2163-3-23**] 03:29AM BLOOD WBC-18.8* RBC-2.95* Hgb-9.2* Hct-27.1*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.3 Plt Ct-648*
[**2163-3-24**] 04:27AM BLOOD WBC-18.8* RBC-2.91* Hgb-8.9* Hct-26.8*
MCV-92 MCH-30.6 MCHC-33.3 RDW-15.2 Plt Ct-610*
[**2163-3-25**] 01:48AM BLOOD WBC-18.6* RBC-2.83* Hgb-8.9* Hct-25.9*
MCV-92 MCH-31.6 MCHC-34.5 RDW-15.2 Plt Ct-658*
[**2163-3-24**] 04:27AM BLOOD PT-12.9 PTT-28.0 INR(PT)-1.1
[**2163-3-24**] 04:27AM BLOOD Plt Ct-610*
[**2163-3-25**] 01:48AM BLOOD PT-12.9 PTT-27.8 INR(PT)-1.1
[**2163-3-25**] 01:48AM BLOOD Plt Ct-658*
[**2163-2-17**] 01:09AM BLOOD Neuts-92* Bands-2 Lymphs-3* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2163-3-25**] 01:48AM BLOOD Neuts-85.6* Lymphs-4.6* Monos-4.3
Eos-4.9* Baso-0.6
[**2163-2-15**] 07:04PM BLOOD Glucose-99 UreaN-22* Creat-1.2 Na-140
K-3.8 Cl-107 HCO3-24 AnGap-13
[**2163-3-23**] 03:29AM BLOOD Glucose-121* UreaN-77* Creat-2.4* Na-135
K-4.1 Cl-98 HCO3-23 AnGap-18
[**2163-3-24**] 04:27AM BLOOD Glucose-128* UreaN-52* Creat-1.6* Na-137
K-3.7 Cl-99 HCO3-30 AnGap-12
[**2163-3-25**] 01:48AM BLOOD Glucose-128* UreaN-80* Creat-2.2* Na-137
K-3.7 Cl-99 HCO3-28 AnGap-14
[**2163-3-25**] 01:48AM BLOOD ALT-108* AST-81* LD(LDH)-239 AlkPhos-336*
Amylase-84 TotBili-0.5
[**2163-3-12**] 03:34AM BLOOD ALT-153* AST-181* LD(LDH)-335*
AlkPhos-690* Amylase-70 TotBili-2.7*
[**2163-3-10**] 02:06AM BLOOD ALT-144* AST-167* LD(LDH)-296*
AlkPhos-576* Amylase-61 TotBili-2.6*
[**2163-2-15**] 07:04PM BLOOD ALT-110* AST-116* CK(CPK)-1061*
AlkPhos-43 TotBili-0.3
[**2163-3-25**] 01:48AM BLOOD Lipase-96*
[**2163-3-12**] 03:34AM BLOOD Lipase-80*
[**2163-3-8**] 04:37AM BLOOD Lipase-60
[**2163-2-16**] 01:45AM BLOOD Lipase-50
[**2163-3-25**] 01:48AM BLOOD Albumin-2.5* Calcium-9.7 Phos-4.0 Mg-2.2
[**2163-3-24**] 04:27AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.1
[**2163-3-23**] 03:29AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.5
[**2163-3-18**] 02:22AM BLOOD calTIBC-179* Ferritn-814* TRF-138*
[**2163-3-3**] 04:17PM BLOOD Triglyc-242*
[**2163-3-12**] 03:34AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2163-3-25**] 08:35AM BLOOD Vanco-14.4
[**2163-3-23**] 06:32AM BLOOD Vanco-19.8
[**2163-3-22**] 06:00AM BLOOD Vanco-21.5*
Brief Hospital Course:
Mr. [**Known lastname 1924**] is a 65 year-old male who underwent a open
thooracoabdominal aortic aneurysm repair on [**2163-2-15**]. For
details of the operation, please refer to the specific operative
note. The cross clamp time was 40 minutes and bypass time was
164 minutes. He was stable immediately postop, however,
remained intubated and sedated due to the length of the
operation. He continued to have good urine output and was awake
the following day but remained intubated for diuresis. It was
noted that he was unable to move his bilateral lower extremities
but able to follow commands with his upper extremities. A CT
torso as well as MRI was performed which showed a T8-conus
infarct. Neurology was consulted at that time at if was felt
that nothing further could be done for the cord infcartion. He
remained stable and was extubated on [**2163-2-19**] and continued to
have good urine output. He had a increase in his creatinine to
a peak of 1.9 then started to decrease to 1.6. On [**2163-2-20**] was
found to be unresponsive in the chair and hypotensive. He
underwent CPR, shock and a dose of epinephrine. He was
re-intubated and underwent a CT head which was negative for an
acute process at that time. After the code, he required
Neosynephrine and Levophed for blood pressure support. He
became anuric and renal was consulted and thought it was likely
ATN. CRRT was initiated on [**2163-2-21**]. He continued to require
vasopressor support (neo synephrine and vasopressin). He had
atrial fibrillation rhythm on [**2163-2-22**] and his neo synephrine was
changed to Levophed. He was given amiodarone and his atrial
fibrillation converted to sinus rhythm. He grew GNRs from his
blood cultures on [**2163-2-20**] and was started on vanco/cefepime.
His central lines were re-sited complicated by a right
pneumothorax requiring a right chest tube. A CT torso was
performed to assess for a source of his GNRs bacteremia/sepsis
and was found to have perforated bowel. He underwent an
exploratory laparatomy on [**2163-2-22**] where a left colectomy was
performed for ischemic bowel and his abdomen was left open. He
remained intubated and sedated and he was taken back the
following day where his abdomen was washed out and further
resection of ischemic rectum was resected. The following day, a
third takeback operation was performed with a transverse
colectomy, end colostomy. G-J-tube, and abdominal closure with
vicryl mesh was performed. A VAC dressing was placed to his
abdominal wound. Please refer to the individual operative notes
for further details of the procedure. He remained ctritically
ill on CRRT and continued to require vasopressor suuport
postoperatively. It was noted that he had a sudden decrease in
his platelet count and a HIT antibody was sent which eventually
was positive. His lines were exchanged for non-heparin coated
lines and all heparin was stopped. For prophylaxis, he was
started on argatroban on [**2163-2-25**]. A surveillance CT torso was
performed on [**2163-3-1**] to evaluate for possible abcesses and it
was noted that he had a subcapsular liver hematoma. The
argatroban was discontinued at this time. He continued to
require ventilatory support and eventually underwent a
tracheostomy on [**2163-3-4**]. He continued to remain neurologically
intact as far as his mental status, however, continued to have
no ability to move his bilateral lower extremities. He further
continued to be anuric requiring CRRT. Another Surveillance CT
scan to evaluate the subcapsular hematoma was performed on
[**2163-3-28**] which showed enlargement despite no anticoagulation
medications. During the week of [**2154-3-6**] he began to have
episodes of bradycardia with hypotension. He was evaluated by
cardiology was an eventual permanent pacemaker was placed on
[**2163-3-15**]. He continued to have episodes of bradycardia, with
the pacemaker functioning properly to maintain his heart rate.
CRRT was eventaully stopped and her was transitioned to
hemodialysis, tolerating it well. Tubefeeds were started once
his ostomy started to function and he was maintained on tube
feeds via his J-tube. Infectious disease was initially
consulted for his gram negative bacteremia and recommended a
prolonged course of antibiotics given his risk on continued
infections. On [**2163-3-17**], his open abdominal wound was
sufficiently healed and a split-thickness skin graft was
performed. He tolerated the procedure well and the VAC dressing
for his skin graft was taken down 5 days afterwards to reveal
that much of the skin graft had taken. At this time, he was
deemed stable and a rehab screen was initiated. A passy-muir
valve was fitted for his tracheostomy on [**2163-3-23**]. He remained
neurologically stable, able to answer questions appropriately.
His blood pressure was stable without the need for vasopressor
support and he was able to tolerate trach collar for the
majority of the day, requiring ventilatory rest at night. He
continued to tolerate his tube feeds through his J-tube ,
however, continued to remain oliguric requiring hemodialysis.
He has been maintined on vancomycin, meropenem, and fluconazole
as appropriate antibiotic coverage for bacteroides and [**Female First Name (un) **].
He remains only with pneumoboots for DVT prophylaxis.
Medications on Admission:
Lipitor 20 mg PO/NG DAILY, Hydrochlorothiazide 25 mg PO/NG
DAILY, Aspirin 81 mg PO/NG DAILY, Multivitamins 1 TAB PO/NG
DAILY, Acetaminophen 500 mg PO/NG Q6H:PRN pain, Lorazepam 0.5 mg
PO/NG Q4H:PRN pain,Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. acetaminophen 325 mg/10.15 mL Solution Sig: 10.15-20.30 ml PO
Q6H (every 6 hours) as needed for fever/pain.
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm
Intravenous HD PROTOCOL (HD Protochol): continue through [**4-5**] .
5. Lines
PICC Line - saline flushes
Tunneled HD - citrate
6. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 0.84 mg Subcutaneous
DAILY (Daily): DVT prophalaxis - discussed with renal dose with
[**1-31**] normal dosing .
8. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q24H (every 24 hours): continue through [**4-5**].
9. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig:
Fifty (50) ML PO QHD (each hemodialysis) for 14 days: started
[**3-25**] after HD .
10. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours): give after HD on dialysis days - continue through
[**4-5**].
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. epoetin alfa 10,000 unit/mL Solution Sig: 4000 (4000) units
Injection QHD.
14. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
qam.
16. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension
Sig: Five (5) ml PO TID (3 times a day).
17. ranitidine HCl 15 mg/mL Syrup Sig: Fifteen (15) ml PO DAILY
(Daily).
18. Insulin sliding scale - Regular insulin q6h
Q6H
Regular
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
280-319 mg/dL 10 Units
320-359 mg/dL 12 Units
> 360 mg/dL Notify M.D.
19. Change after IV antibiotics complete
When IV antibiotics completed [**4-5**] please start on
Cipro 250 mg [**Hospital1 **]
Flagyl 250 mg TID
Diflucan 400 mg after HD
Lifetime suppressive therapy
20. Outpatient Lab Work
CBC with differential, Chem 7, LFTS- to be drawn weekly while on
antibiotics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Acute renal failure
Atrial fibrillation
Bradycardia
Spinal infarct with paraplegia
Mesenteric ischemia
Bacteremia
Respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
ThoracoAbdominal Aortic Aneurysm (AAA) Surgery Discharge
Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-6**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Increase your activities as you can tolerate-
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Avoid prolonged periods of sitting without your legs elevated
?????? To avoid constipation: use stool softener while taking pain
medication
What activities you can and cannot do:
?????? No driving until cleared
?????? You should get up every day, get dressed, and gradually
increasing your activity
?????? Increase your activities as you can tolerate-
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? Your thoracotomy incision may be left uncovered, unless you
have small amounts of drainage from the wound, then place a dry
dressing over the area that is draining, as needed
?????? Take one 81mg aspirin daily, unless otherwise directed
?????? An appt has been scheduled for you to to see Dr. [**Last Name (STitle) **] in
2 weeks.
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2163-3-31**] 1:40
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2163-4-11**]
9:30
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2163-5-9**] 11:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2163-4-14**] 2:00
Completed by:[**2163-3-25**]
|
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"E878.2",
"038.3",
"569.83",
"785.52",
"305.1",
"344.1",
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
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[]
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14424, 15670
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2649, 2673
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2890, 3742
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248, 358
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1406, 2507
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14261, 14400
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2551, 2626
|
2705, 2791
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,213
| 144,260
|
9781
|
Discharge summary
|
report
|
Admission Date: [**2136-10-27**] Discharge Date: [**2136-11-13**]
Date of Birth: [**2097-6-4**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1945**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
39yo with a h/o hypertriglceridemia and daily EtOH use who
presented to [**Hospital3 26615**] w 1wk lower back pain and 1d acute
stabbing abdominal pain and emesis. He was found to have a WCC
of 19.7, amylase of 295, and lipase of 1157. CT abd/pelvis was
consistent with acute pancreatitis. He was treated with IVF and
bowel rest, along with benzos for persumed Etoh withdrawal. On
[**10-23**] he had coffee ground emesis followed by respiratory
failure requiring intubation. CXR showed BL infiltrates and he
was started on vancomycin and zosyn on [**10-23**]. He received 4
units of RBCs by [**10-25**] for droping HCT. A repeat CT scan on
[**10-26**] showed increaseing peripancreatic stranding and fluid
consistent with worsening pancreatitis. It was thought there
was a new fluid collection abutting the body of the pancreas c/w
a pseudocyst. Zosyn was switched to unasyn on [**2136-10-26**].
.
While on the ventilator, the patient was difficult to keep
sedated, requiring high doses of propofol. Per med flight, prior
to transfer at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] the patient had 3, 3 min episodes
generalized seizures. Prior to leaving he was loaded with 1gm of
dilatin. On transit he received 6 mg of ativan and 200mg
fentanyl in addition to propofol gtt.
Past Medical History:
Lower back pain since [**Month (only) 216**]
Petrous apex cholesterol cyst s/p surgical drainage in [**2127**]
dyslipidemia / hypertriglyceridemia
daily alcohol use
HTN
Prior pancreatitis in [**2126**] (mother unable to confirm).
Appendectomy and ruptured cecum at age of 18
Social History:
Lives with his mother in [**Name (NI) 32944**]. Recent divorce, foreclosure,
and end of a relationship with a girlfriend living in the
[**Name (NI) 32945**]. He works driving a construction truck
- Tobacco: 1.5 ppd [**Last Name (LF) 1818**], [**First Name3 (LF) **] time smoking
- Alcohol: Daily rum drinking, per mother [**12-31**] to 1 quart of rum
daily. Increased intake over the last 3-4 months.
- Illicits: denies
Family History:
Family History: Father: Etoh abuse, died of cancer 3 years ago.
no seizure history.
Physical Exam:
ADMISSION
Vitals: 99.8 P 90 BP 131/70 R 16 O2 sat 100% on 500/14/100%/5
wt 83.9 kg. (admission wt 167 lb)
General: intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
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 (no grimacing), non-distended.
slightly tympanic. bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. right PICC in place, left a line in place.
skin: in right groin papular erythematous rash without pus or
vescicles. pustular acne on the back.
neuro: exam limited by sedation. PERRL, NL tone. no clonus. 2+
DTRS throughout. NL babinski.
DISCHARGE
Vitals 98.9 122/69 90 18 97%RA
Gen: NAD, Comfortable
Neck: Supple, no JVD, no LAD
Heart: RRR, no mrg
Lungs: CTA b/l, no mrg
Abd: Soft, LUQ mildly TTP, nondistended, no rebound, no
guarding, naBS
Ext: 2+ DP/radial pulses, no edema/cyanosis/clubbing
Skin: no rashes
Pertinent Results:
LABS FROM OSH [**10-10**]
WBC 19.7 [**10-20**], nadir at 12.7 on [**10-23**].4 on [**10-27**]
cr 2.0 on [**11-24**] cr 0.7.
amlyase 295 [**10-20**], peak 1102 [**10-21**], 78 [**10-24**]
lipase 1157 [**10-20**], peak 2948, [**10-27**] lipase 121
ABG [**10-23**] 7.299/47.8/74.3
FS 120s to 170s
Blood Counts:
[**2136-10-27**] 02:38PM BLOOD WBC-23.3*# RBC-3.37*# Hgb-10.8*#
Hct-32.0*# MCV-95 MCH-32.2* MCHC-33.8 RDW-16.9* Plt Ct-524*
[**2136-10-29**] 03:26AM BLOOD WBC-22.4* RBC-2.88* Hgb-9.4* Hct-27.6*
MCV-96 MCH-32.5* MCHC-33.9 RDW-16.6* Plt Ct-567*
[**2136-11-2**] 02:55AM BLOOD WBC-21.5* RBC-3.09* Hgb-9.9* Hct-29.5*
MCV-96 MCH-31.9 MCHC-33.4 RDW-15.9* Plt Ct-689*
[**2136-11-4**] 03:11AM BLOOD WBC-10.3 RBC-2.48* Hgb-7.8* Hct-23.3*
MCV-94 MCH-31.3 MCHC-33.4 RDW-15.9* Plt Ct-610*
[**2136-11-6**] 03:09AM BLOOD WBC-12.4* RBC-2.64* Hgb-8.3* Hct-24.9*
MCV-94 MCH-31.3 MCHC-33.2 RDW-15.7* Plt Ct-684*
[**2136-11-12**] 07:15AM BLOOD WBC-12.7* RBC-3.21* Hgb-9.6* Hct-29.5*
MCV-92 MCH-29.9 MCHC-32.5 RDW-16.3* Plt Ct-908*
[**2136-11-13**] 07:25AM BLOOD WBC-15.1* RBC-3.79* Hgb-11.3* Hct-34.8*
MCV-92 MCH-29.8 MCHC-32.4 RDW-16.0* Plt Ct-1149*
Coags:
[**2136-10-30**] 02:21AM BLOOD PT-13.2 PTT-23.2 INR(PT)-1.1
[**2136-11-12**] 07:15AM BLOOD PT-14.7* PTT-25.7 INR(PT)-1.3*
Chemistry:
[**2136-10-27**] 02:38PM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-139
K-4.4 Cl-109* HCO3-22 AnGap-12
[**2136-10-30**] 02:21AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-25 AnGap-15
[**2136-11-5**] 03:19AM BLOOD Glucose-159* UreaN-18 Creat-0.7 Na-133
K-5.1 Cl-105 HCO3-25 AnGap-8
[**2136-11-13**] 07:25AM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-136
K-4.4 Cl-98 HCO3-25 AnGap-17
Liver:
[**2136-10-27**] 02:38PM BLOOD ALT-30 AST-48* LD(LDH)-350* AlkPhos-64
Amylase-63 TotBili-1.4
[**2136-11-6**] 03:09AM BLOOD ALT-26 AST-23 LD(LDH)-319* AlkPhos-141*
TotBili-0.4
Pancreas:
[**2136-10-27**] 02:38PM BLOOD Lipase-129*
[**2136-10-28**] 04:22AM BLOOD Lipase-130*
[**2136-10-29**] 03:26AM BLOOD Lipase-62*
[**2136-10-30**] 02:21AM BLOOD Lipase-76*
[**2136-10-31**] 05:55AM BLOOD Lipase-135*
[**2136-10-27**] 02:38PM BLOOD Triglyc-387*
[**2136-10-27**] 03:22PM BLOOD freeCa-1.19
[**2136-10-30**] 09:28PM BLOOD freeCa-1.14
[**2136-11-7**] 03:53AM BLOOD freeCa-1.22
Blood Gas:
[**2136-10-28**] 04:46AM BLOOD Type-ART Temp-38.2 Rates-[**11-29**] Tidal V-700
PEEP-5 FiO2-40 pO2-77* pCO2-47* pH-7.33* calTCO2-26 Base XS--1
Intubat-INTUBATED
[**2136-11-7**] 03:53AM BLOOD Type-ART Temp-37.7 Rates-20/2 Tidal V-500
PEEP-5 FiO2-40 pO2-88 pCO2-44 pH-7.44 calTCO2-31* Base XS-4
-ASSIST/CON Intubat-INTUBATED
Micro:
ASPERGILLUS GALACTOMANNAN neg
ANTIGEN B-GLUCAN neg
.
[**2136-10-26**]: OSH CT abd/pelvis: Increasing peripancreatic stranding
and fluid consistent with worsening pancreatitis. New fluid
collection abutting the body of the pancreas, consistent with a
pseudocyst. New BL pleural effusions. Prominent areas of
consolidation in both lower lobes, new since the prior study.
These could represent atelectasis. Infiltrate cannot be
excluded. Evaluation of the vascular structures and pancreatic
enhancement is limited.
.
[**2136-10-27**] CXR: bibasilar opacities, consistent with small pleural
effusions and areas of consolidation which could represent
atelectatis and/ or infiltrate. Mild interstitial prominence may
relate to low lung volumes. Mild pulmonary edema cannot be
excluded.
.
[**2136-11-2**]:
CT abd/pelvis
1. Extensive peripancreatic stranding and fluid, little changed
from prior
study, and compatible with provided history of pancreatitis.
There is no
loculated fluid collection to suggest abscess or pseudocyst
formation. The pancreatic parenchyma enhances homogeneously,
without evidence for pancreatic necrosis.
2. No evidence for vascular complication.
3. Increase in bilateral moderate pleural effusions, with
dependent opacities most likely representing atelectasis.
However, there is additional multifocal air space opacity in the
right middle lobe and lingula, new from prior study and
concerning for pneumonia.
[**2136-11-7**]:
Head MRI
No acute intracranial pathology.
Brief Hospital Course:
This is a 39yo male w hx of EtOH abuse, HLD, presenting from OSH
w acute pancreatitis, and intubation for PNA
.
# Pancreatitis: This is a patient who presented with abdominal
pain, elevated amylase / lipase, and evidence of pancreatitis on
imaging. It was thought that this was most likely [**1-31**] to recent
increased Etoh use. His high triglycerides were also thought to
be contributing. On transfer, [**Hospital1 18**] imaging did not show
evidence of pseudocyst or necrosis. Lipase was downtrending.
After extubation (discussed below), patient had an improving
abdominal exam with decreasing pain control requirements. The
patient tolerated clears and subsequent advancement of his diet.
He was stable and was discharged with close outpatient
follow-up with his PCP.
.
#Leukocytosis and Thrombocytosis: During this admission,
thrombocytosis was noted on the patient's laboratory studies:
534K ([**10-27**]) to 1149 ([**11-13**]). His WBC count was persistently
elevated, with only rare early cells. In the setting of a
serious illness, it was thought that these findings were likely
reactive in etiology and lagging behind his clinical recovery.
There was low suspicion of an underlying myeloproliferative
disorder. The hematology team recommended repeating laboratory
studies 4 weeks post-discharge to evaluate for normalization of
his labs. At that point, if his leukocytosis and thrombocytosis
had not resolved, they recommended that he undergo additional
testing, including BCR-ABL and JAK2 testing. They did not
recommend starting aspirin given his recent GI bleed. These
recommendations were discussed with the patient's PCP.
.
# Hypoxic resp failure: This is a patient who developed hypoxic
respiratory failure in the setting of a likely aspiration and
subsequent pneumonia. He was transfered here intubated with
persistent BL infiltrates, treated with vanco/zosyn for possible
VAP/asp pna. There were some difficulties with weaning the
patient from fentanyl, so he was started on methadone. His
respiratory status improved and he was successfully extubated.
His methadone was tapered and stopped prior to discharge.
.
# Seizure-like activity: This is a patient who at OSH vague
"seizure-like activity" was noted in OSH d/c summary for which
he was started on Keppra. On transfer, [**Location (un) **] reported,
"generalized seizures" in transit requiuring 6mg ativan and 1gm
of Dilatin. Given that this occurred 7d after admission, it was
thought this was unlikely [**1-31**] Etoh withdrawal and more likely
metabolic dysfunction resulting in a seizure. Patient had no
documented seizures in ICU, but remained exceedingly agitated
requiring multiple sedatives. MRI brain showed no suspicious
lesions or cause for seizures or agitation. Keppra was d/ced
after patient failed to show any concerning seizure activity--it
was thought that the previously reported seizure-like activity
may have been [**1-31**] to agitation in the setting of inadequate
sedation.
.
# Coffee ground emesis: This is a patient with coffee ground
emesis at OSH on [**10-23**] requiring 4 units pRBCs. It was thought
this was [**1-31**] EtOH gastritis vs stress ulcer vs NG tube induced
esophagitis. After transfer, patient's HCT dropped once more
while in ICU, but stabilized without intervention. His HCT
remained stable without signs of bleeding or hemolysis. His
PCP's office was contact[**Name (NI) **] regarding arranging outpatient EGD
follow-up.
.
# Etoh withdrawal: This is a patient who was transferred here
after being treated for EtOH withdrawal. In the ICU the patient
remained on several different benzodiazepines, as well as
propofol, precedex, and haldol at different times for sedation.
After 2 weeks was slowly tapered off all in conjunction with
extubation. He expressed interest in quitting drinking and was
seen by social work to discuss resources available to him.
.
# HTN: This is a patient with baseline HTN on lisinopril, HCTZ
and metoprolol as an outpatient. At OSH, lisinopril, HCTZ were
held. The patient was continued on metoprolol at transfer, with
several episodes of hypertension after transfer. Patient was
switch to home metoprolol dose with good effect. At discharge,
low-dose lisinopril was started given history of hyperlipidemia.
.
#Nicotine Cessation: After extubation patient requested a
nicotine patch, expressing an interest in quitting. He was
continued on the patch at discharge and encouraged to follow up
with his PCP.
Medications on Admission:
lisinopril 10mg daily
metoprolol 100mg PO daily
Tri-chlor 145mg PO daily
Hydrochlorothiazide 25mg PO daily
simvastatin 10mg daily.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
4. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Acute pancreatitis
Pneumonia
SECONDARY
Alcohol Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 853**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred here for treatment of your
pancreatitis and pneumonia. This pancreatitis was a result of
your heavy use of alcohol. You were treated with antibiotics
and are now improved.
You were also found to have an elevated number of platelets in
your blood. You were seen by the hematology service who said it
was likely reactive from your pancreatitis. If it is still
elevated in a month's time, please see your primary care doctor
for further workup.
The following changes were made to your medications:
-STOPPED Hydrochlorothiazide (HCTZ)
-STARTED omeprazole (prilosec)
-DECREASED Lisinopril to 5 mg
Please see below for your scheduled follow up appointments.
Followup Instructions:
Name: [**Last Name (LF) 3078**],[**First Name3 (LF) **] S
Address: [**Location (un) 32946**], [**Doctor Last Name 32947**] BLDG, [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 32949**]
Appointment: Monday [**11-19**] at 2:00PM
|
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
"03.31",
"96.04",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13065, 13071
|
7717, 12197
|
282, 308
|
13177, 13177
|
3606, 7694
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2408, 2477
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13092, 13156
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12223, 12355
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13328, 14102
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2492, 3587
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230, 244
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336, 1637
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13192, 13304
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1659, 1935
|
1951, 2375
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,125
| 108,908
|
47979
|
Discharge summary
|
report
|
Admission Date: [**2101-4-14**] Discharge Date: [**2101-4-22**]
Service: MICU
CHIEF COMPLAINT: Abdominal pain, vomiting and diarrhea.
HISTORY OF PRESENT ILLNESS: A 78-year-old woman with a
history of multiple psychiatric admissions for bipolar
disorder as well as hypertension, chronic obstructive
pulmonary disease, diverticulosis, Barrett's esophagus who
was recently on ciprofloxacin for a urinary tract infection
for the past three days and was found on the floor by her
husband covered in brown feces and vomit. She was noted to
then be vomiting dark brown material. She reported abdominal
pain that was right-sided, crampy and nonradiating on the
night prior to admission also associated with vomiting and
diarrhea. She also noted fatigue. The husband called 911
and the patient was seen by Emergency Medical Services at the
scene with vital signs: Heart rate 98, blood pressure
138/palp, respiratory rate 16, oxygen saturation 96% on four
liters nasal cannula.
On arrival to the Emergency Department, her vital signs were
150/82, 92, 18, 100% on room air with a temperature of 96.2.
She vomited a small amount of coffee ground material times
two. An NG tube was placed to suction and the patient
subsequently had bright red blood per rectum. Two peripheral
IV's were placed. Labs were notable for a WBC count of 26.5,
hematocrit of 47 and a BUN/creatinine of 35/1.4. She
received two liters of normal saline, levofloxacin and Flagyl
as well. CT of the abdomen was performed which demonstrated
diffuse colonic thickening.
Surgery was consulted who considered ischemic versus
infectious colitis.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Chronic obstructive pulmonary disease on two liters nasal
cannula home oxygen.
3. Bipolar disorder.
4. Barrett's esophagus.
5. Osteoporosis.
6. Macular degeneration.
7. Status post cholecystectomy.
8. History of thrush.
9. Multiple psychiatric admissions for bipolar disorder,
most recent [**3-1**] to [**2101-3-31**].
10. Urinary tract infections.
11. Echocardiogram [**11/2099**] with ejection fraction of 65-70%.
12. Constipation and abdominal pain of long-standing
duration.
13. Diverticulosis.
ALLERGIES: Prednisone, sulfa, calcium channel blockers,
Keflex, Benadryl and beta blockers.
MEDICATIONS:
1. Clonidine patch 0.2 q. week.
2. Cozaar 50 mg p.o. b.i.d.
3. Albuterol p.r.n.
4. Atrovent two puffs q.i.d.
5. Flovent 110 mcg two puffs b.i.d.
6. Prilosec 20 mg p.o. b.i.d.
7. Seroquel 200 mg p.o. q. hs.
8. Lasix 40 mg p.o. q. day.
9. Lactulose p.r.n.
10. Aspirin 81 mg p.o. q.o.d.
11. Cipro 250 mg p.o. b.i.d.
12. Depakote 500 mg p.o. q. hs.
13. Hydralazine 25 mg p.o. b.i.d.
14. K-Dur 10 mEq p.o. q. day.
15. Dulcolax p.r.n.
16. Two liters nasal cannula oxygen.
17. Os-Cal.
18. Milk of magnesia.
19. Nitro patch ?
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient is a former heavy tobacco smoker
who quit 13 years ago. No history of alcohol abuse. She
lives alone. She is separated from her husband who does
provide some support as well as her daughter. [**Name (NI) **] history of
drugs or herbal supplement use.
PHYSICAL EXAMINATION: 101.2, 128/47, 107, 28, 90% on room
air. General: This is an elderly woman lying on her left
side with an NG tube in place. Declining to lie flat for an
examination but otherwise in no acute distress. HEENT:
Right pupil surgical. Left pupil 2 mm, nonreactive. No
scleral icterus. Mucus membranes moist. No lesion. Neck
supple. No lymphadenopathy. No bruits. Jugular venous
pressure could not been seen. Cor regular rate and rhythm.
Normal S1, S2. Grade [**2-10**] holosystolic murmur at the right
upper sternal border without radiation. No S3 or S4
appreciated. Lungs: Diffusely decreased breath sounds
bilaterally. No crackles, wheezes or rhonchi. Abdomen:
Protuberant, distended, no obvious surgical scars.
Examination limited by patient refusing to lie flat.
Positive high pitched bowel sounds. Soft, diffusely tender,
no rebound or guarding. Extremities warm, well perfused, 2+
dorsalis pedis pulses bilaterally. Rectal: Guaiac positive.
Skin warm, dry, no rashes.
LABORATORY: WBC 26.5, hematocrit 47, platelet count 324,000.
84 bands, 3L4. BUN/creatinine 35/1.4. Anion gap 15. Urine
tox negative. Serum tox negative. ABG 7.3/49/65.
RADIOLOGY: KUB without volvulus or intestinal obstruction.
Probable distended bladder. Chest x-ray: No free air.
ELECTROCARDIOGRAM: Normal sinus rhythm, normal axis,
intervals, no ectopy. Left atrial enlargement, no Q-waves.
J-point elevation in V1 and V2. One millimeter ST depression
in 2, 3 and F. Positive left ventricular hypertrophy. When
compared to EKG in [**2100-2-5**], the ST depressions were
new.
HOSPITAL COURSE:
1. Colitis: While in the MICU, the patient had spiked a
fever to 101.2 and had significant bandemia. She had an
anion gap of 15 with a lactate of 4.1. She continued to note
abdominal pain with diarrhea initially. Was being treated
with vancomycin, levofloxacin and Flagyl and received
aggressive intravenous fluid hydration. Clostridium
difficile and stool cultures were sent and were all negative.
It was unclear whether or not the patient had infectious
colitis versus ischemic colitis with super infection from
transmutation of flora. Gastroenterology was consulted who
could not provide a definitive diagnosis either. Due to the
patient's cardiac issues the patient was not sent for scope.
Over the course of several days, the patient's fever went
down and her white count decreased. She was taken off the
vancomycin and maintained on levofloxacin and Flagyl. She
will continue a 14 day course of these medications. She
should have an outpatient colonoscopy performed by
Gastroenterology.
No source of upper GI bleeding was noted. It is possible
that this could have been from her lower GI sources.
Outpatient workup is indicated. She was tolerating a regular
diet at the time of discharge.
2. Atrial fibrillation: The patient's blood pressure
medications were held on admission due to concern over
gastrointestinal bleeding. On the day after admission the
patient was noted to be atrial fibrillation with a rapid
ventricular response. She was given Lopressor IV push that
resulted in a six second pause. Given the patient's reported
history to beta blockers and calcium channel blockers,
Electrophysiology was consulted, especially with the concern
of AV nodal disease. The patient was started on a verapamil
drip. She was then changed to p.o. verapamil 80 mg p.o.
t.i.d. The patient fluctuated between atrial fibrillation
and normal sinus rhythm with a well controlled rate. The
verapamil was discontinued on hospital day three. The
patient was transferred to the floor for additional workup of
her GI issues. On the night she was sent to the floor the
patient again had atrial fibrillation with a rapid
ventricular response with a heart rate in the 150's to 170's
with a blood pressure in the 70's systolic. She was brought
back to the MICU and placed on a verapamil drip with good
control of her blood pressure. She was then changed to
verapamil 40 mg p.o. t.i.d. with good control of her
ventricular response. She went back and forth between atrial
fibrillation and normal sinus rhythm. Decision was made not
to anticoagulate given her gastrointestinal issues and recent
GI bleed.
Electrophysiology continued to consult and directed that if
her rate was not well controlled with the p.o. verapamil that
additional nodal blockade with amiodarone or other agents may
be necessary and might require a pacemaker. They were not
willing to do this procedure at this time due to her stable
condition and GI issues.
3. Chronic obstructive pulmonary disease: This patient was
maintained on her albuterol, Atrovent and Flovent inhalers.
She did not experience any COPD exacerbations. She was
maintained on her home oxygen requirement and was discharged
on one liter of home oxygen.
4. Hypertension: The patient has likely poorly controlled
hypertension as an outpatient. She had her antihypertensives
held and then restarted. The patient was on Cozaar as an
outpatient and was placed on captopril as an inpatient. She
did not have any adverse reactions to this medication. She
was maintained on low dose to keep her blood pressure
systolic greater than 120 give a question of ischemic
colitis. She was discharged on verapamil and lisinopril.
5. Bipolar disorder: The patient was initially seen with
Depakote 500 mg p.o. q. hs. and Seroquel 200 mg p.o. q. hs.
The patient was seen to be very somnolent during her
admission in the MICU on this dose of Seroquel. The dose was
decreased to 100 mg p.o. q. hs. and the patient was more
alert. She will be discharged on this dose with follow up
with her psychiatrist.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Patient will be discharged to
rehabilitation. She will follow up with Psychiatry,
Gastroenterology and Cardiology.
DISCHARGE DIAGNOSES:
1. Colitis, ischemic versus infectious.
2. Atrial fibrillation complicated by rapid ventricular
response and hypotension.
3. Lower gastrointestinal bleed.
4. Upper gastrointestinal bleed.
5. Chronic obstructive pulmonary disease on home oxygen.
6. Bipolar disorder.
DISCHARGE MEDICATIONS:
1. Tylenol 325 mg to 650 mg p.o. q. 4h. p.r.n.
2. Atrovent two puffs q.i.d.
3. Albuterol two puffs q.i.d. p.r.n.
4. Depakote 500 mg p.o. q. hs.
5. Flagyl 500 mg p.o. t.i.d. for five days until [**2101-4-27**].
6. Simethicone 80 tabs 1.5 tabs q.i.d. p.r.n.
7. Levofloxacin 250 mg p.o. q. day for five days until
[**2101-4-27**].
8. Seroquel 100 mg p.o. q. hs.
9. Prevacid 30 mg p.o. q. day.
10. Verapamil 40 mg p.o. t.i.d.
11. Lisinopril 10 mg p.o. q. day.
11. Calcium and vitamin D.
12. Aspirin 81 q.o.d. held due to lower GI bleed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2101-4-22**] 12:37
T: [**2101-4-22**] 12:23
JOB#: [**Job Number 101226**]
|
[
"296.7",
"009.1",
"427.31",
"562.10",
"557.9",
"276.5",
"733.00",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2832, 2842
|
9005, 9278
|
9301, 10105
|
4754, 8824
|
3150, 4737
|
8839, 8984
|
108, 148
|
177, 1629
|
1651, 2815
|
2859, 3127
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,976
| 102,355
|
46834
|
Discharge summary
|
report
|
Admission Date: [**2168-7-2**] Discharge Date: [**2168-7-5**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 63 y/o F with history of hep C/ETOH cirrhosis with
multiple admissions for AMS who presents here with altered
mental status. At nursing home, she was found to have altered
mental status and was sent to an outside hospital where a UA was
positive, chest xray and head CT were negative. She was given 1
dose of levaquin at the outside hospital. She was transferred
here and her UA was positive and a CXR shows mild pulmonary
edema.
She has had several recent admissions for altered mental status.
Most recently [**Date range (1) 99384**] she was here with AMS and underwent
an infectious workup with negative results. CT of the head was
performed which was unremarkable. She underwent abdominal
ultrasound which did show patent TIPS. During hospital course,
she had no signs of active GI bleeding. Her hematocrit was
stable and she was not transfused. The patient was continued on
Lactulose and Rifaximin, as well as Zyprexa. She was also
admitted [**Date range (1) 99382**] for mental status
changes requiring intubation for airway protection. She was
treated for hepatic encephalopathy with increased lactulose
doses w/ improvement in her mental status.
In the ED, her vitals signs were Tm 100 BP 100/49 HR 79 sat97%
2LNC RR14. No ascites to tap for dxtic. She was given nalaxone,
as her tox screen was positive opiods and a mild improvement in
her mental status. UA was positive. Received a dose of
Vancomycin 1gm IV.
While in the MICU she was treated with Ciprofloxacin for urinary
tract infection, and lactulose/rifaximin for hepatic
encephalopathy. She remained hemodynamically stable upon
transfer to the floor.
Past Medical History:
1) Iron deficiency anemia
2) GI bleed - hemorrhoids, s/p TIPS; also w/ known portal
gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis with recurrent hepatic encephalopathy
8) Psychotic disorder on olanzapine
9) polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) temporal lobe epilepsy (per daughter no seizure in 30 yrs)
12) subcutaneous variceal rupture s/p hematoma exploration in
LLQ
13) Chronic kidney disease (baseline Cr ~1.4)
14) Fractures: clavicle and pubic rami
Social History:
Lives in nursing home. History of tobacco, EtOH and drug abuse.
She is originally from [**State 3908**]. She worked as an administrative
assistant when she was younger, but is now on SSDI (for
?schizophrenia and seizure disorder). Patient's daughter,
[**Name (NI) 4850**], is involved in care.
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
Vitals - T: BP:137/57 HR:84 RR: 02 sat: 96 2L
GENERAL: laying in bed, NAD, tangential in thought
SKIN: no jaundice
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no m/r/g
LUNG: CTAB
ABDOMEN: patient refused exam
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
NEURO: CN II-XII intact
Pertinent Results:
Admission Labs:
[**2168-7-2**] 07:44PM LACTATE-1.4
[**2168-7-2**] 04:25PM GLUCOSE-94 UREA N-36* CREAT-2.2* SODIUM-139
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-14* ANION GAP-21*
[**2168-7-2**] 04:25PM estGFR-Using this
[**2168-7-2**] 04:25PM CK(CPK)-229*
[**2168-7-2**] 04:25PM cTropnT-0.11*
[**2168-7-2**] 04:25PM CK-MB-13* MB INDX-5.7
[**2168-7-2**] 04:25PM WBC-7.2 RBC-3.63*# HGB-11.1*# HCT-35.8*#
MCV-99* MCH-30.5 MCHC-30.9* RDW-15.9*
[**2168-7-2**] 04:25PM NEUTS-75.1* LYMPHS-16.0* MONOS-7.0 EOS-1.7
BASOS-0.2
[**2168-7-2**] 04:25PM PLT COUNT-140*
[**2168-7-2**] 04:25PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2168-7-2**] 04:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-MOD
[**2168-7-2**] 04:25PM URINE RBC-21-50* WBC-[**6-21**]* BACTERIA-MOD
YEAST-NONE EPI-[**3-16**]
[**2168-7-2**] 04:25PM URINE HYALINE-[**3-16**]*
Pertinent Labs/Studies:
Trop: .11 -> .2 -> .13
CK: 229 -> 505 -> 192
Cr: 2.2 -> 2.4 -> 1.8 -> 1.1
Radiology:
ECG ([**7-2**]): Sinus tachycardia. Delayed R wave transition.
Compared to tracing #1 there is now an R wave in lead V2. This
may represent altered lead placement. Clinical correlation is
suggested
CXR ([**7-2**]): Mild pulmonary edema, similar to that seen on
[**2168-6-1**].
CXR ([**7-4**]): Mild worsening of pulmonary edema is seen, mainly
in the periphery of both lungs, left more than right.
U/S Abd/Pelvis ([**7-2**]): Patent TIPS. Velocities appear
appropriate although accuracy is diminished due to patient
motion. No evidence of ascites. Gallbladder sludge and stones.
No ultrasonic evidence of cholecystitis.
.
Micriobiology:
Urine cultures: [**2168-7-2**] : <10,000 organisms/ml.
Blood cultures: [**2168-7-2**] + [**2168-7-3**]: No growth
Discharge Labs:
[**2168-7-5**] 09:00AM BLOOD WBC-3.8* RBC-3.27* Hgb-10.0* Hct-30.6*
MCV-94 MCH-30.6 MCHC-32.7 RDW-16.3* Plt Ct-151
[**2168-7-5**] 09:00AM BLOOD Glucose-130* UreaN-26* Creat-1.1 Na-135
K-4.7 Cl-110* HCO3-17* AnGap-13
[**2168-7-4**] 05:05AM BLOOD CK(CPK)-192*
[**2168-7-5**] 09:00AM BLOOD Mg-1.3*
Brief Hospital Course:
Mrs. [**Known lastname **] is a 63 yo female with history of HepC/ETOH
cirrhosis, history of prior substance abuse, and recurrent
hepatic encephalopathy, who presents with altered mental status.
.
#. Altered Mental Status: Patient was found by nursing home to
have altered mental status on [**2168-7-2**]. On admission to OSH,
patient's U/A had large blood, moderate leukocytes, and moderate
bacteria. Patient also had a toxicology screen which was
positive for opioids. Review of med list from extended care
facility does not reveal opiod use, it is not clear where or
when patient received narcotics prior to admission to [**Hospital1 18**]. At
OSH, the patient was given one dose of Levoquin and naloxone,
after which she had some improvement in her mental status. On
admission to [**Hospital1 18**], patient received three doses of
Ciprofloxacin, was restarted on her home dose of lactulose and
rifaximin, and received IV hydration for treatment of acute
renal failure as the team thought her mental status change could
be related to dehydration, hepatic encephalopathy, or her UTI.
With above interventions the patient's mental status improved
and she is currently back to her baseline, oriented x 2, often
tangential in thought.
.
#. Acute Renal Failure: Patient's Cr was elevated from baseline
of 1.2 to 2.4 on admission. The patient appeared hypovolemic and
received two boluses of IV fluids, as the team believed her ARF
was caused by dehydration in the setting of lactulose
administration, diuresis and poor PO intake. The patient's Cr
returned to her baseline of 1.1 with volume resuscitation and
holding diuretics. On discharge the patient's diuretics have
been held. Would recommend daily weights with the reinitiation
of Lasix 10 mg daily if the patient has a weight gain of [**2-14**]
pounds or clinical evidence of fluid overload.
.
#. Urinary Tract Infection: Patient was found to have a positive
urine analysis upon admission to the OSH. She was given one
dose of Levoquin before transfer to [**Hospital1 18**]. Upon admission at
[**Hospital1 18**], patient completed a course of 500 mg of Ciprofloxacin PO
q24h (i.e. 3 days) although of note her urine culture <10,000
bacteria.
.
#. Cirrhosis: Patient has a history of HCV cirrhosis with
history of recurrent hepatic encephalopathy. She is s/p TIPS
for GI bleeding and portal gastropathy. Patient was continued
on her previous regimen of lactulose, rifaximin, and ursodiol.
Her LFTs remained stable throughout this admission and was
treated for encaphalopathy as above.
.
#. Iron deficiency anemia: On review of her records, patient is
known to have a history of iron deficiency anemia, most likely
secondary to known portal hypertensive gastropathy and internal
hemorrhoids on recent EGD/Colonoscopy. On this admission, her
Hct remained stable and she did not require any blood
transfusions.
.
#. Seizure disorder: On review of her records, patient has a
history of a seizure disorder, which has been well controlled on
her outpatient medications. Patient was continued on
Levetiracetam and had no acute events while in the hospital.
.
#. Psychiatry: Patient has a history of psychosis, possibly due
to schitzophrenia per chart review. She was continued on her
outpatient regimen of olanzapine with return to baseline mental
status as above
.
#. Code Status: FULL CODE
Patient was previously listed as DNR/DNI last admission after
discussion with attending on record. This admission the
patient's daughter/HCP wished to readdress this decision and
after discussion with family members made decision that she
would like the patient's code status to be changed to FULL CODE
at this time. This was discussed extensively with the patient's
daughter including current health status, chronic disease and
prognosis. After conversation the patient's daughter still
reported she wanted to maintain full code status
Medications on Admission:
1. Acetaminophen 325 mg 1-2 Tablets PO Q8 PRN Not to exceed
2gm/day.
2. Milk of Magnesia Oral
3. Bisacodyl 5 mg once a day as needed for constipation.
4. Levetiracetam 500 mg PO twice daily.
5. Metoprolol Tartrate 100 PO 2 times a day
6. Ursodiol 300 mg PO 2 times daily
7. Olanzapine 5 mg PO BID
8. Ferrous Sulfate 325 mg DAILY
9. Rifaximin 600 mg 2 times a day
10. Hexavitamin Daily
11. Omeprazole 20 mg daily
12. Diphenhydramine HCl 12.5 mg/5 mL q6h as needed for pruritis
13. Menthol-Cetylpyridinium 3 mg as needed
14. Aranesp (Polysorbate) 25 mcg/mL one injection weekly
15. Ipratropium Bromide 0.02 % q6h as needed for shortness of
breath
16. Lactulose 10 gram/15 mL 60 ML PO four times a day: Titrate
to maintain 4-6BMs per day.
17. Calcium Carbonate 500 mg twice daily
18. Cholecalciferol (Vitamin D3) 400 unit Twice daily
19. Furosemide 10mg daily
20. Olanzapine 5 mg Tablet, Rapid Dissolve q6h for agitation
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Milk of Magnesia 400 mg/5 mL Suspension [**Hospital1 **]: Five (5) PO
once a day as needed for constipation.
3. Bisacodyl 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day as
needed for constipation.
4. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
5. Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO
twice a day.
6. Ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
7. Olanzapine 2.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release [**Hospital1 **]: One (1) Capsule, Sustained Release PO once a day.
9. Rifaximin 200 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times
a day).
10. Multivitamin Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Aranesp (Polysorbate) 25 mcg/mL Solution [**Hospital1 **]: One (1) ml
Injection once a week: Please continue as previous.
13. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1)
nebulization Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
14. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day): Please titrate for [**3-15**] BMs/day.
15. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (3) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (3) **]: One (1)
Tablet PO twice a day.
17. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day (3) **]: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Altered mental status
Hepatic Encephalopathy
Acute Renal Failure
Urinary Tract Infection
.
Secondary Diagnoses:
Iron deficiency anemia
H/o recurrent GI bleed - grade 4 rectal varices, s/p TIPS [**11-18**];
also w/ known portal gastropathy
Sigmoid diverticulosis
Schatzki's ring
Duodenal polyps and duodenitis
MGUS
Etoh/ HCV cirrhosis
Psychotic disorder on olanzapine
Polysubstance abuse - etoh, cocaine, marijuana
COPD
Temporal lobe epilepsy (per daughter no seizure in 30 yrs)
Discharge Condition:
Good. Patient's mental status is currently at baseline. Her
acute renal failure has resolved.
Discharge Instructions:
Please take all medications as prescribed.
.
Please keep all outpatient appointments as scheduled.
.
Please return to the hospital if you experience any increase in
confusion, fevers, chills, difficulty breathing, or any other
concerning symptoms.
Followup Instructions:
Please keep following scheduled appointments:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-8-2**] 1:10
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-8-2**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-8-19**] 9:00
Completed by:[**2168-7-5**]
|
[
"571.2",
"298.9",
"276.2",
"280.9",
"305.90",
"780.39",
"276.52",
"496",
"599.0",
"585.9",
"572.2",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12348, 12421
|
5606, 5815
|
313, 320
|
12952, 13050
|
3470, 3470
|
13346, 13799
|
2889, 3022
|
10469, 12325
|
12442, 12542
|
9523, 10446
|
13074, 13323
|
5287, 5583
|
3037, 3451
|
12563, 12931
|
252, 275
|
348, 1983
|
3486, 5270
|
5831, 9497
|
2005, 2560
|
2576, 2873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,658
| 163,434
|
40278
|
Discharge summary
|
report
|
Admission Date: [**2100-11-19**] Discharge Date: [**2100-11-22**]
Date of Birth: [**2019-10-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Altered Mental Status/Delirium
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 y/o male with CAD, sCHF and dCHF (EF 45-50%), pacemaker, CKD
(baseline Cr 2.0-2.4), AF (on coumadin), hx stroke (no residual
weakness), COPD/emphysema (not on home O2), who presents from
[**Hospital3 **] facility to the ED after what appears to be an
unwitnessed mechanical fall with acute agitation.
.
He was supposed to be admitted to [**Location (un) 620**] for CHF, fluid
overload, as his breathing is worse over last 2 days. However,
he got up and fell, with + head strike. EMS diverted from
[**Location (un) 620**] due to AMS en route.
.
Of note, per discussion with daughter, pt has had progressive
SOB over months. His lasix and zaroxylyn have been titrated by
cardiology. He was last noted to be conversant and in good
spirits yesterday. Of note, he was noted to have "jerking
movements" by his RN at [**Hospital3 **]. She reports that he has
been drinking wine and bloody [**Doctor First Name **] at the rehab "over the past
few days." When gathering additional collateral information,
daughter reports that pt was encouraged to seek psychiatry help
as he has had "outbursts" in the past but never directed at
other people.
.
Initial ED vitals - not provided. Exam: somnolent, arouses to
voice but does not follow simple commands. Laceration left
posterior scalp. Labs: Cr 3.8 (baseline 2.4). FAST: trace
pericardial effusion, otherwise negative. Pt given lasix 20 mg
IV. Pt underwent lac repair with 4 staples. Tetanus given in ED.
Pt also underwent x-rays left shin due to bruise, pending at
this time.
.
Neuro consulted: Neurological examiantion shows classic textbook
metabolic encephalopathy with diffuse myoclonic jerks as well as
asterixis. This is diagnostic of metabolic encephalopthy, such
as acute on chronic renal failure in this patient. (Cr of 3.8,
baseline 2 to 2.2). The differential would be seizure, which is
unlikely given well conversant behaviour during the classic
myoclonic jerks. No further neurological work up indicated at
this point.
.
Vitals on transfer - 97.2, 71, 21, 113/89, 100 RA
Mental Status: alert, oriented to self, confused, unable to
follow commands.
Access: 22G, 18G
.
On arrival to the MICU, pt is confused, unable to follow
commands.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- CAD, status post PCI about 7 or 8 years ago
- CHF, both systolic and diastolic
- Ischemic cardiomyopathy with EF of 45% to 50% with akinesis of
the inferior and inferolateral walls.
- HTN
- HLD
- Permanent pacemaker implant in [**2085**] following sinus
bradycardia, PR prolongation and Mobitz type 1. Secondary AV
block presenting with syncope
- hx stroke (no residual weakness)
- emphysema/COPD
- CKD, baseline 2 to 2.4
- pAF on coumadin
- OSA
Social History:
Fell at home in [**Hospital3 **] ([**Location (un) **]) with a nurse in the
other room. No smoking, or drugs. No recent report of EtOH at
[**Hospital3 **].
Family History:
NC
Physical Exam:
VS: afebrile, HR 84, BP 116/76, RR 18, 100% RA
General: alert, oriented to self, confused, unable to follow
commands
HEENT: head bandaged with posterior blood and sutures, no
scleral icterus noted, MM dry, no lesions noted in oropharynx
Neck: No carotid bruits appreciated. No nuchal rigidity
Pulmonary: mild bibasilar crackles
Cardiac: Irreg Irreg.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: minimal pedal edema
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, says "I am in hospital in [**Location (un) 620**].
[**2023-12-16**]." Very inattentive and not able to relate history.
Language is fluent with intact repetition and comprehension. Pt
was able to name both high and low frequency objects. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall 0/3 at 15
minutes. There was no evidence of apraxia or neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
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:
Classic mutifocal bilateral brief twitches enough to move
various
joints. Pathognomic of myoclonic jerks due to metabolic
encephalopathy. He has both positive and negative myoclonus
(asterixis)
Unable to test individual muscle strength in view of
inattention.
at least antigravity in all limbs and is symmetric.
-Sensory: Intact to tocuh and pain in all limbs.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was extensor bilaterally.
-Coordination/Gait: Defd.
.
At discharge:
Objective: aaox3
Vitals: 97, 125/68, 69, 18, 100% RA
Examination:
HEENT: head bandaged with posterior blood and sutures, no
scleral icterus noted, MM dry, no lesions noted in oropharynx
Neck: No carotid bruits appreciated. No nuchal rigidity
Pulmonary: mild bibasilar crackles
Cardiac: Irreg Irreg.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: minimal pedal edema
Skin: no rashes or lesions noted.
Pertinent Results:
[**2100-11-22**] 06:50AM BLOOD WBC-5.9 RBC-3.62* Hgb-10.3* Hct-30.9*
MCV-85 MCH-28.4 MCHC-33.3 RDW-14.6 Plt Ct-179
[**2100-11-21**] 07:40AM BLOOD WBC-7.7 RBC-3.54* Hgb-10.2* Hct-30.1*
MCV-85 MCH-28.8 MCHC-33.8 RDW-14.7 Plt Ct-161
[**2100-11-20**] 02:24AM BLOOD WBC-7.7 RBC-3.45* Hgb-10.4* Hct-29.2*
MCV-85 MCH-30.3 MCHC-35.7* RDW-14.6 Plt Ct-158
[**2100-11-19**] 11:37AM BLOOD WBC-7.5 RBC-3.79* Hgb-11.1* Hct-31.8*
MCV-84 MCH-29.3 MCHC-34.9 RDW-14.4 Plt Ct-195
[**2100-11-20**] 02:24AM BLOOD Neuts-81.9* Lymphs-10.4* Monos-4.4
Eos-3.0 Baso-0.3
[**2100-11-19**] 11:37AM BLOOD Neuts-81.4* Lymphs-12.6* Monos-4.1
Eos-1.7 Baso-0.2
[**2100-11-22**] 06:50AM BLOOD Plt Ct-179
[**2100-11-22**] 06:50AM BLOOD PT-28.7* PTT-37.1* INR(PT)-2.8*
[**2100-11-21**] 07:40AM BLOOD Plt Ct-161
[**2100-11-21**] 07:40AM BLOOD PT-27.4* PTT-38.2* INR(PT)-2.6*
[**2100-11-20**] 02:24AM BLOOD Plt Ct-158
[**2100-11-20**] 02:24AM BLOOD PT-29.7* INR(PT)-2.9*
[**2100-11-19**] 11:37AM BLOOD Plt Ct-195
[**2100-11-19**] 11:37AM BLOOD PT-29.5* PTT-34.5 INR(PT)-2.9*
[**2100-11-22**] 06:50AM BLOOD Glucose-118* UreaN-55* Creat-2.5* Na-146*
K-3.6 Cl-110* HCO3-26 AnGap-14
[**2100-11-21**] 07:40AM BLOOD Glucose-116* UreaN-60* Creat-2.9* Na-145
K-4.0 Cl-110* HCO3-26 AnGap-13
[**2100-11-20**] 02:24AM BLOOD Glucose-90 UreaN-73* Creat-3.5* Na-143
K-4.2 Cl-107 HCO3-23 AnGap-17
[**2100-11-19**] 11:37AM BLOOD Glucose-114* UreaN-78* Creat-3.8* Na-142
K-4.8 Cl-105 HCO3-24 AnGap-18
[**2100-11-19**] 11:37AM BLOOD ALT-22 AST-20 AlkPhos-79 TotBili-0.3
[**2100-11-22**] 06:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
[**2100-11-21**] 07:40AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.3
[**2100-11-20**] 02:24AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2
[**2100-11-19**] 11:37AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2
[**2100-11-19**] 11:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2100-11-19**] 11:50AM BLOOD K-4.7
[**2100-11-21**] Renal USS
Limited study without evidence of hydronephrosis. Mild cortical
thinning compatible with chronic renal disease.
[**2100-11-20**] CXR
1. Dual-lead left-sided pacer with its lead terminating over the
expected
location of the right atrium and right ventricle, respectively.
Stable
cardiac and mediastinal contours with stable overall cardiac
enlargement.
Interval appearance of mild interstitial and pulmonary edema.
More focal
patchy opacity at the right costophrenic angle may be related to
the edema
although an early aspiration or infectious process cannot be
excluded. No
large pleural effusions. No evidence of pneumothorax.
[**2100-11-19**] Tib/Fib AP/Lateral
Focal soft tissue swelling with no evidence of an underlying
bony
abnormality in the area of concern as indicated by the patient.
Degenerative
changes of the left knee.
[**2100-11-19**] CXR
Hazy bibasilar opacities, slightly more nodular on the right.
Diagnostic considerations favor atelectasis given volume loss;
however, early
developing pneumonia or aspiration cannot be entirely excluded.
In addition,
given the lack of comparison studies, an underlying occult
pulmonary nodule
also cannot be excluded.
[**2100-11-19**] CT head without contrast
1. No acute intracranial process.
2. Left occipital subgaleal hematoma and laceration.
3. Age-related atrophy and chronic small vessel ischemic
changes.
[**2100-11-19**] CT C-spine without contrast
No acute fracture or traumatic malalignment. Mild degenerative
changes as outlined above.
Brief Hospital Course:
81 y/o male with CAD, sCHF and dCHF, pacemaker, CKD (baseline Cr
2.0-2.2), AF (on coumadin), hx stroke (no residual weakness),
COPD/emphysema, who presents after unwitnessed mechanical fall,
and is noted to have toxic metabolic encephalopathy and acute
agitation/delerium.
.
# Altered mental status/toxic metabolic encephalopathy/acute
delerium: neurological examination shows classic textbook
metabolic encephalopathy with diffuse myoclonic jerks as well as
asterixis. This is diagnostic of metabolic encephalopthy, with
most likely etiology as acute on chronic renal failure. Unclear
if he has an underlying psychiatry history, as daughter does
report prior episodes of "outbursts." CT head is negative which
makes ICH unlikely. Stox and Utox negative. INR is 2.9 which is
reassuring for protection against embolic strokes, although
lacunar strokes and the other stroke syndromes typically do not
present with change in mental status and diffuse myoclonus. The
differential would be seizure, which is unlikely given well
conversant behaviour during the classic myoclonic jerks. Per
neurology, no need for further w/u (no MRI, EEG). IVF challenge
was given to correct uremia to which the patient's Cr responded.
The patient was put on 0.2 Precedex overnight in the MICU to
which he apparently responded well. He was subsequently
transferred to the floor, where his mental status improved
gradually. At the time of discharge he was a&ox3 and at his
baseline per patient and daughter.
.
# [**Last Name (un) **] on CKD: DDx includes pre-renal cause from worsening of CHF
leading to decreased perfusion of kidneys vs. pre-renal from
poor PO intake/dehydration. Urine sediment was bland with urine
electrolytes further suggeting prerenal. Renal USS showed no
evidence of obstructive uropathy. His creatinine had trended
down to baseline by the time of discharge.
.
# Dyspnea: mild pulmonary vascular congestion was found, but no
frank volume overload on CXR was seen. No wheezing to suggest
COPD exacerbation. No fever, wbc, cough, sputum to suggest
pneumonia. We continued albuterol and ipratropium nebs. On the
night of [**2100-11-19**], he became dyspneic, but with good oxygen
saturation. He was given 20 mg PO lasix and his dyspnea
improved suggesting mild acute failure. He was discharged on 10
mg lasix, as well as metoprolol tartrate for blood pressure
control.
.
# Unwitnessed fall: suspected mechanical fall, but unclear
etiology. Has had 3-4 episodes of fall this year per daughter.
[**Name (NI) **] cardiopulmonary symptoms to suggest arrhythmia prior to fall.
No evidence for block on EKG. Patient reported weakness worse
from his baseline during his stay in the MICU.
.
# sCHF and dCHF: mildly volume overloaded on exam. Ischemic
cardiomyopathy with EF of 45% to 50% with akinesis of the
inferior and inferolateral walls. We held diuretics, but started
10 mg lasix daily at the time of discharge. Metalozone was
held: nursing home to consider whether uptitration of lasix or
addition of metalozone is required for blood pressure control
.
# CAD: status post PCI about 7 or 8 years ago. We continued
aspirin and statin
.
# AF: Patient was on coumadin. INR was 2.9 and we continued
coumadin
.
# HTN: We held lasix, metolazone, imdur initially. However,
following discusion with PCP, 12.5 mg [**Hospital1 **] metoprolol and 10mg
daily lasix were added at the time of discharge. Patient had
once been on beta-blocker, but this had been changed during a
previous admission for COPD exacerbation. In the current
setting, his dyspnea is at baseline and he would benefit from a
beta-blocker long term in the setting of CHF. Rehab to monitor
BP, fluid overload and add back metalozone, imdur and uptitrate
lasix if required.
.
# GERD: We continued omeprazole [**Hospital1 **]
.
# Depression: We continued mirtazapine
.
# BPH: doxazosin was held but restarted at the time of
discharge.
.
TRANSITIONAL ISSUES:
-patient antihypertensive regimen was changed: He came in on
metalozone, lasix, imdur. He was discharged on 12.5 mg
metoprolol tartrate [**Hospital1 **], 10mg lasix daily. He will require
close monitoring of BP, dyspnea, fluid overload and titration or
alteration of his antihypertensive medication as required.
-sodium was trending up at discharge, please check electrolytes
daily and correct free water deficit as required.
-please continue physical therapy
Medications on Admission:
- lasix 20 mg daily
- coumadin 5 mg daily
- simvastatin 40 mg daily
- asa 81 mg daily
- folic acid 1 mg daily
- omeprazole 20 mg daily
- cardura
- senna
- colace
- albuterol
- mirtazipine 15 mg qHS
- dulera 2 mg [**Hospital1 **]
- MVI
- purelax 17 mg qod
- vitamin C
- zaroxylyn 2.5 mg every other week
- imdur 30 mg daily
Discharge Medications:
1. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Cardura 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Dulera 200-5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation twice a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. Purelax 17 gram Powder in Packet Sig: One (1) PO once a
day.
15. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary: Metabolic encephalopathy, acute on chronic renal
failure
Secondary: congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 88388**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted following a fall
and were found to be confused and shaking. We found that this
was probably due to worsening of your kidney functionn, probably
due to increased alcohol intake and dehydration recently.
Ultrasound tests did not show any obstruction in your kidneys.
You were treated with fluids in the intensive care unit and your
mental status and kidney function improved.
We made the following changes to your medications:
-STARTED metoprolol tartrate
-CHANGED furosemide to 10 mg daily
-STOPPED Metalozone
-STOPPED Imdur
.
Please continue your other medications as usual.
Followup Instructions:
Name: [**Doctor Last Name **] [**Last Name (LF) **],[**First Name3 (LF) 20**] H.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3070**]
***Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge
Completed by:[**2100-11-23**]
|
[
"333.2",
"530.81",
"V12.54",
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"305.00",
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"414.8",
"427.31",
"V45.82",
"280.9",
"327.23",
"285.21",
"584.9",
"873.0",
"293.0",
"492.8",
"349.82",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15720, 15793
|
9597, 13495
|
338, 345
|
15939, 15939
|
6153, 9574
|
16833, 17249
|
3693, 3698
|
14353, 15697
|
15814, 15918
|
14005, 14330
|
16115, 16630
|
4695, 5672
|
3713, 4226
|
5686, 6134
|
13516, 13979
|
16659, 16810
|
2583, 3031
|
268, 300
|
373, 2399
|
15954, 16091
|
3053, 3503
|
3519, 3677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,326
| 148,589
|
36497
|
Discharge summary
|
report
|
Admission Date: [**2171-1-4**] Discharge Date: [**2171-1-7**]
Date of Birth: [**2133-2-23**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Left lower quadrant, retroperitoneal bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 M with tuberous sclerosis with renal angiolipomas and
previous right retroperitoneal bleed treated conservatively
transferred from [**Hospital 1474**] Hospital with two day history of left
lower quadrant pain and mild vertigo. Patient was at his group
home on day of admission when he developed left lower quadrant
pain and generally "not feeling well." He was found to have a
hematocrit of 19 at the hospital, where he underwent
non-contrast CT scan; CT scan showed a significant left
retroperitoneal bleed x2 believed to be secondary to a bleeding
angiomyolipoma. Patient was transfused two units of blood and
transferred to the [**Hospital1 18**].
.
In the ED, patient's vitals were: T98.9, HR96, BP116/65, RR18,
100%O2 sat on RA. Surgery was consulted and felt there was no
emergent need to take patient to the operating room.
Interventional Radiology also evaluated patient and felt any
invasive intervention would be potentially too complicated given
multiple tumors in that region. If patient continues to bleed,
however, plan is for IR to attempt intervention first. Urology
(Dr. [**Last Name (STitle) **] felt that given patient's past right retroperitoneal
bleed which responded well to conservative management, patient
should receive blood transfusions and close monitoring. Patient
has refused any surgical interventions in the past for these
tumors (as recently as 10/[**2169**]). He was seen in the ED with his
father (legal guardian) and mother at the bedside. Patient
reported positive flatus and non-bloody brown bowel movements
the morning of admission and the evening prior. Patient states
he had some nausea on the morning of admission but no emesis. He
denied any SOB, chest pain, leg pain. His pain has improved
after pain medications were administered in the ED. Patient was
transferred to the MICU for close management.
.
In the MICU, patient arrived with vitals T99.5 HR93 BP126/63
saturating 98% on 2L NC. He developed a fever to 101.2 which
defervesced with Tylenol. Blood cultures were drawn and no
infectious etiology or localizing symptoms noted thus far. It
was felt patient's low grade fever may be attributable to his
retroperitonal hematoma. When his hematocrit was found to be
23.5 after 3 units of pRBC, he was transfused another unit with
appropriate hematocrit bump to 27. Patient's hematocrit on
morning of transfer to CC7 was stable at 25.
.
When seen in the MICU shortly prior to transfer, patient was
pleasant, in no apparent distress with father at the bedside. He
denies any more abdominal pain and denies shortness of breath,
dizzyness, fatigue/lethargy. Did not feel any fevers/chills.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- Tuberous sclerosis
- Chronic renal insufficiency
- Angiomyolipomas
- Seizure disorder: per mother, no seizures since [**2148**]
- Hypertension
- Right retroperitoneal bleed: managed conservatively
Social History:
No tobacco, EtOH, or drugs. Lives in group home. [**Name (NI) **]
father lives in [**Name (NI) 1727**] and is his legal guardian and his mother
lives in [**Name (NI) 27256**], MA. There are problems in guardianship
regarding his custody. Patient plans to go to his mother's home
in [**Location 27256**] upon discharge, given her proximity to the [**Hospital1 18**].
He will not need any medical services, per father.
Family History:
Sister with breast cancer
Physical Exam:
Vitals: T:99.1 BP:129/62 P:98 R:17 O2:94%RA
General: Alert, oriented, no acute distress, pleasant
HEENT: Sclera anicteric, NCAT, MMM, [**Last Name (un) **]/oropharynx clear,
slightly poor dentition
Neck: Soft, supple, no JVD/LAD
Skin: Numerous papillioform skin lesions on nasolabial folds,
cheecks, neck
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no rubs/gallops,
3/6 systolic ejection murmur
Abdomen: Firm and mildly distended, non-tender, +BS
Ext: Warm, well perfused; +DP/PT pulses, no
clubbing/cyanosis/edema
Pertinent Results:
Chem 10
139 107 23 125 AGap=13
4.7 24 1.9
Ca: 8.1 Mg: 1.8 P: 3.3
.
CBC
6.8 > 7.0 < 272
20.1
N:84.5 L:11.0 M:4.0 E:0.4 Bas:0.2
.
PT: 15.0 PTT: 33.6 INR: 1.3
.
CXR ([**2171-1-5**], Portable AP): The heart size is moderately
enlarged, similar in appearance compared to the study from the
prior day. There is no focal infiltrate or effusion.
.
CT abdomen: Large left retroperitoneal hematoma likely secondary
to bleeding
angiomyolipoma of the left kidney. Contrast-enhanced CT may be
performed to
assess for active extravasation.
.
EKG: Sinus rhythm. Delayed R wave progression that is
non-diagnostic. There are also septal T wave changes that are
non-specific. Compared to the previous tracing of [**2170-3-29**] there
is no significant diagnostic change.
.
Brief Hospital Course:
37 yo male with tuberous sclerosis and renal angiolipomas,
previous right retroperitoneal bleed who presents with new acute
onset left retroperitoneal bleed that was treated
conservatively. Patient's hematocrit stabilized from Hct 19 -->
25 with no more symptoms.
.
# Retroperitoneal bleed: Likely secondary to bleeding renal
angiomyolipoma as complication of tuberous sclerosis. Patient's
retroperitoneal bleed tamponaded and was managed conservatively.
Urology/surgery/interventional radiology all followed patient
closely during the admission, with plans for interventional
radiology procedure first if patient became hemodynamically
unstable. Patient's hematocrit was initially checked every 8
hours with a goal of Hct >25. He was also monitored with serial
abdominal exams. following.
.
# Fever: Questionable whether related with loss of blood, 4
units of blood products transfused or retroperitoneal blood
collection. Urinalysis was negative and the chest xray
unrevealing. Blood cultures also did not grow anything back and
patient's white blood count remained normal.
.
# Trigger word: The word, "surgery" makes patient severely
anxious/uncomfortable with potential behavioral issues. Per
family, "intervention" was recommended to be used instead only
if absolutely necessary. As patient declined surgical
intervention during this hospitalization, his retroperitoneal
hematoma was conservatively managed.
.
# Chronic renal failure: Stable during this hospitalization.
Baseline Creatinine 1.5-1.6.
.
# Hypertension: Patient was initially hypotensive secondary to
the retroperitoneal hematoma. He was closely monitored in the
MICU and started on low-dose short acting Metoprolol once stable
(instead of his home Toprol). Patient's blood pressures and
heart rate were monitored and he was discharged on lower dose of
his long-acting Metoprolol with instructions to resume his home
dose of Toprol after seeing his primary care physician.
.
# Seizure history: Clinically stable during this
hospitalization. Patient was continued on outpatient
carbamazepine.
.
# Code: Full (discussed with patient)
.
Medications on Admission:
* Claritin 10mg daily (non-formulary)
* Fluticasone Nasal 2 sprays each nostil
* Amantadine 100mg twice daily
* Carbatrol 400mg qAM, 600mg qPM
* Toprol XL 200mg daily
Discharge Medications:
1. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. Amantadine 50 mg/5 mL Syrup Sig: Two (2) PO BID (2 times a
day).
4. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
5. Carbamazepine 200 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day: Please check your
blood pressures daily. You will likely need to resume your
higher dose of 200mg daily once your blood pressures improve.
Please speak with your primary care doctor about this. .
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Left retroperitoneal bleed, tuberous sclerosis with
renal angiomyolipomas
Secondary: Past right retroperitoneal bleed, chronic renal
insufficiency, hypertension, seizure disorder
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 with abdominal pain and found to have a
spontaneous bleed into your left lower back (retroperitoneal).
You were treated conservatively with close monitoring and blood
transfusions. The bleed stopped and gradually walled itself off
- it will likely slowly reabsorb.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> DECREASE your Toprol to 75mg daily for now. Please check
your blood pressures daily. Once they start improving and are
consistently above 140-150/90s, you can discuss with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9457**] your home Toprol dose of
200mg daily.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at his [**Hospital1 1474**] office. You have an appointment on
[**Last Name (LF) 2974**], [**1-18**] at 10am. You can reach his office at:
[**Telephone/Fax (1) 64296**]
.
Please follow up with your urologist, Dr. [**First Name8 (NamePattern2) 161**] [**Name (STitle) 162**] [**Name8 (MD) 163**], MD.
You have an appointment for [**Last Name (LF) 766**], [**1-21**] at 11:15 am. You
can reach his office at: [**Telephone/Fax (1) 921**]
|
[
"780.39",
"759.5",
"285.1",
"317",
"568.81",
"403.90",
"223.0",
"585.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8572, 8578
|
5463, 7567
|
307, 314
|
8810, 8810
|
4669, 5440
|
9955, 10511
|
4024, 4051
|
7784, 8549
|
8599, 8789
|
7593, 7761
|
8987, 9932
|
4066, 4650
|
2998, 3352
|
225, 269
|
342, 2979
|
8824, 8963
|
3374, 3574
|
3590, 4008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,474
| 162,514
|
39154
|
Discharge summary
|
report
|
Admission Date: [**2188-2-17**] Discharge Date: [**2188-2-22**]
Date of Birth: [**2135-9-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
jaundice, confusion
Major Surgical or Invasive Procedure:
Intubation [**2188-2-21**]
PICC placement [**2188-2-19**]
Paracentesis [**2188-2-18**]
History of Present Illness:
52-year-old man with history of alcoholic cirrhosis, hepatic
encephalopathy, CAD s/p CABG, DM2, HTN presented with one week
of increasing jaundice and altered mental status. Patient has
recently started drinking again. For the past few days his wife
has noticed worsening jaundice. He has been more confused and
slower to respond than normal. Also reports some mild RUQ pain,
increased LE edema.
.
Reports some subjective fevers, chronic coughs, dysuria at home.
Also some nonbloody vomiting when he was drinking. His last
drink was 1 week ago. Before that he was drinking 6 beers a day.
.
In the ED, initial VS: T 98.9, HR 102, BP 153/64, RR 18, 100%RA.
Oriented x 3, positive asterixis, jaundice, RUQ tenderness. WBC
9.8, INR 2.7, Cr 6.9, and Tbili 29.9 with AST 248, ALT 86. RUQ
showed cirrhosis and moderate ascites but no cleear pocket of
fluid for paracentesis. Patient received ceftriaxone 1 gm IV x 1
for presumed SBP. Also lactulose. Hepatology aware. By the time
of arrival to MICU, T 98.0, HR 92, BP 131/92, RR 14, 97%RA.
Past Medical History:
Alcoholic and hep C cirrhosis
CAB s/p CABG: 20 years ago, s/p stent at [**Hospital1 2177**] a few years ago per
wife
DM2
HTN
Polysubstance abuse
Social History:
Drinks 6 beers/day; stopped using heroin 15 years ago; currently
on disability
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
T 98.0, HR 92, BP 131/92, RR 14, 97%RA
GENERAL: middle-aged man lying in bed, talking slowly
NEURO: oriented x 3, able to name months backwards slowly,
positive asterixis
HEENT: EOMI, sclera icteric
CARDIAC: RR, 3/6 systolic murmur best heart at RUSB
LUNG: CTAB
ABDOMEN: slightly firm, distended, mildly tender diffusely,
bowel sounds present
EXT: trace ankle edema bilaterally
DERM: scattered ecchymoses throughout body
Pertinent Results:
[**2188-2-17**] 09:43PM GLUCOSE-81 UREA N-64* CREAT-6.8* SODIUM-132*
CHLORIDE-99 TOTAL CO2-19*
[**2188-2-17**] 09:51PM K+-5.1
[**2188-2-17**] 09:43PM AMMONIA-80*
[**2188-2-17**] 09:43PM WBC-9.1 RBC-3.37* HGB-12.5* HCT-36.1*
MCV-107* MCH-37.1* MCHC-34.5 RDW-15.3
[**2188-2-17**] 09:43PM PLT COUNT-107*
[**2188-2-17**] 05:50PM ALT(SGPT)-86* AST(SGOT)-248* ALK PHOS-128 TOT
BILI-29.9*
[**2188-2-17**] 05:50PM LIPASE-51
[**2188-2-17**] 05:50PM ALBUMIN-2.4* CALCIUM-7.4* PHOSPHATE-7.5*
MAGNESIUM-2.1
[**2188-2-17**] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-2-17**] 05:03PM TYPE-[**Last Name (un) **] PO2-39* PCO2-44 PH-7.27* TOTAL
CO2-21 BASE XS--6 COMMENTS-GREEN TOP
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] was a 52-year-old man with history of alcoholic
cirrhosis, hepatic encephalopathy, CAD s/p CABG, DM2, HTN who
presented after several days of increasing jaundice and altered
mental status, concerning for acute alcoholic hepatitis and
decompensated liver failure. His work up revealed no evidence of
portal vein thrombosis, active systemic infection, or
significant GI bleed. He developed progressive renal failure and
became volume overloaded. As he was not a candidate for liver
transplant given his recent alcohol use, he was also not a
candidate for dialysis. Patient's encephalopathy and volume
overload progressed to the extent that he was unable to protect
his airway and required intubation. Family was informed of the
patient's poor prognosis given his progressive renal failure,
respiratory failure, liver failure, and coagulopathy. After
several family meetings regarding goals of care the patient was
ultimately made CMO. He was terminally extubated on [**2188-2-21**]. On
[**2188-2-22**] patient was pronounced dead.
Medications on Admission:
lisinopril 10 mg qday
metoprolol 12.5 mg qday
aspirin
glyburide 5 mg qday
methadone 40 mg qday
Discharge Medications:
No discharge medications as patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute on chronic liver failure
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
|
[
"567.23",
"038.9",
"789.59",
"403.90",
"V45.81",
"507.0",
"303.91",
"070.44",
"571.2",
"276.1",
"572.4",
"571.1",
"585.9",
"584.9",
"995.92",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"54.91",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
4311, 4320
|
3015, 4096
|
323, 411
|
4394, 4412
|
2259, 2992
|
4477, 4496
|
1756, 1774
|
4242, 4288
|
4341, 4373
|
4122, 4219
|
4436, 4454
|
1789, 1803
|
264, 285
|
439, 1475
|
1817, 2240
|
1497, 1644
|
1660, 1740
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,328
| 182,179
|
35295
|
Discharge summary
|
report
|
Admission Date: [**2198-9-16**] Discharge Date: [**2198-9-22**]
Date of Birth: [**2166-2-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Fever x 10 days, rashes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt. is a 32 year old painter w/PMH of unspecified childhood
rheumatological diseases who presents with 10 day hx of fevers
to 102.5, chills, nausea, vomiting, and a frontal headache. The
patient also developed a macular rash 3 days ago which began on
his ankles, appeared on his ears, then his knees, and finally
his elbows and his abdomen. Pt. mentions that his fevers wax
and wane, and that he feels heat intolerance. Pt. also has a
nonproductive cough. He presented to [**Hospital6 **]
where he received an extensive workup that returned negative for
Lyme, Babesia, Erlichia. Blood cultures at OSH were negative to
date. Pt. also had labs drawn which were notable for a mild
pancytopenia w/WBC at 3.4 w/L.shift, Hct at 33, Plt at 110. Pt.
also had elevated AST and ALT at 146 and 117. CSF findings had
were notable for monocytes of 100. Pt. mentions recent travel
to [**Country **] 6 months ago, having sexual relations once 6 months
ago during which time he used a condom. The patient also
mentions using some sort of brazilian possibly homeopathic
medication for stress, under the names of "Donaren" (possibly
trazodone), "Cloridrato" (possibly chloride), "Trazodoma"
(possibly trazodone as well), and "Viferrin" (unknown). Pt.
reports stopping these medications about a week prior to
symptoms. Pt. also mentions having scraped his lower right knee
playing soccer 2 days before the onset of symptoms.
Pt. denies any diarrhea, constipation, loss of consciousness,
visits to wooded areas, tick bites, animal bites, exposure to
any new type of toxin (patient reports no changing of materials
for his paint recently), chest pain. Patient was a direct
transfer to the floor.
Past Medical History:
-An ambiguous childhood "rheumatism"
-dx of schistosomiasis in [**Country **], not treated
-Hernia surgery [**04**] years ago
Social History:
Patient lives with his younger brother and works as a painter.
Patient denies any tobacco or alcohol use. He mentions his last
sexual encounter was 6 months ago, and it was protected sex,
unclear whether with men or women or both. Patient also
mentions being tested and being negative for HIV in the past.
Family History:
Patient has parents who are living and healthy, 3 brothers, no
children. No family history of disease noted.
Physical Exam:
on discharge
Vitals. Tm 99.7 96.3 18 100/67 88 98%RA
Pain: 0/10
Access: PIV
Gen: nad, sitting up in bed
HEENT: anicteric, o/p clear, mmm
CV: RRR, no m appreciated
Resp: CTAB, no crackles and no wheezing
Abd; soft, nontender, +BS, no HSM appreciated
LN: +b/l inguinal nontender LAD, L inguinal biopsy site
minimally tender, dressing is dry, no hematoma
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: stable macular erythematous rash b/l LE and deeper
erythmatous rash over areas on face and arms, none over torso
psych: appropriate
.
Pertinent Results:
AST 101->75->161->149
ALT 126->106->145->165
LDH 481->450-->508->465
hgb around [**11-7**]
.
HIV neg
HCV, Hep B serologies, HAV IgM neg, IgG pos, EBV neg, CMV neg,
HIV neg (including VL), RPR neg
Lyme neg, HGE neg, babesia neg, tularemia neg
[**Doctor First Name **], ANCA, RF, ASO neg
[**9-16**] ESR 20, CRP 97.3
.
.
Imaging/results:
.
CT a/p pending: 1. Small bilateral pleural effusions with patchy
right basilar airspace disease, suspicious for pneumonia, and
linear left basilar airspace disease, likely atelectasis.
2. Left paraaortic, right iliac chain and bilateral inguinal
lymphadenopathy.
3. Splenomegaly.
4. Mild sigmoid diverticulosis.
.
CXR [**9-19**]: improved pulm edema (still present)
.
CTA [**9-16**]: no PE, +axillary, mediastinal LAD, splenomegaly,
bibasilar consolidation and effusion, pulm edema
.
[**9-17**]: abd US: GB sludge, SM 15.2cm
.
Echo: normal (55%)
.
Brief Hospital Course:
.
32 year old male Brazilian painter from [**Hospital3 4298**]
admitted to OSH [**9-13**] with 10 day hx of fevers to 102.5, chills,
nausea, vomiting, and a frontal headache and rash since [**9-12**].
Underwent extensive w/u at OSH that was negative (LP, babesia,
anaplasma, tularemia, lyme). Was placed on ceftriaxone and
doxycycline at OSH. Continued to have fevers, rash, and
[**Month/Year (2) **], thus pt transfered to [**Hospital1 18**] [**9-16**]. Shortly after
arrival, developed acute respiratory distress and hypoxeia, was
transfered to MICU [**9-17**]. Started on Vanc/zosyn. Imaging with
bilateral consolidation and pulm edema, with subsequent rapid
improvement over next 2days, thus more c/w pneumonitis and
vanc/zosyn stopped. His resp status remained stable on room air
and he had no other issues the rest of hospital stay.
He had an interesting rash on torso, face, arms, legs, and this
was biopsied by Derm (torso), which ended up showing acid fast
bacilli consistent with leprosy. However, per derm and ID, this
did not explain the more systemic process and was likley
something that he acquired long ago (given his origin from
[**Country 4194**]) but manifested itself during immunocompromised state.
Thus decided not to treat currenlty and he can have f/u as
outpt.
Further w/u ID/rheum was sent here and was NEGATIVE (see chart)
including hep serologies, EBV/CMV, herpes, HIV, [**Doctor First Name **]/ANCA/RF.
ESR/CRP were elevated as expected of systemic process.
He was kept on streptomycin initially until tularemia confirmed
negative. he was kept on doxy for tick borne disease and his
RMSF titers were [**Doctor First Name 80489**], thus he will complete 2week course
of doxi. On day of discharge, he mentioned that he had been told
he had schistosomiasis in the past in [**Country 4194**] and was not treated
for this. Spoke to ID attending, no good way to check for actual
infection vs exposure, but this can be addressed in [**Hospital **] clinic.
Toxo IgM also pending at time of discharge
Still did not have good explanation for his symptoms (LAD,
[**Hospital **], SM) after ruling out most infectious/rheum
illness, thus lymphoproliferative d/o (elevated LDH) high on
differential. He underwent excisional LN biopsy 9/26 per surgery
and results of this (cx, cytology, immunochem, pathology) are
pending at time of discharge. He will have f/u [**Hospital **] clinic with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] since he knows the patient the best, who will make
further recs on follow up pending biopsy results.
By time of discharge, he was otherwise doing very well. having
low grade fevers but no HA or other complaints. Discharged in
stable condition.
.
.
Please see progress note below for detail:
.
Fevers,lymphadenopathy/SM, mild [**Last Name (NamePattern1) **], Rash: Infectious
(viral/fungal) vs ymphoproliferative vs less likely
rheumatological. Extensive infectious/rheum w/u thus far has
been NEGATIVE (LP, cultures (Abx stopped), babesia, lyme and
tularemia (streptomycin stopped), EBV, CMV, hepatitis, HIV,
autoimmune w/u). thus concern is now more for
lymphoproliferative d/o (esp given LDH elevated , diffuse LAD
and SM) or rare viral syndrome. Fevers have resolved, he is
doing much better.
-s/p excisional biopsy of inguinal LN [**9-21**], awaiting
Cx/stains/cytology/architecture
-he will f/u in [**Hospital **] clinic for this, they will contact him for
appointment. they will refer him to appropriate specialty
thereafter.
-per ID, since RMSF [**Last Name (LF) 80489**], [**First Name3 (LF) **] complete 2weeks of doxy,
discharge with 1 more week
-IgM toxo sent again today
-not treating leprosy for now as below.
.
.
Hypoxia/resp distress: bilateral consolidation and pulm
edema->MICU. Not much cough. Rapid improvement over 2days. More
consistent with pneumonitis or viral PNA. CT scan [**9-20**] still
with R basilar consolidation, but clinically NO PNA, so will not
treat (s/p vanc/zosyn X3days stopped [**9-19**])
-currently on RA
.
.
[**Month/Year (2) 5779**]- Patient with persistent elevated liver enzymes.
Negative hepatitis serologies as well as EBV and CMV serologies
and viral loads. Patient without new medication exposure, period
of known ischemia. Normal TSH. Most likely associated with the
systemic process(lymphoproliferative/viral/fungal) as above.
Liver synthetic function has been good. CT scan with
unremarkable liver.
-monitor trend as outpt
.
.
Leprosy; as above, rash bx on abdomen c granulomatous
inflammation, AFB (+), all c/w leprosy. HOWEVER, per derm/ID,
this does NOT explain the more systemic process that is going on
and may have just manifested during an acutely immunosuppresed
state. No need to treat acutely, outpt f/u.
.
.
Normocytic Anemia: Iron studies compatible with chronic disease
or inflammation. No evidence of active bleeding and stable HCT.
Guiac negative stools, negative hemolysis labs and no
schizocytes on smear. hgb now around [**11-7**]
.
.
Medications on Admission:
Trazodone
Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
FEVERS, RASH, LYMPHADENOPATHY, [**Name (NI) **] unclear etiology
[**Name (NI) 80490**]
LEPROSY
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted for rash, fevers, swollen lymph nodes. You
also had a lung infection. Your fevers have gotten better. We
are still not sure what is causing all your symptoms, but we
obtained one of your lymphnodes so we can get more information.
It is VERY important to you follow up with the Infectious
Disease department ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) who will follow up on the
results of the biopsy and refer you to appropriate doctor after.
please finish one more week of antibiotics
Please keep groin area dry and clean, do not remove the steri
strips, they will come off on their own.
Followup Instructions:
YOU should be hearing from infectious disease doctor regarding
follow up appointment. IF you dont hear from them this week,
please call the clinic at [**Telephone/Fax (1) 457**] and make an appointment
with Dr. [**First Name (STitle) **]
|
[
"785.6",
"285.29",
"486",
"030.9",
"782.1",
"780.6",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
9421, 9427
|
4144, 9122
|
339, 345
|
9565, 9571
|
3233, 4121
|
10250, 10490
|
2553, 2664
|
9182, 9398
|
9448, 9544
|
9148, 9159
|
9595, 10227
|
2679, 3214
|
276, 301
|
373, 2063
|
2085, 2212
|
2228, 2537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,921
| 187,904
|
16599
|
Discharge summary
|
report
|
Admission Date: [**2183-9-21**] Discharge Date: [**2183-10-1**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
cough, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86F with h/o CHF and recent admission [**Date range (1) 7039**] for PNA, who
presents from her [**Hospital3 **] facility with worsening cough
for a few days. The cough was non-productive and she had no
associated fevers, but she did reports some chills and runny
nose. She also endorses dysuria. Two days ago, her daughter and
HCP [**Known firstname **] had a conversation with pt's VNA, who reported that
the patient had more difficulty breathing. [**Doctor First Name **] visited
yesterday and was concerned about her mother's labored breathing
and cough. This morning a separate daughter [**Name (NI) 17804**] went to see
[**Name (NI) **] and brought her into the ED.
.
In the ED, VS were: T 100.3 (rectal) SBP: 120s, HR: 80-120
(afib), noted to be tachypneic and hypoxic to 92%RA. On exam she
had diffuse rales and rhonchi. A CXR was obtained that showed
PNA as well as likely CHF. Blood cultures were drawn and she
received vanc and cefepime (H/O MRSA). An EKG showed afib with
no ischemia and CE's were negative, but she was also given ASA.
While in the ED she complained of back pain and received
morphine and zofran. She then developed respiratory distress and
her sats then dropped into 80s on nasal cannula. In the setting
of respiratory distress, she became agitated and hypertensive.
She was tried on BIPAP but did not tolerate this, and so was
placed on a NRB. She became hypertensive to the 200s, and a
nitro gtt was started. She then became hypotensive to SBP 70s,
and this persisted even while off the nitro gtt, so peripheral
neosynephrine was started. A discussion occurred between the ED
staff and daughter [**Name (NI) **] [**Name (NI) **] (HCP) and son who is back-up HCP,
and pt was confirmed as DNR/DNI, no central lines. Family
understood that pressors could only be continued for max of 24
hours via peripheral route, and understood. Last set of VS prior
to transfer to MICU were: 99.5 80 112/45 18 100% NRB.
.
Currently she appears comfortable and is not in any acute
respiratory distress.
Past Medical History:
AFib
Diastolic CHF
Mild-Mod MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
Osteoporosis
Chronic venous stasis
RLS
s/p vertebroplasty [**12-19**], [**8-22**]
h/o falls
depression/anxiety
Social History:
The patient lives at as [**Hospital3 **] facility in [**Location (un) 1411**],
[**Location (un) 583**] Gardens ([**Telephone/Fax (1) 47057**]). No smoking, no drinking
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.7 75 105/50 23 100% NRB
Gen: elderly female sitting in bed, NAD
HEENT: PERRL, EOMI, MM dry
Neck: no LAD, supple, JVP of 7cm, not elevated but + HJR
Heart: regularly irregular, no m/r/g
Lungs: diffuse expiratory rhonchi throughout, but no crackles
appreciated
Abd: +BS, NT/ND, soft
Ext: 1+ pitting edema bilaterally, both legs equally
erythematous from shin to knee, non TTP
Neuro: AAOx3, CN 2-12 intact b/l, 5/5 strength distally.
Skin: faint macular rash on b/l forearms?
Pertinent Results:
Cardiology Report ECG Study Date of [**2183-9-21**] 12:03:06 PM
Sinus tachycardia. The P-R interval is prolonged at 220
milliseconds. Atrial ectopy. Left axis deviation. There is a
late transition which is probably normal. Compared to the
previous tracing the rate is faster and ectopic beats are new.
.
[**2183-9-21**] CXR
CHEST, SINGLE VIEW: There is persistent cardiomegaly.
Cardiomediastinal and hilar contours are unchanged. There is
multifocal airspace opacification involving the right lower
lobe, left upper lobe, and to a lesser extent the right upper
lobe. There are small bilateral pleural effusions. There is no
pneumothorax. Osseous structures are unchanged.
IMPRESSION: Multifocal airspace opacification could represent
asymmetric
pulmonary edema from heart failure, multifocal pneumonia, or
aspiration.
.
[**2183-9-26**] PA&lat
FINDINGS: As compared to the previous radiograph, the
pre-existing
parenchymal opacities have clearly decreased in extent. There
are remnant
opacities at the bases of the right upper lobe, the retrocardiac
lung areas, and the right lung base. Bilaterally, there might
also be a minimal pleural effusion. No newly occurred focal
parenchymal opacity suggestive of pneumonia. Multiple healed rib
fractures. Moderate cardiac enlargement
without signs of overhydration. Extensive degenerative changes
in the right shoulder.
.
[**2183-9-30**] 06:06AM BLOOD WBC-4.9 RBC-3.27* Hgb-10.1* Hct-30.7*
MCV-94 MCH-30.9 MCHC-32.9 RDW-17.0* Plt Ct-272
[**2183-9-29**] 05:00AM BLOOD WBC-5.7 RBC-3.42* Hgb-10.6* Hct-32.1*
MCV-94 MCH-31.1 MCHC-33.2 RDW-16.4* Plt Ct-276
[**2183-9-28**] 05:45AM BLOOD WBC-5.7 RBC-3.23* Hgb-9.9* Hct-30.0*
MCV-93 MCH-30.7 MCHC-33.1 RDW-16.3* Plt Ct-256
[**2183-9-27**] 07:25AM BLOOD WBC-5.4 RBC-3.53* Hgb-10.8* Hct-32.8*
MCV-93 MCH-30.6 MCHC-32.9 RDW-16.3* Plt Ct-267
[**2183-9-26**] 07:10AM BLOOD WBC-5.2 RBC-3.64* Hgb-11.5* Hct-33.6*
MCV-92 MCH-31.5 MCHC-34.2 RDW-16.3* Plt Ct-249
[**2183-9-25**] 03:10AM BLOOD WBC-5.6 RBC-3.48* Hgb-11.1* Hct-31.7*
MCV-91 MCH-31.8 MCHC-35.0 RDW-16.3* Plt Ct-205
[**2183-9-24**] 05:36AM BLOOD WBC-6.2 RBC-3.34* Hgb-10.1* Hct-31.0*
MCV-93 MCH-30.3 MCHC-32.7 RDW-16.3* Plt Ct-211
[**2183-9-23**] 03:03AM BLOOD WBC-6.1 RBC-3.21* Hgb-10.0* Hct-30.7*
MCV-96 MCH-31.0 MCHC-32.4 RDW-16.4* Plt Ct-194
[**2183-9-22**] 02:56AM BLOOD WBC-7.5 RBC-3.07* Hgb-9.5* Hct-28.5*
MCV-93 MCH-30.8 MCHC-33.2 RDW-16.4* Plt Ct-199
[**2183-9-21**] 12:10PM BLOOD WBC-7.1 RBC-3.87* Hgb-12.0 Hct-36.1
MCV-93 MCH-31.1 MCHC-33.3 RDW-16.5* Plt Ct-270
[**2183-9-30**] 06:06AM BLOOD Glucose-76 UreaN-19 Creat-0.7 Na-141
K-4.2 Cl-101 HCO3-35* AnGap-9
[**2183-9-29**] 05:00AM BLOOD Glucose-82 UreaN-23* Creat-0.7 Na-140
K-4.3 Cl-100 HCO3-34* AnGap-10
[**2183-9-28**] 05:45AM BLOOD Glucose-81 UreaN-25* Creat-0.8 Na-139
K-4.1 Cl-100 HCO3-34* AnGap-9
[**2183-9-27**] 07:25AM BLOOD Glucose-89 UreaN-24* Creat-1.0 Na-138
K-4.3 Cl-96 HCO3-35* AnGap-11
[**2183-9-26**] 07:10AM BLOOD Glucose-83 UreaN-22* Creat-0.7 Na-138
K-3.8 Cl-96 HCO3-34* AnGap-12
[**2183-9-25**] 03:10AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-138
K-3.6 Cl-95* HCO3-35* AnGap-12
[**2183-9-24**] 08:06PM BLOOD K-3.8
[**2183-9-24**] 05:36AM BLOOD Glucose-107* UreaN-19 Creat-0.8 Na-134
K-4.1 Cl-95* HCO3-32 AnGap-11
[**2183-9-23**] 05:54PM BLOOD Glucose-120* UreaN-19 Creat-0.8 Na-133
K-4.3 Cl-94* HCO3-30 AnGap-13
[**2183-9-23**] 03:03AM BLOOD Glucose-84 UreaN-25* Creat-0.9 Na-134
K-4.7 Cl-102 HCO3-26 AnGap-11
[**2183-9-22**] 02:56AM BLOOD Glucose-77 UreaN-21* Creat-0.9 Na-137
K-4.4 Cl-104 HCO3-26 AnGap-11
[**2183-9-21**] 12:10PM BLOOD Glucose-85 UreaN-20 Creat-1.0 Na-137
K-4.8 Cl-100 HCO3-26 AnGap-16
[**2183-9-26**] 07:10AM BLOOD ALT-9 AST-14 AlkPhos-84 TotBili-0.4
[**2183-9-22**] 02:56AM BLOOD CK(CPK)-33
[**2183-9-21**] 12:10PM BLOOD ALT-11 AST-21 LD(LDH)-318* CK(CPK)-59
AlkPhos-99 TotBili-0.3
[**2183-9-22**] 02:56AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2183-9-21**] 12:10PM BLOOD cTropnT-0.02*
[**2183-9-21**] 12:10PM BLOOD CK-MB-NotDone proBNP-3940*
[**2183-9-26**] 07:10AM BLOOD Albumin-3.0* Calcium-9.1 Phos-3.3 Mg-1.8
[**2183-9-30**] 06:07AM BLOOD Vanco-20.9*
[**2183-9-21**] 12:18PM BLOOD Lactate-1.3
Brief Hospital Course:
#Healthcare-associated pneumonia: The patient was begun on
vancomycin and cefepime for HCAP coverage. The patient had a
fever on hospital day 4 and cefepime was changed to meropenem.
Urinary legionella antigen was negative. Blood cultures have not
grown to date. She subsequently improved subjectively, with
resolution of fever and improvement in oxygen requirement. She
will complete a 14-day course of antibiotics (vancomycin through
[**10-4**] and meropenem through [**10-7**]).
.
#Acute on Chronic Diastolic CHF: The patient was treated with
diuretics with improvement in her symptoms and oxygenation.
Lisinopril and metoprolol were given for afterload reduction.
She will be discharged on lasix 10 mg daily, with instructions
to check daily weights and uptitrate the dose of lasix as
needed.
.
#AFib with RVR: Had one episode of AFib with RVR to 130s while
febrile, which responded to IV metoprolol. The patient was
monitored on telemetry and heart rate was well-controlled with
oral lopressor. Aspirin was continued. Given her CHADS score of
3, the patient may benefit from initiation of anticoagulation
therapy as an outpatient.
.
#Hypotension: The patient had a hypotensive episode of the
setting of a nitro gtt, which required peripheral vasopressors
for only a few hours. Her blood pressure remained within normal
range throughout the remainder of the admission.
.
#Anemia: The patient's hematocrit remained stable at ~30%. She
had two guaiac positive stools, but no gross bleeding. Further
evaluation of this problem may be pursued as an outpatient.
.
#Osteoarthritis - Continued tramadol and tylenol as needed.
.
#Osteoporosis - Continued vitamin D and calcium.
.
#Chronic Venous Stasis ?????? Continued topical therapy.
.
#Nutrition - Evaluated by speech and swallow therapy who
recommended a PO diet of nectar thick liquids and puree
consistencies, pills crushed with puree, 1:1 supervision for all
PO, alternating between bites and sips, and maintenance of
aspiration precautions.
.
# PPx - SQ heparin, PPI, bowel regimen
Medications on Admission:
# Latanoprost 0.005 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic HS
# Pantoprazole 40 mg daily
# Calcium Carbonate 500 mg Tablet PO TID W/MEALS
# Cholecalciferol (Vitamin D3) 400 unit PO DAILY
# Aspirin 81 mg Tablet PO DAILY
# Trazodone 50 mg PO HS
# Tramadol 50 mg PO Q6H prn
# Lisinopril 10 mg PO daily
# Acetaminophen 325 mg Tablet PO Q4H prn pain
# Ropinirole 0.25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QPM (once a
day (in the evening)).
# Ammonium Lactate 12 % Lotion [**Month/Year (2) **]: One (1) Appl Topical ASDIR
(AS DIRECTED): apply generously to legs after soaking.
# Fosamax 70 mg q saturday.
# Sarna Anti-Itch 0.5-0.5 % Lotion prn itching.
# Docusate Sodium 100 mg PO BID
# Magnesium Hydroxide 30 ML PO Q6H
# Senna 8.6 mg PO BID
# Bisacodyl 10 mg Suppository as needed.
Discharge Medications:
1. Alendronate 70 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO qSAT.
2. Furosemide 20 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO DAILY (Daily):
hold for sbp<90.
3. Latanoprost 0.005 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic HS (at
bedtime).
4. Meropenem 500 mg IV Q6H
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection TID (3 times a day).
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
9. Ammonium Lactate 12 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical ASDIR
(AS DIRECTED): apply generously to legs after soaking.
10. Camphor-Menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) application
Topical once a day as needed for itching.
11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) INH
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
14. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) liquid PO BID
(2 times a day).
16. Ropinirole 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
17. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
18. Cholecalciferol (Vitamin D3) 400 unit Capsule [**Last Name (STitle) **]: Two (2)
Capsule PO once a day.
19. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
20. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) supp Rectal at
bedtime as needed for constipation: Please give if no BM in 2
days.
21. Vancomycin 750 mg IV Q 24H
Hold for day [**9-27**]
22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
23. Lopressor 50 mg Tablet [**Month/Year (2) **]: 0.25 Tablet PO twice a day: hold
for sbp<100, hr<55.
24. Lisinopril 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day:
hold for sbp<95.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
1) Healthcare-associated pneumonia
2) Acute on chronic diastolic CHF
3) Atrial fibrillation
Secondary
1) Moderate mitral regurgitation
2) Hypertension
3) Chronic lower extremity venous stasis
4) Osteoarthritis
5) Osteoporosis
Discharge Condition:
clinically improved with stable vital signs.
Discharge Instructions:
You were admitted to the hospital with pneumonia and worsening
heart failure. Your symptoms improved with antibiotics and
diuretics (water pills).
Please continue taking the antibiotics as prescribed: vancomycin
through Saturday, [**10-4**] and meropenem through Tuesday,
[**10-7**].
No changes were made to your other medications. Please continue
taking your medications as prescribed.
Please weigh yourself every morning and call your physician if
your weight increases by more than 3 lbs. Please adhere to a
diet with less than 2 grams of sodium daily.
Please follow up with [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 715**] on Tuesday, [**10-7**] at
9:00 AM. The office phone number is [**Telephone/Fax (1) 719**].
Please call your physician or return to the Emergency Department
immediately if you experience fever, chills, sweats, dizziness,
lightheadedness, chest pain, shortness of breath, difficulty
lying flat, worsening cough, abdominal pain, discomfort with
urination, bloody or dark stools, or leg pain or swelling.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],[**MD Number(3) 1240**]:[**Telephone/Fax (1) 719**] Date/Time:[**2183-10-7**]
9:00.
Completed by:[**2183-10-1**]
|
[
"276.3",
"507.0",
"578.1",
"427.31",
"427.81",
"458.9",
"518.81",
"511.9",
"401.9",
"V85.0",
"715.90",
"428.33",
"333.94",
"733.00",
"300.4",
"518.0",
"424.0",
"584.9",
"414.01",
"459.81",
"428.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13052, 13118
|
7430, 9469
|
234, 240
|
13397, 13444
|
3266, 7407
|
14548, 14739
|
2705, 2723
|
10327, 13029
|
13139, 13376
|
9495, 10304
|
13468, 14525
|
2738, 3247
|
180, 196
|
268, 2286
|
2308, 2504
|
2520, 2689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,466
| 185,829
|
11094
|
Discharge summary
|
report
|
Admission Date: [**2178-7-9**] Discharge Date: [**2178-7-27**]
Date of Birth: [**2106-1-8**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Left foot gangrene. The information was
obtained from hospital records and the daughter. The patient
is Portugese speaking.
HISTORY OF PRESENT ILLNESS: This is a 72-year-old Portugese
speaking male with a history of left foot ulceration and
cellulitis. Cultures have grown out MRSA and Morganella
which was treated without changes. Noninvasive studies
demonstrated severe femoral-tibial disease and left forefoot
flow deficit. Right ABI was 0.4, resting, and left ABI was
not measured.
The patient was evaluated at [**Hospital6 **] from [**2178-5-12**], to [**2178-6-7**], by Vascular Surgery, and felt that the
patient was not a viable candidate for revascularization, and
the patient's daughter referred the patient to Dr. [**Last Name (STitle) **],
who was seen in the office on the day of admission. He is
now admitted for intravenous antibiotics, open TMA, then with
potential bypassing graft depending on wound response.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PAST MEDICAL HISTORY: Daily Insulin dependent. Atrial
fibrillation. Sick sinus syndrome. Hypercholesterolemia.
History of alcohol abuse. History of congestive heart
failure. History of dehydration with orthostasis. History
of mild chronic renal insufficiency, 3.5-2.0. Chronic
anemia. Negative upper GI on barium enema. Hematocrit was
24, transferrin 17, total IBC 206, ferratin 4.5. Obstructive
sleep apnea, blood gases on room air of 7.48, 42, 93, 97%.
T12 compression fracture. Left foot infection of MRSA
Morganella morganii which was sensitive to Gentamicin,
Bactrim, Unasyn, Ceftriaxone, Ceftazidime, ................,
and Cipro, and ................ Gallstones by ultrasound,
asymptomatic. Cataract, left eye.
PAST SURGICAL HISTORY: Pacemaker on [**2176-7-7**], VVI mode.
Echocardiogram in [**2175**] showed normal left ventricular
function, trivial aortic stenosis. Echocardiogram on [**2178-6-7**] showed normal left ventricular function, dilated
hypertrophy left ventricle, right ventricle dilated, right
atrium, dilated, left atrium dilated, aortic stenosis without
significant changes from previous echocardiogram. O.S.
laser.
MEDICATIONS ON ADMISSION: Atenolol 25 mg q.d., Avandia 4 mg
b.i.d., .................. 2.5 mg q.Thursday, Potassium
Chloride 20 mEq q.d., Ativan 4 mg b.i.d., Protonix 40 mg
bedtime, Spironolactone 50 mg t.i.d., Flomax 0.4 mg h.s.,
Lasix 80 mg q.a.m. and 40 mg q.p.m., Neurontin 100 mg t.i.d.,
................... 5 mg t.i.d., Nephrocaps 1 daily,
Simethicone 80 mg t.i.d., Insulin 75/25 20 U q.a.m.
SOCIAL HISTORY: He is retired, barely inactive. He is a
non-smoker. He drinks 3-4 glasses of wine; he previously
drank 1 gallon per day. He has not any alcohol over the last
two months.
REVIEW OF SYSTEMS: Positive for difficulty in hearing.
Ankle edema. Hip claudication bilaterally with no rest pain.
No history of stroke or myocardial infarction.
PHYSICAL EXAMINATION: Vitals signs: Afebrile, pulse rate
72, blood pressure 120/60 in the right arm, 116/60 sitting,
118/60 lying. General: The patient was a drowsy, obese,
Portugese speaking male. HEENT: Unremarkable. Tongue was
midline but fissured. Pulses: Carotids were palpable
without bruits. Brachial and radial pulses were palpable
bilaterally. Abdominal aorta was non-prominent. Femoral
pulses were palpable bilaterally. No bruits. Absent
popliteal, dorsalis pedis, and posterior tibial spot
palpation bilaterally. Chest: Diminished base sounds
bilaterally with crackles two-thirds up on the right side.
Heart: Irregularly, regular rhythm with diminished S1 and
S2. There were no murmurs, rubs or gallops. Pacemaker
battery implant in the pectoral area on the right. Abdomen:
Distended and dull to percussion. Bowel sounds were
diminished. Could not assess for organomegaly or masses.
There were no bruits. Extremities: Right hand was deformed
with 3+ edema. The right and lower extremities from knee to
foot were with 3+ edema with severe chronic edematous
changes, cellulitis, and bullous lesions, and venous
insufficiency skin changes. The left foot was with dry
gangrene of the hallux and first toe. The drainage was
without odor. There was erythema present in the first toe
joint; capsule was exposed.
LABORATORY DATA: Admission labs included a white count of
8.0, hematocrit 29.9, platelet count 411,000; BUN 34,
creatinine 1.5, potassium 3.3, supplemented and rechecked at
3.5; PT and INR were normal.
Chest x-ray showed single lead, pacemaker in the right
ventricle with moderate cardiomegaly. There were no
infiltrates or effusion. There was a 6 mm left upper lobe
nodule.
Electrocardiogram was paced rhythm.
HOSPITAL COURSE: KUB done on admission showed probable
ascites, and large loops of small bowel, air in the
descending colon.
HOSPITAL COURSE: The patient was continued on his
preadmission medications. He was begun on intravenous
antibiotics of Vancomycin and Bactrim. Right IJ was placed
on the day of admission secondary to lack of peripheral
venous access. Chest x-ray was negative for pneumothorax.
The patient underwent a right first metatarsal amputation on
[**2178-7-9**], without complication and was transferred to
the Recovery Room.
He remained stable. Chest x-ray showed line in appropriate
placement. The patient was in congestive heart failure.
Cardiology was requested to the see the patient and help with
management of his congestive heart failure. Recommendations
to continue with beta-blockers, ACE inhibitors, and Lasix as
needed. [**Last Name (un) **] was consulted to manage the patient's
diabetes.
Other recommendations made included avoiding Avandia because
of fluid retention and non-steroidals because of diminished
renal function and fluid retention, and to monitor I&Os and
daily weights, consider Demadex if weight increases or
congestive heart failure symptoms increase, and hold
Spironolactone.
On postoperative day #1 there were overnight events.
Postoperative hematocrit was 23.8. BUN and creatinine
remained stable. Lasix was continued. They felt that the
low hematocrit was secondary to volume overload. The patient
underwent an arteriogram on [**7-13**] which demonstrated
patent aorta, the renals were patent. There was bilateral
plaque disease in the iliacs, and commons were satisfactory.
Left external iliac had no gradient, and common femoral and
bilateral femorals were satisfactory. There was minimal SFA
disease. The short segment of the AK-BK popliteal which was
occluded. There was diseased BK popliteal with patent tibial
.................. trunk. The PT, peroneal and AT all
occluded at the origin. The PT and peroneal were with
moderate diffuse disease. The BT reconstructed at the ankle
and perfused arch. The AT reconstructed at the ankle and
perfused to DP.
An attempt was made on [**2178-7-17**], to recannulate the
popliteal occlusion without success. The patient's volume
status margin was very narrow, and he continued to have
intermittent episodes exacerbation of congestive heart
failure requiring continual adjustment in his medications.
He received a unit of packed cells on [**2178-7-14**], for his
continuing anemia. His posttransfusion hematocrit was 25.9,
up from 24.3. The patient was continued to be diuresed.
Physical Therapy began to work with the patient with
non-weightbearing ambulation. Recommendations were to
consider anticoagulation for chronic atrial fibrillation and
maintain an INR of [**1-10**].
On [**7-18**], the patient was transferred to the SICU for
sepsis observation secondary to increasing ischemia of the
left extremity and postoperative fevers, agitation, and
hypotension, and decreased SVR, with increased cardiac
output. A white count at the time of transfer was 9.0, with
a hematocrit of 25.4, BUN 19, creatinine 1.5, potassium 4.1,
calcium 1.14, phosphorus 3.6, magnesium 2.2. Cultures of the
foot were obtained on admission which grew .................
Bacterium, gram-negative rods, anaerobes,
..................., ..................., and
..................
The patient went to surgery on [**7-18**] for a left femoral
BK popliteal bypass with non-reversed saphenous vein graft.
He tolerate the procedure well and transferred to the PACU
with a Dopplerable dorsalis pedis and posterior tibial.
Postoperatively he remained with a low-grade temperature of
38.8??????. His SVR was 618. His index was 3.9. His
postoperative hematocrit was 25.9. His BUN and creatinine
remained stable. Diuresis was continued. Because of the
patient's persistent temperature elevation and increasing
cardiac output and diminishing SVR, the patient was
pancultured, and Levaquin was added to his intravenous
antibiotics.
Over the next 48 hours, the patient's SVR and index improved.
His white count remained stable at 8.9. He was transfused a
unit of packed red blood cells for a hematocrit of 24.7. His
posttransfusion hematocrit was unchanged. His blood cultures
grew gram-positive rods. Clindamycin was added to his
antibiotic regimen at this point. He continued to show
improvement in his temperature curve and his hemodynamics.
On [**7-22**], the patient underwent a left TMA without
complication. Postoperatively he continued to remain
afebrile. He was transferred to the VICU for continued
monitoring and care. His blood cultures were with
questionable Lactobacillus, and his wound cultures from the
operating room were with no growth. He continued to remain
afebrile. His hematocrit stabilized at 25.3. His renal
function remained stable. He was transfused a unit of packed
red blood cells on [**7-24**] followed by intravenous Lasix.
He was transferred to the regular nursing floor. Physical
Therapy began to work with the patient, and a rehabilitation
screening was begun.
GI was consulted to see the patient regarding his ascites.
They felt that the patient had underlying liver disease
secondary to his chronic alcohol abuse, and this was
exacerbated the stresses of surgery. Ultrasound of the
abdomen and liver were obtained to determined the presence of
ascites and evaluate the haptic portal vein system. This
result was pending at the time of dictation. He also
underwent a diagnostic paracentesis. These results were
pending at the time of dictation.
At the time of discharge, the patient was afebrile.
Hematocrit was 26.2, white count 7.3. Electrolytes were with
a BUN of 20, creatinine 1.4, potassium 4.0. His wound
cultures were no growth. The patient was started on
Aldactone 50 mg q.d., as per GI recommendations. The
remaining GI evaluation and follow-up will be done on an
outpatient basis. The patient should follow-up with Dr.
[**Last Name (STitle) **] in two weeks to assess his left foot wound. He will
remain strict non-weightbearing.
DISCHARGE MEDICATIONS: NPH Insulin 4 U q.a.m., Aldactone 50
mg q.d., Flagyl 500 mg b.i.d., Levofloxacin 500 mg q.d.,
Lasix 80 mg b.i.d., Percocet [**12-9**] 5/325 q.4-6 hours p.r.n.
pain, Atenolol 25 mg daily, Simethicone 80 mg t.i.d.,
Captopril 6.25 mg t.i.d., Tylenol 650 mg q.4-6 hours p.r.n.,
Dulcolax tab [**12-9**] p.r.n., Colace 100 mg b.i.d., Vancomycin 1 g
IV q.18 hours, Clindamycin 600 mg q.8 hours,
................... 1.5 mg q.Thursday, Flomax 0.4 mg q.h.s.,
Nephrocaps 1 q.d., Neurontin 100 mg q.d., Bactrim DS 1 b.i.d.
DISCHARGE INSTRUCTIONS: Dressings with normal saline,
wet-to-dry dressing packed in the plantar surface of the
wound with dry sterile dressings and Ace bandage daily. The
patient is non-weightbearing. Foot should be elevated when
the patient is in chair.
DISCHARGE DIAGNOSIS:
1. Ischemic left foot changes status post hallectomy and toe
amputation status post left femoral below-knee popliteal
bypass graft, status post left TMA.
2. Diabetes type 2, controlled.
3. History of alcohol abuse with abdominal ascites, etiology
quarried.
4. Biventricular failure.
5. Chronic blood loss anemia, corrected.
6. Septicemia, treated.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2178-7-27**] 10:47
T: [**2178-7-27**] 11:49
JOB#: [**Job Number 35810**]
|
[
"427.31",
"250.01",
"428.0",
"440.24",
"789.5",
"296.7",
"280.0",
"305.00",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.12",
"84.11",
"54.91",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
10937, 11449
|
11729, 12365
|
2317, 2690
|
4953, 10913
|
11474, 11708
|
1888, 2290
|
3070, 4808
|
2901, 3047
|
157, 284
|
313, 1132
|
1155, 1864
|
2707, 2881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,022
| 196,449
|
33111
|
Discharge summary
|
report
|
Admission Date: [**2155-12-7**] Discharge Date: [**2155-12-19**]
Date of Birth: [**2155-12-7**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: The patient is the 2195 g
product of a 34-1/2 gestation (EDC [**2156-1-17**]), born to
a 26-year-old, G2, P1 mom, with prenatal screen: blood type O+,
antibody negative, RPR nonreactive, rubella immune, hepatitis
B negative, and GBS unknown. This pregnancy was complicated
by multiple urinary tract infection most consistently during
the pregnancy. Mom was being treated with Macrobid at the
time of delivery. There was no maternal fever. Rupture of
membranes was less than 24 hours. There was no concern for
chorioamnionitis. This infant was born by unstoppable preterm
labor. Apgar scores were 8 at one minute and 8 at five
minutes. He was taken to the NICU for further management.
FAMILY HISTORY: Mom had a previous infant born at 24 weeks
in [**Year (4 digits) 76961**]; the child is 10 years old and he is in good
health.
SOCIAL HISTORY: Parents are married and mom is from [**Name (NI) 76961**] and
dad is from [**Country 7192**]. The name of this baby is [**Name (NI) **].
REVIEW OF SYSTEMS: All other systems unavailable.
DISCHARGE PHYSICAL EXAM: The weight is 2250 g (25-50th
percentile), length is 46 cm (25-50th percentile), head
circumference is 32.5 cm (25-50th percentile). In general the
patient alert and awake. Skin is well perfused. Chest with
clear breath sounds bilaterally. No respiratory distress.
Heart regular rate. No cardiac murmur. Abdomen soft,
nontender, nondistended. Bowel sounds within normal. Liver at
1 cm of costal margin. Monilla rash. GU normal male. Testes
distended bilaterally. Neurologic soft fontanel. Moves all 4
extremities. Tone appropriate for corrected age.
HOSPITAL COURSE: Respiratory: The patient remained on room
air with no ventilatory support all along his
hospitalization. He presented only one spell on [**12-10**] and
then no more spells during the rest of the hospitalization.
Cardiovascular: The patient remained stable during his
hospitalization.
Fluids, electrolytes and nutrition: Feeds began on day of
life 1, was well tolerated and increased progressively. The
calories were increased to 24 on [**12-10**] and the baby is
all p.o. feeds since [**12-16**].
GI: The baby has a monilla rash treated with nystatin since
[**12-16**]. The baby has been on phototherapy from [**12-9**]
to [**12-12**]. Bilirubin was maximal at 12.3 and 0.3 on
[**12-9**].
Hematology: The initial hematocrit was 56.3 Initial platelets
were 249. On [**12-17**] the hematocrit was 44.1 and retic of
0.9.
Infectious disease: Maternal risk factor include unstoppable
preterm labor with no other risk factor. Rupture of membranes
was less than 24 hours and no maternal fever. Blood cultures
and CBC with differential were obtained on admission. Initial
white count was 12.1 with no left shift. Blood culture
remained negative. The infant was treated with antibiotics
for 48 hours. The antibiotics were then stopped.
Neurology: The patient remained stable. Normal neurological
exam during hospitalization.
Audiology: Hearing screen was performed with automated
auditory brainstem response and the infant passed.
Ophthalmology: The patient does not qualify for an eye exam
because of the advanced gestational age.
Psychosocial: [**Hospital6 256**] Social
Work involved with family. The contact social worker can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 50269**] [**Last Name (NamePattern1) 1538**] ([**Telephone/Fax (1) 76962**]
[**Location (un) 76963**] Health Center [**Last Name (NamePattern1) **] [**Location (un) **], [**Numeric Identifier 76964**].
CARE RECOMMENDATION: The infant is currently p.o. ad lib
with mother milk or [**Name (NI) 37112**] 24 calorie/oz at a minimum of
150 ml/kg/day.
MEDICATION: Ferrous Sulfate 0.17 ml (25 mg/ml)po daily
Goldline baby vitamins 1 ml po daily.
Nystatin ointment for monilla rash.
Iron supplementation is recommended for preterm and low
birth weight infants until 12 months of corrected age. All
infants fed predominantly breast milk should receive vitamin
D supplementation at 200 international units, may be provided
as a multivitamin preparation daily until 12 months of
corrected age.
CAR SEAT POSITION SCREENING: passed prior to discharge.
STATE NEWBORN SCREEN: The state newborn screen has been sent
as per protocol on [**12-10**].
IMMUNIZATIONS RECEIVED: The child has received hepatitis B
vaccine on [**12-10**] and he is not a candidate for Synagis.
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 4
criteria: 1) born at less than 32 weeks, 2) born between 32
and 35 weeks with 2 of the following: Day care during RSV
season, a smoker in the household, neuromuscular disease,
airway abnormalities, or school-age siblings, 3) with chronic
lung disease, or 4) hemodynamically significant CHD.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for all
household contacts and out-of-home caregivers. This infant
has not received Rotavirus vaccine. The American Academy of
Pediatrics recommend initial vaccination of preterm infants
at or following discharge from the hospital if they are
clinically stable and at least 6 weeks but fewer than 12
weeks of age.
FOLLOW-UP APPOINTMENTS RECOMMENDED: See the pediatrician at
[**Hospital1 **] [**Location (un) **] on [**12-20**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 34-1/7 weeks.
2. Rule out sepsis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**],MD [**MD Number(2) **]
Dictated By:[**Doctor Last Name 75307**]
MEDQUIST36
D: [**2155-12-17**] 18:52:10
T: [**2155-12-17**] 19:41:33
Job#: [**Job Number 76965**]
|
[
"774.2",
"V30.00",
"V05.3",
"765.27",
"782.1",
"778.8",
"765.18"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.83",
"95.43",
"99.55",
"64.0"
] |
icd9pcs
|
[
[
[]
]
] |
3530, 5746
|
867, 995
|
5767, 6084
|
1797, 3472
|
1170, 1202
|
165, 850
|
1012, 1150
|
3497, 3506
|
1228, 1779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,705
| 187,523
|
5134
|
Discharge summary
|
report
|
Admission Date: [**2197-9-18**] Discharge Date: [**2197-10-5**]
Date of Birth: [**2156-9-19**] Sex: M
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
fever, malaise, and cough for 1 week
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
40-year-old human immunodeficiency virus-infected male status
with most recent CD4 count of 416 ([**8-/2197**]), VL 1000 copies/mL
([**9-/2197**]),post cardiactransplant in [**3-/2194**] for end-stage dilated
cardiomyopathy,history of transfusion-dependent anemia since
[**8-/2195**],history of thrombocytopenia and recurrent PCP.
The patient's post transplant course has been complicated by
transfusion dependency for platelets and RBC, leukopenia,
unrevealing bone marrow biopsies and assessments,
hospitalizations complicated by persistently elevated alkaline
phosphatases with normal total bilirubins, chronic renal
insufficiency with baseline creatinine running 2.1-2.3, and
intermittent EBV viremia with most recent EBV VL of 20,000
copies/mL with concurrent undetectable CMV VL
([**2197-8-15**]). He has been treated with valganciclovir for this
for the past 10 days with good responses in the past and he was
to have a follow up EBV
VL this week.
He presents with new fevers, generalized weakness, dry cough,
and malaise without SOB, worsening of DOE, or paroxysmal
nocturnal dyspnea. He denied sore throat and oral ulcers. He has
had good O2 saturation. CXR with new left hilar mass, and
transaminitis with hyperbilirubinemia. He denied recent travel,
exposures, and new medicines. He recently had HSV pharyngitis
and pneumonia in [**7-7**] with patchy right upper lung infiltrates
on chest xray that was treated empirically for community
acquired pneumonia with levoquin for 10 days. The next month in
[**8-6**], the patient had a repeat episode of pneumonia and
completed another levoquin course. He was asymptomatic until
last week.
In review of systems, he also has dizziness and dyspnea on
exertion at 1 flight of stairs. He reports R leg swelling a few
weeks ago after walking a lot that has resolved. No recent
weight loss. No headache or photophobia. No report of medical
non-compliance.
Past Medical History:
1. HIV+, most recent CD4 416, VL 1000 copies/mL, h/o KS;
PCP [**12/2196**] with CD4 count of 83 at that time;
response to clinda/primaquin; subsequently restarted on
Bactrim prophylaxis which he has tolerated well; EBV viremia
([**Numeric Identifier 389**] copies/ml)and recent hairy leukoplakia, s/p HSV
pharyngitis [**7-7**]
2. Dilated cardiomyopathy, now s/p cardiac transplant [**2194**]
Cyclosporin levels kept in the low-mid 300s
Low-dose Prednisone; no recent pulses
3. h/o ? chemical hepatitis in [**2196**] (? drug-drug
interactions between caspofungin and cyclosporin)
4. h/o HAV infection; previously HBV and HCV naive
5. h/o chemical pancreatitis
6. Pancytopenia since transplant- negative workups with
negative BMBx x several; last PRBC transfusion was 2
weeks ago
7. Fever, uncertain etiology.
8. Drug rash secondary to Clindamycin.
9. Status post cardiac transplant for endstage cardiomyopathy
from daunarubicin used to treat his KS
10. Gout.
11. Hypertension.
12. Chronic renal insufficiency
13. s/p RUL pneumonia [**7-7**]````````````
Social History:
No tobacco, alcohol, or IV drug use. Has a cat. No sick
contacts or recent new sexual contacts. [**Name (NI) **] sushi or shellfish.
Family History:
Non-contributory.
Physical Exam:
Temp 98.7
BP 112/70
Pulse 84
Resp 16
O2 sat 98%RA
Gen - Alert, no acute distress
HEENT - extraocular motions intact, no conjunctival pallor or
injection, +icterus, mucous membranes minimally moist, white
0.5cm plaques on the lateral tongue
Neck - no JVD, + tender cervical lymphadenopathy left anterior
neck
Chest - +bibasilar crackles
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nondistended, with normoactive bowel sounds, +mild
tenderness in LLQ, no masses or organomegaly
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-16**] intact,
MAEW, no asterixis
Skin-No rashes
Pertinent Results:
[**2197-9-18**] 05:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2197-9-18**] 01:56PM [**2197-9-18**] 01:30PM GLUCOSE-104 UREA N-84*
CREAT-2.6* SODIUM-129* POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-20*
ANION GAP-16 30PM ALBUMIN-3.9 CALCIUM-8.8 MAGNESIUM-1.6
LACTATE-1.5 ALT(SGPT)-229* AST(SGOT)-204* ALK PHOS-747*
AMYLASE-62 TOT BILI-3.3* LIPASE-37 OSMOLAL-304
[**2197-9-18**] 01:30PM ACETMNPHN-NEG
[**2197-9-18**] 01:30PM PT-13.5 PTT-33.4 INR(PT)-1.1
[**2197-9-18**] CXR IMPRESSION:
1. Left hilar fulness, concerning for lymphadenopathy.
2. Faint opacity in the right lower lobe, likely representing
early pneumonia. Clinical correlation and follow up is
suggested.
Legionella Urinary Antigen (Final [**2197-9-19**]): negative
[**2197-9-18**] CMV Viral Load (Pending):
[**2197-9-19**] 06:40AM BLOOD WBC-3.5*# RBC-2.73* Hgb-8.7* Hct-24.5*
MCV-90 MCH-31.8 MCHC-35.4* RDW-24.7* Plt Ct-37*
[**2197-9-19**] 06:40AM BLOOD Neuts-71* Bands-12* Lymphs-15* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-9-19**] 06:40AM BLOOD Plt Ct-37*
[**2197-9-19**] 06:40AM BLOOD Glucose-95 UreaN-78* Creat-2.4* Na-130*
K-4.4 Cl-102 HCO3-17* AnGap-15 ALT-214* AST-210* LD(LDH)-546*
AlkPhos-511* TotBili-3.8* Albumin-3.1* Calcium-7.9* Phos-2.6*
Mg-1.5* Cortsol-32.7* Osmolal-304
[**2197-9-18**] 09:40PM BLOOD HBsAg-NEGATIVE
[**2197-9-18**] 01:30PM BLOOD CRP-27.22*
[**2197-9-19**] 06:40AM BLOOD Cyclspr-270
[**2197-9-18**] 09:40PM BLOOD calTIBC-112* Ferritn->[**2193**] TRF-86*
[**2197-9-18**] 09:40PM BLOOD HCV Ab-NEGATIVE
[**2197-9-19**] 04:12AM BLOOD Type-ART Temp-38.3 Rates-/28 pO2-60*
pCO2-31* pH-7.36 calHCO3-18* Base XS--6 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2197-9-18**] 09:40PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-PND,
EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND, MYCOPLASMA PNEUMONIAE
ANTIBODY, IGG-PND
[**2197-9-19**] 06:40AM BLOOD Hapto-PND
[**2197-9-19**] 12:23AM URINE Color-LtAmb Appear-SlHazy Sp [**Last Name (un) **]-1.015
RBC-3* WBC-0 Bacteri-NONE Yeast-NONE Epi-<1
[**2197-9-18**] 05:00PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2197-9-19**] ABDOMINAL ULTRASOUND: IMPRESSION: Gallbladder wall
edema. The differentials for this include biliary causes such as
cholecystitis or AIDS cholangiopathy, or nonbiliary causes such
as hepatitis, heart failure, cirrhosis or low protein. Hilar
scan is recommended to exclude acute cholecystitis.
CT CHEST & ABDOMEN W/O CONTRAST [**2197-9-19**] IMPRESSION:
1. Increased size of the lymph adenopathy in the aortopulmonary
window, near the left hilum of the lung. These lymph nodes are
approximately 1.1 cm in size. Additionally, there has been an
increase in the size of the precarinal lymph nodes. The largest
of these nodes measures 1.6 cm.
2. Small bilateral pleural effusions.
3. Hyperdense liver as seen on the prior study is unchanged.
4. Enlarged spleen, which currently measures 14 cm in its
longest diameter.
Brief Hospital Course:
40yo HIV+ man with CD4 416 and HIV viral load 1000/ml s/p
cardiac transplant in [**2194**] with EBV viremia on galvancyclovir
and multiple other medical problems who presented with one week
of fever, chills, dry cough, and malaise. Concern for pulmonary
disease with hepatic processes such as pneumonia with
cholestasis vs granulomatous disease vs EBV induced
lymphoproliferative disease. During a prolonged hospital
course, the pt was intubated for respiratory distress, required
continuous hemofiltration, remained transfusion dependent for
pancytopenia, was unable to be weaned from pressors or from the
ventilator, and was eventually made comfort measures only. The
patient passed away quietly with his mother and father present
on [**Name (NI) **] 2d, [**2197**].
Medications on Admission:
ABACAVIR SULFATE 300MG--One tablet twice a day
ALLOPURINOL 100MG--Take two tablets by mouth every day
ANDROGEL 1%(50MG)--Apply once daily to skin on upper shoulders
BACTRIM DS 800-160MG--Take one tablet by mouth every day
CARDIZEM CD 180MG--Take two capsules by mouth every day
CELLCEPT 500MG--Take one tablet by mouth every day
CLARITIN 10MG--One every day as needed
COLCHICINE 0.6MG--Take one tablet by mouth every day
EPIVIR 150MG--One tablet by mouth twice a day
KALETRA 33.3-133.3--Take three capsules (lpv 400 mg/rtv 100 mg)
by mouth twice a day
LORAZEPAM 1MG--Take one tablet by mouth q 12h as needed
MARINOL 2.5MG--Take one capsule by mouth twice daily before
lunch and dinner
NEORAL 25MG--Take two capsules by mouth every day - no
substitutions
NEUPOGEN 480MCG/1.6--Take for 2 days and have wbc rechecked
PREDNISONE 1MG--Take 7 mg (one 5 mg tablet and two one mg
tablets) once daily
PREDNISONE 5MG--Take 7 mg ( one 5 mg tablet and two one mg
tablets ) by mouth once daily
PRILOSEC 20MG--One capsule twice a day
TEMAZEPAM 30MG--Take one tablet by mouth at bedtime as needed
for insomnia
VALGANCICLOVIR HCL 450MG--Take one tablet by mouth twice a day x
30 days
Discharge Medications:
expired
Discharge Disposition:
Home
Discharge Diagnosis:
HIV, pancytopenia, cardiopulmonary failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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9,434
| 160,531
|
14758
|
Discharge summary
|
report
|
Admission Date: [**2129-1-17**] Discharge Date: [**2129-1-28**]
Date of Birth: [**2052-8-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Left femoral line
History of Present Illness:
76 yo M with ESRD on HD, CAD, AAA repair, Aflutter, AVR, COPD,
[**Hospital **] transferred from [**Hospital **] hospital with sepsis.
and weak. He was dialysed 5 times in the past 1 week as patient
had gained around 9 kg. He also noted to have diarrhea,
decreased PO intake. He also complained of left flank pain for
the last 1-2 weeks. On the morning od admission, he felt really
weak and slumped to the ground. His daughter checked his BP
which was SBP of 30's. He was immediately taken to [**Location (un) **]. In
the EMS, his SBP was in 60's. At [**Location (un) **], he got Fluid boluses
and was started on pressors. They tried SCL but were not
successful. He was then transferred to [**Hospital1 18**] for further
management. In the ED, he got a fem line (under sterile
precautions) and was started intially on Neo and then switched
to Levo. His UA was dirty, he had leukocytosis and elevated CKs.
He also received Vanc, Cefepime.
Past Medical History:
atrial fibrillation/atrial flutter
CAD s/p CABG
thoracic ascending aortic aneurysm
s/p AVR
HTN
CKD - on HD MWF
s/p pacer
s/p AAA repair ??????01
AF ?????? s/p cardioversion ??????03
COPD
hypothyroid
carotid stenosis
possible renal artery stenosis
kyphosis
asthma
asbestosis
restless leg
Social History:
Patient lives with his wife and one of his 3 children. He quit
smoking 40 years ago ([**2090**]), smoked for 18 years. Retired
salesman. Asbestos exposure in submarines 50 yrs ago. Denies
any EtOH, no IVDU.
Family History:
no h/o DM, HTN, no Cancer
Mother died of heart disease at 90
Physical Exam:
Vitals: 97.8, 91/71, 66, 14, 100%/3L NC
Gen: alert, oriented, in no acute distress
HEENT: furrowed tongue, mild glossitis
Neck: thick neck, no JVD appreciable
Heart: S1/S2, many ectopic beats, 3/6 SEM at LUSB
Lungs: bilateral wheezes, no crackles
Abdomen: tense, no tenderness/guarding/rigidity, normoactive BS
Flank: no tenderness
Ext: no edema
Neuro: no focal deficits
Pertinent Results:
[**2129-1-17**] 05:20PM BLOOD CK(CPK)-1598*
[**2129-1-18**] 02:18AM BLOOD CK(CPK)-1143*
[**2129-1-18**] 05:57PM BLOOD CK(CPK)-696*
[**2129-1-18**] 02:18AM BLOOD CK-MB-24* MB Indx-2.1 cTropnT-0.30*
[**2129-1-17**] 05:20PM BLOOD Cortsol-29.1*
[**2129-1-18**] 12:25AM BLOOD Cortsol-39.1*
[**2129-1-18**] 01:00AM BLOOD Cortsol-44.5*
[**2129-1-17**] 05:20PM WBC-19.5* RBC-3.34* HGB-11.2* HCT-33.6*
MCV-101* MCH-33.5* MCHC-33.3 RDW-17.9*
[**2129-1-17**] 05:20PM GLUCOSE-76 UREA N-41* CREAT-5.1*# SODIUM-138
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
.
EKG: Aflutter with 4:1 block, no acute ST-T wave changes
.
Chest Xray: Overall improvement in the congestive heart failure
seen in early [**Month (only) 216**]. Likely there is still a mild degree of
pulmonary edema. Stable appearance to the mediastinum.
.
LUE U/S [**2128-1-19**]:
1. Nonvisualization of left upper extremity veins with multiple
collateral vessels identified, suggestive of a chronic
obstruction. This can be further evaluated with an MR
examination.
2. No evidence of deep venous thrombosis in the right upper
extremity.
3. Fistula graft within the left forearm which is widely
patent, however, it appears to be anastomosed to arterial
vessels. No venous flow is noted within the region of the
fistula graft anastomoses.
.
Echo [**2128-1-22**]:
1.The left atrium is mildly dilated. The right atrium is
moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Left ventricular systolic function is
hyperdynamic (EF>75%).
3. Right ventricular chamber size is normal.
4.A bioprosthetic aortic valve prosthesis is present. The aortic
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.]
5. The mitral valve leaflets are mildly thickened. There is
severe mitral annular calcification. Moderate to severe (3+)
mitral regurgitation is seen.
6. Severe [4+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2128-8-25**], the MR [**First Name (Titles) **] [**Last Name (Titles) 28495**]
significantly. An accurate assessment of the aorta could not be
made on the present study.
.
[**1-24**] Fistulography L arm: Angiography of the arterialized L
brachial vein showed an occluded L subclavian vein. The L
subclavian vein was occluded. The procedure was abandoned in
favor of surgical intervention.
FINAL DIAGNOSIS:
1. thrombosed L AV fistula
2. occluded L subclavian vein
.
[**1-25**] HD catheter exchange by IR: Uneventful exchange of right IJ
dialysis catheter, as above. The tip of the catheter, which was
removed, was sent for cultures. The line is ready to use.
.
[**1-27**] Left fistula ligation without any major complications.
Brief Hospital Course:
76 yo M with ESRD on HD, CAD, AAA repair, Aflutter, AVR, COPD
with hypotension from urosepsis vs overdialyzing, requiring MICU
stay. He was transiently on pressors. Broad spectrum antibiotics
were started in the ICU, as well as a Heparin gtt for Aflutter
and L UE clot. He was transferred to the floor with stable BP,
off pressors, on Vancomycin and Cefepime.
.
1) Hypotension: ? line sepsis vs. pneumonia vs hypovolemia [**2-18**]
aggressive HD and decreased PO intake. Cortstim test was
negative for adrenal insufficiency. Likely sources of infection
are HD catheter, PNA, less likely urine. Off Levophed gtt after
24h, BP was stable, then transferred to floor. Patient received
IV fluids as needed. Vancomycin (started [**1-19**]) and Cefepime
(started [**1-17**]) were continued. A total course of 21 days should
be given. Multiple blood and urine cultures from [**1-17**] through [**1-19**]
came back negative. HD catheter cultures were sent off on [**1-25**]
and also came back negative. Pt was hemodynamically stable on
discharge and afebrile.
.
2) CAD s/ CABG: Pt developed elevation of troponin to 0.3 (from
0.14 from [**August 2128**]), CPK elevated to 1598 although no elevation of
CK-MD index. EKG no evidence of any acute ST-T wave changes.
This could represent demand ischemia in the setting of sepsis,
hypotension. Cardiac enzymes were cycled x3 and remained stable.
Pt was continued on Lipitor. ASA was held on Heparin gtt. Pt was
continued on toprol XL with holding parameters once his blood
pressure was stable after transfer from the ICU. An Echo from
[**1-21**] to assess LV function showed EF of 75%, but [**Month/Day (1) 28495**] MR. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]p appointment with cardiologist Dr. [**Last Name (STitle) **] should be
scheduled for 1-2 weeks after discharge.
.
3) Atrial flutter: His rate was controlled in 4:1 bloc. It was
therefore unlikely that this was contributing to the
hypotension. Pt was continued on his BB. Anticoagulation was
started. A heparin gtt was initiated which was discontinued
shortly pior discharge since he went for an AV fistula ligation.
He also developed guaiac positive stools on two occasions during
his hospital stay. The first time, the heparin gtt has been held
transiently (see below). The second time, Coumadin was just
started at 3mg qHS and was held as well for guaiac positive
stools. A hematocrit should be checked at rehab. It should be
decided after further Hematocrits whether anticoagulation with
Coumadin is being continued as an outpatient.
.
4) L UE clot: Present since fistula operation in [**11-22**]. The
patient was on a heparin gtt for the majority of his hospital
stay. However, the drip has been discontinued shortly prior
discharge. A fistulogram on [**1-24**] was performed and showed a large
clot that could not be cleared during the procedure. Transplant
surgery ligated the fistula on [**1-27**] without any major
complications. Swelling of his arm improved soon thereafter. An
outpatient followup appointment has been scheduled by transplant
surgery in order to follow up on his ligated AV fistula.
.
5) ESRD: Pt received routine HD on M/W/F or as needed. Pt was
continued on Nephrocaps and PhosLo. HD catheter was exchanged
over wire on [**1-25**] by IR. HD catheter tip was sent for culture and
came back negative. He should resume his regular outpatient HD.
Vancomycin should be given with hemodialysis. Levels should be
checked prior each Vanco dose.
.
6) Anemia: Likely secondary ESRD. Iron studies consistant with
ACD. HCT baseline of 34-40. Hct was trending down to 31. Pt
received Epo with HD and dose was increased on [**1-26**].
.
7) Guaiac positive stools: Pt had Guaiac pos stool on [**1-21**].
Heparin gtt was transiently held and pt was briefly on PPI IV
BID, but repeat hct remained stable at a lower baseline. One
unit of PRBC were transfused on [**1-26**]. The heparin drip was
restarted but discontinued shortly prior discharge for an AV
fistula ligation. Coumadin was started after the procedure at
3mg qHS but was held as well because of another guaiac positive
stool. A hematocrit should be checked at rehab. It should be
decided after further Hematocrits whether anticoagulation with
Coumadin is being continued as an outpatient. It is recommended
that the patient is undergoing an outpatient GI workup for this
GI bleed.
.
8) Dizziness: The patient developed intermittent, mild dizziness
when moving. These symptoms appeared shortly prior discharge.
One likely diagnosis would be BPPV among others, and should be
further worked up as an outpatient. His VS remained stable.
.
9) HTN: Continued BB after transfer to the floor.
.
10) COPD: Continued nebs. Xopenex (Levalbuterol) to be
considered if tachycardic.
.
11) Hypothyroid: Continued levothyroxine; initial elevated CK
could be from hypothyroidism. TSH was 64, Free T4 was 0.57 while
patient was still in the ICU. Synthroid dose was increased from
75 mcg to 100 mcg daily. Patient was discharge on this higher
dose.
.
12) PPX: heparin gtt (for majority of hosptial stay), one dose
of Coumadin, held after guaiac positive stools, Heparin sc for
the remainder, pneumoboots, protonix, HOB elevation
.
13) FEN: heart healthy diet
.
13) Access: L Femoral line discontinued on [**1-19**], HD catheter,
PICC, PIV
.
15) Code: DNR/I
Medications on Admission:
ASA 81 mg
Carbidopa-Levodopa 10-100 mg Tablet TID
Atorvastatin 40 mg QD
Morphine 15 mg [**Hospital1 **]
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
Metoprolol Succinate 25 mg Tablet SR QD
Pantoprazole 40 mg
Ipratropium Bromide Q6H
Docusate Sodium 100 mg [**Hospital1 **]
Ropinirole 1 mg [**Hospital1 **]
Nephrocaps QD
Levothyroxine 75 mcg QD
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. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous QHD (each hemodialysis) for 10 days: Started [**2129-1-19**].
Complete 21 day course. Check Vanco level prior each HD.
15. Cefepime 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q24H (every 24 hours) for 8 days: Started [**2129-1-17**]. Complete 21
day course.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. ? Sepsis
2. Atrial flutter
3. L Upper extremity clot
.
Secondary Diagnosis:
1. CAD s/p CABG
2. Hypertension
3. COPD
4. Hypothyroid
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Discharge Instructions:
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed. Your coumadin has
been held.
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] M.
[**Telephone/Fax (1) 14895**]) as needed. Please schedule a followup appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 2394**]) in [**1-18**] weeks from now.
.
[**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] from transplant surgery has scheduled an oupatient
appointment for you. Her phone number is [**Telephone/Fax (1) 7207**]. The
appointment is:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2129-2-10**]
9:10
.
Vancomycin and Cefepime to be continued until 21 day course is
completed or for one week after discharge. Vancomycin levels
should be checked prior each Hemodialysis.
.
*******Patient had guaiac positive stools during
hospitalization. Outpatient GI workup is necessary.********His
Hematocrit should be checked at rehab. His last Hct at discharge
was 26.5.********* Coumadin (3mg qHS) was started during the
hospitalization but has been held prior discharge. It should be
decided as an outpatient when to restart.*********
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"39.95",
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"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
12987, 13102
|
5471, 10803
|
326, 345
|
13301, 13352
|
2335, 5107
|
13710, 14924
|
1867, 1929
|
11208, 12964
|
13123, 13123
|
10829, 11185
|
5124, 5448
|
13376, 13687
|
1944, 2316
|
275, 288
|
373, 1312
|
13223, 13280
|
13142, 13201
|
1334, 1623
|
1639, 1851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,644
| 126,989
|
13616
|
Discharge summary
|
report
|
Admission Date: [**2137-2-2**] Discharge Date: [**2137-2-12**]
Date of Birth: [**2065-7-13**] Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Epigastric / LUQ pain with localized peritonitis and ARF (Cr
5.9), Hypotension
Major Surgical or Invasive Procedure:
Percutaneous Cholecystostomy Tube
History of Present Illness:
71 year old woman, h/o multiple abdominal surgeries for peptic
ulcer disease with recurrent stenosis, gastrectomy in [**2109**] for
PUD (s/p multiple revisions), CAD s/p CABG x 5, CHF with EF=25%,
who presented to [**Hospital3 2783**] with sudden onset of
abdominal and back pain associated with hypotension. Pt states
that she woke up 2 nights prior, went to bathroom, and fell
(wasn't using her walker); does not know if she syncopized.
Denies loss of bowel or bladder function; denies prodromal
CP/SOB/seizure/palpitations. Was not confused afterwards and
denies trauma to head. The next day she felt fine, but the
following morning, she woke up with severe, sharp, lower
abdominal pain ([**7-5**], constant, RLQ/RMQ) with pain in her mid
back. Denies nausea/vomiting/diarrhea. States her legs felt weak
but denied any loss of bowel/bladder function. States she also
felt dizzy but denies lightheadedness or syncope. Also reports
some SOB/wheezing. Denies any change in weight (b/l wt about 134
lb) or increase in LE edema. No new rashes. States that for a
few weeks, she has been taking QID Celebrex (1 tab) plus
Ibuprofen (2 tabs) as per her PCP for joint pain. Denies any new
medications. She reports decrement in UO starting today.
.
She presented to the [**Hospital1 2436**] ED with this abdominal pain, leg
weakness. VS were initially stable (97.4 84/38 73 18 98% RA)
with some low SBP. Bedside US was negative for AAA, and
non-contrast abdominal CT did not show significant abnormalities
(?gallstones, diverticulitis of sigmoid). Labs were notable for
Creatinine of 5.8 (new), potassium of 7.6 (treated with HCO3,
insulin, D50, kayexalate). She was also noted to have a
non-anion gap acidosis with a HCO3 of 8. WBC was 10.5 with 8%
bands, and she was given 1 dose of imipenem. Her mental status
remained within normal limits, and she was started on dopamine
and levophed for hypotension (SBPs 70-80s). ABG showed severe
acidosis -- 7.01/32/63. She was transferred to [**Hospital1 18**] for further
management.
Past Medical History:
1. PUD s/p gastrectomy in [**2109**], with numerous revisions,
converted to roux en y. Most recent revision at [**Hospital1 18**] in [**2133**].
Has had several balloon dilations
2. ?Crohn's disease
3. CABG x 5 in [**2126**] (?[**Hospital1 18**])
4. HTN
5. COPD
6. MDD
7. OA
8. CHF, EF=25% (most recent TTE in [**12-2**], cardiologist in
[**Location (un) 2199**]-Dr. [**Last Name (STitle) **]
9. Eczema
Physical Exam:
VS: 95.9 120/59 83 21 96% 2L NC
Gen: pleasant female, lying in bed, NAD
HEENT: PERRL, OP with dry MM, no JVD
Neck: no bruits, no JVD
Lungs: scattered crackles, no w/r
CV: 3/6 SEM LLSB but heard throughout, no r/g
Abd: soft, multiple surgical scars, with TTP RMQ/RLQ, some
voluntary guarding, no rebound; soft abdominal bruit
Extr: no c/c/e, DP 2+ Bilat; rectal was guaiac neg as per OSH
Neuro: moving all 4 extremities, CN II-XII intact
Pertinent Results:
RENAL U.S. [**2137-2-2**] 9:41 PM
IMPRESSION: No hydronephrosis. Normal arterial waveform is seen
within both kidneys. Cholelithiasis without evidence of
cholecystitis.
.
CT ABDOMEN W/O CONTRAST [**2137-2-3**] 5:53 AM
IMPRESSION:
1. Incompletely visualized right-sided pneumothorax. This was
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] immediately upon completion
of the study.
2. Stone seen in distal common duct, with intrahepatic biliary
dilatation. Distended gallbladder with mutiple gallstones.
Discussed with Dr. [**Last Name (STitle) **].
3. Status post esophagojejunostomy, mild wall thickening of
efferent limb.
4. No evidence of contrast extravasation from the bowel. No free
air seen within the abdomen.
5. Small amount of perihepatic ascites.
6. Nonobstructing right renal stone.
7. Small bilateral pleural effusions.
.
GB DRAINAGE,INTRO PERC TRANHEP BIL US [**2137-2-3**] 4:49 PM
IMPRESSION: Technically difficult, but successful
ultrasound-guided percutaneous cholecystostomy
.
CHEST (PORTABLE AP) [**2137-2-4**] 3:11 AM
HISTORY: Multiple abdominal surgeries, pain, and hypotension.
Right pneumothorax.
IMPRESSION: AP chest compared to [**2-2**] and 11:
Right apical pleural catheter unchanged in position. No
appreciable pneumothorax or right pleural effusion. Left lung
grossly clear. Heart size normal. Nasogastric tube passes below
the diaphragm and out of view. Right jugular line tip projects
over the superior cavoatrial junction.
.
CHEST (PORTABLE AP) [**2137-2-6**] 3:23 PM
Reason: s/p removal of pigtail catheter. eval for resolution of
PTX
IMPRESSION: No evidence of pneumothorax on this semi-upright
film.
.
[**2137-2-12**] 05:31AM BLOOD WBC-7.2 RBC-3.21* Hgb-9.6* Hct-28.4*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.3 Plt Ct-297
[**2137-2-12**] 05:31AM BLOOD Glucose-82 UreaN-25* Creat-1.7* Na-142
K-4.2 Cl-111* HCO3-22 AnGap-13
[**2137-2-12**] 05:31AM BLOOD ALT-24 AST-32 AlkPhos-199* TotBili-0.3
[**2137-2-11**] 08:54PM BLOOD Lipase-137*
[**2137-2-12**] 05:31AM BLOOD Calcium-7.4* Phos-4.2 Mg-1.7
[**2137-2-5**] 02:00AM BLOOD calTIBC-146* Ferritn-195* TRF-112*
[**2137-2-7**] 11:54AM BLOOD PTH-664*
[**2137-2-7**] 01:53PM BLOOD freeCa-0.90*
Brief Hospital Course:
A/P: 71 yo female, h/o multiple abdominal surgeries, CAD s/p
CABG, CHF, p/w abdominal and back pain, hypotension, transferred
for further management.
.
1. Renal Failure and hyperkalemia: New renal failure (last Cr
here in [**2133**] was wnl). She has been taking large doses of NSAIDS
as an [**Last Name (LF) 3782**], [**First Name3 (LF) **] AIN is a possibility. In addition, if she has
been hypotensive at home, ATN is a possibility as well.
Currently oliguric (had 100 cc UO at OSH when foley placed). No
other new medications or exposures. [**Month (only) 116**] be prerenal/dehydrated
if has systemic infection.
Labs, BUN, Cr, and lytes were monitored daily. Her meds were
renally doseed. Her K was treated appropriate (hold home K
supplements). She received 1 L HCO3. Her acidosis and
hyperkalemia likely in setting of this ARF; may need HD if can't
manage these metabolic derangements. Initial Cr 5.8, K 8.1.
Oliguric. K better with HCO3 (was acidemic on admit). BUN/Cr
peaked at 80/7.1, now coming down with increased UOP. Resp
status good.
Also hypoCa on admit, suspect vit D defic and sepsis. Repleting
with IV CaGluc, po Ca, calcitriol.
.
2. Non-gap acidosis: No diarrhea; ?renal failure or RTA. Very
low serum bicarbonate (may be consistent with distal RTA). Most
likely in setting of renal failure
.
3. Abdominal pain: Surgery was consulted for the pain. An US
showed Cholelithiasis without evidence of cholecystitis. Stone
in distal CBD, with intrahepatic biliary dilatation. Distended
GB w/ mult gallstones. On [**2-3**], she went to IR: perc. GB
drainage.
The Bile grew out GPR and GNR. She was started on Zosyn amd then
switched to Augmentin when cultures grew out ENTEROCOCCUS.
She will go home with the cholecystostomy tube in place and
return in a couple weeks for a laparoscopic cholecystectomy.
.
4. Hypotension: ?setting of infection /sepsis. Has received 2 L
at OSH. On Dopa/Levophed. EF=25%. She received 1L with HCO3
(hyperchloremic acidosis). She was on pressors and theses were
weaned (dopa first). On [**2137-2-11**] she was hypotensive to 80/60
with ambulation. She was encouraged to maintain hydration,
especially in the presence of diarrhea. She received a 1L fluid
bolus for hypovolemia. She then received 1 unit of PRBC on
[**2137-2-11**] for symptomatic anemia and hypotension. Her
pre-transfusion HCT was 26.9, and post-HCT was 28.4. She
ambulated with PT and was assymptomatic.
.
5. CAD: hold BB, spironolactone, nitrate for now; can continue
ASA, EKG without acute changes (some peaked T-waves). ASA for
now
.
6. Resp: She had a small right pneumothorax on CXR and CT. IP
placed a pigtail drain and had adequate drainage. The drain was
clamped and subsequently pulled. A repeat CXR showed no
pneumothorax.
COPD: advair, albuterol nebs as needed
.
7. FEN: NPO for now, IVF as above. She had a NGT placed for
nausea and ileus. The NGt was removed on [**2137-2-6**] and she was
started on a regular diet. She tolerated a diet.
.
8. Stool: She reported loose stool on HD [**4-1**]. Stool was sent for
C.diff and was negative.
.
9. Hypernatremia: on HD6 pt was noted to be nypernatremic,
likely secondary to her post-ATN diuresis. She was treated with
D5W, and her sodium was w/in normal limits by HD8.
.
10. +UTI: a urine culture was + for yeast and she was started on
Fluconazole on [**2137-2-11**]
Medications on Admission:
Celexa 40mg, Aldactone 25mg, Isosorbital 30mg, ASA 81mg, Remeron
30mg, Lipitor 20mg, Amitryptillline 25mg, Hydroxyzine 25 mg qhs,
Klonopin 5 mg TID, Folic Acid 1 mg qd, Risperdal 0.5 mg [**Hospital1 **],
Advair [**Hospital1 **], Vitamin E, Celebrex 200 mg qd,
K-dur 20 meq qd, Florastor 250 mg [**Hospital1 **], Fe gluconate 325 mg [**Hospital1 **],
Tylenol
Trazodone 50 mg qhs, Coreg 6.25 mg [**Hospital1 **], [**Doctor First Name **] 60 mg [**Hospital1 **],
Wellbutrin 200 mg
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Four (4)
Tablet, Chewable PO QID (4 times a day).
Disp:*480 Tablet, Chewable(s)* Refills:*2*
3. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*
5. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Choledocholithiasis, Cholangitis
Sepsis
Acute Renal Failure
+UTI
Hypocalcemia
Vit D deficiency
Hypotension
Anemia
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* 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.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**12-29**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2137-2-28**]
1:00
This is a Renal follow-up. Re-check a PTH at this appointment.
Call ([**Telephone/Fax (1) 773**] with questions.
Completed by:[**2137-2-12**]
|
[
"V45.81",
"112.2",
"276.0",
"576.1",
"401.9",
"414.00",
"574.50",
"496",
"995.92",
"038.9",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
10532, 10623
|
5580, 8919
|
360, 395
|
10781, 10788
|
3345, 5557
|
11103, 11541
|
9448, 10509
|
10644, 10760
|
8945, 9425
|
10812, 11080
|
2887, 3326
|
242, 322
|
423, 2445
|
2467, 2872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,150
| 113,737
|
12168
|
Discharge summary
|
report
|
Admission Date: [**2106-7-25**] Discharge Date: [**2106-8-6**]
Date of Birth: [**2031-5-28**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Shellfish / Ace Inhibitors
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75-yr-old male with PAF (on amio), HTN, AAA, CRI (Cr baseline
1.4), SCLC with brain and spinal mets (diagnosed in [**7-19**],
treated with five cycles of carboplatin/Taxol + chest XRT) s/p
recent whole brain radiation, who presented to the ED with LE
swelling but was found to have hypotension and fever.
.
Pt noted mild b/l LE swelling over the last two days which he
has never experienced before. He denies any CP, SOB but noted
some dizziness and lightheadedness over the last few days. He
continued to take his BP meds despite these symptoms. Per his
report, he developed the LE swelling after his last whole brain
radiation on Friday and was told by his radiation-oncologist
that it might be related to that and the steroids he is
currently receiving. However, he was concerned and called his
daughter in [**Name (NI) 108**] who came up to [**Name (NI) 86**] and brought him to the
ED.
.
In the ED, his BP was found to be 65/40. He was tachy to the
120s and had a Temp of 100.6. Lactate of 2.1. A UA was negative.
However, a CXR revealed an infiltrate below his lung mass in
line with post-obstructive pneumonia. He received 4L IVF with
only transient effect on his BP. He was started on Levo and
Clindamycin for presumed postobstructive pneumonia. Code Sepsis
was called and a right IJ was placed. Levophed was started given
hypotension that was resistant to fluid resuscitation. His
Levophed drip was at 0.75 mcg/kg on transfer to the ICU.
.
On ROS, he endorsed a mildly productive cough over the last two
weeks. Sputum has only been whitish to clear. No F/C/N noted. No
sick contacts. [**Name (NI) **] CP or SOB as above. No urinary symptoms or
abnormal bowel movements. No blood in stool or urine noted. No
nosebleeds but easy bruising. Chronic back pain from spinal mets
with no change in severity.
.
Oncologic History (per onc notes from [**6-25**] and [**7-13**]): Dx in
8/[**2104**]. Initially presentation with bulky disease and near
complete tracheal obstruction s/p Y stenting (removed again in
10/[**2104**]). S/p chemo with carboplatin and etoposide on
[**2105-8-11**]. His first cycle of chemotherapy was complicated by
S. bovis endocarditis; completed 4 weeks of IV penicillin in
early [**Month (only) 359**]. Initially, believed to have extensive stage
disease, with metastases in the left adrenal gland and liver.
However, follow-up CT scans revealed no change in the adrenal
lesion while his pulmonary lesions decreased in size. In
addition, the hepatic lesions seen on his initial CT were not
seen on later exams were felt to be an artifact and not
metastatic spread. Mr. [**Known lastname 4401**] completed five cycles of
chemotherapy and radiation therapy to the chest.
Past Medical History:
- PAF, on Amio, not on anticoagulation (has been on coumadin
prior to his first round of chemo in [**2104**]); followed by Dr.
[**Last Name (STitle) 73**] (last seen on [**2106-7-7**])
- HTN
- Hyperlipidemia
- CRI, Cr baseline 1.4
- PVD
- AAA S/P repair over one year ago
- ? Etoh abuse
- H/o S. bovis endocarditis (during first cycle of chemo); s/p 4
wks of penicillin in [**9-/2105**]
- Colonoscopy on [**2105-9-1**]: fragments of adenoma with high grade
dysplasia and focal intramucosal carcinoma but no invasive
carcinoma.
- SCLC as above
Social History:
Lives alone. Family lives in [**State 38104**] and [**State 108**]. Has five kids and
many grandchildren. Divorced. Quit smoking over two years ago.
Smoked 1 pack per week for 50 years. Remote EtOH use in the past
(1-2 drinks per month). No drug use.
Family History:
Son died of brain tumor at age 16. Did not know parents, was
raised by step parents.
Physical Exam:
VS: Temp: 97.0, BP: 119/76 (on NE), HR: 97, RR: 18, O2sat 94% on
2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry MM
NECK: no supraclavicular or cervical lymphadenopathy, no jvd,
right IJ in place
RESP: coarse BS at both bases, no wheezes, rhales or rhonchi
CV: Tachy, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ LE edema b/l, cold feet but good pulses
SKIN: bruises b/l on UEs, no jaundice
NEURO: AAOx3. 5/5 strength throughout.
Pertinent Results:
141 106 62
============117
4.6 25 1.8
.
CK: 290 MB: 7 Trop-T: 0.04
.
WBC 5.1, Hct 45.0, Plt 58
N:93 Band:2 L:4 M:1 E:0 Bas:0
.
PT: 12.4 PTT: 26.0 INR: 1.1
.
Lactate 2.1
.
.
EKG: Afib at HR of 101, normal axis, no ST changes
.
Imaging:
CXR [**2106-7-25**]: Comparison was made with a prior chest radiograph
dated [**2106-3-9**]. Again note is made of opacity in the right
upper lobe extending from the right hilum, representing
post-radiation change
as seen on prior torso CT dated [**2106-5-27**]. Thoracic aorta is
tortuous. Cardiac contour is unchanged. Linear atelectasis in
right upper lobe with pleural thickening is again noted. There
is atelectasis in the right lower lobe. Overall appearance of
the chest is unchanged. Left lung is clear. IMPRESSION: Overall
unchanged appearance of the chest with post-radiation change and
volume loss of the right lung.
.
MRI spine [**2106-7-19**]: Diffuse leptomeningeal metastases involving
the lower thoracic cord, the conus medullaris, and the cauda
equina.
Abdominal aortic aneurysm just above the aortic bifurcation
measuring
approximately 3.1 cm in size.
Mild degenerative changes of the lumbar spine with multilevel
mild bilateral foraminal stenoses, but without canal stenosis.
.
MRI brain [**2106-6-25**]: Multiple, new metastatic lesions (left
parietal;
left medial temporal lobe; met extending from the pituitary
infundibulum into the hypothalamus; right lateral pons; left
cerebellar tonsil and the left cerebellar hemisphere; right
frontal leptomeningeal metastasis).
Brief Hospital Course:
75-yr-old male with PAF (on amio), HTN, AAA, CRI (Cr baseline
1.4), SCLC with brain and spinal mets (diagnosed in [**7-19**],
treated with five cycles of carboplatin/Taxol + chest XRT) s/p
recent whole brain radiation, who presented to the ED with LE
swelling but was found to have hypotension, fever and RLL
infiltrate.
.
# Fever/hypotension: Met SIRS criteria given BP, HR and temp.
Lactate of 2.1 in the ED. Normal AG. Left-shift on differential
with 2% bands. Likely source is lungs given RLL infiltrate on
CXR, which was confirmed on CT. UA was negative and no urinary
symptoms. No lines as entry sites. No open wounds on skin or
mucosa. No abdominal tenderness and LFTs wnl. Thus, no other
obvious sources making pneumonia most likely reason for his
fever/hypotension. Pt received 4L IVF in the ED and was started
on Levophed after CVL placement. Antihypertensive meds were
held. Levophed was weaned off, as well as supplemental O2.
Received Levo/Clinda x1 in the ED. Started Vanc/Zosyn in ICU.
Hemodynamically stable off pressors. Likely component of
dehydration contributing to hypotension as out of proportion of
other clinical picture.
Patient was transfered to the oncology floor when he was
stabilized. Was stepwise titrated down off antibiotics to levo,
and patient completed [**9-26**] day course. He remained off
suppelmental oxygen and was afebrile with normal WBC. Patients
blood pressure's returned to [**Location 213**] normal, and patient returned
to baseline hypertension. HTN meds were restarted, and patient
was well controlled. Towards the end of hospitalization,
patient developed presumed herpetic oral ulcers. Patient had
continued hypotension, HTN meds held, believed to be due to poor
PO intake. Pressures maintained w/ IVF. Patient should have PO
intake enouraged, and IVF if necessary. Patients SBP has ranged
from 90-105 at time of discharge, and patient is asymptomatic.
.
# Thrombocytopenia, now leukocytopenia: Plt of 58 on admission.
H/o easy bruising but no overt bleeding. Last Plt count was 214
one month ago. Baseline around 100-200 indicating chronic
thrombocytopenia, likely due to current radiation therapy. Coags
unremarkable. HIT ab negative. Patient was transfused with one
unit of platelets, increasing count from 21 to 54. Patient w/
leukocytopenia, but ANC > 1000. Should have continued
monitoring.
.
# LE swelling: new onset per patient. LE minimal on exam today.
Preserved EF on Echo from [**2104**]. Possibly due to steroids per
radiation-oncologist. Lenis negative. Consider Echo as well once
stable and euvolemic, in order to assess EF.
.
# Acute on CRF: CRI due to HTN per OMR. Cr baseline around 1.4.
Cr of 1.8 on admission. Likely prerenal given dehydration and
recent orthostatic hypotension as outpatient. Received IVF for
septic picture and Cr down to 0.9 today.
.
# Cardiac:
PAF, on Amio, not on anticoagulation since first cycle of chemo
in [**2104**]; followed by Dr. [**Last Name (STitle) 73**], last seen on [**2106-7-7**]. Found
to be in Afib on admission EKG but not in RVR. Pt between Afib
and tachy sinus on tele, but hemodynamically stable. Patient
was continued on amioderone for rhythem control, and BB was held
at times due to hypotension.
.
# SCLC: SCLC with brain and spinal mets. Diagnosis in [**7-/2105**]
with bulky disease and near complete tracheal obstruction s/p Y
stenting and removal. S/p five cycles of chemotherapy and
radiation therapy to the chest in [**2104**]. Patient completed whole
brain radiation to treat brain disease. Was complaining of back
pain radiating down buttocks. Patient completed spinal XRT
during this hospitalization with a significant improvmeent in
pain. Dexamethasone was increased during this XRT therapy, and
is now being tapered.
.
# Chronic anemia: Hct baseline around 26-36. Normal B12/folate
in [**2105-10-14**], but high Ferritin in line with ACD due to
malignancy. Hct of 45 on admission, likely due hemoconcentration
in setting of dehydration/infection.
.
# Oral Ulcers- Believed to be herpetic in appearence. Patient
started on acyclovir and given lidocain gel for pain relief.
Patient with poor PO intake due to ulcers causing hypotension.
PO intake must be encouraged utill ulcers heal.
Medications on Admission:
amiodarone 200 daily
aspirin 81 daily
dexamethasone 8mg daily, per tapering protocol (OMR note from
[**2106-7-16**])
Diovan 80 per day
metoprolol tartrate 50 mg twice a day
Percocet 5/325 mg twice a day for pain
Protonix 40 once a day
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO once a day
for 8 days: Take 4mg every day on [**8-5**], then take 2mg every day
for three days until [**8-8**], then take 2mg every other day for
three days until [**8-13**], then stop taking.
Disp:*8 Tablet(s)* Refills:*0*
6. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
Disp:*1 ML(s)* Refills:*1*
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*1 bottle* Refills:*2*
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*250 ML(s)* Refills:*0*
9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours) for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days: Take 2mg every day for three days until [**8-9**], then
take 2mg every other day for three days until [**8-15**], then stop
taking.
Disp:*0 Tablet(s)* Refills:*0*
4. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
Disp:*1 ML(s)* Refills:*1*
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*1 bottle* Refills:*2*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*250 ML(s)* Refills:*0*
7. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours) for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
9. Oral Wound Care Products Gel in Packet Sig: One (1)
Mucous membrane tid ().
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Saliva Substitution Combo No.2 Solution Sig: One (1)
Mucous membrane [**3-23**] x day () as needed for use prior to eating
for mouth pain.
12. Artificial Saliva 0.15-0.15 % Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1456**] [**Hospital **] Health Care Center
Discharge Diagnosis:
Pneumonia
Small Cell Lung Cancer
sepsis
acute renal failure
hypotension
Pneumonia
Small Cell Lung Cancer
sepsis
acute renal failure
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after an admission
for fevers and low blood pressure. You were found to have
pneumonia. This pneumonia was so serious that it required
hospitalization to the intensive care unit. We have
successfully been treating this infection with antibiotics, and
your blood pressures have returned to [**Location 213**]. If you develop
fevers, SOB, CP, confusion, or any other concerning symptoms
call your doctor.
You have also developed oral ulcers which has made it
difficult for you to eat/drink. We are giving you medication to
treat the source of the ulcers, as well as medication to numb
the pain. It is important that you drink at least 8 glasses of
water of day, as poor water intake has caused low blood
pressure.
You are being discharged from the hospital after an admission
for fevers and low blood pressure. You were found to have
pneumonia. This pneumonia was so serious that it required
hospitalization to the intensive care unit. We have
successfully been treating this infection with antibiotics. If
you develop fevers, SOB, CP, confusion, or any other concerning
symptoms call your doctor.
You have also developed oral ulcers which has made it
difficult for you to eat/drink. We are giving you medication to
treat the source of the ulcers, as well as medication to numb
the pain. It is important that you drink at least 8 glasses of
water of day, as poor water intake has caused low blood
pressure. If you develop light headedness, dizziness,
confusion, or faint, call your doctor.
You have also developed low blood counts, believed to be due
the the radiation. If you develop bleeding, SOB/weakness, or
fevers, call your doctor.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2106-8-26**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2106-8-26**] 2:30
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"414.00",
"054.2",
"V45.81",
"284.8",
"403.91",
"585.6",
"486",
"276.51",
"584.9",
"427.31",
"198.5",
"198.3",
"162.8",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13155, 13236
|
6055, 10289
|
302, 309
|
13413, 13422
|
4505, 6032
|
15176, 15562
|
3886, 3972
|
10575, 13132
|
13257, 13392
|
10315, 10552
|
13448, 15153
|
3987, 4485
|
257, 264
|
337, 3035
|
3057, 3602
|
3618, 3870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,469
| 136,144
|
46346+58906
|
Discharge summary
|
report+addendum
|
Admission Date: [**2101-6-6**] Discharge Date: [**2101-6-14**]
Date of Birth: [**2037-1-6**] Sex: F
Service: [**Female First Name (un) **] [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 64 year old female
with a history of metastatic melanoma, who was referred from
chemotherapy clinic on [**2101-6-6**], to the [**Hospital1 346**] with the chief complaint of
shortness of breath times one week. The patient reportedly
began radiation and chemotherapy two weeks prior to
admission, over which period she noted gradually diminishing
energy. The patient reportedly noticed an acute worsening of
her symptoms two days prior to admission, characterized by
increasing dyspnea on exertion accompanied by dry cough and
lower left extremity edema.
The patient reportedly denied calf tenderness but did
complain of increased abdominal girth and poor appetite with
concomitant nausea but no vomiting. The patient was
subsequently recommended for evaluation at [**Hospital1 346**] Emergency Department for further
management.
PAST MEDICAL HISTORY:
1. Metastatic melanoma with metastases to the brain and
retroperitoneal and inguinal lymph nodes, now status post
right parietal and left temporal resection.
2. Mild hypertension.
3. Peripheral vascular disease.
4. Endometriosis status post total abdominal hysterectomy
and bilateral salpingo-oophorectomy.
HOME MEDICATIONS:
1. Hydrochlorothiazide.
2. Atenolol.
3. Lipitor.
4. Aspirin.
5. Zofran.
6. Thalidomide.
7. Temozolomide.
ALLERGIES: Penicillin and codeine.
SOCIAL HISTORY: Formerly worked as a nursing supervisor at
[**Hospital3 1280**]. The patient is divorced with two sons.
HOSPITAL COURSE: In the Emergency Department, the patient
underwent a plain chest radiograph which demonstrated an
interval increase in the size of her cardiac silhouette as
compared to prior film obtained on [**2101-5-17**].
Subsequent CAT scan of the chest demonstrated a large
pericardial effusion with no evidence of pulmonary arterial
thrombi and notable bilateral pleural effusions.
The patient was subsequently admitted to the cardiac care
unit under the directly of Dr. [**Last Name (STitle) 1537**] with the presumptive
diagnosis of cardiac tamponade. The patient was sent to the
cardiac catheterization laboratory for a pericardiocentesis;
the procedure was performed without complications and
resulted in the drainage of approximately 730 cc. of
serosanguinous fluid with an immediate reduction in filling
pressures appropriate to the relief of this pericardial
pressure.
A pericardial drainage was left in place and the patient was
subsequently transferred back to the Coronary Care Unit.
Although the finalized results of this pericardial tap
cytology are still pending at the time of this dictation,
sufficient evidence existed at the time of drainage to
suspect that the patient's pericardial effusion was malignant
in nature and an Oncology consultation was obtained.
Following discussions with the patient and her family, the
patient elected to temporarily hold her chemotherapy pending
resolution of her effusion and abdominal distention.
On hospital day number three, the patient's pericardial drain
was removed without complications.
A follow-up echocardiogram demonstrated a small to moderate
sizes persistent pericardial effusion which appeared to be
loculated, with no further evidence of tamponade.
At this point, a Thoracic Surgery consultation was obtained.
Following a thorough evaluation of the patient and review of
her assorted studies, the patient was recommended for a
combined thoracoscopy, drainage of right pleural effusion and
pericardial window. Following a discussion of the relative
risks and benefits of this procedure, the patient consented
to undergo the stated procedure on [**2101-6-10**].
On [**2101-6-10**], the patient therefore underwent a left sided
thoracoscopy with a concomitant left pleurodesis and
pericardial window. The patient tolerated the procedure well
and required one liter of fluid intraoperatively with minimal
associated blood loss. The patient was subsequently
extubated in the Operating Room and returned to the Coronary
Care Unit for further evaluation and management.
This dictation will be completed under separate dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2101-6-13**] 19:52
T: [**2101-6-13**] 20:26
JOB#: [**Job Number 98516**]
Name: [**Known lastname 15735**], [**Known firstname 540**] Unit No: [**Numeric Identifier 15736**]
Admission Date: [**2101-6-6**] Discharge Date: [**2101-6-14**]
Date of Birth: [**2037-1-6**] Sex: F
Service:
HOSPITAL COURSE: Postoperatively, the patient progressed
well clinically. Her pain was initially well-controlled with
a Dilaudid PCA, which was transitioned to adequate pain
control via oral pain medications once the patient was
tolerating a full regular diet. The patient had a left-sided
chest tube which remained in place with continuous wall
suction through postoperative day number three, at which
point, it WAS removed without complication.
On postoperative day number three, the patient's Foley
catheter was also removed without complication. The patient
was subsequently noted to be independently productive with
adequate amounts of urine for the duration of her stay. The
patient was transferred to the Thoracic Surgery Service under
the direction of Dr. [**First Name4 (NamePattern1) 15737**] [**Last Name (NamePattern1) 15738**] for further management,
where she remained through postoperative day number four, [**2101-6-14**], at which point, she was cleared for discharge to a
transitional care unit with instructions for follow-up.
DISCHARGE STATUS: The patient is to be discharged to a
transitional care unit with instructions for follow-up.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Proclor perazine 10 mg po q. 6 hours prn.
2. Zolpidem tartrate 5 mg po q.h.s. prn.
3. Magnesium oxide 400 mg po b.i.d.
4. Heparin 5,000 units subcutaneously b.i.d.
5. Colace 100 mg po b.i.d.
6. Teniacides A & B with calcium 8.6 mg tablets, 1 tablet po
b.i.d. prn.
7. Protonix 400 mg po q.d.
8. Alprazolam 0.25 mg po t.i.d. prn.
11. Ibuprofen 600 mg po t.i.d. prn.
12. Acetaminophen 325-650 mg po q. 4-6 hours prn.
13. Zofran 2-4 mg intravenously q. 6 hours prn.
14. Dulcolax 10 mg po q.d. prn.
15. Percocet 1-2 tablets po q. 4-6 hours prn for pain.
DISCHARGE INSTRUCTIONS: The patient has maintained her chest
tube dressing in place for 24 hours following discharge.
Afterwards, at which point it may be removed. The patient
has maintained incisions clean and dry at all times. Patient
may shower, but should pat dry incisions afterwards; no
bathing or swimming until further notice. No driving while
on prescription pain medications. Patient may resume a full
regular diet.
FOLLOW-UP: Patient is to follow-up with her primary care
physician in one to two weeks. Patient is to follow-up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15738**] four weeks following discharge; the
patient is to call [**Telephone/Fax (1) 1477**] to schedule an appointment.
[**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) 2448**] [**Name8 (MD) **], M.D. [**MD Number(1) 2449**]
Dictated By:[**First Name3 (LF) 15739**]
MEDQUIST36
D: [**2101-6-13**] 08:08
T: [**2101-6-13**] 20:53
JOB#: [**Job Number 15740**]
|
[
"401.9",
"198.3",
"196.2",
"V10.82",
"443.9",
"196.5",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.12",
"34.6"
] |
icd9pcs
|
[
[
[]
]
] |
6056, 6617
|
4850, 6009
|
6642, 7648
|
1414, 1565
|
6024, 6033
|
218, 1062
|
1084, 1396
|
1583, 1689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,022
| 191,182
|
53292
|
Discharge summary
|
report
|
Admission Date: [**2162-9-13**] Discharge Date: [**2162-10-6**]
Date of Birth: [**2092-1-14**] Sex: M
Service: CSU
We anticipate discharge of the patient on the morning of
[**10-6**].
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 70 year old gentleman with
known aortic stenosis was followed in [**Hospital 1727**] Medical Center
with serial echocardiograms and recently began experiencing
worsening symptoms with increased dyspnea on exertion. He
was referred into our Medical Center for Dr. [**Last Name (Prefixes) **] to
evaluate.
PAST MEDICAL HISTORY:
1. Aortic stenosis.
2. Coronary artery disease with circumflex stent in [**2158**] and
percutaneous transluminal coronary angioplasty to the left
anterior descending coronary artery and ramus in [**2149**].
3. Cryptogenic cirrhosis, Child's type A.
4. Gout.
5. Hemorrhoids.
6. Gastritis/duodenitis.
7. Hypertension.
8. Anemia.
9. Pancreatitis question post cholecystectomy.
10. Paroxysmal atrial fibrillation.
11. Psoriasis.
12. Thrombocytopenia.
13. Arthritis.
14. Recurrent urinary tract infections.
15. Gastroesophageal reflux disease.
16. Chronic sinusitis.
17. Peripheral vascular disease.
18. Ureteral stones.
19. Asthma.
20. Epididymitis.
ALLERGIES: He had no known allergies.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Right shoulder surgery.
3. Tonsillectomy.
4. Bilateral cataract surgery.
5. Sinus surgery.
6. Bilateral knee effusion.
SOCIAL HISTORY: Lives with his wife. Is retired. He has no
use of tobacco or alcohol or drugs at this time.
MEDICATIONS ON ADMISSION: Atenolol 100 P.O. once daily,
quinidine 324 mg P.O. 3 times a day,
triamterene/hydrochlorothiazide 37.5 mg P.O. once daily,
Relafen 750 mg P.O. once daily, Nexium 40 mg P.O. once daily,
Allopurinol 300 mg P.O. once daily, Flovent and albuterol
inhalers, fluocinonide 0.05 percent and Dovonex 0.005 percent
medications for psoriasis.
Cardiac catheterization in [**Month (only) 205**] of 204 showed 70 percent
lesion of the left anterior descending coronary artery and 50
percent lesion of the ramus, 70 percent lesion of the
circumflex, 50 percent lesion of the obtuse marginal, 80
percent lesion of the right coronary artery. Aortic valve
area is 0.8 cm sq with a mean gradient of 49 and a 5.5 cm
ascending aorta. Echocardiogram in [**2162-5-27**] showed
ejection fraction of 60 percent, aortic valve area of 0.7 cm
sq, a peak gradient of 72 mm and a mean gradient of 50 as
well as mild mitral regurgitation. Abdominal CT scan
obtained at the outside hospital showed a normal liver and
spleen without any focal abnormalities. Gallbladder was
absent with no ductal dilatation. Abdominal aorta had mild
calcifications. Please refer to the follow up report.
PHYSICAL EXAMINATION: Temperature 97.8, heart rate 58, blood
pressure 142/88, respiratory rate 18, saturation 98 percent
on room air. He is sitting in bed in apparent distress. His
pupils equal, round and reactive to light. Extraocular
movements were intact. He was anicteric, noninjected. His
neck was supple. He had no obvious skin lesions, no
lymphadenopathy or thyromegaly. No bruits or jugular venous
distension. His lungs were clear bilaterally. His heart was
regular rate and rhythm with S1 S2 tones and a grade III/VI
blowing systolic murmur. His abdomen was obese, soft,
nontender with positive bowel sounds. His extremities were
warm with no edema. He had 2 plus bilateral carotid pulses,
1 plus bilateral radial pulses, 1 plus bilateral femoral
pulses and no palpable dorsalis pedis and posterior tibial
pulses.
He was admitted preoperatively for Bentall procedure and
coronary artery bypass grafting and the idea was to have a
hepatology consult first prior to surgery given his history
of cirrhosis and thrombocytopenia. He was seen by the
hepatology fellow on the day of admission. With attempts to
try to correct on his prior notes from his hospitalization
where the diagnosis was made, preliminary carotid ultrasound
also showed no significant hemodynamic lesions in either the
right or left carotid bifurcation. On in-house day two his
laboratories were as follows: Sodium 144, potassium 4.1,
chloride 105, bicarb 28, BUN 20, creatinine 1.4 with a blood
sugar of 146. ALT 18, AST 12, alkaline phosphatase 112,
total bilirubin 0.5, albumin 4.1, amylase 113, lipase 124,
HDL 47, cholesterol 191, white count 7.6, hematocrit 39.2,
platelet count 165,000. PT 12.8 with an INR of 1.0. He was
alert and oriented. His exam was unremarkable with a chest x-
ray that showed multiple calcified granulomas throughout his
lungs, no pneumonia or congestive heart failure but he had a
5 mm nodule in the right lower lobe. Repeat echocardiogram
showed ejection fraction to be 60 percent with a 5.4 cm
ascending aorta normal root diameter, severe aortic stenosis,
mild mitral regurgitation. Hepatology attending stated he
would not perform a liver biopsy at this time prior to his
surgery.
On [**9-15**] he underwent coronary artery bypass grafting
times four with a left internal mammary artery to the left
anterior descending coronary artery, a vein graft to the
obtuse marginal, vein graft to the posterior descending
coronary artery and a vein graft to the ramus. 2) Aortic
valve replacement, 25 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial
valve. 3) Ascending aorta and hemiarch replacement with 30
mm Gel-weave graft. He was transferred to the Cardiothoracic
Intensive Care Unit in stable condition on a dobutamine drip
at 2.5 mcg per kilo per minute, propofol drip titrated and a
nitroglycerine drip at 1.2 mcg per kilogram per minute. On
postoperative day one his postoperative laboratories were as
follows: Potassium 5.0, white count 12.4, hematocrit 29.3,
platelet count 103,000. BUN 17, creatinine 1.4. His INR was
1.4. He was on dobutamine drip at 2.5, insulin drip at 1 and
propofol drip at 10. The plan was to wean his ventilator, he
started on Lasix diuresis and to try to wean his dobutamine.
His lungs were clear bilaterally. His heart was regular rate
and rhythm. His incisions were clean, dry and intact. He
remained on the ventilator that morning. He was moving all
four extremities at the time. He was evaluated initially by
Case Management and followed daily by the hepatology service.
That evening the patient developed atrial fibrillation which
was initially tolerated and rate controlled with Lopressor.
Eventually his heart rate increased. Again he was started on
diltiazem drip. He was also given intravenous Lasix with
minimal response as well as albuterol nebulizer. The
decision was made to attempt cardioversion. He was attempted
at 200, 300 and 350 joules without any evidence of sinus
rhythm. He was then intubated for worsening hypoxia. He had
stable blood pressure throughout. On postoperative day two
he was extubated. His dobutamine was decreased. He was
given a unit of packed red blood cells and he was now on a
Nipride drip at 0.25 mcg per kilogram per minute. His
creatinine was stable with 1.3 with a potassium of 4.1. His
INR dropped slightly to 1.2 with a white count of 12.2 and a
hematocrit of 32.0. His heart was regular rate and rhythm.
He had decreased breath sounds at both bases. His chest
tubes remained in place. He had 1 plus peripheral edema. He
was started on low dose beta blocker with hydralazine PRN
with plan to try to wean his Nipride. He also continued on
Lasix diuresis and the plan was to try and get him out of bed
and get started with physical therapy. He was also seen by
the electrophysiology service fellow that afternoon.
However, he remained on diltiazem drip and electrophysiology
service recommendations were followed. Again the patient had
some labile wound dynamics with another episode of atrial
fibrillation. An attempt was made to put a Swan-Ganz
catheter back in. On postoperative day three the patient
remained intubated on Neo-Synephrine drip at 0.7. He had a
blood pressure of 110/56 with a heart rate of 105 and atrial
fibrillation. He remained intubated at that time. His
creatinine was stable at 1.3 and he remained sedated.
Attempts were made again at DC cardioversion which were
unsuccessful by the electrophysiology service fellow. He was
loaded with amiodarone as well as his diltiazem drip. He was
started on norinone on postoperative day 4 and also on his
insulin drip and amiodarone drips. He remained intubated and
sedated. His heart was irregular, in atrial fibrillation of
106 with blood pressure of 129/71. Laboratories for
additional liver function tests were sent off and he was
started on heparin drip as well as his diltiazem drip.
On postoperative day five he was converted, had 10 beats of
sinus rhythm again and went back into atrial fibrillation.
He was also started on Natrecor drip as well as his heparin.
In addition he continued with beta blockade and Diamox. He
remained sedated with bilateral coarse breath sounds. The
plan was to attempt to wean him from the ventilator. On
postoperative day he was cardioverted to normal sinus rhythm.
Diltiazem drip was off. He remained on amiodarone drip and
heparin drips as well as insulin, norinone and Natrecor at
0.01. He remained intubated and sedated. Additional
attempts were give with intravenous Lasix and Natrecor to
help with diuresis and to try and wean him from the
ventilator. He was also seen by Case Management and followed
daily by Electrophysiology Service. He was started on tube
feeds on postoperative day seven and levofloxacin for his
pulmonary status. On postoperative day eight he was started
back on beta blockade with Lopressor. His diltiazem drip was
decreased and later that day his tube feeds were held for
residuals. His Lasix was increased and he remained on
amiodarone, heparin, insulin, norinone, Natrecor, Neo-
Synephrine, Predanex and propofol. His creatinine rose
slightly to 1.6. His hematocrit was stable at 36.1. He was
also seen by physical therapy and rehabilitation services. A
left subclavian line was also placed on the 28th. On the
28th he had a rash also that was evaluated across his chest
and groin area which was evaluated by the dermatology team
who determined it was some folliculitis and recommended
Cleocin gel or erythromycin gel B.I.D Please refer to the
dermatology attending note on the 28th.
[**Last Name (STitle) 28556**]lso seen by the clinical nutrition team on the 29th
for evaluation of his tube feeds. On postoperative day nine
he did culture out Citrobacter in his sputum. His
antibiotics were changed to Zosyn. His tube feeds were held
for high residuals. He had some transient hematuria. He had
a left subclavian Swan in place. His Lasix was discontinued.
He remained intubated and sedated and his Natrecor was
weaned. He also received one unit of packed red blood cells
for volume. On postoperative day 10 he was extubated
successfully. He had another run of atrial fibrillation and
was bolused with amiodarone and remained on amiodarone and
heparin as well as insulin, norinone, Natrecor and Zosyn. He
had a swallow evaluation also. He was alert and oriented
times three with decreased breath sounds in his bases as he
remained in atrial fibrillation. On postoperative day 11 the
Norinone wean began and aggressive pulmonary toilet began.
Patient seemed to be improving at that point. He remained on
Zosyn and an amiodarone drip with the plan to switch him over
to P.O. amiodarone. He had a bedside swallowing evaluation
on the [**8-27**] and with considered risk for
aspiration their recommendations were followed. Dr. [**Last Name (Prefixes) **] the stroke attending to evaluate the patient for an
acute stroke at 3 P.M. on [**9-27**] as he complained of
right arm weakness. The stroke attending though the etiology
was probably not stroke but asked that a head CT be ordered
to rule out a small infarction for which there was low
suspicious and to treat his right forearm cellulitis.
On postoperative day 13 patient remained on Zosyn and
amiodarone and heparin drip with no events overnight with a
good blood pressure of 130 to 140 systolic over 50s
diastolic, heart rate in the 60s in sinus rhythm. His right
hand was noticeably more swollen than the left due to his
probable cellulitis. The incisions were otherwise clean, dry
and intact. His lungs were clear bilaterally. His abdomen
was soft. Overall he seemed to be improved and the plan was
to try and get him up and get him going with some mild
physical therapy and ambulation as well as aggressive
pulmonary toilet. His central venous line was discontinued
on postoperative day 15 and he remained on Zosyn and
amiodarone. Repeat swallowing evaluation was done on
[**9-29**] and his rash seemed much improved. He was seen by
the ORL service to assist with evaluation of his swallow
study and functional endoscopic evaluation of his swallowing.
There was some concern by ear, nose and throat this his
supraglottis was suspicious for thrush and they recommended a
short treatment of Diflucan intravenous and to follow up on
re-evaluation of his larynx after the course of Diflucan.
His vocal cords were moving normally and there was no
evidence of nerve damage or epiglottis or laryngeal edema
causing any airway compromise. He was cleared for P.O.
status post his video swallow evaluation and was re-evaluated
by the nutrition team. His CT scan of his head also showed
no intracranial hemorrhage or major vascular or territorial
infarcts. Patient continued to improve.
Hepatology saw the patient also on the 5th and recommended
that he follow up with them as an outpatient. On
postoperative day 17 the Zosyn was discontinued. Patient was
continued on Diflucan for his oral thrush. The amiodarone
was changed to P.O. and his Coumadin was restarted on
[**10-2**]. On postoperative day 18 he had no events
overnight. BUN 17, creatinine 0.9, white count 4.8,
hematocrit 27, platelet count 191,000, potassium 4.0. He
remained on a heparin drip also until his Coumadin became
therapeutic as well as amiodarone and fluconazole. He
continued on a pureed diet and on [**10-3**] he was
transferred out to the floor with stable vital signs. On the
7th his INR was 1.3 and not quite therapeutic. He continued
to receive his nightly dose of Coumadin. The patient was
also on aspiration precautions. Bladder training was
restarted with the patient with intermittent clamping of his
Foley catheter. Patient went back into atrial fibrillation
on postoperative day 19, [**10-4**], but was in the 80s and
tolerating it well from a blood pressure point of view with a
blood pressure of 120/66. His creatinine was stable at 1.0.
He was fine on focal examination but was a little bit
agitated and upset. His lungs were clear bilaterally. His
heart was irregularly irregular. He had a sternal click
which was noted. He was rebolused with intravenous
amiodarone with a plan to contact electrophysiology service
for cardioversion if the patient had continued atrial
fibrillation with a goal of keeping him rate controlled. His
Foley was discontinued and he received another dose of
Coumadin. In attempt to get him therapeutic he was a little
bit forgetful but otherwise alert and oriented. Incisions
appeared to be healing [**Last Name (un) **].
He was seen again by Case Management on [**10-4**] and had a
bedside swallow follow up also performed by ORL. They
recommended soft solid diet with regular liquids and did some
retraining with the patient. The patient continued to work
with physical therapy who re-evaluated after he got to the
floor. On postoperative 20 the patient converted to sinus
rhythm overnight but to void with the Foley out. His voice
continued to be hoarse but he did not have evidence of thrush
in his mouth. Still he had a grade I to II/VI systolic
ejection murmur with a positive sternal click. He did not
complain of any nausea. He had a small area of dark eschar
along his incision. He said subjectively that he felt much
better and was now back in sinus rhythm. Electrocardiogram
with GC was checked which was 0.45 on telemetry. He was
ordered for 5 mg of Coumadin on the night of postoperative
day 20 and started his vitamin C, multivitamins and iron.
Discharge planning was restarted and rehabilitation screens
were done.
DISCHARGE MEDICATIONS: To be dictated tomorrow.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement. 2. Coronary artery
bypass grafting times four and ascending aorta and
hemiarch replacement.
2. Status post stent [**2158**] of the circumflex and percutaneous
transluminal coronary angioplasty of the left anterior
descending coronary artery ramus in [**2149**].
3. Cryptogenic cirrhosis, Child's type A, doubt.
4. Hemorrhoids.
5. Gastritis/duodenitis.
6. Hypertension.
7. Anemia.
8. Post cholecystectomy pancreatitis.
9. Paroxysmal atrial fibrillation.
10. Psoriasis.
11. Thrombocytopenia.
12. Arthritis.
13. Recurrent urinary tract infections.
14. Gastroesophageal reflux disease.
15. Chronic sinusitis.
16. Peripheral vascular disease.
17. Ureteral stones.
18. Asthma.
19. Epididymitis.
Again discharge medications to be dictated tomorrow, the
10th, the day of his discharge.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2162-10-5**] 17:04:32
T: [**2162-10-5**] 18:56:06
Job#: [**Job Number 109667**]
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5,692
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54073
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Discharge summary
|
report
|
Admission Date: [**2148-1-15**] Discharge Date: [**2148-1-20**]
Date of Birth: [**2099-9-1**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin / Clindamycin
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Sustained VT refractory to ICD
Major Surgical or Invasive Procedure:
-Redo median sternotomy and epicardial ventricular tachycardia
ablation using the CryoCath device
-Right ventricular biopsy
-Elective intubation for surgery
-Central venous line placement for surgery
History of Present Illness:
48 yoM, who is an EP patient with arrhythmogenic right
ventricular cardiomyopathy (ARVC), hx of SVC syndrome, bilateral
subclavian stenosis, hx of endocarditis and multiple ICD
complications, admitted after sustained VT refractory to ICD
firing for elective external ablation and pacemaker placement,
whose post-operative course has been complicated by VT
responsive to BB.
.
He was diagnosed with VT at the age 17 and was managed on
quinidine until the age of 33; during this interval he was very
active - ran a marathon and [**Hospital Ward Name **]-dived - and only had rare
episodes of VT, which would spontaneously resolve with cessation
of physical activity. At the age of 33, an ICD was implanted;
however, his course since then has been complicated by multiple
infections and line dislodgements, requiring replacement of
multiple ICDs.
.
4 weeks prior to this hospitalization, his ICD fired while he
was carrying a wood duck house in the [**Doctor Last Name 6641**]; it fired 5 times
and he returned to sinus. 5 days later, his ICD fired again,
this time after he was startled by a Moose while hunting.
However, this time, he sustained VT. He called his wife, who
found him in the [**Doctor Last Name 6641**] and took him to the local ED.
.
At the local ED, his VT was refractory to medications and he was
finally DC cardioverted and transferred to [**Hospital1 18**] for further
management. During this hospitalization, the patient was
scheduled for an epicardial ablation, but during the procedure,
the EP team was not able to perform the ablation because the ICD
lead was stenosed to LV and not functioning. The ICD lead could
not be removed in EP lab. The patient was discharged home on
Lifevest and scheduled to return for elective thoracic surgery
for epicardial ablation and replacement of ICD on right side in
[**2-4**] weeks.
.
He underwent the procedure Monday [**1-15**]. During the procedure,
Dr. [**Last Name (STitle) **] mapped the epicardium and Dr. [**Last Name (STitle) 914**] ablated
areas of the inferior aspect of the right ventricle with a
Cryo/Cath in several different locations; a biopsy of the area
was also taken. Right sided ICD was placed.
.
Post-operatively he did well intitially, but then had an episode
of sustained VT on POD2 with persistent ICD firing. His BB was
started and uptitrated and he has since remained in sinus.
.
.
CARDIAC REVIEW OF SYSTEMS:
(+) Per HPI. Has noticed increased diffuse UE edema and skin
tightness, improving LE edema, and facial edema.
(-) Denies chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.
OTHER REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies any exertional buttock or calf pain; prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism;
bleeding at the time of surgery, hemoptysis, black or red
stools.
.
Also denies fevers, chills, myalgias, joint pains; cough,
wheezes; diarrhea, or recent change in bowel habits; dysuria or
change in voiding habits; rashes or skin breakdown;
numbness/tingling in extremities; feelings of depression or
anxiety. All of the other review of systems were negative.
.
Past Medical History:
Cardiac Risk Factors: (-)Diabetes, (-)Dyslipidemia,
(-)Hypertension, (-) Smoking, (-) FH early MI or sudden cardiac
death
.
Cardiac History:
-Right ventricular ICD
-Arrhythmogenic right ventricular cardiomyopathy
-Exertional syncope due to VT at the age of 16, treated
chronically with quinidine
-Inducible VT by EP study on [**2135-5-10**]
-Dual chamber ICD implant (left pectoral) on [**2135-5-11**],
with a pacesetter atrial lead and a CPI ventricular lead.
-New right-sided ICD in [**2139**], at an outside hospital following
lead fracture.
-Endocarditis involving the right-sided ICD in [**2143-11-3**].
-Hemi-sternotomy and lead extraction on [**2143-11-6**].
-Implant of a [**Company 1543**] 6949 RV lead on [**2144-1-23**],
following venoplasty of an occluded right axillary subclavian
vein.
-Right ventricular 6949 lead extraction on [**2145-8-2**], due
to high impedance and lead recall with implant of a St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 110841**] right ventricular dual coil defibrillation lead following
right subclavian venoplasty.
.
Coronary Artery Bypass Grafts:
None
.
Percutaneous Coronary Interventions:
None
.
Pacing / ICD:
As above
Social History:
-Smoking/Tobacco: None
-EtOH: None
-Illicits: None
-Lives at/with: Wife, 15yo son, also has 2 children from
previous marriage; works as a real-estate manager. Loves to hunt
duck and big game. Also loves gather wood (no axe swinging) for
his woodstove.
Family History:
-Mother 72 and well
-Father died of esophageal cancer at 58.
-Four siblings, who are alive and in good health.
.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission PE:
.
VS: T=96.4...BP= 90/60, HR 60s...O2 sat= 98% RA
GENERAL: WDWN [**Male First Name (un) 4746**] in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Pacer pocket is without erythema or warmth.
LUNGS: CTA BL
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+
Left: Radial 2+ DP 2+
Discharge PE:
VITALS: 98.2 78 108/63 78 18 97 RA
.
Discharge PE:
.
GENERAL: WDWN in NAD. Alert & Oriented x3. Mood, affect
appropriate. No central or peripheral cyanosis; no jaundice, no
palor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple; no JVD. R IJ in place.
CARDIAC: PMI non-displaced. RR, normal S1, S2; no S3, S4. No
m/r/g. No thrills, lifts.
CHEST: Well healing sternotomy wound CDI.
LUNGS: Bronchial breath sounds half-way up R lung fields
posteriorly, asymmetric compared to Left. Otherwise, no
adventitial sounds. Respirations unlabored, no accessory muscle
use.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
GROIN: No femoral bruits.
EXTREMITIES: No cyanosis, clubbing, or edema. Mildly tense UE
skin and bilateral hand [**2-4**]+ edema.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 2+
Left: DP 2+
NEURO: CN2-12 intact; moving 4 extremities spontaneously
Pertinent Results:
Admission Labs:
[**2148-1-15**] 11:07PM TYPE-ART PO2-173* PCO2-38 PH-7.31* TOTAL
CO2-20* BASE XS--6
[**2148-1-15**] 11:07PM O2 SAT-98
[**2148-1-15**] 09:48PM TYPE-ART PO2-148* PCO2-35 PH-7.34* TOTAL
CO2-20* BASE XS--5
[**2148-1-15**] 09:48PM GLUCOSE-147*
[**2148-1-15**] 09:48PM O2 SAT-98
[**2148-1-15**] 08:43PM WBC-10.7 RBC-4.01* HGB-11.7* HCT-34.5* MCV-86
MCH-29.2 MCHC-33.9 RDW-13.8
[**2148-1-15**] 08:43PM PLT COUNT-185
[**2148-1-15**] 08:43PM PT-16.6* PTT-29.5 INR(PT)-1.5*
[**2148-1-15**] 08:26PM TYPE-ART PO2-152* PCO2-57* PH-7.21* TOTAL
CO2-24 BASE XS--5
[**2148-1-15**] 08:26PM GLUCOSE-128* NA+-139 K+-3.5
[**2148-1-15**] 08:26PM freeCa-1.07*
[**2148-1-15**] 05:28PM TYPE-ART PO2-175* PCO2-46* PH-7.30* TOTAL
CO2-24 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2148-1-15**] 05:28PM GLUCOSE-112* LACTATE-0.7 NA+-140 K+-3.2*
CL--109
[**2148-1-15**] 05:28PM HGB-11.8* calcHCT-35
[**2148-1-15**] 05:28PM freeCa-1.05*
[**2148-1-15**] 01:52PM TYPE-ART PO2-458* PCO2-32* PH-7.49* TOTAL
CO2-25 BASE XS-2 INTUBATED-INTUBATED
[**2148-1-15**] 01:52PM GLUCOSE-93 LACTATE-1.0 NA+-138 K+-3.8 CL--106
[**2148-1-15**] 01:52PM HGB-12.9* calcHCT-39
[**2148-1-15**] 01:52PM HGB-12.9* calcHCT-39
[**2148-1-15**] 01:52PM freeCa-1.08*
[**2148-1-15**] 10:25AM PT-14.4* INR(PT)-1.2*
.
EKG:
[**1-15**]: Sinus rhythm. Diffuse ST-T wave changes may be due to
ischemia. Compared to the previous tracing of [**2147-12-27**] QRS
change is not quite as wide so full criteria for right
bundle-branch block are not quite met and the rate has
increased.
.
STRESS:
[**2144**]:
This 44 year old man s/p AICD '[**35**] with a history of right
ventricular dysplasia was referred to the lab for arrhythmia
evaluation. The patient exercised for 13 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol and stopped for fatigue. The estimate peak METS are
15.1 which represents an excellent physical working capacity for
his age. No arm, neck, back or chest disocmfort was reported by
the patient throughout the study. There were no ST segment
changes during exercise or in recovery. The rhythm was sinus
with several isolated vpbs. Appropriate hemodynamic response to
exercise on beta blocker therapy.
.
IMPRESSION: No anginal type symptoms, ischemic EKG changes or
significant exercise induced ectopy. Nuclear report sent
separately.
.
Nuclear:
1. Normal myocardial perfusion. 2. Mild left ventricular
enlargement. 3. LVEF 53%.
.
CARDIAC CATH:
No recent
.
ECHOCARDIOGRAM:
.
[**1-15**] TTE:
1. The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2. Overall left ventricular systolic function is low normal
(LVEF 50-55%).
3. The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
7. There is a very small pericardial effusion.
Drs. [**Last Name (STitle) 914**] and [**Name5 (PTitle) **] were notified in person of the
results.
After lead extraction, there was no increase in the size of the
pericardial effusion.
.
[**12-27**] TTE:
The right atrial pressure is indeterminate. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). **The right ventricular cavity is dilated
with severe global free wall hypokinesis.** No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.
.
Compared with the prior study (images reviewed), the pericardial
effusion now appears more circumferential, but likely similar in
absolute volume of fluid.
.
.
IMAGING:
.
[**12-18**] CT-Coronary:
IMPRESSION:
1. Mild nonobstructive noncalcified plaque within LAD, LCX, and
RCA, causing up to 30% luminal narrowing.
2. Borderline mediastinal and hilar lymph nodes, that might be
consistent with the diagnosis of sarcoisdosis. No evidence of
pulmonary sarcoidosis. No definite evidence of abnormal
myocardial perfusion/thickening to suggest cardiac sarcoidosis.
3. Partially visualized left upper lobe pulmonary nodule, stable
since at least [**2145-6-4**].
4. Retained cardiac pacer wire within proximal left
brachiocephalic vein, unchanged since [**2145**].
5. Small hiatal hernia.
.
PA-L CXR [**1-17**]:
The patient was extubated in the meantime interval. The
appearance of the pacemaker with its leads transversing the
chest is unchanged. The right internal jugular line tip is not
seen, but most likely does not extend beyond the superior/mid
SVC.
.
There is interval removal of the mediastinal drains and chest
tube. There is no evidence of left pneumothorax. There is
minimal apical right pneumothorax, new compared to prior study.
Bibasilar consolidations have slightly progressed in the
interim, most likely consistent with interval progression of
atelectasis.
.
PATHOLOGY [**1-15**]:
Right ventricular outflow tract, myocardial biopsy (A):
-Cardiac muscle with degenerative features and replacement by
fibrofatty scar tissue (see note).
Right ventricular wall scar, myocardial biopsy (B):
- Cardiac muscle with degenerative features and replacement by
fibrofatty scar tissue (see note).
- Areas with inflammatory infiltrate composed of neutrophils and
occasional eosinophils.
Tissue on pacing lead (C):
-Acellular scar tissue.
.
Note:
(A-B): The histologic findings are consistent with
arrhythmogenic right ventricular cardiomyopathy (ARVC).
.
Discharge Labs:
.
[**2148-1-20**] 07:00AM BLOOD WBC-5.4 RBC-3.23* Hgb-9.7* Hct-28.3*
MCV-88 MCH-30.1 MCHC-34.4 RDW-14.2 Plt Ct-214
[**2148-1-20**] 07:00AM BLOOD Plt Ct-214
[**2148-1-20**] 07:00AM BLOOD PT-17.0* PTT-28.7 INR(PT)-1.5*
[**2148-1-20**] 07:00AM BLOOD
[**2148-1-20**] 07:00AM BLOOD Glucose-91 UreaN-16 Creat-0.9 Na-140
K-3.8 Cl-103 HCO3-26 AnGap-15
[**2148-1-20**] 07:00AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.6
Brief Hospital Course:
48 yoM, who is an EP patient with arrhythmogenic right
ventricular cardiomyopathy (ARVC), hx of SVC syndrome, bilateral
subclavian stenosis, hx of endocarditis and multiple ICD
complications, admitted after sustained VT refractory to ICD
firing for elective external ablation and pacemaker placement,
whose post-operative course was complicated by VT responsive to
BB.
.
ACTIVE ISSUES:
.
# Sustained VT in the setting of a history of paroxysmal VT:
Underlying etiology found to be ARVC by pathology this
admission. Underwent elective epicardial ablation performed in
tandem by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**] as well as placement of a
new pacemaker by Dr. [**Last Name (STitle) **]. He tolerated the redo sternotomy
well but did have an episode of post-operative sustained VT
refractory to ICD firing as detailed below. He was discharged on
Quinidine 648 q8, Toprol XL 100 daily, and Warfarin.
.
# Post-operative sustained VT: Post-operatively had an episode
of sustained VT refractory to ICD firing thought to be due to
post-operative catecholamines. He was re-started on a BB and did
not have any further episodes; he was discharged on BB as
detailed above.
.
# Post-Op edema in the setting of known SVC syndrome:
Post-operatively had minimal edema that resolved with gentle
lasix diuresis. When transferred to [**Hospital1 1516**], had worsening UE edema
bilaterally and subjective facial edema. His symptoms were
thought to be secondary to mechanical obstruction caused by the
patient's history of multiple pacer wires; given that his
symptoms was thought to be hardware related, further diuresis
was held. **The patient's UE edema will need close follow-up
after discharge.**
.
# ICD Post-Op management, history of endocarditis: Discharged on
a course of Levofloxacin 500 q24 Day 1 = [**1-16**], Course = 7 days.
.
# Anemia: Hct on discharge was approximately 25 from 35 on
admission. Iron studies suggested iron deficiency anemia. **Hct
and response to Fe supplementation started on discharge will
need to be followed.**
.
# Elective intubation for surgery: Electively intubated and
durably extubated without complications.
.
INACTIVE/CHRONIC ISSUES:
None
.
TRANSITIONAL ISSUES:
As above in **.
Medications on Admission:
Cardiac Meds
-Quinidine 648 mg TID
-Atenolol 100 mg daily
-Coumadin 2.5 mg daily
.
Other Meds
.
ALLERGIES/ADR'S:
-Nafcillin
-Clindamycin
Discharge Medications:
1. quinidine gluconate 324 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO three times a day.
2. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain for 21 days.
Disp:*63 Tablet(s)* Refills:*0*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 14 days.
Disp:*28 Capsule(s)* Refills:*2*
9. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Arrhythmogenic Right Ventricular Cardiomyopathy (the source of
your ventricular tachycardia)
.
SECONDARY:
-None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you at the [**Hospital1 771**] ([**Hospital1 18**]).
.
You were hospitalized to undergo heart surgery in which your
chest was opened and electrically overactive regions of your
heart were precisely mapped and strategically destroyed; the
purpose of this procedure was to stop your heart from
recurrently going into a potentially dangerous fast rhythm known
as ventricular tachycardia. At the same time of this operation,
a new Implantable Cardioverter Defibrillator (ICD) was placed
into your right chest to protect you from the potential dangers
of ventricular tachycardia if they were to recur at some point
in the future despite the aforementioned surgery. Both
procedures were performed successfully and you have made a very
good recovery.
.
You had an episode of ventricular tachycardia after the surgery,
but this was likely due to a combination of you not being on
your regular beta-blocker at the time as well as being in a
post-operative state in which your heart was easily excitable
because of stress hormones normally released in the body in
response to surgery. It is reassuring that you have not had any
further episodes of ventricular tachycardia since your
beta-blocker has been restarted, which suggests that the surgery
was successful.
.
As you know, the care that you received in the hospital is not
the end of your treatment. It is very important that you
continue the following heart regimen after you are discharged:
# START: Levofloxacin 500 mg daily for 4 days, then STOP.
# START: Toprol XL 100 mg daily
# STOP: Atenolol 100 mg daily
# CONTINUE: Quinidine 648 mg three times daily
# CONTINUE: Coumadin 2.5 mg daily
# START: Aspirin 81 mg daily
# REFRAIN: From physical exertion or adrenaline-inducing
activities, such as hunting, if at all possible
# REFRAIN: From activities that could dislodge your ICD leads,
such axe-swinging
.
It is also very important that you continue your post-operative
recovery regimen from thoracic surgery after leaving the
hospital.
# START: Incentive spirometer. **Your goal should be to fill the
entire spirometer four times per hour. It will be painful at
first, but the pain gets better the more you use the spirometer
and with increased activity as well as time.**
# START: Ibuprofen 600 mg every 8 hours as needed for pain.
**For the first week after hospitalization, it will help prevent
pain by taking this every 8 hours even if you don't have pain.**
# START: Percocet tabs every 8 hours as needed for breakthrough
pain
# START: Colace to prevent constipation that can be caused by
Percocet; you may stop this medication after you stop taking
Percocet
# STOP TEMPORARILY: Heavy lifting more than [**6-12**] lbs for 1 month
# STOP TEMPORARILY: Driving until you can lift [**6-12**] lbs without
pain
.
We have also started you on a medication for your low blood
count, which is the result of your surgery as well as iron
deficiency.
# START: Iron supplement 325 mg daily. Take this medication
until your primary care physician instructs you to stop taking
it.
.
Otherwise, continue taking your other medications as previously
prescribed and attend all of the follow-up appointments detailed
below.
Followup Instructions:
Since it is the weekend, no physician offices are open. Your
follow-up appointments with the following physicians will be
scheduled after your discharge and the physicians' offices will
contact you shortly with dates and times.
.
# Dr. [**Last Name (STitle) **]
# Dr. [**Last Name (STitle) 914**]
# Dr. [**First Name (STitle) **]
|
[
"423.1",
"V58.61",
"459.2",
"285.1",
"996.04",
"427.1",
"447.1",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.97",
"38.93",
"37.33",
"37.25"
] |
icd9pcs
|
[
[
[]
]
] |
17031, 17037
|
13447, 13818
|
314, 516
|
17203, 17203
|
7097, 7097
|
20578, 20911
|
5206, 5434
|
15864, 17008
|
17058, 17182
|
15703, 15841
|
17354, 20555
|
13021, 13424
|
5449, 6162
|
15660, 15677
|
3212, 3710
|
6227, 7078
|
244, 276
|
13833, 15616
|
544, 2921
|
7114, 13005
|
17218, 17330
|
15632, 15639
|
3732, 4921
|
4937, 5190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,761
| 149,923
|
38635
|
Discharge summary
|
report
|
Admission Date: [**2137-12-10**] Discharge Date: [**2137-12-14**]
Date of Birth: [**2076-7-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Catheterizaton with thrombectomy (at other hospital)
Balloon Pump placement (OSH) and removal ([**Hospital1 18**])
History of Present Illness:
61 yo M being transferred from [**Hospital3 417**] after cath for
prox LAD instent thrombosis, thereafter requiring dopamine and
IABP.
.
Reportedly, pt had Taxus stent placed in [**State 4260**] in [**2134**] in setting
of a positive stress test. Pt was recently diagnosed with
prostate cancer and in the setting of pre-XRT was asked to stop
ASA, Plavix (both on [**12-5**] days ago) and lipitor (3 weeks
ago), all okayed by his out-of-state cardiologist. Pt presented
this morning with STEMI with thrombosed long proximal LAD stent.
.
Patient was playing basketball at a gym, felt [**5-24**] chest
pressure with dyspnea. Called EMS. Was in cath lab within 40-45
minutes of CP onset. On presentation to [**Hospital3 **] ED, 97.3, 92,
BP 131/98, 18, 100%on4L. Received moriphine, nitro, aspirin.
After EKG revealed STEMI, received plavix, lopressor.
.
Was successfully revascularized without requiring of additional
stenting. During procedure was hypotensive with SBP 70s, started
on peripheral dopamine. Was dyspneic, received 20 mg IV lasix
and hi flow 02. RHC showed PA and RA sats 55.
.
On transfer pt has RHC and IABP in place with augmented DBPs in
90s. Pt is currently on IV heparin (for IABP), Reopro (for stent
thrombosis), ASA, Plavix (loaded with 600mg), and 5 of dopamine
peripherally.
.
Pt has never been to [**Hospital1 18**] previously but requiring transfer for
management of IABP as well as to be closer to [**Hospital3 328**] for
reassessment of prostate cancer treatment plans.
.
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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
- Taxus Stent to LAD in [**2134**]
3. OTHER PAST MEDICAL HISTORY:
GERD c/b barretts
Prostate Ca ([**Doctor First Name 85850**] [**5-22**])(was going to receive chemo
(taxotere)/xrt but had elevated liver enzymes).
Anxiety, has used lorazepam occ.
Social History:
Married; was a VP for a consulting company
-Tobacco history: 10 pack year hx, quit 30 years ago
-ETOH: none recently
-Illicit drugs: none
Family History:
Father died from MI at 67. Uncles and brothers with CAD, [**Name (NI) 5290**]
beginning in late 30's-mid 40's
Maternal aunt with breast Ca.
Physical Exam:
VS: T= 97 BP=99/74 HR= 88 (88-105) RR=14 O2 sat= 100%on NRB
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, S1,S2 obscured by IABP. 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 (anteriorly), 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, IABP in place in Right
femoral. Cool feet with good capillary refill.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
Echo [**2137-12-10**]: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
to severe regional left ventricular systolic dysfunction with
mid to distal septal, anterior and apical akinesis (the apex is
nearly dyskinetic). The basal segments are hyperdynamic. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. with borderline normal free wall
function. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. Very small pericardial effusion. No tamponade is
seen.
Echo [**2137-12-13**]: IMPRESSION: Moderate to severe regional left
ventricular systolic dysfunction, c/w CAD. Mild pulmonary
hypertension. Compared with the prior study (images reviewed) of
[**2137-12-10**], the findings are similar.
[**2137-12-11**] 06:35AM BLOOD WBC-8.7 RBC-4.15* Hgb-12.0* Hct-35.1*
MCV-85 MCH-29.0 MCHC-34.3 RDW-13.2 Plt Ct-161
[**2137-12-11**] 06:35AM BLOOD Glucose-112* UreaN-25* Creat-0.9 Na-138
K-3.9 Cl-106 HCO3-24 AnGap-12
[**2137-12-10**] 03:09PM BLOOD CK(CPK)-[**Numeric Identifier **]*
[**2137-12-11**] 06:35AM BLOOD CK(CPK)-3502*
[**2137-12-11**] 02:22PM BLOOD CK(CPK)-2137*
[**2137-12-10**] 03:09PM BLOOD CK-MB-GREATER TH cTropnT-21.3*
[**2137-12-11**] 06:35AM BLOOD CK-MB-400* MB Indx-11.4* cTropnT-12.6*
[**2137-12-11**] 02:22PM BLOOD CK-MB-188* MB Indx-8.8* cTropnT-8.39*
[**2137-12-11**] 06:35AM BLOOD Mg-2.1 Cholest-201*
[**2137-12-11**] 06:35AM BLOOD Triglyc-150* HDL-55 CHOL/HD-3.7
LDLcalc-116
Brief Hospital Course:
SUMMARY
61 M with hx of CAD s/p Taxus stent to LAD in [**2134**], Prostate Ca
([**Doctor First Name **] 7 or 8), GERD and anxiety presents with chest pressure
and dyspnea after playing a basketball game in the setting of 5
days off of asa/plavix. He had a thrombectomy in roughly 45
minutes from the time of onset. However, given that this lesion
was proximal to D1 in the LAD, he had significant myocardial
damage. He required a balloon pump for 2 days and then did well
thereafter.
BY PROBLEM
STEMI [**12-17**] Instent Thrombosis c/b Cardiogenic Shock requirin
IABP + Dopamine
Known CAD
Systolic Dysfunction without clinical failure
LV hypokinesis and Akinesis
The patient was more than 2 years out from a DES and was
taken off of aspirin and plavix in preparation for radiotherapy
marker/seed placement. 5 days later (when 90% of his platelets
would be active), he had a thrombus. He has prostate ca, so he
may be slightly hypercoagulable at the outset. Mr [**Known lastname 85851**] was
revascularized at [**Hospital3 417**] and restarted on ASA, Plavix in
addition to Reopro. Required dopamine and an IABP. These were
weaned gradually. He required three seperate boluses of
furosemide for pulmonary edema. An ECHO revealed depressed EF
and HK/AK. He did well and was discharged on ASA, Plavix,
Atorvastatin, Toprol and Lisinopril.
PROSTATE CA
Mr. [**Known lastname 85851**] was taken off of his antiplatelet therapy for
XRT. He was going to be involved in an XRT/Taxotere regimen. We
had to put him back on aspirin and plavix for the reasons above.
We were in touch regularly with his oncologist [**Doctor First Name **]-[**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) 85852**]
at [**Company 2860**] regarding recent events. We continued his avodart and
held his casodex. Ultimately, he will balance the risks of
bleeding during a seed placement with the benefits of
anti-platelet therapy. He may need inpatient seed placement.
These are all issues that will be discussed outpatient.
Anxiety
Patient did well with prn lorazepam
GERD
Patient took [**Hospital1 **] Nexium for the duration of his time on
plavix without an event. While there is a theoretical
interaction at CYP 2C19 between ppi's and plavix, it has never
affected him. We attempted famotidine in house but the patient
preferred a ppi. He was discharged with the instruction to
continue his ppi but recognize that he may be advised
differently by his cardiologist and that while he, personally,
has never had an event on nexium, there may be less risk with
pantoprazole.
Medications on Admission:
Aspirin 81 mg
Plavix 75 mg
Omeprazole unk dose
Lipitor Unk mg
Avodart 0.25 daily
Lupron since [**10-19**]
Casodex 50 mg daily
Compazine 10 mg q6 PRN
Decadron 8 mg q 12 the day before chemo and then 2 hours prior
MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily () as
needed for prostate.
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
STEMI c/b systolic dysfunction
CAD
Secondary
Prostate Ca
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Mr. [**Known lastname 85851**], it was a pleasure to participate in your care. You
were admitted with a clot in your coronary artery stent that
caused a large heart attack. You did well afterward but will
need to continue taking medications and participate in cardiac
rehab to ensure more recovery. You will have to call to arrange
rehab and cardiology follow up. If you have any trouble setting
up these services on monday, it is imperative that you call us
at [**Telephone/Fax (1) 2756**] or [**Telephone/Fax (1) 65432**] (speak to [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**] or
one of the 'CCU Residents'). You will have to discuss your blood
thinners with your radiation oncologist and cardiologist,
balancing the risk of bleeding with clotting. You will also have
to determine when to resume your casodex. You will have to have
your blood checked next week as you have started a new blood
thinner called coumadin which is followed by blood tests.
INSTRUCTIONS
1) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
2) Arrange cardiac rehab
3) Schedule follow up with a Cardiologist
MEDICATIONS
CONTINUE
1) Aspirin 325 mg daily (blood thinning)
2) Plavix 75 mg daily (blood thinning)
3) Atorvastatin 80 mg daily (anti-cholesterol and
inflammation)
START
4) Toprol XL 12.5 mg Daily (blood pressure and heart rate)
5) Lisinopril 2.5 mg Daily (blood pressure)
6) Coumadin 5 mg Daily - you must have your "INR" blood test
on Monday. Do so at your PCP or at [**Name Initial (PRE) **] cardiologist's office
HOLD
7) Casodex. Determine with your oncologist and cardiologist
when you may resume
CONSIDER
8) Nexium vs Pantoprazole. Ultimately, you will decide which
medicine to take with the cardiologist of your choosing
Followup Instructions:
You will need cardiac rehabilitation and cardiology follow up.
You must have a blood test - INR - on monday.
You will need to call to set these services up in your area
CARDIOLOGY
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4541**]
[**Street Address(2) 85853**]
[**Location (un) 796**], [**Numeric Identifier 85854**]
([**Telephone/Fax (1) 85855**]
IF YOU HAVE ANY TROUBLE GETTING A DOCTOR OR A BLOOD TEST CALL:
[**Telephone/Fax (1) 2756**] or [**Telephone/Fax (1) 65432**] (speak to [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**] or one
of the 'CCU Residents')
Completed by:[**2137-12-14**]
|
[
"530.81",
"185",
"785.51",
"V45.82",
"414.01",
"410.91",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9604, 9610
|
5933, 8517
|
328, 454
|
9719, 9719
|
4158, 5910
|
11699, 12345
|
3019, 3161
|
8784, 9581
|
9631, 9698
|
8543, 8761
|
9864, 11676
|
3176, 4139
|
2598, 2633
|
278, 290
|
482, 2518
|
9733, 9840
|
2664, 2847
|
2540, 2578
|
2863, 3003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,073
| 170,901
|
34705
|
Discharge summary
|
report
|
Admission Date: [**2143-8-30**] Discharge Date: [**2143-9-9**]
Date of Birth: [**2078-7-10**] Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Alphagan P
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Bile duct cancer
Major Surgical or Invasive Procedure:
[**2143-8-30**]: Common bile duct excision,cholecystectomy, Roux-en-Y
hepaticojejunostomy over a 5-French feeding tube.
[**2143-9-3**]: Tube cholangiogram
History of Present Illness:
65-year-old male who initially presented with painless jaundice,
E.
coli bacteremia, and a mid bile duct stricture. He was
successfully treated for his bacteremia and had undergone ERCP
with stenting of the mid bile duct stricture. He is now to
undergo surgery
Past Medical History:
- CAD s/p MI in [**2111**]
- HTN
- OA
- OSA, wears BiPap at night
- hyperlipidemia
- glaucoma and cataracts
Social History:
married. nonsmoker, 1-2 drinks/week, no illegal drugs
Family History:
negative for malignancy; father and sister with DM
Physical Exam:
VS: 100.4, 90, 103/63, 20, 96%
General: NAD
Card: RRR
Lungs: CTA bilaterally, no rales or wheezes
Abd: Soft, slightly distended, appropriately tender
Extr: 1+ edema. Right ankle developed swelling and pain during
the hospitalization
Pertinent Results:
On Admission: [**2143-8-30**]
WBC-9.9# RBC-3.83* Hgb-13.1* Hct-39.3* MCV-103* MCH-34.2*
MCHC-33.3 RDW-15.5 Plt Ct-275
PT-14.9* PTT-26.5 INR(PT)-1.3*
Glucose-118* UreaN-18 Creat-1.0 Na-142 K-5.2* Cl-111* HCO3-21*
AnGap-15
ALT-95* AST-98* AlkPhos-66 TotBili-1.5
Calcium-8.9 Phos-5.3*# Mg-1.7
On Discharge: [**2143-9-8**]
WBC-6.0 RBC-3.38* Hgb-11.4* Hct-33.9* MCV-101* MCH-33.7*
MCHC-33.6 RDW-14.8 Plt Ct-236
Glucose-95 UreaN-10 Creat-0.9 Na-140 K-3.9 Cl-107 HCO3-23
AnGap-14
ALT-25 AST-28 AlkPhos-56 TotBili-0.8
Calcium-8.4 Phos-3.0 Mg-2.0
Brief Hospital Course:
65 y/o male with history of painless jaundice, E. coli
bacteremia, and a mid bile duct stricture, who underwent ERCP
with stenting of the mid bile duct stricture. He is now brought
to the operating room for common bile duct excision,
cholecystectomy, and Roux-en-Y hepaticojejunostomy with Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Per Dr [**Last Name (STitle) 4727**] operative note at the time of surgery, the mid
third of the bile duct was firm and fibrotic consistent with a
known tumor. The biliary stent was in place. After division of
the distal common bile duct, the distal margin was
initially positive for adenocarcinoma. An additional distal
margin was taken that was interpreted as negative. Our initial
proximal margin was positive for carcinoma in situ, but no
invasive carcinoma. Our second proximal margin was negative. The
patient had normal anatomy otherwise. He did have a fatty liver.
The patient tolerated the procedure without complications and
minimal blood loss. He was given an epidural for pain management
and then transitioned to IV then PO pain meds as tolerated.
The NGT was d/cd on POD 3 and the patient slowly started to
increase his diet. His abdomen was slightly distended, but he
did have return of bowel function by POD 5.
T Tube choalngiogram was checked on POD 5 showing patent right
hepatico-jejunostomy
anastomosis with contrast flow freely through the anastomosis.
No bowel leak
visualized at the right hepatic duct. No dilation of right
hepatic duct and
its branches visualized. The Roux tube was capped and the JP
drain was pulled.
The incision has a small area at the middle portion that had
slight amount of discharge. Staples were not removed and a dry
dressing was kept on the site.
He also had complaint of right ankle pain and swelling. LENIs
were obtained and there was no evidence of DVT in either leg.
Radiographs of the foot were also obtained and did not show
evidence of acute fracture, he did have some degenerative
changes. He was evaluated by PT who deemed him safe to d/c to
home.
Although the patient initially did have return of some bowel
function, he started to appear more distended and an ileus was
confirmed by KUB on [**9-3**]. PO intake was scaled back and we
awaited return of bowel function. His distention improved and
his diet was again advanced as tolerated.
Two areas of the incision were opened prior to his discharge and
he was started on a week of PO Keflex. The wounds will be packed
and he is discharged to home with VNA.
Outpatient follow up with oncology will be arranged once he is
healed from surgery.
Medications on Admission:
albuterol, atenolol, flovent, lisinopril
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 5450**]/Southern NH
Discharge Diagnosis:
Bile duct cancer, pathology final report pending
ileus
wound cellulitis
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, increased abdominal/back pain,
diarrhea, constipation, inability to take or keep down food,
fluids or medications.
Monitor the incision for redness, drainage or bleeding. The
incision dressings should be changed once a day with damp saline
gauze to 2 open areas by visiting nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 5450**].
Schedule follow up with your PCP. [**Name10 (NameIs) **] need to resume
lisinopril.
No heavy lifting
No driving if taking narcotic pain medication
Followup Instructions:
Provider:[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-9-18**] at
3:20
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2143-9-27**] 11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2143-9-9**]
|
[
"719.47",
"576.2",
"156.1",
"719.07",
"682.2",
"401.9",
"272.4",
"E878.2",
"V43.64",
"278.00",
"575.2",
"E878.8",
"365.9",
"414.01",
"412",
"997.4",
"560.1",
"327.23",
"366.9",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"51.63",
"87.54",
"51.22",
"51.37"
] |
icd9pcs
|
[
[
[]
]
] |
4561, 4635
|
1855, 4469
|
299, 456
|
4751, 4760
|
1293, 1293
|
5417, 5932
|
971, 1024
|
4656, 4730
|
4495, 4538
|
4784, 5394
|
1039, 1274
|
1597, 1832
|
243, 261
|
484, 746
|
1307, 1583
|
768, 883
|
899, 955
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,032
| 158,822
|
9596
|
Discharge summary
|
report
|
Admission Date: [**2175-9-3**] Discharge Date: [**2175-9-18**]
Date of Birth: [**2120-9-9**] Sex: F
Service: Gynecology/Oncology
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
gravida 2 para 2 with a history of stage IIIB cervical cancer
who presented for a total pelvic exenteration secondary to
cancer recurrence on bladder biopsy which was performed on
[**2175-8-3**]. The patient had initially presented in
[**2174-10-14**] with heavy irregular vaginal bleeding. A
cervical biopsy in [**2174-11-13**] showed invasive squamous
cell carcinoma. At this time she was stage IIIB. The
patient began cisplatin and radiation therapy in [**2174-12-14**]. At that time she was also noted to have left-sided
hydronephrosis secondary to cancer obstruction and a double-J
ureteral stent was placed on the left side. In [**2175-1-13**] the patient had completed five cycles of cisplatin
and concomitant radiation therapy.
In [**2175-8-13**], the patient had brachytherapy (50 hours), On
[**2175-2-25**], a CT scan showed no metastases. On
[**2175-8-3**], the patient had a cystoscopy to replace
a double-J stent in her left ureter. At that time a bladder
mass was found which was biopsied. Pathology showed that it
was recurrent cervical carcinoma in the bladder. On [**2175-8-10**], a CT scan showed no metastases; therefore, it appeared
that the patient had an isolated central pelvic recurrence.
At that point, the treatment options were discussed with the
patient and that total pelvic exenteration would be the
curative option at this point. Once the procedure was
discussed with the patient, including the risks and benefits
of the procedure, and all questions were answered, she was
consented for a total pelvic exenteration.
Only complaint on admission was urinary frequency and
occasional hematuria.
PAST GYNECOLOGICAL HISTORY: Please see History of Present
Illness for details of stage IIIB cervical cancer. No
history of abnormal PAP smears; although, her last PAP smear
was nine years prior to diagnosis of cancer. The patient
denies a history of sexually transmitted diseases or
endometriosis.
PAST OBSTETRICAL HISTORY: Status post spontaneous vaginal
delivery times one and cesarean section times one. No
complications with either procedure.
PAST MEDICAL HISTORY: In [**2164-3-15**] the patient was
diagnosed with melanoma of her right posterior calf, stage [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] level 4. A surgical excision was performed without
complications. There was no evidence of recurrence.
PAST SURGICAL HISTORY: Cesarean section times one.
MEDICATIONS ON ADMISSION: Valium 5 mg p.o. t.i.d. p.r.n.
ALLERGIES: IV CONTRAST and BACTRIM.
SOCIAL HISTORY: The patient is a cardiac nurse. She is
widowed. She denies tobacco or alcohol use.
FAMILY HISTORY: Father died of bladder cancer in [**2157**] with
liver and bone metastases. Her mother died at the age of 72
of a abdominal aortic aneurysm. Her mother also had
hypertension.
REVIEW OF SYSTEMS: Review of systems revealed urinary
frequency, hematuria. Denied any bowel dysfunction.
PHYSICAL EXAMINATION ON ADMISSION: Physical examination on
admission was significant for a nontender and nondistended
abdomen with positive bowel sounds. There was a vertical
cesarean section scar. There was a question whether the
uterus was palpable just below the umbilicus. On pelvic
examination, the vulva and vagina had extensive radiation
affect. The vaginal canal was foreshortened. The cervix
was not identifiable. There was no obvious tumor on bimanual,
and rectovaginal examination revealed smooth vaginal walls
and smooth rectal mucosa. There was no nodularity, but there
was extensive radiation affect.
LABORATORY ON ADMISSION: Crossed and typed for 4 units.
Complete blood count and Chem-10 were sent. The patient's
preoperative hematocrit was 31.5. Her creatinine was 1.2;
however, her baseline creatinine was 1.1 to 1.4. The rest of
the preoperative laboratories were within normal limits.
HOSPITAL COURSE: In summary, the patient is a 54-year-old
gravida 2 para 2 with stage IIIB cervical cancer, status post
chemotherapy radiation and brachy therapy, who presented with
localized recurrence in the bladder. She was admitted on the
day prior to her total pelvic exenteration for preoperative
bowel preparation with Fleets soda.
The patient underwent a total pelvic exenteration, [**Location (un) 2848**]
pouch, and colostomy on [**2175-9-4**]. Please see the
Operative Note for details of the procedure. Intraoperative
the patient received 15 liters of intravenous fluids,
12 units of packed red blood cells, 7 units fresh frozen
plasma, 6 packs of platelets, 100 cc albumin, 1000 cc of
hespan. Estimated blood loss was 5.5 liters.
Intraoperatively, the patient's hematocrit decreased to a low
of 14.1. Her platelets decreased to a low of 61, and her INR
at maximum was 5.
Postoperatively, the patient was admitted to the Surgical
Intensive Care Unit. She was transferred to the floor on
postoperative day three.
1. CARDIOVASCULAR: The patient was in normal sinus rhythm
throughout her hospital course. In the Surgical Intensive
Care Unit, her blood pressure was kept greater than 100
systolic and greater than 60 diastolic. She was repleted
with crystalloid as well as with blood products to keep her
hematocrit greater than 25. She did not require pressors.
There were no active cardiac issues both in the Medical
Intensive Care Unit and on the floor.
2. HEMATOLOGY: In the operating room, the patient appeared
to have a mild coagulopathy. Her blood products including
fresh frozen plasma and platelets were repleted as needed.
Coagulation panel was checked in the Medical Intensive Care
Unit. The patient did not have any further coagulopathy
postoperatively. The patient was transfused as needed to
keep her hematocrit greater than 25. She received a total of
14 units of packed red blood cells between the operating room
and the Surgical Intensive Care Unit. She did not require
further packed red blood cells on the floor. The patient was
Rh negative. Given that, she received Rh positive platelets.
She was given RhoGAM times one.
3. PULMONARY: The patient was intubated in the operating
room and was taken to the Surgical Intensive Care Unit
intubated. Chest x-ray revealed proper placement of the
endotracheal tube, and there was no evidence of infiltrate.
The patient was sedated on propofol. Attempts were made to
wean the patient off of the respirator, and eventually, on
postoperative day two, the patient was extubated. Once the
patient was extubated, throughout the hospital course there
were no further respiratory issues. She was given incentive
spirometry for the prevention of atelectasis.
4. INFECTIOUS DISEASE: Given that the patient underwent a
major intra-abdominal surgery, she was started on Kefzol and
Flagyl postoperatively. She was afebrile on Kefzol and
Flagyl. On postoperative day three, she had a temperature
to 100.6 which was likely secondary to atelectasis. On
postoperative day three, there was some erythema noted at the
wound side. Therefore, her antibiotics were changed to
ampicillin, ceftriaxone, and Flagyl. She completed a 7-day
course of the triple antibiotics and was then started on a
oxacillin for skin coverage. On postoperative day 14 (day
five of the oxacillin) the patient was changed to
dicloxacillin. She was sent home with a 7-day course total
of the dicloxacillin (including the day she had spent on the
oxacillin).
5. GENITOURINARY: The patient had a [**Location (un) 2848**] pouch created.
Postoperatively, there were issues with low urine output.
Her [**Location (un) 1661**]-[**Location (un) 1662**] output was high in the Surgical Intensive
Care Unit. Her urine output did improve after receiving
blood. By postoperative day two, the patient was draining
urine from the [**Location (un) 2848**] pouch. On postoperative day two, the
pouch started to be irrigated every three hours with 60 cc of
normal saline. Throughout the rest of her hospital course,
the patient maintained adequate urine output. Her creatinine
throughout her hospital course was within her baseline range
of 1.1 to 1.4. On the day prior to discharge there was some
drainage of urine surrounding the Foley catheter that was in
the [**Location (un) 2848**] pouch. This was thought to be secondary to mucous
plugging the urostomy. This resolved with irrigation and
flushing of the [**Location (un) 2848**] pouch with normal saline. Throughout
her hospital course, the urostomy was violaceous and appeared
to have no breakdown.
6. GASTROINTESTINAL: The patient had a colostomy at the
time of the operation. The patient was made n.p.o. She was
started on intravenous fluid hydration in the Surgical
Intensive Care Unit, and her electrolytes were followed and
repleted as needed. She was placed on Protonix for
gastrointestinal prophylaxis. The patient was started on
total parenteral nutrition on postoperative day three. The
patient had a right internal jugular to receive the total
parenteral nutrition. This was changed to a left PICC line
on postoperative day four. The patient also had an
nasogastric tube that was placed intraoperatively. This was
maintained on low wall suction and was discontinued on
postoperative day five. On postoperative day six, the
patient's diet was advanced to clears, and her diet was
advanced as tolerated. The total parenteral nutrition was
weaned, and on postoperative day 13 the patient's total
parenteral nutrition was discontinued. She was started on a
multivitamin and was receiving Boost supplements. Nutrition
laboratories were checked while the patient was on total
parenteral nutrition, and there were no abnormalities.
7. NEUROLOGY: While in the Surgical Intensive Care Unit,
the patient was on propofol while intubated and was also
receiving intravenous morphine and Versed as needed for pain
control. When the patient was transferred to the floor, she
was receiving morphine as needed for pain control as well
until she was tolerating adequate p.o. At that time she was
changed to Percocet which provided good pain relief.
8. PROPHYLAXIS: The patient was placed on Pneumo boots
until she was ambulating and received Protonix as
gastrointestinal prophylaxis.
9. POSTOPERATIVE CARE: The patient had staples to close
her skin incision. These should remain for approximately one
month postoperatively.
10. CODE STATUS: Throughout her hospital course, the
patient remained full code.
CONDITION AT DISCHARGE: Condition at the time of discharge
was stable.
DISCHARGE DIAGNOSES:
1. Stage IIIB cervical cancer with local recurrence to the
bladder.
2. Status post total pelvic exenteration, [**Location (un) 2848**] pouch, and
colostomy.
3. History of melanoma.
MEDICATIONS ON DISCHARGE:
1. Dicloxacillin 500 mg p.o. q.d. times six days for a
total 10-day course of dicloxacillin and oxacillin.
2. Multivitamin 1 tablet p.o. q.d.
3. Tums 1 tablet p.o. b.i.d.
4. Zofran 4 mg p.o. q.8.h. p.r.n.
5. Percocet one to two tablets p.o. q.4-6h. p.r.n.
6. Motrin 600 mg p.o. q.6h. p.r.n.
7. Prilosec 20 mg p.o. b.i.d.
8. [**Location (un) 2848**] pouch flush 60 cc of 0.25% acetic acid and normal
saline via the Foley catheter q.3h. to irrigate and flush.
9. Change ostomy bag as instructed.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**First Name (STitle) 1022**] nine days after discharge.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4871**]
Dictated By:[**Name8 (MD) 2409**]
MEDQUIST36
D: [**2175-9-19**] 12:21
T: [**2175-9-23**] 08:03
JOB#: [**Job Number 32542**]
|
[
"787.02",
"276.8",
"286.9",
"V10.41",
"427.69",
"196.2",
"198.1",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"56.71",
"99.15",
"46.13",
"68.8",
"54.74"
] |
icd9pcs
|
[
[
[]
]
] |
2852, 3030
|
10714, 10899
|
10925, 11429
|
2662, 2732
|
4079, 10630
|
2606, 2635
|
10645, 10693
|
3050, 3160
|
11450, 11824
|
175, 2296
|
3791, 4060
|
2319, 2582
|
2749, 2835
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,058
| 140,092
|
53033
|
Discharge summary
|
report
|
Admission Date: [**2141-3-18**] Discharge Date: [**2141-3-26**]
Service:
HISTORY: This is a [**Age over 90 **]-year-old male originally admitted to
the C-Med service. He was later transferred to the CCU.
This is a [**Age over 90 **]-year-old gentleman with a past medical history
of three vessel coronary artery disease which included a 90%
stenosis of the right coronary artery, a 70% proximal lesion,
along with a 90% distal lesion in the LAD, and a 100% lesion
in the circumflex, who was admitted to the C-Med service
following a one day history of chest pain. He also reported
shortness of breath, but denied nausea, vomiting, and
diaphoresis. At home, before coming to the hospital, the
patient took three doses of sublingual nitro with minimal
relief and the pain started to increase and radiate down his
left arm, at which point he decided to go to the Emergency
Room. In the Emergency Room, his cardiac enzymes showed flat
CK's, but his troponins were slightly elevated with values of
4.4 and 4.1. He was then transferred to the C-Med service
for further evaluation. While on the floor he was extremely
hypertensive with a blood pressure of approximately 200
systolic. At that time, he was given a dose of hydralazine
and became hypotensive and complained of severe stabbing
chest pain. A stat EKG showed ST depressions in leads V3
through V6 and it was determined to transfer the patient to
the CCU. An arterial line and a femoral line were placed
emergently. He was started up on dopamine and an Integrilin
drip. During the initial few minutes of his time in CCU, he
vomited twice and he became bradycardiac down into the range
of 20's to 30's. It was determined to intubate the patient
to protect his airway. He was sedated with fentanyl and
Versed.
PAST MEDICAL HISTORY: 1. Coronary artery disease. He had a
catheterization in [**11-15**] which revealed three vessel disease,
at which time it was determined to medically manage. 2.
Hypertension. 3. Hyperlipidemia. 4. Aortic regurgitation.
5. Mitral regurgitation. 6. Lung cancer status post right
pneumonectomy. 7. Hypothyroidism. 8. Bladder cancer treated
with BCG. 9. Anemia. 10. Macular degeneration. 11.
Bilateral hearing loss.
ALLERGIES: He has no known drug allergies.
MEDICATIONS: Aspirin, 81 q d; Lopressor, 50 b.i.d.; Levoxyl,
100 mcg; Detrol; Lipitor; Imdur, 60 q d; Zestril, 10 q d.
CARDIAC HISTORY: He had a catheterization in [**11-15**] which
showed his left ventricular ejection fraction to be
approximately 46%. His anterior and apical walls were
hypokinetic. His inferior wall was mildly hypokinetic. The
proximal RCA was 90% stenosed. His right PDA was 90%
stenosed. His left main showed 30% stenosis. His LAD showed
a proximal 70% lesion and a distal 90% lesion. His first
diagonal showed a 60% lesion. His proximal circumflex was
100% occluded.
LABORATORY/DIAGNOSTICS: His initial labs upon admission
showed a white blood count of 6.1, a hematocrit of 37.1, a
platelet count of 231. PT of 12, PTT of 24.6, an INR of 1.
His first two CK values were 88 and 74. His first two
troponins were 4.1 and 4.4.
His EKG showed a sinus rhythm at 90 beats per minute, left
axis deviated, with ST depressions in leads I, II, and III,
AVL, and V3 through V6.
PHYSICAL EXAMINATION: He was afebrile with a blood pressure
of 90/43 for a MAP of 50 on levo and dopamine. His heart
rate was 110, his respiratory rate was 13. His oxygen
saturations were 96% on room air. In general, this is a
frail appearing gentleman who was sedated, intubated, and
unresponsive. His cardiac exam revealed a heart that was
tachycardiac, had a II/VI systolic ejection murmur that
radiated to the axilla and also to the carotids. His
pulmonary exam, he was without breath sounds on the right.
He had decreased breath sounds on the left consistent with
COPD. His abdomen was soft, nontender, nondistended. His
extremities showed +1 pulses bilaterally without edema,
cyanosis or clubbing.
HOSPITAL COURSE: This [**Age over 90 **]-year-old man with a history of
three vessel coronary artery disease, aortic regurgitation,
mitral regurgitation was admitted emergently following a
hypotensive episode on the floor. He showed ST depressions
in leads V4 through V6 following a dose of hydralazine. His
problems included the following: 1. Cardiac. The patient
was continued on aspirin, Lipitor, and a low dose beta
blocker, during his stay. He had several episodes of
supraventricular tachycardia and he was placed on amiodarone
which controlled the SVT. 2. Pulmonary. The patient was
ventilated throughout his stay. On [**3-25**], an attempt was made
to wean him off the ventilator. He became hypotensive,
tachycardiac, and his oxygen saturations dropped
significantly. He was placed back on BIPAP. Following a
discussion with his family, it was determined that they would
make him a Do No Resuscitate, Do Not Intubate. A chest x-ray
revealed a likely aspiration pneumonia in the lower lobe of
his left lung. 3. Infection. The patient was placed on a
broad-spectrum of antibiotics to cover his infection.
Unfortunately, the patient continues to decompensate and he
passed away on [**2141-3-26**]. He was in the CCU from [**3-18**] to [**3-26**]
when he passed away likely secondary to a combination of
sepsis and respiratory arrest.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2141-4-12**] 10:04
T: [**2141-4-12**] 10:14
JOB#: [**Job Number **]
|
[
"398.91",
"272.0",
"410.91",
"401.9",
"244.9",
"276.2",
"458.2",
"396.3",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4013, 5622
|
3305, 3995
|
1808, 3282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,410
| 131,973
|
52205
|
Discharge summary
|
report
|
Admission Date: [**2130-5-30**] Discharge Date: [**2130-6-5**]
Date of Birth: [**2047-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cipro / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
On [**2130-5-30**]:
1. Redo sternotomy.
2. Coronary artery bypass grafting x 1 with saphenous vein
graft to the right coronary artery.
3. Redo aortic valve replacement with a 21-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]
tissue valve, reference number [**Serial Number 24303**], serial number
[**Serial Number 108001**].
History of Present Illness:
82 year old male s/p bioprosthetic
AVR with CABG in [**2119**], SSS s/p pacemaker who presented from
adult
daycare with chest pain that started at 1PM this afternoon. He
notes that he was in usualy state of health and repairing a
mechanical watch when he started to feel a "tight squeezing
pain"
on the left side of his chest. This pain was non-radiating. He
noted that during this episode was marked by nausea and
shortness
of breath. This episode lasted for two hours. He was brought to
the emergency room and admitted for further evaluation. Upon
[**Year (4 digits) 461**] he was found to have severe calcific stenosis of
biprosthectic aortic valve and is now being referred to cardiac
surgey for redo-aortic valve replacement.
Past Medical History:
Aortic Stenosis, Coronary artery disease
Secondary:
Dyslipidemia
Hypertension
Sick sinus syndrome s/p dual chamber pacemaker
Aortic stenosis of bioprosthesis
Mild dementia
Nephrolithiasis
GERD
BPH
Right prox fibula fx from car accident, [**12/2127**]
Social History:
Mr. [**Known lastname 7858**] lives by himself in an elderly care
facility in [**Location (un) **]. His closest relation is his son, who
is also his emergency contact. [**Name (NI) **] is a widower whose wife
passed in the early [**2088**]. When he was younger, he worked as a
watch repairman.
EtOH: He takes [**1-2**] glass of wine 3-4 times a week.
Tob: He smoked 60 years ago but is not currently a smoker.
His children do the bills and do his medications. Previous
cardiology notes from Dr. [**First Name4 (NamePattern1) 751**] [**Last Name (NamePattern1) 16157**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] document a
history of poor medical compliance.
Family History:
His father died of heart disease and his mother died of cancer.
Physical Exam:
Physical Exam on Admission
Pulse:59 Resp:18 O2 sat:96/RA
B/P 112/74
Height:69" Weight:69.9 kgs
General:
Skin: Dry [x] intact [x]
HEENT: EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [x] systolic grade 3
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
Extremities: Warm [x], well-perfused [x] Edema [-=
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: p Left: p
DP Right: p Left: p
PT [**Name (NI) 167**]: p Left: p
Carotid Bruit Right: - Left: -
Pertinent Results:
Intra-op TEE [**2130-5-30**]:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. There
is a small echodensity in the LAA suggestive of thrombus or
trabeculation.
No spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF=35 %). No masses
or thrombi are seen in the left ventricle.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen.
The mitral valve leaflets are severely thickened/deformed. Mild
to moderate ([**1-2**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the operating
room prior to incision.
POST-BYPASS:
The patient is AV paced on milrinone, vasopressin and
epinephrine infusions. There is a well seated bioprosthetic
valve in the aortic position. Peak and mean gradients across the
valve are 40 & 20mmHg respectively. There is good leaflet
mobility. There is no [**Male First Name (un) **] or subvalvular membrane. There is no
AI. The MR is now mild. The TR is now mild. Biventricular
function is improved on inotropic support, EF45%. The aorta
remains intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-6-1**] 09:25
.
[**2130-6-5**] 05:51AM BLOOD WBC-7.2 RBC-3.03* Hgb-9.2* Hct-28.9*
MCV-96 MCH-30.6 MCHC-32.0 RDW-14.3 Plt Ct-202
[**2130-6-4**] 03:35AM BLOOD WBC-7.0 RBC-2.91* Hgb-9.2* Hct-27.9*
MCV-96 MCH-31.6 MCHC-32.9 RDW-14.1 Plt Ct-157
[**2130-6-5**] 05:51AM BLOOD UreaN-17 Creat-0.6 Na-138 K-4.2 Cl-103
[**2130-6-3**] 05:54AM BLOOD Glucose-173* UreaN-20 Na-139 K-4.6 Cl-105
HCO3-25 AnGap-14
[**2130-6-5**] 05:51AM BLOOD Mg-2.1
Brief Hospital Course:
On [**2130-5-30**] Mr.[**Known lastname 7858**] was taken to the operating room and
underwent Redo sternotomy, Coronary artery bypass grafting x 1
with saphenous vein graft to the right coronary artery, Redo
aortic valve replacement with a 21-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue
valve, CROSS-CLAMP TIME: 78 minutes.PUMP TIME: 106 minutes.
Please refer to operative report for further surgical details.
He tolerated the procedure well and was transferred to the CVICU
for invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. Permanent
pacer was interrogated. Chest tubes and pacing wires were
discontinued without complication. The patient was transferred
to the telemetry floor on POD 2 for further recovery. He had
some periods of agitation. Psychiatry was consulted, given his
history of dementia. He did receive one dose of IV Haldol and
he was placed on Zyprexa prn. Mental status cleared prior to
discharge. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating, yet
deconditioned, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to NewBridge
on the [**Doctor Last Name **] in [**Location (un) 1411**] in good condition with appropriate
follow up instructions.
Medications on Admission:
simvastatin 20 mg DAILY
atenolol 25 mg DAILY
lisinopril 20 mg DAILY
tamsulosin 0.4 mg Daily
aspirin 325 mg DAILY
tramadol 50 mg PRN Q6hours
omeprazole 40 mg DAILY
senna 8.6 mg Daily
docusate sodium 100 mg [**Hospital1 **]
Lidoderm 5 %(700 mg/patch) Adhesive Patch
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Aortic Stenosis, Coronary artery disease
Secondary:
Dyslipidemia
Hypertension
Sick sinus syndrome s/p dual chamber pacemaker
Aortic stenosis of bioprosthesis
Mild dementia
Nephrolithiasis
GERD
BPH
Right prox fibula fx from car accident, [**12/2127**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right- healing well, no erythema or drainage
Edema trace
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 and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2130-7-6**]
1:00
Cardiologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2130-6-21**] 2:40
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2130-7-4**] 1:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 31235**] in [**1-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2130-6-5**]
|
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5,193
| 142,691
|
16110
|
Discharge summary
|
report
|
Admission Date: [**2138-3-16**] Discharge Date: [**2138-3-21**]
Date of Birth: [**2067-9-19**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Tape [**12-23**]"X10YD / Morphine / Atorvastatin / Zocor /
Tobramycin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Fall with incontinence of stool.
Major Surgical or Invasive Procedure:
Cerebral angiography with attempted stent placement
Endotracheal intubation (for procedure)
History of Present Illness:
The patient is a 70 year old woman with a history of a
coiled basilar artery aneurysm s/p coiling and VPS, AF, CAD (s/p
stents), HTN, HL, DM2 who reportedly has had ataxia for one
month. Her history is limited as the patient herself is a poor
historian. Her husband brought her to [**Hospital1 **] [**Location (un) 620**] [**Name (NI) **] after today
she fell on her rear end when trying to walk up stairs and had
incontinence. There was no head injury or loss of consciousness.
She does endorse some mild periorbital (right predominant)
headache without nausea or vomiting. She has felt dizzy and
"light on the legs"; today it started when she woke up and was
persistent. She says she has not been taking her medications for
at least one week but does not provide an explanation why. At
[**Hospital1 **]
[**Location (un) 620**], she reportedly said that her symptoms had acutely
worsened over about four hours. She received a NCHCT which
revealed a left cerebellar hypodensity of unknown chronicity
(likely subacute). She was also found to be hyperglycemia and
hypertensive. She was transferred here for further care.
Past Medical History:
- Basilar artery aneurysm s/p coiling in [**2133**] at OSH
- Anoxic encephalopathy following AAA rupture in [**2130**]
- H/o ruptured AAA. Course c/b the following:
- repair of AAA rupture on [**2131-7-13**]
- mesenteric ichemia resulting in exlap and ileocecotomy
[**2131-7-14**]
- necrotizing pancreatitis d/t hypertriglyceridemia s/p
multiple debridements
- ileostomy and mucocutaneous fistula [**2131-7-16**]
- multiple abdominal washouts on [**8-11**], [**7-29**], [**8-4**], [**8-6**]
- skin graft to the lower [**1-24**] abdominal wall on [**8-9**]
- tracheostomy [**2131-8-2**]
- left eye vision loss, felt to be d/t cerebral artery aneurysm
(temporal artery biopsy negative)
# Ventral hernia with component separation requiring attempt at
colostomy closure and abdominal wall closure with marlex mesh on
[**2133-1-13**]
- [**2-27**]: split-thicknessskin graft to her abdominal wall defect
.
# Multiple hospitalizations for abdominal wound breakdown
requiring VAC; currently undergoing abdominal wall mesh
debridement and consideration of surgery with plastics, although
patient deferring at this time
# Type II DM
# PNA
# Hypertension
# A Fib - periop, on coumadin until [**5-29**] and then off for
unclear reasons
# Hypercholestermia
# STEMI: [**2-27**]: (inferior STEMI) - had total occlusion of RCA -
s/p BMS x2.
Social History:
Lives in single family home w/husband. Social history is
significant for the absence of current tobacco use. She drinks
one screwdriver a night.
Retired nurse
Family History:
Father died of an MI in his 60's, but no other family members
with CAD.
Physical Exam:
On admission:
VS T: 97.3 HR: 70 BP: 123/89 to 165/122 RR: 16 SaO2: 98%
General: NAD, lying in bed comfortably. / Head: NC/AT, no
conjunctival icterus, no oropharyngeal lesions / Neck: Supple,
no
nuchal rigidity / Cardiovascular: Irregular rhythm, no murmurs /
Pulmonary: Equal air entry bilaterally, no crackles or wheezes /
Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm, no
edema, palpable radial/dorsalis pedis pulses / Skin: No rashes
or
lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name and hospital but
not year. Does not recall a coherent history. Inattentive.
Follows commands, midline and appendicular. Language fluent with
intact repetition and verbal comprehension. Normal prosody. No
paraphasic errors. High frequency naming intact. No dysarthria.
No apraxia or neglect.
- Cranial Nerves - [II] PERRL 2.5->2 brisk. VF full to
confrontation and number counting. [III, IV, VI] Mild left eye
abduction weakness, otherwise intact, 2-3 beats right beating
end-gaze nystagmus to R. [V] V1-V3 without deficits to light
touch bilaterally, +corneals bilaterally. [VII] No facial
asymmetry. [VIII] Hearing intact to finger rub bilaterally. [IX,
X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5
bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to light touch, pinprick, or
proprioception bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response obscured by brisk withdrawal bilaterally.
- Coordination - +Dysmetria with left arm and left leg, intact
with right arm and right leg.
- Gait - Unable to assess at the time of examination..
Pertinent Results:
Admission Labs:
[**2138-3-16**] 06:45AM BLOOD WBC-4.9 RBC-3.90*# Hgb-12.4# Hct-38.9#
MCV-100* MCH-31.7 MCHC-31.8 RDW-12.4 Plt Ct-184
[**2138-3-16**] 06:45AM BLOOD PT-10.7 PTT-24.4* INR(PT)-1.0
[**2138-3-16**] 04:17AM BLOOD Glucose-409* UreaN-23* Creat-1.2* Na-135
K-4.4 Cl-97 HCO3-23 AnGap-19
[**2138-3-16**] 06:45AM BLOOD ALT-6 AST-9 CK(CPK)-34 AlkPhos-95
TotBili-0.2
[**2138-3-16**] 04:17AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0
[**2138-3-17**] 04:55AM BLOOD Triglyc-210* HDL-40 CHOL/HD-6.2
LDLcalc-166*
[**2138-3-17**] 04:55AM BLOOD %HbA1c-13.9* eAG-352*
[**2138-3-16**] 06:45AM BLOOD [**Month/Day/Year **]-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2138-3-16**] 06:45AM BLOOD TSH-0.86
[**2138-3-16**] 08:30AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2138-3-16**] 08:30AM URINE RBC-12* WBC-35* Bacteri-FEW Yeast-NONE
Epi-0
[**2138-3-16**] 08:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.030
[**2138-3-17**] 07:47AM URINE Hours-RANDOM Creat-140 Na-55 K-25 Cl-57
TotProt-111 Prot/Cr-0.8*
[**2138-3-16**] 8:30 am URINE Source: Catheter.
**FINAL REPORT [**2138-3-18**]**
URINE CULTURE (Final [**2138-3-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Discharge Labs:
[**2138-3-21**] 05:10AM BLOOD WBC-5.0 RBC-3.34* Hgb-10.6* Hct-33.3*
MCV-100* MCH-31.8 MCHC-32.0 RDW-13.5 Plt Ct-145*
[**2138-3-21**] 05:10AM BLOOD PT-10.6 PTT-26.2 INR(PT)-1.0
[**2138-3-21**] 05:10AM BLOOD Glucose-182* UreaN-12 Creat-1.0 Na-142
K-4.0 Cl-110* HCO3-23 AnGap-13
[**2138-3-21**] 08:23AM BLOOD Type-ART Temp-36.7 pO2-155* pCO2-37
pH-7.44 calTCO2-26 Base XS-1 Intubat-NOT INTUBA Vent-SPONTANEOU
Comment-EXCESSIVE
REPORTS:
CXR [**2138-3-16**]: In comparison with the study of [**2137-4-27**], the
right ventriculopleural shunt is again seen. Hyperexpansion of
the lungs with tortuosity of the aorta persists. The right
costophrenic angle is now clear and there is no evidence of
acute focal pneumonia.
CT/CTA Head/neck [**2138-3-16**]: No change in the left cerebellar
infarct compared with the previous CT of the [**Hospital3 628**].
No acute hemorrhage seen. CT angiography of the neck
demonstrates approximately 50-60% stenosis at the right carotid
bifurcation with exuberant calcification. Other arteries of the
neck demonstrate no evidence of high-grade stenosis. CT
angiography of the head demonstrates no evidence of occlusion or
stenosis or filling defect in the posterior circulation
arteries. In the
anterior circulation, no occlusion or stenosis seen. MRI can
help for further assessment if clinically indicated.
MRI [**2138-3-17**]: Subacute infarction involving the left
cerebellar hemisphere and left superior cerebellar peduncle.
There is enhancement of the basilar artery aneurysm coil pack,
likely representing residual flow within the aneurysm.
Questionable 7-mm enhancing lesion in the left cerebellar
hemisphere posteriorly of unknown significance, which may
represent an old infarction. Follow up can be obtained to assess
stability.
EKG: [**2138-3-18**]: Sinus rhythm with premature atrial complexes.
Leftward axis. Possible prior inferior myocardial infarction.
Delayed R wave progression. Non-specific ST segment flattening
in the high lateral leads. Left ventricular hypertrophy.
Compared to the previous tracing of [**2137-4-21**] the ventricular rate
is increased and atrial ectopy is now seen.
Rate PR QRS QT/QTc P QRS T
89 154 90 376/426 58 -27 126
Cerebral angiogram [**2138-3-19**]: Left vertebral artery
arteriogram shows widely patent left vertebral artery. At the
basilar artery there is a giant thrombosed aneurysm in the
basilar apex with a small portion filling measuring about 2 x 3
mm. This does not communicate with the rest of the aneurysm.
GROIN U/S [**2138-3-19**]: 2.5 cm right groin hematoma without
evidence of pseudoaneurysm or fistula.
GROIN U/S [**2138-3-20**]: Small stable hematoma in the right groin.
CXR [**2138-3-20**]: Cardiac silhouette is enlarged, and accompanied
by mild pulmonary [**Year (4 digits) 1106**] engorgement, new perihilar haziness
and more confluent opacities at the bases, accompanied by small
effusions. Findings are likely due to perihilar and basilar
edema, but superimposed process such as aspiration at the lung
bases is also possible. Followup radiographs may be helpful.
Brief Hospital Course:
Ms [**Known lastname **] was brought to [**Hospital1 **] [**Location (un) 620**] by her husband after she
"fell on her rear end" when trying to walk up stairs and had
incontinence. There was no head injury or loss of consciousness.
At this OSH, she received a NCHCT which revealed a left
cerebellar hypodensity of unknown chronicity. For the work up of
this presumed stroke, she was transferred to [**Hospital1 18**]. She was seen
by our ED Neurology resident and was found to be dysmetric on
the left, few beats of right beating nystagmus and was quite
inattentive. Her CTA on admission showed the presence of
cerebrovascular atherosclerosis which was expected given her
history of [**Hospital1 1106**] risk factors. She was admitted for further
work up including MRI. Initial labs showed the presence of a
urinary tract infection, later speciated as E coli. She was
started and completed a course of ceftriaxone for this.
The MRI showed evidence of restricted diffusion in the left
cerebellar hemisphere. It also showed her basilar aneurysm with
evidence of prior coils (both from [**Hospital1 **] and from [**Hospital1 112**]). There was
no evidence of underlying mass or [**Hospital1 1106**] malformation. Her
examination remained largely stable; her level of awareness
would often fluctuate in a manner that was consistent with her
history of anoxic brain damage (at the time of prior AAA
repair). Her LDL returned at 160, A1c at 13.9. Her husband
admitted that she stopped taking her medications several months
ago. He appeared rather overwhelmed attending to both his own
medical needs as well as hers, and claimed that some of her
medications would often make her sleepy, so she just stopped
taking all of them. Her blood sugars as expected were difficult
to control, and in conjunction with the [**Last Name (un) **] Diabetes service,
we were able to obtain better control of her blood sugars using
sliding scale and scheduled insulin. She was restarted on her
antihypertensives, anticholesterol medications. She was
initially placed on an antiplatelet medication. In the setting
of her stroke while on atrial fibrillation, we initially
considered coumadin. We consulted neurosurgery regarding her
aneurysm, and they reported to us that while she had received a
coil placement to her aneurysm in the past, she had failed to
come for a follow up angiogram. They scheduled her for a repeat
angiogram with possible stent/coiling on [**2138-3-19**] and she was
loaded with plavix.
Unfortunately, the angiogram was not successful. Per procedure
notes from [**2138-3-19**], "the left vertebral artery was
catheterized and AP, lateral filming done. This showed a small
amount of recanalized area for the aneurysm. We now proceeded to
catheterize the left vertebral artery with a 6 French 070 Neuron
catheter. Following this, multiple attempts were made to
catheterize the thrombosed
segment. This was a very small area and therefore we decided
that it would
not be optimal to coil it. Right common femoral artery
arteriogram was done.
This revealed that there was significant number of stents in the
right common
iliac artery and therefore an Angio-Seal was not used and the
patient was
taken back to the ICU in a stable condition after being
extubated". She returned to the ICU and was hemodynamically
stable at that time. She did develop a groin hematoma, and
required two units of PRBC transfusion to catch up with her
blood loss. She remained hemodynamically stable and her h/H
responded appropriately. She was transferred back to the ICU in
stable condition. Dr. [**First Name (STitle) **] from the division of
Cerebrovascular surgery will see her in clinic in follow up. It
is essential that she keep this appointment.
She was seen by our physical therapists who recommended that she
go to acute rehabilitation to build her strength and balance.
Her husband was educated and counseled about her medication
noncompliance. He agreed that they needed help at home to manage
her several medications.
TRANSITIONAL ISSUES:
- Please be sure to have Ms. [**Known lastname **] meet all of her follow up
appointments, including her follow up with Dr. [**First Name (STitle) **] from the
Department of Neurosurgery
- She requires anticoagulation as secondary prophylaxis against
strokes. Please continue her daily aspirin and daily warfarin.
Discontinue her ASPIRIN when her INR reaches a goal of [**1-24**].
- If at all possible, please try to arrange VNA services for Ms.
[**Known lastname **] at the time of discharge.
- Please continue to titrate her daily insulin requirements.
- Her blood counts have been stable thus far, please measure
daily CBCs so as to ensure that her h/H remains stable
(following her right groin hematoma).
Medications on Admission:
Doses were not confirmed with actual home medication bottles.
Furthermore, both PCP and patient reported that patient had been
OFF medications x 6 months:
[**Known lastname **] 81
Metoprolol succ 150 daily
Pravastatin 40
Clopidogrel
Pancrelipase [**1-24**] caps daily
Gabapentin 1200 TID
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Continue until [**Month/Day (3) **] 325mg daily .
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin glargine 100 unit/mL Solution Sig: As instructed
Subcutaneous twice a day: 15 units AM
18 units PM .
6. insulin regular human 100 unit/mL Solution Sig: As instructed
Injection four times a day: Insulin sliding scale (120-160 for
2U, 160-200 for 4U, etc.).
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Cerebellar stroke
Poorly controlled diabetes mellitus type II
Hypertension
Hyperlipidemia
Atrial fibrillation
History of AAA repair
Basilar artery tip aneurysm
Discharge Condition:
Mental Status: Inattentive, often poorly oriented.
Level of Consciousness: Alert to somnolent at times, depending
upon the quality of sleep she receives at night
Activity Status: Ambulatory with one assist
Discharge Neurological examination: Slight dysmetria on left,
normal eye movements, generally symmetric strength and
sensation.
Discharge Instructions:
Dear Ms. [**Known lastname **]:
It was a pleasure to care for you during your hospitalization
at [**Hospital1 18**]. You were admitted to the hospital after a FALL with
incontinence of stool. Through a series of physical
examinations, laboratory tests and neuroimaging studies, we
determined that you sustained a stroke of your cerebellum, a
part of your brain that governs balance and coordination. This
likely occurred due to your irregular heart rate (atrial
fibrillation). We also measured various laboratory tests and we
found that your diabetes and elevated cholesterol were elevated
to dangerous levels. We restarted you on all the medications
that you are required to take everyday. While you were in the
hospital, you were seen by our neurosurgical colleagues. You
received an angiogram in an attempt to fix your basilar artery
aneurysm. Unfortunately, this was not successful, and so it is
important that you return for a repeat procedure.
- We have started you on a blood thinner called WARFARIN. You
will remain on aspirin until your blood tests reveal that
WARFARIN is acting appropriately. This will reduce the risk of
future strokes.
- We were able to organize a short stay at rehabilitation for
you, where you will receive daily exercises and physical therapy
to build your strength and balance.
- It is important that you take your medications on a daily
basis as prescribed. Do not hesitate to contact us should you
have any questions or concerns.
- Please be sure to follow up with your primary care physician
and Dr. [**Last Name (STitle) **] from the Division of Stroke Neurology. We also ask
that you surely follow up with Dr. [**First Name (STitle) **] from Neurosurgery.
Prior to this visit, you will receive a follow up MRI/MRA.
- Please come to the ED should you experience any of the below
listed unexplained symptoms.
Followup Instructions:
Please follow up with your primary care physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Ph: [**Telephone/Fax (1) 46064**]
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/WESTW
Address: [**Street Address(2) 21600**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 9310**]
[**2138-4-1**] at 2:15PM
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from Neurosurgery
[**2138-4-17**]
YOU will first have an MRI at 8:20AM (phone:[**Telephone/Fax (1) 327**])
Date/Time:[**2138-4-17**] 8:20
Your clinic visit will be at 9:30AM
Phone:[**Telephone/Fax (1) 3666**]
[**Hospital Unit Name **], [**Location (un) **]
Please also follow up with Dr. [**Last Name (STitle) **] from Stroke Neurology.
Phone:[**Telephone/Fax (1) 657**]
[**2138-5-13**] at 3:00PM
[**Location (un) 830**], [**Location (un) 86**], MA: [**Numeric Identifier **]
[**Hospital Ward Name 23**] Building, [**Location (un) 858**]
Completed by:[**2138-3-22**]
|
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"998.12",
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"403.90",
"V45.82",
"412",
"041.49",
"305.1",
"276.2",
"781.3",
"585.9",
"272.4",
"434.11",
"V15.88",
"427.31",
"348.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
17023, 17120
|
10421, 14429
|
382, 476
|
17324, 17324
|
5399, 5399
|
19558, 20653
|
3184, 3258
|
15502, 17000
|
17141, 17303
|
15188, 15479
|
17685, 19535
|
7325, 10398
|
3273, 3273
|
14450, 15162
|
310, 344
|
504, 1624
|
5415, 7309
|
3287, 3737
|
17339, 17661
|
3762, 5380
|
1646, 2991
|
3007, 3168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,913
| 161,978
|
25856
|
Discharge summary
|
report
|
Admission Date: [**2101-8-31**] Discharge Date: [**2101-9-5**]
Date of Birth: [**2045-7-5**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: We were asked to consult on this
patient who had cardiac catheterization which revealed 3-
vessel disease.
Mr. [**Known lastname 26056**] reported that he went recently for routine
physical. At that time his EKG was abnormal. He was referred
for stress echo which was also abnormal, although he normally
walks 2 to 3 miles per day and denied any chest pain or
dyspnea. On [**8-24**], ETT echo showed normal left ventricular
function but a large inferolateral posterior myocardial
infarction with no current ischemia noted. Please refer to
the official report dated [**2101-8-24**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Anxiety.
4. Status post appendectomy.
5. Myocardial infarction.
He denied any claudication, paroxysmal nocturnal dyspnea,
orthopnea, edema, or lightheadedness.
MEDICATIONS PRIOR TO ADMISSION:
1. Clonazepam 0.5 mg PO 3 times a day.
2. Lipitor 20 mg PO once daily.
3. Atenolol 200 mg PO once daily.
4. Diovan 160 mg PO once daily.
5. Aspirin 325 mg PO once daily.
SOCIAL HISTORY: He is married and drinks approximately 1
bottle of wine a week.
FAMILY HISTORY: He has a positive family history of coronary
artery disease.
He denied any TIA, cerebrovascular accident, melena or GI
bleed.
ALLERGIES: No known drug allergies.
Cardiac catheterization showed diffusely diseased LAD, mid
60%, 70% at the diagonal 1 origin, occluded circumflex, and a
total occlusion in the AV groove of the RCA. His LV EDP was
15. Ventriculography was not performed.
PHYSICAL EXAMINATION: Height 6 feet, weight 227. He was in
no apparent distress. He is lying flat after his cardiac
catheterization. His lungs are clear bilaterally. His
extremities are warm and well perfused with no peripheral
edema. His abdomen was soft and nontender, nondistended.
PREOPERATIVE LABORATORY DATA: White blood cell count 7.4,
hematocrit 40.7, platelet count 237,000, PT 13.3, PTT 27.2,
INR 1.2. Repeat platelet count 199,000. Urinalysis showed
trace amount of blood but was otherwise negative. Sodium
141, K 4.4, chloride 102, bicarb 29, BUN 22, creatinine 1.2,
blood sugar of 121. ALT 35, AST 28, alkaline phosphatase 54,
total bilirubin 0.9. Albumin 4.4, calcium 9.6, phosphorous
4.9, magnesium 1.9, cholesterol 137, HB AIC 5.5%.
Triglycerides 150, HDL 35, cholesterol to HD ratio 3.9.
Preoperative chest x-ray showed slightly enlarged heart but
in top normal heart size and no acute cardiopulmonary
pathology.
Preoperative EKG showed sinus rhythm at 60 with left atrial
enlargement and prior inferior and lateral myocardial
infarction. Please refer to the official report dated [**2101-8-31**].
The patient was referred to Dr. [**Last Name (STitle) **], who saw him and
consulted and determined that he would need a coronary artery
bypass grafting which he underwent the following day, on
[**2101-9-1**], with coronary artery bypass grafting x 5
with left internal mammary artery to the LAD, a vein graft to
the diagonal 1, and a vein graft to diagonal 2, vein graft to
the OM, and a vein graft to the patent ductus arteriosus. He
was transferred to the cardiothoracic ICU in stable condition
on an epinephrine drip at 0.02 mcg per kg per minute and
Norcuron drip at 0.5 mcg per kg per minute, Levophed drip of
0.04 mcg per kg per minute and a titrated propofol drip. He
was extubated late that evening. He was saturating well on 4
liters nasal cannula.
On postoperative day, he remained extubated with a
postoperative ejection fraction of 25 to 30% and remained on
Levophed drip at 0.04, lidocaine at 2.0 and Norcuron at
0.375. Epinephrine had been turned off. He was in sinus
rhythm at 87, with blood pressure of 109/59.
POSTOPERATIVE LABORATORY DATA: White blood cell count 14.7,
hematocrit 31.3, K 4.5, BUN 14, creatinine 0.7, INR 1.5. He
was awake and alert. His right IJ Swan remained in place. His
incisions were clean, dry and intact. His abdomen was obese
with hypoactive bowel sounds. He had a 2+ peripheral edema.
His epicardial pacing wires remained in place. His lidocaine
was weaned as was Levophed over the course of the day.
Norcuron as decreased slightly. He continued to improve. He
remained in cardiothoracic ICU.
On postoperative day 2, he had some anxiety which was better
after treatment with Ativan and clonazepam. His Norcuron was
down to 0.25 which was weaned off during the day. His chest
tubes were removed. He was continued on perioperative
vancomycin as well as antianxiety agents. His Lasix diuresis
was begun intravenously. He continued to improve
hemodynamically with a blood pressure of 98/54, in sinus
rhythm with a heart rate of 89. Creatinine remained stable at
0.9. Chest tubes put out 220 and he remained in overnight.
On postoperative day 3, he was off all drips for 24 hours. He
was alert and oriented. His stapled incisions were clean, dry
and intact. His leg incision was clean, dry and intact with
no peripheral swelling. His Foley was out. His blood
pressure, beta blockade was begun, and diuresis continued. On
postoperative day 3, he had been transferred out to the
floor. He was transitioned to PO Percocet for pain with good
effect. He began to work with the nurses and the physical
therapist on increasing his activity level and exercise
tolerance. He was seen by case management to help plan for
his discharge.
He continued to make excellent progress.
On postoperative day 4, he was doing very well. His Lopressor
was increased to 25 twice a day. His blood pressure was
131/86, in sinus rhythm at 79. He was continued on his anti-
anxiety agents. He was restarted on his Lipitor and continued
with aspirin therapy as well as Lasix diuresis. He did level
5 with physical therapy and was cleared for discharge. His
pacing wires were discontinued without incident and later
that afternoon the patient was discharged to home in stable
condition with visiting nurses.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 5.
2. Hypertension.
3. Hyperlipidemia.
4. Myocardial infarction.
5. Anxiety.
6. Status post appendectomy.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg PO twice a day for 10 days.
2. Potassium chloride 20 mEq PO twice a day for 10 days.
3. Colace 100 mg PO twice a day.
4. Enteric coated aspirin 81 mg PO once a day.
5. Captopril 6.25 mg PO 3 times a day.
6. Lipitor 10 mg PO once a day.
7. Percocet 5/325 one to two tablets PO p.r.n. q 4hours for
pain.
8. Metoprolol 25 mg PO twice a day.
9. Clonazepam 0.5 mg PO twice a day.
He was instructed to follow up with Dr. [**Last Name (STitle) **] in the office
in 4 weeks for postoperative surgical visit, to follow up
with Dr. [**Last Name (STitle) 23430**], his primary care physician, [**Last Name (NamePattern4) **] 1 to 2 weeks
post discharge and to follow up with Dr. [**Last Name (STitle) **], his
cardiologist, in 2 to 3 weeks post discharge. He was
discharged home in stable condition on [**2101-9-5**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2101-9-30**] 15:09:24
T: [**2101-10-1**] 03:04:40
Job#: [**Job Number 64355**]
|
[
"300.00",
"410.41",
"272.4",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"37.23",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
1283, 1671
|
6044, 6206
|
6229, 7303
|
1008, 1184
|
1694, 6023
|
163, 748
|
770, 976
|
1201, 1266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,979
| 103,620
|
53026
|
Discharge summary
|
report
|
Admission Date: [**2163-9-25**] Discharge Date: [**2163-10-4**]
Date of Birth: [**2100-9-29**] Sex: F
Service: MEDICINE
Allergies:
Hydralazine Hcl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
1. Jump graft replacement of arteriovenous graft with removal of
infected portion of arteriovenous graft ([**2163-9-26**])
2. Right internal jugular HD tunnelled line ([**2163-10-3**])
3. Right internal jugular temporary HD line ([**2163-9-27**])
History of Present Illness:
Briefly, Mrs. [**Known lastname 9037**] is a 62 year old female with a past
medical history significant for ESRD on MWF HD, DM 2, HTN, COPD,
carotid stenosis s/p PCI and PVD admitted for fever and found to
have MSSA bacteremia from an infected AV graft s/p AVG revision.
The patient underwent "jump graft" procedure on [**2163-9-26**] that was
complicated by edema and bleeding. In addition, her hospital
course has been complicated by a new O2 requirement felt to be
atelectasis versus volume overload.
Past Medical History:
-ESRD, secondary to HTN and DM, on HD M/W/F via left upper arm
AV graft created [**2162-11-30**], considering transplant with
extended criteria donor
-Type 2 DM, c/b nephropathy and retinopathy
-HTN
-Anemia
-PVD, s/p left extremity arteriography, left superficial femoral
artery, popliteal and anterior tibial angioplasty
-Hyperlipidemia
-COPD
-s/p PCI of carotid stenosis with stent to L ICA, on ASA and
plavix
-s/p cholecystectomy
-s/p C-section
-s/p surgery for retinopathy, cataracts
Social History:
Ms. [**Known lastname 9037**] is married and lives with her husband and daughter.
She is independent in ADLs and ambulatory with a cane. She
denies tobacco, alcohol, or illicit drugs.
Family History:
Significant DM, heart disease. Sister on HD.
Physical Exam:
VS: Tc 98.5, Tm 99.3, 142/44, 80, 18, 97%1L
GA: awake, NAD
HEENT: EOMI, PERRL, minimally reactive pupils, b/l lens
transplant, MMM, oropharynx clear without erythema or exudate,
no LAD, no JVD, neck supple, no conjunctival hemorrhage
CV: RRR, nl S1+S2, no M/R/G
Lung: CTAB, no wheezes, rales or rhonchi
Abd: soft, NT, ND, +BS, no rebound or guarding, no HSM
Extremities: W/WP, no C/C/E, 2+ DP/PT pulses bilaterally, LUE
with dressing w/serous drainage in place over AVG revision
Skin: warm, dry and intact with no rashes. L knee with
hypopigmented area from fall
Neuro/Psych: A+Ox3. CN II-XII grossly intact with no focal
deficit. Moving all extremities. Strength, sensation and
movement symmetric. Gait not observed.
Pertinent Results:
ADMISSION LABS:
[**2163-9-25**] 08:38PM LACTATE-1.7 K+-4.8
[**2163-9-25**] 08:25PM GLUCOSE-245* UREA N-55* CREAT-8.7*#
SODIUM-135 POTASSIUM-5.2* CHLORIDE-91* TOTAL CO2-27 ANION
GAP-22*
[**2163-9-25**] 08:25PM WBC-11.4*# RBC-4.02* HGB-12.0 HCT-34.9*
MCV-87 MCH-30.0 MCHC-34.5 RDW-15.4
[**2163-9-25**] 08:25PM NEUTS-85.8* LYMPHS-7.8* MONOS-4.3 EOS-1.6
BASOS-0.6
[**2163-9-25**] 08:25PM PLT COUNT-243
.
DISCHARGE LABS:
[**2163-10-4**] 07:54AM BLOOD WBC-11.8* RBC-3.34* Hgb-9.8* Hct-28.5*
MCV-85 MCH-29.2 MCHC-34.3 RDW-16.5* Plt Ct-292
[**2163-10-4**] 07:54AM BLOOD Glucose-100 UreaN-19 Creat-5.1*# Na-142
K-3.7 Cl-96 HCO3-35* AnGap-15
[**2163-10-4**] 07:54AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
.
MICROBIOLOGY:
[**2163-9-25**] BLOOD CULTURES (4/4 bottles):
STAPH AUREUS COAG +
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 2 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
IMAGING:
[**2163-9-25**] CT Torso:
IMPRESSION: 1. Mild perinephric fat stranding bilaterally,
without hydronephrosis or
nephrolithiasis. Recommend correlation with urinalysis. 2. Small
right upper lobe pulmonary nodules. These may represent the
residual of consolidation which was previously present in that
location. Nevertheless, followup to exclude pulmonary nodules is
recommended with a dedicated CT scan of the chest in
approximately 6-12 months. 3. Unchanged partially calcified
nodularity of the right adrenal gland. 4. Uterine fibroids. 5.
Atherosclerotic disease.
.
[**2163-9-27**] TRANSTHORACIC ECHO:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2163-4-22**],
findings are similar.
.
[**2163-9-29**] TRANSESOPHAGEAL ECHO:
IMPRESSION: No evidence of endocarditis. Hyperdynamic left
ventricle with symmetric left ventricular hypertrophy.
.
[**10-1**] MR [**Name13 (STitle) 6452**]/THORACIC SPINE W/O CONT:
Non-enhanced examination, with: 1. No finding to suggest
thoracolumbar vertebral osteomyelitis, discitis or paraspinal,
or epidural fluid collection or abscess. 2. Transitional anatomy
at the lumbosacral junction, with numbering convention, as
described above.
3. Diffusely and uniformly hypointense vertebral bone marrow
signal, likely related to the ESRD on hemodialysis. 4. T8-9 and
T9-10 left paracentral and foraminal protrusions, respectively,
without spinal cord or exiting neural impingement. 5. Normal
thoracic spinal cord caliber and intrinsic signal intensity. 6.
L4-5: Disc degeneration with moderate bulging and bilateral
subarticular zone stenosis without definite neural impingement.
Brief Hospital Course:
# MSSA Bacteremia/AVG infection: Ms. [**Known lastname 9037**] was transferred to
the MICU shortly after admission for hypotension, fever and
altered mental status concerning for sepsis. Initially, she was
covered empirically with vancomycin and piperacillin/tazobactam.
Antibiotics were changed to nafcillin 2 g IV Q4 hours once
blood cultures returned MSSA. The source was felt to be an
infected AV graft in her left arm. On [**2163-9-26**] she was taken to
the OR and had placement of a jump graft in the left arm by the
transplant surgery service. On Tuesday [**2163-9-27**], she had a
hemodialysis session through a temporary HD line in the right
IJ. During this HD session, she felt unwell with abdominal pain
and developed a fever shortly thereafter. Blood cultures were
sent, as there was concern for a transient bacteremia. TTE from
[**2163-9-27**] and TEE from [**2163-9-29**] showed no evidence of endocarditis.
She intermittently complained of back and neck pain similar to
her previous arthritis pain, but an MRI of the thoracic and
lumbar spine showed no evidence of thoracolumbar vertebral
osteomyelitis, discitis, or paraspinal or epidural fluid
collection or abscess. The day prior to discharge the patient
was switched to cefazolin which will be dosed on dialysis days
for a total 6 week course.
# Bleeding/Anemia: Patient had ongoing oozing/bleeding from AVG
site. Hematocrit trended down but ultimately stabilized. She
likely has uremic platelets and requires aspirin and plavix for
[**Doctor First Name 3098**] disease s/p PCI. Received three total doses of DDAVP as
well as erythropoietin with hemodialysis.
# ESRD: Patient initially had a right internal jugular temporary
line but had repeated problems with clotting of the line. The AV
graft was accessed for dialysis occasionally. She had a RIJ HD
tunnelled line placed on [**10-3**]. She received nephrocaps and her
calcium acetate dose was increased to 1334mg TID with meals per
renal recommendations.
# HTN: Home antihypertensives were held during most of the
admission, but the patient began to have SBPs in the low 200s.
Her outpatient regimen was restarted prior to discharge.
# Hypoxia: Likely secondary to atelectasis. Patient performed
incentive spirometry and was weaned to room air. Denied any
shortness of breath on discharge.
# DM2: Patient's disease c/b nephropathy and retinopathy.
Continued humalog 75/25 12 units [**Hospital1 **].
# HLD: Continued on atorvastatin.
# CAD/PVD: Continued on aspirin, atorvastatin, and clopidogrel.
# COPD: Continued ipratropium-albuterol nebs as needed for
shortness of breath.
# Arthritis: Patient had intermittent neck and back pain and was
treated with tramadol 50 mg q6h prn.
#Prophylaxis: The patient received heparin products.
#Code: Full code
Medications on Admission:
ASA 325 mg daily
atorvastatin 80 mg daily
calcitriol .25 mg MWF
Ca Acetate 6667 TIDac
clopidogrel 75 mg qd
humalog 75/25 12 units [**Hospital1 **]
ipratropium-albuterol nebs prn SOB
labetalol 200 mg [**Hospital1 **]
lisionpril 20 mg [**Hospital1 **] (hold AM dose prior to HD)
loperamine 2 mg qid prn diarrhea
tramadol 50 mg [**Hospital1 **] prn
B complex-vit C-folate 1 cap daily
docusate, senna
amlodipine 10 mg daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF
(Monday-Wednesday-Friday).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Outpatient Lab Work
Weekly lab work (CBC, Bun, Cr, LFTs). All laboratory results
should be faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 1353**].
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
12. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
[**Telephone/Fax (1) **]:*180 Capsule(s)* Refills:*2*
14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: Twelve (12) UNITS Subcutaneous twice a day.
15. Cefazolin 1 gram Recon Soln Sig: 2 grams QMon/Wed, 3 grams
QFri Intravenous QMWF: Dosed after HD. STOP AFTER [**2163-11-9**].
[**Month/Day/Year **]:*QS * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Methicillin-sensitive staphylococcus aureus sepsis
Arteriovenous graft infection
End-stage renal disease
Secondary Diagnoses:
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. You were admitted for a fever and found to have an infection
in your blood from your infected A-V graft. This infected graft
was replaced and you were started on antibiotics. You will need
to complete a 6 week course of antibiotics and have weekly lab
work done.
- Ancef (cefazolin) 2g IV every Monday & Wednesday after
dialysis, 3g IV every Friday after dialysis (STOP AFTER [**11-9**])
- Weekly lab work (CBC, Bun, Cr, LFTs). All laboratory results
should be faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 1353**].
2. You had ongoing bleeding from the site of your A-V graft
revision and this was followed by the transplant surgeons. As a
result of this your red blood counts were low. You should follow
up your blood counts with your PCP.
3. It is very important that you take your medications as
prescribed.
4. It is very important that you keep all of your doctors
[**Name5 (PTitle) 4314**].
Followup Instructions:
Department: TRANSPLANT CENTER
When: MONDAY [**2163-10-10**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2163-10-24**] at 10:10 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2163-11-14**] at 11:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2163-10-4**]
|
[
"996.62",
"440.4",
"403.91",
"E878.2",
"997.39",
"250.40",
"272.4",
"995.91",
"285.21",
"518.0",
"250.50",
"362.01",
"038.11",
"583.81",
"440.20",
"585.6",
"433.10",
"V45.11",
"716.90",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.72",
"38.95",
"39.42"
] |
icd9pcs
|
[
[
[]
]
] |
10896, 10954
|
6011, 8804
|
327, 576
|
11164, 11164
|
2639, 2639
|
12286, 13240
|
1838, 1884
|
9274, 10873
|
10975, 11100
|
8830, 9251
|
11347, 12263
|
3065, 5988
|
1899, 2620
|
11121, 11143
|
266, 289
|
604, 1109
|
2655, 3049
|
11179, 11323
|
1131, 1621
|
1637, 1822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,053
| 158,024
|
28771+57606
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-4-15**] Discharge Date: [**2179-4-25**]
Date of Birth: [**2107-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
left arm pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 with saphenous
vein graft to the posterior descending artery, obtuse
marginal artery, ramus intermedius artery, and left anterior
descending artery.-[**2179-4-20**]
History of Present Illness:
70 year old male s/p NSTEMI in [**2172**] s/p DES to mid RCA and
proximal OM2 presents with his anginal equivalent of left arm
pain. He reports he woke up with left arm pain which resolved
with 1/2 tab of nitro after three minutes. He
had similar left arm pain an hour later which went away again
with full tab of nitro this time and has not recurred since. He
went to his PCP where he was noted to have elevated cardiac
biomarkers and thus sent to [**Hospital1 18**] for further evaluation. Upon
cardiac catheterization he was found to have left main disease
and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History:
Percutaneous coronary intervention, in [**2172**] anatomy as follows:
2 vessel CAD, with successful intervention of RCA and OM2.
.
Other Medical History:
Hematuria - 2 months ago in the setting of plavix, workup
revealed prostatic trauma
Social History:
Pt smoked 25 pack yrs, quit in [**2146**]. +ETOH 2 glasses of
wine/day, No illicit drugs. He lives with his wife in [**Name (NI) 13588**].
Family History:
asthma, + DM, no CAD
Physical Exam:
Admission Physical Exam
Pulse:76 Resp:18 O2 sat:97/RA
B/P 155/73
Height:5'8" Weight:172 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]: 2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right: Left:
none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69524**] (Complete)
Done [**2179-4-20**] at 3:51:04 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2107-1-7**]
Age (years): 72 M Hgt (in): 68
BP (mm Hg): 120/70 Wgt (lb): 169
HR (bpm): 72 BSA (m2): 1.90 m2
Indication: Chest pain. Coronary artery disease.
ICD-9 Codes: 410.91, 786.05, 786.51
Test Information
Date/Time: [**2179-4-20**] at 15:51 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2012AW0-: Machine: us3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 63 ml/beat
Left Ventricle - Cardiac Output: 4.53 L/min
Left Ventricle - Cardiac Index: 2.39 >= 2.0 L/min/M2
Aorta - Annulus: 2.6 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 2 mm Hg
Aortic Valve - LVOT VTI: 11
Aortic Valve - LVOT diam: 2.7 cm
Aortic Valve - Valve Area: *2.7 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.7 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 45 ms
Mitral Valve - MVA (P [**11-23**] T): 4.8 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 155 ms 140-250 ms
TR Gradient (+ RA = PASP): 11 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in ascending aorta. Focal calcifications in
aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened 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: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The patient was under general anesthesia
throughout the procedure. No TEE related complications. Results
Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
No spontaneous echo contrast is seen in the body of the left
atrium.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
The right ventricular cavity is dilated with normal free wall
contractility.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the operating
room.
POST-BYPASS:
The LV systolic function appears normal, estimated EF>55%. The
RV function is preserved. The MR remains trace. Other valvular
function are unchanged. There is no evidence of aortic
dissection.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2179-4-20**] 19:05
?????? [**2169**] CareGroup IS. All rights reserved.
[**2179-4-25**] 06:35AM BLOOD WBC-7.5 RBC-3.19* Hgb-10.1* Hct-30.0*
MCV-94 MCH-31.6 MCHC-33.6 RDW-12.9 Plt Ct-281
[**2179-4-14**] 11:36PM BLOOD WBC-6.5 RBC-4.61 Hgb-13.9* Hct-42.5
MCV-92 MCH-30.1 MCHC-32.6 RDW-12.2 Plt Ct-231
[**2179-4-24**] 06:30AM BLOOD PT-11.8 PTT-24.7* INR(PT)-1.1
[**2179-4-25**] 06:35AM BLOOD UreaN-22* Creat-0.9 Na-137 K-4.0 Cl-97
[**2179-4-14**] 11:36PM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-141
K-3.6 Cl-104 HCO3-24 AnGap-17
Brief Hospital Course:
On [**2179-4-20**] Mr.[**Known lastname **] was taken to the operating room and
underwent Coronary artery bypass grafting x4 with saphenous vein
graft to the posterior descending artery, obtuse marginal
artery, ramus intermedius artery, and left anterior
descending artery with Dr.[**Last Name (STitle) **]. CROSS-CLAMP TIME: 88
minutes.PUMP TIME: 96 minutes.Please see operative report for
further surgical details. He tolerated the procedure well and
was transferred to the CVICU for hemodynamic monitoring. He
awoke neurologically intact and was extubated without
difficulty. He weaned off pressor support. All lines and drains
were discontinued per protocol. Beta-blocker/aspirin/statin and
diuresis were initiated. POD #1 he was transferred to the step
down unit for further monitoring. Physical Therapy was consulted
for evaluation of strength and mobility. He had transient
episodes of postoperative atrial fibrillation and placed on
Amiodarone with conversion to normal sinus rhythm. The remainder
of his hospital admission was essentially uneventful. He was
cleared for discharge to home with VNA services on POD# 5. All
follow up appointments were advised.
Medications on Admission:
Aspirin 325mg daily
Nifedipine 60 mg daily
lisinopril 20 mg daily
Metoprolol Tartrate 100 mg [**Hospital1 **]
Simvastatin 40 mg daily
Fish oil daily
Centrum silver daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Coronary artery disease
Secondary:
Dyslipidemia
Hypertension
Percutaneous coronary intervention, in [**2172**] anatomy as follows:
2
vessel CAD, with successful intervention of RCA and OM2.
Hematuria d/t Plavix 3 years ago
Past Surgical History
Percutaneous coronary intervention, in [**2172**] anatomy as follows:
2
vessel CAD, with successful intervention of RCA and OM2.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-5-27**] 1:15
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-5-4**] 10:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 11302**] in [**11-23**] weeks [**Telephone/Fax (1) 29110**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2179-4-25**] Name: [**Known lastname 11831**],[**Known firstname 499**] Unit No: [**Numeric Identifier 11832**]
Admission Date: [**2179-4-15**] Discharge Date: [**2179-4-25**]
Date of Birth: [**2107-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 135**]
Addendum:
Medication change prior to discharge as follows:
Amiodarone 400 mg twice daily x 7 days, then decrease to 200 mg
twice daily x 7 days, then decrease to 200 mg once daily until
otherwise directed by Cardiologist
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2179-4-25**]
|
[
"433.30",
"401.9",
"272.0",
"E878.2",
"V58.66",
"997.1",
"V45.82",
"433.10",
"427.31",
"414.01",
"V15.82",
"041.19",
"599.0",
"412",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"88.56",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13149, 13361
|
7735, 8907
|
288, 490
|
10839, 11065
|
2369, 7712
|
11989, 13126
|
1667, 1689
|
9128, 10343
|
10442, 10818
|
8933, 9105
|
11089, 11966
|
1704, 2348
|
234, 250
|
518, 1148
|
1170, 1494
|
1510, 1651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,182
| 120,820
|
38871
|
Discharge summary
|
report
|
Admission Date: [**2154-3-4**] Discharge Date: [**2154-3-8**]
Date of Birth: [**2094-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**Known firstname 922**]
Chief Complaint:
Fever of unknown origin, drainage from surgical [**Known firstname **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 year old male well known to the csurg service as he is status
post ruptured thoracoabdominal aneurysm repair on [**2154-1-20**]. He
was transferred today from [**Hospital 5503**] Rehab with fever of
unknown origin and new thoracoabdominal drainage and new rash.
He was transferrd to [**Hospital1 18**] for further workup.
Past Medical History:
Type A aortic dissection with rupture s/p thoracoabdominal
repair
Hypertension
atrial fibrillation
blindness s/p aortic dissection repair
respiratory failure s/p Trach and G-J tube
[**2154-1-20**] - Emergent salvage repair of ruptured thoracoabdominal
aortic aneurysm with a 34-mm Dacron tube graft using deep
hypothermic circulatory arrest.
[**2154-1-22**] - Chest and abdomen exploration, Removal of packs, Chest
closure.
[**2154-1-25**] - abdomen closure/ feeding jejunostomy
[**2154-2-4**] tracheostomy
Social History:
Admitted from [**Hospital 5503**] Rehab
Lived with finance prior to surgery
Family History:
Unknown
Physical Exam:
Pulse:82 Resp: O2 sat:CPAP .4/PS+10/P+5
B/P Right: 106/52 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]pruritic, reticular erythematous diffuse
rash
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [] non-distended [x] non-tender [x] bowel sounds
+
[]incisional juncture open area 2Lx2Wx1D cm purulent drainage
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact, except (B)blindness
Pertinent Results:
[**2154-3-8**] 03:07AM BLOOD WBC-10.6 RBC-2.89* Hgb-8.3* Hct-25.9*
MCV-90 MCH-28.8 MCHC-32.1 RDW-14.7 Plt Ct-450*
[**2154-3-8**] 03:07AM BLOOD Glucose-109* UreaN-26* Creat-0.9 Na-136
K-4.8 Cl-102 HCO3-31 AnGap-8
[**2154-3-4**] 05:53PM BLOOD ALT-33 AST-22 LD(LDH)-176 AlkPhos-99
Amylase-58 TotBili-0.7
[**2154-3-4**] 05:53PM BLOOD Lipase-30
[**2154-3-8**] 03:07AM BLOOD Calcium-8.6 Mg-2.0
[**3-4**]: right sided CVL in the lower SVC. s/p aortic aneurysm
repair. persistent retrocardiac density.
[**3-5**] Urine: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**3-5**] Urine: URINE CULTURE (Final [**2154-3-7**]): NO GROWTH.
[**3-4**]: Sputum: SERRATIA MARCESCENS. MODERATE GROWTH.
[**3-6**]: [**Month/Year (2) 409**] Cx: [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
SPARSE GROWTH.
URINE CULTURE (Final [**2154-3-6**]): ESCHERICHIA COLI.
[**3-5**]: Blood Culture, Routine: NGTD
Brief Hospital Course:
59 yo M with a PMHx significant for Type A aortic dissection s/p
emergent repair with very complicated post op course notable for
trach and GJ tube presented to [**Hospital1 18**] on [**3-4**] from [**Hospital 5503**]
Rehab with fever of unknown origin. Pt had been
hospitalized at [**Hospital1 18**] from [**1-20**] - [**2-18**] for his aortic dissection
and post op course. He was transferred to [**Hospital 5503**] Rehab on
[**2-18**] for physical therapy. The patient had been noted to have an
open area of his thoracic [**Month/Year (2) **] that hs been draining a
moderate amount of purulent bloody drainage. Pt was also having
some foul smelling loose stools and thus started on IV Flagyl
and had stool sent for C. diff which was negative on [**3-3**]. On
[**3-3**], pt was also noted to be more agitated and pulling at his
trach. He was documented to have a single rectal temp on [**3-4**] of
103.5 given tylenol and rechecked to be 102.1 and subsequently
temperature of 100.4. Pt was also noted to have the onset of a
diffuse body drug rash presumed to be due to the flagyl and pt
started on hydrocortisone topical cream. CXR was obtained with
concern for haziness at left base and thus patient was
transferred to [**Hospital1 18**] for concern for development of ventilator
associated pneumonia. Pt also noted to be having some diarrhea
and thus concern for C. difficile as well.
Pt was transferred to [**Hospital1 18**] and on exam noted to have minimal
opening of incision on chest of 2x2x1 cm with only
serosanguinous drainage which was cleaned and had swab sent for
culture which grew [**Female First Name (un) 564**] Albicans, sparse growth. The patient
was also noted to have copious thick yellow respiratory
secretions. He was started on empiric vancomycin therapy. The
infectious disease team was consulted and recommended cefepime
based on ecoli in the urine and Serratia in the sputum. White
blood cell count from a peak of 18 to 10 and he remained
afebrile x 72 hours prior to discharge. Per Infectious disease
recommendations, his antiboitics were changed to Meropenem on
[**3-8**] and this is to continue for a 10 day course.
Also noted on admit was a new stage III decub ulcer, which was
treated by the [**Month/Year (2) **] care nurse. [**First Name (Titles) 409**] [**Last Name (Titles) **] was as
follows: type pressure ulcer, location:coccyx size:5.5 x 5cm
[**Last Name (Titles) 409**] bed: irregular, 80% pink tissue, 20% pale yellow exudate:
moderate yellow Odor: none [**Last Name (Titles) 409**] edges: maceration, lifting Peri
[**Last Name (Titles) **] tissue: intact, no induration or fl uctuance.
Recommendations were pressure relief per pressure ulcer
guidelines Support surface Kainair, turn and reposition every
1-2 hours, heels off bed surface at all times multipodius, if
OOB, limit sit time to one hour at a time and sit on a pressure
relief cushion. Gya [**Month (only) **] chair cushion, elevate LE's while
sitting, moisturize B/L LE's and feet [**Hospital1 **] with Aloe Vesta
ointment
Commercial [**Hospital1 **] cleanser or normal saline to irrigate/cleanse
open [**Hospital1 **].
Pat the tissue dry with dry gauze, apply moisture barrier
ointment to the peri [**Hospital1 **] tissue with each DRG change, apply
Sacrum Mepilex dressing, change dressing every 3 days.
On admission, the patient was in sinus ryhthm and remained in
sinus rhtym throughtout his hospital course. Per Dr. [**Last Name (STitle) 914**]
the the Amiodarone is to continue until he see his cardiologist
but he no londer required anticoagulation with Coumadin. He is
to remain on subcutaneous Heparin for deep venous thrombsis
prevention.
The patient's G tube was noted to be clogged on admission. This
was resolved with papain solution and was patent at the time of
discharge. He was tolerating tube feeds at goal.
The patient required minimal suctioning and was tolerating trach
collar for several hours prior to discharge.
At the time of discharge, the patient was afebrile with
decreased white blood cell count and no signs of active
infection. He is to continue on Meropenem x 10 days per
Infectious disease recommendations. He is to continue trach
collar trials during the day with increases in duration as
tolerated. [**Last Name (STitle) 409**] care per recommendations above.
Medications on Admission:
Medications at Rehab
1. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-24**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed for wheezes.
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily for 7days then 200mg daily.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin yeast.
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation/anxiety.
14. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: 3mg on [**2-18**] target INR 2-2.5 (received 5mg last 4 days)
.
17. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mililiters PO
BID (2 times a day).
3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis.
4. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mililters PO
DAILY (Daily).
10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-24**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Per J tube.
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-24**]
Drops Ophthalmic Q 8H (Every 8 Hours).
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation/anxiety.
15. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous q AM.
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for dry skin/itch.
18. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) 20.3 ml
PO Q6H (every 6 hours) as needed for pain.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
20. Lipase-Protease-Amylase 8,000-30,000- 30,000 unit Tablet
Sig: One (1) Tablet PO once a day as needed for G tube clogging.
21. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO ONCE
(Once) as needed for G tube clogging: Crush and mix with 30 cc
water PRN for G tube clogging.
22. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 10 days.
23. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Per previous Sliding scale
parameters.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Drug Reaction Rash, Ventalator associated pneumonia, Urinary
tract infection
Discharge Condition:
Alert, oriented, moves all 4
Tolerating Tube feeds
Tolerating Trach Collar
Discharge Instructions:
Pt is to continue on CPAP PEEP 5 Pressure support 8 with trach
collar trials during the day as tolerated
[**Location (un) 409**] care as per recommendations
Please bath daily including washing incisions gently with mild
soap, no baths or swimming, and check incisions
Please NO lotions, cream, powder, or ointments to incisions
Followup Instructions:
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 86266**] in 2 weeks
Referral for a cardiologist needed from Dr. [**Last Name (STitle) **] and please make
appt in [**11-24**] weeks
General Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] in 4 weeks [**Telephone/Fax (1) 2998**]
Completed by:[**2154-3-8**]
|
[
"369.00",
"V44.0",
"693.0",
"997.31",
"V58.67",
"536.49",
"438.7",
"041.85",
"401.9",
"707.23",
"E931.5",
"V58.61",
"427.31",
"041.4",
"599.0",
"E879.8",
"707.03",
"V55.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11143, 11241
|
2858, 7175
|
342, 349
|
11362, 11439
|
1927, 2835
|
11816, 12279
|
1344, 1353
|
8850, 11120
|
11262, 11341
|
7201, 8827
|
11463, 11793
|
1368, 1908
|
232, 304
|
377, 704
|
726, 1235
|
1251, 1328
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,932
| 159,867
|
5142+55639
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-3-15**] Discharge Date: [**2120-4-10**]
Date of Birth: [**2064-7-11**] Sex: F
Service: SURGERY
Allergies:
Codeine / Vancomycin / Morphine / Keflex / Cipro Cystitis /
Penicillins / Pramoxine / Fentanyl / indomethacin
Attending:[**First Name3 (LF) 19859**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2120-3-15**]: Endoscopy of ileostomy, partial decompression of
obstruction
[**2120-3-18**]: Exploratory laparotomy, lysis of adhesions, repair
internal hernia
History of Present Illness:
55 F w/ extensive surgical history including colostomy for
diversion following failed rectal advancement flaps, ischemic
colitis leading to colectomy and ileostomy placement, multiple
partial small bowel obstructions and chronic abdominal pain
presents w/ several hours of acute onset severe abdominal pain
and no ileostomy output (gas or liquid) for over 12 hours. Pain
woke her from sleep and is described as 8/10 intensity, mostly
as a sharp pressure in her pelvis without radiation. Minimal
nausea and no vomiting. No f/c/CP/SOB. No BRB per stoma.
Past Medical History:
Past Medical History
1. Chronic abdominal pain with narcotic dependence gastoparesis,
s/p G-tube placement
2. Endometriosis
3. Anemia
4. Hypokalemia
5. Osteoporosis
6. Atypical chest pain syndrome (association w/ ST depressions,
MIBIs in [**2113**],[**2114**],[**2117**])
Past Surgical History
1. Hemorrhoidectomy c/b muscle injury requiring local
advancement
flap reconstruction ([**2091**])
2. Colostomy after failed flap reconstruction
3. Total abdominal colectomy for ischemic colitis with end
ileostomy [**2106**]
4. Appendectomy
5. Laparoscopic Cholecystectomy ([**2105**])
6. Bilateral inguinal hernia repair ([**2098**]'s)
7. G-tube for gastroparesis
8. TAH/BSO (for endometriosis)
9. R hip ORIF ([**2115**],[**2117**])
10. L hip ORIF ([**2116**])
Social History:
Patient married. Lives with husband. [**Name (NI) **] 2 children (daughter is
a [**Name (NI) 112**] nurse) and son lives in [**Location **]. She is on disability. No
alcohol, no smoking or drug use.
Family History:
No premature CAD or sudden death
Daughter - Crohn's disease.
Father - lung cancer (smoker).
Mother - CV disease with a pacemaker.
Physical Exam:
Admission:
Vitals: 98.1 108 132/71 20 100%
GEN: A&O,tearful. Shifting & uncomfortable 2ary to abd pain
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R. Right sided portacath in place no surrounding
erythema
PULM: Clear to auscultation b/l, No W/R/R
ABD: Multiple well healed abdominal scars. G-tube in LUQ venting
green liquid & some CT contrast. Distended. Firm/tympanitic.
Voluntary guarding throughout. Tender to palpation throughout
although most tender suprapubic region. Not tender surrounding
ileostomy. Tender to bed shake.
Ext: No LE edema, LE warm and well perfused
Discharge:
AVSS
nad
ctab
RR no M/R/G
abd s/nt/nd with gtube in place
Imaging:
CT Scan:
[**3-18**]: . Worsening of appearances with high-grade small bowel
obstruction with
transition point within the right lower quadrant and collapsed
small bowel
proximal and distal to the ileostomy. Findings were discussed
with team by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2:55 a.m. 2. Increase in intra-abdominal
ascites. No free air.
3. New bilateral pleural effusions and overlying atelectasis. 4.
Stable subcutaneous edema within the tissues bilaterally.
[**3-25**]:
1. High-grade small bowel obstruction with transition point
likely in the
right lower quadrant with decompressed terminal ileum and end
ileostomy.
Small volume free fluid in the abdomen and pelvis. No evidence
for spillage
of orally administered material into the peritoneal cavity;
however, oral
contrast has not transited through all loops of small bowel. 2.
Fluid in the deep posterior pelvis anterior to the coccyx likley
within a dilated loop of bowel; however, differentiation between
a dilated loop of bowel and a pelvic fluid collection is
difficult. 3. Bilateral pleural effusions, increased. Bibasilar
ground-glass changes concerning for infection. 4. Status post
cholecystectomy with persistent CBD and left biliary duct
dilation.
CXR: [**3-24**]
FINDINGS: As compared to the previous radiograph, the extensive
bilateral
pulmonary edema is unchanged in extent and severity. Also
unchanged are
bilateral small pleural effusions as well as moderate
cardiomegaly. Unchanged
course and position of the right central venous access line.
Pertinent Results:
13.2
10.0 >----< 228
38.6
N:79.8 L:11.5 M:4.2 E:3.7 Bas:0.7
143 103 7
------------< 86
4.1 31 0.8
ALT 30 Lip 20
AST 40
AlkP 112
Tbil 0.2
KUB: Few loops of dilated small bowel in the pelvic regionnwith
air fluid levels, specially on RLQ. Gastrostomy tube in place.
Finding consistent with PSBO vs Ileous
CT abd: Small bowel obstruction, with transition point noted in
the posterior right pelvis. Suggestion of mesenteric swirling at
the level of transition point, could relate to intenal hernia.
Trace perihepatic fluid.
Brief Hospital Course:
The patient was evaluated in the emergency department by the
surgical service, including attending surgeon Dr. [**Last Name (STitle) **], the
patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**], and the chronic pain service. While the
patient has a long history of chronic abdominal pain, she and
her husband stated that this pain was as bad as it had ever been
and her PCP [**Name Initial (PRE) 18142**]. The physical exam and CT findings were
concerning for a small bowel obstruction. Dr. [**Last Name (STitle) **] had an
extensive discussion with the patient and her husband of the
risks and benefits of surgery, particularly in light of her
extensive surgical history. Because the CT demonstrated a fairly
distal transition point, it was decided to insert an endoscope
through the ileostomy in an attempt to decompress the
obstruction. If that were to fail, the patient agreed to
laparotomy. Prior to being taken to the operating room, an
epidural was placed for pain control.
In the operating room, an endoscope was inserted through the
ileostomy and advanced to the presumed transition point. No
mucosal ischemia was noted. Please refer to the operative note
for further details.
The ileostomy produced 150cc of serous output with minimal gas
throughout the first postprocedure day. The G-tube was vented to
gravity and drained over a liter over the course of the day.
Initial output was coffee ground in quality and she was started
on Protonix and the output became bilious. The epidural ceased
to function and the patient was transitioned to a Dilaudid PCA
with good pain control. She did require IV fluid bolus for
intravascular dehydration as evidenced by low urine output.
Over the course of the next day ileostomy output remained very
low and the patient's pain increased throughout the day as did
her abdominal distension. Early on POD#3 a CT scan was obtained
that demonstrated worsening small bowel dilitation with
peristence of the previously identified transition point; small
bilateral pleural effusions; and new perihepatic ascites. After
discussion with the patient during which she consented to
surgery, she was taken to the operating room for an exploratory
laparotomy. An internal hernia was identified and the source of
obstruction repaired. The bowel appeared pink and viable
throughout. Please refer to the operative note for further
details. Postoperatively the patient was recovered in the PACU
and indeed remained there overnight for close monitoring given
occasional desaturations. A chest X-ray demonstrated bibasilar
effusions/atelectasis as previously seen on CT.
On HD 7, her epidural was removed. She has episodes of confusion
and blood cultures, urinalysis, chest x ray were obtained. Labs
were drawn and electrolytes repleted. CXR appeared improved from
her prior xray. She was tachycardic to 120s intermittently. Her
hematocrit was stable at 34 and WBC 9.3. EKG was unchanged from
her prior once on [**2120-3-19**].
On HD 8, she desaturated to 70s but recovered on O2. A chest
xray showed pulmonary edema and her breathing improved with
lasix. On HD 9, her wound began to have purulent, foul-smelling
drainage. ID was consulted due to her multiple antibiotic
allergies and recommended daptomycin and flagyl in addition to
the levafloxacin for broad coverage. Wound cultures grew group B
strep. She was advanced to clears and tolerated that but did not
take in much PO. on HD 10, her staples were dc'd and wound
opened to be packed with dry gauze. She received additional
lasix for low O2 sats due to pulmonary edema. Her IVF were
stopped and she was started on tube feeds through her G-tube.
Her dapto was switched to vanco. Overnight, she started to have
stool-appearing output from her wound. On HD 11 she underwent a
CT scan that showed obstruction but no obvious leak or abscess.
TF were stopped. PICC was placed and TPN started. Her INR was
checked and returned 9.3. She received IV Vit K and repeat INR
was 1.5.
On HD 12, she continued to be agitated and desat'd to low 80s
when off oxygen. CXR showed worsening pulmonary
edema/opacification and she had increased work of breathing.
Thus, she was transferred to the ICU for closer monitoring. Her
IV fluids were stopped and she diuresed well. She had a CT scan
[**2120-3-28**], which showed an abscess, for which she had to undergo
intubation and extubation, which was drained the same night w/
200cc of serousanguinous/purulent drainage. She became agitated
intermittently and was given haldol and ativan. Psychiatry was
consulted and recommended haldol, ativan, zyprexa, and valproic
acid. Her tube feeds were started at a low rate. A wound VAC was
placed. She was transferred out of the ICU on [**2120-4-1**] to floor.
She was stable on the floor but with intermittent confusion and
continued to receive haldol and ativan. Her TF were stopped and
she was started on clears on [**4-2**]. Her TF were restarted [**2120-4-4**]
and she was advanced to a full liquid diet. Her medications were
switched to PO. Her abscess drain was dc'd.
On [**2120-4-6**] she had a follow-up CT scan, which showed a
persistent 3 cm pelvic fluid collection. She also had some
nausea/vomiting and her WBC count increased to 16 so TF were
held for a day. She was started on abx and her WBC count then
decreased and any residual abdominal pain resolved. She began
tolerating a regular diet in addition to her TFs. She had some
nausea from her TFs when they went up to 40. The patient says
that she knows how to monitor her tube feeds and will adjust
them as she wishes at home. She says she may or may not continue
the 30cc/hr TF recommendation and may switch to bolus feeds
herself. She will take weights 2x per week on discharge. The
patient states she feels well and expressed strong desire to be
discharged home. She is medically stable and thus will be
discharged with appropriate follow up care.
Medications on Admission:
FLUTICASONE - 50 mcg Spray 2 each nostril daily
INDOMETHACIN - 25 mg/5 mL Suspension - [**1-8**] tsp by mouth
four times daily PRN pain
LIDODERM patch - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply [**1-8**] patches daily for 12 hours
LORAZEPAM - 2 mg Tablet - [**1-8**] Tab(s) by mouth 4 times daily PRN
pain or anxiety
MEPERIDINE - 100 mg Tablet - [**1-8**] Tablet(s) by mouth Q3H PRN pain
MEPERIDINE - 100 mg/mL Soln [**1-8**] vials Q3H PRN breakthrough pain
NYSTATIN - 100,000 unit/mL Suspension - 1 tsp by mouth four
times
a day Swish and swallow
PROMETHAZINE - 6.25 mg/5 mL Syrup - [**1-8**] tbsp Syrup(s) by mouth q
3 hours as needed for nausea or vomiting
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet by mouth daily
SUMATRIPTAN - 20 mg Spray, Non-Aerosol - 1 whiff nasally once at
onset of migraine
TERIPARATIDE [FORTEO] - 20 mcg/dose (600 mcg/2.4 mL) Pen
Injector
- 20 mcg sc at bedtime
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
sprays each nostril Nasal once a day.
2. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) adhesive patch Topical twice a day as needed for pain.
3. Ativan 1 mg Tablet Sig: 1-2 Tablets PO four times a day as
needed for anxiety.
4. meperidine 100 mg Tablet Sig: 1-2 Tablets PO q3h as needed
for pain.
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day.
6. promethazine 6.25 mg/5 mL Syrup Sig: [**1-8**] tbsp PO q3h as
needed for nausea.
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
8. teriparatide 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig:
Twenty (20) micrograms Subcutaneous at bedtime.
9. Peptamen Oral
10. magnesium oxide Oral
11. tizanidine 4 mg Capsule Sig: Two (2) Capsule PO three times
a day.
12. dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 2 weeks.
Disp:*42 Capsule(s)* Refills:*0*
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. haloperidol 2 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety/agitation.
Disp:*60 Tablet(s)* Refills:*0*
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
17. Tube Feeds
Peptamen 1.5 Full strength via G-tube
Starting rate: 40 ml/hr
Goal rate: 40 ml/hr
Flush w/ 30 ml water q8h
Length of need: indefinite
18. Demerol 100 mg/mL Solution Sig: [**1-8**] vials Injection q3h as
needed for pain: Please take as directed by Dr. [**Last Name (STitle) 1007**]. .
19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 21084**],
You were admitted to the West 3 (Dr.[**Name (NI) 19861**] surgery service
for surgery for small bowel obstruction.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new
medications as prescribed. The enclosed medication list is your
most up to date list at this time. Please take the prescribed
analgesic medications as needed. You may not drive or operate
heavy machinery while taking narcotic analgesic medications.
You may also take acetaminophen (Tylenol) as directed, but do
not exceed 4000 mg in one day. Please get plenty of rest,
continue to walk several times per day, and drink adequate
amounts of fluids. Avoid strenuous physical activity and
refrain from heavy lifting greater than 10 lbs., until you
follow-up with your surgeon, who will instruct you further
regarding activity restrictions. Please also follow-up with
your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you
have increased pain, swelling, redness, or drainage from the
incision
site.
*Avoid swimming and baths until cleared by your surgeon.
*You will have in home VNA to come and change your VAC every 3
days until you follow up with Dr. [**Last Name (STitle) **]
We have also set you up with VNA for your continued tube feeds
and your in home Physical Therapy.
Please weigh yourself 2x per week and record these weights
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
Please follow up in clinic with Dr. [**Last Name (STitle) **] in [**2-9**] weeks. Call
today to make this appointment.
Please also follow up with Dr. [**Last Name (STitle) 1007**] ([**Telephone/Fax (1) 10492**]) within one
week so he can further adjust your pain medication and further
guide your care as you transition back home. You may follow up
with our pain clinic at [**Hospital1 18**] if Dr. [**Last Name (STitle) 1007**] feels you would
benefit from this.
You do not need to follow up with the Psychiatry department at
this time.
Name: [**Known lastname 3501**],[**Known firstname **] S. Unit No: [**Numeric Identifier 3502**]
Admission Date: [**2120-3-15**] Discharge Date: [**2120-4-10**]
Date of Birth: [**2064-7-11**] Sex: F
Service: SURGERY
Allergies:
Codeine / Vancomycin / Morphine / Keflex / Cipro Cystitis /
Penicillins / Pramoxine / Fentanyl / indomethacin
Attending:[**First Name3 (LF) 3278**]
Addendum:
After the patient left the hospital Dr. [**Last Name (STitle) 3503**], ID fellow, stopped
by the floor to express concern that the patient was discharged
on antibiotics which may not completely cover her infection. Dr.
[**Last Name (STitle) 3503**] stated that she has an appointment to see the patient as an
outpatient to follow up on this issue and adjust treatment as
needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**Name6 (MD) 1832**] [**Last Name (NamePattern4) 3279**] MD [**MD Number(2) 3280**]
Completed by:[**2120-4-10**]
|
[
"536.3",
"311",
"238.71",
"786.59",
"280.9",
"V45.77",
"348.39",
"V15.51",
"E878.2",
"788.5",
"998.59",
"V45.79",
"733.00",
"518.4",
"552.8",
"041.11",
"560.1",
"263.9",
"V55.1",
"518.82",
"V55.2",
"789.03",
"285.29",
"780.09",
"276.8",
"557.9",
"511.9",
"567.22",
"569.81",
"304.01",
"338.29",
"V45.72",
"276.3",
"276.51",
"V85.0",
"041.02",
"338.19",
"595.9",
"V88.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"88.14",
"96.04",
"96.6",
"45.12",
"03.90",
"53.59",
"96.71",
"54.59",
"99.15",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
17176, 17373
|
5125, 11034
|
385, 548
|
14019, 14019
|
4552, 5102
|
15787, 17153
|
2144, 2275
|
11985, 13873
|
13972, 13998
|
11060, 11962
|
14170, 14324
|
15198, 15764
|
2290, 4527
|
14356, 15183
|
331, 347
|
576, 1130
|
14034, 14146
|
1152, 1911
|
1927, 2128
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,834
| 107,726
|
7098
|
Discharge summary
|
report
|
Admission Date: [**2100-7-14**] Discharge Date: [**2100-7-22**]
Date of Birth: [**2048-1-28**] Sex: F
Service: Medicine, [**Hospital1 **] Firm
CHIEF COMPLAINT: Abdominal distention.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
female with a history of hypertension, hypercholesterolemia,
and alcohol dependence who presents with approximately a
3-month history of increasing abdominal girth which has been
acutely worsening in the last three weeks with dyspnea and
lower extremity edema.
The patient had associated mild pain in the periumbilical
region with possible chills, nausea, and vomiting secondary
to abdominal fullness. The patient also noticed yellowing of
eyes, [**Location (un) 2452**] urine, and tarry stools. The patient denied
fevers, headache, and chest pain. No history of intravenous
drug use, tattoos, hepatitis, or unsafe intercourse. She
drinks four drinks per day and two times this amount on
weekends. The patient was admitted to the Medicine Service
in fair condition.
PAST SURGICAL HISTORY: Breast reduction.
PAST MEDICAL HISTORY: Past medical history as above.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: As noted in the History of Present Illness
plus a 40-pack-year history of smoking.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 97.4 degrees
Fahrenheit, heart rate was 125, blood pressure was 131/71,
respiratory rate was 16, and oxygen saturation was 99% on
room air. In general, anxious but in no acute distress. A
distended abdomen. Head, eyes, ears, nose, and throat
examination revealed the neck with lymphadenopathy,
thyromegaly, and was supple. Cardiovascular examination
evaluated tachycardia with a regular rate. Respiratory
examination revealed the lungs were clear to auscultation
bilaterally. Gastrointestinal examination revealed bowel
sounds were present. The abdomen was taut. Periumbilical
tenderness in the right and left lower quadrant.
Genitourinary examination revealed no costovertebral angle
tenderness. Musculoskeletal examination revealed no aches.
Good range of motion. Neurologic examination revealed alert
and oriented times three. No asterixis. Extremity
examination revealed 2 to 3+ bilateral lower extremity edema.
Dermatologic examination revealed positive spider angiomata,
plus palmar erythema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Hepatitis
serologies indicated past exposure to hepatitis A but was
negative for hepatitis B or hepatitis C. Anti-smooth muscle
antibody titer was 1:80; which was nonspecific. Antinuclear
antibody was negative. Alpha-fetoprotein was within normal
limits.
RADIOLOGY/IMAGING FINDINGS: Abdominal ultrasound
echocardiogram revealed ascites plus gallbladder wall
thickening; consistent with ascites. The liver had an
increased echogenic texture. No intrahepatic ductal
dilatation. Positive flow in portal vein. Positive flow in
the common hepatic artery.
A computed tomography of the abdomen showed "heterogenously
decreased attenuation of the liver with reflux of contrast
material into the hepatic veins with associated large amount
of ascites. Fatty replacement/tumor infiltration/other
chronic liver disease are differential possibilities.
Congestive hepatopathy was thought less likely."
A chest x-ray was negative.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. ASCITES ISSUES: In the Emergency Department, at the time
of presentation on [**2100-7-14**], a paracentesis of one liter
was done with Gram stain and culture negative for organisms,
white blood cell count was 210 (with 7 polys) and consistent
with spontaneous bacterial peritonitis. Serum-ascites
albumin gradient was greater than 1.1; indicating portal
hypertension. [**Last Name (un) 26460**] discriminant factor was less than 32;
so treatment was not started for possible alcoholic hepatitis
given AST of 159 and ALT of 19; which is greater than a 2:1
ratio. Amylase and lipase were within normal limits.
A transjugular liver biopsy with Hepatology consultation was
done in the Intensive Care Unit on [**2100-7-15**] which found
changes consistent with toxic metabolic injury plus fibrosis
of the portal and sinusoidal portions. Stenosis was also
noted in the inferior vena cava close to this junction with
the hepatic vein. The pathology was felt to be sufficient to
explain the ascites. Therefore, a stent procedure was
considered but ultimately deferred at this time.
Upon discussion with Hepatology consultation, medical
management through aggressive diuresis was constituted. A
regimen of Lasix 80 mg, spironolactone 200 mg by mouth once
per day, and pentoxifylline 400 mg three times per day
resulted in fluid loss and decreased body weight. The
patient also denied any new onset of shortness of breath.
2. LEUKOCYTOSIS ISSUES: On admission, white blood cell
count was 25.3 was noted. The differential possibilities
included possible cholangitis; alkaline phosphatase was 998
and GGT was 1003. Prophylaxis was started with
metronidazole, levofloxacin, and ampicillin.
Possibility number two was possible spontaneous bacterial
peritonitis. All paracentesis done on [**2014-7-14**], and 20
were negative for spontaneous bacterial peritonitis with a
white count of 210, 173, and 46; respectively. Ascites
protein was 3.1; making spontaneous bacterial peritonitis
unlikely. However, concern over a possible gastrointestinal
bleed made prophylaxis against spontaneous bacterial
peritonitis with levofloxacin 500 mg a necessity. This was
discontinued on [**2100-7-20**].
Possibility number three; urine cultures. Peritoneal
cultures and blood cultures were all negative; ruling out
likely bacteremia.
Possibility number four; pneumonia. A chest x-ray was
negative. No signs on review of systems or examination.
3. ALCOHOL ABUSE WITHDRAWAL CONSIDERATION ISSUES: The
patient showed no signs of delirium tremens. Lorazepam given
q.6h. as needed to alleviate anxiety possibly related to
alcohol withdrawal.
The patient's stay was complicated by a possible
gastrointestinal bleed/fall in hematocrit. On [**2100-7-15**]
the patient had a hematocrit drop of 25.5 to 14.1 and was
transferred to the Intensive Care Unit for workup of possible
variceal bleed. Esophagogastroduodenoscopy and colonoscopy
performed in the Intensive Care Unit were negative for
gastrointestinal bleed, and no source of bleeding was
identified. 4500 cc of clear straw-colored fluid was removed
by paracentesis.
The patient received a transfusion of 4 units of packed red
blood cells, one unit of fresh frozen plasma, and 10 mg of
vitamin K. The patient returned to the floor on [**2100-7-18**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up in both the Liver Clinic with Dr. [**Last Name (STitle) 497**] as well as with
new primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in the resident clinic.
MEDICATIONS ON DISCHARGE:
1. Folic acid 1 mg by mouth once per day.
2. Thiamine 100 mg by mouth once per day.
3. Pantoprazole 40 mg by mouth q.12h.
4. Pentoxifylline 400 mg by mouth three times per day.
5. Furosemide 80 mg by mouth once per day.
6. Spironolactone 200 mg by mouth once per day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 21646**]
MEDQUIST36
D: [**2100-7-24**] 11:25
T: [**2100-8-4**] 10:19
JOB#: [**Job Number 26461**]
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83,203
| 149,759
|
42333
|
Discharge summary
|
report
|
Admission Date: [**2163-9-29**] Discharge Date: [**2163-10-8**]
Date of Birth: [**2089-4-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
ARF
Major Surgical or Invasive Procedure:
placement of HD line
History of Present Illness:
Mr. [**Known lastname 91706**] is being transferred to the [**Hospital1 18**] MICU after a
prolonged stay at the [**Hospital 8**] Hospital ICU where he was
managed by Surgery. He was initially admitted there [**2163-9-11**] with
gallstone pancreatitis. His first week of his hospitalization,
he required multiple pressors, but did not have any surgical
intervention. He was treated with Unasyn. By the second week of
his admission, he was able to be weaned off pressors, but
remained intubated. He was agressively diuresed, put per report
is still up 20 lbs from his dry weight. He was also found to be
+ for C diff, and started on po Vanc. He is also on a course of
IV Vanc for concern for right foot cellulitis. He developed
progressive renal failure to Cr 3.8 with minimal UOP. He is also
developing a metabolic acidosis. He continues to have fever of
an unclear etiology. Of note, his R IJ has been changed over a
wire, but not replaced. Arrangements were made to transfer the
patient to [**Hospital1 18**] for further management of acute severe
pancreatitis and renal failure. Prior to transfer the patient
underwent tracheotomy tube placement.
.
Upon transfer to the [**Hospital1 18**] MICU, pt is sedated, unable to follow
commands.
Past Medical History:
HTN
L collar bone repair
Social History:
per OSH notes
- Tobacco: Prior 1ppd, quit 2 years ago
- Alcohol: denies
Family History:
unable to obtain
Physical Exam:
Admission Exam:
General: tracheostomy in place, exhaling through mouth. Sedated,
minimally arousable.
HEENT: Limited exam given inflation of eyelids but sclera
anicteric, PERRL. Somewhat dry MM, limited exam of oropharynx
Neck: difficult to evaluated JVP given trach and body habitus
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Distant heart sounds; regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: bowel sounds present; distended, somehwat firm
GU: foley draining clear urine
Ext: warm, pedal edema; no clubbing or cyanosis.
.
Pertinent Results:
Admission Labs:
[**2163-9-29**] 10:17PM BLOOD WBC-15.3* RBC-3.19* Hgb-9.2* Hct-28.5*
MCV-89 MCH-29.0 MCHC-32.4 RDW-15.6* Plt Ct-396
[**2163-10-2**] 04:34AM BLOOD Neuts-88.3* Lymphs-9.0* Monos-1.8*
Eos-0.6 Baso-0.4
[**2163-9-29**] 10:17PM BLOOD PT-15.4* PTT-25.1 INR(PT)-1.3*
[**2163-9-29**] 10:17PM BLOOD Glucose-141* UreaN-109* Creat-3.8*
Na-146* K-4.8 Cl-115* HCO3-15* AnGap-21*
[**2163-9-29**] 10:17PM BLOOD Calcium-8.3* Phos-9.1* Mg-2.3
[**2163-9-29**] 10:33PM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-35 pH-7.29*
calTCO2-18* Base XS--8
[**2163-9-29**] 10:33PM BLOOD Lactate-2.1*
[**2163-9-29**] 10:33PM BLOOD freeCa-1.14
.
Micro:
[**10-4**] cdiff inconclusive
[**10-3**] fungal blood culture pending
[**10-2**] catheter IV tip
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
[**2163-10-2**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2163-10-2**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2163-9-30**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL INPATIENT
[**2163-9-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2163-9-30**] URINE URINE CULTURE-FINAL INPATIENT
[**2163-9-30**] CATHETER TIP-IV WOUND CULTURE-FINAL
[**2163-9-30**] 12:15 am FOREIGN BODY Source: foley catheter tip.
INAPPROPRIATE FOR CULTURE. INTERPRET RESULTS WITH
CAUTION.
**FINAL REPORT [**2163-10-4**]**
WOUND CULTURE (Final [**2163-10-4**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
PSEUDOMONAS AERUGINOSA.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
GRAM POSITIVE COCCUS(COCCI).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
[**2163-9-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
KUB [**2163-9-29**]
Mildly dilated transverse colon with a nonspecific bowel gas
pattern. Overall, findings are suggestive of focal ileus in the
setting of
pancreatitis. This could be further evaluated with abdominal CT
if clinically indicated.
.
CXR [**2163-9-29**]
Extensive subcutaneous emphysema in the neck, supraclavicular
regions and
small pneumomediastinum is better seen in subsequent CT of the
chest as well as collapse of the left lower lobe and almost
complete collapse of the right lower lobe. There are small right
and moderate left pleural effusions. Cardiac size is normal.
There are low lung volumes. The NG tube is out of view below the
diaphragm. Left IJ catheter tip is in the left brachiocephalic
vein. Tracheostomy tube is in standard position.
.
CT Neck/Chest [**2163-9-29**]
1. Extensive subcutaneous emphysema extending throughout the
cervical soft
tissues, superiorly to the face and inferiorly through the
pectoralis and
paraspinal musculature. Small amount of pneumomediastinum. Aside
from the
entry site of the tracheostomy, no obvious source for air leak
is identified.
2. Probably tracheobronchomalacia.
3. Limited views of the abdomen demonstrate ascites, anasarca,
mesenteric fat stranding as well as right renal and adrenal
lesions. Further evaluation with dedicated abdominal imaging is
recommended.
.
Renal US [**2163-9-30**]
1. No hydronephrosis seen in the right kidney. The left kidney
could not be visualized. Note is made that this is an extremely
limited ultrasound due to the patient's body habitus and the
patient's inability to position for the examination.
2. Trace of ascites. The marked peripancreatic stranding that
was seen on
prior CT was not evaluated with ultrasound.
.
CT AP [**2163-10-1**]
1. Within the limitations of non contrast administration, no
discrete
loculated drainable fluid collections are identified. Extensive
stranding and fluid demonstrated in the region of the pancreas
compatible with known
clinical diagnosis of severe pancreatitis. Heterogeneity in the
region of the pancreatic neck can either represent
interdigitating fluid or necrosis.
2. Moderate amount of simple intra-abdominal ascites.
3. Small right and moderate left pleural effusion. Bibasilar
right greater
than left atelectasis.
4. Multiple scattered renal lesions, some of which represent
hyderdense
cysts, though some demonstrate increased complexity such as a
3.3 x 2.4 cm
exophytic lesion in the lower pole of the left kidney. This may
represent a solid renal mass or a lesion with sequella from
chronic hemorrhage.
If prior imaging is not available elsewhere to demonstrate long
term
stability, characterization with contrast enhanced CT scan is
recommended when clinically feasible. Alternatively, ultrasound
may be considered, though this may be technically challenging
given patient body habitus.
5. Incidentally noted 6.0 x 4.1 cm right adrenal myelolipoma.
.
b/l LENIs [**2163-10-2**]
FINDINGS: Images of the right common femoral vein are obscured
by an
indwelling venous catheter. The more distal right common femoral
vein is
compressible on color Doppler. The right superficial femoral,
right popliteal
and right calf veins also demonstrate compressibility, however
grayscale
images are nondiagnostic. The left superficial femoral vein
compresses, along
with the left popliteal and left calf veins. Again, [**Doctor Last Name 352**]-scale
images are of
nondiagnostic quality.
IMPRESSION: Technically limited study due to patient body
habitus and
extensive lower limb edema. On the images obtained there is no
evidence of
thrombus in lower extremity.
.
[**2163-10-1**] CT abd
INDICATION: 74-year-old male with pancreatitis and persistent
fevers.
Evaluate for focal fluid collections.
EXAMINATION: CT of the abdomen and pelvis without intravenous
contrast.
COMPARISONS: Renal ultrasound from [**2163-9-30**] and CT of the chest
from
[**2163-9-30**].
TECHNIQUE: Helically acquired axial images were obtained from
the lung bases
to the pubic symphysis after the administration of oral contrast
only.
Intravenous contrast was deferred secondary to impaired renal
function.
Coronal and sagittal reformations are provided for review.
FINDINGS:
CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY:
There is a small left and moderate right pleural effusion. There
is
associated bibasilar atelectasis with increasing right lower
lobe atelectasis
since [**2163-9-30**]. The visualized portion of the tracheobronchial
tree is
patent.
There is a moderate amount of simple fluid attenuation
intra-abdominal
ascites. The liver and spleen are unremarkable.
There is a 6.0 x 4.1 cm well-marginated oval mass centered
within the right
adrenal gland that demonstrates both punctate calcifications and
macroscopic
fat compatible with an adrenal myelolipoma. The left adrenal
gland is
unremarkable. There are multiple scattered hypodensities and
hyperdensities
seen throughout both kidneys, likely representing a combination
of simple and
hyperdense cysts. However, exophytically arising from the lower
pole of the
left kidney, there is a 3.3 x 2.4 cm lesion that measures higher
attenuation
than simple fluid and demonstrates several punctate
calcifications.
In the region of the pancreas, there is extensive stranding and
fluid
compatible with clinically known diagnosis of pancreatitis.
Portions of the
pancreas demonstrate some heterogenity in the neck which either
may represent
interdigitated fluid or necrosis. There are no discrete
loculated drainable
fluid collections identified.
The visualized portions of intra-abdominal small and large bowel
are
unremarkable. An enteric tube is demonstrated with tip
terminating within the
stomach. There is no evidence of obstruction. There is no
intra-abdominal
free air. There is no mesenteric or retroperitoneal
lymphadenopathy.
CT OF THE PELVIS WITH ORAL CONTRAST ONLY: A rectal catheter is
demonstrated
in place. The rectum and sigmoid colon are collapsed. The
bladder is
collapsed around a Foley catheter with air in the nondependent
portion. There
is no pelvic free fluid. There is no pelvic or inguinal
lymphadenopathy.
There is extensive atherosclerotic calcification demonstrated
within the
abdominal aorta and its major branches.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions.
There is anterior osteophytic formation, spanning greater than
four vertebral
bodies compatible with DISH.
IMPRESSION:
1. Within the limitations of non contrast administration, no
discrete
loculated drainable fluid collections are identified. Extensive
stranding and
fluid demonstrated in the region of the pancreas compatible with
known
clinical diagnosis of severe pancreatitis. Heterogeneity in the
region of the
pancreatic neck can either represent interdigitating fluid or
necrosis.
2. Moderate amount of simple intra-abdominal ascites.
3. Small right and moderate left pleural effusion. Bibasilar
right greater
than left atelectasis.
4. Multiple scattered renal lesions, some of which represent
hyderdense
cysts, though some demonstrate increased complexity such as a
3.3 x 2.4 cm
exophytic lesion in the lower pole of the left kidney. This may
represent a
solid renal mass or a lesion with sequella from chronic
hemorrhage.
If prior imaging is not available elsewhere to demonstrate long
term
stability, characterization with contrast enhanced CT scan is
recommended when
clinically feasible. Alternatively, ultrasound may be
considered, though this
may be technically challenging given patient body habitus.
5. Incidentally noted 6.0 x 4.1 cm right adrenal myelolipoma.
The study and the report were reviewed by the staff radiologist.
.
CT chest, abd [**2163-10-3**]
FINDINGS:
CHEST: Moderate left and small right pleural effusions are
similar in size to
[**10-1**]. Moderate left and small right dependent atelectasis
is also
stable. No new consolidations are detected in either lung. An
apparent 6mm
subpleural nodule in the left lower lobe (2:24) could represent
atelectasis
but should be followed on subsequent imaging. The heart and
great vessels are
of normal caliber and appearance. Diffuse coronary artery
calcifications are
present. A central venous catheter terminates in the low SVC.
Endotracheal
tube terminates in appropriate position. No mediastinal, hilar
or axillary
adenopathy is present.
ABDOMEN: Moderate ascites is again seen throughout the abdomen.
Extensive
peripancreatic stranding is visualized consistent with
pancreatitis, with
extension along the anterior pararenal fascia bilaterally, more
markedly on
the left. The pancreatic head enhances normally, but only
minimal enhancing
pancreatic tissue is seen in the body and tail, consistent with
pancreatic
necrosis. No discrete rim-enhancing fluid collection is
identified although
a loculated collection of fluid about the greater curvature of
the stomach is
consistent with a developing pseudocyst. The liver enhances
homogeneously
without focal lesions. No intra- or extra-hepatic biliary
dilatation is
present. The gallbladder is not distended. The spleen is normal.
The left
adrenal gland is normal. A 6 x 4 cm marginated oval mass
centered within the
right adrenal gland again demonstrates punctate calcifications
and macroscopic
fat compatible with an adrenal myelolipoma. Scattered
hypodensities and
hyperdensities are seen within both kidneys likely representing
a combination
of simple and hyperdense cyst. An exophytic lesion arising from
the lower
pole of the left kidney measures 3 x 2.4 cm, measures higher
attenuation than
simple fluid and demonstrates several punctate calcifications.
No mesenteric
or retroperitoneal adenopathy is present. The stomach and small
bowel are
relatively decompressed. Small bowel wall thickening is
secondary to ascites.
PELVIS: The remainder of the bowel is decompressed. A rectal
tube has been
inserted. The bladder is collapsed around a Foley catheter.
Ascites
continues into the pelvis and diffuse anasarca seen within the
subcutaneous
tissues.
BONE WINDOWS: There are no concerning lytic or sclerotic
lesions. Confluent
anterior syndesmophytes in the thoracic spine are consistent
with DISH.
IMPRESSION:
1. Findings consistent with necrotizing pancreatitis, with
continued
extensive peripancreatic inflammatory change. A stable loculated
fluid
collection about gastric greater curvature is suggestive of
developing
pseudocyst though does not appear organized at the present time.
2. Stable small right and moderate left pleural effusions and
bibasilar
atelectasis. Moderate ascites is unchanged.
3. Complex exophytic left lower pole renal lesion which should
be evaluated
with MRI when patient is clinically stable.
4. Incidentally noted right adrenal myelolipoma which can be
evaluated at
time of follow up MRI or within 6 months.
5. Small left lower lobe subpleural nodule which should be
evaluated on
follow-up imaging.
CHEST ON [**10-8**]
HISTORY: Intubation.
Compared to the film from the prior day there is no significant
interval
change.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SAT [**2163-10-8**] 11:09 AM
Final Report
CT ABDOMEN AND PELVIS WITHOUT CONTRAST
DATE: [**2163-10-6**].
Comparison made to CT [**2163-10-3**], [**2163-10-1**] and renal
ultrasound
[**2163-9-30**].
CLINICAL HISTORY: 74-year-old man with necrotizing pancreatitis,
C. diff
infection, weaned off sedation, poor mental status, like to
evaluate for toxic
megacolon versus pancreatic pseudocyst.
TECHNIQUE: MDCT axial images of the abdomen and pelvis were
obtained without
the use of intravenous contrast. Oral contrast was administered.
Sagittal
and coronal reformatted images were constructed.
FINDINGS:
ABDOMEN: There has been minimal interval improvement in basilar
consolidations. The left pleural effusion measuring simple fluid
is
approximately stable in size. There is a small amount of pleural
fluid on the
right. A subpleural nodular opacity at the left base measuring
approximately
5 mm is unchanged (2:4). There is also a 5 mm nodular opacity at
the right
base (2:3). This is adjacent to a linear strand of atelectasis.
Extensive
coronary artery calcifications are noted. There is no
pericardial effusion.
The lack of intravenous contrast limits evaluation of the solid
parenchymal
organs. There is no evidence of toxic megacolon. Bowel loops are
nondilated.
A non-distended portion of transverse colon demonstrates bowel
wall
thickening. A gastric tube terminates in the distal body of the
stomach.
There is low attenuation of a portion of the head, the entire
neck and body
and a portion of the tail of the pancreas. Low-density
corresponds to areas
of necrosis demonstrated on prior contrast-enhanced examination.
There is
significant surrounding peripancreatic fat stranding extending
along the
anterior pararenal fascia, again greater on the left. There is
also a
moderate degree of ascites in the abdomen and pelvis which
measures simple
fluid. Again visualized is a stable-appearing loculated
collection of fluid
around the greater curvature of the stomach likely representing
a developing
pseudocyst. This measures approximately 10.9 x 4.4 x 6.6 cm in
AP, transverse
and craniocaudal dimensions respectively. There are no new
obvious areas of
loculated fluid collection.
The liver, spleen, left adrenal gland and gallbladder have a
grossly normal
unenhanced appearance. The kidneys demonstrate multiple lesions
bilaterally
some of which represent simple cysts and some complicated cysts
(hemorrhage or
containing proteinaceous material). However, there is an
exophytic lesion
arising from the lower pole of the left kidney measuring 2.6 x
3.4 cm. This
contains internal calcifications and measures 40 Hounsfield
units. Anterior
to this is a low-density exophytic lesion measuring 1.8 x 1.8 cm
with
calcification in the rim of the lesion. This measures near
simple fluid in
Hounsfield units. Again demonstrated is the 5.6 x 3.8 cm right
adrenal gland
lesion with areas of fat.
There is no abdominal lymphadenopathy. Extensive atherosclerotic
calcifications are present within the normal caliber aorta.
PELVIS:
A moderate amount of ascites is present in the pelvis. The
bladder is
decompressed with Foley catheter and contains air, likely from
instrumentation. A rectal tube is in place. A right common
femoral venous
catheter and left common femoral arterial catheter are present.
There is
extensive anasarca in the subcutaneous tissues.
OSSEOUS STRUCTURES: Degenerative changes are present in the
thoracic spine
and facet arthropathy is noted in the lower lumbar spine. There
are no
destructive osseous lesions.
IMPRESSION:
1. Findings consistent with necrotizing pancreatitis with
stable-appearing
extensive peripancreatic inflammatory change. A stable loculated
fluid
collection adjacent to the greater curvature of the stomach is
suggestive of
developing pseudocyst.
2. Stable left greater than right pleural effusions and
bibasilar
consolidation and/or atelectasis.
3. Moderate ascites.
4. Complex exophytic left lower pole renal lesion and adjacent
cystic lesion
with calcification in the rim. These should be evaluated with
MRI when
patient is clinically stable as the left kidney is poorly
visualized by
ultrasound.
5. Incidentally noted probable right adrenal myelolipoma may
also be assessed
at time of MRI.
6. 5 mm lower lobe nodular opacities may relate to inflammatory
changes and
should be followed on subsequent imaging.
The study and the report were reviewed by the staff radiologist.
Final Report
INDICATION: 74-year-old man with necrotizing pancreatitis, poor
mental status
after weaning sedation.
TECHNIQUE: Contiguous axial MDCT data were acquired through the
head without
intravenous contrast.
FINDINGS: No hemorrhage, large territorial infarction, edema,
mass, or shift
of normally midline structures is appreciated. The [**Doctor Last Name 352**]-white
differentiation
is preserved. Mild periventricular hypodensities are consistent
with small
vessel ischemic changes. Mucosal thickening is seen in the
bilateral sphenoid
sinuses. The mastoid air cells are partially pneumatized and are
mostly fluid
filled.
IMPRESSION: No acute intracranial process. Findings were
discussed with Dr.
[**Last Name (STitle) **] via phone at 7:45 p.m. on [**2163-10-6**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: FRI [**2163-10-7**] 10:38 AM
Brief Hospital Course:
74yo M admitted to [**Hospital 8**] Hospital with necrotizing
pancreatitis. His course there was complicated by C diff and
worsening renal failure.
.
# Pancreatitis:Acute necrotizing pancreatitis. The patient
continued to have fever and abdominal distension upon transfer,
although bladder pressures remained <30 cmH2O. CT abdomen at
[**Hospital1 18**] showed severe pancreatic necrosis, extensive stranding and
fluid around the pancreas but no discrete drainable fluid
collections. GI, General Surgery, Renal and ID consultation
teams assisted in management. The hospital course was
characterized by overall progressive clinical decline, with
escalating mechanical ventilator requirement, hypoxemia,
escalating vasopressor needs, progressive acidosis despite
continue renal dialysis, rising lactic acidosis and rising WBC.
Following daily updates with available family members, with
continued overall clinical decline and lack of progress despite
maximal medical MICU supportive measures, decision to move to
focus on patient comfort. Upon discontinuation of vasopressors
and dialysis, the patient quietly and peacefully passed away on
[**2163-10-8**] at 4pm. The family (sister [**Doctor First Name 17236**] was notified and
post mortem examation was declined.
.
# Fevers: Persistnet fevers attributed predominately to
underlying acute pancreatitis, although several infectious
sources also identified. Foley catheter tip with debris stuck
in tip, GPCs and GNRs on gram stain. Also, CVL from OSH appeared
erythematous at the entry site, although culture of that tip was
negative. Pt has been treated for C diff (C Diff + on [**2163-9-18**]).
Cultures are NGTD. Pt not tolerating being off wall suction, so
continuing IV Flagyl, bladder pressures remained elevated (26
this AM). Con't IV vanc given concern for catheter tip infection
and small area of right foot concerning for cellulitis. Added
cefepime to cover for gut and urinary sources, particularly
given persisant fat stranding on CT. IV Flagyl will cover gut
anaerobes. Patient was started on oral vanc on [**10-5**] once
residuals in gut had decreased given concern for untreated cdiff
with rising leukocytosis. He was also started on Ticacyline and
PR Vancomcyin when not taking orally because of significant
ileus.
.
# Resp failure: ARDS not clearly documented from OSH. Pt now
has gross volume overload likely compromising respiratory
status. Restrictive physiology of abdominal distention is likely
contributing. Pt may also benefit from diuresis to improve his
mechanics. Pt was started on CVVH for fluid removal.
.
# Anemia: Possible sites of acute drop, either bleed in the
belly or retroperitoneum vs. hemolysis. No RP bleed on CT,
negative hemolysis workup.
.
# ARF: Worsening throughout his stay at [**Hospital 8**] Hospital.
Worsening metabolic acidosis and volume overload; transferred
here to initaite CVVH. Concern for a component of obstruction
given debris in foley catheter tip, but no hydronephrosis on US
and no improvement in Cr after foley changed. HD line placed and
CVVH initiaed [**2163-10-2**] through [**2163-10-8**].
.
# Trach with air leak: Per report, was a difficult dissection
given neck habitus. Rigid bronch scope with switched trach
(fenestrated replaced) on [**2163-9-30**] by IP. SubQ air improved.
.
# Hyperglycemia: Pt had been on insulin gtt at OSH, but covered
with sliding scale here (glc in the 100s-200s).
.
# Kidney masses: Incidentally noted 3.3 x 2.4 cm exophytically
arising lesion from the lower pole of the left kidney and 6.0 x
4.1 cm adrenal myelolipoma on the right seen on abd CT. these
had also been noted on OSh imaging.
Medications on Admission:
Upon transfer
Vanc po 125mg q6 (started [**2163-9-24**]; d/ced evening of [**2163-9-28**])
vanc po 500mg po q6 hours (started [**2163-9-28**])
pantoprazole 40mg IV BID
Heparin SQ 5000 units TID
artificial tears
chlorhexidine
Fent gtt 0.5 mcg/kg/hr
Nystatin 600,000 per OGT q8 hours
albuterol/ipratroprium 8 puffs q6 hours
free H20 240cc q4 hours
lactobacillus 1 tab [**Hospital1 **]
Prostat (nutrition) 1 tube per OGT [**Hospital1 **]
Vanc 1500mg q36 hours (started [**2163-9-24**])
Miracle Cream topical [**Hospital1 **]
Phos-Lo 1334mg TID
Insulin gtt
haldol 5mg q6 hours PRN
albuterol 8 puffs q1 hour PRN
Zofran PRN
Tylenol 650mg q6 (last dose [**2163-9-29**] AM)
has gotten 3 doses of albumin (75g total)
Lasix between blood transfusions
.
Home meds:
atenolol
ASA 81
Discharge Disposition:
Expired
Discharge Diagnosis:
pancreatitis
clostridium difficile
acute renal insufficiency
septic shock
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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"707.20",
"512.1",
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"V66.7",
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"790.01",
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icd9cm
|
[
[
[]
]
] |
[
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"97.23",
"38.91",
"96.56",
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icd9pcs
|
[
[
[]
]
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26025, 26034
|
21558, 25204
|
308, 330
|
26151, 26161
|
2391, 2391
|
26213, 26345
|
1755, 1773
|
26055, 26130
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25230, 26002
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26185, 26190
|
1788, 2372
|
264, 270
|
358, 1602
|
2407, 21535
|
1624, 1650
|
1666, 1739
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,125
| 144,677
|
5965+55712+55716
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2191-11-29**] Discharge Date: [**2191-12-5**]
Date of Birth: [**2109-12-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine Containing Agents Classifier / Tetanus
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Coronary artery disease and mitral regurgitation.
Major Surgical or Invasive Procedure:
[**11-30**]: Coronary Artery Bypass Grafting x4 with Left internal
mammary
artery to left anterior descending artery and saphenous vein
grafts to obtuse marginal, ramus and the posterior descending
arteries.
Endoscopic harvesting of the long saphenous vein.
Mitral valve repair with a size 30 [**Company 1543**] Profile 3-D ring.
History of Present Illness:
This 81 year old white male with known coronary artery disease
is 10 days
out from a myocardial infarction with demand ischema increasing
in frequency. He ruled in for infarct this admission with peak
troponin 1.5. Catheterization the day of admission at [**Hospital1 **]
revealed triple vessel disease and mitral regurgitation. He was
transferred for surgery.
Past Medical History:
hypertension
Atrial flutter
Coronary Artery Disease
s/p Myocardial Infarction
Prostate CA (s/p radiation seeding-now on hormone tx)w/urinary
retention-hematuria
Congestive Heart Failure
noninsulin dependent Diabetes Mellitus
hyperlipidemia
breast CA(left)
colon CA s/p Colectomy
Social History:
Race: caucasian
Last Dental Exam: many years ago
Lives with: family
Occupation: retired
Tobacco: Quit 5 cigarettes/day x 50-60 yrs(10 pack years)chews
cigars 5/day
ETOH:socially [**3-8**] drinks/week
Family History:
Family History:+CAD, father died MI(67yo) Mother died MI(83yo)
Physical Exam:
Admission:
Pulse: 86 Resp: 20 O2 sat: 98% RA
B/P Right: 157/80 Left:
Height: 6'0" Weight: 82.7K
General: Alert, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur none
Abdomen:Soft[x] non-distended[x] non-tender[x] bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: - Left: -
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2191-12-2**] 05:40AM BLOOD WBC-9.9 RBC-3.06* Hgb-9.8* Hct-27.7*
MCV-91 MCH-31.9 MCHC-35.3* RDW-14.4 Plt Ct-178
[**2191-12-1**] 03:31AM BLOOD WBC-12.0*# RBC-3.66*# Hgb-11.7*#
Hct-33.1* MCV-91 MCH-32.1* MCHC-35.5* RDW-14.7 Plt Ct-238
[**2191-12-3**] 06:50AM BLOOD UreaN-16 Creat-1.0 K-3.7
[**2191-12-2**] 05:40AM BLOOD Glucose-136* UreaN-22* Creat-1.4* Na-135
K-4.6 Cl-102 HCO3-26 AnGap-12
[**2191-12-1**] 03:31AM BLOOD Glucose-72 UreaN-16 Creat-1.0 Na-136
K-4.5 Cl-107 HCO3-23 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**11-29**] after cardiac catheterization
performed at [**Hospital1 **] MC. He had received Plavix before and at
catheterization. At the time of transfer he was pain free on
both Heparin and nitroglycerin infusions. He was evaluated for
surgical candidacy. During this workup he experienced ongoing
chest pain and was brought emergently to the operating room on
[**11-30**]. Please see OR report for details. In summary he had
coronary artery bypass grafting and mitral valve replacement
with Left internal mammary artery to left anterior descending
artery and saphenous vein grafts to obtuse marginal, ramus and
the posterior descending arteries. Endoscopic harvesting of the
long saphenous vein. Mitral valve repair with a size 30
[**Company 1543**] Profile 3-D ring. His bypass time was 124 minutes with
a crossclamp of 112 minutes. He tolerated the operation well and
was transferred from the operating room to the cardiac surgery
ICU in stable condition. He did well in the immediate post-op
period, woke neurologically intact and was extubated.
He remained hemodynamically stable and was transferred to the
stepdown floor on POD1.
All tubes, lines and drains were removed according to cardiac
surgery protocol. Beta blockade was resumed and he was diuresed
towards his preoperative weight. he had some dysrhythmia and an
EPS consult was obtained on [**12-5**].
Physical therapy worked with him for mobiltiy and strengthening.
Over the next several days his activity level was gradually
advanced, his medications were titrated to effect and on
POD****** he was discharged home with visiting nurses.
Additionally, he was seen for dental evaluation prior to
surgery, the recommendation was for extraction, patient refused
to have extractions while in the hospital, despite multiple
discussions about the need to remove infected teeth given his
prosthetic heart ring. He was discharged on Clindamycin,
ongoing.
He developed urinary retention requiring foley insertion on
[**12-4**]. Given his history of retention and cancer, he was sent
home on Flomax (on chronically) and will follow up with his
urologist.
Medications on Admission:
Medications at transfer: ASA 325', Lisinopril 2.5', Lipitor 80',
Ranitidine 50", Lopressor 37.5", NTG gtt, Heparin gtt,
Solu-Medrol 80 TID thru [**11-30**]
Medications at home: Cardiazem 100", Lasix 20', Glipizide 5',
Imdur 30", KCL 20'
Plavix - last dose: [**11-28**] (75mg x2 days)
Allergies: PCN, Tetnus toxoid, IVP dye
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day.
Disp:*120 Capsule(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Grafting x4
Mitral Stenosis
s/p Mitral valve Repair
hypertension
Atrial flutter
s/p Myocardial Infarction
Prostate CA (s/p radiation seeding-now on hormone tx)w/urinary
retention-hematuria
Congestive Heart Failure
Noninsulin dependent Diabetes Mellitus
hyperlipidemia
breast CA(left),
s/p Colectomy for cancer
Discharge Condition:
stable
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
[**Hospital Ward Name 121**] 6 [**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) **] in 3 weeks ([**Telephone/Fax (1) 6256**]at
[**Hospital6 **]
Dr [**First Name4 (NamePattern1) 3441**] [**Last Name (NamePattern1) 14334**] at Mtro West ([**Telephone/Fax (1) 6256**]) in 3 weeks with Dr.
[**Last Name (STitle) **]
Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5292**] ([**Telephone/Fax (1) 5294**]) in [**3-8**] weeks
please call for all appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2191-12-5**] Name: [**Known lastname 3992**],[**Known firstname 33**] N Unit No: [**Numeric Identifier 3993**]
Admission Date: [**2191-11-29**] Discharge Date: [**2191-12-5**]
Date of Birth: [**2109-12-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine Containing Agents Classifier / Tetanus
Attending:[**First Name3 (LF) 265**]
Addendum:
lasix 40mg daily for 7 days and KCL 20Meq daily for 7 days
addede to discharge medications
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 437**] VNA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2191-12-5**] Name: [**Known lastname 3992**],[**Known firstname 33**] N Unit No: [**Numeric Identifier 3993**]
Admission Date: [**2191-11-29**] Discharge Date: [**2191-12-5**]
Date of Birth: [**2109-12-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine Containing Agents Classifier / Tetanus
Attending:[**First Name3 (LF) 265**]
Addendum:
Given atrial flutter, EP would like patient on Coumadin. After
lengthy discussion with patient and daughter, discussing
indications, risks, benefits and need for lab testing and
careful follow up, he agrees to take Coumadin.
I spoke with Dr. [**Last Name (STitle) 4010**], his local PCP, [**Name10 (NameIs) 3308**] agrees to regulate
the dosing while patient is at daughter's and before he returns
to NH. Mr. [**Known lastname **] was given 2.5 mg tablets to take 5mg daily
11/2-4, then have a PT/INR first thing in the morning on
[**12-8**], after which time Dr. [**Last Name (STitle) 4010**] will direct him
further.
Chief Complaint:
see notes
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day.
Disp:*120 Capsule(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: Take daily in evening as directed. Take 2 tablets
(5mg)11/2/3/4.Hva eblood work [**12-8**] at 0800 by Dr. [**Last Name (STitle) 4010**] then as
he directs.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 437**] VNA
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Grafting x4
Mitral Stenosis
s/p Mitral valve Repair
hypertension
Atrial flutter
s/p Myocardial Infarction
Prostate CA (s/p radiation seeding-now on hormone tx)w/urinary
retention-hematuria
Congestive Heart Failure
Noninsulin dependent Diabetes Mellitus
hyperlipidemia
breast CA(left),
s/p Colectomy for cancer
Discharge Condition:
stable
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
[**Hospital 4011**] clinic in 2 weeks
Dr [**Last Name (STitle) 4012**] in 4 weeks [**Telephone/Fax (1) 2092**]
Dr [**First Name4 (NamePattern1) 4013**] [**Last Name (NamePattern1) 4014**] (cardiologist) in [**3-8**] weeks
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 4015**] in [**3-8**] weeks
please call for all appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2191-12-5**]
|
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
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icd9pcs
|
[
[
[]
]
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11340, 11398
|
2906, 5070
|
376, 712
|
11803, 11812
|
2394, 2883
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12216, 12697
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1656, 1706
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9920, 11317
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11419, 11782
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5096, 5252
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11836, 12193
|
5273, 5422
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1721, 2375
|
9886, 9897
|
740, 1104
|
1126, 1407
|
1423, 1625
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,100
| 193,165
|
26949
|
Discharge summary
|
report
|
Admission Date: [**2131-3-12**] Discharge Date: [**2131-3-27**]
Date of Birth: [**2084-4-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 46 year old female who reportedly fell last night
after having "a lot" to drink, as per an OSH. She does not
recall falling and she was unable to recall the incident. She
was admitted to an OSH on the morning after her fall where her
ETOH was 340 at 10:40am. X-rays of her c-spine and chest were
unremarkable. A CT of her head demonstrated a SDH, so she was
transferred to [**Hospital1 18**] for a higher level of care.
Past Medical History:
PMHx: Depression
All: NKDA
Social History:
Reportedly drinks "a lot" nightly, unable to quantify
how much
Family History:
noncontributory
Physical Exam:
O: T: BP: 150/100 HR: 150 R 22 O2Sats 100 (3L NC)
Gen: WD/WN, comfortable, NAD, somnolent (but was agitated when
she first arrived [**Name8 (MD) **] RN), smells of EtOH.
HEENT: Pupils: PERRL, Head: 5cm laceration right occipital
region, not bleeding at this time, but it is open and rather
deep
Neck: Supple.
Lungs: Decreased BS, CTA bilaterally.
Cardiac: Tachycardic. S1/S2.
Abd: Soft, BS+, c/o diffuse tenderness but very nonspecific, no
rebound or guarding
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Somnolent but arousable, cooperative with exam,
overall difficult to assess, pt likely still intoxicated and had
1mg Ativan to settle her down.
Orientation: Oriented to person but not to place and date.
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with poor comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields not assessed.
III, IV, VI: Extraocular movements impossible to assess at this
time
V, VII: Facial strength and sensation not able to assess
VIII: Hearing intact to finger rub bilaterally.
IX, X: inable to assess
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue not able to assess.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength 3/5 throughout, able to move all 4 but unable
to assess strength, unable to assess pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Coordination: unable to assess
Pertinent Results:
Labs on Admission
[**2131-3-12**] 02:40PM BLOOD WBC-11.1* RBC-3.79* Hgb-12.3 Hct-34.3*
MCV-91 MCH-32.5* MCHC-35.8* RDW-15.3 Plt Ct-379
[**2131-3-12**] 02:40PM BLOOD Neuts-89.9* Bands-0 Lymphs-6.9* Monos-2.1
Eos-0.9 Baso-0.2
[**2131-3-12**] 02:40PM BLOOD PT-12.8 PTT-19.7* INR(PT)-1.1
[**2131-3-12**] 02:40PM BLOOD Glucose-143* UreaN-9 Creat-0.6 Na-142
K-3.9 Cl-104 HCO3-21* AnGap-21*
[**2131-3-12**] 02:40PM BLOOD ALT-131* AST-145* AlkPhos-254* Amylase-52
TotBili-0.3
[**2131-3-13**] 12:21AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.3*
[**2131-3-12**] 02:40PM BLOOD ASA-NEG Ethanol-235* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-3-12**] 07:48PM BLOOD Lactate-4.9*
[**2131-3-12**] 10:30PM BLOOD Glucose-128* Lactate-2.3*
Brief Hospital Course:
CT head w/o contrast was done which showed moderate left
subdural hematoma , with at most 1-2 mm of rightward shift of
normally midline structures and probable right parietal scalp
laceration. CT C-spine showed no evidence of fracture of the
cervical spine. The patient was admitted to the ICU for close
monitoring. She was evaluated by the trauma service and found
to have no other injuries besides head trauma. Her c-spine was
cleared and collar was removed. She was maintained on CIWA scale
for concerns about alcohol withdrawal. She was able to follow
commands but was not consistently oriented to place and time.
She was transferred to neuro stepdown unit on hospital day 3.
.
The patient was later transferred to medicine for further
medical management. She was maintained on the CIWA. Her mental
status gradually improved. The patient's course was later
complicated by a period of hypotension with SBPs in the 70s, HR
70s. She received aggressive fluid hydration but she was not
able to maintain her pressures. On physical exam the patient
was lethargic and her extremities were warm. The concern was
that the patient was possibly becoming septis. In the setting of
being aggressively hydrated, the patient auto-diuresed liters of
urine.
.
The patient was transferred to unit. She received Dopamine gtt
and received a dose of Vancomycin. The patient was seen by
renal and endocrine. The differential diagnoses included
diabetes insipidus and polyuria in the setting of solute
diuresis. The patient was initially started on pressors
(dopamine). Vasopressin gtt was also started. The patient's
urine osms increased appropriately. This favored the diagnosis
of polyuria secondary to solute diuresis. A repeat head CT was
also done which showed no interval change in the subdural
hematomas.
.
Once the patient's pressures stabilized she was transferred to
the floor. Her BPs remained stable. Her mental status
continued to improve. The patient expressed an interest in
seeking help for her alcoholism. After holding a family meeting
and with the patient in agreement, the decision was made to
discharge the her to an alcoholic rehab facility.
Medications on Admission:
Risperidol, neurontin
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. Subdural hematoma after fall
2. Hypotension, now resolved
.
Secondary Diagnoses
3. Alcoholism
4. Bipolar Disorder
Discharge Condition:
Neurologically stable
Discharge Instructions:
You are discharged to an Extended Care Facility where you will
continue your current medications.
Please contact your physician or present to the ER if you
experience fevers, chills, night sweats, headache, dizziness or
other symptoms.
Please keep your follow-up appointments.
Followup Instructions:
Dr.[**Name (NI) 4674**] office will be contacting you about an
appointment. At that time they will also schedule a Head CT.
Their number is [**Telephone/Fax (1) 1272**].
.
You have an appointment set up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] on Wednesday
[**4-4**] at 10:15am. Phone number [**Telephone/Fax (1) 18325**]
Completed by:[**2131-4-30**]
|
[
"296.80",
"852.20",
"303.00",
"291.81",
"E888.9",
"458.29",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5528, 5577
|
3290, 5456
|
277, 283
|
5738, 5762
|
2539, 3267
|
6089, 6482
|
890, 907
|
5598, 5717
|
5482, 5505
|
5786, 6066
|
922, 1432
|
233, 239
|
311, 743
|
1766, 2520
|
1447, 1750
|
765, 794
|
810, 874
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,433
| 132,473
|
53288+59514
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-12-21**] Discharge Date: [**2178-12-26**]
Date of Birth: [**2109-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic and tricuspid endocarditis
Major Surgical or Invasive Procedure:
[**2178-12-21**] Aortic Valve Replacement([**Street Address(2) 17009**]. [**Male First Name (un) 923**] Epic
Bioprosthetic Valve) and Tricuspid Valve Replacement([**Street Address(2) 12523**].
[**Male First Name (un) 923**] Epic Bioprosthetic)
History of Present Illness:
This 69 year old male was recently diagnosed with aortic and
tricuspid endocarditis with Streptococcus. This has been
treated with 6 weeks of Vancomycin. He is admitted for surgery
at this juncture.
Past Medical History:
Aortic and tricuspid valve endocarditis(Streptococcus)
Psoriatic arthritis
Hyperlipidemia
Hypertension
Hepatitis C
osteomyelitis rifht foot after surgery
s/p Right hip arthroplasty
s/p hemorrhoidectomy
diverticular disease
degenerative joint disease
Social History:
He is not married.
He has no children and lives alone.
No history of tobacco or alcohol.
Denies IVDA.
Family History:
No family history of CAD, MI, cancer. Per patient no family
medical problems.
Physical Exam:
discharge:
VSS, abebrile
Lungs- clear
Cor- RSR. crisp heart sounds
Sternum stable, no drainage
exts- trace edema
neuro- grossly intact
Pertinent Results:
[**2178-12-21**] Intraop TEE:
PRE-CPB:1. The left atrium is normal in size. No thrombus is
seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic root. The ascending
aorta is mildly dilated. There are simple atheroma in the
ascending aorta. There are complex (>4mm) atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. There
is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate to
severe ([**1-19**]+) aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
8. The tricuspid valve leaflets are severely thickened/deformed.
Moderate to severe [3+] tricuspid regurgitation is seen.
9. There is moderate pulmonary artery systolic hypertension.
10. There is no pericardial effusion.
POST-CPB:
On infusion of phenylephrine, sinus rhythm. Well-seated
bioprosthetic valves in the aortic and tricuspid positions. No
AI, trivial trans aortic gradient. Trivial TR at position where
PA catheter is across valve. Minimal TS. Preserved LV and RV
systolic function. LVEF is 60 %. MR remains trace. Aortic
contour is normal post decannulation.
[**2178-12-24**] 05:31AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.2* Hct-25.9*
MCV-83 MCH-29.7 MCHC-35.7* RDW-15.8* Plt Ct-94*
[**2178-12-24**] 05:31AM BLOOD Glucose-99 UreaN-30* Creat-1.7* Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
[**2178-12-24**] 05:31AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.2* Hct-25.9*
MCV-83 MCH-29.7 MCHC-35.7* RDW-15.8* Plt Ct-94*
[**2178-12-24**] 05:31AM BLOOD Glucose-99 UreaN-30* Creat-1.7* Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent aortic and tricuspid valve
replacements with bioprosthetic valves by Dr. [**Last Name (STitle) **]. he weaned
from bypass on low dose neo synephrine and propofol. For
surgical details, see operative note. Following the operation,
he was brought to the CVICU in stable condition. Within 24
hours, he awoke neurologically intact and was extubated without
incident.
He was by the nephrology service for follow up of his acute
renal dysfunction which was felt to be pre renal and medication
related.
The patient was transferred from the ICU on [**2177-12-21**]. His
hematocrit was 21% and the patient received one unit of packed
red blood cells with an appropriate response. His hematocrit
decreased to 22.4% on [**2177-12-22**] and he received two additional
units of packed red blood cells. The hematocrit remained stable
subsequently. The patient was evaluated by the physical therapy
service, and rehab was recommended.
Or tissue cultures were sterile and no further antibiotics were
necessary. He was ambulatory, albeit very limited due to his
deconditioning but stable for transfer to rehabilitation.
Medications on Admission:
Vancomycin - stopped [**2178-11-30**]
Xanax 0.25 mg TID
Lisinopril 5mg/D
Lasix 20mg/D
trazadone 50mg HS prn
Zoloft 200mg/D
Flonase
Discharge Medications:
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed.
. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H
(every 4 hours) as needed for pain.
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
. Influen Tr-Split [**2177**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED) for 1 doses.
Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for psoriasis: to psoriasis.
Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical three
times a day as needed for psoriasis: to psoriasis.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
aortic and tricuspid endocarditis
s/p aortic and tricuspid valve replacements
hypertension
chronic renal insufficiency
hyperlipidemia
Hepatitis C
degenerative joint disease
pulmonary fibrosis
psoriatic arthritis
diverticular disease
s/p right hip arthroplasty
s/p orchiectomy
narcolepsy
s/p hemorrhoiectomy
s/p osteomyelitis right foot(after surgery)
congestive heart failure (in past secondary to valvular disease)
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr.[**Last Name (STitle) **] in [**1-19**] weeks
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26225**] in [**12-18**] weeks ([**Telephone/Fax (1) 72383**])
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] in 3 weeks
Please call for appointments
Completed by:[**2178-12-26**] Name: [**Known lastname 299**],[**Known firstname 4095**] J Unit No: [**Numeric Identifier 17979**]
Admission Date: [**2178-12-21**] Discharge Date: [**2178-12-26**]
Date of Birth: [**2109-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
1. There was anemia of postoperative blood loss for which the
patient was transfused.
2. There was no postoperative renal failure as his baseline
creatinine was >2 and was 1.7 when last checked prior to
discharge.
3. I see no evidence of postoperative atrial flutter. he had
brief atrial fibrillation which did not delay his discharge.
Chief Complaint:
see original summary
Major Surgical or Invasive Procedure:
[**2178-12-21**] Aortic Valve Replacement([**Street Address(2) 13712**]. [**Male First Name (un) 744**] Epic
Bioprosthetic Valve) and Tricuspid Valve Replacement([**Street Address(2) 17980**].
[**Male First Name (un) 744**] Epic Bioprosthetic)
History of Present Illness:
see original summary
Past Medical History:
Aortic and tricuspid valve endocarditis(Streptococcus)
Psoriatic arthritis
Hyperlipidemia
Hypertension
Hepatitis C
osteomyelitis rifht foot after surgery
s/p Right hip arthroplasty
s/p hemorrhoidectomy
diverticular disease
degenerative joint disease
Social History:
He is not married.
He has no children and lives alone.
No history of tobacco or alcohol.
Denies IVDA.
Family History:
No family history of CAD, MI, cancer. Per patient no family
medical problems.
Physical Exam:
see original summary
Brief Hospital Course:
see original summary
Medications on Admission:
see original summary
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
5. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Influen Tr-Split [**2177**] Vac (PF) 45 mcg/0.5 mL Syringe Sig:
One (1) ML Intramuscular ASDIR (AS DIRECTED) for 1 doses.
13. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for psoriasis: to psoriasis.
14. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical three
times a day as needed for psoriasis: to psoriasis.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 42**] Center - [**Location (un) 3178**]
Discharge Diagnosis:
aortic and tricuspid endocarditis
s/p aortic and tricuspid valve replacements
hypertension
chronic renal insufficiency
hyperlipidemia
Hepatitis C
degenerative joint disease
pulmonary fibrosis
psoriatic arthritis
diverticular disease
s/p right hip arthroplasty
s/p orchiectomy
narcolepsy
s/p hemorrhoiectomy
s/p osteomyelitis right foot(after surgery)
congestive heart failure (in past secondary to valvular disease)
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr.[**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1477**])
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17981**] (in [**12-18**] weeks [**Telephone/Fax (1) 17982**])
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] in 3 weeks
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2179-1-15**]
|
[
"585.9",
"403.90",
"272.4",
"696.0",
"285.1",
"515",
"424.2",
"070.54",
"780.57",
"041.09",
"427.31",
"300.4",
"424.1",
"426.13",
"V43.64",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"99.04",
"35.27"
] |
icd9pcs
|
[
[
[]
]
] |
10660, 10743
|
9214, 9236
|
8369, 8615
|
11203, 11210
|
1491, 3562
|
11610, 12067
|
9074, 9154
|
9307, 10637
|
10764, 11182
|
9262, 9284
|
11234, 11587
|
9169, 9191
|
8309, 8331
|
8643, 8665
|
8687, 8938
|
8954, 9058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,009
| 194,618
|
22255
|
Discharge summary
|
report
|
Admission Date: [**2164-12-19**] Discharge Date: [**2164-12-27**]
Date of Birth: [**2119-6-10**] Sex: F
Service: MEDICINE
Allergies:
Meperidine
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
[**Last Name (un) **] Tube Placement
Intubation
TIPS Revision
Cordis Placement
Venogram with Variceal Coiling
History of Present Illness:
45 F w/ pmh of EtOH cirrhosis s/p TIPS x 2 on [**Last Name (un) **] list
and pancreatitis transf from OSH w/ UGIB. Per [**Hospital 17436**] hospital,
patient was admitted [**12-17**] after having 2 pints of coffee ground
emesis. Her Hgb steadily dropped from 9 on admission, 8.4 to 7.8
the next day. This afternoon, had bright red emesis. Underwent
EGD and had Grade III esophageal and gastric varices. Her
octreotide drip was increased to 100/hr for transfer and she
received 2 units of packed RBC. Per physician at [**Name9 (PRE) 17436**], patient
BP ranged from 80-100 during stay, with HR in 85-90. She has
been receiving Rifamixin and Cipro for SBP prophylaxis and has
never been encephalopathic during her hospital stay.
On the floor, patient 103/52 89 14 100 RA.
She denies any pain, aside from chronic pain for her hip. Is
currently not nauseated, febrile or having chills. She has not
had any chest pain, shortness of breath or lightheadedness. Her
stools have been dark and tarry over the last couple of days and
she has felt fatiqued.
Past Medical History:
Osteoarthritis
H/o alcohol abuse
Benzodiazapine abuse
Alcohol-induced cirrhosis ([**2157**]) s/p TIPS
Alcohol-induced pancreatitis
Gastroesophageal reflux disease
Ovarian cysts
Caesarian-section x2
Appendectomy
Tubal ligation
Thrombocytopenia
Social History:
Lives with husband and 16 y/o daughter in [**Name (NI) **] ME. Limited
employment secondary to health. 12 pack-year smoking history,
currently [**12-7**] ppd. ETOH abuse. benzodiazapine abuse.
Family History:
mother 64 died of emphysema
father 67 died of ETOH related dz
Physical Exam:
Vitals: T:98.7 BP:108/53 P: 77 R: 12 O2: 100 RA
General: Alert, oriented, no acute distress, nonjaundiced
HEENT: Sclera slight yellow hue, MMM, oropharynx clear
Neck: supple, JVP 7-8, 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, uncomfortable on palpating RUQ, 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:
Labs on admission and discharge:
.
[**2164-12-19**] 06:44PM BLOOD WBC-3.2* RBC-3.27*# Hgb-10.2*# Hct-27.8*#
MCV-85 MCH-31.3 MCHC-36.7* RDW-14.8 Plt Ct-59*
[**2164-12-27**] 05:40AM BLOOD WBC-10.7# RBC-4.38 Hgb-13.6 Hct-37.4
MCV-85 MCH-31.2 MCHC-36.5* RDW-15.7* Plt Ct-131*#
[**2164-12-27**] 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
.
[**2164-12-19**] 06:44PM BLOOD PT-15.0* PTT-32.2 INR(PT)-1.3*
[**2164-12-27**] 05:40AM BLOOD PT-15.9* PTT-31.2 INR(PT)-1.4*
.
[**2164-12-19**] 06:44PM BLOOD Glucose-98 UreaN-22* Creat-1.2* Na-138
K-6.7* Cl-110* HCO3-24 AnGap-11
[**2164-12-27**] 05:40AM BLOOD Glucose-103 UreaN-16 Creat-1.2* Na-141
K-3.7 Cl-105 HCO3-23 AnGap-17
.
[**2164-12-19**] 06:44PM BLOOD ALT-26 AST-73* LD(LDH)-559* AlkPhos-57
Amylase-100 TotBili-2.3*
[**2164-12-27**] 05:40AM BLOOD ALT-36 AST-73* LD(LDH)-437* AlkPhos-113
TotBili-12.1*
.
[**2164-12-19**] 06:44PM BLOOD Albumin-3.2* Calcium-7.9* Phos-2.8 Mg-1.7
[**2164-12-27**] 05:40AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.2 Mg-1.8
.
[**2164-12-26**] 05:50AM BLOOD PEP-NO SPECIFI IgG-801 IgA-241 IgM-500*
IFE-NO MONOCLO
[**2164-12-20**] 03:21PM BLOOD freeCa-0.99*
[**2164-12-22**] 09:14PM BLOOD freeCa-1.14
.
Urine studies:
.
[**2164-12-21**] 04:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.039*
[**2164-12-21**] 04:11AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2164-12-21**] 04:11AM URINE RBC-[**10-25**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2164-12-22**] 09:41AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-8.0 Leuks-NEG
[**2164-12-22**] 09:41AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.019
.
Microbiology:
.
Sputum Cx:
GRAM STAIN (Final [**2164-12-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2164-12-23**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
.
BCx [**12-21**] - [**12-22**] - negative.
UCx - yeast.
.
Imaging/Studies:
.
CXR [**12-19**]:
PA PORTABLE UPRIGHT CHEST RADIOGRAPH: The heart size is normal.
Mediastinal
and hilar contours are unremarkable. The lungs are clear. There
is no
pneumothorax or pleural effusion. A TIPS stent overlies the
liver and
multiple coiled wires overlie the epicardium, which are
unchanged.
IMPRESSION: No acute cardiopulmonary process.
.
RUQ US [**12-20**]:
.
IMPRESSION:
1. Patent TIPS with stable velocities. Patent portal veins with
appropriate
direction of flow.
2. Echogenic liver but no focal lesions identified. No biliary
dilatation.
3. Small right pleural effusion. No ascites.
.
TIPS Revision: [**12-20**]
.
IMPRESSION:
1. Portal venogram demonstrating focal area of stenosis at the
proximal
aspect of the TIPS which responded to angioplasty with a 10 mm
balloon.
2. Reduction of portosystemic gradient from 10 mmHg to 5 mmHg
post
angioplasty.
3. Uncomplicated coil embolization of gastric varix from mid
splenic vein.
No reflux of contrast was seen in proximal or mid splenic vein
beyond the
region of previously placed coils.
4. Placement of central venous triple-lumen catheter via the
right internal
jugular vein. The catheter is ready to use.
PLAN: The patient is to return to the medical intensive care
unit and
possibly undergo a CT scan to evaluate patency of direct
splenocaval shunt seen on CT performed [**2161-1-27**].
.
Variceal embolization [**12-20**]:
.
IMPRESSION:
1. Near-complete embolization of the varices at the
esophagogastric junction
with Amplatzer vascular plug and coils.
2. If the patient rebleeds again, pure ETOH can be used for
embolization.
.
CXR [**12-21**]:
.
IMPRESSION: AP chest compared to [**12-20**]:
Small right pleural effusion layering posteriorly has increased
since [**12-20**]. Lungs are clear. Heart size normal. No left pleural effusion
or
pneumothorax. ET tube in standard placement, right
supraclavicular central
venous introducer tip projects over the mid SVC and a [**State **]
or Sengstaken
tube is positioned with the fundic balloon inflated, in standard
placement.
.
CXR [**12-21**]:
.
The previously seen [**State **] or Sengstaken tube was removed and
replaced by
an OG tube with the OG tube tip being currently in the stomach.
The TIPS is
in unchanged position as well as the coil embolization of
gastric varices.
The ET tube tip is approximately 3 cm above the carina. The
right internal
jugular line tip is in mid-SVC. Right pleural effusion is
demonstrated. Left
subpulmonic effusion cannot be excluded.
.
RUQ us [**12-25**]:
.
IMPRESSION:
1. Patent TIPS with improved velocities, as described. Patent
portal veins
with appropriate direction of flow.
2. Echogenic liver with no focal lesions identified.
3. Partial visualization of right pleural effusion. No ascites.
.
Pelvic U/S [**12-26**]:
.
IMPRESSION: Limited study - within these limitations no
son[**Name (NI) 493**] evidence
for polyps, fibroids, or abnormal endometrial stripe. If vaginal
bleeding
persists, consider son[**Name (NI) 58034**] or hysteroscopy for more
complete
evaluation.
.
Brief Hospital Course:
This is a 45 F w/ pmh of EtOH cirrhosis transferred from OSH for
massive hematemesis, received total of 8u PRBCs, underwent a
TIPS revision, [**Last Name (un) **] tube placement, variceal embolization
and was transferred from ICU to the floor w/ stable HCT for
further management. While on the floor, HCT has been stable,
encephalopathy improved. Patient developed episodes of vaginal
bleeding 40-50cc x2. She was evaluated by OBGYN and underwent a
pelvic ultrasound. Her bleeding was felt to be perimenopausal
and follow up with OBGYN was arranged prior to discharge.
Patient was not encephalopathic, her HCT was stable. Her
bilirubin was elevated from baseline, this was felt to be due to
GIB and multiple transfusions patient received. She was
discharged with appropriate follow up. Please see below for
problem based, detailed account of [**Hospital 228**] hospital course.
# GI Bleed: The patient was transferred directly to the MICU.
She has known grade III esophageal varices and gastric varices.
She was started on octreotide drip, IV PPI. Her propranolol and
spironolactone were held. The night of admission, an emergent
endoscopy was performed, however GI was unable to visualize the
source. With NGT placement, showed bright blood and she
received 3 units of PRBCs that night and a total of 8U during
her ICU stay. The day after admission, she was taken to the IR
suite for revision of her TIPS procedure on [**2164-12-20**]. The
pressures were decreased, however the patient had another
episode of UGIB upon returning to the floor. The patient was
transfused 2 units of PRBCs and platelets. The patient
continued to have hematemesis, thus the patient was intubated
and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed by GI. She was then taken back
down to the IR suite for angiography. She was found to have an
anamolous IVC leading to 8 significant varices. She underwent
coiling of these varices, including gastric varix from
mid-splenic vein. Varices at esophagogastric junction were
embolized with coils at the feeding [**Last Name (un) **] from the hepatic vein.
On [**2164-12-21**], the [**Last Name (un) 10045**] was pulled, and she was transfused an
additional 2 units of platelets and one unit of PRBCs. She was
able to be extubated without difficulty on [**2164-12-23**] and did not
have any significant output following extubation. Patient was
then transferred to the floor.
.
Patient did have known grade I-II esophageal varices and gastric
varices. She continued to have melanotic stools for one day,
which then resolved, but remained guiac positive. She has had
no hematemesis after transfer from the ICU. HCT remained stable
around 30-34 and was 37 at time of discharge. Once on the
floor, her octreotide was discontinued and she was changed to PO
PPI. Patient was treated with 500mg Ciprofloxacin [**Hospital1 **] for GIB.
No ppx was provided no ascites on multiple imaging modalities.
Her Propranolol was restarted and uptitrated to 40mg [**Hospital1 **].
.
# EtOH Cirrhosis: MELD score as of [**12-4**] was 12. Her INR was
1.3 - 1.4, Cr ranged between 1.0 - 1.3 and Tbili was elevated
from baseline 2 to 12 (likely due to GIB). She was to undergo
evaluation w/ Dr. [**First Name (STitle) 1726**] at [**Hospital3 2358**] for a possible liver
[**Hospital3 **], however was hospitalized here prior to that. On
admission, the patient was continued on rifaxamin, lactulose w/
goal of 3 BM per day. Her home ciprofloxacin was switched to
ceftriaxone in the setting of the acute bleed. She was then
able to be switched back to cipro prior to leaving the MICU. A
paracentesis was attempted on [**2164-12-22**], however there was an
insufficient pocket. On transfer to the floor, she did not show
signs of encephalopathy, there were no ascites. She was
continued of lactulose and rifaximin. Her Tbili 7.6 -> 12,
mostly direct. A repeat U/S was performed to assess for TIPS
patency, flow and ascites. TIPS was patent w/ nl flow and there
were no ascites on reassessment. Elevated bili was felt to be
likely due to GIB. At time of discharge, patient was continued
on rifaxamin 400 TID, Lactulose w/ goal of 3 BM per day and she
was restarted on propranolol as above. Spironolactone from home
regimen was discontinued given no ascites and to allow room for
uptitration of propranolol.
.
# Thrombocytopenia: Recent range 72-100,000. Likley from
cirrhosis and splenomegaly. The patient had episodes of
decreased platelets, the lowest of which was 36, for which she
received transfusions while actively bleeding. Her platelet
count improved to 69K. Baseline range 72-100,000. At time of
discharge, Platelet count was 131.
# Osteoarthritis: Worst area in left hip. The patient takes
oxycodone as an outpatient. The patient was started on morphine
and fentanyl for pain control. A lidocaine patch was also
initiated.
.
# Vaginal bleeding. Pt. w/ ~ 50cc x2 of vaginal bleeding in
setting of 36K of platelets. INR was 1.4. LMP 2wks ago, but pt.
w/ ammenorrhea since onset of liver disease w/ spotting Q6mo.
Last PAP 3 years ago in clinic in ME, reportedly negative.
Patient had no GYN care since. Patient has had tubal ligation,
and C/S x2, but otherwise no other OBGYN surgeries. No pain or
discharge. Not sexually active in over 6mo. NT abdomen on exam.
No source of bleeding on transvaginal us identified. Given sx
consistent with menstruation,it was felt that the bleeding was
physiologic and will spontaneously resolve, per OBGYN
consultation. Appropriate OBGYN follow up was arranged.
.
Patient was discharged in a hemodynamically stable condition,
with appropriate GYN and GI follow up.
Medications on Admission:
Medications - Prescription
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1 Capsule(s) by mouth every other week
LACTULOSE - 10 gram/15 mL Solution - 30ML Solution(s) by mouth
once a day
LANSOPRAZOLE [PREVACID] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) -
30 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
once a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
as directed once a day
OXYCODONE - 5 mg Capsule - 1 Capsule(s) by mouth every 8 hours
as needed for pain
PROPRANOLOL - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 20 mg Tablet
- 1 Tablet(s) by mouth twice a day
RIFAXIMIN - 200 mg Tablet - 2 Tablet(s) by mouth three times a
day
SPIRONOLACTONE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain
--------------- --------------- --------------- ---------------
.
Medications on transfer:
Xifaxan 1200 mg QD
Nexium 40 mg IV Q 12
Octreotide 50 mcg/hour
Trazodone 25 mg QHS PRN
Lactulose 20 grams QD
fentanyl 50 mcgQ 4 Hr PRN
.
Allergies: Demerol results in confusion and nausea.
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*5 bottles* Refills:*2*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain for 10 days: hold for sedation.
Disp:*30 Tablet(s)* Refills:*0*
7. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO every other week.
Disp:*8 Capsule(s)* Refills:*2*
10. Outpatient Physical Therapy
please complete outpatient PT given severe osteoarthritis of the
leg.
11. Outpatient Lab Work
CBC, Chem 10, LFTs, PTT/PT/INR and please fax results to Dr. [**Name (NI) 8390**] Office at [**Hospital1 18**].
Discharge Disposition:
Home
Discharge Diagnosis:
Prmary: Esophageal and gastric variceal bleed
Secondary: Alcoholic cirrhosis, Pancreatitis, GERD.
Discharge Condition:
stable hematocrit, hemodynamically stable without bleeding.
Discharge Instructions:
You were transferred from an outside hospital with a variceal
bleed. You had a TIPS revision and embolization of bleeding
varices. You tolerated this well. You were intubated for
bleeding. You had several blood transfusions.
You were transferred out of the ICU and had no repeated bleeding
episodes and are otherwise stable. You had vaginal bleeding and
were seen by gynecology that feels this is your menses. You will
need to follow up with your liver doctor, gynecology and [**Hospital1 **] to discuss your osteoarthritis.
-Please take all medications as prescribed to you
-please do not take your diuretics until you follow up with your
liver doctor as you appear dry on exam and based on liver tests
-Please return to the hospital if you experience bleeding from
your mouth, bleeding from your rectum or black stools. This is
an emergency
Should you experience confusion, increasing shakiness, shortness
of breath, chest pain, leg swelling, fevers, chills or any other
symptom concerning to you, please call your [**Hospital1 3390**] or call Dr.
[**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) **] at the Cosco Bay [**Hospital **] clinic ([**Telephone/Fax (1) 58035**]) or go
to the nearest emergency room.
Followup Instructions:
ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2165-1-14**] 9:30 follow up
in the OB/[**Hospital **] clinic for endometrial biopsy. # is [**Telephone/Fax (1) 2664**]
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2165-1-14**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 58036**], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2165-1-14**] 3:00
.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D to follow up regarding your
hip surgery.
Please arrange for physical therapy evaluation as an outpatient
with your home provider.
Please follow up for the ECHOCardiogram scheduling. Please call
[**Telephone/Fax (1) 9832**] to set up the appointment.
Completed by:[**2165-1-12**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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16404, 16410
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283, 394
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16552, 16614
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2595, 7938
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14968, 16381
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16431, 16531
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16638, 17870
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2041, 2576
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235, 245
|
422, 1469
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14754, 14945
|
1491, 1736
|
1752, 1947
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,273
| 174,176
|
46505
|
Discharge summary
|
report
|
Admission Date: [**2159-11-29**] Discharge Date: [**2159-12-11**]
Date of Birth: [**2096-10-2**] Sex: M
Service: SURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
LLE ischemia
Major Surgical or Invasive Procedure:
[**2159-11-30**] CARDIAC PERFUSION PERSANTINE
[**2159-12-4**] Ultrasound imaging-guided vascular access, common iliac
contra third order, abdominal aortogram, extremity unilateral,
extremity native arthrosclerosis with rest
[**2159-12-6**] Left profunda femoral artery to posterior tibial artery
bypass graft with in situ saphenous vein, angioscopy, vein
inspection, valve lysis.
History of Present Illness:
53F with chronic low back and left hip pain s/p laminectomy in
[**2158-10-19**] c/b DVT, requiring anticoagulation and IVC filter. Pain
continued to be unrelieved and with additional multiple
interventions at the [**Location (un) **] Spine Center (bursa injections,
sacroiliac injections, physical therapy). Received an arthrogram
at OSH (5 days ago) for evaluation and since then complaining of
worsening L thigh pain and swelling.
Noticed swelling increasing to her knee. Still with severe pain
to LLE. She is still able to ambulate and denies any motor or
sensory loss. Continues to take her coumadin for DVT (INR
checked at 3.3). Denies any trauma. Minimal ambulation given
chronic back pain. All other ROS negative.
Past Medical History:
PMH: HTN, HL, CAD, DVT, PTSD, anxeity, brain/aortic aneurysm
(2.5
cm), DVT (R) on coumadin, h/o substance abuse in [**2148**], H.pylori
PSH: TAH, laminectomy w/ fusion for spinal stenosis, IVC filter,
s/p partial thyroidectomy ~6 years ago,
Social History:
Originally from [**Country 5976**], moved to the US when he was 16. Works as a
security officer at [**Location (un) 86**] Latin School. He has been married for
41 years, 3 biological children, 20 adopted children. Currently
smokes 3 cigarrettes/day, previously smoked 3 ppd x40 years.
drinks alcholol on rare social occasions. No illicits.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Cancer (unknown type) in both parents.
Physical Exam:
Physical Exam:
VITAL SIGNS - 97.2 66 140/63 18 100%
Gen: in bed, uncomfortable, irritated, mild distress with pain
Neck: supple
Lungs: CTA
Cardio: RRR
Abd: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.
Abd
aorta not enlarged by palpation. No abdominal bruits.
Ext: Ecchymosis to left thigh with extension to knee. Tenderness
circumferentially with evidence of hematoma but overall soft
throughout. Normal motor/sensory.
Pulses fem [**Doctor Last Name **] DP PT
L p p p p
R p p p p
Pertinent Results:
[**2159-11-29**] 04:37PM BLOOD WBC-7.0 RBC-3.57* Hgb-9.8* Hct-30.6*
MCV-86 MCH-27.4 MCHC-31.9 RDW-16.3* Plt Ct-158
[**2159-12-6**] 06:45PM BLOOD Hgb-8.2* Hct-24.5* Plt Ct-131*
[**2159-12-10**] 08:20AM BLOOD WBC-6.5 RBC-3.46* Hgb-10.1* Hct-30.0*
MCV-87 MCH-29.3 MCHC-33.7 RDW-16.7* Plt Ct-108*
[**2159-11-29**] 04:37PM BLOOD PT-20.2* PTT-29.2 INR(PT)-1.9*
[**2159-12-6**] 06:45PM BLOOD PT-15.5* PTT-32.4 INR(PT)-1.4*
Stress test - No significant ST segment changes noted and no
anginal type
symptoms reported with Persantine. Appropriate hemodynamic
response.
Nuclear report filed separately.
PMIBI - No focal myocardial perfusion defect identified on
stress or rest images. Left ventricular ejection fraction 47%
Vein - The greater saphenous veins are patent bilaterally.
Please see
digitized image on PACS for formal sequential measurements. The
vessels
appear to be patent from the saphenofemoral junction through to
the level of the ankle.
Brief Hospital Course:
In brief, Mr. [**Known lastname **] is a 63-year-old male with thoracic and
aortic aneurysms was who is status post thoracic aneurysm
repair, had embolization from an ectatic popliteal artery to his
digital vessels. He was treated with anticoagulation and
stabilized over the course of several weeks. We also did not
want to perform an operation because he had a spinal cord
ischemia with hypotension during thoracic aneurysm repair and
was starting to recover. He was admitted to Dr.[**Name (NI) 1720**]
surgical service on [**2159-11-29**]. He was maintained on lovenox.
PMIBI/cardiac clearance was obtained prior to surgery. His
procedures were diagnostic angiogram on [**2159-12-3**] and L profunda
to posterior tibial artery bypass graft with in situ saphenous
vein, angioscopy, vein inspection, valve lysis on [**2159-12-6**]. No
complications to the procedure. He was kept on our pathway and
had an uncomplicated postoperative course. Physical therapy
cleared for home. Patient to be discharged home on [**2159-12-11**] with
[**Name (NI) 269**], PT and health aide. His following hospital course can be
summarized by the review of systems -
Neuro - Patient pain was well controlled with percocet. He had
no neurological issues during this hospitalization
Cardio - Followed closely by Atrius cardiology and consulted for
cardiac clearance. Chemical stress test on [**2159-11-30**] revealed no
focal myocardial perfusion defect with ventricular ejection
fraction of 47%. He was maintained on all his home medications
with adjustment per cardiology. His discharge dosing will be
Lopressor 50mg PO QID and Amlodipine 2.5 mg PO daily. He will
continue his statin and aspirin.
Pulm: No respiratory issues. He is discharged on room air and no
oxygen requirements.
GI: Maintained on H2B. Diet advanced as tolerated per pathway.
No issues.
GU: His home medication, Tolterodine, was resumed for overactive
bladder. No issues with hematuria or incontinence. Foley was
removed POD2 and urinated without difficulty.
Heme: He had been found to have a thrombosed popliteal artery
aneurysm which had showered emboli distally into his foot. He
had been on lovenox and a heparin gtt for systemic
anticoagulation prior to the surgery, but because he has now
undergone bypass of the popliteal aneurysm, there is no further
need for system anticoagulation. Accordingly, lovenox/heparin
gtt have not been resumed after surgery. This plan has been
formulated with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], attending vascular surgeon. He
will continue his aspirin.
ID: Given preoperative antibiotics and was not continued
postoperatively. Patient remained afebrile throughout this
hospital course.
Endo: Since his admission from rehab, he was maintained on a
sliding scale of insulin in addition to his metformin. Metformin
was held prior to angiogram procedure to prevent any
nephropathy. This was resumed on day of discharge with strict
blood sugar monitoring. He will follow up with his PCP regarding
any further antiglycemic agents. Home health aide will be
assigned to assist with blood glucose checks.
Dispo: Physical therapy continually working with patient.
Cleared to be discharged home.
Medications on Admission:
norvasc 2.5'; asa 81'; lipitor 10'; colace 100''; ferrous
sulfate 325'; folic acid '; reg insulin ss; metoprolol tartrate
25''; zantac 150''; senna'; flomax 0.4'; detrol 1''; comadin;
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
11. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Left lower extremity ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-21**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2159-12-25**] 1:00
PCP within one week
Completed by:[**2159-12-11**]
|
[
"530.81",
"496",
"272.4",
"V45.82",
"440.24",
"V58.61",
"442.3",
"440.4",
"V70.7",
"401.9",
"250.00",
"444.22",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"88.42",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
8141, 8218
|
3701, 6922
|
282, 666
|
8292, 8292
|
2730, 3678
|
11162, 11367
|
2058, 2180
|
7157, 8118
|
8239, 8271
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2210, 2711
|
229, 244
|
695, 1418
|
8307, 8419
|
1440, 1684
|
1700, 2042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,320
| 113,335
|
36458
|
Discharge summary
|
report
|
Admission Date: [**2131-5-10**] Discharge Date: [**2131-6-20**]
Date of Birth: [**2081-3-24**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Erythromycin Base / Penicillins / Influenza
Virus Vaccine / Latex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
COPD, T7-T9 epidural abscess
Major Surgical or Invasive Procedure:
PROCEDURES: [**2131-5-10**] by: Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
1. Fusion T2-L1.
2. Extra cavitary decompression T7-T8.
3. Multiple thoracic laminotomies.
4. Multiple lumbar laminotomies.
5. Osteotomy T7, 8, 9
6. Instrumentation, T2-L1.
6. Autografts.
[**2131-5-10**] by Thoracic Surgery Dr. [**Last Name (STitle) **]
Placement of bilateral chest tubes for bil pleural effusions
[**2131-5-10**] Vascular Surgery
1. Ultrasound-guided puncture of right common femoral vein.
2. Inferior vena cavogram,
3. Placement of Gunther Tulip IVC filter.
[**2131-5-20**] Dr. [**Last Name (STitle) 363**] and Dr. [**First Name (STitle) **]
1. Partial vertebrectomies of T6, 7 and 8.
2. Fusion T6-T9.
3. Anterior spacer.
4. Autograft, bone morphogenic protein, and allograft.
5. Bronchoscopy and:
Left posterolateral thoracotomy, partial
vertebrectomy of T6, T7 and T8; fusion of T6 to T9; anterior
spacer; autograft bone morphogenic protein and allograft; and
finally bronchoscopy.
[**2131-5-23**] Dr. [**Last Name (STitle) 363**]
Revision laminectomies T6, 7 and 8.
2. Incision and drainage.
3. Debridement.
[**2131-5-24**] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
Flexible bronchoscopy.
Therapeutic aspiration of secretions.
[**5-30**] swallow eval:
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of level 4, mild to moderate
dysphagia.
[**2131-6-5**] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 67965**]
Flexible bronchoscopy with aspiration and 8-0
Portex tracheostomy tube placement.
History of Present Illness:
50F with with history of severe COPD
requiring oxygen, colon CA s/p resection and colostomy recent
MRSA osteomyletis of MTP joint s/p resection in [**1-19**]; this AM at
rehab noted to have SOB with sats as low as 45%. EMS placed her
on 100% nonrebreather and gave 40mg lasix. O2 sat improved to
99%. Taken to [**Hospital3 **] ED and received levaqiun and BiPAP. She
c/o weakness in her legs, weakness with walking. CT chest showed
T7-T9 destructive changed associated with swelling, concerning
for abscess. MRI, per report, shows evidence of spinal cord
compression. She presents for surgical evaluation.
Past Medical History:
MRSA, sepsis due to osteomyelitis of the MTP joint s/p resection
s/p long term tx with vancomycin
COPD, severe, O2 dependent; h/o hypercapnic respiratory failure
requiring intubation
Costocondritis
History of PE (on coumadin)
Chronic anemia
DM with neuropathy
CHF
Diverticulosis, Colon CA s/p colostomy
h/o SBOs
s/p hysterctomy c/b abd wound dehiscence
h/o Cdiff colitis
HTN
IgA and IgG deficiency
hypercholesterolemia
Gout
Restless leg syndrome
Social History:
does not smoke, drink alcohol; widow
Family History:
Her father had diabetes. Her mother died of CAD and HTN.
Physical Exam:
On transfer to MICU on [**2131-6-14**]:
Vitals: Tc: 99.4 Tm: 101.2 at MN BP: 161/76 P: 116 R: 29 O2: 98%
on CPAP 10 PEEP 5 40% FIO2
General: trached, minimally arousable to verbal stimuli and
sternal rub
Skin: scattered ecchymoses, no rash, left thoracotomy w/
staples, small yellow wound at incisional end overlying L-spine
w/ scant yellow discharge
HEENT: Sclera anicteric, pupils 2mm and sluggish, MMD, poor
dentition w/ gingival inflammation, oropharynx clear
Neck: supple, JVP unable to assess [**2-12**] trach collar, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy, Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, LLQ ostomy w/ brown liquid stool, mild line
incisional scar healed, soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly appreciated
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PICC line in R antecub
Neuro: Drowsy [**2-12**] recent narc dosing, reflexes 2+ b/l,
withdrawling to pain in all four extremities, intermittent fine
motor tremor noted in right lower extremity
foley w/ yellow clear urine
Pertinent Results:
[**2131-5-10**] 01:22AM BLOOD WBC-13.4* RBC-3.26* Hgb-9.0* Hct-30.6*
MCV-94 MCH-27.7 MCHC-29.5* RDW-17.8* Plt Ct-569*
[**2131-5-10**] 01:22AM BLOOD Neuts-96.5* Lymphs-2.1* Monos-1.4* Eos-0
Baso-0
[**2131-5-10**] 01:22AM BLOOD PT-21.4* PTT-31.1 INR(PT)-2.0*
[**2131-5-10**] 01:22AM BLOOD Glucose-221* UreaN-17 Creat-0.5 Na-144
K-4.4 Cl-99 HCO3-30 AnGap-19
[**2131-5-10**] 01:22AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.8
[**2131-5-30**] 10:35AM BLOOD Albumin-2.4* Iron-9*
[**2131-5-30**] 10:35AM BLOOD calTIBC-117* Ferritn-367* TRF-90*
[**2131-5-30**] 10:35AM BLOOD Triglyc-260*
[**2131-6-14**] 07:24AM BLOOD TSH-4.2
[**2131-5-12**] 02:33AM BLOOD CRP-290.6*
[**2131-5-23**] 12:02AM BLOOD IgG-561* IgA-158
.
[**2131-5-10**] 12:00 pm TISSUE T8.
STAPH AUREUS COAG +. RARE GROWTH.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2131-6-13**] 12:15 am URINE Source: Catheter.
.
[**2131-5-12**] 5:16 pm STOOL CONSISTENCY: LOOSE
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2131-5-25**] 4:05 pm BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE.
RESPIRATORY CULTURE (Final [**2131-5-28**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
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
.
[**2131-6-1**] 8:27 am SPUTUM Source: Endotracheal.
RESPIRATORY CULTURE (Final [**2131-6-4**]):
THIS IS A CORRECTED REPORT [**2131-6-4**].
OROPHARYNGEAL FLORA ABSENT.
YEAST. RARE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
.
[**2131-6-2**] 3:48 pm URINE Source: Catheter.
URINE CULTURE (Final [**2131-6-6**]):
PSEUDOMONAS AERUGINOSA.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
[**2131-6-11**] 5:09 pm URINE Source: Catheter.
URINE CULTURE (Final [**2131-6-12**]):
YEAST. >100,000 ORGANISMS/ML..
.
[**2131-5-10**] PATH
SPECIMEN SUBMITTED: T8 bone, disc T7-8/bone.
I. T8 bone (A): Fragments of cartilage and bone with acute
osteomyelitis and osteonecrosis.
II. Disc T7-8/bone (B): Fragments of skeletal muscle, fibrous
connective tissue and bone with acute osteomyelitis and
osteonecrosis.
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 I
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
.
[**2131-5-10**] MRI T & L-SPINE W/ & W/O CONTRAST: IMPRESSION: Limited
examination secondary to motion artifacts, vertebral mass lesion
identified at T7, T8 and T9 levels, possibly consistent with
metastatic disease, versus an over-imposed infectious process
with discitis, additionally, there is also spinal cord
compression and with edema at T9 level. Compression fracture
identified a T11, T12, L1, L2 and L4 levels. Multilevel disc
degenerative disease in the cervical, thoracic, and lumbar
spine as described above.
.
[**2131-5-22**] CT T & L-SPINE W/O CONTRAST:
1. Osseous hardware in grossly stable alignment with new
vertebral body
spacer at T7-T8. Evaluation of intrathecal detail is extremely
limited given artifact and thus epidural collection/hematoma
cannot be excluded. MRI recommended to evaluate for these
findings as indicated.
2. Progression of consolidation/collapse within the left lower
lobe of the
lung not fully evaluated on this spine study.
.
[**2131-5-22**] MRI T & L-SPINE W/ & W/O CONTRAST: 1. Significantly
limited study due to extensive artifacts from the posterior
spinal hardware from T2-L1 levels. Within these limitations,
there is posterior spinal T2 hyperintense area extradural in
location, at T8-T10 levels, causing displacement of the thecal
sac anteriorly with mild deformity of the cord but no definite
cord compression. The posterior spinal canal abnormality may
relate to fluid collection like seroma/hematoma with or without
granulation tissue.
2. Extensive artifacts noted in the upper thoracic spine,
significantly limiting evaluation of the cord at this level from
T1-T8 as the thecal sac and cord are obscured. There is
possibility of soft tissue material in the spinal canal in this
location, with mass effect on the cord until proven otherwise.
Assessment of the cord at this level is significantly limited
due to artifacts.
This can be further evaluated with the CT myelogram to assess
the outline of the thecal sac and any mass effect on the thecal
sac, and the intrathecal contents, if there is continued concern
based on the clinical symptoms.
3. Multilevel extensive degenerative changes in the cervical and
the lumbar
spine as described before causing moderate spinal canal stenosis
or neural foraminal narrowing in the lumbar spine. Please see
the detailed report on the prior study done on [**2131-5-10**].
4. Evaluation for prevertebral soft tissue or abnormal
enhancement is limited on the present study due to lack of fat
saturated sequences. There is increased STIR signal noted in the
prevertebral soft tissues at the level of T8-T10, representing
prevertebral soft tissue swelling, the cause of which can relate
to edema, fluid collection, or abscess. Post-surgical changes in
the thoracic spine at multiple levels, most prominently at T7-T9
levels, not adequately assessed due to artifacts.
.
[**2131-6-2**] UNIL HIP XRAY: Three views of the left hip were
reviewed. There is no evidence of fracture. There is no evidence
of dislocation. There is no evidence of pathological sclerosis.
The vascular calcifications are demonstrated in the femoral
artery.
.
[**2131-6-3**] CT ABD/PELVIS: 1. Large amount of stranding as well as
several fluid collections seen along the posterior spine
extending from the lower cervical level to the upper thoracic
spine level, likely postoperative in nature. No CT sign of
infection, however this cannot be completely excluded by imaging
alone.
2. Small bilateral pleural effusions, greater on the right with
bilateral
lower lobe atelectasis.
3. No acute intra-abdominal process.
4. Postoperative thoracic spine changes as described.
.
[**2131-6-15**] EEG: This is an abnormal portable EEG recording due to
the slow
and disorganized pattern and the bursts of generalized slowing.
This abnormality suggests a widespread encephalopathy.
Medications, metabolic disturbances, and infection are among the
most common causes. Of note is that although the right leg
twitching had no EEG correlate it does not completely exclude
the possibility of the patient having focal motor seizures.
There are no epileptiform features seen in this recording and no
lateralized features. Note is made of a tachycardia with a
single ectopic beat.
.
[**2131-6-16**] CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST: Pansinus
mucosal thickening, most prominent in the right maxillary sinus
where a combination of mucosal thickening and inspissated
secretions are observed. The findings may represent sinusitis.
No focal fluid collections are seen.
.
[**2131-6-16**] MRI T-SPINE W/ & W/O CONTRAST:
1. Since the previous MRI of [**2131-5-22**], there is now increased
fluid seen surrounding the interbody device placed following
corpectomy with fluid extending into the anterior epidural space
on the left side, narrowing the
spinal canal at T7 and T8 level with compression of the spinal
cord.
2. Superficial fluid collection in the left upper thoracic
region and also
fluid extending from laminectomy site to subcutaneous fat in the
upper thoracic region. The fluid extending from the laminectomy
site to the subcutaneous fat has considerably decreased since
the previous study.
3. Extensive bilateral pleural parenchymal changes in the lungs,
which can be further evaluated with CT of the chest.
.
[**2131-6-16**] MRI L-SPINE W/ & W/O CONTRAST: Compressions of T12 and
L1 vertebral bodies identified. The compressions may have
slightly increased since the previous study. Multilevel
degenerative changes are seen in the lumbar region. No
intraspinal fluid collection in the lumbar region. Small fluid
collection left of the midline at L3-4 level within the
subcutaneous fat as described above.
Brief Hospital Course:
HPI:
50 y.o female with COPD, htn, DM2, IgG, IgA deficiency, hx colon
CA w/ colostomy, from [**Hospital3 **] Hospital from rehab [**5-9**] with
SOB, hypoxia though to be secondary to COPD exacerbation. There
she complained of LE weakness. Chest CT there showed T7-T9
destruction with soft tissue swelling and concern for
disciitis/epidural abscess and MRI T spine showed evidence of
cord compression with epidural abscess seen from T7-T10.
Brief Hospital Course:
Pt transferred from OSH on [**5-10**] underwent Fusion T2-L1, Extra
cavitary decompression T7-T8, Multiple thoracic laminotomies,
Multiple lumbar laminotomies, Osteotomy T7, 8, 9,
Instrumentation, T2-L1, Autografts. Subsequent osteo w/ MRSA
growing from T7-T10 to OR [**5-20**]: Partial vertebrectomies of T6, 7
and 8, Fusion T6-T9, Anterior spacer, Autograft, bone
morphogenic protein, and allograft, bronchoscopy. Developed
hematoma [**5-23**] went back to OR for Revision laminectomies T6, 7
and 8, Incision and drainage, Debridement. [**5-24**] she was
bronched w/ Left lung collapse secondary to mucus retention. Pt
failed weaning trials off vent and underwent trach [**6-5**]. Low
grade temps w/ known MRSA spine osteo, Pseudomonas VAP & UTI,
C.Diff. On Vanc + Rif 6wk course to d/c [**7-5**]. On 25mg
prednisone since COPD exac [**5-9**], weaning started [**6-12**].
Persistently agitated, q/ questionable pain control during
course. Psych, neuro, CPS consults. Neuro rec EEG r/o seizures
[**6-13**]. IVC filter placed during hospital course d/t risk of
anticoagulation. PEG placed [**6-12**] for TF. Repeated failed trach
collar trials, ? vent rehab, but persistent fevers w/ most
recent culture sputum pos sparse pseudomonas. blood and urine
cultures pending. Known persistent peri-spinous fluid
collection, no imaging or surgical procedures intended, per
neurosurg.
Operative Dates:
[**2131-6-12**] PEG (bedside)
[**2131-6-5**] trach, bronch
[**2131-5-24**] bronch
[**2131-5-22**] epidural evac
[**2131-5-20**] L thoracotomy, ant T6-8 corpectomies, ant cage T6-T9
[**2131-5-10**] Fusion T2-L1, mulit T-L lami, IVC filter, CT R and L
Antibiotic:vanco/cefepime/flagyl/rifampin
Anticoagulant:SQH
TLD:IVC filter:Day37
Foley:Day4
PMH: MRSA, sepsis due to osteomyelitis of the MTP joint s/p
resection
s/p long term tx with vancomycin; COPD, severe, O2 dependent;
h/o hypercapnic respiratory failure; requiring intubation,
Costocondritis
History of PE (on coumadin), Chronic anemia, DM with neuropathy
CHF, Diverticulosis, Colon CA s/p colostomy, h/o SBOs, s/p
hysterctomy c/b abd wound dehiscence, h/o Cdiff colitis
HTN, IgA and IgG deficiency, hypercholesterolemia, Gout,
Restless leg syndrome
Meds: Albuterol 2.5 QID, atrovent 0.5 QID, cardizem 60 QID,
prilosec 20', SSI; prednisone po 25', vit C 500", gabapentin
300"; requip 0.25 po tid; mvi, oxycontin cr 40", colace prn;
maalox prn; bisacodyl prn; percocet prn
ID - flagyl PO until leaves; at that point, switch to PO vanco
AND stays on IV vanco - total 6 weeks; rifampin for hardware,
will need weekly LFTs
Micro/Imaging:
[**2131-6-13**] urine pending
[**2131-6-13**] blood NGTD
[**2131-6-12**] blood NGTD
[**2131-6-11**] sputum Pseudomonas, Yeast
[**2131-6-11**] urine >100k yeast
[**2131-6-11**] blood x2 NGTD
[**2131-6-4**] sputum Pseudomonas
[**2131-6-2**] blood ngtd
[**2131-6-2**] urine GNRs, yeast
[**2131-6-2**] sputum Pseudomonas
[**2131-6-2**] cath tip ngtd
[**2131-6-2**] cdiff neg
[**2131-6-1**] sputum Pseudomonas
[**2131-5-27**] BAL no PMN, no micro; MRSA
[**2131-5-25**] BAL RLL 1+PMN, no micro; MRSA
[**2131-5-25**] BAL LLL 1+ PMN, no micro; MRSA
[**2131-5-21**] BAL No PMNs, no micros; 3000 yeast
[**2131-5-21**] BAL 2+ PMNs, no micros: 3000 yeast
[**2131-5-21**] tip NG
[**2131-5-18**] cdiff neg
[**2131-5-12**] cdiff POSITIVE
[**2131-5-12**] sputum >25 PMNs, <10 epis, GPC, GPR; +yeast (sparse)
[**2131-5-12**] blood ng final
[**2131-5-11**] picc tip ng final
[**2131-5-11**] blood ng final
[**2131-5-10**] T7 2+ GPC, MRSA
[**2131-5-10**] T8 4+ PMN, 1+ GPC, MRSA
[**2131-5-10**] blood x2 ng final
Events:
[**2131-6-14**] transferred to medicine
[**2131-6-13**] febrile, recultured, ID reconsulted
[**2131-6-12**] PEG, febrile again, foley changed -lots yeast per nsg,
ID rec'd surv.clx
[**2131-6-12**] psych -rec'd EEG/neuro c/s for jerking, stop zyprexa,
check CK
[**2131-6-11**] awaiting PEG placement, pancultured for fever - UClx >
100K yeast
[**2131-6-10**] diuresing, IP - unable to tap effusions, preop for PEG
[**2131-6-10**] episode hypotension after meds?? resolved w/IVF, time
[**2131-6-8**] CPS consult
[**2131-6-6**] bronch, diuresis, rehab screen - unable to wean off
vent
[**2131-6-5**] OR for open tracheostomy; ID rec'd no double coverage
for pseudomonas
[**2131-6-4**] GYN c/s - no vaginal bleeding
[**2131-6-3**] CT torso - no intraabd process; vag bleeding
[**2131-6-2**] T spike to 101.6 -> started cefepime for presumed VAP
[**2131-6-1**] intubated
[**2131-5-31**] diamox stopped; ?PICC
[**2131-5-30**] passed swallow - thin liquids
[**2131-5-28**] extubated; started on rifampin; L CT pulled; ID - add
rifampin, weekly LFTs
[**2131-5-26**] L chest tube pulled back 4cm
[**2131-5-25**] reintubated, bronch
[**2131-5-24**] L white out; bronch - mucous plugs, 20 lasix
[**2131-5-23**] R CT pull,ed post pull R apical PTX; 3upRBC
[**2131-5-22**] new LLE weakness, ?epidural collection
[**2131-5-21**] BAL - plugs
[**2131-5-20**] OR; 800 EBL, resite L CT; got dose of lovenox
[**2131-5-16**] extubated
[**2131-6-5**] Trach placed-respl failure secretions.
Assessment:
50F epidural abscess on MRI T7-10, s/p T2-L1 fusion, bilat CT
placement s/p epidural evac s/p trach/bronch now s/p PEG
placement
Plan:
Neuro: pain regiment per CPS
CV: home dilt, PO lopressor, stable hemodynamically thus far
Pulm: cont pred taper, remains vent dependent
GI: cont TF, advance to goal
ID: febrile once again, f/u ID consult recs; d/c hydral/reglan -
??drug fever, cont vanc x 6 wks; per ID; cefepime for VAP;
flagyl for CDiff; Rifampin for hardware - weekly LFTs; cont
surveillance clx, ??scan back
GU: urine > 100K yeast -rec treatment
Transferred to medicine [**6-14**]- thank you for your care
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Hospital course after transfer to MICU service (SICU above
completed by surgical RN):
#. Fevers: Patient had had multiple infectious processes during
prolonged hospitalization and had defervesced for several days
before again starting to spike fevers. Initial concern was for
recurrent epidural process because of persistently draining
superficial wound. MRI T and L spine showed with new fluid
collection concerning for abscess tracking back to epidural
space. An attempt by interventional radiology was made to drain
this fluid collection, but was unsuccessful. She was continued
on Vancomycin and rifampin for at least a 6 week course (last
day [**2131-7-5**]) for her epidural abscess. Will continue flagyl
while on this regimen to prevent CDiff. In addition she had
copious secretions and completed an 8 day course of cefipime for
VAP (last dose [**2131-6-16**]). Also, her urine grew yeast on two
different occasions despite changing of the foley and she was
treated with fluconazole for 7 days (last dose [**2131-6-20**]). In
addition to infectious etiologies, drug fever was also
considered and medications that could potentially contribute
were discontinued including gabapentin, famotidine, and
hydralazine. The patient remained afebrile after these
interventions for > 5 days prior to discharge.
#. Epidural abscess: Pt continued on vanc and rifampin (last
dose [**2131-7-5**]). Pt noted to have continued purulent drainage from
surgical site. MRI T and L spine on [**6-15**] showed new fluid
collection concerning for abscess tracking back to epidural
space with evidence of cord compression on Radiology read. Ortho
Spine attending felt that this was mild and recommended
CT-guided aspiration on [**2131-6-18**] however per radiology the fluid
collection was too small to tap and may all be related to
post-op changes so no tap was done. Vanc and rifampin to
continue until [**2131-7-5**] and while on these she will remain on
flagyl for CDiff. Will f/u with Dr. [**Last Name (STitle) 363**] for further treatment
as outpatient in 10 days.
#. VAP: Patient had been diagnosed with VAP a few days prior to
transfer to medical service and completed 10 day cefepime course
for pseudomonal VAP.
#. Yeast UTI: Patient was noted to have yeast in the urine even
after foley changed. She was treated with fluconazole X 7 days.
#. Weakness: The patient noted to have low tidal volumes leading
to difficulty with weaning off vent. Thought to have components
from both critical illness myopathy as well as oversedation from
polypharmacy. She was placed on tapers of clonidine, neurotin,
and steroids and was able to be weaned off vent to trach mask
for several hours daily at time of discharge.
#. Agitation/altered mental status: Had some upper extremity
"twitching" after starting zyprexa. EEG consistent with
widespread encephalopathy. Evaluated by psych/neuro. Tapered off
of nonessential medications including steroids, clonidine,
ativan, and neurontin with improvement in mental status. Also
started on fentanyl patch for better pain control.
#. Tachycardia: Sinus on multiple EKGs with rates 100-130s.
Likely [**2-12**] agitation and pain. Has been treated with pain meds
and with sleep does come down. Would continue to treat pain and
agitation PRN and check EKG if irregular or rate >130.
#. Hypercarbic respiratory failure: In setting of VAP and volume
overload. Has been tolerating trach mask for 3-4 hours twice
daily. PCO2s at baseline on vent are in 70s. Has been receiving
lasix (10 mg IV daily PRN for diuresis if appears overloaded on
exam.
#. Hypercalcemia: Has had slowly trending up calcium. Suspect
immobilization. Will need to check calcium at least weekly and
more often if symptoms of hypercalcemia develop and treat
appropriately.
Medications on Admission:
Albuterol 2.5mg neb 4x daily
Atrovent 0.5 4x daily
Cardizem 60mg 4x daily
Prilosec 20 po daily
ISS
Prednisone po 25'
Vitamin C 500 po bid
Gabapentin 300 [**Hospital1 **]
Requip 0.25 po tid
MVI
Oxycontin cr 40 po q12h
Colace prn
maalox prn
bisacodyl prn
percocet prn
Discharge Medications:
1. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
4. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for to affected skin.
5. Rifampin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q12H (every
12 hours).
6. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
7. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
2-4 Puffs Inhalation Q2H (every 2 hours) as needed for wheezing.
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**2-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Insulin Regular Human 100 unit/mL Solution [**Month/Day (3) **]: per sliding
scale units Injection ASDIR (AS DIRECTED).
11. Lorazepam 0.5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times
a day).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (3) **]: One (1)
injection Injection TID (3 times a day).
13. Prednisone 10 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: switch to 5mg x3 days once this has been completed
then off.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
gram Intravenous Q 24H (Every 24 Hours): course to continue
until [**2131-7-5**].
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
21. 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.
22. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
23. Transportation
Please book transportation to [**Hospital1 18**] for follow-up appointments
listed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Pseudomonal Ventilatory Associated Pneumonia
hypercarbic respiratory failure
malnutrition
spine methacillin-resistant staph aureus osteomylitisepidural
abcess
clostridium deficile colitis
Delirium
fungal urinary tract infection
anxiety
diabetes mellitus
Discharge Condition:
Hemodynamically stable, requiring CPAP w/ PS from ventilator.
Discharge Instructions:
You were treated for your epidural abcess and MRSA osteomyelitis
of the spine. You required multiple surgical interventions to
treat this and will continue to require long-term antibiotics to
treat your osteomyelitis and clotridium deficile colitis. During
your stay, you also had respiratory failure and continue to
require ventilatory support.
Medications:
- Vancomycin/Rifampin until [**2131-7-5**], with likely plan for
bactrim suppression to follow
- Flagyl 1 week after vancomycin has been discontinued
Followup Instructions:
It is essential that you follow up with the infectious disease
team as scheduled below in order to continue to insure proper
antibiotic treatment:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-7-2**] 11:30
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] (spine surgery) on [**2131-6-28**] 1:30pm at [**Hospital1 18**]
[**Hospital Ward Name 23**] 2 [**Hospital **] Clinic. Please call ([**Telephone/Fax (1) 3573**] with
questions.
Completed by:[**2131-6-20**]
|
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"041.12",
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"785.0",
"348.30",
"730.08",
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icd9cm
|
[
[
[]
]
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[
"84.51",
"81.62",
"03.09",
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icd9pcs
|
[
[
[]
]
] |
26431, 26503
|
13700, 22223
|
376, 2004
|
26801, 26865
|
4441, 13213
|
27423, 27994
|
3180, 3238
|
23584, 26408
|
26524, 26780
|
23293, 23561
|
26889, 27400
|
3253, 4422
|
307, 338
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2032, 2640
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22238, 23267
|
2662, 3110
|
3126, 3164
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,922
| 106,937
|
38045
|
Discharge summary
|
report
|
Admission Date: [**2187-8-26**] Discharge Date: [**2187-8-28**]
Date of Birth: [**2139-8-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40 y/o male found underneath a bicycle with positive ETOH of
219. The patient states that he recalls drinking 6-7 beers at
the bar starting at 7pm. He does not recall the events before or
after fall. There were no witnesses to the event. Patient c/o
headache, neck pain, nausea, emesis, L shoulder pain, and R arm
pain.
Past Medical History:
HIV, HTN, DM
Social History:
Lives alone. Works as a cleaning supervisor. Tob DC'ed
1 mon ago, prior to that he smoked 6 cig per day for 15 years.
Family History:
NC
Physical Exam:
Physical Exam at Admission:
T 97.6 BP: 107/83 HR: 103 R 21 99%NCO2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3.5 B reactive EOMs intact
Neck: C-spine collar. No palpable tenderness.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, hospital, and date.
Language: Speech fluent with good comprehension. Speaks Spanish
but had no difficulty with interrogation.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-24**] throughout with the exception
of
Left deltoid-not tested due to pain and restricted ROM. No
pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Pertinent Results:
CT head w/o contrast [**2187-8-26**]:
L parietal soft tissue edema, coup-countercoup injury involving
subarachnoid blood in the middle cranial fossa, R ambient
cistern, and inferior bifrontal subarachnoid blood with poss
intraparaenchymal extension.
CT HEAD W/O CONTRAST [**2187-8-26**] 1:31 PM
1. Interval progression of hemorrhagic contusions in the left
inferior
frontal lobe and the right inferior temporal lobe, with
new/emergent focus of hemorrhagic contusion in the right
cerebellar hemisphere
2. Stable subarachnoid hemorrhage. No new mass effect or
herniation
CT HEAD W/O CONTRAST [**2187-8-27**]
1. Stable appearance of hemorrhagic contusions
2. Subarachnoid blood unchanged.
3. No new mass effect or herniation.
Brief Hospital Course:
Patient is a 48 y/o male s/p bicycle accident, details of
accident unclear, no witness. He was positive for ETOH
consumption and came to the ED complaining of headache, n/v, L
shoulder pain, and R arm pain. Patient recieved a CT scan which
showed a countercoup injury with a R EDH and SAH. He was
admitted to trauma ICU for further observation. CT scan showed
no mass effect or midline shift. Repeat head CT in afternoon
showed no change from previous scan. Cervical spine was cleared
by trauma for injury. On physical exam, patient's left shoulder
had limited ROM secondary to pain. He was also reported to be
vomitingx2. Patient is alert and oriented x3, with good strength
overall. He also presents with dysmetria on the R when asked to
perform finger to nose. EOMs intact, but some end gaze nystagmus
noted. Head CT in AM of [**8-27**] stable from previous scans and
patient was transferred to floor. Physical therapy worked with
the patient. It was felt that he could be discharged to home. He
was sent home in a chair car on [**2187-8-28**].
Medications on Admission:
Lisinopril, Lantus, Metformin,
HIV med-no name given.
Discharge Medications:
1. Outpatient Lab Work
Please have a dilantin level drawn in 1 week.
Please have results faxed to [**Telephone/Fax (1) 87**].
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Phenytoin Sodium Extended 200 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO four
times a day: This medication contains Tylenol. Do not take
additional Tylenol with it.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Closed head injury
R EDH
SAH
Discharge Condition:
Neurologically Stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed dilantin, an anti-seizure medicine,
take it as prescribed and follow up with laboratory blood
drawing in one week. Please have results faxed to [**Telephone/Fax (1) 87**].
??????
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Follow-up with your primary care physician for your shoulder
pain in 2 weeks.
Completed by:[**2187-8-28**]
|
[
"305.00",
"401.9",
"V08",
"851.82",
"250.00",
"E826.1",
"V15.82",
"787.01",
"719.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4949, 4955
|
2903, 3952
|
328, 335
|
5028, 5052
|
2153, 2880
|
6138, 6441
|
873, 878
|
4057, 4926
|
4976, 5007
|
3978, 4034
|
5076, 6115
|
893, 1107
|
280, 290
|
363, 685
|
1404, 2134
|
1122, 1388
|
707, 721
|
737, 857
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,608
| 103,903
|
4564
|
Discharge summary
|
report
|
Admission Date: [**2163-6-6**] Discharge Date: [**2163-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
invasive sqamous scalp ca
Major Surgical or Invasive Procedure:
PICC line placement, neurosurgical intervention cancelled,
History of Present Illness:
Patient is a [**Age over 90 **] year old female with afib, cad, dm who was
transferred from [**Hospital1 **] [**Hospital1 **] for lesion on scalp (can see
brain matter). She was evaluated as an outpatient intially by
dermatology that did a biopsy of the scalp mass and she was
diagnosed with squamous cell carcinoma. The ulcerative lesion
eroding skull extending intracranially and was to have
neurosurgical intervention but the patient was supertheraputic
INR of 7.7 so she was sent to the MICU. She was reversed with
reversed with 10 IV K, 2u FFP. She was also noted to have arf
with cr of 2, anuric, dry on exam with a
sodium 158-->161. She received a NS bolus and then D5W and
avoiding lasix and acei given renal failure, renal ultrasound
with R hydro and pelvic mass (family does not want w/u). Patient
was placed on vanc and cetriaxone for meningitis proprolaxis
since there is CSF communicating with skin secondary to scc.
Patient is having PICC placed in the AM for long-term abx and
fluids. Cultures are pending.
Family is aware of poor prognosis and she is dnr/dni, family
wants conservative med management.
Past Medical History:
CHF-unknown type or EF.
bradycardia s/p pacemaker
afib-s/p cardioversion at [**Hospital1 112**]
htn
hyperthyroidism
arthritis
hernia repair
anxiety
h.o SCC of the scalp year ago per records
glaucoma
Social History:
Lives in [**Location **]. No tobacco, EtOH, or illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.9, 102/666, 64, 22, 98% RA, FS140
General: Alert, trembling, cooperative
HEENT:PERRLA, 3x3cm irregular discolored raised mass, EOMI,
anicteric, MMM
neck-JVD to ear?positional, no LAD
chest-b/l ae no w/c/r
heart-s1s2 4/6 systolic murmur heard throughout precordium
abd-+bs, soft, Nt, ND
ext-NO c/c/e 1+ puluses, cold, r first toe ichemic ulcer
neuro-aaox2, moves all extremities.
Pertinent Results:
[**2163-6-6**] 05:35PM PT-63.8* PTT-41.1* INR(PT)-7.7*
[**2163-6-6**] 05:35PM WBC-13.1*# RBC-3.65* HGB-10.8* HCT-35.6*
MCV-98 MCH-29.7# MCHC-30.5* RDW-13.7
[**2163-6-6**] 05:35PM cTropnT-0.07*
[**2163-6-6**] 05:35PM WBC-13.1*# RBC-3.65* HGB-10.8* HCT-35.6*
MCV-98 MCH-29.7# MCHC-30.5* RDW-13.7
[**2163-6-6**] 05:35PM CK(CPK)-33
[**2163-6-6**] 05:55PM LACTATE-1.7
CT head:
TECHNIQUE: Axial non-contrast images performed in an outside
hospital
([**Hospital3 **]) were submitted for review. No
reconstructions were
available. No formal report was provided.
FINDINGS:
Within the brain parenchyma, there is global parenchymal
atrophy, indicated by
enlargement of the ventricles and sulci. There is also
periventricular and
subcortical white matter hypodensity, consistent with small
vessel ischemic
disease. A right cerebellar lacunar infarct is also noted. There
is no
hemorrhage, edema, or mass effect. There is no shift of normally
midline
structures. The [**Doctor Last Name 352**]-white matter differentiation appears
preserved.
There is a large destructive lesion involving the vertex of the
calvarium.
There is no underlying brain mass lesion or brain abscess,
although there is
an extra- axial, likely subdural, soft tissue/fluid component to
this lesion,
although this is difficult to evaluate due to volume averaging
at the vertex
and the lack of reconstructions. The lesion at the vertex causes
significant
osseous destruction. There is subcutaneous gas, which also
extends
intracranially, with resultant pneumocephalus.
IMPRESSION:
1. Extensive destructive lesion involving the calvarial vertex,
with
intracranial extension indicated by pneumocephalus and
extra-axial,
intracranial soft tissue/fluid component. This does not appear
to be of
primary CNS etiology. Differential includes infectious process
or a
subcutaneous or osseous malignancy. Further evaluation with
contrast-enhanced
MRI is recommended.
2. Small vessel ischemic disease, lacunar infarcts, and global
parenchymal
atrophy. There are no brain mass lesions or brain abscesses
identified.
Renal ultrasound [**2163-6-7**]:
FINDINGS: The left kidney measures 9 cm in length. There is no
left-sided
hydronephrosis. The right kidney measures 9.5 cm in length.
There is
moderate right-sided hydronephrosis. There is no renal mass or
stone. There
is a large > 15 cm cystic pelvic mass, which cannot be further
characterized.
Bladder is not visualized.
IMPRESSION:
1. Moderate right-sided hydronephrosis.
2. Non-specific, large cystic pelvic mass.
Brief Hospital Course:
Patient was a [**Age over 90 **] year old female with h.o CHF, DM, afib, who
presented with invasive scalp squamous cell carcinoma with
intracranial extension who died after code status was CMO.
.
# CMO - Had family meeting [**6-10**]. Discussed to stop vital signs,
non-essential medications other than eye drops, pain meds, and
PO antibiotics. Patient was continued on maintainance IV fluids.
.
# Pain control - This was the family's primary goal of care.
There were multiple etiologies of the pain including her chonic
right shoulder pain, sacral decubiti with possible abcess,
painful scalp leison, or the >15cm pelvic mass. Pain control was
transitioned from outpatient oxycontin pills to fenanyl patch
and oxycodone liquid. Patient was comfortably sedated and only
required additional pain medication when she was moved.
Palliative care was involved in pain management.
.
# Squamous cell ca, intracranial- The carcinoma developed over
an unknown time period. It probably developed before her care to
nursing home facility given that there was a rapid decline in
her functional status and intracraninal involvement of the
tumor. She was evaluated as an outpatient by dermatology and
was determined to have a squamous cell ca as per biopsy on [**5-25**].
Initially, the family wanted to have a neurosurgical
intervention, but the patient's INR was 7.7 so she was
transferred to the MICU for reversal. Later, the family decided
not to have surgery once it became apparent that the morbity was
high. Patient was started on vancomycin and ceftriaxone for
meningitis ppx and this was changed to PO cefepoxidime after a
family meeting determining that she would not want IV
antibiotics. Wound care was done to address her head wound.
.
# Resolved hypovolemia/ acute renal failure/ hypernatremia -
secondary to dehydration and intravascular hypovolemia in the
setting of diruetic use. Cr 2.0 on admission, most recent
baseline at [**Hospital1 18**] 1.1. This was the reason for the PICC line
placement and why the family wanted IVF.
.
# Pelvic mass - There is a large > 15 cm cystic pelvic mass seen
on renal ultrasound. This may be a source of pain.
.
# afib not on anticoagulation - Patient has a history of atrial
fibrillation but was placed on anticoagulation for a recent
phelbiltis. Given that the scalp wound oozes blood, the family
has decided that they do not want anticoagulation.
.
# DM-HISS
.
COMFORT MEASURES ONLY
DISCHARGE TO DEATH
Medications on Admission:
Medications at home:
Lasix 40 mg PO daily
Lisinopril 40 mg PO daily
OxyContin 20 mg PO q12, 10mg PO qHS
Xalatan 0.005 % Eye Drops 1 Drops(s) Once Daily, at bedtime
Azopt 1 % Eye Drops Ophthalmic 1 drop daily
Tylenol 1g PO TID
Serax 10mg PO BID
MVI PO daily
Pro-Stat 64 -- Unknown Strength, Twice Daily
Zinc Chelated 50 mg PO daily
Vitamin C 500 mg SR PO daily
Simethicone 80 mg chewable tab PO prn
.
Medications on transfer:
CeftriaXONE 1 gm IV Q24H
Vancomycin 1000 mg IV ONCE (dose by level)
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Humalog insulin sliding scale
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Pantoprazole 40 mg PO Q24H
Docusate Sodium (Liquid) 100 mg PO BID
Multivitamins 1 TAB PO DAILY
Oxazepam 10 mg PO BID:PRN anxiety
Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Bisacodyl 10 mg PO/PR DAILY:PRN
Senna 1 TAB PO BID:PRN
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
intracranial extension of invasive sqamous cell carcinoma
Secondary:
resolved acute renal failure secondary to dehydration
pelvic mass of unknown etiology
atrial fibrillation, chronic
hypertension
diabetes mellitus, type 2
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2163-6-15**]
|
[
"591",
"348.8",
"789.30",
"365.9",
"276.0",
"V66.7",
"253.6",
"716.90",
"250.00",
"707.03",
"198.3",
"V45.01",
"428.0",
"427.31",
"338.29",
"300.00",
"401.9",
"E934.2",
"171.0",
"584.9",
"252.00",
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"414.01",
"790.92",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8186, 8195
|
4816, 7262
|
286, 346
|
8472, 8481
|
2258, 2634
|
8534, 8569
|
1813, 1831
|
8157, 8163
|
8216, 8451
|
7288, 7288
|
8505, 8511
|
7309, 7688
|
1846, 2239
|
221, 248
|
374, 1493
|
2643, 4793
|
7713, 8134
|
1515, 1715
|
1731, 1797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,433
| 101,280
|
2181
|
Discharge summary
|
report
|
Admission Date: [**2173-6-14**] Discharge Date: [**2173-6-17**]
Date of Birth: [**2126-10-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46-yo-man w/ active cocaine use presents w/ LE edema. 10 days
ago, he developed b/l LE edema that has gotten progressively
worse until now. Three days ago, he developed dyspnea on
exertion when climbing stairs, assoc w/ 2-pillow orthopnea and
PND. He denies any recent chest pain, palpitations, headache,
confusion, weakness, numbness, abd pain, or hematuria. No
recent viral syndromes or URIs. He does admit to cocaine use
last night. Today, his wife convinced him to present to the ED
for evaluation.
.
In the ED, his BP was 230/170. BNP was elevated at 7500. CXR
revealed evidence of cardiomegaly and pulm edema. He was
treated w/ ASA 325 mg, lasix 10 mg IV, and hydralazine 10 mg IV
x 2. He responded well to lasix w/ good UOP, but diastolic BP
remained elevated at 170, prompting initiation of nitroprusside
gtt. He is now admitted to the CCU for further care.
Past Medical History:
none
Social History:
significant for current tobacco use. Drinks 3-4 beers a few
times weekly, no h/o withdrawal symptoms, seizures or DTs.
Snorts cocaine 1-2 times monthly. Never injected drugs.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T , BP 181/122, HR 84, RR 12, O2 98% 2L/m
Gen: lying flat in bed, pleasant and conversational, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear w/ MMM.
Neck: Supple with JVP of 8 cm.
CV: reg s1, loud s2, + 2/6 systolic murmur radiating to axilla,
no s3/s4/r
Pulm: CTA b/l w/ no crackles or wheezing
Abd: obese, +BS, soft, NTND.
Ext: warm, 2+ DP b/l, 2+ pitting edema to knees b/l
Neuro: a/o x 3, CN 2-12 intact
Pertinent Results:
[**2173-6-14**] 05:30PM WBC-7.7 RBC-5.00 HGB-15.0 HCT-42.8 MCV-86
MCH-30.0 MCHC-35.0 RDW-14.6
[**2173-6-14**] 05:30PM PLT COUNT-315
[**2173-6-14**] 05:30PM CK-MB-4 proBNP-7489*
[**2173-6-14**] 05:30PM cTropnT-0.02*
[**2173-6-14**] 05:30PM ALT(SGPT)-77* AST(SGOT)-60* CK(CPK)-195* ALK
PHOS-104 AMYLASE-100 TOT BILI-0.4
.
EKG demonstrated NSR at 87 bpm, nl axis, nl int, LVH w/ strain
pattern, no ischemic changes.
.
CXR: Moderate to severe enlargement of the cardiac silhouette,
and particularly the left atrium accompanied by pulmonary
vascular congestion and mild pulmonary edema consistent with
heart failure.
.
Conclusions:
The left atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy with mild cavity dilation and severe
global
hypokinesis. No left ventricular thrombus is seen. Tissue
Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The
right ventricular cavity is mildly dilated with severe free wall
hypokinesis.
The aortic valve leaflets (3) are minimally thickened. No aortic
stenosis or
aortic regurgitation is seen. The mitral valve leaflets are
structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a
very small circumferential pericardial effusion.
IMPRESSION: Moderate symmetric eft ventricular hypertrophy with
severe global
biventricular hypokinesis c/w diffuse process (toxin, metabolic,
cannot
exclude myocarditis; in the absence of LVH on ECG, an
infiltrative process
should also be considered). Mild mitral regurgitation. Moderate
pulmonary
arterial hypertension. Very small circumferential pericardial
effusion.
Possible abnormality on the aortic valve as described above
without aortic
regurgitation. .
If clinically indicated a TEE would be better able to define an
abnormality of
the aortic valve.
.
.
Brief Hospital Course:
46-yo-man w/ cocaine abuse presents w/ LE edema and DOE likely
from diastolic heart failure in the setting of cocaine use
complicated by hypertensive urgency.
.
Hypertensive urgency: BP 230/170 on presentation, most likely
from chronic HTN exacerbated by cocaine use. No signs of
end-organ damage at present except for elevated creatinine,
which is more likely a chronic problem. The patient was started
on labetalol and Lisinopril. His blood pressure was taken down
from 230 systolic to approx 160 systolic/100 diastolic on
discharge. His lower extremity edema improved with diuresis. An
echo performed on admission showed an LF EF of 25%. It is hoped
with good blood pressure control and use of an ACE-I with follow
up in addition to cocaine abstaining will improved his cardiac
function.
.
Renal Failure: creatinine on admission was 1.6 Likely acute
hypertensive nephropathy plus probalbe long-standing
hypertensive disease. discharged on ACE-I.
.
Substance Use: Social work saw patient and counceled him
regarding substance abuse.
.
Discharged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], cardiology follow up as well as
scheduled appointment with a new PCP @ [**Street Address(1) 11615**]
Health Center.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- hypertensive emergency
- ARF
- mild transaminitis likely [**2-19**] etoh and cocaine abuse
- cocaine abuse
- lower extremity edema improved
Discharge Condition:
well
Discharge Instructions:
You came in with hypertensive emergency. You were treated with
medications to improve your blood pressure. Notably you were
discharged on:
1. Lisinopril 20mg daily
2. HCTZ 25mg daily
3. Labetalol 400mg [**Hospital1 **]
4. ASA 162mg daily
.
It is extremely important for you to take these medications. It
is very important that you followup with your cardiology.
.
Please return to the ED if you experience SOB, chest pain,
fevers, chills, dizziness, decreased urine output. It is also
very important that you abstain from cocaine use.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 171**] on Monday [**2173-6-21**] at 10:00 in [**Hospital Ward Name 23**] 7th.
It is extremely important for you to keep this appointment.
.
You have a Primary Care Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**] on [**6-25**] @ 1:45
pm. Please arrive 1 hour prior to the appointment to complete
the Free Care Application there. You need to bring a picture ID,
proof of citizenship, proof of address. The Clinci phone number
is [**Telephone/Fax (1) 7976**]
.
Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on [**7-12**] at 10:30am.
His number is ([**Telephone/Fax (1) 11617**]. His secretary can help you
clarify your insurance.
|
[
"428.0",
"585.9",
"305.00",
"404.01",
"584.9",
"305.60",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5616, 5622
|
3924, 5166
|
279, 285
|
5816, 5822
|
1975, 3901
|
6412, 7154
|
1429, 1511
|
5221, 5593
|
5643, 5795
|
5192, 5198
|
5846, 6389
|
1526, 1956
|
232, 241
|
313, 1191
|
1213, 1219
|
1235, 1413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,544
| 163,687
|
845
|
Discharge summary
|
report
|
Admission Date: [**2201-1-29**] Discharge Date: [**2201-2-19**]
Date of Birth: [**2137-1-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Codeine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
gastro-intestinal bleed
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy x3
capsule endoscopy x2
PICC line placement
History of Present Illness:
The patient is a 64 M with CAD s/p 4V-CABG [**2180**], AVR [**2200-3-24**] [**Male First Name (un) 923**] mechanical valve, HTN, AFIB, DM2, transferred from
[**Hospital 5871**] Hospital to [**Hospital1 18**] ICU for workup of acute GIB. Admitted
to [**Location (un) 5871**] on [**1-11**] considering replacing his mechanical with
porcine valve, but there he had CP and dizziness per GI consult
note there, but was found to have INR 5 and Hct 18. Over 2
weeks, he received 14 U RBC, Hct up to 30s but then drifted
down. Did capsule limited by food but possibly melena, EGD
negative, bleeding scan negative, found blood trickling down
from terminal ileum. Patient did not notice any blood, but blind
in R eye and mostly blind in L eye. Patient was transferred to
[**Hospital1 18**] for further evaluation and potential replacement of
metallic aortic valves with porcine valve that would not require
anti-coagulation.
Past Medical History:
Coronary artery disease
s/p CABGx4 [**6-/2181**], last cath [**1-/2200**]: Three vessel coronary artery
disease. Successful stenting of the SVG-OM with drug-eluting
stent.
CRI with acute creatinine rise post cardiac catheterization
MI [**2193**]
PVD
AF
DVT
Diabetes
HTN
Neuropathy/Retinopathy
Iron deficiency anemia
Depression/Anxiety
s/p Subdural hematoma with evacuation
Multiple PCI's
Atrial Flutter ablation [**2190**]
Multiple toe amputations
Green Field Filter placement
s/p Right lower extremity bypass
Left saphenous vein harvest
Aortic stenosis
Social History:
Lives with wife in [**Name (NI) 5871**], MA. Prior alcohol and drug abuse
(pills/cocaine). He is disabled. Smoked [**12-2**] ppd stopping in
[**2195**]. Does not drink or use drugs at this time.
Family History:
2 uncles died of [**Name (NI) 5290**] at age 57 and 60.
Physical Exam:
VS: 97.0 / 100/60 / 81 / 20 / 97% RA
Gen: sleeping but arousable, NAD, w/o complaint
HEENT: R eye completely blind, L eye partially blind. L PERRL, L
EOMI, oropharynx clear w/o erythema, mouth with poor dentition
Neck: supple, no LAD, JVD 6
Chest: CTA B, well-healed sternotomy scar
CV: Irregularly irregular, S1, S2 with with mechanical click. No
murmurs
Abd: Soft, obese, ND, NT, +BS, no organomegaly
Extremities: WWP, left foot partial amputation at mid-tarsal
level, right foot with several digits amputated. 1+ non-pitting
edema in both LE, R>L. Numerous ecchymoses over both forearms.
Picc line in place on left arm.
Neuro: Alert and oriented x3. CN III-XII grossly intact.
Sensation to light touch intact in all extremities. Muscle
strength 5/5 throughout all extremities
Pertinent Results:
[**2201-1-29**] 08:08PM WBC-5.5 RBC-3.21*# HGB-9.7* HCT-28.7* MCV-89
MCH-30.0 MCHC-33.7 RDW-16.5* PLT COUNT-260
[**2201-1-29**] 08:08PM PT-17.5* PTT-102.7* INR(PT)-1.6*
[**2201-1-29**] 08:08PM GLUCOSE-230* UREA N-27* CREAT-2.0* SODIUM-133
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-9
.
Imaging:
[**2201-1-29**]: Chest xray: The patient has had median sternotomy. Mild
cardiomegaly has been present without change since [**2193**]. Also
unchanged is a prominent left upper lobe pulmonary artery which
should not be mistaken for juxtahilar nodule. Lungs are
essentially clear. Left posterior healed rib fractures are
longstanding. No pleural abnormality or evidence of central
adenopathy.
.
.
Endoscopy:
[**2201-1-30**]: EGD/Enteroscopy: Normal mucosa in the stomach
Normal mucosa in the upto mid jejunum
Normal mucosa in the duodenum
Otherwise normal EGD to mid jejunum
.
[**2201-2-6**]: EGD: Normal mucosa in the esophagus
Normal mucosa in the duodenum
Mild gastritis in the stomach
Gastric nodule.
[**2201-2-6**]: Capsule Endoscopy: 1. Angioectasia (nonbleeding) in the
distal duodenum or proximal jejunum 2. Angioectasias in the
jejunum that are not bleeding 3. Phlebectasia 4. nonbleeding
Angioectasias in the distal jejunum
5. diminutive nonbleeding polyp in the ileum 6. Lymphoid
hyperplasia in the terminal ileum.
.
[**2201-2-12**]: EGD/enteroscopy: Food in the stomach body
Food in jejunum. No angiodysplasia seen.
Erosion in the antrum compatible with erosive gastritis
Otherwise normal EGD to mid jejunum
Brief Hospital Course:
In brief, the patient is a 64 M with CAD s/p 4V-CABG [**2180**] and
drug-eluting stent to SVG in [**1-/2200**], AVR [**2200-3-24**] [**Male First Name (un) 923**]
mechanical valve, HTN, AFIB, DM2, transferred from [**Hospital 5871**]
Hospital to [**Hospital1 18**] ICU for workup of acute GIB.
.
1. Acute Blood Loss anemia from GI bleed: The patient initially
presented to [**Hospital 5871**] Hospital with shortness of breath and chest
pain; he was found to have a marked anemia, bloody stools, and a
supratherapeutic INR. He was transfused with pRBCs and
stabilized. Evaluation there pointed to a GI source but could
not localize a lesion. During his stay there his home regimen of
aspirin, Plavix, and coumadin was discontinued due to the risk
of exacerbating the GI bleed. He arrived at [**Hospital1 18**] on a heparin
drip. He was transferred to [**Hospital1 18**] for further evaluation. He
was first admitted to the Cardio-Thoracic surgery service for
consideration for replacing the metallic aortic valve with a
porcine valve that would not require anti-coagulation. However,
given that he had already undergone a re-do sternotomy; it was
not felt safe to open the chest again. After several attempts at
localizing a lesion, small angioectasias were found in multiple
sections of the small bowel. Also, mild gastritis was found.
However, no active bleeding was indentified. Given the
dispersed location of the angioectasias included some very
distal lesions, an endoscopic therapeutic option was not
feasible. His hematocrit was stabilized by the time of
discharge for ~2 weeks as the evaluation continued. He will be
discharged on a PPI at twice daily dosing to complete 1 month
afterwhich he will decrease the dose to daily. He will be
anti-coagulated with coumadin with INR target of 2.5-3.5. His
INR and hematocrit should be closely monitored weekly for 1
month. Strict attention should be made to maintain his INR in a
therapeutic range to decrease the likelihood of re-bleeding. His
anti-platelet agents were not restarted during this hospital
stay due to the risk of re-bleeding would likely outweigh the
risk of in-stent thombosis now 13 months since the placement of
the most recent stent. These medications could be re-considered
as an outpatient. His hematocrit at discharge was 28.9 and his
INR was 2.7.
.
2. AV replacement: The patient continued on anti-coagulation
with heparin drip monotherapy while the GI bleed evaluation
continued. He was discharged with coumadin as above.
.
3. CAD, CHF - The patient has an extensive history of coronary
disease including a CABG in [**2180**] and subsequent
re-vascularizations. Given his risk of life-threatening GI
bleeding his anti-platelet agents were discontinued. He
remained chest pain free during his hospital stay. He was
well-compensated from his CHF. He remained on carvedilol with
adequate heart rate and blood pressure control. He remained on a
statin. Aspirin and plavix were held as above. If his blood
pressure would tolerate it, he would be a good candidate for
adding [**First Name8 (NamePattern2) **] [**Last Name (un) **] to his heart failure regimen.
.
4. Itch: The patient complained of intense itchiness of his
lateral forearms. In talking with the patient's wife this has
been a chronic problem for him and gets adequate control of the
symptoms with over-the-counter remedies. The area of concern
was without appreciable skin changes or rash. He was discharged
with anti-histamines and topical therapies for symptomatic
relief. An evaluation by an allergist may be of benefit as an
outpatient.
.
5. Diabetes Mellitus type 2: The patient had variable blood
sugar control as his diet would vary with regard to procedures
done to evaluate the GI bleeding. He was followed closely by
the [**Last Name (un) **] Diabetes consult service to titrate his insulin
dosing. He will be discharged with glargine insulin and humalog
sliding scale.
.
6. Chronic kidney disease - The patient has a baseline chronic
kidney disease likely related to diabetes, hypertension and
residual damage from IV contrast administration. He remained
close to his baseline Cr throughout his hospital stay except for
a mild rise which was thought secondary to pre-renal azotemia
from inadequate oral intake. His creatinine recovered to his
baseline with oral hydration.
.
7. Hypertension: The patient had stable blood pressure on home
blood pressure regimen.
.
8. AFIB: There were no acute issues. He remained well rate
controlled with his carvedilol. He was anti-coagulated as above.
.
9. Depression: There were no acute issues, and he remained on
his home regimen.
.
10. FEN: diabetic, cardiac diet
11. PPX: No bowel regimen needed, PPI, heparin gtt
12. CODE: Full
13. DISPO: The patient was discharged in good condition to
follow-up with his PCP and have his blood drawn periodically to
monitor his INR and hematocrit.
Medications on Admission:
Home Medications:
Protonix 40 mg daily
Crestor 40 mg daily
Coreg 25 mg twice daily
Plavix 75 mg daily
Tricor 145 mg daily
Avandia 4 mg daily
Coumadin 6mg daily (M-W-F), 7mg daily (T-Th-Sat-Sun)
Fluoxetine 40 mg daily
Lasix 20 mg daily
Niaspan 1000 mg twice daily
Vicodin prn
Aspirin 81 mg daily
Colace 100 mg twice daily
Vitamin D
Lantus 15 units daily
Regular insulin Sliding Scale
.
Medications on Transfer:
heparin drip
Colace
ASA 81
Niaspan
Nexium 40 [**Hospital1 **]
Coreg
Lantus / humalog
Timoptic
Fluoxetine
Lipitor
ambien PRN
calcium
lasix
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-2**]
Drops Ophthalmic TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
3 weeks: after 3 weeks decrease to once daily dose.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO twice a day.
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
once a day.
6. Outpatient Lab Work
Please have the following labs drawn on [**2201-2-21**] and forward
result to Dr.[**Name (NI) 5875**] office (telephone: [**Telephone/Fax (1) 5876**])
Hematocrit, PT/INR
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Lantus 100 unit/mL Solution Sig: Thirteen (13) units
Subcutaneous at bedtime.
Disp:*10 mL* Refills:*2*
13. Humalog 100 unit/mL Solution Sig: 0-18 units Subcutaneous
four times a day: dose according to enclosed sliding scale.
Disp:*10 mL* Refills:*2*
14. Benadryl 25 mg Capsule Sig: [**12-2**] Capsules PO every eight (8)
hours as needed for itching.
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*1 bottle* Refills:*0*
16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute Blood Loss anemia from gastro-intestinal bleed
Aortic stenosis s/p aortic valve replacement
Diabetes mellitus type 2 controlled with complication of
retinopathy
CHF - systolic
Coronary Artery Disease s/p CABG
Renal Failure acute and chronic
.
Secondary:
Depression
Atrial fibrillation
Pruritis
Discharge Condition:
good. ambulating without assist. hematocrit stable. tolerating
oral medication and nutrition.
Discharge Instructions:
You have been evaluated for a gastro-intestinal bleed. The
likely source(s) of the bleeding was (were) small abnormal blood
vessels in your small bowel. Several attempts were made to treat
the lesions directly, but these were beyond the reach of the
enteroscopes. As the bleeding stopped, you were restarted on
your coumadin and discharged to home with close follow-up with
your primary doctor.
.
You should have your blood counts checked regularly as described
in the discharge medication section. Also now that you are back
on the coumadin, you will need regular monitoring of the dose to
limit the risk of re-bleeding.
.
Please attend the recommended follow-up appointments as
described below.
.
Please take the medications as prescribed. Your medications have
changed since you originally entered the hospital. Please take
only those medications listed in the discharge paperwork.
.
If you develop any new or concerning symptoms particularly any
signs of re-bleeding (bloody stools, dizziness, shortness of
breath, or chest pain); seek medical attention immediately by
calling 911. For at least a month, you should have your family
members look at your stools to make sure there is no blood.
Followup Instructions:
1: Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) 5873**] on Thursday, [**2-26**] at 11am. Please call [**Telephone/Fax (1) 5878**] with questions.
.
2: Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] on [**Last Name (LF) 766**], [**3-23**] at
11:45am. Please call [**Telephone/Fax (1) 5879**] with questions.
.
3. Blood Test: Please go to [**Hospital 5871**] Hospital on Saturday, [**2-21**] in the morning to get your blood drawn.
|
[
"412",
"357.2",
"427.31",
"V15.1",
"250.60",
"285.1",
"V45.81",
"403.90",
"569.85",
"584.9",
"428.0",
"428.20",
"V12.51",
"250.50",
"V15.2",
"585.9",
"535.40",
"362.01",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11858, 11864
|
4569, 9469
|
319, 392
|
12217, 12313
|
3016, 4546
|
13562, 14114
|
2144, 2201
|
10068, 11835
|
11885, 12196
|
9495, 9495
|
12337, 13539
|
2216, 2997
|
9513, 9880
|
256, 281
|
420, 1336
|
9905, 10045
|
1358, 1915
|
1931, 2128
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,466
| 185,052
|
50452
|
Discharge summary
|
report
|
Admission Date: [**2198-4-2**] Discharge Date: [**2198-4-16**]
Date of Birth: [**2122-1-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Tracheostomy and PEG placment
History of Present Illness:
76 yo gentleman who fell down stairs, sustaining multiple facial
fractures. He had multiple unseccessful attempts at intubation
by EMTs in the field. He was then transported to [**Hospital1 18**] and was
intubated.
Past Medical History:
Bipolar depression, HTN, Bilateral inguinal hernias, Hiatal
hernia
Social History:
Married; lives with wife
Family History:
Noncontributory
Pertinent Results:
[**2198-4-2**] 05:06PM GLUCOSE-219* LACTATE-5.6* NA+-142 K+-3.6
CL--107 TCO2-17*
[**2198-4-2**] 05:00PM UREA N-17 CREAT-1.7*
[**2198-4-2**] 05:00PM WBC-20.7* RBC-5.59 HGB-15.4 HCT-49.4 MCV-88
MCH-27.6 MCHC-31.2 RDW-14.1
[**2198-4-2**] 05:00PM PLT COUNT-343
[**2198-4-2**] 05:00PM PT-12.6 PTT-23.9 INR(PT)-1.1
CT HEAD W/O CONTRAST
IMPRESSION:
1. Multiple facial fractures involving the left
zygomaticomaxillary complex, nasal bones, and, very likely the
left orbital floor. Further evaluation with dedicated facial
bone CT is recommended as discussed with Dr. [**Last Name (STitle) **] and other
members of the Trauma Surgery team.
2. Moderate left proptosis.
3. Marked left periorbital soft tissue swelling and subcutaneous
emphysema.
4. Air-fluid levels in the paranasal sinuses, consistent with
hemorrhage.
5. No intracranial hemorrhage.
CT C-SPINE W/O CONTRAST
IMPRESSION: Multilevel degenerative changes of the cervical
spine. No evidence of acute fracture.
CT CHEST W/CONTRAST [**2198-4-2**] 5:14 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
IMPRESSION:
1. Large bilateral lower lobe consolidations, likely
representing a combination of aspiration and atelectasis.
2. Aspirated material within the right and left mainstem
bronchus.
3. NG tube terminates just below the GE junction with a
distended stomach. Further advancement is recommended.
4. Left adrenal lesions, incompletely characterized on this
single-phase study, with appearance suggestive of underlying
hyperplasia. This could be further evaluated with a dedicated CT
or MRI.
5. Multiple hypoattenuating lesions within both kidneys too
small to characterize.
6. Cholelithiasis.
7. Subcentimeter hypoattenuating focus within the right lobe of
the liver too small to characterize.
8. Large left inguinal hernia.
9. Grade 1 anterolisthesis of L5 over S1 with associated
spondylolysis.
Cardiology Report ECG Study Date of [**2198-4-10**] 7:56:12 PM
Baseline artifact. Regular wide complex rhythm. Intraventricular
conduction
delay. Right bundle-branch block type. Inferior Q waves.
Consider prior
inferior myocardial infarction. This may be an idioventricular
rhythm.
Q-T interval prolongation. ST-T wave abnormalities. Since the
previous
tracing of [**2198-4-10**] the QRS complex has widened. There are
probable
retrograde P waves in the ST segment. Clinical correlation is
suggested.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 0 158 476/479 0 25 97
Brief Hospital Course:
He was admitted to the Trauma Service. He was taken to the
Trauma ICU where he was monitored closely. Plastic Surgery was
consulted given his facial fractures; these injuries were
nonoperative. On the following day he underwent bronchoscopy and
was found to have foreign body in his airway; it appeared that
it was fragments of his dentures; these were removed without
incident. After several days in the ICU his sedation was weaned
and he was allowed to wake up with goal of extubation. He was
extubated and failed trials x2 and was re intubated. After
discussion with his family the decision was made to perform a
tracheostomy; he was taken to the operating room on [**4-10**] for
this as well as placement of a Dobbhoff. A Speech and Swallow
evaluation was performed for Passy Muir; he was able to tolerate
and use of this was implemented into his plan of care. He was
started on a ground diet with thin liquids; his diet consistency
should be upgraded once re-evaluation done at rehab. His
tracheostomy was removed at bedside on [**4-13**] without incident and
he has been maintaining adequate oxygen saturations on room air.
ENT was also consulted given his repeated attempts pre-hospital
at intubation; there was concern for damage to his epiglottis.
No acute issues were identified; it is being recommended that he
have an outpatient ENT follow up either here at [**Hospital1 18**] or through
his primary care provider as an [**Name9 (PRE) 54923**].
He was eventually transferred to the regular nursing unit and
initially required a 1:1 sitter. As his mental status improved
the sitter was discontinued. There were no behavioral issues
identified during his hospital stay. He is alert and oriented
and oriented x2-3; at times forgets where he is; he is
cooperative with his care.
He was evaluated by Physical and Occupational therapy and it has
been recommended that he go to a rehab facility for a short time
in order to improve his overall functional abilities.
Medications on Admission:
Lithium 300''', Sertraline 200', Trazadone 25qhs, Lisinopril 20'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name9 (PRE) **]: One (1) ML
Injection TID (3 times a day).
2. Lithium Carbonate 300 mg Capsule [**Name9 (PRE) **]: One (1) Capsule PO TID
(3 times a day).
3. Sertraline 100 mg Tablet [**Name9 (PRE) **]: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO TID
(3 times a day): hold for HR<60; SBP<110.
5. Lisinopril 20 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO DAILY (Daily):
hold fro SBP< 110.
6. Albuterol 90 mcg/Actuation Aerosol [**Name9 (PRE) **]: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Name9 (PRE) **]: Four (4)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
8. Senna 8.6 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
9. Trazodone 50 mg Tablet [**Name9 (PRE) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
s/p Fall
Multiple facial fractures:
1.Left zygomaticmaxillary
2.Nasal bone
3.Left orbital floor
4.Left medial ptyergoid plate
Respiratory failure
Discharge Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 6429**] for an
appointment.
Completed by:[**2198-4-20**]
|
[
"401.9",
"507.0",
"588.1",
"802.4",
"802.6",
"518.5",
"802.0",
"934.1",
"296.89",
"801.44",
"873.42",
"507.8",
"276.0",
"E880.9",
"E849.0",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"38.91",
"96.6",
"38.93",
"21.71",
"08.81",
"96.04",
"96.72",
"33.23",
"98.15"
] |
icd9pcs
|
[
[
[]
]
] |
6659, 6744
|
3263, 5240
|
321, 353
|
6934, 6941
|
782, 3240
|
6964, 7106
|
746, 763
|
5358, 6636
|
6765, 6913
|
5266, 5335
|
273, 283
|
381, 598
|
620, 688
|
704, 730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,193
| 175,465
|
34201
|
Discharge summary
|
report
|
Admission Date: [**2147-5-2**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2109-11-26**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
fulminant liver failure
Major Surgical or Invasive Procedure:
head bolt
History of Present Illness:
Mrs. [**Known lastname **] is a 37F with no significant PMH who presents
from an OSH with fulminant hepatic failure. She was in her USOH
until approximately [**4-26**]. She went out with some friends and
consumed substantial amounts of EtOH and used cocaine
intranasally. The next day, she developed myalgias and fatigue.
On [**4-28**], she had nausea, fevers and chills and later began
vomitting, no hematemesis. This continued for 2 days and was not
able to tolerate PO food. Her mother brought her to an OSH
because of her worsening fatigue/n/v and oliguria since [**4-29**].
Denies any melena/CP/SOB. Has mild ab discomfort. Denies any
recent travel. The pt reports taking unknown dietary
supplements.
She has been taking ibuprofen and acetaminophen intermittently,
although she can not rememeber the exact amounts (likely not
more
than 3g acetaminophen daily). She received acetylcysteine and
acyclovir at the OSh and was transferred for transplant
evaluation.
Past Medical History:
depression.anxiety
Social History:
Lives with 10 yo daughter. [**Name (NI) 1403**] at a day spa. Initiating
divorce proceedings [**12-31**] spousal infidelity. [**11-30**] PPD on and off
over last 15 years, reports [**11-30**] glasses of wine 4-5 times per
week, uses cocaine but never IV drugs.
Physical Exam:
Vitals: T: 95.9 BP: 138/84 P: 90 R: 19 SaO2: 99%RA
General: Drowsy, but easily rousable and attentive, A&Ox3,
appropriate, cooperative
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry
Neck: supple, no significant JVD
Pulmonary: CTAB
Cardiac: RRR, no murmurs,
Abdomen: soft, moderately tender throughout, no palpable
hepatosplenomegaly, no masses, no rebound/guarding
Extremities: no c/c/e, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Pertinent Results:
[**2147-5-2**] 07:52AM BLOOD WBC-9.2 RBC-3.95* Hgb-12.7 Hct-36.0
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.1 Plt Ct-125*
[**2147-5-4**] 09:46AM BLOOD WBC-4.0 RBC-2.82* Hgb-9.0* Hct-24.5*
MCV-87 MCH-31.9 MCHC-36.7* RDW-14.0 Plt Ct-48*
[**2147-5-2**] 07:52AM BLOOD PT-41.5* PTT-36.3* INR(PT)-4.5*
[**2147-5-3**] 02:57AM BLOOD PT-46.6* PTT-41.5* INR(PT)-5.2*
[**2147-5-3**] 12:01PM BLOOD PT-13.5* PTT-32.9 INR(PT)-1.2*
[**2147-5-4**] 09:46AM BLOOD PT-23.9* PTT-89.4* INR(PT)-2.3*
[**2147-5-2**] 07:52AM BLOOD Plt Ct-125*
[**2147-5-4**] 09:46AM BLOOD Plt Ct-48*
[**2147-5-2**] 07:52AM BLOOD Glucose-163* UreaN-47* Creat-7.3* Na-143
K-3.4 Cl-100 HCO3-19* AnGap-27*
[**2147-5-4**] 09:46AM BLOOD Glucose-106* UreaN-23* Creat-4.6* Na-139
K-3.5 Cl-93* HCO3-17* AnGap-33*
[**2147-5-2**] 07:52AM BLOOD ALT-6375* AST-3665* CK(CPK)-176*
AlkPhos-118* Amylase-32 TotBili-4.2*
[**2147-5-3**] 06:06AM BLOOD ALT-4870* AST-2127* LD(LDH)-1464*
AlkPhos-127* Amylase-32 TotBili-6.0*
[**2147-5-4**] 09:46AM BLOOD ALT-2085* AST-992* AlkPhos-131*
TotBili-6.4*
[**2147-5-2**] 07:52AM BLOOD calTIBC-211* Ferritn-GREATER TH TRF-162*
[**2147-5-2**] 07:52AM BLOOD Osmolal-311*
[**2147-5-4**] 01:35AM BLOOD Osmolal-302
[**2147-5-2**] 07:52AM BLOOD HBsAg-POSITIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-POSITIVE IgM HAV-NEGATIVE
[**2147-5-2**] 07:52AM BLOOD HIV Ab-NEGATIVE
[**2147-5-2**] 07:52AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2147-5-2**] 07:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6.0
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2147-5-2**] 07:52AM BLOOD HCV Ab-NEGATIVE
[**2147-5-2**] 08:55AM BLOOD Type-ART pO2-108* pCO2-33* pH-7.41
calTCO2-22 Base XS--2
[**2147-5-3**] 10:21AM BLOOD Type-ART Rates-24/ Tidal V-650 PEEP-5
FiO2-60 pO2-270* pCO2-23* pH-7.48* calTCO2-18* Base XS--3
Intubat-INTUBATED
[**2147-5-3**] 08:34PM BLOOD Type-ART Tidal V-650 PEEP-5 FiO2-60
pO2-234* pCO2-17* pH-7.45 calTCO2-12* Base XS--8
Intubat-INTUBATED
[**2147-5-4**] 09:58AM BLOOD Type-ART pO2-178* pCO2-26* pH-7.51*
calTCO2-21 Base XS-0
[**2147-5-2**] 08:55AM BLOOD Lactate-5.2*
[**2147-5-3**] 08:34PM BLOOD Lactate-11.2*
[**2147-5-4**] 09:58AM BLOOD Glucose-99 Lactate-7.4*
[**2147-5-2**] 08:15AM URINE RBC-10* WBC-27* Bacteri-FEW Yeast-NONE
Epi-8
[**2147-5-2**] 08:15AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-300 Ketone-10 Bilirub-MOD Urobiln-1 pH-6.0 Leuks-TR
[**2147-5-2**] 08:15AM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2147-5-2**] 08:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
CT HEAD W/O CONTRAST [**2147-5-3**] 6:47 AM
CT HEAD W/O CONTRAST
Reason: evaluate for cerebral edema
IMPRESSION: No definite evidence for cerebral edema or other
acute intracranial process. However, the study is not sensitive
for mild or early cerebral edema and followup would be
recommended as clinically indicated.
BRAIN SCAN [**2147-5-4**]
BRAIN SCAN
Reason: 37 YEAR OLD WOMAN WITH FULMINANT HEPATIC FAILURE
RADIOPHARMECEUTICAL DATA:
24.6 mCi Tc-[**Age over 90 **]m Neurolite ([**2147-5-4**]);
HISTORY: 37 year-old woman with fulminant hepatic failure -
Please assess brain
perfusion in the setting of increased ICP.
INTERPRETATION: Following the intaveous injection of 24.6 mCi
Tc-[**Age over 90 **]m Neurolite,
dynamic flow and static images of the brain in multiple
projections were
obtained. There is no scintigraphic evidence of perfusion to the
cerebral
cortex.
The perfusion abnormalities noted above are consistent with
brain death.
IMPRESSION: Absent perfusion to the cerebral cortex on
scintigraphy is
consistent with the clinical history of brain death.
Brief Hospital Course:
ON admission patient had full serologies, labs, etc. drawn, echo
and liver u/s in anticipation of possible need for transplant.
She was sleepy but arousable all day, still not making urine.
Hepatology, renal, ID, and neurosurg consults were all obtained.
Overnight from [**Date range (1) 5568**] her mental status deteriorated, and she
was urgently intubated and sedated. In the am she had an HD line
place and was started on CVVH. A Head CT showed diffuse
cerebral edema and a head bolt was also placed that am for ICP
monitoring. Initial ICP was in the 30s but then remained in the
20s to high teens throughout the day. The patient was placed on
the transplant list as status 1 that day. That 2nd night of [**5-3**]
she deteriorated ON, had ICPs in the 40s, hypertensive. Was
placed in a pentobarb coma and started on mannitol in an effort
to decrease her ICPs. ICPs have been in the teens since. Head
CT showed worsening cerebral edema. Also, pupils were fixed and
dilated in the morning of [**5-4**], a change from bilaterally
reactive only 12 hours earlier. Neurology consult was then also
obtained for prognosis and her neurological condition. Brain
scan and EEG were c/w brain death. The family had been present
throughout. There was a family meeting with the transplant
attending and the decision was made to withdrawe care. The
patient expired at 1340 on [**2147-5-4**] with family present.
Discharge Disposition:
Expired
Discharge Diagnosis:
fulminant hepatic failure from hepatitis B
Discharge Condition:
death
Completed by:[**2147-5-4**]
|
[
"070.20",
"788.5",
"348.5",
"300.00",
"276.3",
"790.29",
"311",
"584.9",
"518.81",
"276.2",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.10",
"39.95",
"96.04",
"96.71",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
7179, 7188
|
5753, 7156
|
318, 329
|
7274, 7309
|
2136, 5730
|
7209, 7253
|
1661, 2117
|
255, 280
|
357, 1325
|
1347, 1367
|
1383, 1646
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,218
| 137,323
|
49186
|
Discharge summary
|
report
|
Admission Date: [**2190-8-16**] Discharge Date: [**2190-8-27**]
Date of Birth: [**2110-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Change in MS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 80-year-old man w/ hypertension, anxiety,
ulcerative colitis, diverticulosis w/ recent GI bleeding, recent
NSTEMI, and dementia recently started on Exelon, who presents
today for evaluation of an episode of unresponsiveness. The pt
was in his USOH until about noon today at his NH when he became
unresponsive. VS at the time: Temp 96.8F, HR 68, R 20, BP 78/50,
FSBS 105. He was responsive only to painful stimuli. He was
transferred to [**Hospital **] Hospital, where his BP was 94/66. He
continued to be unresponsive on transfer but his
unresponsiveness resolved spontaneously (total time approx 20
minutes). He had a negative Head CT, but was noted to have an
elevated Troponin to 0.11. He became agitated and received 0.5mg
Ativan, and was transferred to [**Hospital1 18**] for further work-up. On
arrival in the ED, VS - Temp 97.3F, HR 70, BP 92/56, R 12,
O2-sat 100% RA. In the ED repeat troponin was .06. EKG showed
t-wave inversions in I, II, and V3-V6. Cards was consulted and
"code STEMI" was called, but cardiology thought it wasn't
indicated because ST changes were non-pathologic. Pt was given
1500cc of fluid and admitted to the MICU for hypotension with
SBPs in the 80s.
Past Medical History:
Diverticulosis s/p recent bleed (treated at [**Location (un) 620**]), and a
prior bleed in [**2188**]
Ulcerative colitis
Hypertension
Dementia
Osteoarthritis
Status post hip replacement in [**2188-2-20**]
Anxiety
Social History:
Lives at a nursing home, which he was sent to after his last
hospitalization for NSTEMI (in [**5-30**]). Since then he has had a
more rapid decline in his functional status and he now requires
a wheel chair. He is somewhat forgetful. Diet: Dysphagia
mechanical soft w/ Honey thick liquids
Family History:
NC
Physical Exam:
Tmax: 35.6 ??????C (96 ??????F)
Tcurrent: 35.6 ??????C (96 ??????F)
HR: 75 (63 - 75) bpm
BP: 120/66(80) {82/56(64) - 120/66(80)} mmHg
RR: 14 (12 - 18) insp/min
SpO2: 86%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
O2 Delivery Device: 2L by NC.
SpO2: 86%
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (), (S1: Normal), (S2: Normal), No(t) S3, No(t)
S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): Self and time., Movement: Purposeful,
Tone: Normal
Pertinent Results:
[**2190-8-17**] 01:00AM BLOOD WBC-5.1 RBC-3.81* Hgb-11.7* Hct-35.2*
MCV-92 MCH-30.8 MCHC-33.3 RDW-14.6 Plt Ct-207
[**2190-8-17**] 01:00AM BLOOD Neuts-66.4 Lymphs-24.2 Monos-6.7 Eos-2.2
Baso-0.5
[**2190-8-17**] 01:00AM BLOOD PT-14.4* PTT-29.2 INR(PT)-1.3*
[**2190-8-17**] 01:00AM BLOOD Glucose-88 UreaN-20 Creat-0.7 Na-135
K-4.8 Cl-103 HCO3-25 AnGap-12
[**2190-8-17**] 01:00AM BLOOD ALT-45* AST-46* LD(LDH)-371* CK(CPK)-121
AlkPhos-125* Amylase-60 TotBili-0.7
[**2190-8-17**] 06:41AM BLOOD ALT-41* AST-27 CK(CPK)-103
[**2190-8-16**] 06:00PM BLOOD CK-MB-5 cTropnT-0.06*
[**2190-8-17**] 01:00AM BLOOD CK-MB-5 cTropnT-0.07*
[**2190-8-17**] 06:41AM BLOOD CK-MB-6 cTropnT-0.06*
[**2190-8-17**] 01:00AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.3 Mg-2.2
[**2190-8-17**] 06:41AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-8-17**] 01:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2190-8-17**] 01:00AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-4* pH-5.0 Leuks-SM
[**2190-8-17**] 01:00AM URINE RBC-[**11-11**]* WBC-[**6-1**]* Bacteri-FEW
Yeast-NONE Epi-0-2
[**2190-8-17**] 08:08AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2190-8-16**]
CXR FINDINGS:
There is stable cardiomegaly. There is minimal blunting of the
left
costophrenic angle. There are multiple gas-filled loops of bowel
seen in the upper abdomen, likely unchanged since the prior
examination. There are no focal consolidations. Mild edema is
appreciated.
CONCLUSION:
Stable cardiomegaly with mild edema. No pneumonia seen.
The study and the report were reviewed by the staff radiologist.
ECG: EKG: NSR at 60bpm, LAD, IVCD, <1mm ST elevations in V1-V3,
<1mm Q waves in V1-V3, <1mm ST depressions in V5-V6, TWI in I,
II, and V3-V6. All new from prior in [**5-30**].
CAROTID DOPPLER: FINDINGS: The carotid arteries are tortuous,
which makes evaluation more
difficult. There is mild intimal thickening, consistent with
atherosclerotic
plaque formation noticed involving the ICA bilaterally. However,
there is no
significant ICA stenosis noticed on either side, and no evidence
of
significantly altered flow dynamics. The following peak systolic
flow
velocities were obtained in m/sec.
RIGHT SIDE: CCA 0.56, proximal ICA 0.73, mid ICA 0.49 and distal
ICA 0.45.
LEFT SIDE: CCA 0.81, proximal ICA 0.4, mid ICA 0.4 and distal
ICA 0.55.
The ICA/CCA ratios are 1.3 on the right and 0.67 on the left.
There was
antegrade flow recorded in both vertebral arteries.
IMPRESSION:
1. No significant ICA stenosis on either side.
2. Antegrade flow in both vertebral arteries
NON-CONTRAST HEAD CT: This exam is slighlty limited by motion.
There is no hemorrhage, hydrocephalus, shift of normally midline
structures or evidence of major vascular territorial infarct.
Hypodensities in the periventricular and subcortical white
matter reflects chronic microvascular ischemic change. The
ventricles and sulci are prominent consistent with age-related
involutional change. The cavernous carotids and left vertebral
artery are densely calcified. The visualized paranasal sinuses
and mastoid air cells remain normally aerated.
IMPRESSION: Exam is slightly limited by motion. There is no
acute
intracranial process. If there is concern regarding ischemia
then MRI with diffusion- weighted imaging is more sensitive.
ECHO:The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 15-20 %). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] The right ventricular cavity is dilated
with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Dilated LV with severe left ventricular systolic
dysfunction. Dilated and hypokinetic RV. At least moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2190-5-24**], the
lV is now dilated and global LV systolic dysfunction has
worsened - the basal segments had reasonable function on prior
but are now moderate to severely hypokinetic. The right
ventricle is now dilated and hypokinetic. The degree of mitral
regurgitation has increased.
Brief Hospital Course:
# Change in mental status - Differential is long, including
cardiac etiologies (ischemia, arrhythmia, CHF), infectious
processes (developing sepsis, CNS infection, pna, UTI),
medication/drug effect (prescribed use, improper use, OTCs or
illicit drugs), CVA, trauma (subdural, epidural), respiratory
failure (hypercarbia, carbon monoxide poisoning), vasovagal
reaction, electrolyte abnormality, hyperuricemia, dehydration,
etc. However, his improved mental status, initial labs, and
imaging are largely reassuring. Urinalysis showed evidence of
infection and he was treated with ciprofloxacin, but urine
cultures were negative and this was discontinued. Blood cultures
showed no growth. Cardiac enzymes remained flat at 0.06 after
reportedly being 0.11 at osh. Was kept on telemetry with no
concerning rhythms. Exelon was dicontinued. Urine and serum tox
were neg. Finger sticks were WNL. TSH and B12 were measured with
a low B12 and B12 supplementation was initiated. Patient
improved with fluid resuscitation of 3 liters and was alert, but
not oriented. Neurological deficits were noted by primary team
with left upper extremity weakness, flattening of the left
nasolabial fold and left ptosis and neurology was consulted. A
head CT showed no ischemic changes. Carotid dopplers were
negative and an Echo showed overall worsening of systolic
dysfunction with an ejection fraction of 15-20%, but no mural
thrombi. No further intervention was indicated.
.
# Dementia: Chronic, but has been progressive over the past
month. Held exelon as was only new med and may have contributed
to his acute MS change. There is no evidence that exelon will
have any additional benefit for his advanced dementia and is
relatively contraindicated in the elderly. Rapidly progressing
nature of patient's dementia was discussed extensively with his
son and it was explained that after extensive work-up, no
potentially reversible causes have been identified and we
recommend no further intervention can be recommended. Patient's
status was discussed with son and the decision was made to
provide only comfort measures and Palliative care team was
consulted. Patient became agitated and responded minimally to
haldol and olanzapine. Patient was started on po morphine for
pain and agitation relief. Pt died on respiratory distress on
[**2190-8-27**].
.
# Hypotension - Patient had hypotension with syetolic blood
pressures in the 70's that was initially unresposive to fluids
which prompted an ICU admission. Anti-hypertensives were held
and blood pressures eventually improved to 100's systolic with
more aggressive fluid resuscitation of 3 Liters. With
progressive decrease in po intake and the decision to hold IVF
blood pressure ultimately dropped and patient became
unresponsive.
.
# h/o CHF: EF = 25-30% on previous ECHO. Repeat ECHO showed
worsening of systolic dysfunction with ejection fraction of
15-20%. Continued home ASA and statin. Held b-blocker, ACEi, and
diuretics because of hypotension. Fluids to maintain urine
output and blood pressure resulted in dyspnea. Decision was
made to provide comfort measures only and IVF were no longer
administered.
Medications on Admission:
Home Medications:
- ASA 325mg PO daily
- Mesalamine 800mg PO TID
- Citalopram 40mg PO daily
- Simvastatin 80mg PO QHS
- Prilosec 20mg PO daily
- Metoprolol tartrate 12.5mg PO BID
- Lisinopril 2.5mg PO daily
- Multivitamin w/Minerals PO daily
- Lasix 20mg PO daily
- HCTZ 25mg PO daily
- Milk of Magnesia 30ml liquid PO daily PRN constipation
- Bisacodyl 10mg Suppository daily PRN constipation (try MoM
first)
- [**Name2 (NI) 20342**] enema PR daily PRN constipation (try Bisacodyl first)
- Maalox 30ml PO Q6hrs PRN Gi distress
- Tylenol 650mg PO Q4hrs PRN
- Recently started on Exelon
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Hypotension
Dementia
Delirium
Secondary:
Systolic Heart Failure
Discharge Condition:
Expired
Discharge Instructions:
Pt expired [**2190-8-27**]
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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58,774
| 154,395
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36929
|
Discharge summary
|
report
|
Admission Date: [**2119-4-26**] Discharge Date: [**2119-6-1**]
Date of Birth: [**2079-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Calamine / Caladryl
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Type A aortic dissection
Major Surgical or Invasive Procedure:
[**2119-4-26**] Emergency repair of type A aortic dissection ascending
aorta and hemi arch replacement with a size 24 Gelweave graft.
Aortic valve resuspension. Right axillary artery cannulation.
[**2119-5-9**] Diagnostic laparoscopy with conversion to Open
Cholecystectomy.
[**2119-5-24**] Placement of Right Subclavian Tunnelled Line
History of Present Illness:
This 40 year old white male with hypertension presented to an
outside emergency room with back pain and diarrhea. A CTA was
preformed, demonstrating a type A dissection. He was emergently
transferred to [**Hospital1 18**] for surgical intervention.
Past Medical History:
Hypertension, Obesity
Social History:
Rare ETOH, nonsmoker. Works as a car salesman.
Family History:
Parents both with MIs in their 50s
Physical Exam:
Admission: WDWN, obese white male in NAD
BP rt 153/100
Cor:RSR w/o murmur SR 93
Lungs: clear.
Extremeties: warm, well perfused. No edema. Pulses sym 2+
throughout
Neuro: intact
Pertinent Results:
[**2119-5-30**] 05:55AM BLOOD WBC-13.5* RBC-3.00* Hgb-8.5* Hct-27.1*
MCV-90 MCH-28.3 MCHC-31.4 RDW-14.2 Plt Ct-534*
[**2119-5-31**] 05:35AM BLOOD WBC-15.3* RBC-2.95* Hgb-8.4* Hct-26.0*
MCV-88 MCH-28.4 MCHC-32.3 RDW-14.9 Plt Ct-538*
[**2119-5-31**] 05:35AM BLOOD PT-19.5* PTT-57.3* INR(PT)-1.8*
[**2119-5-30**] 11:00PM BLOOD PT-18.9* PTT-54.1* INR(PT)-1.7*
[**2119-5-30**] 03:40PM BLOOD PT-18.4* PTT-48.9* INR(PT)-1.7*
[**2119-5-31**] 05:35AM BLOOD Glucose-100 UreaN-73* Na-137 K-4.4 Cl-95*
HCO3-26 AnGap-20
[**2119-5-29**] 05:30AM BLOOD Glucose-109* UreaN-78* Creat-7.7* Na-138
K-5.5* Cl-96 HCO3-27 AnGap-21*
[**2119-5-27**] 05:35AM BLOOD Glucose-105 UreaN-85* Creat-7.8*# Na-137
K-5.3* Cl-96 HCO3-24 AnGap-22*
[**2119-5-21**] 01:02AM BLOOD ALT-27 AST-26 AlkPhos-138* TotBili-0.9
[**2119-5-27**] 05:35AM BLOOD Amylase-433*
[**2119-5-29**] 05:30AM BLOOD Calcium-9.2 Phos-8.5* Mg-2.7*
[**2119-5-27**] 05:35AM BLOOD Calcium-9.4 Phos-7.6*# Mg-2.6
[**2119-4-29**] 04:47AM BLOOD %HbA1c-5.4
[**2119-5-23**] 03:58AM BLOOD Glucose-104 Lactate-0.9 Na-134* K-5.2
Cl-96*
EXAM: MRI of the thoracic spine.
CLINICAL INFORMATION: Patient with aortic surgery and difficulty
moving the
legs. Further evaluation of thoracic spine previous study was
limited.
TECHNIQUE: T1, T2 inversion recovery sagittal and T2 axial
images of the
thoracic spine obtained. The axial images are limited by motion.
Comparison
was made with the MRI of [**2119-5-25**].
FINDINGS: The sagittal T2 inversion recovery images demonstrate
no definite
evidence of abnormal signal within the spinal cord. Mild
heterogeneity of the
cord signal throughout the thoracic region appears artifactual.
There is mild
disc bulging seen at T2-T3, T5-6 and T7-T8 levels slightly
indenting the
thecal sac. At T2-3the, there is a small central protrusion seen
with minimal
indent to the anterior aspect of the spinal cord. There is no
evidence of
intraspinal fluid collection identified. No abnormal signal seen
within the
vertebral bodies.
IMPRESSION: No definite abnormal signal seen within the thoracic
spinal cord.
Disc bulging at T2-3 level slightly indents the anterior aspect
of the spinal
cord. Mild degenerative changes are also seen at other levels in
thoracic
region. No evidence of discitis or osteomyelitis.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SUN [**2119-5-28**] 6:57 PM
HISTORY: Recent ascending aortic arch replacement due to type A
dissection
with decreased movement of right leg since surgery. Assess for
cord injury.
Comparison is made to recent head CT of [**2119-5-17**] as well as
most recent CT
torso of [**2119-5-17**].
TECHNIQUE: Multiplanar T1- and T2-weighted sequences were
obtained through
the thoracic and lumbar spine. Large field of view sequence of
the entire
spine was also obtained.
MRI OF THE THORACIC SPINE
Please note the thoracic spine images are largely motion
degraded related to
patient motion as well as CSF pulsation artifact. Slight loss of
normal
bright T2 signal surrounding the thecal sac is also present
which may relate
to some re-distribution of patient's known prior subarachnoid
hemorrhage. This
limits evaluation for any focal cord edema or pathology.
Minimal multilevel degenerative bulges are noted without any
significant
foraminal or canal compromise. Increased signal is noted on the
scout HASTE
images within the aortic arch which likely relates to
blood/hematoma from the
patient's known dissection.
MRI OF THE LUMBAR SPINE:
Conus medullaris terminates at approximately L1-L2 interspace of
the distal
cord and exiting nerve roots appear unremarkable. Abnormal
increased T2/STIR
signal is noted within the posterior paravertebral muscles and
the
subcutaneous fat which may relate to prolonged bed rest or other
etiologies
such as rhabdomyolysis. The overall signal within the vertebral
bodies is
slightly abnormal with increased fatty content within the marrow
for patient
age. No focal spinal cord or vertebral body lesions are noted.
A mild disc bulge is noted at the L3-L4 interspace causing mild
right
foraminal narrowing but no significant central canal, lateral
recess, or left
foraminal narrowing.
At L4-L5 there is diffuse disc bulge which results in mild
bilateral foraminal
narrowing but no significant narrowing of the lateral recesses
or central
canal.
Incidentally detected on the large field of view images is
posterior disc
protrusions at the C5-C6 and as C6-C7 interspaces with mild mass
effect on the
ventral aspect of the cord noted at C5-C6. Posterior fossa
structures appear
unremarkable. Some mild mucus cysts are noted in the maxillary
sinuses.
IMPRESSION:
1. Difficult evaluation of the signal within the thoracic cord
due to motion
and pulsation artifacts. If there remains clinical concern for a
focal
postoperative thoracic cord infarct would recommend repeating
the thoracic
spine imaging when feasible.
2. Mild spondylosis within the thoracic and lumbar spines as
detailed above.
Partially evaluated disc protrusion noted within the cervical
spine which
results in mild mass effect on the ventral aspect of the cord at
C5-C6.
3. Increased edema within the posterior paravertebral
musculature of
uncertain etiology that may to patient's prolonged bed rest.
Findings were discussed with nurse practitioner, [**Doctor Last Name 14777**] on
[**5-26**] at
10:15 a.m.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: FRI [**2119-5-26**] 4:29 PM
HISTORY: 40-year-old man status post type A dissection repair
and
cholecystectomy with persistent fevers and white count.
COMPARISON: CT torso [**2119-5-7**].
TECHNIQUE: Helical imaging was performed from the thoracic inlet
through the
pubic symphysis after oral contrast administration. IV contrast
was not
administered. Sagittal and coronal reformations were prepared.
CT CHEST: The patient is status post aortic arch repair, which
appears
unchanged. There is stable fluid collection in the mediastinum
adjacent to the
aortic arch repair, (2:14). There is no evidence for gas or gas
collections
in the mediastinal fluid to suggest presence of abscess. There
are scattered
mediastinal nodes which appear stable. There is no pericardial
effusion.
There is a moderate-sized left pleural effusion and small right
pleural
effusion. There is slight increase in size of left basilar
atelectasis with
air bronchograms. There is decreased right basilar atelectasis
compared to
previous examination. There are no clearly defined masses or
nodules in the
chest. The tip of a right-sided central line catheter terminates
in the mid
SVC. There is no pneumothorax. There is no significant axillary
lymphadenopathy. Sternal cerclage wires appear normal. There is
no evidence
for sternal dehiscence. A nasogastric tube courses through the
esophagus
entering into the stomach. The tip of the endotracheal tube
terminates 3.5 cm
from the carina.
CT ABDOMEN: Lack of IV contrast limits evaluation of solid
intra-abdominal
organs. The spleen is moderately enlarged measuring 18 cm in AP
dimension. On
liver windows there is heterogeneous density of the spleen with
the
periphery appearing hypodense concerning for infarcts. The
adrenals appear
normal. The kidneys are unremarkable in their appearance without
stones or
hydronephrosis. The pancreas appears normal. The gallbladder is
absent. The
liver appears unremarkable without intrahepatic biliary ductal
dilatation.
There are scattered retroperitoneal and mesenteric nodes, none
of which reach
CT criteria for pathologic enlargement. Oral contrast is seen
within the
stomach and a nasogastric tube is also within the stomach.
Abdominal loops of
small bowel appear normal. There is trace simple fluid in the
left paracolic
gutter and adjacent to the liver, increased in volume since the
prior
examination. There is no free air in the abdomen.
CT PELVIS: Simple fluid tracks into the pelvis again new since
prior
examination. There is a rectal Flexi-Seal catheter. Otherwise,
the rectum,
sigmoid colon and pelvic loops of small and large bowel appear
unremarkable.
There is no free air in the pelvis. The bladder appears
unremarkable. There
is no significant pelvic or inguinal adenopathy. The tip of a
right femoral
line catheter terminates in the right femoral vein (2:129).
There are skin
staples in the patient's mid abdomen without evidence for
dehiscence. There
is no evidence for breakdown of the ventral wall incision. There
are no
hernias.
BONE AND SOFT TISSUE WINDOWS: Sternal cerclage wires appear
intact. There are
no suspicious sclerotic or lytic lesions. There is diffuse
anasarca,
progressed since the prior examination.
IMPRESSION:
1. Increased simple fluid in the abdomen and pelvis without
evidence for
abscess or loculated collections. Increase in body anasarca.
2. Improvement in right basilar atelectasis. Stable moderate
left pleural
effusion with left basilar atelectasis/consolidation.
3. Stable appearance to the postoperative mediastinum with fluid
collection
adjacent to the aortic arch repair. There are no locules of air
in this
region to suggest infection.
4. Status post cholecystectomy. No intrahepatic biliary ductal
dilatation.
5. Heterogeneous density of the spleen concerning for splenic
infarcts.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: [**Doctor First Name **] [**2119-5-18**] 11:35 AM
Clinical: Ascending aortic dissection.
Gross:
Pathology:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname 83338**], [**Known firstname 449**]", and the medical record number and "aorta."
It consists of multiple fragments of yellow to red soft tissue.
Some fragments are hemorrhagic, while others are rubbery. The
specimen measures 6.5 x 5.5 x 2.5 cm in aggregate and is
represented in A.
Brief Hospital Course:
The patient was taken emergently to the Operating Room where the
ascending aorta was replaced with a 24mm Gelweave graft and the
aortic valve was resuspended. He had 21 minutes of hypothermic
circulatory arrest and 2 minutes of cerebral circulatory arrest.
See operative note for additional details. Postoperatively he
was taken to the CVICU for invasive monitoring. His
postoperative course will now be broken down by systems.
CARDIAC: Experienced paroxsmal atrial fibrillation and was
eventually started on Warfarin anticoagulation. He remained
persistently hypertensive and required multiple after-load
agents as well rate-control medications. Maintained on
Amiodarone, Metoprolol, Labetolol, Clonidine and Hydralazine
prn.
PULMONARY: Weaned and extubated then required reintubation due
to collapse with prolonged intubation, extubated [**5-22**] without
complications. He required placement of left chest tube for
pleural effusion.
RENAL: Experienced a decline in renal function. A Quinton
catheter was placed and CVVH was instituted on [**2119-4-28**]. This was
ultimately switched to hemodialysis. On [**2119-5-24**], a right
subclavian tunnelled line was placed without complication. At
discharge, there are no signs of recovery of renal function.
NEURO: Early postop, was noted to have possible seizure.
Neurology was consulted and a CT of the head showed no acute
intracranial process. When awoken he was unable to move right
leg. Follow up head CT scan was notable for small subarachnoid
hemorrhage but not indicative of loss of right leg function,
spine was consulted and MRI did not reveal infarct. There was
no urgent or emergent neurosurgical intervention warranted. It
was recommended that he continue on Aspirin and Warfarin.
Follow up head CT showed resolution of subarachnoid bleed when
on heparin and coumadin. The patient did begin to move the
right lower extremity prior to discharge.
ID: Experienced persistent postoperative fevers associated with
elevated white count. Pan-cultures were obtained and the ID
service was consulted. Empiric antibiotics were initiated per
recommendations. Quitin tip was postitive for Klebsiella.
GI: Suspected to have acalculous cholecystitis and underwent
cholecystectomy.
NUTRITION: Initially maintained on TPN with transition to tube
feeds. Speech and swallow examination revealed possible silent
aspiration and strict NPO was recommended. The patient
subsequently passed a speech and swallow evaluation and tube
feeds were discontinued once adequate PO intake was established.
OTHER: Followed closely by Wound Care for sacral ulcer.
The patient was discharged to Rehab on POD 36 with appropriate
follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet PO DAILY (Daily).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-18**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed for agitation.
11. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): after 7 days decrease dose to 200mg daily.
15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
16. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Forty
Five (45) ML PO Q 8H (Every 8 Hours).
17. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
18. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
21. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
22. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous once
a day for 1 days: last dose [**2119-6-2**].
23. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 10 days: last dose [**2119-6-11**]
dose per HD protocol.
24. Outpatient Lab Work
Weekly CBC with diff, chem 7
Blood cultures with results to Dr. [**Last Name (STitle) 13895**] (ID) fax:
[**Telephone/Fax (1) 1419**]
25. Warfarin 5 mg Tablet Sig: as directed Tablet PO once a day:
Subclavian and IJ clot, afib and repeatedly clotting HD line.
goal INR 2-2.5 .
26. Outpatient Lab Work
check INR QOD until stable
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Type A Aortic dissection, s/p repair
Postoperative Respiratory Failure
Postoperative Renal Railure
Suspected acalculous cholecystitis
Postop Fevers
Postop Atrial Fibrillation
Postop Aspirtation/Dysphagia
Postop Sacral Decubitus Ulcer
Small Subarachnoid Hemorrhage
Hypertension
Obesity
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Weekly CBC with differential, chem 7
Blood cultures with results to Dr. [**Last Name (STitle) 13895**] (ID) fax:
[**Telephone/Fax (1) 1419**]
Dr. [**First Name (STitle) **] on [**7-3**] at 1pm [**Telephone/Fax (1) 170**]) in the [**Hospital **]
medical building [**Last Name (NamePattern1) **]. [**Hospital Unit Name **].
Dr. [**First Name (STitle) **] (general surgery) 2 weeks [**Telephone/Fax (1) 673**]
PCP [**Name Initial (PRE) 176**] 1 week of discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2119-6-6**]
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"E915",
"038.9",
"276.2",
"V64.41",
"996.73",
"401.9",
"934.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"51.22",
"99.15",
"39.61",
"96.04",
"96.05",
"39.57",
"96.72",
"39.64",
"34.04",
"39.95",
"35.11",
"38.93",
"33.23",
"88.72",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
16886, 16965
|
11463, 14159
|
309, 647
|
17294, 17301
|
1301, 11440
|
17705, 18297
|
1052, 1088
|
14214, 16863
|
16986, 17273
|
14185, 14191
|
17325, 17682
|
1103, 1282
|
245, 271
|
675, 927
|
949, 972
|
988, 1036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,722
| 132,756
|
52971
|
Discharge summary
|
report
|
Admission Date: [**2113-11-15**] Discharge Date: [**2113-11-17**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 109180**] is a [**Age over 90 **] y/o M with PMH of low-grade b-cell
non-hodgkins lymphoma most recently treated in [**2113-8-21**] with
rituxan, and CAD s/p CABG and pacer who was biba from home after
the sudden onset of SOB. Pt states he first noticed the
shortness of breath after he had been walking on his treadmill
for about 4 minutes. He said he had to stop and "didn't feel
right." He tried walking again after a short while and felt the
same. He says onset was relatively sudden, over the course of 45
minutes or so, characterized by tightness, cough, and SOB. No
CP. Pt states he noticed a similar feeling a few days earlier
but it went away. He has had a cough for approx. 1 week which
was also noticed by home home nurse, Pat. It is productive of
mucus "like saliva" but not green or yellow in color. He says he
has felt "congested" during the past week since he began
coughing. No palpitations, F/C/S, or abdominal pain. Says his BM
a little loose today but no other change in bowel movements. EMS
was called and found the patient to be wheezing with a room air
oxygen saturation 89%. He was also tachypneic in the 30s, but
began satting well on NRB. No h/o COPD or pulm disease.
In the ED vitals were 94, 193/132, 25, 100% NRB. EKG was done in
ED which showed paced beats. CXR showed PNA in RLL. He was given
levofloxacin in the ED for CAP coverage (lives at home) and
nebs. He was ordered for cefepime but had not received it by the
time of transfer to the floor, so this was discontinued in favor
of CTX/azithro regimen starting in AM. Stool guaiac negative.
On transfer, ED vitals were VS: 98.0, 150/51, 60, 16, 100% 6L
NRB. On the floor the patient is comfortable and in no acute
distress, providing the above history. Pt expressed uncertainty
with being treated by physicians he does not know and would like
"the most experienced doctor" to perform any procedures that
must be done to him.
Past Medical History:
- Non-hodgkins lymphoma: mesenteric, axillary/epitrochlear
recurrence (rituxin/leukeran/prednisone and radiation, rituxin
monotx for recurrence)
- HL
- HTN
- CAD (CABG x5v, pacer x13-15yrs)
- GERD
- Bilat total hip replacment c/b peripheral neuropathies
- anemia (pt states he has long history of anemia that is
"always near borderline")
- renal failure (baseline cr 1.6-1.8)
Social History:
Married to his wife [**Name (NI) **], 2nd marriage. Previously worked
in textiles. 2 sons, 1 daughter. [**Name (NI) 4084**] smokes, ocassional EtOH,
no other drug use. Lives at home and walks with a cane.
Family History:
- 2 sisters deceased
- Brother died 101
- Unknown cancer history
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: coarse crackles in RLL but otherwise no crackles or
wheezes. frequent coughing during lung exam
CV: systolic murmur [**3-26**] heard over entire precordium. irregular
rate with frequent early beats.
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: CN2-12 intact bilat, decreased hearing on right (pt wears
hearing aid bilat but was not wearing aid on right at time of
exam), strength 5/5 in UE and LE bilat
Pertinent Results:
Labs on Admission:
[**2113-11-15**] 05:35PM WBC-7.3 RBC-3.42* HGB-11.6* HCT-34.2*
MCV-100* MCH-33.9* MCHC-33.9 RDW-14.4
[**2113-11-15**] 05:35PM NEUTS-60.6 LYMPHS-28.7 MONOS-5.3 EOS-4.7*
BASOS-0.7
[**2113-11-15**] 05:35PM PLT COUNT-208
[**2113-11-15**] 05:35PM GLUCOSE-118* UREA N-27* CREAT-1.6* SODIUM-137
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19
[**2113-11-15**] 06:45PM LACTATE-1.2
Imaging:
CXR: [**2113-11-15**]
Cardiomegaly, pulmonary edema, small bilateral pleural
effusions.
Post-diuresis chest radiograph recommended to exclude underlying
pneumonia in the lower lobes.
CXR: [**2113-11-16**]
Resolution of temporary severe CHF episode with pulmonary
congestion, remaining right lower lobe infiltrate which ought to
be followed. No other new abnormalities.
Echo: [**2113-11-16**]
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The ascending aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Moderate
mitral regurgitation. Pulmonary artery hypertension. Mild aortic
regurgitation.
Brief Hospital Course:
1. Pneumonia
2. Acute diastolic CHF
3. Non-hodgkins lymphoma
4. CABG s/p CABG
5. Hypertension
6. Mitral regurgitation
7. Pulmonary hypertension
8. GERD
9. Chronic kidney disease, stage III
10. Anemia, likely secondary to CKD
Admitted with acute onset of dyspnea likely multifactorial from
right lower lobe pneumonia and CHF. As per his pneumonia, he was
covered empirically with antibiotics for presumed CAP with
ceftriaxone and azithromycin. As per acute on chronic CHF
exacerbation, etiology was unclear and may have been
precipitated by underlying infection and catecholamine surge
during exertion. He was ruled out for acute ischemia with
cardiac enzymes x 2. Echo showed biventricular hypertrophy and
moderate mitral regurgitation. Patient's breathing responded
well to diuresis with decrease in oxygen requirement and
significant improvement in CXR. Given that he did not appear
total body overloaded and that his creatine increased with
initial diuresis, opted not discharge him on standing diuretics.
He will see his PCP soon after [**Name9 (PRE) 702**] for further evaluation.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
daily
FELODIPINE - (Prescribed by Other Provider) - 10 mg Tablet
Extended Release 24 hr - Tablet(s) by mouth
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20mg
ASPIRIN 325mg po daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. felodipine 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended 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. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Pneumonia, unknown organism
2. Acute diastolic CHF
3. Non-hodgkins lymphoma
4. CABG s/p CABG
5. Hypertension
6. Mitral regurgitation
7. Pulmonary hypertension
8. GERD
9. Chronic kidney disease, stage III
10. Anemia, likely secondary to CKD
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 with shortness of breath, likely the result of
both pneumonia and congestive heart failure.
Please continue the prescribed antibiotic, completely the
medication as prescribed.
No other changes were made to your medications.
Followup Instructions:
Care connections
|
[
"285.21",
"585.3",
"V43.64",
"428.0",
"530.81",
"486",
"V45.81",
"428.33",
"584.9",
"403.90",
"424.0",
"202.80"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7621, 7679
|
5514, 6603
|
260, 266
|
7965, 7965
|
3654, 3659
|
8415, 8434
|
2870, 2937
|
7022, 7598
|
7700, 7944
|
6629, 6999
|
8147, 8392
|
2952, 3635
|
213, 222
|
294, 2229
|
3673, 5491
|
7980, 8123
|
2251, 2629
|
2645, 2854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,873
| 156,872
|
3476+55472+55473+55474+55479
|
Discharge summary
|
report+addendum+addendum+addendum+addendum
|
Admission Date: [**2147-4-11**] Discharge Date: [**2147-5-4**]
Service: SURGERY
Allergies:
All drug allergies previously recorded have been deleted
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Incarcerated paraesophageal hernia.
Major Surgical or Invasive Procedure:
Reduction and repair and gastropexy of incarcerated
paraesophageal hernia, repair of esophageal perforation,
gastrostomy and jejunostomy
History of Present Illness:
This is an 84-year-old woman has a known paraesophageal hernia.
She was thought to be a very high risk for an elective repair
several years ago and at that time the hernia did not appear
to be the type that would have a high propensity towards
incarceration. However, she now presents with an incarcerated
stomach with films showing no passage of barium. She presents
now for urgent repair.
Past Medical History:
paraesoph hernia, GERD, CAD/MI/CABG, A-Fib, COPD, HTN, h/o
[**Doctor First Name 329**] [**Doctor Last Name **] tear w/ dilatation, TIAs, DMII, dyslipid, RA, PVD,
? Hepatitis C
Social History:
Quick tobacco 1 year ago. Occasional alcohol use. No
recreational drugs.
Pertinent Results:
RADIOLOGY Final Report
CT ABDOMEN W/O CONTRAST [**2147-4-10**] 11:24 PM
1. Organoaxial gastric volvulus. Contrast does not pass beyond
the pylorus. No evidence of pneumatosis or free intra-abdominal
air.
2. Lower lobe pneumonia.
3. Bilateral pleural effusions.
4. Known type III hiatal hernia.
5. Extensive atherosclerotic calcifications of descending aorta
and its tributaries.
6. Severe degenerative bony changes with rotary scoliosis and
facet arthropathy.
BAS/UGI AIR/SBFT [**2147-4-11**] 1:10 AM
Organoaxial gastric volvulus. Obstruction at the level of the
pylorus.
CT ABDOMEN W/CONTRAST [**2147-4-24**] 12:00 PM
1. Status post esophagectomy. No fluid collections are
identified, although significant effusions, atelectasis and
airspace disease is seen.
2. Thyroid nodules and calcifications.
3. Subcapsular splenic hematoma versus infarction.
4. Significant widespread arthrosclerotic disease is identified.
BAS/UGI AIR/SBFT [**2147-4-24**] 12:27 PM
No evidence for esophageal leak.
[**2147-4-23**] URINE URINE CULTURE-FINAL {YEAST}
Brief Hospital Course:
Upon presentation to the [**Hospital1 69**],
the patient was immediately admitted to the Crimson Surgical
Service. A full work-up was done, including a CT scan of the
abdomen, which showed organoaxial gastric volvulus. A decision
was made to take the patient to the operating room. The patient
tolerated the procedure [please see operative note for further
details]. Post-operative, she was immediately admitted to the
surgical intensive care unit. She remained intubated until day
2 post-op. She remained in the SICU for a total of 7 days,
where treatment of pre-admission pneumonia was started with IV
Zosyn. On post-op day 2, her tubefeeds were started.
She was continued on Zosyn after being transferred to the
surgical floor. Her white blood count improved and her
antibiotics was switched to Levofloxacin. It remained within
normal limits until it up-trended when levofloxacin was removed.
Hence, levofloxacin was restarted.
She was pan-cultured several times. Only yeast grew from her
urine culture. She was appropriately treated with Fluconazole.
During her hospital stay, the Physical Therapy team as well as
Nursing has help her regain some of her strength.
On day of discharge, she had been tolerating her tubefeeds,
while producing adequate flatus, stool, and urine. She has been
ambulating with assistance. She had remained afebrile
throughout her hospital stay while her white blood count was
normalizing to normal limits. She has remained NPO [and needs
to remain NPO until at least seen in clinic].
She was discharged in stable condition to a rehabilitation
center with specific intructions for post-hospital care and
follow-up.
Discharge Medications:
1. Insulin SC (per Insulin Flowsheet)
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every four (4) hours.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q3-4H (Every 3 to 4 Hours) as needed for pain.
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY
(Daily).
11. Trandolapril 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Albuterol Sulfate 0.083 % Solution Sig: [**1-9**] Inhalation
every four (4) hours as needed for wheezing.
17. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
18. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): until seen in clinic (about 10-14 days); give
through J tube.
19. NPO at all times
20. Outpatient Lab Work
Patient on Lasix, please check electrolytes at least once a week
21. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
22. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Incarcerated paraesophageal hernia
Discharge Condition:
Stable
Discharge Instructions:
[**Month (only) 116**] return to taking outpatient medications. Please follow
directions as discussed previously with Dr. [**Last Name (STitle) **].
Please take medications as prescribed and read warning labels
carefully. If symptoms returns and/or worsens, please go to the
emergency room. If signs of infections such as fevers above
101.5 degrees, purulent discharge from wound, increased pain and
redness around wound, please call or go to the emergency room.
Remember to call for a follow up appointment (bellow). Light
activities until seen in clinic. [**Month (only) 116**] eat regular food, as
tolerated. [**Month (only) 116**] take quick showers but no baths. Absolutely no
smoking because it leads to poor wound healing.
If staples are still in placed, they will be removed when seen
in clinic. If outer plastic/gauze dressing is still intact, you
may peel it off at home. If steri-stips are in placed, they
will fall off in in about a week. Trim edges if desired, but do
not peel them off.
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office for a follow up appointment
in about 2 weeks ([**Telephone/Fax (1) 1483**].
Completed by:[**2147-4-25**] Name: [**Known lastname 2518**],[**Known firstname 2519**] N Unit No: [**Numeric Identifier 2520**]
Admission Date: [**2147-4-11**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2063-1-11**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 203**]
Addendum:
On day of patient's scheduled discharge to rehab, she
experienced afibrillation with ventricular response up to the
120's. This problem was controlled by adjusting her metropolol,
lasix, and digoxin. She was discharged one day after her
initial scheduled discharge.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 2075**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2147-4-27**] Name: [**Known lastname 2518**],[**Known firstname 2519**] N Unit No: [**Numeric Identifier 2520**]
Admission Date: [**2147-4-11**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2063-1-11**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 203**]
Addendum:
Cardiology were consulted for patient's atrial fibrillation with
with ventricular response, but it was decided that coumadin
should not be restarted at this time because of the patient's
previous history of gastro-intestinal bleed (presumably from
diverticulosis according to her health-care
proxi--grand-daughter [**Name (NI) 2521**])). Attempts to contact Dr. [**Last Name (STitle) 2522**]
(PCP) and Dr. [**Last Name (STitle) 2523**] unsuccessful, and a message was left.
The clinic's nurse returned the call and she said that she found
no records of coumadin given and that both doctors [**Name5 (PTitle) **] be
notified of the situation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 2075**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2147-4-28**] Name: [**Known lastname 2518**],[**Known firstname 2519**] N Unit No: [**Numeric Identifier 2520**]
Admission Date: [**2147-4-11**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2063-1-11**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 203**]
Addendum:
Pt's medications were adjusted after she was found to have a
heart rate to the 160s for several episodes in the days prior to
discharge. On cardiology's recommendation, the lopressor was
changed from [**Hospital1 **] to tid, with the control of hr to a maximum of
120s, but remaining in the 80-90s for the majority of the time.
Pt remains in a-fib/flutter, but now with better control of
rate. Pt's digoxin was decreased from 0.188 to 0.125 for a serum
level of 2.4. This level decreased to 1.6 on the day of
discharge and will be monitored as an outpatient. Pt is to
follow up with both Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 690**].
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 2075**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2147-5-1**] Name: [**Known lastname 2518**],[**Known firstname 2519**] N Unit No: [**Numeric Identifier 2520**]
Admission Date: [**2147-4-11**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2063-1-11**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 203**]
Addendum:
Pt's discharge was delayed by ongoing tachycardia which was
treated with further increases in her metoprolol to 100 PO tid.
With this regimen her hr has been in the 60-90s range, and her
BP has been adequate. Her PCP was also [**Name (NI) 178**] and the
descision was jointly made not to start her on coumadin at this
time. This was based on the assessment that the risk of an
elevated INR would be greater to her given her history of GI
bleed and her poor ambulatory status than the reduction in risk
of thromboembolic stroke from atrial fib/flutter.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 2075**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2147-5-4**]
|
[
"530.11",
"401.9",
"428.0",
"511.9",
"447.1",
"714.0",
"486",
"552.3",
"250.00",
"496",
"112.2",
"530.4",
"427.31",
"998.2",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.82",
"43.19",
"53.7",
"99.04",
"46.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11438, 11658
|
2246, 3912
|
298, 437
|
5928, 5937
|
1171, 2223
|
6998, 7769
|
3935, 5759
|
5870, 5907
|
5961, 6975
|
223, 260
|
465, 858
|
880, 1057
|
1073, 1149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,342
| 178,338
|
5259
|
Discharge summary
|
report
|
Admission Date: [**2121-5-12**] Discharge Date: [**2121-5-16**]
Date of Birth: [**2062-12-17**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Face swelling.
Major Surgical or Invasive Procedure:
Laryngoscopy.
History of Present Illness:
The patient is a 58 year old female with a history of lupus,
antiphospholipid syndrome w/ pulmonary and renal vein thromosis
on coumadin, stage V lupus nephritis who presents with 4 days of
progressive left facial swelling. Four days prior to
presentation, the patient began to develop a head ache. The
following morning she noticed swelling of her left lace and
neck. On the prior to presentation, the swelling became
markedly worse, and the patient developed subjective fevers and
chills. She felt as if her tougue could not fit within her
mouth, and noticed some dysphagia. She had no difficult
breathing, but pain with opening of her mouth. The pain
radiated to her left year, and has been upable to take much PO
intake. the patient reports no recent illness or sick contacks.
The patinet denies any history of salivary duct stones, neck
surgery, dental pain or recent procedures.
In the ED, initial vs were: T 100.5 P 120 BP 130/75 R 20 O2 sat
98% on RA. Patient had a CT scan that demonstrated a
submandibular gland obstructing stone with evidence of
infection. She was seen by ENT, underwent larygoscopy, was
given unasyn and vanc, 10mg IV decadron, and IV moprhine for
pain control. The patient was admitted to the MICU for airway
monitoring.
Past Medical History:
1. Systemic lupus erythematosus with antiphospholipid syndrome
on chronic anticoagulation-status post pulmonary embolism, renal
vein thrombosis
2. Stage V membranous glomerulonephritis Nephrotic syndrome,
now stage 3.
3. Depression
4. Obstructive sleep apnea
Social History:
The patient does not smoke any cigarettes, but she does drink
two to three alcoholic beverages per week. She is married and
works as a real estate [**Doctor Last Name 360**] and has one child who is healthy.
Family History:
Is notable for diabetes mellitus, and she does have one cousin
who did have lupus and was deceased of complications with
therapy.
Physical Exam:
On admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
Vitals: T 97.9, BP 142/82, HR 63, RR 16, O2sat 100% on RA
Tm 98.6, 142-143/76-82, 63-72, 16, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear; face with very
mild assymtetric swelling of left side with slight neck
fullness; nontender; no appreciable exudate on oral exam
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2121-5-12**] 04:36PM LACTATE-1.8
[**2121-5-12**] 04:20PM GLUCOSE-118* UREA N-16 CREAT-1.0 SODIUM-140
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2121-5-12**] 04:20PM CK(CPK)-104
[**2121-5-12**] 04:20PM cTropnT-<0.01
[**2121-5-12**] 04:20PM CK-MB-3
[**2121-5-12**] 04:20PM WBC-6.6# RBC-4.59 HGB-12.5 HCT-38.5 MCV-84
MCH-27.3 MCHC-32.5 RDW-14.9
[**2121-5-12**] 04:20PM NEUTS-86.8* LYMPHS-9.7* MONOS-1.9* EOS-1.2
BASOS-0.4
[**2121-5-12**] 04:20PM PLT COUNT-205
[**2121-5-12**] 04:20PM PT-25.7* PTT-26.9 INR(PT)-2.5*
On discharge:
[**2121-5-16**] 07:25AM BLOOD WBC-9.9 RBC-3.58* Hgb-9.8* Hct-30.2*
MCV-85 MCH-27.4 MCHC-32.5 RDW-15.0 Plt Ct-215
[**2121-5-16**] 07:25AM BLOOD PT-30.0* PTT-114.0* INR(PT)-3.1*
[**2121-5-16**] 07:25AM BLOOD Glucose-95 UreaN-23* Creat-1.0 Na-144
K-3.7 Cl-111* HCO3-24 AnGap-13
[**2121-5-15**] 02:46AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3
Wound Cultures showed mixed flora as well as [**Female First Name (un) **] ALBICANS.
STUDIES:
CT Neck with Contrast, [**2121-5-12**]:
Artifact from the dental amalgam degrades the images, within
these limitations there is a 20 x 15 mm enhancing inflammatory
mass below is angle of left mandible may be related to
infection/inflammation of the salivary gland or inferior
extension of the left parotid gland. Several enlarged neck lymph
nodes are seen.
Fiberoptic exam per ENT note:
Nasopharynx - right medial aspect of fossa of Rosenmuller with
approx 0.5cm clear watery cyst, posterior pharyngeal [**Name6 (MD) **] in NP
with 0.5cm mass with overlying granular muscosa in midline,
Larynx - valleculae clear, crisp epiglottis, patent piriforms
bil, crisp vocal folds with good mobility.
Brief Hospital Course:
# Left Facial Swelling: The patient presented with left
submandibular gland infection and large [**Location (un) 21511**] duct stone.
The patient was at risk for Ludwig's angina given rate of
progression of infection (over 1 day) and given that infection
already involves left submandibular space, and sublingual space.
Had been seen by ENT in ED, without evidence of airway
compromise. No evidence of laryngal swelling on scope. She
received antibiotics in ED and one time dose of dexamethasone.
She continued on vanc/unasyn while gland cultures were sent.
These returned with finding of mixed flora and [**Female First Name (un) **] albicans.
She was discharged on Augmentin and Fluconazole. ENT also
recommended [**Doctor Last Name 21512**] wedges QID and salivary massage QID to help
stimulate secretions. She was also discharged on Prednisone.
# Anti-phospholipid syndrome (APLS): The patient has a history
of PE and renal vein thromosis, managed on coumadin as
outpatient. Her INR remained therapeutic on this admission.
# Lupus: The patient has a history of Lupus managed by Dr.
[**Last Name (STitle) **]. No evidence of acute flare. No reason to suspect any
correlation with other autoimmune process like Sojourn's. She
continued hydrochlorquine but held cellcept in setting of
infection. She was discharged on Prednisone rather than Cellcept
until follow up with Dr. [**Last Name (STitle) 1667**].
# Glomerularnephritis: This had significantly improved on
cellcept. Grade 3 membranous glomerularnephritis with Cr at
baseline at 1.1. She was continued on hydrochloroquine and
lisinopril. Cellcept was held in setting of infection and was
discharged on Prednisone. She will likely resume Cellcept to be
decided at follow-up with Dr. [**Last Name (STitle) 1667**].
# Depression: She was continued on Prozac.
Medications on Admission:
Fluoxetine 40mg daily
Flovent
Hydrochloroquine 200mg [**Hospital1 **]
Lisinopril 40mg daily
Cellcept 500mg [**Hospital1 **]
Omeprazole 20mg daily
Mirapex 0.125mg qhs PRN
Coumadin
Vitamin D [**2111**] units daily
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,WE,FR,SA).
6. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO DAYS (MO,TH).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5)
Tablet PO DAILY (Daily).
8. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
9. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Flovent HFA Inhalation
11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Sialadenitis
Secondary:
-Systemic lupus erythematosus
-Membranous glomerulonephritis
-Antiphospholipid syndrome
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted for facial and neck swelling and found to have
sialdenitis (infection in salivary gland due to stone). The
stone is no longer obstructing your duct and the swelling has
improved. You should continue to take Augmentin as written
(875mg by mouth twice a day) for an additional 10 days. You
should also follow up with ENT in [**6-20**] days. Please continue to
use [**Doctor Last Name 5942**] slices to stimulate saliva and warm compresses as your
have been.
Dr. [**Last Name (STitle) 1667**] would like you to take 7.5mg of prednisone daily
instead of the Cellcept until you can follow up with her. You
have an appointment with her on [**2121-5-27**] at which time you can
further discuss your medication.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please have your INR checked on Monday [**5-19**] as your
antibiotics can interfere and your Coumadin dose may need to be
adjusted.
Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2121-5-27**]
10:30
ENT: Please see Dr. [**First Name (STitle) **] at [**Location (un) **]. on [**5-28**] at
2pm ([**Location (un) 55**]). The phone number there is [**Telephone/Fax (1) 2349**].
Please fill out the new patient forms and bring these with you
(If you need additional copies they can be found on the webiste
[**URL 21513**]/)
Provider: [**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2121-6-23**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2121-6-27**] 11:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2121-5-26**]
|
[
"528.3",
"327.23",
"493.90",
"V58.61",
"311",
"581.2",
"527.2",
"333.94",
"784.2",
"795.79",
"710.0",
"527.5",
"V12.51",
"112.0",
"289.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"29.11"
] |
icd9pcs
|
[
[
[]
]
] |
8162, 8168
|
5180, 7010
|
293, 309
|
8334, 8353
|
3458, 3458
|
9366, 10410
|
2126, 2257
|
7272, 8139
|
8189, 8313
|
7036, 7249
|
8377, 9343
|
2272, 2272
|
4033, 5157
|
239, 255
|
337, 1600
|
3472, 4019
|
1622, 1884
|
1900, 2110
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,851
| 191,602
|
39252
|
Discharge summary
|
report
|
Admission Date: [**2106-9-2**] Discharge Date: [**2106-9-7**]
Date of Birth: [**2035-12-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Right Craniotomy for sdh evacuation
History of Present Illness:
70F who was diagnosed with breast cancer in [**2104**] with metastatic
spread to bone. The patient is currently on Gemcitabine and was
to begin cycle 2 on [**9-1**]; however, the patient presented to
[**Hospital1 18**]
[**Location (un) 620**] with complaints of weakness for the past two days. The
weakness has been mainly noticed in the BLE. Pt stated the
weakness progressed as such that she could not walk. An MRI of
her spine was done which showed bone mets but no significant
compression. However, the MRI is not of best quality given the
amount of motion artifact. A Neurology consult was obtained and
a
MRI brain was done which revealed a large R SDH with about 10mm
of midline shift. [**Hospital1 18**] [**Location (un) 86**] Neurosurgery was contact[**Name (NI) **] and
the
patient was transferred.
Past Medical History:
Metastatic breast cancer to bone dx'd [**2104**], colostomy, CHF,
diverticulitis, HTN, hypothyroidism, Cdiff, uveitis, depression,
anemia of chronic disease, GERD, vit B12 deficiency
Social History:
Lives with daughter, [**Name (NI) **], who is the HCP. Quit smoking 2yrs
ago.
Prior to admission and current status, patient was walking with
a
walker.
Family History:
Prostate cancer
Physical Exam:
Gen: Sleepy but easily arrouseable.
Neuro:
Sleep but arouseable. R pupil irregular/ surgical, L pupil
reactive 3-2mm, EOM intact, face symm, tongue midline, speech
clear, comprehension intact. Oriented to self, year, and place.
RUE/LUE full motor, RLE full with 4+ to AT/G/[**Last Name (un) 938**]. LLE withdraws
to noxious and maintains hold of her knee. [**Name8 (MD) **] RN - patient did
move her LLE spont. Sensation appears intact. Bil lower
extremity
edema R>L.
Exam on discharge:
Alert and Oriented x3
CN 2-12 grossly intact
Baseline left foot drop
5/5 motor throughout
Wound: Right cranial incision intact, staples in place
Pertinent Results:
[**9-2**] Admission head CT:
Stable appearance of right subdural hematoma with subfalcine
herniation, medial displacement of the right uncus, and 12 mm of
leftward
shift of normally midline structures.
[**9-2**] Post operative head CT:
Status post evacuation of right hemispheric subdural hematoma
with improved mass effect and leftward shift of midline
structures. Moderate pneumocephalus with mild mass effect on
the frontal lobe.
Brief Hospital Course:
70 y/o F with history of metastatic breast cancer presents s/p
BLE weakness. At OSH, patient had MRI head done which showed
large R SDH and patient was then transferred to [**Hospital1 18**] for
further evaluation. Once at [**Hospital1 18**], patient was admitted to
neurosurgery and placed in the ICU for Q1H neuro checks.
Throughout the day, patient was waxing an [**Doctor Last Name 688**] on examination
and then became less responsive to noxious stimuli. She was
taken to the OR for R burr holes for evacuation of R SDH.
On [**9-3**] the patient's exam improved significantly with respect
to her mental status. She could answer questions appropriately
and was fully oriented. She did continue to have diffuse
weakness that dod not correspond to a focal neurologic injury.
Her foley was removed but then had to be replaced due to urinary
retention, diet was advanced and she was encourage out of bed to
the chair.
On [**9-6**] Ms. [**Known lastname **] looks very bright is Alert and oriented x3
and has a full motor exam. She will be discharged to rehab
today.
On [**9-7**], Foley was removed and the patient was discharged to
extended care facility.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Transfer records.
1. Citalopram 10 mg PO DAILY
2. Cyanocobalamin 1000 mcg IM/SC MONTHLY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Vitamin D 50,000 UNIT PO MONTHLY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO QIDACHS
11. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
13. Prochlorperazine 10 mg PO Q8H:PRN nausea
14. Alendronate Sodium 4 mg PO EVERY 3 MONTHS
15. Ferrous Sulfate 325 mg PO DAILY
16. Calcium Carbonate 750 mg PO BID
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
Discharge Medications:
1. Calcium Carbonate 750 mg PO BID
2. Citalopram 10 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
11. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Heparin 5000 UNIT SC TID
Start in AM on [**9-3**]
16. Morphine Sulfate 2-4 mg IV Q3H:PRN pain
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
19. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever
20. Docusate Sodium 100 mg PO BID
21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
22. LeVETiracetam 500 mg PO BID
23. Cyanocobalamin 1000 mcg IM/SC MONTHLY
24. Alendronate Sodium 4 mg PO EVERY 3 MONTHS
25. Ondansetron 8 mg PO Q8H:PRN nausea
26. Vitamin D 50,000 UNIT PO MONTHLY
27. Milk of Magnesia 60 mL PO Q12H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
R subdural hematoma
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:
?????? 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.
?????? **Your wound was closed with staples. You can have them taken
out at 7-10days postop. You can have them removed at your rehab
facility or make an appointment to see a NP or PA for removal in
clinic at([**Telephone/Fax (1) 88**].
?????? 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 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in ___4____weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2106-9-7**]
|
[
"311",
"174.9",
"V15.82",
"401.9",
"428.32",
"V49.86",
"V44.3",
"285.29",
"530.81",
"788.29",
"244.9",
"266.2",
"348.89",
"428.0",
"198.5",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
6169, 6263
|
2733, 3893
|
315, 353
|
6327, 6327
|
2272, 2292
|
8218, 8486
|
1584, 1602
|
4820, 6146
|
6284, 6306
|
3919, 4797
|
6510, 8195
|
1617, 2086
|
266, 277
|
381, 1191
|
2106, 2253
|
2509, 2710
|
6342, 6486
|
1213, 1398
|
1414, 1568
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,281
| 182,536
|
53701
|
Discharge summary
|
report
|
Admission Date: [**2135-9-3**] Discharge Date: [**2135-9-16**]
Service: MEDICINE
Allergies:
Morphine / Penicillins / Clindamycin / Tricor / Ambien
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Increased lethargy, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo female with PMH of dementia, HTN, CAD, COPD, PEx 4 on
chronic anticoagulation, CRI, and AAA s/p endovascular repair
one month ago who was transferred from her NH today w/ new onset
of lethargy. By report, patient had 3 wk h/o fevers, starting
[**2135-8-20**], with unclear source. Sacral decubitus ulcer debrided on
[**8-19**], and fevers began the following day. Was started on
macrobid for ? UTI on [**8-22**]. Urine cx on [**8-23**] found MRSA in urine
-> treated empirically with levaquin and macrobid. On
speciation, it was found to be MRSA and her abx were switched to
vancomycin. Fevers persisted and wound cx on [**8-27**] grew MRSA. Pt
began to have daily fevers at night (Tmax 101.6) accompanied by
altered mental status. Blood cultures from [**8-30**] and [**8-31**] were
negative, but on blood cx from [**9-1**] grew gram positive cocci.
.
On exam, the patient has no complaints other than her fevers.
She denies any SOB, CP, headaches, dizziness, feeling confused,
nausea, vomiting, diarrhea, bloody stools, dark/tarry stools,
BRBPR, dysuria, hematuria, nuchal rigidity, or photophobia. +
for several episodes of "chills" at the NH.
.
In the ED, T was 103.9, BP 112/66, HR 88, RR 18 and sats were
94% on RA. She appeared somnolent, delerious and diaphoretic.
She was started on the sepsis protocol and a central line and
foley catheter were placed. Her BP began to drop, with a low of
62/26, and she was given 3L of NS but levophed was eventually
started to support her BP. Her UOP was also poor, with 10 cc/2
hours. A CXR was performed which showed no signs of infiltrate.
Urine and blood cultures were sent. She was given vanco,
ceftriaxone and flagyl for empiric coverage.
.
Past Medical History:
1. AAA s/p endovascular repair [**7-19**]
2. Sacral decubitus ulcer, stage III, debrided [**2135-8-19**]
3. h/o PE and DVT since [**2126**](last PE [**3-/2134**], + factor V Leiden)
4. Recurrent cellulitis.
5. Hypertension.
6. CHF (with diastolic dysfunction)
7. Hypercholesterolemia.
8. CAD, s/p coronary artery bypass graft in [**2126**], stent [**2127**]
- pMIBI in [**6-9**]: nl perfusion/LV cavity size and fxn, LVEF 55%.
9. Chronic obstructive pulmonary disease.
10. Chronic venous stasis.
11. Chronic renal insufficiency.
12. Severe osteoarthritis.
13. Gout
14. Dementia
Social History:
She is [**Name Initial (MD) **] former RN who lived with daughter prior to AAA repair.
Has been at [**Location (un) 38380**] at [**Location (un) 7658**] since operation [**2135-7-22**].
Wheelchair bound since [**9-8**] (due to "foot drop"). Incontinent at
baseline. No EtOH, IVDU, tobacco.N
Family History:
NC
Physical Exam:
VS: T 97.6 ax, BP 110/60, HR 62, RR 14, O2 sats 95% on 2L
Gen: Pleasant, elderly woman in NAD. Slightly demented, but
oriented to person, place, and time ("almost [**Month (only) 216**]").
HEENT: NCAT. Eyeglasses on. EOMI. PERRL. No conjunctival
hemorrhages. Neck thick. No appreciable JVD.
CV: Distant heart sounds. RR. NL S1, S2. No m/r/g.
Lungs: Fine crackles at bases, otherwise clear.
Abd: Soft, NTND. +BS.
Ext: No c/c/e. No lesions on palms or soles, no splinter
hemorrhages.
Skin: No rashes. Stage III sacral decubitus ulcer, on tip of
coccyx. Gaping hole approx. 2x3 in, circular, surrounded by
violaceous skin changes. Wound is open, foul smelling, and
covered with purulent discharge. There is a tail of broken skin
that extends off towards the right hip. Just inferior to this
decubitus is a stage II ulcer that is beginning to form. It has
just broken through the superficial layer of skin and appears
raw.
Neuro: AAOx3. CN II-XII grossly intact. Follows simple commands.
Wiggles toes bilaterally, squeezes hands bilaterally.
Pertinent Results:
On admission:
139 105 16 / 119 AGap=18
4.7 21 1.0 \
.
96
11.9 \ 9.6 / 437 D
/ 30.7 \
N:82.0 L:12.5 M:2.7 E:2.6 Bas:0.2
.
Lactate: 2.4 -> 2.3 -> 2.0 -> 1.5
.
SvO2 sat: 73
.
PT: 20.3 PTT: 37.2 INR: 2.7
.
UA: hazy/1021/small LE/neg nitrite/30 prot/0-2 RBC/[**4-9**] WBC/mod
bact
.
CXR: Small left pleural effusion with underlying collapse and/or
consolidation, improved compared with [**2135-7-19**].
.
EKG: NSR, rate 77bpm, normal intervals, normal axis, Q wave in
III, ? Q wave vs. poor R wave progression in V1/V2, no ST or T
wave changes.
[**2135-9-3**] 11:55 pm SWAB Source: sacral decub.
**FINAL REPORT [**2135-9-10**]**
GRAM STAIN (Final [**2135-9-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
WOUND CULTURE (Final [**2135-9-7**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PROBABLE ENTEROCOCCUS. HEAVY GROWTH.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| GRAM NEGATIVE ROD(S)
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2135-9-10**]):
BACTEROIDES FRAGILIS GROUP. HEAVY GROWTH.
BETA LACTAMASE POSITIVE.
[**2135-9-3**] 5:50 pm BLOOD CULTURE
**FINAL REPORT [**2135-9-9**]**
AEROBIC BOTTLE (Final [**2135-9-9**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2135-9-8**]):
BACTEROIDES FRAGILIS GROUP.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 110259**]
([**2135-9-3**]).
[**2135-9-3**] 8:40 pm URINE Site: CATHETER
**FINAL REPORT [**2135-9-5**]**
URINE CULTURE (Final [**2135-9-5**]):
YEAST. >100,000 ORGANISMS/ML..
[**2135-9-6**] 6:30 pm CATHETER TIP-IV Source: right IJ.
**FINAL REPORT [**2135-9-9**]**
WOUND CULTURE (Final [**2135-9-9**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
CT abdomen/pelvis:
HISTORY: Status post AAA repair with graft, gram-negative
bacteremia. Sacral
decubitus ulcer.
COMPARISON: [**2135-8-11**].
TECHNIQUE: Axial images through the abdomen and pelvis following
administration of oral and IV contrast. Multiplanar reformatted
images were
obtained. Optiray was administered due to patient preference.
CT OF THE ABDOMEN WITH CONTRAST: There are new small bilateral
pleural
effusions with bibasilar dependent atelectasis. There is
evidence of
respiratory motion. The liver, spleen, adrenal glands, and
pancreas are
normal. Again seen are multiple stones within the gallbladder,
as well as a
small hiatal hernia. Both kidneys are atrophic, but enhance
symmetrically.
There is again an area of low attenuation within the left
kidney, previously
visualized, but too small to characterize. The loops of large
and small bowel
are unremarkable. There is no free air within the abdomen. There
is a small
amount of free fluid in both paracolic gutters. The patient is
status post an
aortobiiliac endovascular graft, which at the similar level is
stable in size,
measuring approximately 4.8 x 5.2 cm. Allowing for differences
in technique
and measurement level, this is not significantly changed. This
infrarenal
abdominal aortic aneurysm and focal aneurysm of the right distal
common iliac
artery is stable in appearance. There is also dense
calcification of the
descending aorta. No pathologically enlarged lymph nodes.
CT OF THE PELVIS WITH CONTRAST: The appendix is normal. There is
a small
amount of soft tissue stranding following along the iliac
vessels bilaterally,
and extending into the pelvis dependently. From the region of
the decubitus
ulcer, there is soft tissue stranding is anterior to the sacrum
and extending
to it, surrounding it. This extends into both sciatic foramen
and in the
rgion of the levator ani bilaterally. Again seen is the soft
tissue stranding
within both groins as well as small bilateral inguinal lymph
nodes. The uterus
and adnexa are unremarkable. The bladder and distal ureters are
normal. The
Foley catheter is within the bladder.
BONE WINDOWS: There is no definite evidence of osseous
destruction. There
are degenerative changes throughout the spine.
REFORMATTED IMAGES: Somewhat limited due to patient motion. No
definite
osseous destruction. No periaortic fluid.
IMPRESSION:
1. Stable appearance of the infrarenal abdominal aortic
aneurysm, without
evidence of surrounding fluid.
2. Small bilateral pleural effusions.
3. Extensive decubitus ulcer with inflammatory reaction
extending to the
sacrum. Osteomyelitis cannot be excluded and could be correlated
with MRI.
Brief Hospital Course:
A/P: 89yo female with extensive PMH most significant for
endovascular repair of AAA [**2135-7-19**], presenting with gram
negative rod bacteremia, fevers, and increasing lethargy.
.
1. Sepsis: On arrival to ED, patient was hypotensive, febrile,
had an elevated WBC and an elevated lactate, concerning for
sepsis. Per report from her NH, she has blood cx positive for
gram positive cocci, speciation pending. She was placed on the
sepsis protocol, a central line was placed and she was
pan-cultured. CXR did not show a focal infiltrate. She was
placed on norephinephrine for pressor support, and was weaned
off quickly.
.
Source of fever was initially unknown, and there was suspicion
for a drug fever as it appears to have begun at time of
vancomycin administration at OSH. Etiology likely drug fever vs.
infection. There was also concern for seeding of endovascular
AAA graft, causing intermittent bacteremia and possibly fever,
as well as her sacral decubitus ulcer. Patient was afebrile as
of [**2135-9-5**]. Gentamycin was originally added for synergy with
Vancomycin, but was discontinued as of [**2135-9-6**] because her
blood culture grew out gram-negative cocci and MRSA was not
thought to be the source of her fevers. Pt was originally
covered with Vancomycin for MRSA and Cefepime for gram-negative
bacteria. Vancomycin was decreased to 1g Q24h as of [**2135-9-6**]
because the trough on [**2135-9-5**] exeeded therapeutic levels. At
time of discharge, her dosing of vancomycin was 1g IV q48h.
.
ID recommended pelvic MRI to r/o osteo and seeding of AAA graft,
but Pt was not able to fit into the MRI. A CT with iv contrast
of abdomen and pelvis was ordered instead. Patient's CT showed
stable appearance of the infrarenal abdominal aortic aneurysm,
without evidence of surrounding fluid, as well as a large sacral
decubitus ulcer with inflammatory reaction extending to the
sacrum.
.
Blood cultures from the nursing facility were negative. Wound
culture from the sacral decubitus ulcer was positive for
bacteroides fragilis, pseudomonas aeruginosa, enterococcus, and
gram negative rods, and blood cultures were positive for
bacteroides fragilis. Stool c. diff was negative, and catheter
tip culture showed coagulative negative staphyloccocus. Urine
culture was positive for yeast.
.
Surgery was consulted to debride the sacral decubitus ulcer in
the ER, and deferred until patient was hemodynamically stable.
Cultures from the nursing home showed MRSA; cultures obtained
here were noted as above. The ulcer was last debrided on [**8-19**]. A
bedside debridement was performed on [**2135-9-10**]. Patient was
instructed to use wet to dry dressings [**Hospital1 **] for the ulcer, and to
follow up in plastics clinic in [**11-18**] days post-discharge.
.
ID recommendations for antibiotics after ulcer debridement
included a six week course of levofloxacin, metronidazole, and
vancomycin for GNR/GPC bacteremia, to end on [**10-21**].
Patient is to check weekly labs, to be faxed to infectious
diseases for follow-up. Pt will need ID follow-up, her first
appointment is scheduled for Tuesday, [**2135-10-18**] at 10:00 AM
with Dr. [**First Name (STitle) 2505**] in the [**Hospital Ward Name 23**] Clinical Center of [**Hospital1 771**].
.
2. Urinary tract infection. Patient reportedly had MRSA in her
urine from urine cx at nursing home. She was originally treated
with macrobid, then levaquin, then cipro, and now on vancomycin
since [**8-24**]. UA does not support an overwhelming UTI. Repeat
urine cultures have consistently shown funguria. Patient was
placed on a 7 day course of fluconazole, to be finished on [**9-12**].
.
3. Diarrhea. Patient developed copious amounts of green stool.
Clostridium difficile assays were negative; patient was on
metronidazole for her bacteremia.
.
4. Anemia. Patient received a blood transfusion for her anemia.
.
5. Cardiovascular: Patient was not symptomatic and EKG did not
show any signs of ischemic changes. ASA was d/c'd on [**8-17**] by her
wound care doctor [**3-9**] to its effect on wound healing. Atenolol
and lasix were being held [**3-9**] hypotension. She was restarted on
ASA 81 mg po qd, as well as atenolol 12.5 po daily. Her blood
pressures were stable on discharge.
.
6. CRI: Her baseline creatinine is 1.0-1.6, but has been 1.0
over last month. Her creatinine was 1.4 at time of discharge.
Urine electrolytes and sediment were pending at time of
discharge, to be followed up by her outpatient PCP.
.
7. Hypercoagulability: Patient has heterozygous factor V Leiden
mutation, making her hypercoagulable. Patient's coumadin was
held until INR was <2.0, and was transitioned to heparin for
ulcer debridement by plastics. She was then placed back on her
coumadin, and was discharged with lovenox to bridge until her
coumadin was therapeutic.
.
8. FEN: Patient was placed on a cardiac, heart healthy diet with
no maintenance IVF. Daily electrolytes were checked and repleted
as needed. A nutrition consult was obtained, and recommendations
for vitamin C and zinc sulfate were added. Albumin was checked
as well to assess her nutritional status.
.
9. Dermatitis. Patient likely has a candidal skin infection on
her arm. She denies prurutis. Patient was afebrile with no WBC
count. Nystatin powder was applied to the site. The rash began
[**Date range (1) 19036**], and was morbilliform but asymptomatic, starting on the
arms and then spreading to chest and flanks. Dermatology was
consulted, and the feeling was that it was likely a drug rash
caused by either the cefepime or the ceftriaxone, both of which
had been discontinued by that date. The rash was watched and
treated with low-dose topical steroids. The rash regressed and
remained asymptomatic. It was recommended that the steroids be
discontinued at discharge to prevent steroid-mediated skin
sequelae.
.
10. Prophylaxis. Patient was on a bowel regimen, and received
vitamins.
.
11. PT/OT: Patient was evaluated by physical and occupational
therapy to improve upper extremity function. She is to continue
to receive PT/OT at her outside facility.
.
12. Access: Patient has PICC line in place for extended IV
antibiotic course.
.
13. Code status: DNR/DNI
.
14. Contact: with patient and with daughter [**Name (NI) 6744**] [**Name (NI) 12056**] (H)
[**Telephone/Fax (1) 110260**], (C) [**Telephone/Fax (1) 110261**]
Medications on Admission:
Coumadin 1.5mg PO QD
Atenolol 25mg PO QD
FeSO4 325mg PO BID
Allopurinol 150mg PO QD
Lipitor 40mg PO QD
Lasix 20mg PO QD
Folic acid 1mg PO QD
Gabapentin 300mg PO TID
MVI 1 tab PO QD
Vanco 1gm Q24 -> started [**8-24**], dose [**Month (only) **] to 700mg Q24 on [**9-1**]
based on peak/trough (and pt was dosed 6am on day of admission)
Dulcolax suppository 1 tab PR QD prn
MOM 30cc PO QD prn
Tylenol 650mg PO Q4 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 39 days: Until [**2135-10-21**]. .
15. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours): Until your coumadin dose is
therapeutic. .
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
17. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 39 days: Until
[**2135-10-21**]. .
18. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 39 days: Until [**10-21**], [**2135**].
19. Outpatient Lab Work
Weekly lab work:
CBC with differential
LFTs
BUN
Creatinine
Vancomycin trough level - please check this two hours before
your vancomycin dose.
Please fax results to [**Hospital **] clinic at [**Telephone/Fax (1) 110262**] ATTN: Dr. [**First Name (STitle) 2505**].
Discharge Disposition:
Extended Care
Facility:
Heritage Manor
Discharge Diagnosis:
Sacral decubitus ulcer.
Bacteroides fragilis and pseudomonal bacteremia with associated
sepsis.
Funguria.
Diarrhea.
Hypercoagulability state. Factor V Leiden deficiency.
Anemia.
Discharge Condition:
stable
Discharge Instructions:
If you develop fever, chills, shortness of breath, nausea,
vomiting, chest pain, please call your primary care doctor or go
to the ER.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 63983**] PLASTIC HMFP COSMETICS
(NHB) Where: PLASTIC HMFP COSMETICS (NHB) Date/Time:[**2135-9-16**]
1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2135-10-18**] 10:00
Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2136-2-9**] 2:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2135-9-16**]
|
[
"294.8",
"401.9",
"428.32",
"038.43",
"289.81",
"496",
"584.5",
"112.2",
"785.52",
"274.9",
"428.0",
"272.0",
"459.81",
"276.5",
"E930.5",
"693.0",
"995.92",
"707.03",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
19320, 19361
|
10525, 16869
|
287, 293
|
19583, 19591
|
4023, 4023
|
19774, 20388
|
2945, 2949
|
17332, 19297
|
19382, 19562
|
16895, 17309
|
19615, 19751
|
2964, 4004
|
221, 249
|
321, 2020
|
4037, 10502
|
2042, 2621
|
2637, 2929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,845
| 153,841
|
49922
|
Discharge summary
|
report
|
Admission Date: [**2130-2-10**] Discharge Date: [**2130-2-16**]
Date of Birth: [**2052-7-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors /
Angiotensin Recp Antg&Calcium Chanl Blkr / Meloxicam
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Chief Complaint: abdominal pain
Reason for ICU admission: pancreatitis/metabolic acidosis
Major Surgical or Invasive Procedure:
central venous line placement and removal
PICC placement
History of Present Illness:
Ms. [**Known lastname 805**] is a 77 yo female with history of HTN, DMII, CKD
hypothyroidism, and RA who presented to the ED with abdominal
pain for 1 week. Reports decreased appetite and has not been
eating, only drinking fluids. The pain has worsened over time.
At worst yesterday was [**11-13**]. It starts in her lower mid chest
and radiates to her epigastric region. Denies radiation to her
back. Denied fever, dypsnea, CP, but did admit to dysuria for
the last week. Also recently had a minor fall on [**2-3**].
In the ED, initial vs were: 98.7, 74, 184/82, 16, 100% RA. She
was noted to have a tender pulsatile aorta in the LUQ/left mid
abdomen. Found to be guaiac negative. Lipase elevated at 1689.
KUB showed no free air. CT abdomen without contrast was
performed given poor renal function and preliminarily read as no
AAA. Labs were significant for bicarb of 11, Cr of 6, trop
0.11. EKG without changes from baseline. UA was consistent
with a UTI. She was given ASA 600 mg rectally and 400 mg IV
ciprofloxacin. Got 2.3 L NS and she only put out 70 cc fluid.
On arrival to the MICU, her pain is [**7-14**]. She denies nausea and
states she is starting to feel a little better then when she
came in.
Review of systems:
(+) Per HPI. Admits to constipation, but did have a bm
yesterday.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pressure, palpitations, or weakness. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
#. Hypertension - TTE [**3-14**] - EF >55%. Mild AR
#. DM2 - diagnosed [**2118**], has been on insulin in the past but no
longer takes any diabetes medications
#. CKD - baseline creatinine 3.0
#. Rheumatoid arthritis - diagnosed at age 50; [**Doctor First Name **] 1:1280 -
followed by Dr. [**Last Name (STitle) 6426**]; on chronic steroids
#. Hypothyroidism
#. Osteoarthritis
#. Possible SLE, discoid lupus since [**2121**] with a positive right
sided lymph node biopsy
#. Left renal mass detected in [**2121-8-4**] - pt doesn't want
further w/u
#. Anemia - Normocytic in past
#. Asthma
#. History of low back pain
#. C. diff colitis with recurrence 8 and [**10-9**]
#. ?C ecal Mass on CT - [**Last Name (un) **] [**6-10**] negative. CEA 5.7
Social History:
Drugs: None
Tobacco: None
Alcohol: None
Other: The patient currently lives at home with her daughter
[**Name (NI) 104271**] [**Known lastname 805**], also HCP. The patient at baseline walks with a
cane or a walker. She feeds herself but has meals prepared,
requires assistance with dressing and bathing. Has an aide who
comes 3x/week.
Family History:
Father had DM, CAD, HTN. No cancer or stroke in family.
Physical Exam:
admission:
98.7, 74, 184/82, 16, 100% RA
General: Elderly female laying in bed in NAD. Sleeping, but
easily arousable. Oriented to place and with prompting to time.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Breathing comfortably. Clear to auscultation
bilaterally, no wheezes, rales, ronchi.
CV: Regular rate and rhythm, holosystolic murmur heard best at
the LUSB.
Abdomen: soft, tender to palpation the greatest in the
epigastric and LUQ > RUQ and LLQ > RLQ. No reboutnd or
guarding.
GU: foley with a small amount of concentrated urine present.
Ext: warm, well perfused, slight non-pitting edema present
bilaterally with venous stasis changes present.
Neuro: CN II-XII intact. 5/5 strength in her upper and lower
extremities (except hip flexion limited due to abd pain).
Sensation to light touch intact.
Discharge:
VS: 98 154/78 56 18 99% RA
General: Elderly female laying in bed in NAD, AOx3
Neck: supple, JVP not elevated, no LAD
Lungs: Breathing comfortably. Clear to auscultation bilaterally,
no wheezes, rales, ronchi.
CV: Regular rate and rhythm, holosystolic crescendo-decrescendo
III/VI murmur heard best at the LUSB, + lift at LUSB
Abdomen: soft, mildly tender to palpation in epigastric area, no
rebound or guarding, + bs
GU: no foley
Ext: warm, well perfused, slight non-pitting edema present
bilaterally with venous stasis changes present, TTP bilaterally
Pertinent Results:
Admission labs:
Na 137 K 5.4 Cl 114 Bicarb 11 BUN 74 Cr 6.2 Glu 71
.
Ca 8.6 Mg 2.1 Phos 6.4
freeCa 1.17
.
ALT 21 AST 37 AP 242 Tbili 0.2 Alb 3.1 Lipase 1689 Tprot
6.6
.
CK 113 MB 12 MBI 10.6 Trop 0.11 --> 0.15
.
WBC 9.3 Hct 27.1 Plt 105
N 71.2% L 21.5% M 6.4% E 0.5%
.
PT 14.6 PTT 29.9 INR 1.3
.
Lactate 1.0
UA >50 WBC, mod leuk, sm bld, many bacteria
.
VBG: 7.09/28/94
Trop: 0.11, 0.15
.
ABG: 7.13/24/164
Lactate 0.8
.
Repeat panel 7
Na 139 K 4.5 Cl 120 Bicarb 8 BUN 70 Cr 5.7 Glu 74
.
Micro:
Urine culture ([**2130-2-10**]) - pending
.
BCx x 2 ([**2130-2-10**]) - pending
.
Images:
CXR ([**2130-2-10**]) - No acute pulmonary process. Scarring versus
chronic effusion at right costophrenic angle. Stable
cardiomegaly
.
Abd XR ([**2130-2-10**]) - report pending (no free air)
.
CT abd/pelvis w/o contrast ([**2130-2-10**]) - IMPRESSION: No evidence
for abdominal aortic aneurysm. Prominent pancreas with minimal
surrounding stranding corresponds to clinical diagnosis of
pancreatitis. No apparent complicating features noted, within
limits.
.
TTE ([**2130-2-14**]): The left atrium is elongated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion.
IMPRESSION: Moderate symmetric LVH with normal global and
regional biventricular systolic function. Calcific aortic valve
disease with mild stenosis/mild regurgitation. Mild mitral
regurgitation. Moderate pulmonary hypertension. Very small
pericardial effusion.
.
EKG: normal sinus rhythm, nl intervals, slight upsloping of ST
segments in aVL and V2 (unchanged from baseline)
.
Renal U/S ([**2130-2-15**]):
IMPRESSION:
1. Likely layering debris in the urinary bladder, presumably
related to
provided history of urinary infection.
2. Benign-appearing bilateral renal cysts.
3. Small volume of ascites as described above
.
LUE LENI ([**2130-2-15**]):
IMPRESSION: Left deep venous thrombosis involving the internal
jugular and
brachial veins. Cephalic vein not identified.
.
Chest X-ray for PICC placement ([**2130-2-16**]):
Radiology read dictated: PICC in the right superior caval
junction. OK for use.
Brief Hospital Course:
# Pancreatitis: Initially admitted to MICU for management
considering [**Last Name (un) **] and metabolic acidosis (described below).
Differential for etiology of pancreatitis includes gallstone,
alcoholic, medication-induced, and hypertriglyceridemia. Most
likely gallstone-induced. VBG in ED was 7.09/28/94, showing
uncompensated metabolic acidosis. Abdominal ultrasound showed
evidence of pancreatitis with inflamed pancreatic head.
Patient's abdominal pain resolved over the next few days. IVF
was initially given and she was kept NPO. After her abdominal
pain resolved her diet was advanced to clears and IVF was
stopped. She never required IV pain medications.
On transfer to floor, pain and nausea much improved. She was
given PRN tylenol for pain and advanced to full diet. She will
follow up with [**Hospital **] clinic for management of possible biliary
disease, which was suggested by elevated alk phos, however no
evidence of cholelithiasis on RUQ u/s.
.
# Troponin leak: troponin x2 shows 0.11 and 0.15, in setting of
acidosis and acute pancreatitis. EKG without changes from her
baseline and she was without chest pain. Trop leak was likely
secondary to demand ischemia. She was contined on ASA. Trop, CK,
MB were trended and noted to be decreasing, no changes on serial
EKGs.
.
# Metabolic acidosis: On admission had a non-AG metaboliac
acidosis (although with albumin of 3.1, may be slightly
elevated). Most likely due to her acute on chronic renal
failure. With treatment of pancreatitis and ARF with IVF
including bicarb the acidosis resolved. Was continued on PO
sodium bicarb on transfer to floor, which was discontinued prior
to discharge.
.
# Acute on CKI: Patient has a creatinine baseline of 3.0 and
presented to the ED with creatinine of 6.2. This trended down to
5.7 with 2 L NS in the ED. Likely due to hypovolemia/fluid
shifts in setting of acute pancreatitis. Renal was consulted
and recommended bicarb in the IVF for the acidosis. There was no
acute need for HD and the patient's creatinine trended down with
IVF suggesting it was hypovolemic ARF. Pt's Cr continued to
trend down while on the floor. Home candesartan was held in the
setting of [**Last Name (un) **], and was continued to be held on discharge.
Would consider restarting this as outpatient once renal function
stabilizes.
.
# UTI: Patient with a week of dysuria and a positive UA in the
ED with more than 50 WBCs. Ucx grew yeast ([**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 53550**]) and
repeat UA with continued pyuria, so fluconazole was started to
treat likely yeast UTI for a 7 day course. She also grew coag
positive staph 10,000-100,000 colonies on one urine culture.
The bacteria were felt to be a contaminent as CFU was low and
other cultures were negative for bacterial growth. Renal
ultrasound was done to evaluate for abnormalities (poorly
evaluated in CT scan), showed layering of debris in bladder
consistent with UTI. Will continue fluconazole as outpatient to
complete a 7-day course. Her symptoms improved. She should
have a UA and urine culture checked after fluconazole to assess
for cure.
.
#DVT: LUE swelling noted on exam on [**2-15**], LENI showed occlusive
L brachial clot and a nonocclusive thrombus in L IJ. Was
started on a heparin gtt in order to bridge to coumadin.
Coumadin was started at 5mg per day. PICC line was placed for
heparin drip until INR between 2 and 3 for 24 hours. She will
continue taking coumadin for 3 months and f/u with her PCP.
.
# Delirium: Patient was noted to be delirious on admission to
the ICU. No focal neurologic deficits. Felt to be
toxic-metabolic vs ICU delirium. With family in the room for
re-orientation the patient did improve enough to take her PO
medications. No further events of delirum on the medical floor.
.
# Chronic anemia: Baseline Hct in the mid to high 20's likely
secondary to anemia of kidney disease. Hct of 27.1 on
admission. No clinical evidence of bleeding. Guaiac negative
in the ED. Hcts remained stable during admission.
.
# Thrombocytopenia: Patient has baseline platelets in the low
100's to 150's. Plt on admission at 105. They remained stable
during admission.
.
# ?AAA - noted to have a pulsatile abdomen in the ED,
noncontrast CT of abdomen did not show any signs of AAA.
.
# Hypertension: Was hypertensive throughout stay in MICU but
refused PO meds so was managed with IV hydral and clonidine
patch. As patient's mental status cleared she was started back
on her PO medications including felodipine, lasix, hydralazine
and clonidine patch. On discharge, candesartan was held
considering [**Last Name (un) **]. Would consider restarting as outpatient.
# DMII - diagnosed in [**2118**], has been on insulin in the past but
no
longer takes any diabetes medications. Was maintained on ISS
while in the ICU, discontinued on discharge.
# RA/?SLE - diagnosed at age 50, on chronic steroids (prednisone
5 mg daily) Was given equivalent dose of IV hydrocortisone while
she was NPO and then when taking POs was transitioned back to
prednisone PO.
# Hypothyroidism: She is on levothyroxine 50 mcg daily PO at
home but given not taking POs was switched to IV form.
# Access: Had poor peripheral access so a CVL was placed on
[**2130-2-11**] in the ICU, discontinued on [**2130-2-14**]. Unable to obtain
peripheral access so PICC was placed on [**2130-2-16**].
# Communication: daughter, HCP [**Name (NI) 2659**] [**Name (NI) 805**], [**Telephone/Fax (1) 104273**]
# Code: DNR/DNI, confirmed with HCP, during admission
Medications on Admission:
Aspirin 81 mg daily
Prednisone 5 mg daily
Felodipine 2.5 mg daily
Clonidine 0.2 mg/24 hr Patch qFriday
Hydralazine 50 mg q8h
Levothyroxine 50 mcg daily
Calcitriol 0.25 mcg every other day
Omeprazole 20 mg daily -> she states this has been stopped.
Furosemide 120 mg daily
Candesartan 8 mg daily
Discharge Medications:
1. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Transdermal
once a week: Q Friday.
6. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Four
(4) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. 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.
12. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1300 (1300) Intravenous continious infusion:
Started at 4:15pm on [**2130-2-16**]. Weight based dosing. .
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for crural rash.
15. furosemide 40 mg Tablet Sig: Three (3) Tablet PO once a day.
16. candesartan 8 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Acute on chronic kidney injury
Pancreatitis
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 pancreatitis, which is
inflammation of your pancreas. Because of this you were also
dehydrated and had some worsening kidney function, both improved
with IV fluids. We stopped your candesartan (blood pressure
medication) for now and this may be restarted as your kidney
function improves.
You were also found to have a urinary tract infection. For this
we started an antibiotic, fluconazole, which you should continue
taking once a day until [**2130-2-20**].
Changes to your medications:
START taking fluconazole once a day
START Metoprolol 25mg SR daily
START Paroxetene 10mg daily
START Warfarin 5mg daily (dose adjust based on INR)
START Heparin drip (dose based on PTT, stop when INR therapeutic
for 24 hours)
STOP calcitriol, PCP can restart as needed
STOP omeprazole as you informed us you were not taking this
DECREASED Lasix to 80mg daily given your kidney function
INCREASED Felodipine given high blood pressures
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] R.
Location: [**Hospital **] [**Hospital **] HEALTH CENTER
Address: [**Last Name (un) **], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 14050**]
**Please contact your PCP office to book a follow up appointment
from this hospitalization. You will need an appointment one week
from your discharge date.**
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2130-2-22**] at 2:45 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2130-2-17**]
|
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"577.1",
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"585.4",
"276.51",
"276.2",
"453.83",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15064, 15138
|
7594, 13147
|
468, 527
|
15226, 15226
|
4815, 4815
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16364, 17153
|
3292, 3350
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13493, 15041
|
15159, 15205
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13173, 13470
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15377, 15875
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3365, 4796
|
15904, 16341
|
1800, 2158
|
356, 430
|
555, 1781
|
4831, 7571
|
15241, 15353
|
2180, 2924
|
2940, 3276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,010
| 117,679
|
5684
|
Discharge summary
|
report
|
Admission Date: [**2144-1-15**] Discharge Date: [**2144-1-20**]
Date of Birth: [**2082-2-12**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Keflex / darvon / darvocet / percocet / Percodan
/ strawberry
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
ERCP with stone extraction and stent placement
History of Present Illness:
The patient is a 61yo F depression presenting with
choledocholithiasis with PMH notable for choledocolithiasis 10
years ago s/p CCY.
.
Per patient report and record patient with h/o with
choledocolithiasis s/p gallbladder removal in [**2134**] which was
complicated by cystic stump leak s/p ERCP with sphincterotomy
and stent placment with further complication of duodenal
perforation. Patient has been without instrumentation since that
time.
.
Patient had been in USOH when presented to [**Hospital3 **] with
5 days of abdominal pan [**10-12**], nausea, vomiting and poor po
intake with associated weight loss. She has also noticed
"yellow" stools during this time period as well. She has also
been having subjective fevers and chills. The patient underwent
CT scan that showed a 5x7mm in the CBD with intrahepatic ductal
dilation with air concerning for gas-forming organism. Her
baseline SBP are usually in the 90's per report. She had
documented pressures as low as the 60's at the OSH. She was
given 5L IVF and started on peripheral neo at 50mcg/min. She was
covered with levofloxacin/flagyl/zosyn/vanco po. She was
transferred to [**Hospital1 18**] ED for further evaluation.
.
In the ED, 97.1 93 88/59 18 100% 3L. The patient's labs were
significant leukocytosis of 11.7, Hct 29.7. LFT were remarkable
for TBili 7.3, AP 243, ALT: 95 and AST 40. The patient was
weaned off pressors in the ED. The patient was seen by surgery
who will continue to follow along. The patient was also
evaluated by ERCP with plans to perform the procedure in the AM.
.
On the floor the patient reports feeling better and painis
improved to [**1-13**].
.
ROS: The patient denies any nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
Past Medical History:
Depression
Fibromyalgia
s/p parathyroidectomy [**2140**] for adenoma,
s/p Cholecystectomy [**2134**]
-- biliary sphincterotomy and placement of biliary stent with
subsequent removal. ERCP complicated by duodenal perforation
Social History:
Patient quit smoking 20years ago with a 40 pack year history.
Occasional ETOH. Denies IVDU
Family History:
Mother died of breast cancer at 54
Physical Exam:
VS: Temp: BP: / HR: RR: O2sat
GEN: pleasant, comfortable, NAD, jaundice, tired appearing
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no JVD
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: + tenderness over the umbilicus. tenderness to deep
palpation over the epigastric and RUQ, +b/s, soft
EXT: no c/c/e
SKIN: no rashes/ jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
labs on admission:
[**2144-1-14**] 10:40PM BLOOD WBC-11.7*# RBC-3.50* Hgb-10.6* Hct-29.7*
MCV-85 MCH-30.2 MCHC-35.6* RDW-12.9 Plt Ct-220
[**2144-1-14**] 10:40PM BLOOD Neuts-92.5* Lymphs-4.8* Monos-2.5 Eos-0
Baso-0.2
[**2144-1-14**] 10:40PM BLOOD PT-15.6* PTT-25.6 INR(PT)-1.4*
[**2144-1-14**] 10:40PM BLOOD Fibrino-712*
[**2144-1-14**] 10:40PM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-140
K-3.4 Cl-110* HCO3-23 AnGap-10
[**2144-1-14**] 10:40PM BLOOD ALT-95* AST-40 AlkPhos-243* Amylase-9
TotBili-7.3*
[**2144-1-14**] 10:40PM BLOOD Lipase-13 GGT-262*
[**2144-1-14**] 10:40PM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.2*
Mg-1.9 Cholest-122
[**2144-1-14**] 10:40PM BLOOD Triglyc-136 HDL-7 CHOL/HD-17.4 LDLcalc-88
[**2144-1-15**] 01:30AM URINE RBC-0-2 WBC-[**6-12**]* Bacteri-MOD Yeast-NONE
Epi-0-2
[**2144-1-15**] 01:30AM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.0 Leuks-TR
[**2144-1-15**] 01:30AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.018
CXR: PA & Lateral: Widened mediastinal contour is unchanged and
may be secondary to underlying vascular abnormality/tortuosity
or possibly an underlying mass. An 11-mm nodular opacity
overlies the right first anterior rib. There is no pneumothorax.
There is slight blunting of the costophrenic angles. IMPRESSION:
Prominent mediastinal contour and nodular right apical opacity,
for which dedicated contrast-enhanced Chest CT is recommended
for further evaluation.
ERCP:
Impression: Successful biliary cannulation
Stones at the main duct
Successful stone extraction with spiral basket.
Pus exiting the ampulla
There was a suggestion of narrowing at the biliary hilum
Successful placement of 10cm x 10F biliary stent.
Otherwise normal ercp to third part of the duodenum
Recommendations: Please call Dr.[**Name (NI) 2798**] office at
[**Telephone/Fax (1) 2799**] with any further questions or concerns.
Please call the on call ERCP fellow at [**Telephone/Fax (1) 2756**] with any
immediate concerns such as fever, abdominal pain, bleeding,
following your procedure.
Watch for bleeding, perforation, and pancreatitis.
Repeat ERCP in 3 weeks with Dr. [**Last Name (STitle) **] for stent removal and
reassement of duct for residual stone or stricture.
Continue antibiotic therapy for 14 days.
CT CHEST:
IMPRESSION:
A roughly 11-mm wide right upper lobe nodule corresponding to
lesion seen on
recent chest radiograph should be considered malignant until
proved otherwise.
Any prior chest radiograph should be obtained to see if the
lesion is
longstanding. Otherwise PET CT scanning or short-term followup
in three
months would constitute imaging management. The lesion should be
accessible
to transthoracic CT-guided needle aspiration.
Brief Hospital Course:
61F with history of prior chole c/b stump leak in past now
admitted with findings c/w acute cholangitis / 5x7mm CBD stone.
Febrile o/n but HD stable.
.
# Cholangitis: Patient presented to OSH with symptoms os fevers,
RUQ tenderness and jaundice. CT scan from OSH demonstrated
pneumobilia and a stone in the CBD with intrahepatic ductal
dilation. Initially hypotensive at outside hospital requiring
pressors, however on arrival patient fluid responsive
(Resuscitated with ~6L IVF) and pressors weaned. Patient
continued on Vancomycin and Zosyn for antibiotic coverage. ERCP
was consulted and patient underwent uncomplicated ERCP on
[**2144-1-16**]. ERCP demonstrated successful biliary cannulation,
stones at the main duct, successful stone extraction with spiral
basket, pus exiting the ampulla, and successful placement of
10cm x 10F biliary stent. Her diet was advanced the following
morning to clears, which resulted in increased nausea and
abdominal pain. She then had intermittent abd pain for the next
few days. We suspected mild post ERCP pancreatitis. After more
IVF her pain improved. Repeat LFTs showed improved T. bili,
with mild transaminitis. She was transitioned to Cipro/Flagyl
for which she will need a 14 day total course
- she will need repeat ERCP in 3 weeks
- we recommend repeating LFTs on PCP follow up.
.
# Chest CT Abnormalities: Hilar and right apical abnormalities
noted on initial CXR and on repeat PA/Lateral. CT scan showed
prelim read was 11 x 9mm pulmonary nodule in the right apex,
also with right apical and basilar lung acarring/atelectasis.
PET/CT can be considered for evaluation of metabolic activity).
Given patient's 50 pack-year history and recent 30 pound
unintentional weight loss, this will require close follow-up to
rule-out malignancy.
Final read:
A roughly 11-mm wide right upper lobe nodule corresponding to
lesion seen on
recent chest radiograph should be considered malignant until
proved otherwise.
Any prior chest radiograph should be obtained to see if the
lesion is
longstanding. Otherwise PET CT scanning or short-term followup
in three
months would constitute imaging management. The lesion should be
accessible
to transthoracic CT-guided needle aspiration.
--these findings were discussed with the patient and she
understands the possibility of maligancy.
.
# Coagulopathy: Patient's INR elevated at 1.4 on admission. No
evidence of DIC, fibrinogen was 712. Likely Vit K def in the
setting of poor nutrition. Stable at time of discharge.
.
# Diarrhea: C.difficile sent and was negative.
Medications on Admission:
Codeine
Xanax 2-3mg qhs
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: over the counter.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation: over the counter.
8. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
9. Outpatient Lab Work
CBC, AST, ALT, Alk phos, T. bili at next follow up.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholangitis
Pulmonary nodule
Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to the [**Hospital1 18**] for further evaluation and
treatment of your cholangitis. You underwent ERCP with stone
removal and stent placement and were treated with IV
antibiotics. These were transitioned to oral antibiotics, which
you will need to continue taking for a total of 14 days.
As we discussed, you were found to have a lung nodule of
uncertain significance, though it might be a cancer. Please
follow-up with your primary care physician regarding the
pulmonary nodule found on your chest CT as soon as possible.
Medications started:
Ciprofloxacin 500mg twice daily
Flagyl 500mg three times daily (Avoid with alcohol)
Dilaudid as needed for pain. Do NOT use with alcohol or
driving, take with stool softeners
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 10543**] on Thursday, [**1-23**] at
1:30. You will also need to follow-up with the ERCP for a repeat
ERCP in three weeks for stent removal. Their office will be in
contact with you to schedule that procedure.
PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) 10543**]
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Street Address(2) 4472**]., [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
|
[
"790.92",
"729.1",
"787.91",
"577.0",
"311",
"574.51",
"576.1",
"725",
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] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
9878, 9884
|
6224, 8775
|
363, 412
|
9976, 9976
|
3464, 3469
|
10895, 11425
|
2780, 2816
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|
9905, 9955
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|
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|
2831, 3445
|
299, 325
|
440, 2407
|
3484, 6201
|
9991, 10103
|
2429, 2655
|
2671, 2764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,538
| 130,499
|
8010
|
Discharge summary
|
report
|
Admission Date: [**2166-10-19**] Discharge Date: [**2166-10-28**]
Date of Birth: [**2117-4-21**] Sex: M
Service: SURGERY
Allergies:
Motrin / Lisinopril / Rapamune
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
AV fistula repair x 2.
History of Present Illness:
49M h/o CRT [**7-27**] now w/ several day h/o increased shortness
of breath, worse lying flat, abdominal distension and peripheral
edema. He also complains of 1 week h/o hallucinations. Denies
f/c/n/v/d or any other signs/symptoms. Urine output at baseline,
no hematuria or dysuria.
Past Medical History:
-End-stage renal disease on HD T/T/S secondary to diabetic
nephropathy-started on dialysis [**2163-7-19**]
-diabetes for at least 20 years with retinopathy and neuropathy
with
footdrop
-coronary artery disease with history of ST elevation MI [**7-24**]
c/b pericardial tamponade requiring pericardiocentesis
-three-vessel disease with stents in the RCA and left circumflex
-hypertension
-depression
-hyperlipidemia
PSH:
[**2166-8-1**] ECD renal transplant with delayed graft function
Social History:
The patient does not smoke and he does not drink alcohol. He
lives with his wife, [**Name (NI) **]. From [**Male First Name (un) 1056**] originally. Has
multiple family members in the area including 4 children, one of
which works in BMT on the [**Hospital Ward Name 516**].
Family History:
Significant for myocardial infarction in his father at the age
of 49. Multiple family members with diabetes.
Physical Exam:
GEN: NAD, A&O
PULM: CTAB
RESP: RRR
ABD: Soft, NTND. Incision well healed
EXT: 1+ edema bilat.
Brief Hospital Course:
The patient was seen and evaluated in the ED for shortness of
breath and admitted to the ICU for further management. Previous
biopsy had shown no evidence of rejection. The patient was
started on hemodialysis and a renal ultrasound obtained.
Ultrasound indicated an AV-Fistula & Repeat biopsy showed no
evidence of infection. Angiography was used to confirm the
patients AV-fistula, and this was coiled, the patient recovered
without complication, but after several days no improvement in
his renal function was noted. The patient was observed to have a
persistent av-fistula on ultrasound and was taken for repeat
angiography and coiling. This successfully resolved the
patient's fistula. He did continue to have elevated serum
creatinines and was planned to follow up for continued
hemodialysis.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*qs Capsule(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*qs Tablet(s)* Refills:*2*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*qs Tablet(s)* Refills:*2*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*qs Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED).
Disp:*qs dose* Refills:*2*
9. Lantus 100 unit/mL Cartridge Sig: Six (6) units Subcutaneous
qAM.
Disp:*qs * Refills:*2*
10. Ativan 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*qs Tablet(s)* Refills:*2*
11. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO twice a
day: Total dose = 1.5 milligrams at 6 am and 6 pm daily.
Disp:*180 Capsule(s)* Refills:*0*
12. Diphenhydramine HCl 25 mg Tablet Sig: Two (2) Tablet PO at
bedtime: total dose 50 mg qhs.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
AV Fistula
Discharge Condition:
Good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, decreased urine output, shortness of breath,
or edema.
Continue to get labs drawn every Monday and Thursday as
previous.
No driving if taking pain medication
Drink enough fluids to keep urine light yellow in color
MEDS:
You will no longer need to take your Valcyte.
Please take tacrolimus at 1.5mg twice daily unless instructed to
change your dosing per the clinic.
Followup Instructions:
Please keep all previous appointments as planned. You will still
require Monday and Thursday blood draws as before.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Interventional Cardiology
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-1-19**] 1:20
[**Last Name (LF) **],[**First Name3 (LF) **] (Internal Medicine) [**Telephone/Fax (1) 1792**] Call to
schedule appointment
[**Last Name (LF) **],[**First Name3 (LF) **] R. (Transplant Surgery) [**Telephone/Fax (1) 673**] Call to
schedule appointment
[**Last Name (LF) **], [**First Name3 (LF) **] (Vascular Surgery) [**Telephone/Fax (1) 2625**] Call to
schedule appointment
|
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"736.79",
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"E878.0",
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"276.7",
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icd9cm
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[
[
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[
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,449
| 142,566
|
5468
|
Discharge summary
|
report
|
Admission Date: [**2153-3-7**] Discharge Date: [**2153-3-16**]
Date of Birth: [**2077-3-23**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Relafen / Sulfa (Sulfonamide Antibiotics) / Reglan
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 75 year-old Female with PMH significant for CREST
syndrome, oxygen-dependent idiopathic pulmonary fibrosis,
pulmonary hypertension, rheumatoid arthritis, hypertension,
anxiety disorder and Alzheimer dementia who presented with
several days of exertional dyspnea.
.
She was recently seen by her PCP [**Name Initial (PRE) **] 7-8 days of progressive
dyspnea with exertion, but she denies symptoms while at rest.
She associates this with excessive secretions and a chronic
productive cough which may have worsened over several days. She
also has had a few episode of loose, watery and non-bloody
stools. She is oxygen-dependent on 2L nasal cannula at home and
has noted no increasing oxygen requirements while at home over
the last week. When questioned what brought her to the ED, she
said her husband was worried about her exertional dyspnea. She
also notes some right lower extremity swelling for which she was
referred to the [**Hospital1 18**] ED. She denies fevers or chills. No chest
pain. Exertional dyspnea noted. No headaches or vision changes.
Denies nausea, emesis or abdominal pain. Loose stools occurring
without hematochezia or melena. She denies recent antibiotic
use, denies recent travel or sick contacts. [**Name (NI) **] [**Name2 (NI) **], she was
recently seen by her PCP [**Last Name (NamePattern4) **] [**2153-2-27**] with a prescription for
Azithromycin (prescribed by Dr. [**Last Name (STitle) 1007**] for symptoms noted above.
Last steroid dosing prescribed [**2153-1-21**]; taper
completed.
.
Of note, the patient was recently admitted to [**Hospital1 18**] on [**2153-1-11**]
with weakness and anorexia in the setting of poor PO intake
without focal neurologic deficits, found to have acute renal
insufficiency, mild leukocytosis which responded to IV fluids
and PO intake with concern for failure to thrive. She had no
respiratory issues at that time and was discharged without
pulmonary concerns.
.
In the BIMDC ED, initial VS 98.8 106 140/59 28 without recorded
oxygen saturation. Exam notable for no acute distress and good
air movement without labored breathing. Lung exam noted diffuse
dry crackles with loud P2. 1+ lower extremity edema. Laboratory
studies notable WBC 14.0 (neutrophilia to 90%, no bandemia), HCT
23.9%, pro-BNP 506, Troponin < 0.01, lactate 1.4 and INR 1.0.
Metabolic panel with creatinine of 1.0 and phosphorus of 1.8.
U/A with trace protein and leukocyte esterase. A CXR showed
possible RLL infiltrate worse as compared with prior. She
received albuterol and ipratropium nebulizers, Lasix 20 mg IV x
1 and Levofloxacin 750 mg IV x 1. ABG showed 7.51/33/86/27. She
was admitted to Medicine on the [**Hospital Ward Name 516**].
.
On arrival to the Medicine floor, she was noted to have
increased work of breathing and had a respiratory rate of
greater than 40 bpm with accessory muscle use. Given concern for
impending acute respiratory failure she was transferred to the
ICU on 5L O2 via nasal cannula.
.
On arrival to the [**Hospital Unit Name 153**], she appeared moderately anxious but was
in no acute distress and was speaking in full sentences. She had
no chest pain and denies dyspnea at rest.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. CREST syndrome
2. Idiopathic pulmonary fibrosis (history of pneumonitis)
3. Pulmonary artery hypertension
4. Raynaud phenomenon
5. Esophageal dysmotility (hiatal hernia and reflux esophagitis)
6. Peripheral vascular disease
7. Hypertension
8. Anxiety disorder
9. Rheumatoid arthritis
10. Alzheimer dementia
Social History:
Patient lives at home with her husband. Originally from
[**Country 6257**]. Has one son who is older. Worked for the state doing
administrative duties. High school education. Denies tobacco use
or alcohol use; no recreational substance use.
Family History:
Mother died of stomach cancer (age 78), father died of 'older
age' (age 90s).
Physical Exam:
ADMISSION .
VITALS: 98.6 / 98.2 74 146/48 14-30 100% 2L NC
GENERAL: Appears in no acute distress. Alert and interactive. No
tripoding; speaking in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 1-2 cm above clavicle
at 90-degrees.
CVS: Regular rate and rhythm, loud P2 at LUSB, without murmurs,
rubs or gallops. Prominent S1 and S2 normal.
RESP: Dry inspiratory crackles at right lung base greater than
left with no rhonchi or wheezing. AP diamater increased with
barrel-appearing chest wall. Kyphosis notes of thoracic spine.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; 1+ non-pitting edema of right
greater than left lower extremity to mid-shins with some
varicosities, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
MSKL: OA changes in her PIPs with adequate ROM.
.
Pertinent Results:
[**2153-3-15**] 05:50AM BLOOD WBC-7.7 RBC-2.74* Hgb-7.6* Hct-24.0*
MCV-88 MCH-27.7 MCHC-31.6 RDW-16.6* Plt Ct-247
[**2153-3-14**] 10:45AM BLOOD WBC-12.3*# RBC-2.80* Hgb-8.1* Hct-24.9*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.6* Plt Ct-255
[**2153-3-13**] 06:19AM BLOOD WBC-7.9 RBC-2.78* Hgb-7.8* Hct-24.6*
MCV-88 MCH-28.0 MCHC-31.7 RDW-16.7* Plt Ct-266
[**2153-3-12**] 10:30AM BLOOD Hct-24.2*
[**2153-3-12**] 06:10AM BLOOD WBC-10.7 RBC-2.73* Hgb-7.7* Hct-23.2*
MCV-85 MCH-28.3 MCHC-33.3 RDW-17.2* Plt Ct-255
[**2153-3-11**] 06:24AM BLOOD WBC-8.3 RBC-2.92* Hgb-8.4* Hct-25.7*
MCV-88 MCH-28.7 MCHC-32.6 RDW-16.3* Plt Ct-290
[**2153-3-10**] 06:32AM BLOOD WBC-8.4 RBC-2.98* Hgb-8.6* Hct-26.1*
MCV-88 MCH-28.8 MCHC-32.8 RDW-16.2* Plt Ct-300
[**2153-3-9**] 08:55AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.3* Hct-28.1*
MCV-85 MCH-28.1 MCHC-33.0 RDW-16.5* Plt Ct-316
[**2153-3-8**] 08:10PM BLOOD WBC-10.8 RBC-3.17*# Hgb-9.1*# Hct-27.0*
MCV-85 MCH-28.8 MCHC-33.7 RDW-16.6* Plt Ct-273
[**2153-3-8**] 05:39AM BLOOD WBC-7.3 RBC-2.52* Hgb-7.1* Hct-21.8*
MCV-86 MCH-28.1 MCHC-32.6 RDW-16.5* Plt Ct-254
[**2153-3-7**] 09:49PM BLOOD Hct-24.3*
[**2153-3-7**] 02:25PM BLOOD WBC-14.0* RBC-2.68* Hgb-7.6* Hct-23.9*
MCV-89 MCH-28.3 MCHC-31.7 RDW-16.7* Plt Ct-265
[**2153-3-14**] 10:45AM BLOOD Neuts-85.7* Lymphs-5.4* Monos-8.0 Eos-0.8
Baso-0.2
[**2153-3-8**] 05:39AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Stipple-OCCASIONAL
[**2153-3-7**] 04:20PM BLOOD PT-11.1 PTT-23.4* INR(PT)-1.0
[**2153-3-15**] 05:50AM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-101 HCO3-30 AnGap-12
[**2153-3-14**] 10:45AM BLOOD Glucose-109* UreaN-14 Creat-1.1 Na-141
K-3.5 Cl-103 HCO3-27 AnGap-15
[**2153-3-13**] 06:19AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-138
K-3.8 Cl-103 HCO3-29 AnGap-10
[**2153-3-12**] 06:10AM BLOOD Glucose-98 UreaN-11 Creat-1.1 Na-141
K-3.3 Cl-105 HCO3-30 AnGap-9
[**2153-3-11**] 06:24AM BLOOD Glucose-88 UreaN-12 Creat-1.0 Na-142
K-3.4 Cl-105 HCO3-31 AnGap-9
[**2153-3-10**] 06:32AM BLOOD Glucose-93 UreaN-10 Creat-1.1 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2153-3-9**] 08:55AM BLOOD Glucose-96 UreaN-9 Creat-1.0 Na-142 K-3.9
Cl-105 HCO3-28 AnGap-13
[**2153-3-7**] 02:25PM BLOOD Glucose-122* UreaN-15 Creat-1.0 Na-140
K-3.6 Cl-104 HCO3-26 AnGap-14
[**2153-3-8**] 05:39AM BLOOD LD(LDH)-194
[**2153-3-7**] 02:25PM BLOOD cTropnT-<0.01 proBNP-506
[**2153-3-13**] 06:19AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.4
[**2153-3-12**] 06:10AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8
[**2153-3-11**] 06:24AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2153-3-9**] 08:55AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0
[**2153-3-8**] 03:12PM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9
[**2153-3-8**] 05:39AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.0 Iron-15*
[**2153-3-7**] 02:25PM BLOOD Calcium-8.5 Phos-1.8* Mg-2.1
[**2153-3-13**] 06:19AM BLOOD VitB12-995* Folate-GREATER TH
[**2153-3-7**] 06:14PM BLOOD Type-ART pO2-86 pCO2-33* pH-7.51*
calTCO2-27 Base XS-3
[**2153-3-7**] 06:14PM BLOOD Lactate-1.4
.
Microbiology:
[**2153-3-8**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2153-3-8**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2153-3-7**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2153-3-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2153-3-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
.
[**2-/2070**] EKG:
Sinus rhythm. Left atrial abnormality. Left axis deviation. Left
anterior
fascicular block. Diffuse non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2152-10-14**]
multiple abnormalities as previously noted persist without
major change.
.
CXR [**2-/2070**]:
IMPRESSION: Known chronic interstitial disease with increased
interstitial
markings seen at the lung bases. Interval increase in right base
opacity
raises concern for a superimposed infectious process.
.
repeat [**2-/2070**] CXR:
There is moderate-to-severe cardiomegaly, unchanged from prior
study. The
pulmonary arteries are enlarged. This suggests the presence of
pulmonary
hypertension. The aorta is tortuous. The patient has known
chronic fibrotic interstitial lung disease with peripheral and
bilateral lower lobe and right middle lobe predominance.
Superimposed on this chronic finding, there is new ill-defined
opacity in the right lower hemithorax consistent with infection.
There is no pneumothorax or pleural effusion. Elevation of the
right hemidiaphragm is unchanged.
The study and the report were reviewed by the staff radiologist
.
[**3-8**] ECHO:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 5-10 mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >65%). 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 stenosis or
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.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mildly
dilated ascending aorta. Mild pulmonary hypertension.
.
[**3-8**] LENI:
IMPRESSION: No lower extremity deep vein thrombosis.
.
[**3-9**] CXR:
Findings of chronic interstitial lung disease are most
pronounced and may be largely restricted to the right lower
lung. That area has developed more coarse interstitial lines in
a region of likely honeycombing fibrosis since beginning of
[**Month (only) 404**]. This could be due to either deposition of edema or
inflammation such as aspiration or even atypical pneumonia.
Severe cardiomegaly is longstanding as is pulmonary vascular
congestion, most easily seen in the left lung. This looks like
chronic congestive heart failure, chronic interstitial fibrosing
lung disease, and acute conditions such as mild edema or
atypical pneumonia.
.
[**3-11**] EKG:
Sinus rhythm with two atrial premature beats. Intra-atrial
conduction delay. Left ventricular hypertrophy. Poor R wave
progression. Compared to the previous tracing the findings are
similar.
.
[**3-11**] CXR:
There are lower lung volumes. Cardiomediastinal contours are
unchanged with cardiomegaly and enlarged main pulmonary
arteries. Patient has known
pulmonary fibrosis with interstitial abnormalities, larger in
the lower lobes bilaterally. These opacities have minimally
increased, partially due to the lower lung volumes, but an acute
exacerbation of IPF is suspected. There is no focus of lobar
pneumonia. There is no pulmonary edema, pneumothorax or pleural
effusion.
.
[**3-14**] EKG:
Sinus rhythm. Left axis deviation. Borderline left ventricular
hypertrophy by voltage criteria in the limb leads.
Non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2153-3-11**] there
is no
diagnostic change.
.
[**3-14**] CXR:
IMPRESSION: New left upper zone opacity which may represent
asymmetric edema or new consolidation
.
[**3-16**] CXR:
UPRIGHT AP VIEW OF THE CHEST: Evaluation is limited by head
positioning,
which obscures the lung apices. Within this limitation, there is
little
change in left upper lung opacity. Low lung volumes and
reticular opacities at the lung bases are unchanged and
consistent with stated history of IPF. The cardiomediastinal
silhouette is stable. There is no pneumothorax.
IIMPRESSION: No change in left upper lung opacity or findings
related to IPF.
[**2153-3-16**] 05:45AM BLOOD WBC-9.3 RBC-3.17* Hgb-9.2* Hct-27.0*
MCV-85 MCH-29.0 MCHC-34.0 RDW-16.0* Plt Ct-244
[**2153-3-16**] 05:45AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-139
K-3.6 Cl-101 HCO3-31 AnGap-11
[**2153-3-16**] 05:45AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0
Brief Hospital Course:
IMPRESSION: 75F with a PMH significant for CREST syndrome,
oxygen-dependent idiopathic pulmonary fibrosis, pulmonary
hypertension, rheumatoid arthritis, hypertension, anxiety
disorder and Alzheimer dementia who presented with progressive
exertional dyspnea and increasing oxygen requirement with
imaging findings concerning for consolidation or RLL infiltrate
and arterial blood gas evidence of respiratory alkalosis
transferred initially to the medical ICU for concerns of
impending acute hypoxic respiratory failure.
.
# ACUTE HYPOXIC RESPIRATORY failure - The patient presented with
several days of progressive exertional dyspnea without clear
inciting etiology. Initial CXR with evidence of RLL pulmonary
infiltrate on imaging with leukocytosis to 14.0 despite
remaining afebrile. She has a poor pulmonary substrate with long
standing oxygen-dependent idiopathic pulmonary fibrosis in the
setting of her autoimmune and rheumatologic conditions, limited
scleroderma or CREST syndrome. As of [**1-/2153**], reduced DLCO 5.77
(36% predicted), FVC 1.32 (predicted 58%), FEV1 1.19 (77%
predicted) - ratio 90 (132%) consistent with restrictive
physiology and has been stable since [**2148**] per her PFTs. CT chest
imaging in [**2149**] demonstrated ILD with bronchiectasis,
honeycombing and reticulation (more severe on the right) -
chronic aspiration was noted on that imaging. Last
hospitalization was < 90 days prior and lasted roughly 3-days
and she has no strong history of recurrent PNAs, although
chronic aspiration has been a concern. Given her indolent
presentation and CXR imaging, community-acquired pneumonia
seemed probable with a RLL infiltrate which may have contributed
to her progressive dyspnea with leukocytosis. Her ABG prior to
MICU transfer revealed a primary respiratory alkalosis, in the
setting of hyperventilation attributed to probable anxiety.
Following arrival to MICU her oxygenation remained stable and
she was weaned quickly to her home oxygen requirement of 2L via
nasal cannula. Continued PO Levofloxacin for CAP coverage with a
planned course of 7-days. While on the medical floor, pt
continued to have intermittent periods of acute dyspnea/hypoxia
without clear inciting cause, that would resolve without
intervention. However, oxygen requirement gradually trended
upward to 3L and remained stable. CXR and EKGs unchanged for the
most part. However, pt had another event on [**3-14**] and repeat CXR
at that time showed new LUL infiltrate. ECHO was unchanged from
prior and LENIs were negative for DVT. Pt did not have fever at
the time but did have a mild leukocytosis. There has always been
a concern of chronic aspiration. Therefore, pt was started on
augmentin therapy for presumed aspiration for a 10 day course, 8
days left at time of discharge. It was not felt that pt had a
HCAP as clinically there was no fever, productive cough, marked
change in respiratory status etc. In addition, speech and
swallow evaluation did not suggest aspiration. Inpatient
pulmnonary consultation was obtain for further assistance in
management and pulmonary team suggested tx for ?PNA, sputum cx,
S+S eval, outpatient PFTs and pulmonary evaluation. It was not
thought that pt had acute IPF flare by pulmonary and therefore,
steroids were not recommended. In addition, pt was transfused 1
unit of PRBCs on [**3-15**] to assist with oxygen carrying capacity. Pt
felt symptomatic improvement after transfusion. Denied cough,
SOB, chest pain on day of discharge. Outpatient f/u with Dr.
[**Last Name (STitle) **] [**Name (STitle) 22126**] was scheduled for [**3-30**]. Repeat PFTs can be
considered. PT was started on combivent nebulizer therapy.
.
# LEUKOCYTOSIS - She presented with a leukocytosis to 14.0 with
neutrophil predominance and no bandemia in the absence of
fevers. Clinical evidence of pneumonia based on lung exam and
CXR imaging. U/A reassuring without dysuria or hematuria. Blood
and urine cultures obtained. She was antibiosed with PO
Levofloxacin for 7-days of coverage. Her leukocytosis improved.
However, then again transiently worsened and CXR found evidence
for ?new PNA (no fever or new cough) for which aspiration was
suspected rather than HCAP and pt was started on augmentin for
10 days course per pulmonary recommendations. Resolved by time
of discharge.
.
# IDIOPATHIC PULMONARY FIBROSIS, PULMONARY ARTERY HYPERTENSION -
Strong clinical history of autoimmune and rheumatologic
conditions, limited scleroderma or CREST syndrome. As of [**1-/2153**],
reduced DLCO 5.77 (36% predicted), FVC 1.32 (predicted 58%),
FEV1 1.19 (77% predicted) - ratio 90 (132%) consistent with
restrictive physiology and has been stable since [**2148**] per her
PFTs. CT chest imaging in [**2149**] demonstrating ILD with
bronchiectasis, honeycombing and reticulation (more severe on
the right) - chronic aspiration was noted on that imaging. No
strong history of recurrent PNAs nonetheless. Last 2D-Echo
demonstrated PAP of 26-42 mmHg with minimal TR and normal RA/RV
measurements - notable for moderate pulmonary artery HTN without
evidence of RV overload on exam. Has been maintained on
Sildenafil and Lasix therapy. Followed closely by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
and at [**Hospital3 2358**] for her pulmonary issues. This admission her
exam appears stable and CXR is without volume overload or
worsening interstitial disease - this overall it appears that
her underlying pulmonary disease is stable and she is without
evidence of acute decompensation. We continued nebulizer
treatments, Sildenafil therapy and judiciously dosed her home
Lasix. Repeat echo did not show acute change from prior.
.
# ACUTE ON CHRONIC NORMOCYTIC ANEMIA - Presented with concern
for decreased hematocrit and normocytic anemia. Guaiac negative
in the ED. No hemodynamic instability and no obvious source of
bleeding. Colonoscopy in [**1-/2153**] showed diverticulosis, grade I
hemorrhoids and multiple polyps with biopsies revealing adenomas
and hyperplastic polyps. Hematocrit on admission was 23-24% (and
30% over 2-months prior). Anemia of chronic disease in the
setting of automimmune and chronic rheumatologic conditions is
certainly a baseline contributor. We mantained peripheral access
and active type and screens. She was serially monitored without
hemodynamic concerns. She was transfused a single unit of packed
red cells on [**3-8**] and [**3-15**] with good effect. Iron studies
suggested anemia of chronic disease and hemolysis labs were not
suggestive of hemolysis. HCT was 27 on day of discharge.
.
# CREST SYNDROME (ESOPHAGEAL DYSMOTILITY, RAYNAUD, RHEUMATOID
ARTHRITIS) - Appears clinically stable. Pulmonary issues
discussed in above plan of care. Appears well-controlled on some
intermittent NSAID dosing. No biologic therapy or
immunomodulator therapy for rheumatoid arthritis. Some chronic
OA changes noted in her PIP joints. Continued Tylenol for pain
control. Pt takes meloxicam as outpt.
.
# HYPERTENSION - Recent outpatient clinic notes demonstrate
systolic BP range 110-140 mmHg with no symptoms; no evidence of
nephropathy. Normotensive on admission. We continued Diltiazem
and held her thiazide-diuretic during admission. However, she
can resume triamterene/HCTZ upon DC.
.
# ANXIETY DISORDER - Appeared mildly anxious on exam at times.
Pt was given very low dose, very infrequent doses of ativan prn.
SHe is being discharged without an order for this medication
.
# ALZHEIMER DEMENTIA - Appears stable. Unclear baseline,
although [**Month/Day (4) **] notes mention chronic forgetfullness and short-term
memory impairment. We continued her Donepezil medication.
.
TRANSITION OF CARE ISSUES:
-outpt pulmonary evaluation with repeat PFTs
-CBC trend
Medications on Admission:
HOME MEDICATIONS (confirmed with Pharmacy)
1. Acetylcysteine 600 mg PO TID
2. Albuterol sulfate 90 mcg INH 2 puffs INH TID PRN wheezing
3. Diltiazem 120 mg ER PO daily
4. Diphenoxylate-atropine 2.5 mg-0.025 mg 1-2 tabs PO Q6H PRN
diarrhea
5. Donepezil 10 mg PO daily
6. Furosemide 20 mg PO BID (up to 2 tabs in the AM, 1 tab in the
PM)
7. Meloxicam 7.5 mg PO daily (with food)
8. Mirtazapine 15 mg PO QHS
9. Omeprazole 20 mg EC PO BID
10. Pentoxifylline 400 mg PO ER TID
11. Sildenafil 20 mg PO TID (on an empty stomach)
12. Calcium carbonate-vitamin D3 500 mg (1250 mg)-200 units PO
daily
13. Cholecalciferol vitamin D3 400 units PO daily
14. Simvastatin 40 mg PO daily
15. HCTZ-Triamterene 37.5 mg-25 mg PO daily
Discharge Medications:
1. acetylcysteine 600 mg Capsule Sig: One (1) Capsule PO three
times a day.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
[**1-8**] Inhalation three times a day as needed for shortness of
breath or wheezing.
3. DILT-CD 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours.
5. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day).
10. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO once a day.
14. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a
day.
15. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 8 days.
16. Combivent 18-103 mcg/actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
17. meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain: take with FOOD.
Discharge Disposition:
Extended Care
Facility:
[**Street Address(1) 19427**] Nursing & Rehab Center - [**Location (un) 3307**]
Discharge Diagnosis:
Primary:
Pneumonia, community acquired and aspiration
Secondary:
CREST syndrome
Pulmonary fibrosis
Pulmonary hypertension
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 for shortness of breath and treated for
pneumonia with antibiotics and nebulizer therapy. You were also
evaluated by the pulmonology (lung doctor) team. You were given
a blood transfusion for anemia with good effect. Your symptoms
improved.
.
Medication changes:
1.augmentin for 8 more days for pneumonia
2.nebulizer therapy as needed
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) 22127**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Street Address(2) 22128**]., [**Location (un) 8985**], MA
Phone: [**Telephone/Fax (1) 22129**]
When: Friday, [**2152-3-29**]:00 AM
.
Department: RHEUMATOLOGY
When: MONDAY [**2153-4-16**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2153-5-25**] at 2:00 PM
With: DR. [**First Name (STitle) 251**] [**Name (STitle) **] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2153-7-18**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.3",
"443.9",
"714.0",
"416.8",
"518.81",
"710.1",
"300.00",
"530.5",
"486",
"515",
"507.0",
"V46.2",
"331.0",
"401.1",
"443.0",
"285.9",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
23404, 23510
|
13320, 21047
|
341, 368
|
23677, 23677
|
5403, 13297
|
24334, 25632
|
4198, 4277
|
21812, 23381
|
23531, 23656
|
21073, 21789
|
23862, 24123
|
4292, 5384
|
24143, 24311
|
281, 303
|
396, 3558
|
23692, 23838
|
3580, 3924
|
3940, 4182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,126
| 124,750
|
1942+1943
|
Discharge summary
|
report+report
|
Admission Date: [**2200-2-10**] Discharge Date: [**2200-2-17**]
Date of Birth: [**2147-5-5**] Sex: M
Service: MEDICINE
[**Last Name (LF) **], [**First Name3 (LF) **] E. 12-907
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2200-2-20**] 15:30
T: [**2200-2-24**] 11:48
JOB#: [**Job Number 10736**]
Admission Date: [**2200-2-10**] Discharge Date: [**2200-2-17**]
Date of Birth: [**2147-5-5**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old
male with a history of multi drug resistant HIV status post
failed HAART therapy, stopped on [**2200-2-4**] who presents with a
one week history of bloody diarrhea. The patient also
complains of headache, confusion and lethargy. He denies
In the emergency room the patient was found to be tachycardic
to 140, hypotension to 90/palp, acidotic with ABG of 7.18,
16, 134. Coagulopathic with INR of 65.6 and in acute renal
failure with BUN of 100 and creatinine of 8. The patient was
admitted to MICU on [**2200-2-10**] for further care.
1. Acid Base - The patient anion gap and non-anion gap
metabolic acidosis likely secondary to diarrhea and acute
renal failure. He was treated with D5W and bicarbonate.
Anion gap closed after fluid.
2. Renal - Acute renal failure with creatinine of 8 up from
baseline of 1.7. Creatinine gradually decreased to normal
levels with volume repletion. Renal ultrasound was negative
for obstruction. Renal was consulted. Sediment was
consistent with pre-renal etiology. No evidence of ATN.
3. Fluid Status - The patient's hypotension and tachycardia
improved with volume repletion.
4. Electrolytes - The patient's potassium and magnesium were
aggressively repleted in setting of ongoing diarrhea.
5. Gastrointestinal - Diarrhea followed by bloody diarrhea.
GI was consulted. Bloody diarrhea was thought to be secondary
to elevated INR. EGD and colonoscopy were deferred.
Hematocrit remained stable after transfusion. Stool studies
were sent.
6. Hematology - The patient is on Coumadin for treatment of
DVT. On admission elevated INR was thought to be secondary
to inadvertent Coumadin overdosing. The patient was taking
total of 5 milligrams po bid. His INR was reversed with 6
units of fresh frozen plasma and 10 milligrams of
subcutaneous vitamin K. The patient was also transfused 2
units of packed red blood cells for hematocrit of 35 down
from baseline of 42. Hematology was consulted. TTP was
ruled out by normal sphere.
7. Neurologic - In patient with elevated INR and change in
mental status. There is concern for intracranial bleed. CT
scan of the head was negative for hemorrhage. The patient
returned to baseline mental status with fluid repletion.
8. Infectious Disease - There was initial concern for sepsis
secondary to patient's hypotension. The patient was initially
empirically treated with Levaquin, Ceftriaxone and
Vancomycin. The patient remained afebrile and responded well
to fluid and blood resuscitation so antibiotics were stopped.
Currently the patient continues to have diarrhea but it has
decreased in frequency. No headache, fever, chills, nausea,
vomiting, abdominal pain, night sweats.
The patient was discharged for further care.
PAST MEDICAL HISTORY:
1. Deep venous thrombosis seven weeks ago.
2. HIV times nine years. Most recent CD4 count 9. Viral
load greater than 100,000.
3. Asthma.
4. Molluscum.
5. History of nephrolithiasis and chronic hydronephrosis
secondary to Crixivan.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS:
1. Acyclovir 400 milligrams po tid.
2. Bactrim double strength po q day.
3. Diflucan 100 milligrams po q day.
4. Coumadin 5 milligrams po bid.
5. Neurontin 400 milligrams po bid.
6. Serevent, Flovent and Albuterol inhalers.
7. Azithromycin 600 milligrams po q week.
PHYSICAL EXAMINATION: Temperature 98.4 F, pulse 106 to 116,
blood pressure 123 to 174/ 79 to 106, respirations 17.
Saturation 95 to 99% on room air. In general the patient is
alert, in no acute distress. HEENT - oropharynx is clear.
Moist mucous membranes. Sclerae - anicteric. Cardiovascular
- tachycardic, regular rhythm, no murmurs. Lungs are clear.
Abdomen is soft, nontender, nondistended with positive bowel
sounds. Extremities - no edema.
LABORATORY DATA: White count 4.5, hematocrit 30.1, platelet
count 122,000, INR 2. Chem 7 sodium 137, potassium 3.3,
chloride 107, bicarb 18, BUN 69, creatinine 3.7, glucose 61,
albumin 2.2, calcium 8.6, phosphate 3.8, magnesium 2.3.
Stool studies are pending.
HOSPITAL COURSE:
1. Hematology - In the admitting setting of bloody diarrhea
the patient's hematocrit remained low but stable status post
transfusion.
2. Coagulopathy - The patient's INR was corrected with fresh
frozen plasma and vitamin K as per HPI. Once INR fell below
level of 3 the patient was re-started on Heparin without a
bolus and then re-started on Coumadin.
3. Renal - Acute renal failure secondary to volume
depletion. Creatinine returned to baseline after fluid
resuscitation.
4. Gastrointestinal - Diarrhea became non-bloody once INR was
corrected. Diarrhea continued but decreased in frequency.
Abdominal CT scan was obtained which was negative for bowel
wall thickening. By the end of the hospital stay the patient
was having formed stools.
5. Infectious Disease - Stool studies were sent which were
positive for microsporidia times two as well as 4+ PMNs.
Since microsporidia does not normally cause inflammatory
diarrhea there was suspicion for co-infection with another
organism. However the patient's stool was negative for
Salmonella Shigella, Yersinia, Campylobacter, E coli, Vibrio
as well as negative for C difficile times three, negative for
Cyclospora, ISOSPORA, cryptosporidia, .....................
Blood cultures were negative. Urine culture was negative.
Cryptococcus antigen was negative.
The patient was started on Albendazole for microsporidia.
For his HIV the patient was continued on his Acyclovir,
Bactrim, Diflucan and Azithromycin for opportunistic
prophylaxis.
6. After fluid resuscitation the patient was hypertensive on
the floor. His blood pressure was controlled with po
Lopressor. By the end of hospital stay the patient's blood
pressure had normalized and the Lopressor was stopped.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient to go home.
DISCHARGE FOLLOW UP: The patient to follow up with PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2200-2-18**].
DISCHARGE MEDICATIONS:
1. Bactrim double strength po q day.
2. Diflucan 100 milligrams po q day.
3. Neurontin 400 milligrams po bid.
4. Protonix 40 milligrams po q day.
5. Testosterone shots q one.
6. Albuterol MDI.
7. Albendazole 400 milligrams po bid.
8. Coumadin 5 milligrams po q HS.
9. Azithromycin 600 milligrams po q week.
DISCHARGE DIAGNOSIS:
1. Diarrhea secondary to microsporidia.
2. Elevated INR secondary to inadvertent Coumadin overdosing
with resultant bright red blood per rectum.
3. Acute renal failure, metabolic acidosis secondary to
dehydration and diarrhea.
4. Multi drug resistant HIV.
5. Chronic hydronephrosis secondary to nephrolithiasis from
prior Crixivan therapy.
[**Last Name (LF) **], [**First Name3 (LF) **] E. 12-907
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2200-2-20**] 15:30
T: [**2200-2-24**] 11:48
JOB#: [**Job Number 10736**]
|
[
"078.0",
"009.3",
"584.9",
"042",
"285.9",
"790.2",
"E934.2",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6361, 6424
|
6613, 6930
|
6951, 7522
|
4609, 6339
|
3602, 3876
|
6435, 6590
|
3899, 4591
|
531, 3287
|
3309, 3584
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,080
| 123,967
|
17871
|
Discharge summary
|
report
|
Admission Date: [**2153-2-7**] Discharge Date: [**2153-2-8**]
Date of Birth: [**2076-10-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
woman who was found on the floor in her nursing home at 3:00
a.m. on the day of admission, status post a fall out of bed.
The patient was taken to an outside hospital where a head CT
showed a right frontal contusion. The patient was
transferred to [**Hospital6 256**] for
further management.
HOSPITAL COURSE: On admission, the patient was awake, alert,
moving all extremities spontaneously following commands, but
not speaking. She was admitted to the Neurological Intensive
Care Unit for close neurologic observation and blood pressure
control. The patient was being monitored for increase in ICP
and change in mental status.
The patient had a repeat head CT on [**2153-2-8**] which showed
an increase and blossoming of contusions on the right side,
in the right frontal and the whole right hemisphere of her
brain.
It was discussed with the family and the patient was made
comfort measures only and was transferred back to her nursing
home to be close to her family.
MEDICATIONS AT THE TIME OF DISCHARGE INCLUDE:
1. Digoxin .125 mg p.o. q day.
2. Morphine suppository 30 mg q 4 h prn for pain and
comfort.
The patient's condition had deteriorated overnight and she
was unresponsive, still moving extremities, but not following
commands or opening her eyes prior to discharge. The
patient's condition was otherwise unchanged and the patient
was discharged to nursing home to be close to her family.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2153-2-8**] 13:53
T: [**2153-2-8**] 13:52
JOB#: [**Job Number 49551**]
|
[
"250.00",
"851.40",
"401.9",
"427.31",
"E884.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
499, 1827
|
158, 481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,548
| 198,262
|
5514
|
Discharge summary
|
report
|
Admission Date: [**2148-2-26**] Discharge Date: [**2148-3-4**]
Date of Birth: [**2083-8-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Latex / Cipro
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
new cerebral vascular event likely embolic in nature, found to
have aortic mass at right coronary cusp. Also noted at that time
to have severe tricuspi regurgitation
Major Surgical or Invasive Procedure:
[**2148-2-28**] Resection of aortic mass, Tricuspid valve repair (28mm
MC3 ring)
History of Present Illness:
64 year old woman, found down in bathroom at home. EMS at that
time reported L facial droop and slurred speech. Brought
initially to [**Hospital **] Med ctr. MRI/MRA showed 2 small areas of
restricted diffusion compatible with subacute cerebral infarct,
likely embolic in nature involving
r corona radiata and R temporal parietal regions. no hemorrage.
A TEE showed EF 65% with 1.4x1cm mobile mass (?thrombus)at
sinotubular junction of right coronary cusp.
Past Medical History:
Raynauds
Palpitations
eye lid surgery
Social History:
retired interior designer
Lives with husband
90 pack year smoking history. Quit 8 years ago.
Denies ETOH use
Family History:
Brother w/CAD
Physical Exam:
VS T 98 HR 83 BP 120/80 RR16 O2sat 97%RA
Ht 64" Wt 53.6K
Gen A&Ox3. NAD
Skin Unremarkable
HEENT PERRL, anicteric noninjected
Neck supple, no LA
Chest CTA bilat
CV RRR
Abdm soft, NT/ND/+BS
Ext warm well perfused, no C/C/E. no varicosities
Neuro grossly intact
Pertinent Results:
[**2148-2-26**] 07:40PM GLUCOSE-127* UREA N-13 CREAT-0.7 SODIUM-143
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-27 ANION GAP-10
[**2148-2-26**] 07:40PM ALT(SGPT)-22 AST(SGOT)-25 LD(LDH)-268* ALK
PHOS-98 AMYLASE-65 TOT BILI-0.3
[**2148-2-26**] 07:40PM LIPASE-16
[**2148-2-26**] 07:40PM ALBUMIN-2.8* CALCIUM-8.3* MAGNESIUM-2.2
[**2148-2-26**] 07:40PM WBC-8.3 RBC-4.66 HGB-14.1 HCT-40.5 MCV-87
MCH-30.3 MCHC-34.9 RDW-13.7
[**2148-2-26**] 07:40PM PLT COUNT-316
[**2148-2-26**] 07:40PM PT-11.5 PTT-25.6 INR(PT)-1.0
[**2148-3-4**] 05:30AM BLOOD Hct-27.6*
[**2148-3-3**] 06:00AM BLOOD WBC-8.6 RBC-2.88* Hgb-8.4* Hct-24.9*
MCV-87 MCH-29.3 MCHC-33.9 RDW-13.8 Plt Ct-205#
[**2148-3-3**] 06:00AM BLOOD Plt Ct-205#
[**2148-3-1**] 02:51AM BLOOD PT-11.4 PTT-28.2 INR(PT)-0.9
[**2148-3-3**] 06:00AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
[**2148-2-27**] 08:10PM BLOOD %HbA1c-5.7
[**2148-2-27**] 01:30AM BLOOD TSH-2.3
[**2148-2-27**] 01:30AM BLOOD T4-6.9
[**Known lastname 22262**],[**Known firstname 26**] [**Medical Record Number 22263**] F 64 [**2083-8-5**]
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2148-3-3**] 3:57 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 22264**]
Reason: f/u effusions/atx
Final Report
REASON FOR EXAM: Tricuspid valve repair, S/P resection of aortic
mass.
Comparison is made with prior study [**2148-2-29**].
Moderate bilateral pleural effusions have increased. Bibasilar
atelectases
have worsened. Cardiac size is normal. Mediastinal contours are
unchanged.
There is no pneumothorax or CHF. Sternal wires are aligned.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: MON [**2148-3-4**] 8:15 AM
[**Known lastname 22262**],[**Known firstname 26**] [**Medical Record Number 22263**] F 64 [**2083-8-5**]
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2148-2-27**]
9:49 AM
[**Last Name (LF) **],[**First Name3 (LF) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 147**] FA6A [**2148-2-27**] 9:49 AM
CAROTID SERIES COMPLETE Clip # [**Clip Number (Radiology) 22265**]
Reason: NEW CVA, ? EMBOLIC, LEFT FACIAL DROOP, SLURRED SPEECH
Final Report
CLINICAL HISTORY: 64-year-old woman with left facial droop and
slurred
speech.
COMPARISON: None available.
FINDINGS: Duplex ultrasound evaluation of the carotid and
vertebral arteries was performed. On B-mode imaging there is
mild echogenic smooth plaque within the proximal right internal
carotid artery. There is no significant echogenic plaque seen
within the left internal carotid artery.
On the right, the peak systolic velocities measure 78 in the
proximal ICA, 82 in the mid ICA, 89 in the distal ICA, 87 in the
CCA, and 157 in the ECA. The right ICA/CCA ratio measures 1.02.
On the left, the peak systolic velocities measure 109 in the
proximal ICA, 78 in the mid ICA, 80 in the distal ICA, 108 in
the CCA, and 88 in the ECA. The left ICA/CCA ratio measures 1.0.
There is normal antegrade flow within both vertebral arteries.
IMPRESSION:
1. Less than 40% stenosis in the right internal carotid artery.
2. 0% stenosis in the left internal carotid artery.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2148-2-28**] 11:05 AM
Brief Hospital Course:
Patient was admited to [**Hospital1 18**] for surgical evaluation for aortic
mass excision.
Her preop workup included carotid ultrasound, coronary CTA, and
neuro evaluation prior to surgery. She was also anticoagulated
throughout this time.
After workup she was deemed a surgical candidate and brought to
the operating room on [**2-28**]. At that time she had a resection of
aortic mass and TV repair. Her bypass time was 60 minutes with a
bypass time of 46 minutes. Please see operative report for
details. Post-operatively she was transferred to the cardiac
surgery ICU for continued monitoring and post-op care. She
remained hemodynamically stable and within several hours was
awakened and extubated. On POD1 she was transferred to the
stepdown floor for continuing care.
Over the next few days she was started on Bblockers and
diuretics, her activity level was advanced with the assistance
of nursing and physical therapy. Her appetite and comfort level
gradually improved and on POD5 she was discharged home with
visiting nurses. She is to followup in the wound clinic in 2
weeks and with Dr [**Last Name (STitle) **] in 4 weeks
Medications on Admission:
Lasix 20 daily
KCL 20 daily
Senekot
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
status post sternotomy with resection Aortic mass at right
coronary cusp/Tricuspid valve repair
PMH:
Raynauds dz
CVA
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr [**Last Name (STitle) **] (PCP) in 1 week ([**Telephone/Fax (1) 7401**]) please call for
appointment
Please see your cardiologist in [**11-24**] weeks.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2148-3-4**]
|
[
"397.0",
"434.11",
"V15.82",
"443.0",
"444.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.04",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
7097, 7156
|
4979, 6114
|
458, 541
|
7317, 7324
|
1544, 4956
|
7835, 8245
|
1230, 1245
|
6200, 7074
|
7177, 7296
|
6140, 6177
|
7348, 7812
|
1260, 1525
|
253, 420
|
569, 1027
|
1049, 1088
|
1104, 1214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,174
| 140,461
|
8069+55908
|
Discharge summary
|
report+addendum
|
Admission Date: [**2122-5-1**] Discharge Date: [**2122-5-12**]
Date of Birth: [**2049-6-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Motor vehicle crash - head on collision
Major Surgical or Invasive Procedure:
[**2122-5-3**]
Open reduction internal fixation of right bimalleolar
ankle fracture.
Open reduction internal fixation of right syndesmotic
disruption.
[**2122-5-6**]
Inferior vena cava filter
Fluoroscopy for placement of inferior vena cava filter.
History of Present Illness:
72 yo female living alone, completely independent and fully
functional, with HTN, COPD, GERD, diverticulitis and GERD, who
presented on [**2122-5-1**] following a motor vehicle crash as
unrestrained driver, incurring multiple fractures (right ankle,
left metatarsal, multiple rib fractures) and Grade IV liver
laceration. She was transported to [**Hospital1 18**] for further care.
Past Medical History:
Depression
HTN
Family History:
Noncontributory
Pertinent Results:
[**2122-5-1**] 09:29PM GLUCOSE-158* UREA N-22* CREAT-0.9 SODIUM-142
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13
[**2122-5-1**] 09:29PM CALCIUM-8.6 PHOSPHATE-4.3 MAGNESIUM-1.9
[**2122-5-1**] 09:29PM WBC-15.6* RBC-3.83* HGB-12.1 HCT-35.2* MCV-92
MCH-31.5 MCHC-34.2 RDW-14.6
[**2122-5-1**] 09:29PM PLT COUNT-266
[**2122-5-1**] 05:20PM UREA N-22* CREAT-1.0
[**2122-5-1**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT HEAD W/O CONTRAST [**2122-5-1**] 5:20 PM
FINDINGS: Periventricular white matter hypodensities are
identified consistent with small vessel ischemic changes. There
is no evidence of acute hemorrhage, although filling of the
arteries and veins with intravenous contrast limits sensitivity
for subtle subarachnoid hemorrhage. The ventricles and sulci are
unremarkable. There is no shift of normally midline structures.
There is no evidence of acute fracture. Visualized paranasal
sinuses are clear.
IMPRESSION: No evidence of acute hemorrhage. Small vessel
ischemic changes.
CT C-SPINE W/O CONTRAST [**2122-5-1**] 5:21 PM
FINDINGS: There is no prevertebral soft tissue swelling. The
vertebral alignment is preserved. Degenerative changes are
identified, specifically at C5-C6 with joint space narrowing and
posterior osteophyte formation. There is no evidence of acute
fracture or dislocation. Visualized lung apices are clear.
Incidental note is made of a large thyroid goiter which extends
into the superior mediastinum.
IMPRESSION: No evidence of acute fracture. Degenerative changes
primarily at C5-C6. Large thyroid goiter.
CAROTID SERIES COMPLETE PORT [**2122-5-4**] 8:18 AM
TECHNIQUE AND FINDINGS: Extracranial evaluation of bilateral
carotids was performed with B-mode, color, and spectral Doppler
ultrasound modes.
On the right peak systolic velocities are 109, 76 and 87 cm/s in
the internal, common and external carotid arteries respectively.
The right ICA to CCA ratio is 1.44.
On the left, peak systolic velocities are 70, 70 and 136 cm/s in
the internal, common and external carotid arteries respectively.
The left ICA to CCA ratio is 1.0.
Both brachial arteries presented antegrade flow.
COMPARISON: None available.
IMPRESSION: There is less than 40% stenosis within the internal
carotid arteries bilaterally.
UNILAT UP EXT VEINS US [**2122-5-7**] 10:28 AM
LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
examinations of the left internal jugular, axillary, brachial,
basilic, and cephalic veins were performed and demonstrate
normal compressibility, augmentability, and respiratory
variation in flow. No intraluminal thrombus was identified.
There is a moderate amount of subcutanous edema in the left
forearm in the region of the patient's redness, possibly
cellulitis.
IMPRESSION: No left upper extremity deep venous thrombosis. Left
forearm edema, which may be related to cellulitis.
[**2122-5-2**] 12:32 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2122-5-4**]**
MRSA SCREEN (Final [**2122-5-4**]): No MRSA isolated.
Brief Hospital Course:
She was admitted to the Trauma Service. Orthopedics was
consulted given her fractures. She was taken to the operating
room on [**5-3**] where she underwent ORIF repair of right bimalleolar
ankle fracture on [**2122-5-3**]. She will require follow up in the next
1-2 weeks with Dr. [**Last Name (STitle) **] for the left Lis Franc fracture. For
now she is non weight bearing on both lower extremities.
On [**2122-5-4**] developed some confusion, disorientation, agitation
and hallucinations
following dosage of pain med (Dilaudid and Percocet)--patient
and
family report she was seeing bugs in the room. Treated with one
dose Haldol 1 mg with improvement. Geriatric Medicine was
consulted and made several recommendations pertaining to her
medications.
On [**5-6**] she underwent placement of an IVC filter given that she
is at high risk for developing pulmonary thrombus because of her
fractures and limited mobility. She is also still maintained on
Heparin SQ tid.
During her ICU stay she was noted to have herpetic lesions on
her posterior chest at around T6-7 region. Acyclovir therapy was
initiated promptly; she is due to complete the course on
[**2122-5-13**].
She was evaluated by Physical and Occupational therapy and has
been recommended for rehab after her acute hospital stay. The
screening process was initiated and she was discharged on HD
#11.
Medications on Admission:
Metoprolol 50' (started [**4-30**]), Celexa 10', Baclofen 10', Detrol
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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
3. Psyllium Packet Sig: One (1) Packet PO BID (2 times a
day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) INH Inhalation Q6H (every 6 hours).
11. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO 5X/D () for 4
days.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Grade 4 liver laceration
Right ankle fracture, bimalleollar fracture
Left Lis Franc fracture
Rib fractures Left 5,6, 7 Right 7,8
Herpes Zoster
Discharge Condition:
Good
Followup Instructions:
Follow up in clinic with Dr. [**Last Name (STitle) **], Trauma Surgery in [**1-4**]
weeks, call [**Telephone/Fax (1) 6429**].
Follow up with Dr[**Last Name (STitle) **] [**Name (STitle) **] and [**Location (un) **], Orthoepdic Surgery in
2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2122-5-11**] Name: [**Known lastname 5047**],[**Known firstname 1365**] Unit No: [**Numeric Identifier 5048**]
Admission Date: [**2122-5-1**] Discharge Date: [**2122-5-12**]
Date of Birth: [**2049-6-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 844**]
Addendum:
Patient was discharged with foley catheter in place. The foley
was inserted secondary to concern of incontinence and to avoid
skin breakdown since the pt was found laying in urine on several
occassions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1206**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**]
Completed by:[**2122-5-12**]
|
[
"240.9",
"401.9",
"E943.0",
"788.30",
"E935.2",
"861.21",
"053.9",
"E935.4",
"423.9",
"530.81",
"825.25",
"492.8",
"864.05",
"E812.0",
"311",
"V58.66",
"292.81",
"787.6",
"721.0",
"293.0",
"E939.0",
"824.4",
"807.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"79.36",
"38.7",
"79.37"
] |
icd9pcs
|
[
[
[]
]
] |
8079, 8280
|
4234, 5599
|
356, 615
|
7102, 7109
|
1117, 4211
|
7132, 8056
|
1081, 1098
|
5719, 6771
|
6901, 7081
|
5625, 5696
|
273, 318
|
643, 1027
|
1049, 1065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,905
| 105,853
|
41125
|
Discharge summary
|
report
|
Admission Date: [**2154-5-8**] Discharge Date: [**2154-5-11**]
Date of Birth: [**2082-10-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / IV Dye, Iodine Containing / Albuterol
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
chest pain w/jaw and L arm pain similar to previous MI;
transferred from OSH
Major Surgical or Invasive Procedure:
PCI of LAD with bare metal stent placement
complicated placement of 2-way foley requiring cystoscopy
History of Present Illness:
Per pt and OSH records, pt is a 71 y.o. gentleman with
significant CAD hx, s/p MI x 4, RCA stents x 4 (most recent
placed in [**2147**]), COPD, bladder cancer (w/lung mets), who
presented to [**Hospital3 1280**] with chest pain w/jaw and L arm pain
similar to previous MI. Pt had to stop ASA and Plavix 1 month
ago due to ongoing signficant hematuria related to bladder
cancer tx which required blood transfusions and PRN 3 way
irrigation. In this setting, he developed sudden onset chest
pain on [**5-5**], with cough and assoicated retrosternal left sided
pressure with radiation left arm and jaw. Per pt, these sypmtoms
were identical to those that he has experienced in the past when
he had MIs. He immediately called EMS. EMS called to [**Hospital1 **]
ER where EKG revealed inferior STEMI, bolused with 600mg Plavix
and ASA given. Per pt chest pain resolved in transit. B/c of dye
allergy he was premedicated and then taken to the cath lab. On
cath he was found to have thrombosis of the RCA stent which was
treated with balloon angioplasty in addition to 90% proximal LAD
lesion. LV gram showed LVEF 45-50% with moderate inferior
hypokinesis. Decision was made to transfer to [**Hospital1 18**] for PCI LAD.
.
Of note, pt had slight hematuria yesterday now resolved;
currently urine clear, no evidence of bleeding. Pt had 2
epsiodes of chest pain overnight, responding to sublingual
nitroglycerin, and no EKG changes. On arrival to the floor, pt
feeling well, no chest pain, no difficulty breathing while lying
flat (currently on bed rest b/c of cath), no abdominal pain, no
complaint of LE edema, no SOB. VS were afebrile, 136/87, 81, 93%
on RA.
.
REVIEW OF SYSTEMS
On review of systems, hematurea has resolved. No fever, chills,
was in usual state of health prior to chest pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes II (not on insulin at home),
Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
MI X 4, s/p proximal RCA 4.0 x [**Street Address(2) 89611**] stent and 3.0 x 18 AVE
stent distal RCA [**9-10**], cath [**1-10**] with patent stents and a new
95% mid RCA treated with 3.0 x 15 mm [**Company 2267**] Express
stent also noted to have 60% long LAD at the first septal
branch, cath [**2147**] 99% occluded RCA between two previous patent
stents which was treated with 3.0 x 32 mm Taxus stent
3. OTHER PAST MEDICAL HISTORY:
Prostate/bladder transitional CA with small lung metastases
complicated by massive hematuria (requiring many transfusions
and PRN 3 way foley and necessitated stopping plavix),
type 2 DM,
dyslipidemia,
htn,
carotid stenosis,
spinal stentosis,
COPD -> hx of asbestos exposure, hx of tobacco use (stopped
smoking ~10yrs ago)
Social History:
Married, lives with wife, has step children. Very active, goes
to gym 3x per week.
-Tobacco history: 25yrs 1-2ppd, quit smoking at least 10yrs
ago. Pt also has hx of asbestos exposure from working as plumber
-ETOH: occasional
-Illicit drugs: denies
Family History:
Very significant fam hx, pt reports all immediate family members
have had or died from MIs (brothers, father, mother) before the
age of 60yrs.
Physical Exam:
PHYSICAL EXAMINATION: on admission
VS: T=afeb BP= 136/87 HR= 81 RR= 18 O2 sat=93% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no elevation of JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g appreciated. No thrills,
lifts. No S3 or S4. No carotid bruits apprecaited. Lying flat
w/out difficulty breathing.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Exam limited b/c pt on bedrest and must lie
flat but no difficulty breathing while doing so.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits
appreicated.
EXTREMITIES: No c/c/e. No femoral bruits. Pulses present. Cath
site clean, intact, only small amount of blood on guaze
dressing, no bruits, no hematoma, no tenderness.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs:
[**2154-5-8**] 05:40PM BLOOD Hct-37.5* Plt Ct-687*
[**2154-5-8**] 05:40PM BLOOD Plt Ct-687*
[**2154-5-8**] 05:40PM BLOOD Na-133 K-4.5 Cl-96
[**2154-5-8**] 05:40PM BLOOD CK(CPK)-113
[**2154-5-8**] 05:40PM BLOOD CK-MB-4
.
Cath Report:
Brief Hospital Course:
Pt is a 71 y.o. gentleman with significant CAD hx, s/p MI x 4,
RCA stents x 4 (most recent placed in [**2147**]), COPD, bladder
cancer (w/lung mets), who presented to [**Hospital3 1280**] with chest
pain w/jaw and L arm pain similar to previous MI. Pt had to stop
ASA and Plavix 1 month ago due to ongoing signficant hematuria
related to bladder cancer tx which required blood transfusions
and PRN 3 way irrigation. On cath he was found to have
thrombosis of the RCA stent which was treated with balloon
angioplasty in addition to 90% proximal LAD lesion. Transferred
to [**Hospital1 18**] for PCI of LAD and had hospital course complicated by
hematuria requiring transfusions.
.
# CAD: Pt has significant CAD hx w/multiple MIs, symptoms of
chest pain/pressure radiating to jaw and arms are identical to
symptoms he's had in past. Got plavix & aspirin from EMS. Cath
at [**Hospital3 1280**] found to have thrombosis of the RCA stent which
was treated with balloon angioplasty in addition to 90% proximal
LAD lesion. Placed BMS b/c of issues with plavix causing
bleeding in setting of bladder cancer (undergoing chemotherapy).
Transferred for PCI of LAD lesion which was successful with
placement of another BMS. Restarted on plavix 75cc, aspirin,
metoprolol. Some question and concern of possible bruit but site
looked good and faint bruits bilateral in setting of significant
vascular disease. Pt was deemed ready for discharge when he
began to have large amount of hematuria which rapidly worsened
and necessitated urology consult and transfer to the CCU (see
below). Following return from the CCU he remained stable from a
cardiac standpoint. He should continue aspirin and plavix for
one month. His atovastatin was increased from 20 mg daily to 80
mg. Initiation of lisinopril may also be considered as an
outpatient.
.
# Bladder Cancer: Pt has known metastatic bladder cancer (mets
to lung). Has undergone 2 rounds of chemo prior to admission.
Had to be taken off plavix and aspirin b/c he was having
significant hematuria which required multiple transfusions;
bleeding from tumor. After stopping plavix and aspirin
approximately 1-2mo ago, hematuria had resolved completely -- 1
week prior to MI for which pt was admitted. Initially on
admission, urine was clear after cath and pt doing well. On day
he was about to be discharged ([**2154-5-9**]) he acutely developed
significant hematuria requiring blood transfusion, urgent
urology consult for placement of foley for irrigation and
transfer to CCU. He required 3 units of pRBC's. Placement of
foley was very difficult even with cystoscopy, so patient was
transferred to OR on east for rigid cystoscopy which revealed
1.5 U clotted blood in bladder with no evidence of active bleed
and left bladder metastasis. A 3-way catheter was placed to
allow CBI. He was started on cefazolin for 3 days
periprocedurally. His continuous bladder irrigation was later
stopped and the patient's urine remained clear without clots.
His hematocrit was stable at discharge. He is discharged with a
foley in place and will follow-up with his outpatient urologist.
.
# COPD: Stable no issues currently; on home singulair and
spiriva.
.
# Anxiety: Given recent cancer diagnosis and stresses related to
medical issues patient was having worsening anxiety symptoms and
was given ativan to help w/anxiety symptoms. He takes takes 1mg
ativan PO HS at home prn.
.
# HTN: Had been stable on home regimen so continued home dose of
metoprolol; he was no not on lisinopril at home, but this should
be considered in the future as an outpatient.
.
# DM II: stable on home meds, not on insulin at home. Because of
procedure, pt was switched to ISS; held home metformin,
glipizide and januvia which were restarted at discharge.
.
# GERD: stable on nexium while inpatient.
Medications on Admission:
lopressor 50mg po bid
nexium 40mg po daily
metformin 1000mg [**Hospital1 **]
glipizide 2.5mg daily
lipitor 20mg daily
spiriva 18 mcg once daily
flomax 0.4mg po daily
detrol LA 4mg daily
januvia 100mg HS
singulair 10mg daily
ativan 1mg HS prn for anxiety/insomnia
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. Detrol LA 4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
12. Januvia 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: ST-elevation MI, Bare Metal Stent to LAD,
Hematuria secondary to bladder cancer
.
Secondary Diagnoses: Prostate/bladder transitional cell cancer,
type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 **] for
placement of a stent to open one of the arteries in your heart
after you had a heart attack. After the stent placement, you
had a bleed from your bladder and were briefly transferred to
the intensive care unit where you received blood transfusions.
You received continuous bladder irrigation. Once your bleeding
was stable, you returned to the cardiology floor. Your bleeding
stopped and the continuous bladder irrigation was held. You
continued to do well and are discharged to home with a foley
catheter in place. You should follow-up with your cardiologist
and urologist.
.
The following changes were made to your medications:
-START aspirin.
-START plavix.
-INCREASE lipitor.
.
It was a pleasure taking care of you.
Followup Instructions:
Name: [**Last Name (LF) 1295**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: HEART CENTER OF [**Hospital1 **]
Address: [**Location (un) **],2ND FL, [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 6256**]
Appointment: Friday [**5-24**] at 12PM
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Address: [**Location (un) 7330**], [**Location (un) **],[**Numeric Identifier 66490**]
Phone: [**Telephone/Fax (1) 48435**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 17234**] within
1-2 weeks. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above
|
[
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icd9cm
|
[
[
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[
"87.77",
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icd9pcs
|
[
[
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10538, 10544
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385, 487
|
10778, 10778
|
4924, 4924
|
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515, 2536
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4940, 5174
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10584, 10666
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10793, 10905
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3147, 3471
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2558, 2648
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3487, 3739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,958
| 154,648
|
30156
|
Discharge summary
|
report
|
Admission Date: [**2201-7-6**] Discharge Date: [**2201-7-10**]
Date of Birth: [**2126-8-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Dilantin / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Hyperglycemia
Slurred speech and mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 Italian man, with history significant for HTN, dyslipidemia,
multiple meningiomas (followed by Dr [**Last Name (STitle) 724**] of Neurology) who
presented to ED with word-finding difficulties on [**2201-7-5**]. Of
note, he had recently received the 4th of a series of injections
of a study drug to treat his recurrent meningiomas.
In ED: serum glu 1033, creatinine 1.9 (above baseline), was
placed on insulin drip, IVFs and tranferred to the [**Hospital Unit Name 153**]. In
[**Hospital Unit Name 153**], head CT showed stable meningioma, continued Keppra 750 mg
po BID (renally dosed); Piziritide (for his meningiomas) thought
to be responsible for hyperglycemia [**First Name8 (NamePattern2) **] [**Last Name (un) **]; Insulin drip
stopped [**2201-7-6**], [**Last Name (un) **] recommended to keep on SSI (20U total
today; highest glucose 323) for now without a fixed dose since
it is thought to be drug related; He was seen by his
neuro-oncologist Dr [**Last Name (STitle) 724**] during the ICU stay.
Past Medical History:
Meningioma s/p resection, for cyberknife: first seen in ER
[**2198-2-25**]
with headaches, found to have R parietal mass on head CT. He
was
admitted to neurology for brain tumor w/u, with neurosurg
consulting. [**Month/Day/Year 4338**] with multiple lesions in brain. Stereotactic
biopsy consistent with possible grade II meningiomas (though
some
crush artifact, the MIB-1 was 16%, high for meningioma).
Largest
mass resected in mid-[**Month (only) **], and pt due for f/u with neuro-onc
and
neurosurg, for cyberknife/radiation to other brain lesions this
thursday.
HTN
Dyslipidemia
Cataracts
Recurrent scalp infections
Social History:
Lives with wife in [**Name (NI) 86**] area. Immigrated to the
US in [**2146**]. He has two daughters and a son, all of whom are very
involved and were present during his ED stay. He reports a 55
pack year smoking history (quit 7 years ago) and only occasional
alcohol use.
Family History:
father with [**Name2 (NI) 499**] cancer in 70s, mother with
"[**Name2 (NI) 500**] cancer" at 54; sister recently found to have brain
metastases from breast cancer.
Physical Exam:
Blood sugars 150 - 250s BP 100s/50s HR 60s
Patient is alert and oriented, conversant
Lungs without rales bilaterally
CV regular, S1S2
Abdomen benign
Ambulating independently in the room
Pertinent Results:
[**2201-7-10**] 08:00AM BLOOD WBC-7.8 RBC-4.53* Hgb-14.1 Hct-43.3
MCV-95 MCH-31.2 MCHC-32.7 RDW-14.3 Plt Ct-123*
[**2201-7-9**] 06:15AM BLOOD WBC-7.7 RBC-4.47* Hgb-14.1 Hct-41.7
MCV-93 MCH-31.6 MCHC-33.9 RDW-14.0 Plt Ct-101*
[**2201-7-8**] 05:30AM BLOOD WBC-7.0 RBC-4.34* Hgb-14.0 Hct-40.3
MCV-93 MCH-32.3* MCHC-34.8 RDW-14.3 Plt Ct-86*
[**2201-7-6**] 01:00AM BLOOD WBC-8.3 RBC-4.79 Hgb-15.2 Hct-45.7 MCV-96
MCH-31.8 MCHC-33.3 RDW-14.2 Plt Ct-110*
[**2201-7-10**] 08:00AM BLOOD Glucose-230* UreaN-39* Creat-1.6* Na-138
K-3.8 Cl-105 HCO3-23 AnGap-14
[**2201-7-9**] 06:15AM BLOOD Glucose-196* UreaN-35* Creat-1.6* Na-136
K-3.7 Cl-104 HCO3-25 AnGap-11
[**2201-7-8**] 05:30AM BLOOD Glucose-264* UreaN-29* Creat-1.5* Na-135
K-3.7 Cl-103 HCO3-20* AnGap-16
[**2201-7-7**] 08:31AM BLOOD Glucose-179* UreaN-25* Creat-1.5* Na-137
K-3.9 Cl-104 HCO3-22 AnGap-15
[**2201-7-6**] 07:14AM BLOOD Glucose-603* UreaN-45* Creat-2.1* Na-129*
K-3.5 Cl-95* HCO3-24 AnGap-14
[**2201-7-6**] 04:09AM BLOOD Glucose-761* UreaN-49* Creat-1.9* Na-127*
K-4.0 Cl-93* HCO3-20* AnGap-18
[**2201-7-6**] 02:30AM BLOOD Glucose-980*
[**2201-7-6**] 01:00AM BLOOD Glucose-1033* UreaN-48* Creat-2.2*
Na-122* K-4.2 Cl-83* HCO3-26 AnGap-17
[**2201-7-6**] 07:14AM BLOOD ALT-33 AST-21 LD(LDH)-183 AlkPhos-105
TotBili-1.0
[**2201-7-10**] 08:00AM BLOOD Calcium-8.9 Mg-2.1
[**2201-7-6**] 07:14AM BLOOD Cortsol-23.4*
Echo (done to assess IV/VI SM):
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.1 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: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.2 cm
Left Ventricle - Fractional Shortening: 0.41 >= 0.29
Left Ventricle - Ejection Fraction: 65% to 70% >= 55%
Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 8 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *21 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *1.9 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 904 ms
Mitral Valve - E Wave: 0.4 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 0.50
Mitral Valve - E Wave deceleration time: 224 ms 140-250 ms
TR Gradient (+ RA = PASP): 18 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.6 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2198-5-2**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS (area 1.2-1.9cm2). Mild to moderate ([**12-27**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. No MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PS. Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Resting bradycardia (HR<60bpm).
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild to moderate ([**12-27**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. No 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: Suboptimal image quality. Mild aortic stenosis. Mild
to moderate aortic regurgitation. Mild concentric left
ventricular hypertrophy with preserved left ventricular systolic
function.
Compared with the prior study (images reviewed) of [**2198-5-2**],
heart rate is slower. The severity of valvular disease appears
similar. Estimated pulmonary artery pressures could not be
obtained.
Brief Hospital Course:
In summary, Mr. [**Name13 (STitle) 71870**] is a 74yo male with past medical history
significant for hypertension, dyslipidemia, and multiple
meningiomas (s/p radiation, resections, multiple graft surgeries
and debridements for prior scalp infections) undergoing current
chemotherapy with neuro-oncology who presents now with
complaints of dysphagia and marked hyperglycemia. The [**Last Name (un) **]
consult team believes hyperglycemia is likely due to an
Octreotide component of his study regimen. His neurologic
symptoms resolved prior to transfer from the ICU to the floor.
#Speech changes/ questionable dysphagia: Upon further
questioning, the patient described symptoms of aphasia - word
finding difficulties rather than dysphagia, though he did admit
to some trouble swallowing with pills. A head CT was performed
and showed stable meningiomas. The aphasia was thought to be
possibly due to tumor involvement of Broca's area. These
symptoms resolved in the ICU, however. The patient's home
medications including aspirin and Keppra were continued.
Neuro-oncology followed the patient in the ICU.
#Hyperglycemia: Initially, the patient was started on an insulin
drip for a blood sugar of 1033. He responded to this and on ICU
day #2 the drip was discontinued and SSI was used. The patient's
oncologist was contact[**Name (NI) **] regarding the patient's chemotherapy
regimen, for which he was on cycle 4 which may have relevant
side effects of hyperglycemia although not well defined.
Chemotherapy dose 4 given [**2201-6-25**] (SOM230C chemotherapy, on [**Company 2860**]
protocol #08-266, includes Pasireotide). Pasireotide is known to
react with somatostatin receptors and effects. The [**Last Name (un) **]
diabetes team was contact[**Name (NI) **] and they hypothesized that the
hyperglycemia was secondary to the patient's chemoregimen. They
recommended SSI without additional standing insulin. Followup
was planned with the [**Last Name (un) **] team for early [**Month (only) 216**]. He will not
be placed on the chemo [**Doctor Last Name 360**] again in the future, per Dr [**Last Name (STitle) 724**].
#Meningiomas: The patient has a long history of brain tumors
dating back to [**2197**] after initial biopsies. He is now s/p prior
resection, radiation and undergoing trial with chemotherpay
started back in [**2201-3-26**]. He was followed by Neuro-onc while
in the [**Hospital Unit Name 153**] and was continued on prophylactic doxycycline for
recurrent scalp infections.
#Seizure prophylaxis: His Keppra was decreased to a lower dose
in the setting of the acute kidney injury on admission, and was
returned to his baseline dosing once his Creatinine returned to
baseline (on discharge).
#HTN: The patient's home medication metoprolol was restarted but
was decreased to 37.5 mg TID out of concern for bradycardia. We
did not restart his HCTZ on discharge, as it could contribute to
hyperglycemia. Once this resolves, the decision can be made
about further restarting this medication. Echo done given h/o
hypertension and to evaluate an aortic position murmur. It
revealed a preserved EF with moderate AI, and mild AS.
#Hyperlipidemia: The patient was continued on simvastatin and
aspirin. His Niacin was held, as it can contribute to elevated
blood sugar levels.
#Diarrhea: The patient did have 2-3 episodes of diarrhea however
this resolved during his admission in the ICU.
# Prophylaxis: The patient was maintained on DVT prophylaxis
with heparin.
Medications on Admission:
Doxycycline 100mg [**Hospital1 **]
HCTZ 25mg qd
ASA 325mg qd
Simvastatin 40mg qd
Metoprolol 50mg tid
MVI qd
Levetiracetam 500mg tables - 3 tablets [**Hospital1 **] (1500mg [**Hospital1 **])
Niacin qhs
Colace prn [**Hospital1 **]
Discharge Medications:
1. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Capsule PO
bid.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice a
day: please continue at home dose.
7. Glucocard X-Meter Kit Sig: One (1) Miscellaneous four
times a day: Please provide one kit to the patient. He should
check his blood sugars before meals and follow the instructions
from his discharge instructions.
Disp:*1 one* Refills:*0*
8. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
Disp:*60 Tablet Extended Rel 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
:artners Home Care
Discharge Diagnosis:
Hyperglycemia, severe
Medication reaction, chemotherapy
Recurrent brain meningiomas
Scalp infections, on suppressive antibiotics
Discharge Condition:
Discharge condition: stable
Mental status: alert, comfortable
Ambulatory status: independent
Discharge Instructions:
Mr [**Known lastname 71867**],
It has been a pleasure to take care of you while you have been
in the hospital. As you know, you were here for high blood
sugars that we think were caused by your chemotherapy drug. You
were initially given insulin through your vein in the intensive
care unit, and then through shots during the hospital stay, but
are now taking pills to lower your sugar. You were evaluated
for a stroke and you did not have one, as far as we know.
The [**Hospital **] [**Hospital 982**] Clinic doctors that saw [**Name5 (PTitle) **] while you were
here were Dr [**Last Name (STitle) 15279**] and Dr [**Last Name (STitle) 9978**]. You will see Dr [**Last Name (STitle) 15279**]
in clinic (see the appointment listed below) to continue to
follow your blood surgars.
Dr [**Last Name (STitle) 724**] came to see you about your brain mass, and helped the
team decide on the next steps that would be needed. He will
also see you soon, at an appointment listed below. You will not
be on the injections for now.
We have changed your medications:
1. Do NOT take your hydrochlorothiazide (HCTZ) any more.
2. Do NOT take your NIACIN right now.
3. Please take your metoprolol only twice a day (the same tablet
dose).
4. Please START taking GLIPIZIDE for your blood sugars, one
tablet each day. This may be changed in the future.
****Please check your blood sugars 2-3 times each day, or if you
feel dizzy, very tired, or sweaty. If your blood sugar is less
than 70, please drink some juice or have something to eat. If it
stays less than 70 at two checks, please call your doctor.******
Followup Instructions:
PCP [**Name Initial (PRE) **]: Monday, [**7-20**], 2:15PM
With: [**First Name8 (NamePattern2) 569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48292**],MD
Address: [**Street Address(2) 71871**], [**Location (un) **],[**Numeric Identifier 4770**]
Phone: [**Telephone/Fax (1) 71872**]
Endocrinolgy Appointment: Wednesday, [**8-5**] at 1pm
With: [**Name6 (MD) **] [**Name8 (MD) 15279**], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **] Place,[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Department: NEUROLOGY
When: TUESDAY [**2201-7-21**] at 10:00 AM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2201-9-25**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2202-5-31**] at 10:00 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"584.9",
"276.1",
"790.29",
"E933.1",
"403.90",
"998.30",
"225.2",
"272.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12516, 12565
|
7904, 11383
|
366, 373
|
12759, 12766
|
2752, 7881
|
14484, 15959
|
2365, 2531
|
11662, 12493
|
12586, 12717
|
11409, 11639
|
12857, 14461
|
2546, 2733
|
271, 328
|
401, 1411
|
12781, 12833
|
1433, 2058
|
2074, 2349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,958
| 131,940
|
24191
|
Discharge summary
|
report
|
Admission Date: [**2159-8-10**] Discharge Date: [**2159-8-18**]
Date of Birth: [**2118-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
History of syncopal episodes, found on workup to be due to
anomalous right upper pulmonary vein entering right atrium.
Major Surgical or Invasive Procedure:
Anomalous Pulmonary Vein repair
History of Present Illness:
Mr. [**Known lastname 61452**] is a 40-year-old male who has beenexperiencing
worsening symptoms of shortness of breath andevaluation showed
by multiple modalities that he had at least 1 or 2 pulmonary
veins on the right side that were draining into the SVC/right
atrial junction. He had no documented atrial septal defect by
echocardiography. A MRI confirmed the presence of a vein
entering the SVC from the right side. The left-sided pulmonary
veins appeared to drain into the left
atrium. He had a calculated shunt of 1.9:1 and showed signs of
right ventricular dilatation and right atrial dilatation and
right-sided heart failure. He is presenting for repair of his
anomaly.
Past Medical History:
HTN
oral CA, s/p XRT (chewed tobacco)
depression
Social History:
Lives with wife and children. Denies smoking, occ etoh, no drugs
Family History:
mom with ?heart disease
Physical Exam:
Height 6'7", Wt 260lbs, HR 68, BP 140/90
Tall young man in NAD, well-appearing
PERRLA, EOMI
Neck supple, no JVD, no bruits, no LAD
Lungs CTA b/l
RRR, Nl S1 and S2
Abd soft, NT/ND, NABS
Ext warm, no edema, no varicosities, 2+DP/PT pulses b/l
Pertinent Results:
[**2159-8-10**] 11:33AM BLOOD WBC-14.3*# RBC-3.28*# Hgb-9.9*#
Hct-29.3*# MCV-89 MCH-30.2 MCHC-33.8 RDW-13.3 Plt Ct-145*
[**2159-8-10**] 11:33AM BLOOD PT-17.2* PTT-27.7 INR(PT)-2.1
[**2159-8-10**] 11:33AM BLOOD Plt Ct-145*
[**2159-8-10**] 01:09PM BLOOD UreaN-10 Creat-0.7 Na-140 Cl-107 HCO3-22
[**2159-8-10**] 01:09PM BLOOD Mg-1.9
Brief Hospital Course:
The patient was taken to the operating room on [**2159-8-10**] for a
Warden procedure for correction of partial anomalous pulmonary
venous return. The patient tolerated this procedure well. He was
taken immediately from the operating room to the CSRU. He was
extubated that night after surgery. On post-op day #1, his
pressor was weaned. On post-op day #2, his chest tubes were
removed, his pressors were stopped, and he was ambulated. He was
transferred to the floor. On post-op day #3, the patient was
ambulated with physical therapy and did well. His pacing wires
were removed. He was seen by electrophysiology for a
self-limited run of SVT and was placed on beta blockade. On the
night of post-op day #4, the patient tripped over a chair, but
was unhurt by the incident. Orthostatics and vital signs were
unremarkable. The patient was discharged home on post-op day #7
in stable condition.
Medications on Admission:
ASA 81mg PO Q24
Lisinopril 5mg PO Q24
Torol XL 25mg PO Q24
Zoloft 100mg PO Q24
Androgel QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
7 days: 40 mg QD x 7 days .
Disp:*20 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin EC 81 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*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4 hrs/PRN as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for 1
months.
Disp:*60 Tablet(s)* Refills:*0*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
s/p repair of Anomolous Pulmonary Vein(pericardial patch)
PMH: Squamous Cell CA tongue, LUL nodule, SVT, Tonsillectomy,
Depression
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or
swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds, or weight
gain morethan 2 pounds in one day or five in one week.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr[**Name (NI) 61453**] in 2 weeks
|
[
"V10.01",
"401.9",
"747.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"35.82",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4275, 4333
|
2010, 2905
|
441, 475
|
4508, 4515
|
1656, 1987
|
4783, 4897
|
1355, 1380
|
3046, 4252
|
4354, 4487
|
2931, 3023
|
4539, 4760
|
1395, 1637
|
283, 403
|
503, 1183
|
1205, 1256
|
1272, 1339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,458
| 139,946
|
3056
|
Discharge summary
|
report
|
Admission Date: [**2205-1-22**] Discharge Date: [**2205-2-1**]
Date of Birth: [**2152-7-13**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Valium / Allopurinol
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
DCCV
History of Present Illness:
52 YO female with Hx of CHF (EF55%) seen by Dr. [**First Name (STitle) 437**] in
Cardiology clinic , COPD (FEV1 1.8), Hx of afib, HTN, PVD, CRI
who c/o 1-2 weeks of increased dyspnea on excertion. Patient
states her symptoms have been getting worse over the past few
days. She also noticed that she had increased swelling of her
legs and abdomen. She states she has been taking her lasix but
not too much UOP. She came to the ED because her symptoms were
not improving and got nebulizer treatments, steroids, and dose
of abx in the ED. She was breifly on BiPap in the ED and
transferred to the [**Hospital Unit Name 153**] where her symptoms quickly improved and
she was put back on nasal cannula.
.
Pt uses 2L O2 at home when needed and uses inhalers when needed
at home. She denies any fever or chills. She describes her
dyspnea as "chest tightness."
(+) PND and has 2 pillow orthopnea. No Palpitation.
Also in the ED patient EKG was noted to be in Afib.
Past Medical History:
1. CHF: history of both right- and left-sided CHF with
significant pulmonary hypertension. Most recent cardiac
catheterization in [**1-/2201**] revealed PCW of 32, PAP of 78/33, RA
mean 22 and normal cardiac output. Last echo on [**4-7**],
showed normal left ventricular wall thickness, cavity size, and
systolic function (LVEF>55%). Right ventricular chamber size and
free wall motion were also normal. A left-to-right shunt across
the
interatrial septum is seen at rest. A small secundum atrial
septal defect (ASD) is present.
2. Hypertension
3. COPD: Her PFT??????s on [**2201-9-7**] were within normal limits
(FEV1=1.8 L, FVC= 2.44 L)
4. Atrial fibrillation: Since [**2202-12-11**]
5. ASD: a left-to-right shunt across the interatrial septum was
first observed on echo on [**2200-12-17**].
6. Positive PPD in [**2195**] with negative chest x-ray; no
prophylaxis given.
7. Peripheral vascular disease: s/p left femoral-popliteal
bypass on [**11/2195**]
8. Renal insufficiency: Elevated creatinines since [**2195**],
baseline creatinine is 2.5 on [**2203-8-22**]
9. Gout: First episode in [**2202-12-4**] during hospitalization
for CHF exacerbation.
10. Eczematous dermatitis: Biopsied in [**2203-7-21**], reaction to
allopurinol
11. Fibroid uterus: diagnosed during pelvic ultrasound on
[**2200-5-1**].
12. Duodenitis
Social History:
Patient works as a bus monitor. She lives with her boyfriend.
She quit smoking 4 years ago after a 26-pack-year history. She
drinks socially and denies illegal drug use.
Family History:
Mother died of heart problems at age 27. Grandmother died of
heart problems at 73. Father had kidney problems and died in his
50??????s.
Physical Exam:
T 98.4 BP 149/79 HR 89 RR 20 O2Sat 94% on 2L NC
Gen: Patient sitting up in bed [**Location (un) 1131**] magazine, able to talk
w/o difficulty
Heent: PERRL, EOMI, OP clear, MMM
Neck: Increased JVD not appreciated
Lungs: Bibasilar crackles, no wheezes
Cardiac: Irregularly Irregular, S1/S2 no murmurs
Abdomen: Obese, soft, +BS
Ext: Healed scar on LE B/L, +1 pitting edema upto shin B/L
Neuro: AAOx3
Pertinent Results:
CXR: AP UPRIGHT CHEST RADIOGRAPH: Lung volumes are low. There is
moderate stable cardiomegaly. A left retrocardiac opacity
represents
atelectasis and/or consolidation. No demonstrable pleural
effusions are
seen. No evidence of pneumothorax. Osseous structures are
unchanged.
[**2205-1-23**] 06:19AM BLOOD WBC-6.3 RBC-3.90* Hgb-10.0* Hct-31.9*
MCV-82 MCH-25.5* MCHC-31.3 RDW-16.7* Plt Ct-263
[**2205-1-23**] 06:19AM BLOOD Neuts-87.2* Lymphs-10.7* Monos-1.8* Eos-0
Baso-0.2
[**2205-1-23**] 06:19AM BLOOD PT-14.4* PTT-25.8 INR(PT)-1.4
[**2205-1-23**] 06:19AM BLOOD Glucose-146* UreaN-46* Creat-3.2* Na-142
K-4.4 Cl-103 HCO3-26 AnGap-17
[**2205-1-22**] 09:35AM BLOOD CK(CPK)-68
[**2205-1-22**] 09:35AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-4537*
[**2205-1-22**] 03:50PM BLOOD CK(CPK)-15*
[**2205-1-22**] 03:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2205-1-22**] 08:03PM BLOOD CK(CPK)-59
[**2205-1-22**] 08:03PM BLOOD CK-MB-1 cTropnT-<0.01
Brief Hospital Course:
52 YO female with Hx of diastolic CHF, A fib, COPD admitted with
shortness of breath which has improved, attempted chemical
cardioversion to SR with propafenone.
.
1. Afib - New onset, TEE without clot. Started on propafenone on
[**1-24**] --> [**1-25**] still in AF 80s. [**2205-1-27**] - DCCV after 3 days of
Propafenone. Patient converted to sinus. Patient continued on
propafenone 150mg tid and carvedilol. Started on coumadin by
[**Hospital Unit Name 153**] team. Bridged with Heparin. INR still sub-therapeutic at
1.9 at time of discharge. Coumadin dose increased to 7.5 mg QHS.
She will have INR checked in 2 days as an out-patient. On day
of discharge she went back into a fib, however, she remained
rate controlled. She was discharged on amlodipine and Coreg. She
will follow-up with EP as an out-pt.
.
2. Acute on CRI - Cr up to 3.6 when discharged, BUN 48, likely
secondary to overdiuresis. Lasix IV was held with plan to
restart at Lasix 80mg po qd when discharged. Should have BUN/Cr
checked by PCP in the week following her discharge.
.
3. Heart failure - Hx of diastolic heart failure probably
exacerbated with a fib, symptoms improved when patient was
cardioverted.
.
4. HTN - BP well controlled during her stay. Lisinopril was
discontinued due to her worsening renal failure.
.
5. GERD - Recent EGD which showed duodenitis. Hct stable during
her admission. Patient received pantoprazole. Aspirin was held.
.
6. COPD: Stable, on O2 prn at home. Ipratroprium and albuterol
continued prn.
.
Medications on Admission:
Coreg 75 mg twice daily
Norvasc 10 mg twice daily
lisinopril 10 mg once daily,
folic acid,
Lipitor 20 mg once daily,
Protonix 40 mg once daily,
Imdur 60 mg once daily,
Lasix 80 mg in the morning and 40 mg in the afternoon,
colchicine as needed
Flovent
Atrovent prn
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: Six (6) Tablet PO BID (2 times
a day).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO HS (at bedtime).
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime):
You should have your INR checked regularly with a goal of [**3-8**].
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Please draw PT/INR, BUN, creatinine, potassium on Monday [**2-6**] and send results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**], [**Telephone/Fax (1) 250**].
15. Return to [**Known lastname 14554**] was hospitalized under my care from [**2205-1-22**] -
[**2205-2-1**]. She may return to work as tolerated beginning [**2205-2-2**]
as tolerated. For further questions, please contact myself or
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] at [**Telephone/Fax (1) 250**].
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Diastolic Heart failure
Acute Renal Failure
Chronic Renal Failure
Discharge Condition:
Good- able to ambulate and perform ADLs without assistance.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 liter per day.
Please check INR, please call your PCP SHIP,[**Name9 (PRE) 674**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 250**]
to arrange blood draws.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] (at [**Company 191**]) in [**2-5**] weeks. You
should have your INR/creatinine/potassium drawn with the
accompanying lab slip and have results sent to her if you are
not planning on going to the [**Company 191**] laboratory.
You also have follow up with DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2205-3-4**] 9:30 from cardiology.
You also have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] which you
scheduled.
|
[
"584.9",
"585.9",
"496",
"428.30",
"427.31",
"403.91",
"285.9",
"530.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
8104, 8110
|
4372, 5883
|
296, 302
|
8240, 8302
|
3415, 4349
|
8633, 9257
|
2843, 2982
|
6198, 8081
|
8131, 8219
|
5909, 6175
|
8326, 8610
|
2997, 3396
|
253, 258
|
330, 1291
|
1313, 2640
|
2656, 2827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,232
| 106,505
|
4794+55614
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-8-7**] Discharge Date: [**2150-8-10**]
Date of Birth: [**2072-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Isosorbide / quinidine gluconate
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
VT storm
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
78F with coronary artery disease s/p remote inferior MI, CABG,
and ICD implant originally in [**2136**] transferred from [**Hospital3 **]
with VT@180 refractory to cardioversion. Per the patient her ICD
fired "more times that I can count." Estimate by EP and EMS is
that it fired 15 times today. In the field she was found to have
Vtach at 180 and underwent 2 cardioversions at 100J and 150J
(with Versed sedation) then broke with Amiodarone 150 mg bolus
f/b amio gtt. In the ED the amio gtt was continued. She was seen
by EP who interrogated her ICD and changed several of her
settings. EPS reccomended DC'ing amio and starting lidocaine
bolus + gtt however when the ED stopped the amiodarone she had
20 beats of asymptomatic VT that was terminated with overdrive
pacing from her ICD. She was restarted on amiodarone and
transferred to the CVICU under the care of the CCU team.
Of ntoe she underwent EP study in [**2149-11-15**] for recurrent VT
and found to have larve inferior scar. No ablation becaue of
multiple runs of HD unstable VT during catheter manipulation.
She has actually been off of all antiarhythmic drugs due to
intolerance of quinidine, maxelitine and amiodarone).
She has had the ICD in place since 2/[**2136**]. By report her last
firing was 8 months ago. She denies any recent syncope or
presyncope, chest pain or SOB. She does endorse some fatigue.
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p 3 MIs
Cardiomyopathy, EF 25%
NSVT with easily inducible sustained VT on EP study in [**3-/2136**]
-CABG: x2 [**2126**], [**2132**], both done at NEDH
-PACING/ICD: [**Company 1543**] Micro [**Female First Name (un) 19992**] 2 ICD placed on [**2136-3-29**].
Exchanged for [**Company 1543**] ICD, EnTrust D154VRC ?in [**2143**] (last
interrogation per [**Hospital1 18**] webOMR notes [**2145-9-7**]).
Depression s/p ECT
S/p cholecystectomy
S/p hysterectomy
S/p thyroid surgery for a benign mass
S/p cataract surgery
Social History:
Married. Lives at home with her husband and her brother.
[**Name (NI) 1139**] history: remote smoking history from age 20 to 30
ETOH: occasional social drinking
Illicit drugs: none
Family History:
Mother died of MI at age 38, brother at age 37. Other brother MI
at age 60. Father lived to age [**Age over 90 **] and was healthy. No family
history of arrhythmia, cardiomyopathies.
Physical Exam:
Admission Physical:
VS: 66 133/79 98%on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT.
NECK: Supple with no JVD
CARDIAC: RRR S1 S2 no MRG
LUNGS: CTA BL
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: AAOx3
.
Discharge Physical:
Gen:Aox3, NAD,
Cardio: RRR, no murmurs, rubs or gallops
Lungs: CTAB
Abd: NT/ND. Soft. NBS.
Extremities: No peripheral edema appreciated.
Peripheral Vascular: 2+ radial and PT pulses
Neuro: AOX3. MAE.
Pertinent Results:
ADMISSION/DISCHARGE LABS:
CBC
[**2150-8-7**] 09:20AM BLOOD WBC-9.0# RBC-4.73# Hgb-14.1 Hct-43.1
MCV-91 MCH-29.8 MCHC-32.7 RDW-16.0* Plt Ct-220
[**2150-8-10**] 07:00AM BLOOD WBC-7.3# RBC-4.86 Hgb-14.6 Hct-44.0
MCV-91 MCH-30.0 MCHC-33.1 RDW-16.0* Plt Ct-213
COAGS:
[**2150-8-7**] 09:20AM BLOOD PT-10.9 PTT-28.3 INR(PT)-1.0
[**2150-8-9**] 05:05AM BLOOD PT-12.2 PTT-29.6 INR(PT)-1.1
CMP:
[**2150-8-7**] 09:20AM BLOOD Glucose-121* UreaN-9 Creat-0.7 Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2150-8-10**] 07:00AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-140 K-4.1
Cl-105 HCO3-27 AnGap-12
[**2150-8-8**] 04:09AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.4
[**2150-8-10**] 07:00AM BLOOD Calcium-9.6 Phos-3.5 Mg-1.9
.
.
IMAGING:
NONE
Brief Hospital Course:
78 [**Last Name (un) 9232**] with history of CAD and cardiomyopathy with EF 25% and
recurrent VT's presenting with VT storm, now in sinus rhythm
admitted to the CVICU under care of CCU team for monitoring and
manasgement.
.
# VTACH- The patient was initially stabilized on lidocaine gtt.
She was seen by EP and went for mapping and VT ablation. She
had multiple areas ablated, but there were numerous areas of
ectopy that could have been the source of her VT that it was
felt they were not all captured. As a result, she was continued
on lidocaine when she returned from the lab. She started
mexiletine and the dose was titrated to 150mg PO BID. She did
well on that dose and was subsequently sent home with the
appropriate follow up.
.
Inactive Issues:
# CAD: Continue statin, asa and beta blocker. Mild troponin
elevation is likley secondary to multiple shocks. It improved
without any issues.
.
# HTN: Continue home antihypertensives
.
# HLD: Continue atorvastatin
.
Transitional ISSUES:
- Follow up with EP regarding further management of her
Ventricular Tachycardia
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Atorvastatin 20 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. HydrALAzine 10 mg PO TID
4. Isosorbide Dinitrate 10 mg PO TID
5. Metoprolol Tartrate 50 mg PO TID
6. Oxazepam 30 mg PO TID
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Aspirin 81 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP Frequency is
Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. HydrALAzine 10 mg PO TID
5. Isosorbide Dinitrate 10 mg PO TID
6. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg one Tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Oxazepam 30 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. Dofetilide 125 mcg PO Q12H VT
Please check ECG 2h after EVERY dose and FAX ECG to [**Telephone/Fax (1) 20093**]
RX *Tikosyn 125 mcg one Capsule(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
chronic systolic congestive heart failure
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your defibrillator fired at least 15 times because of
ventricular tachycardia and your were transferred from [**Hospital 6451**] Hospital for treatment. We started a new medicine,
dofetalide, to prevent the ventricular tachycardia and this
seems to be working well. WE also made some adjustments to your
ICD to prevent any unnecessary firing. You will need to take
Dofetalide twice daily and will see Dr. [**Last Name (STitle) **] in 2 weeks.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Dr. [**Last Name (STitle) 20094**] office is working on a follow up appointment
you in [**5-24**] days after your hospital discharge. You will be
called by the office with your appointment date and time. If you
have not heard from the office in 2 business days please call
the office number listed below.
Location: [**Hospital **] HEALTH CENTER
Address: 200 [**Last Name (un) 12504**] DR, [**Location (un) **],[**Numeric Identifier 18464**]
Phone: [**Telephone/Fax (1) 18462**]
.
Department: CARDIAC SERVICES
When: office will call you with an appt at home for this week
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2150-8-21**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2151-1-29**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2151-1-29**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 3371**],[**Known firstname 1049**] Unit No: [**Numeric Identifier 3372**]
Admission Date: [**2150-8-7**] Discharge Date: [**2150-8-10**]
Date of Birth: [**2072-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Isosorbide / quinidine gluconate
Attending:[**First Name3 (LF) 3373**]
Addendum:
Patient's documented hospital course is incorrect. What actually
transpired is documented below:
VT: Patient was initially admitted with multiple episodes of HD
stable VT s/p multiple discharges from her ICD. She was
initially stabilized on on lidocaine gtt with resolution of her
tachyarrhythmia. She expressed a desire to have the ICD function
of her device disabled but after a long discussion with the EP
attending her ICD was ultimatly left on but changes were made to
her settings in an effort to reduce the chance that she would
receive multiple shocks in response to VT. She was started on
dofetilide and her lidocaine was weaned off. She was monitored
in the CCU with no episodes of VT. She was discharged on
dofetilide 125mcg [**Hospital1 **].
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 947**] [**Last Name (NamePattern4) 3374**] MD [**MD Number(2) 3375**]
Completed by:[**2150-8-12**]
|
[
"414.00",
"401.9",
"412",
"428.22",
"425.4",
"V45.81",
"428.0",
"427.1",
"V45.02",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"89.59"
] |
icd9pcs
|
[
[
[]
]
] |
9970, 10136
|
3962, 4703
|
318, 334
|
6345, 6345
|
3226, 3236
|
7095, 9947
|
2528, 2714
|
5521, 6182
|
6232, 6324
|
5065, 5498
|
6496, 7072
|
3252, 3939
|
2729, 3207
|
4958, 5039
|
270, 280
|
362, 1738
|
4720, 4937
|
6360, 6472
|
1760, 2312
|
2328, 2512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,524
| 145,076
|
5286
|
Discharge summary
|
report
|
Admission Date: [**2133-8-16**] Discharge Date: [**2133-8-19**]
Date of Birth: [**2053-5-7**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Ultram / Vioxx / Percocet / Vicodin / Cephalexin
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Exertional Angina
Major Surgical or Invasive Procedure:
right and left cardiac catheterization
History of Present Illness:
History is obtained from the medical record and from the patient
with her son serving as interpreter. Please see also OMR notes
by Dr. [**Last Name (STitle) **] from [**2133-8-13**] and Dr. [**Name (NI) **] from [**2133-6-12**] for
additional information. Briefly, Ms. [**Known lastname 21557**] is a 80 year old
Persian woman who has multiple medical problems including
diet-controlled type II diabetes, hypertension, chronic joint
pain (osteoarthritis and seronegative RA vs. PMR), and recent
visual problems with ocular discomfort. She has had recent
complaints of chest pain and progressive dyspnea on exertion (to
the point where she has had to crawl up stairs and sit down
while shopping) for which she has been evaluated by Dr.
[**Name (NI) **].
.
In terms of her chest pain and DOE, she describes both as
occurring together. The chest pain is present constantly,
ranging from severity of [**4-9**] to [**11-9**] and is worse with
movement, pressure to the chest wall, deep breathing, or
exertion. The shortness of breath is only with activity and does
not occur at rest. She describes the chest pain as pressure-like
in quality and occuring in the center chest to beneath the left
breast. She has had these symptoms for several months but feels
that they have been getting worse recently. She has had a cough
for about the last two months which is occasionally productive
of white sputum; she initially thought that this was due to a
cold and had some associated runny nose, though now feels cough
is not due to URI as it has persisted.
.
She underwent echocardiogram in [**5-/2133**] which showed mild LVH
with preserved ejection fraction (> 55%) and was otherwise
unrevealing in terms of etiology for her dyspnea. In addition,
she has had periodic complaints of heart palpitations for which
she was been monitored by [**Doctor Last Name **] of Hearts; 7 symptomatic episodes
revealed sinus rhythm at rate 60s-80s with occasional APBs and
atrial bigeminy. She did undergo stress test back in [**2124**] by
Persantine MIBI which was negative for ischemia, but has had no
further stress testing since that time. Currently, she is
awaiting ophthalmologic procedure for her eye discomfort, and
her ophthalmologist at Mass Eye & Ear has recommended complete
cardiac work up prior to this procedure (details unclear as
notes are out of our system; however, per Dr.[**Name (NI) 21558**] clinic
note from [**2133-8-13**] it is "non urgent"). In addition, per Dr. [**Name (NI) 21559**] note from [**2133-6-12**], cardiac catheterization is
indicated to evaluate for left main disease prior to surgery
requiring monitored anesthesia care, as well as to further
evaluate for coronary artery disease given her multiple risk
factors for atherosclerosis. She had cardiac catheterization
planned recently, although this procedure was cancelled given
her aspirin allergy and the possible need for intervention. The
patient was given the option of waiting for allergy appointment
to further evaluate this allergy or for CCU admission for rapid
desensitization, and chose the latter.
.
On review of systems, she denies any recent fever, chills,
nightsweats or rigors. She denies prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery. No PND or clear orthopnea (must sleep on her side
secondary to back/spine pain). She does have swelling of the
ankles which has been stable, as well as swelling in the knees
from her arthritis (L > R). She has had palpitations for which
sh has worn KOH monitor as above. She has multiple myalgias and
joint pains for which she is followed in rheumatology clinic;
these are stable. Cough as per HPI with no hemoptysis. No
N/V/D/C, no abdominal pain, no changes in bowel habits (last BM
this morning, normal), no black stools or red stools. She has
had several episodes of LH over the past several days, most
recently two days ago when she felt lightheaded after getting
out of a car and had to sit and hold her head. No syncope. No
dysuria or hematuria. All of the other review of systems were
negative.
Past Medical History:
1. Spinal stenosis
2. Fibromylagia/Polymyalgia rheumatica
3. Hypertension
4. Osteoarthritis
5. Depression
6. s/p bilateral oopherectomy
7. Glucose intolerance
Social History:
Denies alcohol and drugs. Distant history of trying cigarettes
many years ago. Married to husband. [**Name (NI) **] involved and
translates for her. Persian.
Family History:
Denies cancer and cardiovascular problems in family.
Physical Exam:
ADMISSION EXAM:
VS: T=none at time of exam BP=116/74 HR=77 RR=20 O2 sat=91% on
RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI though patient has pain in
her left eye with upward gaze. Erythema and irritation of
medial sclera of right eye, involving [**Doctor First Name 2281**], with overlying
opacification. Left pupil has irregular contours and is slightly
larger than the right, though still reactive. Conjunctiva were
pale pink. No pallor or cyanosis of the oral mucosa; upper and
lower dentures in place. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: Slightly distant S1, S2 with no appreciable M/R/G. TTP
over most of anterior chest wall especially at costosternal
joints on the left.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
BACK: Signficant tenderness to palpation of all vertebrae and
also with tapping at CVA bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. +NABS.
EXTREMITIES: Non-pitting 1+ lower extremity edema, symmetric, no
calf tenderness. DP 2+ PT 2+ bilaterally.
.
DISCHARGE EXAM:
Vitals - Tm/Tc: 98.1/97.2 BP: 116-136/60-70 HR: 64-93 RR:18 02
sat: 99-96 RA, 95-97% on RA with ambulation.
In/Out: Last 24H: 1540/BRP
Weight 64.5kg (65)
GENERAL: elderly female in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+. right brachial cath site with
mild TTP but no erythema.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait
unsteady without cane.
SKIN: no rash
Pertinent Results:
ADMISSION LABS
[**2133-8-16**] 03:50PM GLUCOSE-153* UREA N-23* CREAT-1.0 SODIUM-142
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17
[**2133-8-16**] 03:50PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2133-8-16**] 03:50PM WBC-6.3 RBC-3.67* HGB-11.4* HCT-33.7* MCV-92#
MCH-31.1 MCHC-33.8 RDW-13.6
[**2133-8-16**] 03:50PM NEUTS-60.4 LYMPHS-29.3 MONOS-6.0 EOS-3.5
BASOS-0.8
[**2133-8-16**] 03:50PM PLT COUNT-238
[**2133-8-16**] 03:50PM PT-11.9 PTT-25.2 INR(PT)-1.0
DISCHARGE LABS
[**2133-8-19**] 06:25AM BLOOD WBC-5.7 RBC-3.84* Hgb-12.1 Hct-35.9*
MCV-94 MCH-31.5 MCHC-33.7 RDW-13.9 Plt Ct-219
[**2133-8-19**] 06:25AM BLOOD Plt Ct-219
[**2133-8-19**] 06:25AM BLOOD Glucose-133* UreaN-26* Creat-0.7 Na-140
K-4.0 Cl-99 HCO3-31 AnGap-14
CXR ([**2133-8-16**]):
In comparison with the study of [**6-24**], there are lower lung
volumes that accentuate the prominence of the transverse
diameter of the heart. There is fullness of indistinct pulmonary
vessels consistent with elevated pulmonary venous pressure,
beyond that which would be expected with poor inspiration on a
portable examination.
Cardiac Cath ([**2133-8-17**]):
1. Selective coronary angiography of this right dominant system
revealed
no angiographically-apparent flow-limiting stenoses. The LMCA
was free
from angiographic disease. The LAD had mild plaquing. The
ostial
diagonal branch demonstrated 60% focal stenosis. The LCx was a
small
vessel giving rise to a large OM1 (functionally a ramus
intermedis) and
four other tiny OMs. The RCA was a large dominant vessel with
mild
plaquing.
2. Resting hemodynamics revealed elevated right and left-sided
filling
pressures with RVEDP of 12 mm Hg and LVEDP of 18 mm Hg. There
was
moderate pulmonary arterial systolic hypertension with PASP of
52 mm Hg.
The cardiac index was preserved at 3.17 L/min/m2. There was
significant
systemic arterial systolic hypertension with SBP 181 mmHg.
Diastolic
blood pressures was 82 mm Hg.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
80 F with multiple medical problems and recent complaints of
worsening dyspnea on exertion who presents for planned CCU
admission for aspirin desensitization prior to cardiac
catheterization for further work up of DOE.
.
ACTIVE DIAGNOSES:
.
# Diastolic CHF: Pt has diastolic CHF based on cardiac cath, and
given the absence of coronary disease, this is likely the cause
of her exertional dyspnea. This is consistent with her
longstanding history of HTN. She was diuresed with IV lasix and
her home lasix was increased to 20mg po daily. She was also
started on metoprolol succinate 50 mg qday and lisinopril 2.5mg
po qday. At the time of discharge she was asymptomatic and her
weight was 64.5kg.
.
# Pulmonary HTN: Pt has significant pulmonary HTN (PA pressure
52/18/20) based on cardiac cath, and this is likely also
contributing to exertional dyspnea. This is likely [**3-4**] her left
sided diastolic CHF, but given history of bronchiectasis, cannot
rule out a primary pulmonary component to her elevated PA
pressures. She was discarged on ACEI, diuretic and beta blocker
per above.
.
# ASA Allergy: Pt underwent successful ASA desensitization. ASA
reaction is documented as urticaria/angioedema, but during
desensitization she only experienced pruritis without other
manifestations of hypersensitivity. She was desensitized per
[**Hospital1 18**] protocol without indicent and should continue taking ASA
81 indefinately to prevent recurrence of hypersensitivity.
.
# HTN: Her metoprolol tartrate 25mg qday was changed to
metoprolol succinate 50mg qday. Her lasix was increaed to 10mg
qday and she was started on lisinopril 2.5mg qday. Her BP was
well controlled on this regemin while hospitalzied, but her
medications should be further titrated by her PCP as an
outpatient.
.
CHRONIC DIAGNOSES:
.
# DIABETES: Last HbA1c in [**1-/2133**] was 5.7%. Currently off all
medication. She was covered with ISS while in house her BG was
well controlled
.
# ANEMIA: Her home folic acid and B12 were continued. Her Hct
remained stable in the low/normal range throughout her hospital
course and no intervention was undertaken.
.
# JOINT PAIN: Multifactorial (has RA vs. PMR and osteoarthritis
by history, also status post bilateral total knee arthroplasty).
She was continued on her home Voltaren 1% gel, sulfasalazine and
Ca/Vit D and her pain was well controlled on tylenol prn. Pt is
followed by rheum, who will see her as an outpatient.
.
# VASOACTIVE SYMPTOMS S/P MENOPAUSE: She was continued on her
home Premarin 0.9 mg PO daily; should follow up with PCP
regarding weaning estrogen.
.
# PSYCHIATRIC ISSUES: She was contined on her home mirtazapine
and venlafaxine.
.
TRANSITIONAL ISSUES: She was discahrged home with Cardiology,
PCP, [**Name10 (NameIs) 1957**] and Allergy/Immunology follow up. Dietary teaching
was performed regarding the importance of low Na diet and
warning signs about fluid overload.
Medications on Admission:
- Premarin 0.9 mg PO daily (dose recently decreased per patient)
- Voltaren 1% gel apply to affected area QID PRN pain (not
currently using)
- Folic acid 1 mg PO daily
- Furosemide 10 mg PO daily (actual dose unclear)
- Gabapentin 300 mg PO QID (takes TID per patient)
- Isosorbide mononitrate ER-24 hr 30 mg PO daily
- Metoprolol tartrate 25 mg PO BID
- Mirtazapine 7.5 mg PO QHS
- Omeprazole 20 mg PO daily
- Sulfasalazine 1500 mg PO BID
- Venlafaxine 75 mg PO daily
- Acetaminophen 325 mg TID PRN cold symptoms (not currently
taking)
- Calcium carbonate-vitamin D3 600 mg-200 unit tablet PO BID
- Vitamin B12 1,000 mcg PO daily
Discharge Medications:
1. conjugated estrogens 0.3 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
9. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Acute on Chronic Diastolic Constestive heart failure
Aspirin Desensitization
Hypertension
Chronic Joint pain
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a cardiac catheterization to test for
heart problems that were causing your breathing trouble and
chest pain. You did not have any significant blockages in your
heart arteries but we did find that you had too much fluid in
your body that wa affecting your breathing and making you tired.
We gave you some intravenous furosemide to get rid of the fluid
and will have you take 20 mg of furosemide daily instead of 10
mg to keep the fluid from coming back. If your breathing worsens
again, this means that the fluid is coming back. Weigh yourself
every morning, call Dr. [**First Name (STitle) **] if weight goes up more than 3
lbs in 1 day or 5 pounds in 3 days. It is very important that
you avoid salt in your cooking and check the ingredients for
high salt content. You can have about 2000mg of salt daily.
.
We made the following changes to your medicines:
1. Increase furosemide to 20 mg daily
2. Stop taking metoprolol tartrate, take metoprolol succinate
instead once a day
3. Start aspirin 81 mg daily, do not stop taking this medicine
unless Dr. [**First Name (STitle) 21560**] tells you to.
4. Start lisinopril 2.5 mg daily to lower your blood pressure.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2133-8-26**] at 10:10 AM
With: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2133-9-1**] at 4:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2133-9-9**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 9316**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2133-9-10**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
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"416.8",
"368.13",
"401.9",
"V07.1",
"494.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13638, 13689
|
8749, 9000
|
336, 377
|
13866, 13866
|
6775, 8726
|
15224, 16507
|
4867, 4921
|
12366, 13615
|
13710, 13845
|
11711, 12343
|
14017, 15201
|
4936, 6079
|
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|
11465, 11685
|
279, 298
|
405, 4489
|
13881, 13993
|
9018, 11444
|
4511, 4671
|
4687, 4851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,687
| 124,336
|
23588
|
Discharge summary
|
report
|
Admission Date: [**2109-8-26**] Discharge Date: [**2109-9-1**]
Date of Birth: [**2046-11-25**] Sex: F
Service: MED
TIME OF DEATH: [**2109-9-1**], at 00:45 a.m
HISTORY OF PRESENT ILLNESS: This 62-year-old female with
past medial history of Hep B, primary biliary cirrhosis,
complicated by spontaneous bacterial peritonitis, hepatic
encephalopathy and esophageal varices. The patient was
admitted for worsening of abdominal distention and lower
extremity edema. A liver became available and it was decided
the patient would be brought in for transplantation.
PAST MEDICAL HISTORY: Primary biliary cirrhosis diagnosed in
[**2109-3-5**], hepatitis C cirrhosis complicated by
spontaneous bacterial peritonitis, esophageal varices grade
1, esophageal ulcers, history of rheumatic fever, osteopenia
of the hip and spine, anemia of chronic disease status post
cholecystectomy, status post appendectomy.
MEDICATIONS:
1. Ursodiol 300 mg PO b.i.d.
2. Spironolactone 25 mg one tab PO daily.
3. Bactrim 800 mg one tab PO daily.
4. Lactulose 2 mg PO daily.
5. Prevacid 30 mg PO daily.
SOCIAL HISTORY: Alcohol - he used to drink 2 to 3 glasses o
wine per day. Tobacco - remote history of smoking.
PHYSICAL EXAMINATION: Temperature was 98.9, heart rate 80,
blood pressure 106/50, respiratory rate 20, oxygen 97% on
room air.
GENERAL: In no acute distress.
HEENT: Scleral icterus.
CARDIOVASCULAR: 3/6 systolic ejection murmur.
LUNGS: Clear to auscultation.
ABDOMEN: Distended. Mildly tender in the right upper and left
upper quadrants.
EXTREMITIES: Pitting edema.
LABORATORY DATA: White blood cell was 1.9, hematocrit 24,
platelet count 105, sodium 126, potassium 3.4, chloride 91,
bicarbonate 24, BUN 36, creatinine 1.2. ALT was 30, alkaline
phosphatase 158, total bilirubin 3.8, AST 60, albumin 3.0, PT
80.6, PTT 36, INR 2.3. The patient was brought to the
operating room on [**8-29**] and received piggy-back liver
transplantation. Intraoperative blood loss was [**2104**] cc. The
patient received 12 units of packed red blood cells, 11 units
of FFP, 40 units of platelets, 3 units of cryo. Abdomen was
left open at that time. The patient was brought to the
intensive care unit for her critical care.
On postoperative day 0, there were concern that the patient
was bleeding and multiple blood product transfusions were
given including FFP, packed red blood cells, platelets and
cryo. O2 cylinder was also started. The patient's hematocrit
dropped postoperative 0 and into postoperative 1 slowly
stabilized. At that time she was maintaining her pH and acid-
base level fairly well. The patient was brought back to the
operating room on postoperative day 1 for abdominal closure.
When she was brought back to the intensive care unit it was
noted she developed redness over her right arm and right
body. An aspirate for screening revealed gram negative rods.
These wounds were opened up and packed. Antibiotic coverage
and consultation with infectious disease consisted of
vancomycin, ceftriaxone, fluconazole, meropenem. The patient
also received dose of levofloxacin and gentamycin.
I began the patient on multiple vasopressors on postoperative
day 1 including Pitressin, neomycin and levofloxacin.
The patient's status continued to deteriorate as her pH began
to gradually fall on postoperative day 1 going into
postoperative day 2. The patient's liver function tests also
began to rise. Her initial hepatic ultrasound did show good
flow, however the liver function tests significantly
deteriorated. At this point postoperative day 2, all the
immunosuppression was held except for small amount of Solu-
Medrol. The patient was unable to maintain pH despite
starting bicarbonate drips.
At this point the family approached us about withdrawing
support. After discussion with the family and Dr. [**First Name (STitle) **], it
was decided that the patient be made CMO. The patient was
shortly thereafter expired at 12:35 a.m. on the morning of
[**8-22**]. The patient expired.
Dr. [**First Name (STitle) **]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2109-9-1**] 00:50:24
T: [**2109-9-1**] 02:48:22
Job#: [**Job Number 60384**]
|
[
"728.86",
"995.92",
"286.6",
"570",
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"571.6",
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"427.5",
"038.3",
"795.79",
"456.21",
"424.1",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"50.59",
"00.93",
"99.05",
"99.04",
"54.63",
"50.12",
"54.91",
"86.11",
"89.68",
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] |
icd9pcs
|
[
[
[]
]
] |
1236, 4191
|
211, 582
|
605, 1100
|
1117, 1213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,382
| 198,012
|
41843
|
Discharge summary
|
report
|
Admission Date: [**2160-9-7**] Discharge Date: [**2160-9-12**]
Date of Birth: [**2120-3-19**] Sex: M
Service: MEDICINE
Allergies:
atenolol / Serax / Neurontin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD ([**2160-9-7**])
History of Present Illness:
40 year old man with PMH of alcohol abuse, withdrawal, DT,
alcoholic pancreatitis, pancreatic pseudocyst, HTN, depression,
polysubstance abuse, GERD, tobacco abuse, and withdrawal
seizures from stopping Xanax presents with sudden onset of chest
and abdominal pain at 3 AM yesterday AM waking him from sleep,
with associated nausea and dry heaves. Ultimately, he had two
episodes of vomiting bright red blood, as well as having some
watery diarrhea. he denied any blood int he stools or black
stools, and endorsed feeling week or dizzy. He also endorsed
some mild SOB.
.
His ROS at that time notable for a rash on the bilateral lower
extremities.
.
His admission labs were notable for a glucose of 175 and a BUN
of 20. LFTs showed AST 106 ALT 80, Amylase 239 and Lipase 1309.
His WBC was 44.8 with 88% N, 5% bands, 3% lymphs. His OSH
imaging showed a CXR with no acute disease, a CT of the abdomen
and pelvis showing some gallbladder wall thickening, hyperemia
and inflammatory changes suspicious for acute cholecystitis, as
well as some mild fat stranding around the pancreatitis head,
with a stable pseudocyst in the region of the pancreatic tail.
RUQ u/s showed thickening gallbladder wall up to 1 cm with a
small amount of pericholecystic fluid. No cholethiasis and no
definite son[**Name (NI) 493**] [**Name2 (NI) 90875**] sign. normal caliber CBD and
possible minimal intrahepatic biliary ductal dilatation. EKG at
OSH showed sinus rhythm 70, no ST changes.
.
For his UGIB, GI was consulted, and scoped him, finding as
below.
For his acute pancreatitis, his alcohol level was undetectable,
and his was kept NPO.
From his elevated WBC count, e was started on Unasyn and Flagyl,
and ultimately sent here on Vancomycin, Metronidazole, and
Meropenem. He was placed on BCD.
.
His blood gas at 7 PM on [**2160-9-6**] was 7.29/40.3/111 on
SMV12x500,[**4-20**].
.
Repeat ABG on PSV 5/5 7.38/38/94.
.
Ont he floor, he is sedated and unable to answer questions.
.
Review of systems: Unable to answer
Past Medical History:
Alcohol abuse
Alcohol withdrawal
Delirium tremens
Alcohol pancreatitis
pancreatic pseudocyst
anxiety and depression
hypertension
polysubstance abuse
GERD
Tobacco abuse
withdrawal seizures from stopping Xanax
Social History:
The patient lives at home with his girlfriend. Referred he
stopped drinking alcohol a year ago. Smokes marijuana. Denies
other illicit. Denies IV drugs. Continues to smoke tobacco on a
daily basis.
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.3 BP: 136/93 P: 76 R: 21 O2: 94% Intubated 50%
FiO2.
General: sedated
HEENT: nasal passageways with clot in the nares bilaterally
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: mild TTP in the epigastrium, without rebound, without
hard surgical abdomen.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
[**2160-9-7**] 12:54AM BLOOD WBC-32.8* RBC-4.95 Hgb-15.9 Hct-48.1
MCV-97 MCH-32.0 MCHC-33.0 RDW-14.3 Plt Ct-20*
[**2160-9-7**] 12:54AM BLOOD Neuts-88.1* Lymphs-6.9* Monos-4.3 Eos-0.5
Baso-0.2
[**2160-9-7**] 12:54AM BLOOD PT-15.0* PTT-27.8 INR(PT)-1.3*
[**2160-9-7**] 12:54AM BLOOD Fibrino-475*
[**2160-9-7**] 08:10AM BLOOD FDP-40-80*
[**2160-9-9**] 03:00AM BLOOD Ret Aut-1.5
[**2160-9-7**] 12:54AM BLOOD Glucose-207* UreaN-29* Creat-0.8 Na-141
K-4.7 Cl-112* HCO3-21* AnGap-13
[**2160-9-7**] 12:54AM BLOOD ALT-51* AST-124* LD(LDH)-1754* AlkPhos-49
Amylase-218* TotBili-1.5
[**2160-9-7**] 12:54AM BLOOD ALT-51* AST-124* LD(LDH)-1754* AlkPhos-49
Amylase-218* TotBili-1.5
[**2160-9-7**] 12:54AM BLOOD Lipase-214*
[**2160-9-7**] 12:54AM BLOOD Calcium-7.1* Phos-2.8 Mg-1.7
[**2160-9-7**] 12:54AM BLOOD Hapto-<5*
[**2160-9-7**] 03:50AM BLOOD Type-ART pO2-94 pCO2-38 pH-7.38
calTCO2-23 Base XS--1
[**2160-9-7**] 03:50AM BLOOD Lactate-1.4
Discharge Labs:
Imaging:
AXR ([**2160-9-7**])
The right side up decubitus view of the abdomen (limited) was
reviewed. The imaged portion of the abdomen does not reveal the
presence of free air.
CXR ([**2160-9-7**])
The ET tube tip is 5.5 cm above the carina, slightly eccentric.
The NG tube tip is in the stomach. Heart size and mediastinum
are unremarkable. There is mild interstitial pulmonary edema.
Left lower lobe consolidation is associated with pleural
effusion.
CT Abd and Pelvis ([**2160-9-7**])
1. Findings consistent with worsening pancreatitis including
increased
peripancreatic stranding and increased small volume ascites.
2. Slight increase in size of the pancreatic tail pseudocyst,
now measuring 6.0 x 4.6 cm.
3. Wedge-shaped region of hypoenhancement involving the inferior
aspect of
the spleen with adjacent smaller regions of splenic
hypoenhancement are not significantly changed compared to the
prior study and are concerning for impeding infarction;
recommend attention on follow-up imaging. Note is again made of
marked narrowing of the splenic vein.
4. New small bilateral pleural effusions with associated
compressive
atelectasis.
5. Wall thickening of the second and third portions of the
duodenum are
likely reactive.
6. Bilateral renal hypodensities, some of which are simple cysts
and others that are too small to characterize.
7. 1 cm hypodensity in the right hepatic lobe adjacent to the
gallbladder
fossa is likely a region of focal fat deposition versus a
perfusional anomaly.
Abdominal US ([**2160-9-9**])
1. Gallbladder sludge.
2. Small segment V liver hemangioma.
3. Splenic infarct.
4. Pancreatic tail pseudocyst.
5. Trace ascites seen on CT two days prior not evident on
ultrasound.
EDG ([**2160-9-7**])
-Blood in the esophagus
-Ulcers in the middle third of the esophagus and lower third of
the esophagus
-[**Doctor First Name **]-[**Doctor Last Name **] tear
-Diffuse ulceration and fibrin deposition was seen in the
stomach. There were innumerable ulcers. The fundus had a large
diffuse area of ulceration, adherent clot and fibrin deposition.
There were some areas that appeared to resemble a mass although
it was not possible to distinguish a mass from inflammatory
tissue and fibrin deposition.
-Ulcers in the antrum, pylorus and stomach body
-Ulcers in the duodenal bulb, second part of the duodenum and
third part of the duodenum
-The etiology of the diffuse, severe ulceration is unclear and
could represent a malignant process (ZE syndrome), ischemic
event or caustic intake.
[**2160-9-11**] Repeat EGD
Severe gastropathy consistent with portal hypertensive
gastropathy
Large areas of superficial serpiginous ulceration were noted in
the body and fundus. There was a large area with dusky-black
appearance with thickening of the mucosal folds noted in the
fundus - differential diagnosis necrosis of gastric mucosa,
gastric varices or an underlying infiltrative process. Cold
forceps biopsies were performed for histology at the stomach.
Mild duodenitis in the duodenal bulb. Otherwise normal EGD to
third part of the duodenum
[**2160-9-8**] 03:19AM BLOOD WBC-29.9* RBC-4.00* Hgb-13.3* Hct-37.8*
MCV-94 MCH-33.3* MCHC-35.2* RDW-15.2 Plt Ct-15*#
[**2160-9-8**] 11:24PM BLOOD WBC-31.5* RBC-3.76* Hgb-11.8* Hct-34.6*
MCV-92 MCH-31.4 MCHC-34.1 RDW-15.2 Plt Ct-25*
[**2160-9-9**] 07:30PM BLOOD WBC-31.5* RBC-3.75* Hgb-11.9* Hct-34.8*
MCV-93 MCH-31.7 MCHC-34.1 RDW-15.5 Plt Ct-33*
[**2160-9-10**] 07:00AM BLOOD WBC-30.8* RBC-3.59* Hgb-11.6* Hct-33.7*
MCV-94 MCH-32.3* MCHC-34.5 RDW-15.3 Plt Ct-49*
[**2160-9-11**] 07:35AM BLOOD WBC-31.4* RBC-3.47* Hgb-10.8* Hct-32.9*
MCV-95 MCH-31.3 MCHC-33.0 RDW-15.7* Plt Ct-132*#
[**2160-9-10**] 07:00AM BLOOD Glucose-123* UreaN-16 Creat-0.6 Na-137
K-3.4 Cl-101 HCO3-27 AnGap-12
[**2160-9-8**] 03:19AM BLOOD ALT-36 AST-67* LD(LDH)-1454* AlkPhos-44
TotBili-1.8* DirBili-0.5* IndBili-1.3
[**2160-9-9**] 03:00AM BLOOD LD(LDH)-1255* TotBili-1.7* DirBili-0.6*
IndBili-1.1
[**2160-9-10**] 07:00AM BLOOD LD(LDH)-1100* TotBili-1.1
[**2160-9-8**] 03:30PM BLOOD Hapto-28*
[**2160-9-9**] 03:00AM BLOOD VitB12-535 Folate-7.6 Hapto-28*
[**2160-9-10**] 07:00AM BLOOD Hapto-51
[**2160-9-9**] 02:00PM BLOOD ADAMTS13 ACTIVITY EVALUATION = normal
[**2160-9-7**] 10:42AM BLOOD GASTRIN-Test 11 (normal)
[**2160-9-12**] 07:15AM BLOOD WBC-29.0* RBC-3.42* Hgb-10.9* Hct-31.3*
MCV-92 MCH-31.9 MCHC-34.8 RDW-15.7* Plt Ct-214#
[**2160-9-11**] EGD Bx are pending.
Brief Hospital Course:
40 year M with PMH alcohol abuse, withdrawal, DT, alcoholic
pancreatitis, pancreatic pseudocyst who presents with upper GI
bleed after chronic NSAID and energy drink (MONSTER) intake. He
required intubation for airway protection.
# GI Bleed
Patient was evaluated by GI and underwent a EGD which revealed
diffusely eroded edematous gastric mucosa with central black
membranes v. clot in the fundus but no definitive bleeding site.
He had erosive esophagitis, esophageal/gastric/duodenal ulcers
to the 3rd part of duodenum, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] Tear. No Bx
were done initially b/c of low Platelet. He received 2U PRBC and
3U platelet transfusions. He was started on a PPI drip which
was later transitioned to a PPI PO BID. He was initially kept
NPO and advanced to full diet upon transfer from the ICU.
Gastrin levels were normal. EGD was repeated [**2160-9-11**] with
biopsies. There was still erosive changes seen. He will need
[**Hospital1 **] high dose PPI x at least 6-8 weeks, and have a 3rd repeat
EGD at that time. H. Pylori serology was negative. He was
instructed on NSAID/ASA and Monster/Other energy drink
avoidance.
# Airway protection
Pt was intubated in the setting of hemoptysis for airway
protection. He was successfully extubated the following morning
as he was no longer actively bleeding. He did not have an
oxygen requirement upon transfer to the general medicine floor.
# Abnormal CBC (thrombocytopenia, anemia, possible hemolysis):
The patient was noted to have a leukocytosis, anemia and
thrombocytopenia. No blasts were seen in his WBC differential,
but there were bands at the outside hospital, and the elevated
counts were attributed a possible infection v. pancreatitis. He
was initially started on antibiotics, but these were
discontinued as he clinically improved. Hematology was called
regarding his thrombocytopenia and undetectable haptoglobin on
admission (suggesting a consumptive/hemolytic process). Upon
review of his smear, they saw evidence of few schistocytes which
raised their concern for possible TTP. They felt his case was
not entirely clear as the smear was made on a post-transfusion
blood, which may have been the etiology of the schistocytes.
Upon further discussion, it was decided not to initiate
plasmapheresis and to monitor the patient closely. Given his
low platelet counts, there was also concern for possible ITP and
the patient was started on steroid therapy. The platelet count
rose, permitting repeat EGD w/ biopsy, and the haptoglobin rose
to within normal counts. On discharge the PLT count had
normalized to >200. ADAMTS13 activity was normal. An HIV Ab
test is pending at time of discharge and will be followed up at
his hematology follow-up appointment next week with Dr.
[**Last Name (STitle) **]. He will complete a rapid taper of Prednisone for the
next 5 days after discharge.
# Pancreatitis and pseudocyst:
The exact etiology of his pancreatitis was unclear, though
NSAIDs were high on the differential. His RUQ u/s demonstrated
no gallstones, though there was presence of biliary sludge
(which can also cause pancreatitis). The patient denies current
alcohol use and his EtOH level was negative as per OSH report.
He was given IV hydration and no antibiotics were administered
as the patient did not appear to be infected. He clinically
improved and is tolerating enteric meals. He has a pseudocyst
that will need to be followed by GI/Pancreas team, who will
contact him with appointment information (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).
Given the sludge, it is recommended he undergo elective
cholecystectomy when he recovers from this hospitalization.
.
# Tobacco use: He was placed on nicotine patch and encouraged
to stop smoking to allow his GI ulcers faster healing. He
should continue nicotine patch taper prolonged.
Discharge Medications:
1. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Use 21mg patch daily for 4-6 weeks,
then 14mg patch daily for 2-4 weeks, then 7 mg patch for [**12-9**]
weeks. Do not smoke while using this med.
Disp:*28 Patch 24 hr(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) for
8 weeks.
Disp:*112 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Starting [**2160-9-12**], take 2 tablet once x 1 day, then 1 tablet once
x 2 days, then half tablet once x 2 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed -- erosive esophagitis, esophageal/stomach/duodenal
ulcers.
Severe pancreatitis
Pancreatic pseudocyst
Thrombocytopenia, unspecified
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ICU with bleeding from the upper intestinal
tract (including esophagus, stomach and duodenum). You required
mechanical ventilation for a short period. You were given 2
units of blood. You underwent 2 endoscopies which showed
irregularity of the stomach wall. Biopsies were taken and these
results are pending. You will need to follow up with the
GI/pancreas specialist.
You were found to have low platelets (blood cell involved in
clotting) of unclear etiology and were treated empirically with
steroid medication under hematology consultation. Your platelet
level began to normalize. You need to complete a rapid taper
with Prednisone as prescribed, and have follow up blood counts
with your PCP in one week.
You were found to have pancreatitis and a pancreatic pseudocyst.
Biliary sludge was seen on imaging studies. You were seen by the
GI and surgical specialists. The pseudocyst will need to be
monitored, and it is recommended you have your gallbladder
removed in the future when you have recovered from this
hospitalization.
Please continue to refrain from alcohol, tobacco use, caffeine
use, use of any ibuprofen, motrin, advil, naproxen/naprosyn, or
aspirin containing products in order to promote healing of your
GI ulcers. Please stop drinking MONSTER drinks, or any similarly
marketed energy drink.
Followup Instructions:
GI physician: [**Name10 (NameIs) **] GI team will call you with appointment
information. If you do not hear from them by end of next
Monday, please call [**Hospital1 18**] operator to have Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]
(GI fellow) paged. He is arranging follow up.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2160-9-19**] at 10:00 AM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MD
Specialty: Internal Medicine
When: Monday [**9-22**] at 4pm
Address: [**Location (un) 90876**], [**Location (un) **],[**Numeric Identifier 72661**]
Phone: [**Telephone/Fax (1) 53215**]
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,276
| 165,268
|
30414
|
Discharge summary
|
report
|
Admission Date: [**2188-3-26**] Discharge Date: [**2188-4-1**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
88M PMH HTN, [**Hospital **] transferred from [**Hospital 4199**] Hospital ED where he
had been admitted for respiratory distress, s/p intubation by
EMS. Per his daughters, he was in his USOH, other than a URI
with mild cough, up until this afternoon, when in the evening he
called his daughter c/o acute onset shortness of breath. When
they found him, he appeared to have "facial swelling," felt
warm, and was struggling to breath. EMS arrived and intubated
him. Prior to this event, he reportedly had no F/C/NS, chest
pain or SOB. He was very active, and reportedly walked 2 miles
without difficulty 2 weeks ago.
*
In [**Last Name (un) 4199**] ED, he was initially found to be hypertensive to
239/130. he was noted to be very agitated and was given
initially 4mg ativan IV, then succinylcholine 60mg IV. He was
then given tylenol 650mg, toradol 30mg, zosyn 3.375 IV. He
continued to be agitated, and was given 4mg ativan more, as well
as diprivan 20mg bolus then drip at 10mcg/kg/hr. ABG prior to
transfer 7.30/56/477.
.
On further review after extubation, he had noted a productive
cough x 2 days and wheezing. Also URI symptoms. Denies h/o
asthma or emphysema. No chest pain.
Past Medical History:
HTN
-Afib: history of 2 episodes of syncope, ? related to AF vs
dehydration 1 year ago, and again in [**Month (only) **]
- CAD [**Hospital1 2025**] [**3-18**] with non-flow limiting dz (30% LAD)
-type II DM: on glucotrol
-BPH
-s/p lip resection for cancer (over 20 years ago)
-h/o hematuria (when on ASA 325)
Social History:
Lives alone in [**Location (un) 3146**] in [**Location (un) 448**] apartment. Very
independent, takes care of all ADLs. History of smoking, but
none current. No ETOH.
Family History:
noncontributory
Physical Exam:
Vitals: T 97.3
BP 149/74
HR 62
R 16
Sat 99%
*
VENT: AC 500 x 16 @ 0.5 PEEP 5 Compliance 33 PlatP 14
*
PE: G: Intubated, sedated
HEENT: Clear OP, MMM
Neck: Supple, No LAD, No JVD
Lungs: BS BL, No W/R/C
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: 2+ pitting edema. 2+ DP pulses BL.
Pertinent Results:
[**2188-3-27**] 01:30AM BLOOD WBC-6.9 RBC-3.85* Hgb-10.4* Hct-32.3*
MCV-84 MCH-26.9* MCHC-32.0 RDW-15.7* Plt Ct-176
[**2188-3-27**] 01:30AM BLOOD PT-12.6 PTT-32.3 INR(PT)-1.1
.
[**2188-3-27**] 01:30AM BLOOD Glucose-150* UreaN-26* Creat-1.2 Na-145
K-3.7 Cl-110* HCO3-25 AnGap-14
.
[**2188-3-27**] 01:30AM BLOOD CK(CPK)-50
[**2188-3-27**] 05:07PM BLOOD CK(CPK)-91
[**2188-3-27**] 01:30AM BLOOD CK-MB-5 cTropnT-0.15*
[**2188-3-27**] 05:07PM BLOOD CK-MB-7 cTropnT-0.08*
.
[**2188-3-28**] 03:50AM BLOOD TotProt-5.2* Calcium-8.0* Phos-3.7 Mg-2.0
Iron-18*
[**2188-3-28**] 03:50AM BLOOD calTIBC-261 VitB12-250 Folate-10.3
Ferritn-57 TRF-201
[**2188-3-28**] 09:04PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**2188-3-29**] 06:35AM BLOOD Triglyc-67 HDL-54 CHOL/HD-2.9 LDLcalc-92
[**2188-3-28**] 03:50AM BLOOD PEP-NO SPECIFI
urine legionella antigen: negative
.
NASAL ASPIRATE VERIFIED TEST WITH DR [**Last Name (STitle) **] [**2188-3-29**] 9AM.
Rapid Respiratory Viral Antigen Test (Final [**2188-3-29**]):
Positive for respiratory viral antigens except RSV.
FURTHER IDENTIFICATION TO FOLLOW.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
VIRAL CULTURE (Preliminary): RESULTS PENDING.
Respiratory Viral Identification (Final [**2188-3-29**]):
Positive for Parainfluenza viral antigen.
CULTURE CONFIRMATION PENDING.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
REPORTED BY PHONE TO DR [**Last Name (STitle) **] [**Numeric Identifier 72305**] [**2098-3-29**] 3:15PM.
.
SPUTUM GRAM STAIN (Final [**2188-3-28**]):
[**11-6**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2188-3-30**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
.
BLOOD CX: NO GROWTH TO DATE
.
EKG:
Sinus bradycardia. Left atrial abnormality. Q-T interval
prolongation.
Occasional ventricular ectopy. No previous tracing available for
comparison.
.
ECHO [**2188-3-27**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The left ventricular
inflow pattern suggests impaired relaxation. There is no
pericardial effusion.
.
SINGLE AP PORTABLE VIEW CHEST [**2188-3-27**]: ETT tip is 4.3 cm above
the carina. NG tube is out of view below the diaphragm. There is
mild pulmonary edema. Left lower lobe retrocardiac opacity is
consistent with atelectasis and/or pneumonia. Note is made that
the right CP angle was not included on the film. There is a
suggestion of small left pleural effusion.
.
CT OF THE CHEST WITHOUT CONTRAST [**2188-3-29**]: There is a moderate
right pleural effusion and small-to-moderate left pleural
effusion, simple in nature. There is no pericardial effusion.
There is no consolidation or pulmonary edema. There is a 1 mm
opacity along the inferior right major fissure, possibly
representing a tiny subpleural lymph node. No other nodular
opacities are visualized. The central airways are patent to the
level of the segmental bronchi bilaterally. There are
calcifications of the aortic valve, and coronary artery
calcifications. No lymph nodes within the axillae, mediastinum
or hila meet CT size criteria for pathologic enlargement. In
the imaged portion of the upper abdomen, the visualized portions
of the liver, gallbladder, spleen, pancreas and adrenal glands
are unremarkable. The examination is not tailored for
evaluation of the structures, and assessment is limited without
IV contrast.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions.
Irregularity of the left scapula may be related to a remote
injury.
Coronal reformatted images were generated and confirmed the
described
findings.
IMPRESSION:
1. Moderate right pleural effusion and small-to-moderate left
pleural
effusion, simple in nature. No pulmonary edema at the current
time.
2. Calcifications of the coronary arteries, aorta and aortic
valve.
Brief Hospital Course:
1) Respiratory failure: Suspect secondary to bronchospasm in the
setting of parainfluenza tracheobronchitis with perhaps an
initial component of CHF. Patient was extubated on hospital day
# 3. His bronchospasm was managed with combivent and flovent
inhalers. He also received 5 days of levofloxacin for question
of bacterial superinfection. Urine legionella and sputum
culture were unrevealing. Patient received pneumovax prior to
discharge and was up to date on the influenza vaccine. He was
stable on room air at the time of discharge without wheezing.
.
2) Left sided CHF: TTE showed EF >55%. Creatinine bumped with
diuresis despite mild CHF noted on initial CXR. I suspect the
failure was due to his underlying pulmonary process. He
received initial diuresis in the ICU but this was not continued
given a rise in his creatinine. On the day of discharge, he
appears euvolemic and his blood pressure is well controlled.
.
3) Acute renal failure: Resolved prior to discharge. FeNa <1%
consistent with pre-renal state. Likely due to initial
diuresis.
.
4) CAD: Patient has a history of non-flow limiting CAD on [**3-/2187**]
cath. He denied any chest pain but did have a bump in troponins
but with a negative CKMB. Perhaps this was due to some demand
ischemia. No focal wall motion abnormalities on ECHO and
patient denied any complaints of exertional symptoms prior to
admission. He was unable to continue on an ASA due to hematuria
but is on as statin and beta blocker.
.
5) HTN: Blood pressure improved with the addition of amlodipine
and an increase in his beta blocker.
.
6) BPH: Finasteride
.
7) Hematuria: Patient had foley in place in the ICU to monitor
I/O. This was discontinued on the floor but patient failed his
voiding trial (450 cc retained in bladder). Foley was replaced
but then patient subsequently developed gross hematuria,
primarily bleeding from the penis, AROUND the catheter, while on
ASA. The urine remained relatively clear. His aspirin and SQ
heparin were discontinued and his hematocrit was rechecked in
the AM. His hematocrit was stable and he had no issues with
obstruction. He was thus discharged home with GU follow-up for
further management of his urinary retention and hematuria.
Likely hematuria due to trauma from foley but would consider
cystoscopy for further evaluation if it persists after foley
removed.
.
8) type II diabetes: well-controlled w/o complications. HgbA1C
6.9. RISS. Restarted glipizide prior to discharge.
.
9) Ventricular ectopy: K/Mg repleted, EF >50%
.
10) Anemia: HCT stable. Fe studies c/w Fe def. Patient was
discharged on an iron supplement and will need an outpatient
colonoscopy for evaluation.
.
11) DNR/DNI
.
12) Dispo: discharged home with services (home safety
evaluation, vitals check, medication assistance)
Medications on Admission:
Colace
Proscar 5mg HS
Florinef 0.1 mg daily
Glucotrol XL 5mg daily
Crestor 10mg daily
Toprol XL 25mg daily
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Glucotrol XL 5 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO once a day.
3. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day for 10 days: please use with spacer.
Disp:*1 inhaler* Refills:*0*
7. SPACER
PLEASE USE WITH COMBIVENT AND ALBUTEROL INHALERS
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing:
please use with spacer.
Disp:*1 inhaler* Refills:*0*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) for 10 days: please use with
spacer, please rinse your mouth out after use of this inhaler.
Disp:*1 inhaler* Refills:*0*
10. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: respiratory failure secondary to parainfluenza
tracheobronchitis
Secondary: left-sided congestive heart failure, acute renal
failure, hematuria, hypertension, iron deficiency anemia,
hematuria
Discharge Condition:
Stable - satting well on room air, afebrile
Discharge Instructions:
You were admitted with respiratory failure due to infection with
parainfluenza.
1) Please follow-up as indicated below.
2) Please take all medications as prescribed. Amlodipine has
been started and your toprol XL has been increased for your
blood pressure. You have also been started on an iron
supplement. This pill may cause some stomach upset so please
take this with food. It can also cause a black color to your
stool.
** You have already completed the 5 day course of antibiotic
(levofloxacin).
3) Please come to the emergency room or see your primary care
physician if you develop bleeding from your penis that does not
stop, abdominal pain or inability to urinate, shortness of
breath, chest pain, cough, fevers, chills, or other symptoms
that concern you.
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 72306**], on Tuesday, [**2188-4-8**] at 10:00 AM. Phone: ([**Telephone/Fax (1) 72307**] Location: [**Location (un) 72308**], [**Location (un) 3146**], [**Numeric Identifier 72309**]
Please follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 767**] urology on [**2188-4-21**] at
10:00 AM. Phone: ([**Telephone/Fax (1) 4376**] Location: [**Hospital1 18**], [**Hospital Ward Name **],
[**Hospital Ward Name 23**] building, [**Location (un) 470**]
|
[
"507.0",
"V15.82",
"V58.66",
"250.00",
"E849.7",
"487.1",
"599.7",
"518.81",
"584.9",
"280.9",
"V10.02",
"996.76",
"E935.3",
"414.01",
"600.00",
"427.69",
"E879.6",
"428.0",
"079.89",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11437, 11495
|
7243, 10044
|
247, 260
|
11741, 11787
|
2373, 7220
|
12602, 13215
|
2003, 2020
|
10202, 11414
|
11516, 11720
|
10070, 10179
|
11811, 12579
|
2035, 2354
|
188, 209
|
288, 1470
|
1492, 1802
|
1819, 1987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,633
| 137,457
|
34764
|
Discharge summary
|
report
|
Admission Date: [**2185-7-30**] Discharge Date: [**2185-8-5**]
Date of Birth: [**2132-3-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catherization with IABP insertion [**7-30**]
OPCABx5(LIMA->LAD, SVG->Diag, OM3, PDA, PLV) [**8-1**]
History of Present Illness:
53yo gentleman with h/o CAD s/p MI in [**2168**] (treated with POBA)
who presented with substernal chest pain and diaphoresis while
mowing the lawn around noon today. Pain felt "like heartburn."
No associated shortness of breath or nausea. He notes that his
pain is very similar to the MI he had in [**2168**]. He initially
presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where he was found to have ST elevations
in II, III, and aVF and transferred to [**Hospital1 18**]. He was given
plavix 600mg and ASA and started on integrillin and heparin gtt
prior to transfer. Upon arrival at [**Hospital1 18**], he was chest pain
free.
Past Medical History:
CAD s/p MI in [**2168**], treated with POBA per patient
HTN--per chart; patient denies elevated BP
Hyperlipidemia
Social History:
Social history is significant for the absence of current tobacco
use; he smoked from age 20 years x 1 PPD, stopped around age 40.
There is no history of alcohol abuse: he drinks 4-5 beers about
once a week.
Family History:
There is a strong family history of premature coronary artery
disease: his father died of an MI at age 39 and all of his
brothers have had MIs, usually in their 50s. +DM
Physical Exam:
VS: T 98.3, BP 127/72, HR 66, RR 24, O2 99% on 3L
Gen: Pleasant, overweight middle aged male in no distress, resp
or otherwise. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of [**5-24**] cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds with RR, normal S1, S2. No S4, no S3. No
murmurs.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. Femoral catheter in place with balloon pump.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated NSR with normal axis and intervals and < 1mm
STE with Q waves in III and aVF and Q waves in V1-V3 with poor R
wave progression and J point elevation in V3. Of note, his EKG
from 13:44 from [**Hospital1 **] showed STE in II, III, and aVF with
III>II and Q waves in III, V1-V4. He also had ST depresions in
I, aVL, V1-V2 and STE in V5-V6 at the time, now resolved.
CARDIAC CATH [**2185-7-30**]: 1. Selective coronary angiography in this
right dominant patient revealed severe three vessel CAD. The
LMCA had a 20% lesion. The LAD was occluded in mid portion with
collaterals coming from the RCA and LCX. The LAD gave rise to
one large diagonal which had moderate proximal disease. The LCX
had a long mid lesion to 80% at its tightest. The LCX have off 2
OM's. The RCA had a discrete mid 70% lesion and a 70% distal
with thrombus and a thrombotically occluded rPL that
reconstituted via collaterals. The rPDA had 80% ostial lesion.
2. Resting hemodynamics with BP 108/70 with HR 88 in sinus. The
LVEDP was elevated at 34mmHG. There was no gradient across the
aortic valve. 3. LV gram with EF 45% with no significant mitral
regurgitation. There was inferobasal hypokinesis. 4. IABP placed
and patient referred for surgery.
[**8-1**] Echo: 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. There is moderate symmetric left
ventricular hypertrophy. There is mild to moderate regional left
ventricular systolic dysfunction with hypokinetic inferior mid
papillary segments.. Overall left ventricular systolic function
is mildly depressed (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 appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the
results on Mr.[**Known lastname 79645**] at 1pm on [**2185-8-1**]. . IABP is placed 2 cm
below the left subclavian artery. Post OPCAB: Normal RV sytolic
function. Normal LV systolic function with mild hypokinesis of
the inferior at the base and apex. LVEF 55% Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **]R.IABP in the right place in the descending aorta.
[**2185-7-30**] 04:50PM BLOOD WBC-12.5* RBC-4.92 Hgb-15.6 Hct-46.9
MCV-96 MCH-31.8 MCHC-33.3 RDW-14.1 Plt Ct-175
[**2185-8-4**] 07:25AM BLOOD WBC-14.8* RBC-4.15* Hgb-13.4* Hct-39.1*
MCV-94 MCH-32.2* MCHC-34.2 RDW-13.6 Plt Ct-120*
[**2185-7-30**] 04:50PM BLOOD PT-13.7* PTT-49.7* INR(PT)-1.2*
[**2185-8-2**] 02:53AM BLOOD PT-12.9 PTT-28.8 INR(PT)-1.1
[**2185-7-30**] 04:50PM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-139
K-4.4 Cl-101 HCO3-26 AnGap-16
[**2185-8-4**] 07:25AM BLOOD Glucose-143* UreaN-25* Creat-0.9 Na-140
K-4.5 Cl-99 HCO3-31 AnGap-15
[**2185-8-3**] 12:07PM BLOOD ALT-50* AST-63* LD(LDH)-545* AlkPhos-62
Amylase-24 TotBili-0.8
Brief Hospital Course:
Mr. [**Known lastname 79645**] was transferred to [**Hospital1 18**] and upon admission
underwent a cardiac cath. Cath showed severe three vessel
coronary artery disease and a IABP was placed. Cardiac surgery
was consulted and he was appropriately underwent preoperative
workup. On [**8-1**] he was brought to the operating room where he
underwent a coronary artery bypass graft x 5. Please see
operative report for surgical details. He received vancomycin
perioperative because he was in the hospital prior to surgery.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. On post op day one he was
hemodynamically stable and the intra aortic balloon pump was
removed. Later he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
Also on post-op day one he had episode of rate controlled atrial
fibrillation which was appropriately treated with beta blockers.
He was started on diuretics and diuresised for his preoperative
weight. On post-op day two his chest tubes were removed and he
was transferred to the telemetry floor for further care.
Physical therapy worked with him for strength and mobility. He
continued to progress and was ready for discharge home with
services on post op day 4 in sinus rhythm.
Medications on Admission:
ASA 325mg daily, Metoprolol 50 [**Hospital1 **], Simvastatin 80mg daily,
Zetia 10mg daily, Glucosamine [**Hospital1 **], Vitamin E, Super B Complex
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p Off-Pump Coronary Artery Bypass
Graft x 5
STEMI
Post operative Atrial fibrillation
PMH: Hypertension, Hyperlipidemia, Myocardial Infarction [**2168**] w/
Angioplasty
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Do not use lotions, powders, or creams on wounds.
Call our office for temp.>101.5, sternal drainage.
Shower daily, let water flow over wounds, pat dry with a towel.
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) 9250**] for 1-2 weeks.
Dr. [**Last Name (STitle) 10543**] for 2-3 weeks.
Dr. [**First Name (STitle) **] for 4 weeks.
Wound check appointment - [**Hospital Ward Name 121**] 6, please schedule with RN
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2185-8-5**]
|
[
"305.20",
"V45.82",
"427.31",
"287.4",
"414.01",
"410.41",
"401.9",
"272.4",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"36.15",
"36.14",
"37.61",
"88.56",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8494, 8528
|
5787, 7086
|
330, 440
|
8766, 8772
|
2637, 5764
|
9172, 9555
|
1506, 1677
|
7284, 8471
|
8549, 8745
|
7112, 7261
|
8796, 9149
|
1692, 2618
|
280, 292
|
468, 1129
|
1151, 1266
|
1282, 1490
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
315
| 152,144
|
13173
|
Discharge summary
|
report
|
Admission Date: [**2177-4-24**] Discharge Date: [**2177-5-8**]
Date of Birth: [**2104-10-19**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 72-year-old white male is
status post CABG in [**2164**] and recently presented to his
physician with PND and wheezing. He has had these symptoms
for 2 weeks. This has been associated with increasing fatigue
and dyspnea on exertion. He also has had worsening pedal
edema which he says is chronic. He was seen by his physician
and then evaluated in the emergency room for CHF and treated
with Lasix. He ruled out for a myocardial infarction but had
BNP of 810. He had an echocardiogram which revealed an EF of
35%, moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], and mild AI, with distal septal
dyskinesis, and moderate hypokinesis in the inferior lateral
region. He is transferred for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for a history of
hypertension, coronary artery disease, status post CABG in
[**2164**] (with a saphenous vein graft to the RCA), and a history
of chronic lower extremity edema.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION: Propranolol 20 mg p.o. b.i.d.,
Adalat 30 mg p.o. daily, aspirin 81 mg p.o. daily, and
Combivent inhaler.
FAMILY HISTORY: Significant for coronary artery disease.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
drinks 3 beers a day and quit smoking 20 years ago.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: He is an elderly white
male in no apparent distress. Vital signs were stable,
afebrile. HEENT exam revealed normocephalic and atraumatic.
Extraocular movements were intact. The oropharynx was benign.
Neurologic exam was nonfocal. The neck was supple with full
range of motion. No lymphadenopathy or thyromegaly. The
carotids were 2+ and equal bilaterally without bruits. The
lungs had bibasilar rales. Cardiac exam was regular in rate
and rhythm with a 3/6 systolic murmur and a positive S4. The
pulses were 1+ bilaterally throughout.
HOSPITAL COURSE: He was admitted and underwent cardiac
catheterization which revealed an occluded RCA, 90% stenosis
of saphenous vein graft, a complex LAD lesion at the
bifurcation of 90%, and a 70% left circumflex lesion, with an
EF of 35%.
Dr. [**Last Name (STitle) **] was consulted. He had carotid studies which
revealed a less than 40% bilateral stenosis. He was diuresed.
On [**4-29**] he underwent a redo CABG x 1 with a Mosaic MVR.
He had a LIMA to the diagonal, and he had a 29-mm Mosaic MVR.
His vessels were intramyocardial, and his other vessels were
unable to be bypassed. He was transferred the CSICU on
Levophed, epinephrine, and propofol. On his postoperative
night he had some hypotension but then was more stable by the
morning. He was transfused a unit of blood. He remained
intubated the first day to stabilize his blood pressure. His
epinephrine was discontinued on postoperative day #2. His
Levophed was gradually weaned off. He was extubated on
postoperative day #2. He required aggressive diuresis and
pulmonary therapy. He continued to slowly progress.
DISCHARGE STATUS: He was transferred to the floor on
postoperative day #5. He had his wires discontinued on
postoperative day #6. He continued diuresis and physical
therapy. He was discharged to home in stable condition with
visiting nurse services and home physical therapy on
postoperative day #9.
LABORATORY DATA ON DISCHARGE: His laboratories on discharge
were white count of 10,400, a hematocrit of 27.3, platelets
of 409,000, 138, 5.1, 104, 26, 27, 1.0, and 133.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. b.i.d.
2. Lasix 80 mg p.o. b.i.d. for 1 week and then 80 mg p.o.
daily for another week.
3. Plavix 75 mg p.o. daily.
4. Multivitamin 1 p.o. daily.
5 Lipitor 10 mg p.o. daily.
1. Percocet 1 to 2 p.o. q.4-6h. as needed (for pain).
2. Aspirin 81 mg p.o. daily.
3. Protonix 40 mg p.o. daily.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Hyperlipidemia.
3. Coronary artery disease.
DISCHARGE FOLLOWUP: He will follow up with Dr. [**Last Name (STitle) **] in 4
weeks and with Dr. [**Last Name (STitle) 24717**] in 1 to 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2177-5-8**] 18:31:34
T: [**2177-5-8**] 19:02:15
Job#: [**Job Number 40178**]
|
[
"401.9",
"424.0",
"285.9",
"428.0",
"305.01",
"414.01",
"V45.81",
"272.0",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.60",
"99.04",
"37.23",
"35.23",
"99.07",
"88.53",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
1303, 1345
|
3997, 4063
|
3658, 3976
|
1180, 1286
|
2096, 3477
|
3492, 3632
|
1491, 1527
|
4084, 4475
|
165, 900
|
1542, 2078
|
923, 1153
|
1362, 1471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,565
| 123,845
|
32533
|
Discharge summary
|
report
|
Admission Date: [**2113-9-30**] Discharge Date: [**2113-10-3**]
Date of Birth: [**2075-10-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Repair of Ascending Aortic Dissection [**2113-10-2**]
Repair RT common iliac Artery,LT superficial femoral artery
[**2113-10-2**]
LT Leg fasciotomies [**2113-10-2**]
Exploratory laparotomy [**2113-10-3**]
History of Present Illness:
This is a 37 yom with history of HTN who presented to the ED
overnight with complaint of headache and worried that blood
pressure was too high so he came into the ED. Patient states he
was stressed at work today due to an argument with a supervisor.
He then began to feel a headache with a tense neck and came
into the ED. He denies any chest pain, shortness of breath,
syncope, lightheadedness, abdominal pain, nausea, vomiting, back
pain, hematuria, visual changes, focal weakeness or numbness.
Currently, stiff neck and posterior headache have resolved.
However, he now has a throbbing frontal headache which began
with initiation of NTG gtt.
In the ED: Temp 97.5, HR 92, BP 187/118, RR 18, 97% on RA.
Patient was given Labetolol 40mg IV x 1. He was then given
Labetolol 100mg PO x 1, labetolol 20mg IV x 1, Labetalol 40mg IV
x 1. Patient remained with BPs of 180s/110s and was then
started on Nitro gtt. He was initially sent to the medical
floor but was sent back to the ED as he was above the threshold
of 200mcg/hr of Nitro for the medical floor.
Past Medical History:
Hypertension
Social History:
Occupation: Chef on the [**Hospital Ward Name 516**] of [**Hospital1 18**]
Drugs: none
Tobacco: Current smoker, 20 pack year smoking history
Alcohol: None
Other:
Family History:
Hypertension
Physical Exam:
Tmax: 36 ??????C (96.8 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 73 (73 - 73) bpm
BP: 139/96(105) {139/96(105) - 139/96(105)} mmHg
RR: 13 (13 - 13) insp/min
SpO2: 96%
General Appearance: Well nourished, No acute distress,
Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal,
No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t)
Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: ,
No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)
Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , Obese
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): Person, Place and Time, Movement: Not
assessed, Tone: Normal
Brief Hospital Course:
This is a 37 year old Black male with history of hypertension
who presented to the ED with malignant hypertension and a
systolic BP of greater than 200 after an argument at work. He
was transferred to the MICU on nitro gtt.
Mr. [**Known lastname 75873**] presented to the ED with BP of 187/118. He was
given multiple doses of Labetolol IV and PO with minimal
response. He was then started on Nitro gtt and transferred to
the MICU for further care. Nitro gtt was weaned down on arrival
to the MICU. He was transferred to the medical floor after
weaning off nitro within three hours of transfer. At the time
of transfer off the MICU he was feeling well with no focal
neurological signs.
He developed chest and jaw pain and a CT demonstrated a Type A
Thoracic Aortic Dissection. He was taken emergently to the
operating room where a 24 mm Gelweave graft with Aortic Valve
resuspension was performed. He had 9 minutes of circulatory
arrest with 112 minutes of cardiopulmonary bypass and 69 minutes
of aortic cross clamp time.
In the CVICU cold legs were noted and he returned to the OR for
a fenestration procedure. Repair of his LEFT common iliac artery
and a patch angioplasty of the right superficial femoral artery
were performed. Left leg fasciotomies were then performed.
Dr. [**Last Name (STitle) **] remained in contact with the family.
Postop he remained hypotensive on multiple pressors at high
doses. His acidosis persisted and anuria ensued. CVVH was begun
with boluses of sodium and acidosis. Oxygenation became a
problem and despite all maneuvers his condition continued to
deteriorate.
Due to elevated bladder pressure and rising lactates (15), an
exploratory laparotomy was performed to rule out dead gut. This
was negative. He remained critically ill and despite all
efforts he developed PEA. CPR with multiple defibrillations
were performed. In view of all of the fore mentioned issue and
no return of a pulse, resuscitative efforts were discontinued
and he was pronounced at 1518 hours.
Medications on Admission:
Toprol
Zestril
Norvasc
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Type A Thoracic Aortic Dissection
Malignant Hypertension
Obesity
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
none
Completed by:[**2113-10-3**]
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59,382
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39805
|
Discharge summary
|
report
|
Admission Date: [**2128-10-5**] Discharge Date: [**2128-11-2**]
Date of Birth: [**2058-9-6**] Sex: F
Service: MEDICINE
Allergies:
Zofran
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Pelvic Mass
Major Surgical or Invasive Procedure:
Exploratory laparotomy via vertical midline incision, total
abdominal hysterectomy, bilateral salpingo-oophorectomy,
rectosigmoid resection with end colostomy,ileocecectomy with
primary side-to-side functional end-to-endanastomosis, pelvic
washout, placement of bilateral ureteral stents and closure of
post-operative wound
History of Present Illness:
Ms. [**Known lastname **] is a 70 yo gravida 3 para 3 who initially presented
to [**Hospital1 **] ED on [**9-3**] with tachycardia. She was given 3
units PRBCs for a HR in the
130s. Her hematocrit was then stable and she was discharged
home on [**9-5**] with PCP [**Last Name (NamePattern4) 702**].
As an out-patient she had a CT scan which revealed a pelvic mass
likely originating from her uterus and extending above her
umbilicus. The scan also suggested fistula with the bowel,
right hydronephrosis, and question of invasion of the IVC.
On review of symptoms, she denies fevers, night sweats, chest
pain, palpitations, dysuria, hematuria, vaginal bleeding. She
has lost 20 pounds over the last year which she states was
intentional. She notes some shortness of breath with
ambulation.
Past Medical History:
POBHx:
SVD x 3 ([**2086**], [**2088**], [**2094**]) no complications
PGYNHx: Menopause in her early 50s prior to which she had
regular periods. No hormone therapy. No history of abnormal
Paps, STIs.
PMH: Anemia, asthma as a child
PSH: Denies
Health maintainence: Generally does not seek medical care. Her
last Pap was 20+ years ago. She has never had a mammogram or
colonoscopy.
Social History:
Denies tobacco, alcohol, drugs. Denies DV. Lives with husband.
Retired teacher.
Family History:
Negative for breast, ovarian, colon, or uterine cancer.
Physical Exam:
VS: 98.4 127/74 119 20 100%RA (sitting)
96/67 138 100%RA (standing)
Gen: Pale, NAD, no diaphoresis
Card: Regular rhythm. Tachycardiac. Normal S1, S2. No obvious
murmurs
Resp: Clear lungs bilaterally
Abd: Soft, NT, ND. Firm fixed mass palpated [**1-31**] fingerbreaths
above umbilicus. +BS
Bimanual: Large fixed AV uterus palpated above umbilicus. No
clear adnexal masses palpated.
Rectal: Guaiac positive in office this am.
Ext: NT, no edema. 2+ PT pulses bilaterally.
Pertinent Results:
[**2128-10-29**] 05:08AM BLOOD WBC-4.4 RBC-2.71* Hgb-8.2* Hct-25.8*
MCV-95 MCH-30.4 MCHC-32.0 RDW-16.8* Plt Ct-424
[**2128-10-29**] 05:08AM BLOOD Plt Ct-424
[**2128-10-29**] 05:08AM BLOOD PT-14.2* INR(PT)-1.2*
[**2128-10-29**] 05:08AM BLOOD
[**2128-10-29**] 05:08AM BLOOD Glucose-99 UreaN-31* Creat-0.8 Na-135
K-4.1 Cl-102 HCO3-22 AnGap-15
[**2128-10-26**] 07:17AM BLOOD CK(CPK)-12*
[**2128-10-26**] 12:28AM BLOOD CK(CPK)-16*
[**2128-10-26**] 12:08PM BLOOD CK-MB-2 cTropnT-0.03*
[**2128-10-26**] 07:17AM BLOOD CK-MB-2 cTropnT-0.03*
[**10-28**] CXR: AP single view of the chest has been obtained with
patient in
sitting semi-upright position. Comparison is made with a similar
preceding
examination obtained the day before ([**2128-10-27**]). In
comparison with the previous study, the patient was now able to
perform a deeper inspiration. The pulmonary vasculature is
better accessible and shows considerable perivascular haze most
marked in the lung bases. Complete obliteration of the left
diaphragmatic contour is suggestive of atelectasis in the
retrocardiac space. There is no evidence of new discrete
pulmonary parenchymal infiltrates in comparison with the next
preceding study. Review is also extended to the portable chest
examination of [**2128-10-26**]. At that time, the congestive
pattern in the lungs was also present but less marked. Analysis
of the three examinations in sequence suggests further
deterioration of CHF between [**10-26**] and 29, but now some
improvement during the latest interval [**10-27**] through 30.
Observe that on today's examination, the ultimate left lateral
lower chest wall is not included in the image field.
This, however, does not affect the diagnostic statements
rendered here.
[**10-26**] ECHO: The left atrium and right atrium are normal in cavity
size. The right atrial pressure is indeterminate. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the distal half of the left ventricle.
Basal segments contract well (LVEF = 35 %). The estimated
cardiac index is normal (>=2.5L/min/m2). No masses or thrombi
are seen in the left ventricle. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size is normal. with focal mild
hypokinesis of the apical free wall. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2128-10-1**],
left and right ventricular systolic dysfunction are new
(?Takotsubo or multivessel CAD) and moderate pulmonary artery
systolic hypertension are now seen.
.
Most recent CXR [**11-1**]:
HISTORY: PICC placement.
FINDINGS: In comparison with study of [**10-29**], the tip of the right
subclavian PICC line is in the region of the cavoatrial
junction. Continued opacification at the left base is consistent
with pleural effusion and volume loss in the left lower lobe.
There has been substantial decrease in the pulmonary vascular
congestion
described on the previous study. Mild enlargement of the cardiac
silhouette persists. \
.
MICROBIOLOGY:
All culture date, in [**2128-9-29**], including urine, blood,
RPR, Cdiff, were all negative.
.
Discharge labs:
[**2128-11-2**] 06:45AM BLOOD WBC-2.1* RBC-2.47* Hgb-7.7* Hct-23.3*
MCV-94 MCH-31.1 MCHC-33.0 RDW-16.6* Plt Ct-316
[**2128-11-2**] 06:45AM BLOOD PT-14.7* INR(PT)-1.3*
[**2128-11-2**] 06:45AM BLOOD Glucose-92 UreaN-37* Creat-0.8 Na-136
K-4.9 Cl-103 HCO3-26 AnGap-12
[**2128-11-2**] 06:45AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
.
INR trend:
Hovering at 1.3 for past 3 days. Coumadin 3 mg given 5 mg on
[**10-28**], then 3 mg [**10-29**], [**10-30**], [**10-31**], then 5 mg on [**11-1**].
Brief Hospital Course:
70 yo G3P3 s/p cystoscopy with ureteral stenting (by urology),
TAH-BSO, sigmoid resection, ileal resection, ileocecal
reanastomosis, sigmoid colostomy and IUD removal for uterine
malignancy with fistula to sigmoid and possibly to ileum on
[**10-5**]. Intraoperatively the estimated blood loss was 3000cc's.
She received 7units of packed red blood cells and 4 units of
FFP. Please see operative note for details. Postoperatively
recovered in [**Hospital Unit Name 153**] until [**10-12**] after which time she was
transferred to the postoperative floor. Her incision was closed
on [**10-21**]. She received first dose of chemotherapy (Taxol/[**Doctor Last Name **])
on [**10-26**] hours post chemo had cardiac arrest, code called,
shocked and subsequently stable, transferred back to [**Hospital Unit Name 153**] for
monitoring and evaluation. On [**10-29**] she was transferred out of
the [**Hospital Unit Name 153**] to the medicine floor.
.
Brief course as follows:
70yo woman without PMH until she was found to have a pelvic mass
in [**Month (only) 216**], ultimately diagnosed with originally advanced uterine
malignancy with enterouterine and colouterine fistula, and fecal
pelvic abscess. She was admitted on [**10-5**] to the GYN-ONC service
for planned debulking. She underwent exploratory laparotomy with
total abdominal hysterectomy, bilateral salpingo-oophorectomy,
rectosigmoid resection with end colostomy, ileocecectomy with
primary side-to-side functional end-to-end anastomosis, pelvic
washout, and placement of bilateral ureteral stents. She was
managed in the SICU post-op, where she had pressor-dependent
hypotension and required mechanical ventilation. She was covered
empirically with vancomycin, metronidazole, and cefepime for a
total of 14 days. Pressors were stopped on [**10-8**] and the patient
was extubated on [**2128-10-11**]. ID was consulted once she was on the
floor for fever and altered mental status, and no new source of
infection was found. Mental status returned to [**Location 213**]. She
clinically improved, received her first dose of chemotherapy
(cisplatin-taxol) on [**10-26**], and discharge was planned later that
day.
.
On [**10-26**] she unexpectedly had PEA arrest (?torsades), from which
she was quickly resuscitated then transferred to [**Hospital Unit Name 153**]. She was
hypomagnesemic and hypokalemic, and she had received a dose of
Zofran one hour prior to the event. Cardiology was consulted.
TTE showed new Takotsubo's syndrome (severe hypokinesis of the
distal half of the left ventricle). She was treated with
amiodarone gtt and lopressor, and the former was discontinued
later on [**10-26**]. She has been hemodynamically stable with mild
tachycardia, for which [**Hospital Unit Name 153**] team is titrating lopressor. She was
also started on anticoagulation with enoxaparin given apical
hypokinesis, and warfarin was started on [**10-28**]. She has become
markedly volume overloaded secondary to aggressive
resuscitation, but she has been diuresing well for a few days.
She also had a couple of episodes of NSVT on [**10-28**], asymptomatic
with BP stable, thought to be due to PICC placement, so it was
repositioned. There was a question of nosocomial pneumonia since
her cardiac arrest, for which she was started on vancomycin,
cefepime, and flagyl on [**10-27**]. She has stable anemia of chronic
disease. She has been on TPN since surgery but is also taking
po. GYN-ONC is following closely & planning more chemo in one
month. She was transferred to the Hospital Medicine Service on
[**10-29**] for further management.
.
By problem:
*) Torsades/VTach arrest: On [**10-26**] a code was called for several
episodes of unresponsiveness. When the code team arrived the
patient went into a wide complex tachycardia. In retrospect,
this may have represented polymorphic VT, but was interpreted as
VFIB. A single shock was given with return of her pulse and
sinus rhythm with some ectopy was noted. At this time 150mg of
amiodarone was given and amiodarone drip was started. A 12 lead
EKG showed no acute ischemic changes, but did show a prolonged
QTc.
EP was consulted and believe arrest was due to sympathetic
combined with vagal tone, possibly exacerbated by long QT. An
Echo was done and was concerning for Takusobos cardiomyopathy.
Electrolytes were checked regularly and repleted. Serial EKGs
were done to monitor QT. Patient was started on metoprolol 12.5
mg tid which was increased to 50 [**Hospital1 **]. She was started on
Lovenox for anticoagulation for the takusobus and was switched
to Coumadin. She had several runs of non-sustained Vtach and
was found to have a deep position of the PICC which was pulled
back. She will need cardiology follow-up on discharge. She has
ECHO scheduled for next week to assess cardiac function pre
consideration of further chemotherapy. She had intermittent
ectopy on [**11-1**], but resolved with repletion of her K and Mg.
.
*) Acute systolic CHF: On [**10-27**] the patient complained of
wheezing sensation and had bibasilar crackles on exam, with O2
sats down to 91% on RA. This was in the setting of new beta
blockade and could represent an exacerbation of her mild
reactive airway disease. A CXR concerning for volume overload vs
possible PNA. She was started on antibiotics with plan to
continue for 7 days. She was diuresed with lasix and received 1
nebulizer treatment and her symptoms improved significantly.
.
*) Postoperative course: Mrs [**Known lastname **] recovered slowly from her
surgery. She was intubated in the ICU post-operatively until
[**10-11**]. Ms [**Known lastname **] had a wound vac placed. Her incision was then
closed in the OR [**10-21**] with Prolene and staples. The Prolene and
staples were removed [**10-29**]. Her ostomy started functioning 4
days after surgery. Ostomy RNs have been following and teaching
the patient ostomy care.
.
*) Advanced uterine cancer: pathology was consistent with grade
3 stage IVB endometriod endometrial CA. She received 1 round of
chemotherapy with [**Doctor Last Name **]/Taxol [**10-25**]. The patient and her family
will decide whether to undergo further chemotherapy.
.
*) acute delirium, post operatively: She was intermittently
hypotensive to the 60s/40s intraoperatively and required
pressors post-operatively for 24 hours. On extubation she was
minimally responsive and a head CT was done which showed no
acute intracranial process. Her mental status then improved off
midazolam. On [**10-13**] she had an episode of altered mental status
in which she was alert and appropriate but non-verbal. She had a
head MRI which was negative. Her mental status returned to
baseline slowly over a 3 day time period. She had a full workup
and no infectious, iatrogenic, or metabolic abnormalities were
identified.
.
*) Presumed intraabdominal infection. During her previous
hospitalization she was treated for strep-pneumo bacteremia with
IV ceftriaxone daily. This was continued until her surgery.
Postoperatively she received Vanc/Cefepime/Flagyl for 14 days
given the contamination intra-operatively. Post-operatively all
blood and urine cultures were negative.
.
*) Ureteral obstruction: A stent was placed in the right ureter
due to hydronephrosis and compression by tumor. Her Creatinine
trended up postoperatively to a max of 1.5 and then trended back
to her baseline of 0.8-0.9. In the ICU she initially required a
lasix drip for 24 hours due to total body anasarca. She received
several additional doses of IV lasix throughout her
hospitalization.
.
*) Moderate malnutrition: TPN was started [**10-6**]. She was
tolerating a regular diet as of [**10-18**] but have very poor intake.
TPN was weaned beginning [**10-28**] to encourage more PO intake.
.
*) Anemia, leukopenia related to chemotherapy, malignancy,
chronic disease. She has stable anemia, with Hct of 23.3. If
her Hct remains low, or drops further, she could be transfused,
with diuresis given recent systolic CHF. She had no evidence of
active blood loss.
.
Key follow up:
1. Cardiac - will need ECHO next week, and cardiology follow up
in [**Month (only) **]. Duration of anticoagulation to be determined based
on improvement in hypokinesis.
2. Oncology - she is scheduled for follow up with her oncologist
on [**11-12**], and with her surgeon on [**11-15**]. Further chemotherapy
will be determined based on improvement in cardiac function and
overall functional status.
3. Nutrition - she is on TPN. Lytes should be checked daily
with goal of K > 4, Mg > 2. TPN should be discontinued with
adequate oral intake to permit discharge home.
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 12 days.
Disp:*24 grams* Refills:*0*
4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for pain.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
5. Magnesium Citrate Solution Sig: One (1) bottle PO once
for 1 doses.
Discharge Medications:
1. Hair Prosthesis
Hair prosthesis for chemotherapy-induced alopecia
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) units
Subcutaneous Q12H (every 12 hours).
4. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. TPN
Per attached sheet.
9. Outpatient Lab Work
Daily CMP, CBC
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
grade 3 stage IVB endometriod endometrial Cancer
Takotsubo cardiomyopathy and prolonged QT syndrome
cardiac arrest
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted for elective exploratory laparotomy with total
abdominal hysterectomy, bilateral salpingo-oophorectomy,
rectosigmoid resection with end colostomy, ileocecectomy, pelvic
washout, and placement of bilateral ureteral stents. You were
managed in the surgical ICU post-op, where you required
mechanical ventilation. You were treated with vancomycin,
metronidazole, and cefepime for a total of 14 days for
intra-abdominal infection. You were taken off the ventilator on
[**2128-10-11**]. The Infectious Disease consult team followed you
closely once you were transferred to the floor on the GYN-ONC
service, where you were having fevers. No new source of
infection was found. Your mental status returned to [**Location 213**]. You
clinically improved, received your first dose of chemotherapy
(cisplatin-taxol) on [**10-26**], and discharge was planned later that
day.
.
On [**10-26**] you unexpectedly had cardiac arrest, from which you were
quickly resuscitated then transferred to the medical ICU. Your
magnesium and potassium were low, and as you received a dose of
Zofran one hour prior to the event, that medication may have
caused your cardiac arrest. We have added Zofran to your list of
allergies to be safe. Cardiology was consulted. Echocardiogram
(ultrasound of your heart) showed new congestive heart failure,
likely secondary to the cardiac arrest. You have been treated
with medications to help your heart and prevent formation of
blood clots, and you were given medicine to help remove the
fluid that accumulated in your body after aggressive
resuscitative efforts. You remained stable and were transferred
to the Hospital Medicine Service on [**10-29**] for further management.
You were continued on TPN while your oral intake gradually
increased, and Physical Therapy worked with you to help you walk
and regain strength. Overall, you did remarkably well.
.
Instructions:
-You should not drive for 2 weeks and while taking narcotic pain
medications
-No intercourse, tampons, or douching for 6 weeks
-No heavy lifting or vigorous activity for 6 weeks
-You can shower and clean your wound, but do not use perfumed
soaps or lotions. Be sure to pat completely dry after washing.
.
Key follow up:
ECHO [**11-11**] 10:00 AM
Daily labs, Mg > 2, K > 4
TPN until taking adequate pos
Oncology follow up on [**11-12**]
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2128-11-11**] at 10:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2128-11-12**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GYN SPECIALTY
When: MONDAY [**2128-11-15**] at 4:30 PM
With: [**Name6 (MD) 35354**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5777**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**12-13**] at 8:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"591",
"614.3",
"112.0",
"276.50",
"429.83",
"619.1",
"507.0",
"276.8",
"263.0",
"197.5",
"276.2",
"428.0",
"593.4",
"182.0",
"275.2",
"285.22",
"197.4",
"458.29",
"427.1",
"428.21",
"285.1",
"518.81",
"276.3",
"427.5",
"348.31",
"788.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"65.61",
"96.72",
"99.25",
"59.8",
"99.15",
"48.69",
"54.62",
"68.49",
"45.73",
"46.10",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
16497, 16563
|
6602, 14624
|
278, 604
|
16721, 16814
|
2540, 6077
|
19242, 20367
|
1959, 2017
|
15810, 16474
|
16584, 16700
|
15233, 15787
|
16877, 19089
|
6093, 6579
|
2032, 2521
|
19100, 19219
|
227, 240
|
632, 1430
|
16829, 16851
|
1452, 1843
|
1859, 1943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,897
| 165,777
|
43023
|
Discharge summary
|
report
|
Admission Date: [**2197-3-23**] Discharge Date: [**2197-3-29**]
Date of Birth: [**2159-4-25**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 37-year-old woman who
was struck by a car while she was walking across the street
and was thrown approximately 15-20 feet. There was positive
loss of consciousness. The patient is amnestic to the event
of the accident and recalls that she was returning from her
therapist appointment at the time that this happened. On
admission, she was complaining of left hip pain and left
shoulder pain.
PAST MEDICAL HISTORY:
1. Arthritis in the knees.
2. Anxiety.
ALLERGIES: Sulfa and [**Doctor Last Name **] II inhibitors.
MEDICATIONS: The patient takes non-steroidal anti-
inflammatory drugs as needed for arthritic pain.
SOCIAL HISTORY: The patient lives alone. She denies tobacco
use. She socially drinks alcohol. She is not a smoker. She is
currently unemployed. She used to work as an office manager.
REVIEW OF SYMPTOMS: The patient states that she has had
approximately one week of burning sensation in her bilateral
lower extremities worse in the distal portions of her legs,
specifically in her feet, and a heaviness to her walking. She
denies any specific weakness or other neurological problems,
specifically no visual changes, no dysphagia, no speech
changes, no bowel or bladder incontinence. The burning
sensation started approximately one week prior to her
accident.
PHYSICAL EXAMINATION: VITAL SIGNS: Rectal temperature of
101.1, heart rate 117, blood pressure 113/91, respiratory
rate of 18 and saturation of 99% on room air.
GENERAL: This is a woman who is alert and oriented times
three who is extremely excitable, talking nonstop and seemed
quite anxious. She had a GCS of 14, being somewhat confused
immediately following the accident.
HEENT: Superficial lacerations over the occiput with some
blood. She was in a C-spine collar and had no tenderness in
the C-spine area. Pupils equal, round and reactive to light.
She had full extraocular movement with a midline trachea. Her
tympanic membranes were clear bilaterally.
CARDIAC: She was tachycardiac, but there was no murmur.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nondistended and nontender.
EXTREMITIES: Her pelvis was stable to palpation, however,
there was tenderness to palpation over the left hip. She had
two plus femoral pulses bilaterally. She had two plus
dorsalis pedis pulses bilaterally. She was able to move all
extremities well though she did complain of tenderness to
palpation of the left knee and left shoulder. She also had a
right elbow abrasion with ecchymoses.
RECTAL: Guaiac negative with normal tone.
SPINE: There were no step-offs or deformities of her
thoracic or lumbosacral spine and no tenderness on palpation.
LABORATORY DATA: She had a white blood cell count of 9.6,
hematocrit 42.8, platelets 329. Her Chem-7 was unremarkable.
She had an amylase of 75. Her urinalysis was negative. She
had a negative urine HCG. She had a negative urine toxicity
screen. Her serum toxicity screen had a Tylenol level of six
and otherwise was negative. Specific labs that were sent for
evaluation included a B-12 which was normal, folate which was
normal, a TSH which was elevated at 5.5, an RPR which was
negative and an SPEP which is pending at the time of this
discharge.
RADIOLOGY: The patient had a chest x-ray which showed a left
clavicular fracture. A pelvic x-ray showed a left inferior
and superior rami fracture. A CT of the head showed small
right tentorium subdural hematoma. A CT of the C-spine was
negative. A CT of the abdomen was negative. A CT of the
pelvis with thin cuts showed a nondisplaced buckle fracture
of the left sacral ala not seen on previous x-rays. It showed
a mild comminuted fracture of the left superior pubic ramus
and a nondisplaced fracture of the left inferior pubic ramus.
A left shoulder film confirmed the clavicular fracture. A
right elbow film was negative. A TLS film was negative. A CT
of the chest, abdomen and pelvis showed small amounts of free
fluid in the pelvis and fractures previously described,
otherwise negative.
HOSPITAL COURSE: With the diagnosis of a subdural hematoma,
the patient was transferred to the Intensive Care Unit for
close neurological monitoring. Neurosurgery was consulted.
While in the Intensive Care Unit, the patient's blood
pressure was tightly maintained. She had strict glycemic
control and had Q1 neurology checks. A repeat of the head CT
showed an unchanged subdural hematoma in the morning. The
patient had no neurological deficits and a stable hematocrit.
She was transferred to the floor the following day. She
remained neurologically intact throughout her week stay at
the hospital and no further intervention was made. She is to
follow-up with Neurosurgery in two weeks post discharge for a
repeat head CT.
The patient had a significant hematocrit drop during the
first twenty-four hours of her stay from 42 to 27. Part of
this is thought to be dilutional given the large amount of
fluids that she received. However, she did receive a repeat
head CT and a repeat chest, abdomen and pelvis CT which
showed a small amount of free fluid in the pelvis. She was
transfused two units of packed red blood cells and two units
of plasma. Serial hematocrit checks were followed, which were
stable and she was discharged with a hematocrit of 38.8.
An Orthopedic consult was obtained to evaluate the patient's
pelvic fractures, as well as her clavicle fracture. It was
determined that all of the above were nonoperative. A sling
was recommended for the left upper extremity. She is to be
nonweightbearing on the left upper extremity. However, she
can have full range of motion. She was instructed to
weightbear as tolerated to the bilateral lower extremities.
Physical Therapy saw the patient daily to aid her in this
process. Recovering her independent mobility was the main
reason for the patient's prolonged hospital stay as the
patient had a slow progression of improvement. On the day of
discharge, the patient is able to ambulate independently
using a cane. She was able to walk around the nurse's floor
on her own. She is able to ambulate to and from the bathroom
on her own. She will return to her apartment where she lives
where it has been arranged to have friends stay with her for
the first twenty-four hours. She will follow-up with
Orthopedics in two weeks.
Although the original CT films of the C-spine were negative,
the patient did have some neck tenderness. It was unclear
whether this originated from the neck or was referred pain
from the left clavicular fracture. Therefore, a magnetic
resonance imaging scan of the C-spine was obtained. This was
negative and the patient's C-spine was cleared.
A vague report was made to EMS by bystanders that perhaps the
accident was intentional as bystanders thought they saw her
intentionally walk out into the street. Although the
indication was somewhat vague, a Psychiatry consult was
obtained. Psychiatry did not feel that this incident was a
suicide attempt and did not feel that Ms. [**Known lastname 951**] was actively
suicidal or depressed. However, they did document a fair
amount of anxiety and felt that she would benefit from
neuropsychiatric testing in [**4-25**] weeks following discharge.
As the patient indicated that she had a week's symptoms of
bilateral lower extremity tingling and burning, a Neurology
consult was obtained. Neurology documented a normal
neurological examination and suggested routine surveillance
labs. It was found that her TSH was slightly elevated at 5.5.
This information was conveyed to both the patient and her
primary care physician who will follow this up as an
outpatient.
DISCHARGE: The patient will be discharged to home in good
condition. She is alert and oriented times three, eating a
regular diet and she is able to ambulate on her own with a
cane. She should continue to wear a sling on her left arm and
be nonweightbearing on the left upper extremity until further
seen by Orthopedics. She may continued to weightbear as
tolerated on the legs, and in fact, physical activity is
encouraged. She should use the cane to walk as instructed by
the physical therapist. Of note, she was seen by the
occupational therapist to help her manage her daily tasks.
DIAGNOSES:
1. Stable small subdural hematoma.
2. Pelvic fractures; left superior and inferior pubic rami
fractures, sacral ala fracture.
3. Left clavicular fracture.
4. Bilateral feet paresthesias, unknown etiology.
5. Elevated TSH of 5.5.
FOLLOW UP:
1. The patient has a scheduled appointment with her primary
care doctor, Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 45347**]. Dr. [**Last Name (STitle) **] is based
out of [**Hospital 8**] Hospital's Primary Care Office. With the
patient's permission, a copy of her Discharge Summary will
be faxed to Dr. [**Last Name (STitle) **]. The patient should follow-up with
her primary care physicians tomorrow.
2. The patient should follow-up with Dr. [**Last Name (STitle) 1132**] of
Neurosurgery in two weeks at [**Telephone/Fax (1) 1669**]. She will need a
head CT prior to this appointment and may call the above
number to arrange this.
3. Ms. [**Known lastname 951**] should make an appointment with Dr. [**First Name (STitle) **] in two
weeks, phone number [**Telephone/Fax (1) 1113**].
4. Neuropsychiatric evaluation can be arranged by calling [**Telephone/Fax (1) 92835**]. This can occur in [**4-25**] weeks.
5. Neurology. The follow-up for Neurology is pending at the
time of this dictation.
6. There is no scheduled appointment in the Trauma Clinic.
However, if the patient should have questions or concerns,
she may call [**Telephone/Fax (1) 274**] for an appointment.
DISCHARGE MEDICATIONS:
1. Vicodin 1-2 tablets q 4-6 hours as needed, dispense forty.
2. Colace 100 mg b.i.d., dispense sixty.
3. Ativan 0.5 mg one tablet every six hours p.r.n., dispense
twenty.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 53871**]
Dictated By:[**Last Name (NamePattern1) 41037**]
MEDQUIST36
D: [**2197-3-29**] 12:11:11
T: [**2197-3-29**] 13:04:13
Job#: [**Job Number 92836**]
|
[
"300.01",
"808.2",
"E849.5",
"724.3",
"852.22",
"E814.7",
"810.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9843, 10289
|
4180, 8586
|
8597, 9820
|
1479, 4162
|
165, 567
|
589, 794
|
811, 1456
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,714
| 112,183
|
31730
|
Discharge summary
|
report
|
Admission Date: [**2170-11-1**] Discharge Date: [**2170-11-3**]
Date of Birth: [**2096-8-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 yo M PMH hemorrhagic stroke [**2167**] presents as CODE STROKE.
Called at 11:30pm at bedside within seconds. Last seen well @
6:30pm. Onset of symptoms unknown.
History provided by ED resident as wife not present. Wife last
saw patient well @6:30pm this evening when he went upstairs to
go to the bathroom. She became concerned when he seemed to take
longer than usual so went upstairs to find him lying on the
floor in BR blocking the door. He was unresponsive but
breathing on his own. She called 911, EMS found him without
respiratory
distress but comatose and took him to OSH. At OSH, noted not to
be moving R side of body. Wet read of Head CT showed old R PCA
infarct, no change from prior [**2170-3-30**] and no acute process and of
CT C-spine showed no fx, extensive
degenerative changes. Found to be in atrial fibrillation HR 105
with signs acute ischemia which was thought to be new. He was
intubated due to altered mental status (w/etomidate 10mg and
succinylcholine 100mg), given propofol after intubation and
transferred to [**Hospital1 18**] for neuro eval. (Also, OSH ED note
mentioned Versed 2mg IV and Dopamine for pressor support). No
IV TPA given h/o hemorrhagic stroke.
At [**Hospital1 18**] ED, 99.5 128/74 74 18 100 vent. Head CT performed
at showed dense left MCA sign with early loss of insular
ribboning, loss of [**Doctor Last Name 352**]-white differentiation and
hypoattentuation of the basal ganglia. [**Name (NI) **] PT 10, Cr 3.1 and
FS 166.
ROS: unable
Past Medical History:
- CAD, h/o MI, prior CABG multivessel
- HTN
- Hyperlipid
- Gout
- Partial nephrectomy for benign renal CA (BUN 37 Cr 1.8 in
[**4-4**])
- Prior strokes
Social History:
Lives with wife
Family History:
non-contributory
Physical Exam:
99.5 128/74 74 18 100 vent
Gen: Lying in bed, mildly agitated off propofol
HEENT: NC/AT, moist oral mucosa, intubated
Neck: supple, no carotid or vertebral bruit
CV: irreg irreg, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Spontaneously opening eyes and grimacing. Not
cooperative with exam, does not regard or follow commands.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Resists passive eye opening with conjugate left
eye deviation but able to cross midline with oculocephalic
movements. Grimaces to nasal tickle without obvious asymmetry
but difficult to assess with ETT tube in place. Positive yawn.
Motor/Sensory:
Normal bulk bilaterally. Mildly increased tone on the right.
No observed myoclonus or tremor. Localizes and very purposeful
with left hand, withdraws in legs symmetrically. Right arm
extends to noxious stim.
Reflexes:
+2 brisk symmetric throughout. Right toe upgoing, left down.
Coordination/Gait/Romberg: deferred
Pertinent Results:
[**2170-10-31**] 11:25PM BLOOD WBC-13.1* RBC-4.09* Hgb-13.5* Hct-40.6
MCV-99* MCH-33.0* MCHC-33.2 RDW-13.4 Plt Ct-345
[**2170-11-1**] 03:00AM BLOOD WBC-11.5* RBC-3.67* Hgb-12.1* Hct-36.6*
MCV-100* MCH-33.0* MCHC-33.1 RDW-13.5 Plt Ct-302
[**2170-11-2**] 03:05AM BLOOD WBC-9.4 RBC-3.41* Hgb-11.5* Hct-33.3*
MCV-98 MCH-33.6* MCHC-34.4 RDW-13.6 Plt Ct-276
[**2170-10-31**] 11:25PM BLOOD PT-11.9 PTT-24.5 INR(PT)-1.0
[**2170-10-31**] 11:25PM BLOOD Glucose-122* UreaN-46* Creat-2.4* Na-143
K-4.0 Cl-105 HCO3-26 AnGap-16
[**2170-11-1**] 03:00AM BLOOD Glucose-129* UreaN-46* Creat-2.2* Na-144
K-4.0 Cl-109* HCO3-24 AnGap-15
[**2170-11-2**] 03:05AM BLOOD Glucose-95 UreaN-30* Creat-1.7* Na-140
K-5.0 Cl-110* HCO3-23 AnGap-12
[**2170-10-31**] 11:25PM BLOOD ALT-16 AST-17 CK(CPK)-85 TotBili-0.6
[**2170-10-31**] 11:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-11-1**] 08:57AM BLOOD CK-MB-5 cTropnT-<0.01
[**2170-11-1**] 04:54PM BLOOD CK-MB-4 cTropnT-<0.01
[**2170-11-2**] 03:05AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3
[**2170-10-31**] 11:25PM BLOOD TSH-2.7
[**2170-10-31**] 11:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Head CT ([**10-31**]): Dense left MCA and loss of [**Doctor Last Name 352**]-white matter
differentiation in the left MCA territory consistent with acute
stroke of the left MCA territory.
MRA [**11-1**]: Partial occlusion of the supraclinoid left internal
carotid artery with slow flow in the left middle cerebral
artery. Non-visualization of distal right vertebral artery.
Carotid Dopplers [**11-1**]:
There is a less than 40% right ICA stenosis and less than 40%
left ICA stenosis with nonvisualized right vertebral artery and
antegrade flow in the left vertebral artery.
Renal US: No hydronephrosis
Brief Hospital Course:
Mr. [**Known lastname 74524**] was admitted to the ICU for closer monitoring and
evaluation. His hospital course by problem is as follows:
Neuro: L MCA infarct
Given the finding on OSH EKG of new atrial fibrillation,
cardiac source of emboli more likely than artery-artery emboli.
Patient has a history of intracranial hemorrhage and presented
in ARF. As a result, he was considered not a candidate for IV/IA
TPA or clot retrieval. The following day, his PCP was [**Name (NI) 653**]
and his history was reviewed. Per these records he had prior
infarcts but no history of hemorrhage. He had no history of afib
in the past, however had been work-up and found to have an
elevated anticardiolipin antibody. When this had been found, he
was evaluated for anticoagulation but the decision was made not
to start coumadin.
In the ICU, he remained unresponsive. He was continued on ASA
325mg QD and his Lipitor was increased from 10 to 40. His LDL
was 99. He remained in afib but given the size of the infarct he
was not a candidate for anticoagulation given the high risk for
spontaneous bleeding. He remained in afib but without
tachycardia. His BP was allowed to autoregulate and lopressor
was used PRN for SBP>200. He was rulled out for MI with CE. He
was gradually restarted on his home regimen of felodine 10 QD
and atenolol 25 QD. His Cr improved with gentle IVF
resuscitation. A renal US was negative.
Given his poor prognosis, his family decided to make him CMO. He
was extubated and died shortly there after.
Medications on Admission:
Home meds:
Lyrica 25mg PO TID (not taking it)
allopurinol 100mg PO QD
Avapro 300mg PO QD
HCTZ/triamterene 25/37.5 QD
ASA 81
Trental 100mg PO QD
Atenolol 25mg PO QD
Lipitor 10mg PO QD
NG SL
Felodipine 10mg PO QD
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebral Infarction
Atrial Fibrillation
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"414.01",
"403.90",
"585.9",
"427.31",
"272.0",
"434.11",
"274.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6814, 6823
|
5009, 6526
|
328, 335
|
6906, 6910
|
3235, 4986
|
6961, 7081
|
2094, 2112
|
6787, 6791
|
6844, 6885
|
6552, 6764
|
6934, 6938
|
2127, 2414
|
276, 290
|
363, 1869
|
2577, 3216
|
2454, 2561
|
2438, 2438
|
1891, 2044
|
2060, 2078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,275
| 195,684
|
34084
|
Discharge summary
|
report
|
Admission Date: [**2105-11-26**] Discharge Date: [**2105-12-17**]
Date of Birth: [**2021-11-18**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Malaise, dysuria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is an 83 year old woman with lymphoplasmacytic
lymphoma s/p fludarabine/rituximab X 4 cycles started [**2103-12-18**],
complicated by subsequent development of aplastic anemia in
[**5-25**], who presented to clinic today with a 4 day duration of
malaise, weakness, dysuria, and decreased appetite/PO
consumption. Denies hematuria but urine is dark brown-[**Location (un) 2452**] in
color. Urine is pungent. Denies urgency, fever, chills, nausea,
vomiting, or diarrhea. Has been moving her bowels daily with no
abdominal pain or change in her stool. Patient has a colostomy
bag. Also reports 1 month history of dry cough, only
occasionally productive of clear mucous. Denies any chest pain.
.
She is currently transfusion dependent in terms of her aplastic
anemia and is managed on cyclosporine at this point in time.
Patient has had a long period of observation without recovery of
her counts.
.
In clinic today, patient was given 1 unit platelts, 1 unit
PRBCs, was found to have a positive u/a, blood and urine culture
collected. Upon reaching the floor, patient reports that she
still remains tired, with continued dysuria. She appears
comfortable.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Diagnosed with colon cancer in [**2099**], s/p diverting colostomy,
reversed in [**2100**]. Lymphoplasmacytic lymphoma diagnosed in
[**10/2103**], s/p fludarabine/rituximab X 4 cycles started [**2103-12-18**]
at [**Location (un) **], complicated by aplastic anemia in [**5-25**]. The patient
has had a long period of observation without recovery of her
counts. She did receive cyclosporine with initially improvement
in her white count. This then worsened again and the patient was
most recently treated with Rituxan with a hope that there is an
element of consumption for her platelets and red cells that this
would improve her counts. She is several weeks after completion
of the Rituxan to date. She continues to have a significant
platelet and red cell requirement, although her white cells have
been supported with GCSF and she is not neutropenic. She has
also had a history of a bowel obstruction surgery, without clear
etiology of the obstruction. Although there were no masses
appreciated, this was thought to be due to adhesions and it was
felt not to be safe to proceed to do an extensive exploration.
.
OTHER PAST MEDICAL HISTORY
-Colon cancer [**2099**] as above (adenocarcinoma). S/p diverting
colostomy, reversed in [**2100**]
-Aplastic anemia
-Hypertension
-History of large bowel obstruction, s/p transverse loop
colostomy
-S/p appendectomy
-S/p tonsillectomy
-S/p tubal ligation
-S/p cholecystectomy
Social History:
Widowed for 12 years. She had 4 sons 1 daughter and several
grandchildren. Lives alone in [**Location (un) 16843**], MA. Son helps with
shopping and chores around the house. Denies smoking,
recreational drugs. No alcohol.
Family History:
Father with stroke at 77. Mother heart and renal failure. No
history of cancer.
Physical Exam:
VITAL SIGNS: 98.9, 132/64, 69 20 98% RA.
.
GENERAL: NAD, comfortable, pleasant, appears well
HEENT: Pupils are equal, round, and reactive to light. Sclerae
are nonicteric. EOMI, MMM.
NECK: Supple, with no thyromegaly. There is no cervical or
supraclavicular lymphadenopathy.
LUNGS: Faint right basilar rales heard. No wheezes or rhonchi.
HEART: RRR with nl S1, S2. No m/r/g.
ABDOMEN: Surgical scars noted. The abdomen is soft and
nontender. The spleen tip was not palpable. Colostomy bag noted.
EXTREMITIES: No pedal edema present.
NEURO: 5/5 strength in all extremities. CN 2-12 intact.
Sensation intact in the extremities.
Pertinent Results:
CXR [**11-26**]: Heart size is top normal. Mediastinal position,
contour and width are unremarkable. Lungs are essentially clear.
There is no pleural effusion or pneumothorax. The Port-A-Cath
catheter tip is at the cavoatrial junction. Minimal linear
opacity is seen at the left base, it is most likely consistent
with atelectasis. No pleural effusion or pneumothorax is
present.
.
CT Chest/Abdomen/Pelvis [**2105-11-30**]:
1. Hypoenhancing area within the mid polar right kidney,
concerning for
pyelonephritis given the patient's recent history of
Gram-negative bacteremia. Other considerations include infarct
vs. less likely, infiltrative tumor in setting of known
lymphoma. Clinical correlation recommended and followup imaging
is recommended following treatment to ensure resolution.
2. New small left-sided pleural effusion.
3. Uncomplicated gastric herniation through the colostomy site.
4. 8-mm pancreatic cyst, unchanged over multiple prior studies.
An MRI is
recommended for better evaluation.
.
MRI [**2105-12-2**]: IMPRESSION:
1. Findings consistent with hemosiderosis involving the liver
and spleen.
The pancreas is spared of iron.
2. Splenomegaly and splenic varices.
3. Small amount of ascites and small left pleural effusion.
4. Stable 8-mm cyst in the pancreatic tail, unchanged since
[**5-25**].
Differential diagnosis includes side branch IPMN versus
pseudocyst. Normally, recommendation would include yearly MRI
followup for this lesion in the appropriate clinical setting.
.
ECHO [**2105-12-10**]:
.
Labs:
[**2105-11-26**]:
BLOOD WBC-1.5* RBC-2.73* Hgb-7.9* Hct-22.7* MCV-83 MCH-29.1
MCHC-35.0 RDW-16.5* Plt Ct-14*
BLOOD Neuts-63 Bands-12* Lymphs-11* Monos-11 Eos-0 Baso-0
Atyps-3* Metas-0 Myelos-0 Plt Ct-14*
Glucose-124* UreaN-47* Creat-1.9* Na-137 K-3.6 Cl-99 HCO3-29
AnGap-13
ALT-209* AST-133* LD(LDH)-356* AlkPhos-124* TotBili-2.3*
DirBili-1.1* IndBili-1.2
Calcium-8.3* Phos-3.5 Mg-2.1 UricAcd-9.8*
Gran Ct-1020*
calTIBC-161* Hapto-79 Ferritn-GREATER TH TRF-124*
PT-13.1 PTT-26.7 INR(PT)-1.1 Fibrino-464*
[**2105-12-1**]:
[**Doctor First Name **]-NEGATIVE, AMA-NEGATIVE Smooth-NEGATIVE
IgG-423* IgM-16*
[**2105-12-6**]:
BLOOD WBC-1.6* RBC-2.39* Hgb-7.3* Hct-21.4* MCV-89 MCH-30.7
MCHC-34.3 RDW-15.7* Plt Ct-21*
Neuts-65 Bands-10* Lymphs-10* Monos-6 Eos-1 Baso-0 Atyps-0
Metas-7* Myelos-1*
Glucose-115* UreaN-25* Creat-1.0 Na-139 K-4.3 Cl-108 HCO3-25
AnGap-10
ALT-165* AST-122* LD(LDH)-371* AlkPhos-176* TotBili-1.1
PT-13.2 PTT-28.4 INR(PT)-1.1 Fibrino-223
Calcium-8.3* Phos-2.8 Mg-1.7 UricAcd-4.5
Gran Ct-1311*
CT head ([**2105-12-12**]): IMPRESSION: Left convexity, acute subdural
hematoma. Dense focus along the left tentorium, new since [**Month (only) **]
[**2103**], likely represents subdural hemorrhage rather than a mass
like meningioma. Assess on follow up study for expected
evolution if hemorrhage.
CT head ([**2105-12-14**]): IMPRESSION: Slight decrease in left frontal
subdural hematoma. No change in left tentorial hemorrhage.
Brief Hospital Course:
83 year old woman with lymphoplasmacytic lymphoma and subsequent
aplastic anemia following treatment with fludarabine and
cyclosporine, who presented with malaise, weakness, dysuria and
chronic cough.
.
#. Klebsiella UTI and bacteremia: Culture data revealed
klebsiella urinary tract infection and bacteremia. Initially
treated with PO cipro but changed to cefepime once blood culture
data returned. Patient completed course of IV cefepime for 19
days with significant clinical improvement with no further
fevers or dysuria. Surveillance cultures remained negative.
.
#. Transaminitis: Liver enzymes found to be trending upwards
over the last several months after the diagnosis of aplastic
anemia and transfusion requirement increased. RUQ ultrasound
was performed prior to hospitalization and showed cholelithiasis
but no obstruction. Iron levels were high and hepatology was
consulted to investigate secondary iron overload as a potential
cause for transaminitis. MRI was performed which confirmed
significant iron deposition within the liver and spleen. Was
started on deferoxamine. Experienced bump in LFTs [**1-19**] ATG
treatment (see below), and acyclovir, cyclosporine, and
deferoxamine (all of which can be hepatotoxic) were held. Once
her LFTs stabilized acyclovir, cyclosporine, and deferoxamine
were reinitiated. She will receive deferoxamine infusions at her
[**Hospital 15973**] cancer center.
.
#. Lymphoplasmacytic lymphoma/aplastic anemia: Had been on
chronic cyclosporine without evidence of improvement in counts
as an outpatient. Required frequent blood product transfusions.
Initially cyclosporine was held, and counts began to drop.
Cyclosporine was restarted with appropriate elevation in counts.
Neupogen was also given on a PRN basis to keep ANC above 1000.
Plan was made to begin ATG for treatment of aplastic anemia
following successful treatment of klebsiella UTI/bacteremia. On
the evening of her ATG administration, patient found to develop
labored breathing, tachypnea, tachycardia and hyperglycemia. O2
sats remained in the high 90s. ABG was consistent with mild
respiratory alkalosis. CXR showed mild pulmonary edema. Echo
was WNL. ECG was without abnormality. Vancomycin and lasix
were given. Patient was transferred to the [**Hospital Unit Name 153**] for close
monitoring of respiratory status with suspicion of an
ATG-related reaction. Patient stabilized with iprotropium and
was transferred to the floor in stable condition. Once the
patient's liver enzymes were stable, the patient was started on
cyclosporine at 50 mg [**Hospital1 **]. She will need a cyclosporine level
drawn at her outpatient appointment on [**2105-12-21**].
.
#. Subdural hematoma: On [**12-12**], patient had a mechanical fall
and landed on her buttocks with subsequent head trauma. Denied
any dizziness, lightheadedness, or loss of consciousness. CT
scan showed 5mm left frontal subdural hematoma. Platelets were
given. Neurosurgery was consulted, q4h neuro checks were
performed, and platelets were transfused with goal >75. Head CT
was repeated 12 hours later with no acute changes. Hip films
without fracture. Repeat head CT showed a smaller subdural
hematoma. Neurosurgery recommended followup in [**7-29**] weeks with
Dr. [**Last Name (STitle) 78630**] with repeat non-contrast head CT before the visit. On
discharge, there is no need for platelet transfusions for her
SDH.
.
#. Cough: chronic in nature. Afebrile, not neutropenic. CT
without any acute process. Was treated symptomatically and
improved over hospital course.
.
#. Acute renal failure, likely pre-renal: 1.9 on admission,
likely due to decreased PO intake secondary to malaise
associated with UTI and bacteremia. With IVF, creatinine
function returned to [**Location 213**].
.
# Sinus arrhythmia: The patient was noted to have an irregular
rhythm. EKG showed sinus rhythm with ectopic atrial beats. The
patient was started on Lopressor 12.5 mg [**Hospital1 **] to suppress ectopy.
.
Outpatient followup:
1. Followup MRI in one year to follow cystic structure
visualized.
2. Followup cyclosporine levels
Medications on Admission:
-acyclovir 400mg PO BID
-atenolol 25mg PO qHs
-cyclosporine 125mg PO BID
-folic acid 1mg PO daily
-HCTZ 25mg PO daily
-MVI
-neupogen - no regular schedule.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Outpatient Lab Work
The patient needs labs drawn on [**Last Name (LF) 766**], [**2105-12-21**]. She
will need AST, ALT, LDH, total bilirubin, alkaline phosphatase.
In addition she will need a cyclosporine level. These results
need to be faxed to her oncology nurse [**Last Name (Titles) 3525**], [**First Name8 (NamePattern2) 714**]
[**Last Name (NamePattern1) 3236**] at [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]: [**Telephone/Fax (1) 30658**].
4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Deferoxamine 500 mg Recon Soln Sig: One (1) Recon Soln
Injection 2 times per week: Dose: 500 mg of deferoxamine to be
infused.
Disp:*60 Recon Soln(s)* Refills:*2*
7. Neupogen 480 mcg/0.8 mL Syringe Sig: unknown dose Injection
PRN: as needed.
8. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
twice a day.
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
Primary:
Urinary tract infection
Klebsiella bacteremia
Lymphoplasmacytic lymphoma
.
Secondary:
Aplastic anemia
Acute renal failure
Discharge Condition:
Afebrile, vital signs stable. Able to ambulate without
difficulty. Alert and oriented to person, place, and time.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with malaise
and dysuria and found to have a bacterial urinary tract
infection. This infection had also spread to your blood. You
were given IV antibiotics and your condition improved
significantly. After a full course of antibiotics, you were
given ATG in an effort to treat your aplastic anemia, but you
tolerated this medication poorly. You were briefly transferred
to the ICU to monitor your wheezing and shortness of breath.
You will need to follow up with your oncologist as an outpatient
in regards to further plans.
.
You were noted to have high blood pressure, so amlodipine, a
blood pressure medication, was started.
.
We have made the following CHANGES to your medications:
-Change cyclosporine to 50 mg twice a day (2 pills)
.
Should you develop worsening shortness of breath, wheezing,
fever, chills, pain with urination, lightheadedness, dizziness,
please call the on-call oncology fellow or visit the emergency
room.
Followup Instructions:
Please keep the following previously scheduled appointments:
.
You have an appointment scheduled with Dr. [**Last Name (STitle) **] and his nurse
[**Last Name (STitle) 3525**] at 10:30 am on Thursday, [**12-24**]. The appointment
will be on the [**Location (un) 436**] of [**Hospital Ward Name 23**] Building of [**Hospital3 **]
Hospital [**Hospital Ward Name 516**] at [**Location (un) **] in [**Location (un) 86**], Ma.
.
You will need to followup with Dr. [**Last Name (STitle) 78630**] in neurosurgery. You
can make an appointment with him in [**7-29**] weeks with a CT scan of
your head before your visit. You can reach the office at
[**Telephone/Fax (1) 2731**]-. The office is located in [**Hospital 4171**] [**Hospital **] medical
building, [**Hospital Unit Name **].
|
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42,302
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35690
|
Discharge summary
|
report
|
Admission Date: [**2160-5-4**] Discharge Date: [**2160-5-8**]
Service: MEDICINE
Allergies:
Codeine / Prozac / Shellfish Derived / Macrobid
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Dyspnea and Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 85 year old lady with 2 recent admissions for
COPD admitted via the ED from [**Hospital1 **] of [**Location (un) 55**] for
dyspnea. She was found to have labored breathing at [**Hospital1 **] with
desaturations to the 70s despite 3L nasal cannula. She was give
duoneb and did not improve wheezing/dyspnea. VS prior to
transfer: 98.4 77 154/86 28
.
In ED, vitals were 97.9, 18/69, 80, 24 100% on NRB. The patient
was reported to be awake and able to answer questions. She was
started on BiPAP, given Combivent, solumedrol 125mg IVx1, 500mL
NS and ASA. She was transferred to the ICU on 2L nasal cannula
(have successfully transitioned off BiPAP).
.
On arrival to the ICU, the patient appears comfortable on 2L NC.
She is minimally responsive, answering only to loud voice and
correcting the pronounciation of her name. She is otherwise not
interactive, lying in a contracted position. A conversation with
her [**Hospital1 802**] (who was currently between flights back to [**Location (un) 86**],
expected to return tonight) confirmed that the patient is
conversant at baseline and has a history of erratic behavior
when ill, rather than unresponsiveness. She confirms that the
patient has had recent admissions for "COPD" flare and that she
has not been very well in the intervening time at [**Hospital1 **].
.
Per recent discharge summary ([**Date range (1) **] admission)
Diagnosed with COPD exacerbation as she finished her prior COPD
flare steroid taper. She was started on [**Hospital 48526**] transferred to the
ICU and was transitioned to NC. Her steroids were again tapered
rapidly and she is currently on a Prednisone taper (10mg dose)
from prior admission. The patient expressed paranoid thoughts
and was evaluated by Social work. This was ruled consistent with
her prior atypical psychosis.
Past Medical History:
- COPD with multiple intubations - h/o refusal to use steroids
or
BIPAP. Previously not on home O2 due to insurance issues.
- Diastolic CHF, followed at Sea Coast Cardiology in New
[**Location (un) **]
- CAD s/p "multiple" MI's
- Multiple sclerosis per patient - in the past, has claimed to
be followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 12838**] ([**Telephone/Fax (1) 69783**]. However, when
called this Dr. [**Last Name (STitle) 12838**], there was no record of patient.
Diverticulosis
Diabetes Mellitus (diet controlled)
GERD
- History of non-compliance with home meds and hx of leaving AMA
from multiple hospitalizations
Social History:
Lives at [**Hospital1 **] of [**Location (un) **]. Former dancer and on [**University/College **]
Faculty per [**University/College 802**]. No smoking history, social alcohol
consumption in the remote past.
Family History:
No history of early COPD or pulmonary disease could be obtained.
Physical Exam:
VS - Temp 97.2 F, BP 160/76, HR 87, R 18-20, O2-sat 100% 2LNC
GENERAL - Elderly woman lying with major muscle groups flexed.
HEENT - R pupil with prominent mature cataract, L pupil
reactive. Dry mucous membranes.
NECK - supple, no JVD, no carotid bruits
LUNGS - Breathing comfortably, not using accessory breathing
muscles. Decreased bibasilar lung fields, prominent wheezes and
scattered rhonchi.
HEART - S1 & S2 regular without murmur, further exam limited by
patient positioning.
ABDOMEN - BS present, non tender or distended.
EXTREMITIES - 1+ Distal pulses, no edema appreciated. Knees,
hips, elbows contracted and difficult to straighten, patient
actively resisting. Unable to assess full ROM.
SKIN - no rashes or lesions appreciated
NEURO - Arousable to loud voice, corrected her name
pronounciation. Unable to position patient to assess range of
motion or reflexes. No Clonus.
Discharge Exam:
Vitals: Afebrile, blood pressure ranging from 110s to 160s
systolic, oxygen saturations 90-95% on RA at rest
General: Awake but doesn't open eyes, answers questions
appropriately, oriented to person and hospital. Level of
alertness waxes and wanes from somnolent to attentive.
Pertinent Results:
[**2160-5-4**] 12:00PM BLOOD WBC-7.3 RBC-3.90* Hgb-10.6* Hct-33.1*
MCV-85 MCH-27.2 MCHC-32.0 RDW-16.5* Plt Ct-205
[**2160-5-4**] 07:45PM BLOOD WBC-7.4 RBC-3.75* Hgb-10.4* Hct-32.7*
MCV-87 MCH-27.8 MCHC-31.9 RDW-17.2* Plt Ct-218
[**2160-5-5**] 04:47AM BLOOD WBC-6.1 RBC-3.71* Hgb-10.6* Hct-32.5*
MCV-87 MCH-28.5 MCHC-32.6 RDW-17.2* Plt Ct-214
[**2160-5-6**] 06:50AM BLOOD WBC-5.9 RBC-3.17* Hgb-8.9* Hct-26.9*
MCV-85 MCH-28.1 MCHC-33.2 RDW-17.3* Plt Ct-177
[**2160-5-4**] 12:00PM BLOOD Neuts-76.2* Lymphs-16.6* Monos-5.5
Eos-1.4 Baso-0.3
[**2160-5-4**] 12:00PM BLOOD Glucose-102 UreaN-43* Creat-1.6* Na-143
K-4.6 Cl-102 HCO3-33* AnGap-13
[**2160-5-4**] 07:45PM BLOOD Glucose-146* UreaN-42* Creat-1.5* Na-140
K-5.3* Cl-102 HCO3-29 AnGap-14
[**2160-5-5**] 04:47AM BLOOD Glucose-156* UreaN-45* Creat-1.5* Na-142
K-5.0 Cl-101 HCO3-31 AnGap-15
[**2160-5-6**] 06:50AM BLOOD Glucose-114* UreaN-47* Creat-1.7* Na-140
K-5.0 Cl-102 HCO3-32 AnGap-11
[**2160-5-5**] 04:47AM BLOOD ALT-16 AST-7 LD(LDH)-175 CK(CPK)-26
AlkPhos-45 TotBili-0.3
[**2160-5-4**] 12:00PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2160-5-4**] 07:45PM BLOOD CK-MB-4 cTropnT-0.02*
[**2160-5-5**] 04:47AM BLOOD CK-MB-4 cTropnT-0.01
[**2160-5-4**] 07:45PM BLOOD Calcium-9.6 Phos-3.8 Mg-2.2
[**2160-5-5**] 04:47AM BLOOD Albumin-3.7 Calcium-10.2 Phos-3.3 Mg-2.2
[**2160-5-6**] 06:50AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.3
[**2160-5-4**] 11:41AM BLOOD Type-ART Temp-36.6 O2 Flow-2 pO2-99
pCO2-65* pH-7.37 calTCO2-39* Base XS-8 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2160-5-4**] 04:31PM BLOOD Type-ART pO2-65* pCO2-59* pH-7.39
calTCO2-37* Base XS-7 Intubat-NOT INTUBA
[**2160-5-4**] 12:18PM BLOOD Lactate-1.0
Discharge Labs.
[**2160-5-7**] 06:30AM BLOOD WBC-6.4 RBC-3.52* Hgb-10.1* Hct-30.5*
MCV-87 MCH-28.8 MCHC-33.3 RDW-17.1* Plt Ct-185
[**2160-5-7**] 06:30AM BLOOD Glucose-86 UreaN-38* Creat-1.8* Na-141
K-4.5 Cl-101 HCO3-34* AnGap-11
[**2160-5-7**] 06:30AM BLOOD Calcium-9.9 Phos-2.8 Mg-2.2
Neg Urine culture.
CXR
CHEST, PORTABLE AP VIEW: Lung volumes remain extremely low, with
elevation of
the right hemidiaphragm and colonic interposition as identified
on the prior
CT. Bibasilar atelectasis has not significantly changed. No new
airspace
consolidation is identified. The aorta remains tortuous with
atherosclerotic
calcifications. A right IJ introducer has been placed.
IMPRESSION: Low lung volumes with bibasilar atelectasis, without
significant
change in comparison to prior studies.
Brief Hospital Course:
Ms. [**Known lastname **] is an 85 year old woman who was admitted for ??????COPD
flare?????? due to hypoxia and desaturation. She likely has
restrictive physiology with reactive airways disase. During the
course of her hospitalization she benefited most from sitting
upright while eating, being fed honey thickened liquids, and
receiving Divalproex Sodium Sprinkles (125 mg PO TID) that
seemed to steady her mental status.
Her course and treatment are as follows:
MICU Course:
The patient was admitted to the [**Hospital Unit Name 153**] after transitioning from
BiPAP to NC in the ED. She arrived on NC, satting well and
breathing well but with evidence of hypoactive delerium. She
was started on Prednisone, Azithromycin and home meds. Over her
first night she became agitated and required Haldol total 2mg.
In the am her mental status cleared and her respiratory status
remained stable with neb stable on room air. She was started
on a steroid taper with a fast inital component then slowing
once reaching what appears to be her critical dose of 15mg.
Given her month of steroids she has been started on Bactrim PCP
[**Name9 (PRE) 5**] as well. The patient was transferred to the floor stable on
room air. On the floor, the patient had alternating episodes of
lucency and unresponsiveness, which, per report from her
extended care facility, is a baseline mental status level.
1) Hypoxia/Dyspnea: Ms. [**Known lastname **] has had two recent admissions
for "COPD" flare. Although this diagnosis is questionable given
her lack of smoking history and other pulmonary disease, she
does have severe kyphosis that gives her a restrictive breathing
physiology with a possible reactive component that appears to
respond well to nebulizer, steroid taper, antibiotics and
repositioning. Due to her alternating mental status, she would
probably not be able to tolerate/perform pulmonary function
tests therefore we will not be able to definitively rule out
COPD. Other causes of her hypoxia such as flash cardiopulmonary
edema, infection, valvular disease and pulmonary embolism were
considered, however, these causes were less likely. The
patient's oxygen saturation returned to her baseline saturations
of the low to mid 90s on room air after initiating nubulizer,
steroid therapy and repositioning her to a more upright sitting
position. She was discharged from the hospital on a steroid
taper as outlined in her discharge instructions however we are
not certain that her pulmonary functioning is improving from
this treatment. We encourage standing nebulizer treatment and
optimizing her positioning so as to improve her pulmonary
function. We also reccommend her to have all meals sitting up
right and out of bed in order to prevent aspiration.
****Of note-Ms. [**Known lastname **] had an episode of suspected hypoxia one
day prior to discharge, however it was very difficult to get a
pleth tracing initially based on a finger monitoring. Once
pleth tracing achieved, patient's o2 saturations were in the low
90s on room air, her baseline. No supplemental o2 was given
during this episode. Given this event and her history of
hypoxic episodes that are very short in nature, these episodes
could also be related to difficulty establishing o2 monitoring
as well positioning problems. Recommend forehead monitoring of
o2 sat levels if possible. This tactic might prevent future
hospitalizations.
2) Altered mental status/Psychosis: Mrs.[**Hospital 81202**] healthcare
proxy (her [**Hospital 802**]) was
contact[**Name (NI) **] during this admission as was her health care team at
[**Hospital1 **], each confirmed that during times of illness patient can
decompensate and become paranoid and
delusional. Per her HCP and long term nurse manager at [**Hospital1 **], at
baseline patient has moments of clarity but may relapse into
unresponsiveness in a matter of minutes. During this admission,
she was generally cooperative but was unresponsive on a couple
of occasions. She received depakote sprinkles with good effect
and we reccommend that she be maintained on this medication.
3) Hypertension: We continued her home anti hypertensives with
the exception of the nitroglycerin patch. Her blood pressure
fluctuated during her course. A more stable environment would
offer better insight as to what her optimal medication regimen
for this condition is.
4) Chronic Renal Insufficiency: Patient has CRI with baseline
hct ~ 1.6. Etiology unknown but presumably secondary to
hypertension. Her medications were renally dosed and her urine
output was monitored. She is at baseline incontinent so
monitoring her urine output was troublesome after removing her
foley upon transfer from the MICU. Her creatine slowly trended
up and had a discharge level of 2.0. Medication causes of this
trend are always possible but we did not change medications that
could have caused this rise. Her PO intake was relatively good
but she could benefit from more PO fluids. Recommend to
re-check creatine in a couple of days.
5) Anemia: Her hematocrit ranged from the high 20s to the low
30s similar to her previous hospital courses. Her anemia
appears to be related to her renal insufficiency. She receives
monthly procrit for this condition.
6) Eye ectropion: the patient has right eye lid ectropion on
physical exam and she complains of right eye pain. She would
benefit seeing an opthamologist to evaluate this condition. In
the meantime she has been prescribed artificial tears to relieve
some of the pain associated with this condition.
) FEN - Ms. [**Known lastname **] [**Last Name (Titles) 8337**] a low Na Diet and Honey
thickened liquids. In fact she seem to do her best when eating
her meals. She did not require any IV fluids while on the
floor. We recommend that she have all meals out of bed and in
upright manner to prevent aspiration.
) PPx - DVT ppx with SQ Heparin, Bowel regimen, Pain management
with Tylenol
) Code - Confirmed DNR/DNI with [**Last Name (Titles) **]
) Communication: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 81203**] [**Telephone/Fax (1) 81201**] ([**Name (NI) **], [**Name (NI) 382**]
Medications on Admission:
Atrovent Nebs Q6
Albuterol Nebs Q6h Prn
Prednisone 10mg (taper day [**12-15**], 5mg x3days)
HCTZ 25mg PO Daily
Tylenol PRN
MOM PRN
[**Name (NI) 10687**] PRN
Dulcolax PRN
Fleets enema PRN
Nitropatch 0.2mcg/hr q24 hours
Robitussin 10mL q4 PRN Cough
Amlodipine 10mg PO QHS
ASA 81mg PO Daily
Colace 100mg PO BID
Lisinopril 40mg PO Daily
Metoprolol 25mg PO Daily
Procrit 4000 units Qmonth (due [**5-24**])
Depakote 250mg PO QHS
Ritalin 5mg PO BID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain, headache.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Procrit 4,000 unit/mL Solution Sig: One (1) One injection
4,000 unil/mL solution Injection once a month.
6. [**Month (only) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) 0.02%
solution Inhalation Q6H (every 6 hours).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) 0.083% solution Inhalation Q6H (every
6 hours).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 doses.
11. Prednisone 10 mg Tablet Sig: Seventeen (17) Tablet PO once a
day for 16 days doses: Please give Prednisone PO Daily in the
following manner:Prednisone 30 mg PO Daily on [**5-8**]
Prednisone 15 mg PO Daily on [**5-9**], [**5-10**], [**5-11**], [**5-12**]
Prednisone 10 mg PO Daily on [**5-13**], [**5-14**], [**5-15**], [**5-16**],
[**5-17**]
Prednisone 5 mg PO Daily on [**5-18**], [**5-19**], [**5-20**], [**5-21**],
[**5-22**]
.
12. Divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO TID (3 times a day) as needed for hx of mood swings;
does not tolerate divalproex.
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day. Tablet(s)
16. Milk of Magnesia 800 mg/5 mL Suspension Sig: One (1) PO
once a day as needed for constipation.
17. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
18. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once
a day as needed for constipation.
19. Robitussin-DM 10-100 mg/5 mL Syrup Sig: One (1) PO four
times a day as needed for cough.
20. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
22. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN (as
needed) as needed for ectropion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Restrictive pattern pulmonary disease vs Chronic obstructive
pulmonary disease
.
SECONDARY DIAGNOSES
Depression
Anemia
Chronic kidney disease
Atypical pscyhosis
Discharge Condition:
stable to extended care facility. O2 saturations low 90s on
room air while resting. Alert to person and place but with
waxing and [**Doctor Last Name 688**] level of alertness and somnolence.
Discharge Instructions:
You were admitted to the hospital for treatment of hypoxia that
could be related to COPD but also to the way in which your chest
wall is configured-you have a chest wall that appears to not let
you breath in a normal way. We treated you with steroids and
other medicines
to help open the airways and your symptoms improved.
Please continue to take your medicines as prescribed:
1. we added prednisone; please take a slow tapering dose as
follows.
Prednisone 30 mg PO Daily on [**5-8**]
Prednisone 15 mg PO Daily on [**5-9**], [**5-10**], [**5-11**], [**5-12**]
Prednisone 10 mg PO Daily on [**5-13**], [**5-14**], [**5-15**], [**5-16**],
[**5-17**]
Prednisone 5 mg PO Daily on [**5-18**], [**5-19**], [**5-20**], [**5-21**],
[**5-22**]
2. We discontinued your nitroglycerin 0.2 mg/hr Patch .
3. We added Trimethoprim Sulfamethoxazole 160/800 mg Tablet one
pill on Monday Wednesday Friday which can be discontinued once
prednisone is discontinued.
4. We changed Divalproex to Divalproex Sodium Sprinkles 125 mg
PO TID
5. We discontinued your ritalin
6. We started you on albuterol nebulizers
7. We started you on calcium and vitamin D for your bone health
8. We started artifical tears for your eye pain
Please notify the staff at your extended care facility or call
the doctor or return to the emergency room if you
have any worsening shortness of breath, fever, or other new
concerning symptoms to you.
Followup Instructions:
Please follow-up with your primary provider in the next [**12-14**]
weeks.
Please see an opthamologist in order to evaluate your eyes and
eyelids.
|
[
"428.0",
"V58.65",
"493.22",
"340",
"428.32",
"311",
"799.02",
"414.01",
"298.9",
"530.81",
"403.90",
"250.00",
"585.9",
"041.12",
"507.0",
"294.8",
"V15.81",
"733.00",
"412",
"V13.02",
"285.21",
"374.10",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16018, 16090
|
6825, 13000
|
272, 278
|
16313, 16508
|
4336, 6802
|
17975, 18126
|
3052, 3120
|
13492, 15995
|
16111, 16292
|
13026, 13469
|
16532, 17951
|
3135, 4020
|
4036, 4317
|
213, 234
|
306, 2140
|
2162, 2811
|
2827, 3035
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,296
| 110,614
|
37571
|
Discharge summary
|
report
|
Admission Date: [**2141-10-23**] Discharge Date: [**2141-10-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
left hemiarthroplasty
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year old Yiddish-speaking man with a h/o HTN
and atrial fibrillation who presents to the hospital s/p
witnessed mechanical fall onto his left side. The patient was
walking and is unsure as to why he fell. No h/o head trauma,
LOC, lightheadedness.
In the emergency department, vitals were T 97 BP 152/96 P 64 RR
18 O2sat 88%RA -> high 90s% 2LNC. The patient had hip/pelvis
xrays, which showed a fracture in the left femoral neck. CXR
showed mild pulmonary vasculature congestion. Pt received IV
zofran and IV morphine 4mg in the ED. Pt was evaluated by ortho
- will go to OR for hemiarthroplasty. He was admitted to the
medical service for further evaluation and management of
hypoxia.
On transfer to the floor, the vitals were T 99.7 BP 140/80 P
100 RR 22 O2sat 86%RA, 92% 4LNC. The patient currently has some
mild pain in his left hip, but no other complaints at this time.
No numbness or tingling in his LE. No SOB, CP, palpitations,
lightheadedness, fevers, chills, cough, nausea, vomiting,
constipation, diarrhea.
Past Medical History:
Atrial fibrillation - not on coumadin
HTN
OA
bursitis
s/p peds struck 25 years prior - multiple fractures in b/l UE
and LE
No h/o pulmonary problems or CHF
Social History:
Lives alone, able to perform all ADLs without assistance.
Previous tobacco user, quit 30 years ago. Minimal EtOH use - [**12-30**]
glass of wine every Friday. No illicit drug use
Family History:
No family h/o heart disease. Son died of colon ca.
Physical Exam:
VITAL SIGNS: T 98.8 BP 102/73 HR 97 RR 22 O2 89% 4LNC
GENERAL: Pleasant, well appearing elderly man, in NAD; AAOx2 -
not oriented to year, but is aware of month and current
president
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. EOMI. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: regular rate, tachycardic. S1, S2. No murmurs, rubs or
gallops.
LUNGS: b/l crackles, no wheezing
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: trace pitting edema b/l, 2+ dorsalis pedis/
posterior tibial pulses.
LLE: shortened, externally rotated, +distal pulses
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout - unable to asses
LLE [**1-30**] to pain. No pronator drift. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS [**2141-10-23**]:
BLOOD:
WBC-8.8 Hgb-13.7* Hct-38.7* Plt Ct-182
Neuts-84.5* Lymphs-11.8* Monos-2.3 Eos-1.0 Baso-0.5
PT-12.2 PTT-25.6 INR(PT)-1.0
Glucose-114* UreaN-26* Creat-1.0 Na-142 K-4.0 Cl-106 HCO3-25
AnGap-15
CK(CPK)-57
cTropnT-<0.01
proBNP-329
Calcium-9.4 Phos-2.7 Mg-2.2
Lactate-2.2*
CARDIAC [**Last Name (un) **]:
[**2141-10-23**] 08:00AM BLOOD CK(CPK)-57
[**2141-10-23**] 09:00PM BLOOD CK(CPK)-61
[**2141-10-24**] 03:00AM BLOOD CK(CPK)-77
[**2141-10-24**] 05:15PM BLOOD CK(CPK)-114
[**2141-10-25**] 03:49AM BLOOD CK(CPK)-166
[**2141-10-23**] 08:00AM BLOOD cTropnT-<0.01
[**2141-10-23**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2141-10-24**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2141-10-24**] 05:15PM BLOOD CK-MB-8 cTropnT-0.25*
[**2141-10-25**] 03:49AM BLOOD CK-MB-7 cTropnT-0.17*
LIPID PANEL:
Cholest138 Triglyc-107 HDL-45 CHOL/HD-3.1 LDLcalc-72
MICRO:
BCx: ***
IMAGING:
[**2141-10-23**]:
XR L HIP - Left femoral neck fracture
CXR - Findings compatible with mild pulmonary vascular
congestion. Please note there may be a component of underlying
interstitial lung disease. Clinical correlation is advised.
Follow-up films post-diuresis advised
CT LLE -
1. Impacted femoral neck fracture with external rotation of the
distal femoral shaft.
2. OA with chondrocalcinosis.
3. Diffuse calcified atherosclerotic disease.
4. Fat-containing inguinal hernia on the left.
5. Fatty atrophy of gluteus medius muscle.
CTA CHEST -
1. No pulmonary embolus. No aortic dissection.
2. Ground-glass opacification, bilateral effusions, smooth
septal thickening and reflux of contrast into the IVC consistent
with congestive heart failure.
3. Emphysema.
4. Nodule in the right upper lobe may represent asymmetirc
pulmonary edema, however follow-up after treatment is
recommended to ensure resolution and exclude an underlying mass.
5. Multilevel spinal degenerative changes.
6. Mediastinal and hilar adenpathy likely due to CHF, this will
be
reevaluated at the time of follow-up CT scan.
7. Secretions in the trachea raise the possible of aspiration.
[**2141-10-24**]:
CXR -
1. New left basal increase in left basal consolidation,
concerning for
aspiration given short-term interval change.
2. Background of emphysema and bilateral perihilar opacities,
worrisome for chronic aspiration. Improvement in the
interstitial edema. Right upper lobe nodular density as
described in the prior CT, followup to resolution remains
recommended.
[**2141-10-25**]:
ECHO - The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 10-20mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly 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. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension
CXR - In comparison with the study of [**10-24**], there is continued
bibasilar
opacification consistent with atelectasis and effusion. The
possibility of supervening pneumonia must be considered. No
evidence of elevated pulmonary venous pressure persists.
Brief Hospital Course:
[**Age over 90 **] year old man with a history of atrial fibrillation not on
coumadin, HTN, who presented after a mechanical fall with a left
hip fracture. Hospital course by problem.
.
#.Left Hip Fracture: The patient had a fracture of his left
femoral neck. He was seen by orthopedics who recommended
hemi-arthroplasty once medically stable. His tachycardia and
dyspnea were treated and he went to the operating room on
hospital day #3. He tolerated the surgery well with
approximately 300ccs blood loss. He received fentanyl
post-operatively which made him hypotensive. Further pain
control was with Tylenol only. He was started on Calcium and
Vitamin D for prevention of future fractures. He was started on
Lovenox DVT prophylaxis which he should take for four weeks. He
should follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Dr.[**Name (NI) 8091**]
office. His hip has full weight-bearing capacity.
.
# Atrial fibrillation with RVR: The patient has known baseline
atrial fibrillation, rate controlled with metoprolol and
nifedipine, on just Aspirin at home. On hospital day #2 he
became tachycardic to the 130s in the setting of delirium and
agitation. His rate could not be controlled with extra doses of
PO and IV metoprolol and small fluid boluses. He was
transferred to the ICU because of difficulty managing him on the
floor nad persistent tachycardia. He was continued on his home
dose of metoprolol and started on a diltiazem drip. His heart
rate then improved along with his mental status. He is being
discharged on an increased dose of short-acting metoprolol but
can be transitioned back to metoprolol XL. He is being
discharged on short-acting diltiazem but can be transitioned to
longer-acting diltiazem.
.
# Altered mental status: The patient was alert and oriented
during the day but would become altered at night, pulling out
lines and becoming acutely agitated. On hospital day 2 he was
persistently agitated and tachycardic and had to be transferred
to the ICU. He responded partially to small doses of haldol.
He had to be restrained to keep him from removing all of his
lines. The next day his mental status improved post-operatively
and he is now alert and oriented at his baseline.
# Hypoxemia: The patient had persistent oxygen saturations in
the high 80s and low 90s requiring supplemental oxygen. There
was concern for pulmonary embolism but he had a negative CTA
chest. However, the CT scan of his chest showed pulmonary edema
and changes consistent with chronic aspiration. He was
initially covered for community-aquired PNA on the floor with
Azithromycine and Ceftriaxone based on concern on CXR today for
consolidation; however, he had no fevers or leukocytosis and
antibiotics were stopped. He was given no further fluids and
his hypoxia improved postoperatively. An echocardiogram was
essentially normal, showing just mild LVH and an LVEF>55%, but
his BNP was increased. His oxygenation improved with rate
control and not receiving further fluids, and he was satting 92%
on room air at discharge.
.
#.ARF: His creatinine increased to 1.6 on hospital day #2 from 1
on admission, BUN/Cr> 20 in the setting of receiving Lasix and
an IV contrast load. His creatinine improved to his baseline
with gentle hydration.
.
#.NSTEMI: Patient had elevated troponins, [**10-24**] 3am 0.17, [**10-24**]
5:15pm 0.25. This was most likely secondary to demand ischemia
as EKG showing no focal specific changes. His troponins trended
down prior to discharge.
Medications on Admission:
1. Procardia 30 mg PO daily, 2. Toprol XL 25 mg PO daily, 3. ASA
81 mg PO daily
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Primary diagnosis:
- hip fracture
.
Secondary diagnoses:
- atrial fibrillation with rapid ventricular response
- delirium
- congestive heart failure
Discharge Condition:
Stable. Improved tachycardia and stable hip pain.
Discharge Instructions:
You were admitted because you fell at home and fractured your
hip. You had surgery on you hip, and are now ready to go for
rehabilitation to get strong again. While you were here you
were temporarily confused and had fast heart rates. You are now
oriented again and your heart rate is being treated with
medications.
.
Changes were made to your medications:
- You were switched to short-acting metoprolol at a higher dose.
You now take 25mg every 8 hours. They can transition you back
to long-acting metoprolol at rehab.
- Your Procardia (nifedipine) was stopped.
- You were started on short-acting diltiazem, 30mg every 4
hours.
- You should take Tylenol 1000mg every 8 hours for pain control.
- You should take Lovenox every 12 hours for four weeks.
- You were started on Calcium and Vitamin D to make your bones
stronger.
- You can continue taking Aspirin every day.
.
Please call your doctor or return to the hospital if you have
chest pain, palpitations, difficulty breathing, fevers, chills
or severe pain.
Followup Instructions:
Please call the orthopedics clinic at [**Telephone/Fax (1) 1228**] to make an
appointment in 2 weeks after discharge with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
the nurse practitioner in Dr.[**Name (NI) 8091**] office.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2141-10-30**]
|
[
"599.70",
"428.0",
"997.1",
"427.31",
"715.95",
"428.21",
"275.49",
"518.89",
"410.71",
"441.4",
"285.9",
"584.9",
"820.21",
"E888.9",
"287.5",
"E928.9",
"712.35",
"401.9",
"E878.1",
"550.90",
"780.09",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10720, 10803
|
6360, 8146
|
280, 304
|
10996, 11049
|
2776, 6337
|
12115, 12530
|
1795, 1847
|
10032, 10697
|
10824, 10824
|
9928, 10009
|
11073, 12092
|
1862, 2757
|
10881, 10975
|
232, 242
|
332, 1404
|
10843, 10860
|
8161, 9902
|
1426, 1583
|
1599, 1779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,312
| 123,443
|
1779
|
Discharge summary
|
report
|
Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**]
|
[
"V12.59",
"V45.82",
"424.1",
"414.01",
"272.4",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"35.21",
"88.72",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5865, 5895
|
3078, 4180
|
367, 562
|
6063, 6072
|
1444, 3055
|
6490, 6765
|
1150, 1179
|
4404, 5842
|
5916, 6042
|
4206, 4381
|
6096, 6467
|
1194, 1425
|
281, 329
|
590, 891
|
913, 996
|
1012, 1134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,715
| 157,000
|
39470
|
Discharge summary
|
report
|
Admission Date: [**2123-8-5**] Discharge Date: [**2123-8-5**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Cephalosporins /
Nifedipine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname 71962**] [**Known lastname 87196**] is a [**Age over 90 **] year old CHF, hypothyroidism,
HTN, and atrial fibrillation who presents from her nursing home
after being found down. Per report patient was found down,
unresponsive, pulseless with frothing at the mouth. Blood
pressure and glucose were unmeasurable. EMS was called and
patient was given an amp of D50 en route to the Emergency
Department.
.
In ED VS were T 96.7 HR 107 BP 69/37 RR 20 SpO2 82%. Patient was
awake and conversant on arrival. She denied any complaints. Labs
were notable for INR 12.6, CK 1100, Trop. Rectal exam revealed
guaiac positive brown stools. CT torso without contrast showed
cardiomegaly with moderate sized pleural effusion. Echo showed
large pericardial effusion without tamponade physiology. Due to
persistent hypotension despite nearly 3 L IVF she was treated
empirically with vancomycin 1 g, levoquin 750 mg IV, flagyl 500
mg IV, and vitamin K 10mg IV, and a femoral CVL was placed and
patient continued on levophed.
.
Review of systems: Patient is unreliable historian. She denies
all symptoms and health problems.
Past Medical History:
CHF
Hypothyroidism
A fib on coumadin
HTN
Wrist sprain s/p fall
Social History:
Patient lives in a nursing home and requires assistance with
nearly all ADLs. She denies any recent use of tobacco, alcohol,
or illicit drugs.
Family History:
Noncontributory
Physical Exam:
GA: awake, alert, not oriented NAD
HEENT: PERRLA. dryMM. no LAD. no JVD. neck supple.
Cards: tachycardic, 2/6 systolic murmur
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding
Extremities: cool feet, cyanotic nail beds, prolonged cap
refill,
Skin: perioral cyanosis, scattered ecchymoses of forearms
Neuro/Psych: Poor hearing acuity, follows simple commands, awake
and alert, not oriented, patient moving all four extremities.
Lines/Drains: Foley catheter, Femoral CVL
Pertinent Results:
[**2123-8-4**] 10:40PM PT-100.7* PTT-42.4* INR(PT)-12.6*
[**2123-8-4**] 10:40PM PLT COUNT-200
[**2123-8-4**] 10:40PM WBC-15.7* RBC-4.43 HGB-13.2 HCT-40.9 MCV-92
MCH-29.7 MCHC-32.2 RDW-19.4*
[**2123-8-4**] 10:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-8-4**] 10:40PM ALBUMIN-3.3* CALCIUM-8.9 PHOSPHATE-7.8*
MAGNESIUM-2.4
[**2123-8-4**] 10:40PM CK-MB-20* MB INDX-1.8
[**2123-8-4**] 10:40PM cTropnT-0.19*
[**2123-8-4**] 10:40PM LIPASE-35
[**2123-8-4**] 10:40PM ALT(SGPT)-237* AST(SGOT)-803* CK(CPK)-1107*
ALK PHOS-76 TOT BILI-3.0*
[**2123-8-4**] 10:40PM GLUCOSE-128* UREA N-38* CREAT-2.5* SODIUM-134
POTASSIUM-6.4* CHLORIDE-98 TOTAL CO2-11* ANION GAP-31*
[**2123-8-4**] 10:58PM GLUCOSE-105 LACTATE-7.6* NA+-136 K+-6.0*
CL--102 TCO2-14*
[**2123-8-4**] 11:07PM TYPE-ART O2-100 PO2-255* PCO2-25* PH-7.27*
TOTAL CO2-12* BASE XS--13 AADO2-453 REQ O2-75 INTUBATED-NOT
INTUBA
[**2123-8-4**] 11:07PM TYPE-ART O2-100 PO2-255* PCO2-25* PH-7.27*
TOTAL CO2-12* BASE XS--13 AADO2-453 REQ O2-75 INTUBATED-NOT
INTUBA
[**2123-8-4**] 11:28PM URINE RBC-21-50* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-5**]
[**2123-8-4**] 11:28PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-MOD
[**2123-8-4**] 11:28PM URINE OSMOLAL-318
[**2123-8-5**] 07:52AM LACTATE-7.4*
[**2123-8-5**] 07:52AM TYPE-ART PO2-157* PCO2-27* PH-7.09* TOTAL
CO2-9* BASE XS--20
Imaging:
CXR:
IMPRESSION: Massive cardiomegaly. Diffuse opacification of the
left lower
hemithorax could represent a combination of pleural effusion and
atelectasis. Underlying infectious consolidation not excluded.
Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. 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 cannot be reliably assessed. The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets (3) are mildly thickened. The study is inadequate
to exclude significant aortic valve stenosis. The mitral valve
leaflets are mildly thickened. The tricuspid valve leaflets are
moderately thickened. Severe [4+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is a moderate sized pericardial effusion. Part of the
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. Echocardiographic signs of tamponade
may be absent in the presence of elevated right sided pressures.
IMPRESSION:. Severe pulmonary hypertension and severe right
ventricular dilation and hypokinesis. The LV is small and
underfilled and compressed by the enlarged right ventricle.
Moderate pericardial effusion with heterogenous cellular
components
CT Abdomen/Chest/Pelvis: prelim
1. Cannot assess for pulmonary embolism and dissection given
lack of IV
contrast.
2. Cardiomegaly with moderate sized pericaridal effusion (simple
fluid
density)
3. Moderate right pleural effusion and small left pleural
effusion with
adjacent compressive atelectasis.
4. Diffuse anasarca. Small amount of ascites.
5. wedge compression fracture of T4 of unknown chronicity.
Brief Hospital Course:
[**Age over 90 **] yo w with history of afib (on coumadin), HTN, hypothyroidism
who presented after being found down at her nursing home with
unmeasurable blood pressure and glucose levels. Patient was
hypotensive with an elevated lactate and leukocytosis initially
concerning for sepsis vs. cardiogenic shock.. She was given IVFs
and started on antibiotics and pressors. She began to develop
significant limb ischemia and was progressively deteriorating.
Her son, her Health Care Proxy, decided to make her Comfort
Measures Only. She expired 1:13 PM [**2123-8-5**] secondary to
cardiogenic shock as immediate cause of death. The family
declined an autopsy.
Medications on Admission:
Potassium Chloride 10 meq daily
Senna 2 tabs po bid
Acetaminophen 650 mg po q4h prn pain
Mylanta 30 mL po q6h prn GI upset
Bisacodyl 10 mg pr daily prn constipation
Fleet enema daily prn constipation
Guaifenesin 5 mL po q6h prn cough
Maalox 30 mL po daily prn constipation
Lexapro 5 mg po daily
Milk of Magnesia 30 mL po daily prn constipation
coumadin daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiogenic Shock
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"785.51",
"401.9",
"286.9",
"427.31",
"244.9",
"599.0",
"423.9",
"584.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7023, 7032
|
5924, 6584
|
294, 300
|
7093, 7102
|
2266, 5901
|
7155, 7162
|
1720, 1737
|
6994, 7000
|
7053, 7072
|
6610, 6971
|
7126, 7132
|
1752, 2247
|
1377, 1457
|
242, 256
|
328, 1358
|
1479, 1544
|
1560, 1704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,405
| 198,533
|
26683
|
Discharge summary
|
report
|
Admission Date: [**2179-9-15**] Discharge Date: [**2179-9-22**]
Date of Birth: [**2123-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Chief Complaint: Dyspnea, Pleuritic chest pain, B/L PTX
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
56M with cirrhosis [**3-15**] Hepatitis C acquired from blood
transfusion, chronic thrombocytopenia on trial medication x 3
weeks, HTN admitted from ED with concerning findings on CXR of
B/L PTX and new left pleural effusion. Symptoms started 2 days
prior to admission with progressively worsening shortness of
breath followed by central/right sided pleuritic chest pain
associated with dry cough which started day PTA. CP constant,
non radiating and not associated with exertion or dipahoresis.
He called his hepatologist day prior who recommended increasing
the dose of his lasix. He denies associated fever, chills,
sputum production. +orthopnea. LE edema at baseline per wife and
patient. Has had no recent air travel, diving, or other changes
in altitude or travel. No recent emesis or procedures such as
paracentesis or surgery.
.
Pt had planned flex sig today as outpatient. He reported history
as above and had CXR which showed B/L PTX and L>R pleural
effusion which was concerning for bronchopleural fistula. He was
then sent to the ED for further evaluation.
.
In the ED, initial vs were: 98.6 66 100/52 26 95. Chest CTA
showed small bilateral pneumothorax, no evidence for
bronchopleural fistula, and bilateral pleural effusions, stable
on right new on left. Negative for PE. Blood cx x 2 drawn and he
was given vanco/zosyn for ? infectious etiology. He also
received his home doses of Spironolactone and lasix and morphine
IV with marked improvement in chest pain. Thoracics and Surgery
were both contact[**Name (NI) **] and [**Name2 (NI) **] will see in am assuming pt is stable.
If unstable, thoracics is aware overnight.
.
On the floor, he reports recurrence of chest pain since he
received morphine several hours prior and persistent SOB which
is unchanged from earlier.
.
Review of systems:
(+) Per HPI. Has occasional nausea at baseline for which he
takes compazine.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Cirrhosis:
- Secondary to hepatitis C (from blood txn)
- Listed for liver transplant, MELD previously 17
- AFP 4.9 ([**10-19**])
- grade II varices ([**5-17**])
- ascites requiring paracenteses q2-4 weeks previously but well
controlled now
- h/o hepatic encephalopathy
- h/o SBP on cipro prophylaxis
2. Hepatitis C:
- Genotype 1, Viral load 412,000 IU/mL ([**10-18**])
- failed interferon tx (thrombocytopenia)
3. History of CVA, [**2175**] w/ mild residual R sided weakness
4. Heterozygus for H63D for hemochromatosis
5. Hypertension
6. Osteoporosis
Social History:
.
Married and lives with his wife. Formerly worked as a custodian.
History of smoking but quit 10 years ago. Smoked 1ppd x [**8-18**]
years. Denies alcohol or drug use.
.
Family History:
Family History:
Significant for Alzheimer disease in mother and an unspecified
cancer in father and brother.
Physical Exam:
Physical Exam At Discharge:
Vitals: 98.9 105/53 69 15 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera mildly icteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Trachea midline. Decreased BL left base with a few
crackle, dullness to percussion, crackles right base, No wheezes
or rhonchi
CV: Distant heart sounds. Regular. Normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, scaly periumbilical
skin
Ext: trace pedal edema, warm, well perfused, 2+ pulses, no
clubbing, cyanosis
Pertinent Results:
[**2179-9-15**] 10:09PM LACTATE-1.7
[**2179-9-15**] 10:01PM GLUCOSE-94 UREA N-21* CREAT-1.3* SODIUM-134
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2179-9-15**] 10:01PM CK(CPK)-61
[**2179-9-15**] 10:01PM CK-MB-NotDone cTropnT-<0.01
[**2179-9-15**] 10:01PM CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-1.7
[**2179-9-15**] 10:01PM WBC-5.2 RBC-3.27* HGB-11.5* HCT-32.5* MCV-99*
MCH-35.0* MCHC-35.2* RDW-15.1
[**2179-9-15**] 03:30PM CK(CPK)-92
[**2179-9-15**] 03:30PM cTropnT-<0.01
[**2179-9-15**] 03:30PM CK-MB-NotDone
[**2179-9-15**] 03:30PM WBC-5.7 RBC-3.30* HGB-12.0* HCT-33.1*
MCV-100* MCH-36.3* MCHC-36.1* RDW-15.3
[**2179-9-15**] 03:30PM PT-18.3* PTT-36.0* INR(PT)-1.7*
[**2179-9-15**] 08:15AM WBC-5.9# RBC-3.72* HGB-12.5* HCT-36.5* MCV-98
MCH-33.6* MCHC-34.3 RDW-15.1
[**2179-9-15**] 08:15AM PT-18.4* PTT-37.4* INR(PT)-1.7*
[**2179-9-15**] 08:15AM PLT COUNT-34*
Pleural Fluid: GRAM STAIN (Final [**2179-9-17**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2179-9-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2179-9-23**]): NO GROWTH.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2179-9-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
Sputum: ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Chest X-ray ([**2179-9-19**]): IMPRESSION: No pneumothorax, reduction in
size of left effusion.
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Amylase Albumin
Triglyc
[**2179-9-17**] 10:54AM 2.6 121 331 11 1.8 21
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro
[**2179-9-17**] 10:54AM 5000* [**Numeric Identifier 7206**]* 44* 12* 29* 3* 2* 10*
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, macrophages and neutrophils
Brief Hospital Course:
Brief Hospital Course By Problem:
B/L PTX: Unclear etiology for new onset bilateral PTX given he
has had no recent pressure changes that would precipitate PTX
and no known risk factors for secondary PTX such as COPD, CF,
TB, ankylosing spondylitis, asthma, histiocytosis X, idiopathic
pulmonary fibrosis, lymphangioleiomyomatosis, lung cancer,
Marfan syndrome, necrotizing pneumonia, rheumatoid arthritis, or
sarcoidosis. Primary spontaneous PTX also possibility but he is
not of typical stature, or epidemiology. He has no previous
known underlying lung disease although likely had rupture of
subpleural bleb given mild bullous disease on chest CT which is
out of proportion to smoking history. He has been on new
medication which stimulates megakaryocytes for thrombocytopenia
but PTX or cystic lung disease not obvious side effect. PTX
resolved with intervention, and were no longer visible on chest
x-ray done on [**2179-9-19**]. Given that we could not determine a cause
of his bilateral PTX's, patient was scheduled for follow up in
pulmonary clinic.
.
# Pleural effusion: Pt has chronic small right effusion likely
from known liver disease but has new moderate to large left
pleural effusion which has developed since [**7-/2179**], unclear if
related to new PTX. Patient had thoracentesis done on [**2179-9-17**],
analysis of the pleural fluid, showed multiple WBC's and RBC's
but no organisms, cytology was negative for malignancy and
showed: reactive mesothelial cells, macrophages and neutrophils,
and the fluid was exudative by Lyte's criteria. ID was
consulted who recommended observing the patient off antibiotics,
since he did not have any active signs of infection and to rule
him out for TB. Off antibiotics the patient remained afebrile,
had a PPD placed, pleural fluid was sent for AFB and he was
ordered for induced sputum for AFB x 3. However, when
respiratory came to induce sputum with hypertonic saline on
repeats occasions, they were only able to obtain one sample,
after conferring with ID it was decided that since he was low
risk for TB, his PPD was negative with 0mm induration, his one
sputum sample and pleural fluid were both negative for AFB, that
he could come off precautions and be discharged home. With the
recommendation that if the pleural effusion reaccumulated he
should have another thoracentesis with the fluid sent for repeat
studies. At the time of discharge there was no evidence of
further reaccumulation on exam, and his respiratory symptoms
were improved, with no supplement oxygen requirement. Patient
was scheduled for pulmonary follow up at the time of discharge.
# CP: Dyspnea and CP likely secondary to PTX but will also ROMI
with serial enzymes. No ECG changes to suggest ischemia, cardiac
enzymes negative x 2 and no PE on CTA. Chest pain resolved
during hospital course, and patient had been chest pain free for
over 4 days at the time of discharge.
# Cirrhosis: [**3-15**] hep C acquired from blood transfusion. Stable.
No active issues, continued home medications as per Hepatology
and scheduled patient for liver clinic follow up on [**9-29**].
# Thrombocytopenia: Stable at baseline. Transfused platelets ,
plt #back to pre-txf level.
# HTN: Currently well controlled on home meds of lasix and
aldactone, nadolol
# R>L LE edema: per patient is at baseline but much more
significant on exam since previously documented. There was no
evidence of DVT seen on lower extremity ultrasound, and with
continued home diuretic doses and encouraging the patient to get
out of bed, he lower extremity had improved to trace bipedal
edema at the time of discharge.
Medications on Admission:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Nadolol 20 mg PO DAILY
3. Ciprofloxacin HCl 250 mg PO Q24H
4. Omeprazole 20 mg PO DAILY
5. Docusate Sodium (Liquid) 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Prochlorperazine 5 mg PO Q6H:PRN nausea
8. Furosemide 120 mg PO DAILY
9. Rifaximin 600 mg PO BID
10. Lactulose 30 mL PO TID
11. Senna 1 TAB PO BID:PRN Constipation
12. Spironolactone 250 mg PO DAILY
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
7. Spironolactone 100 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Pneumothoraces with new left pleural effusion
Discharge Condition:
At the time of discharge, the patient was determined to not have
tuberculosis, no longer had an oxygen requirement at rest and
with ambulation, was afebrile, with stable vital signs and had
been deemed safe to leave the hospital by physical therapy.
Discharge Instructions:
You were admitted to the hospital with shortness of breath that
was due to bilateral pneumothoraces, which are small parts of
your lungs that collapsed. Also, you developed a left pleural
effusion, which is a collection of fluid in the space around
your lungs. After observation in the MICU, your pneumothoraces
resolved, without any intervention, however the fluid around
your lung was drained and sent for further testing. The fluid
had white and red blood cells in it, but was the studies were
negative for cancer, or any infection. The infectious disease
doctors were concerned that you could possibly have
tuberculosis, so we placed a PPD which was negative, checked the
fluid and a sputum sample for TB, and both were also negative.
As a result, it was decided that you were stable to go home with
outpatient follow up with the pulmonary and liver doctors.
Since we were unable to determine the reason you had this fluid
around your lungs, it is possible that it may reaccumulate, if
it comes back at any point, then you will need to have it
drained again for further testing.
During your stay, no changes were made to your medication
regimen.
Please call your doctor or return to the hospital if you
experience shortness of breath, chest pain, fever/chills,
productive cough or any other concerning symptoms.
Followup Instructions:
Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
we have scheduled you an appointment on [**10-6**] at 11:45.
Also, please follow up at the Liver Research Center, you are
scheduled to see the study coordinator on [**9-29**] and that day you
will also see Dr. [**Last Name (STitle) 696**], the liver attending.
Also, please follow up with pulmonary medicine, you have an
appointment scheduled on [**10-14**] at 2:30 for pulmonary function
tests and 3:00 will see the doctor. The pulmonary office is
located in the [**Location (un) 8661**] building on the [**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name 5074**], the phone number is [**Telephone/Fax (1) 612**].
|
[
"401.9",
"287.5",
"790.92",
"571.5",
"789.2",
"511.9",
"512.8",
"733.00",
"455.0",
"584.9",
"492.0",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
10845, 10851
|
6125, 6131
|
372, 388
|
10951, 11203
|
4112, 5417
|
12574, 13320
|
3383, 3477
|
10219, 10822
|
10872, 10930
|
9783, 10196
|
11227, 12551
|
3492, 3506
|
5454, 6102
|
3520, 4093
|
2224, 2581
|
292, 334
|
6160, 9757
|
416, 2205
|
2603, 3159
|
3175, 3351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,473
| 136,025
|
251
|
Discharge summary
|
report
|
Admission Date: [**2151-3-21**] Discharge Date: [**2151-3-29**]
Date of Birth: [**2084-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Left rib pain/LUQ pain
Major Surgical or Invasive Procedure:
[**3-21**] Left Thoracentesis
[**3-22**] Left Chest tube insertion
History of Present Illness:
67 yo M s/p CABG/MVR [**2-23**] with complicated post op course, dc'd
home3/16, returned to [**Location **] [**3-21**] c/o LUQ/chest pain. Also c/o some
SOB secondary to pain.
Past Medical History:
CAD s/p CABGx2 [**2124**], PPM, multiple PCI, NIDDM, GERD s/p dilation
of esophageal stricture, proxysmal A.fib, HTN
Social History:
retired communications technician
Family History:
NC
Physical Exam:
98.0 [**Telephone/Fax (1) 2488**] 16
NAD
Lungs with decreased breath sounds bilaterally with crackles at
both bases
CV RRR
Sternum C/D/I
Abd benign
Extrem without edema
Pain to palpation at left rib cage
Pertinent Results:
[**2151-3-29**] 07:10AM BLOOD WBC-4.7 RBC-3.39* Hgb-9.5* Hct-29.9*
MCV-88 MCH-27.9 MCHC-31.7 RDW-14.6 Plt Ct-183
[**2151-3-29**] 07:10AM BLOOD Plt Ct-183
[**2151-3-25**] 02:54AM BLOOD PT-14.0* PTT-37.3* INR(PT)-1.2*
[**2151-3-29**] 07:10AM BLOOD Glucose-126* UreaN-23* Creat-1.3* Na-136
K-4.1 Cl-104 HCO3-26 AnGap-10
[**2151-3-27**] 05:45AM BLOOD Glucose-112* UreaN-32* Creat-1.5* Na-136
K-3.6 Cl-99 HCO3-29 AnGap-12
[**2151-3-26**] 04:45AM BLOOD UreaN-46* Creat-1.6* K-3.8
[**2151-3-25**] 02:54AM BLOOD Creat-2.0* Na-131* K-4.1 Cl-96 HCO3-27
AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 2487**] was admitted to Cardiac surgery. Interventional
pulmonology performed a left thoracentesis for 750 cc
serosanguinous fluid.Thoracic surgery was consulted and
recommended a left chest tube and TPA which was performed.
Pleural fluid cultures showed MSSA for which he was placed on
nafcillin. Infectious diseases recommended 6 weeks of Nafcillin.
CT scan on [**3-26**] showed imporved effusion and VATS was cancelled.
Chest tube was dc'd without incident on [**3-27**]. CXR on [**3-29**] showed
no increase in the effusions, and he was ready for discharge on
[**2151-3-29**].
Discharge Medications:
1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours).
Disp:*240 grams* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day). Tablet(s)
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Until dc'd by Dr. [**Last Name (STitle) 1295**].
12. Lantus Subcutaneous
13. Outpatient Lab Work
Weekly CBC, Bun/Creatinine, LFTs while on Nafcillin
Results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**]
14. Heparin Lock Flush 100 unit/mL Solution Sig: PICC flush per
protocol Intravenous DAILY (Daily) as needed.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Left pleural effusion
s/p Redo sternotomy, CABG x 2, MVRepair [**2151-2-23**]
PMH:
CAD s/p CABGx2 [**2124**], PPM, multiple PCI, NIDDM, GERD s/p dilation
of esophageal stricture, proxysmal A.fib, HTN, HLD
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving while taking narcotic pain medicine.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 1295**] as prior to admission
Dr. [**Last Name (Prefixes) **] in 2 weeks
[**Hospital **] clinic with nurse practitioner ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**] if
possible)
[**Telephone/Fax (1) 2490**]
Dr. [**Last Name (STitle) 931**] in [**4-9**] weeks
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Infectious Disease) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2151-5-3**] 9:00
Completed by:[**2151-3-30**]
|
[
"272.4",
"V45.81",
"E878.2",
"530.81",
"401.9",
"041.11",
"427.31",
"250.00",
"997.3",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"88.72",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
3902, 3953
|
1645, 2249
|
344, 413
|
4202, 4210
|
1069, 1622
|
826, 830
|
2272, 3879
|
3974, 4181
|
4234, 4459
|
4510, 5008
|
845, 1050
|
282, 306
|
441, 618
|
640, 758
|
774, 810
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,254
| 176,394
|
7717
|
Discharge summary
|
report
|
Admission Date: [**2155-10-13**] Discharge Date: [**2155-10-18**]
Date of Birth: [**2102-5-20**] Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p 6 ft Fall
Major Surgical or Invasive Procedure:
[**10-17**] Operative repair left wrist
History of Present Illness:
53 yo male physician who fell off of his porch while doing some
work on his house. Fell ~[**5-30**] ft, landed on neck, back. +LOC. He
was transported to [**Hospital1 18**] for further management.
Past Medical History:
Atrial fibrillation
s/p C6-C7 fusion
Social History:
Employed as an internist
Family History:
Noncontributory
Physical Exam:
Upon admision to ED:
T: 97.7 BP: 139/71 P:60 RR: 15 97% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: L parieto-occipital scalp laceration.
PERRL [**1-23**] bilaterally, EOMI.
Neck: Supple.
Lungs: CTA bilaterally. Tenderness to palpation over L-sided
ribs, no deformity or ecchymoses.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Rectum: NL tone
Extrem: Warm and well-perfused.
Spine: Lumbar midline tenderness over spinous processes.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5
L 5 5 5 0 0 5 5 5 5 5
(unable to assess L hand due to pain from displaced wrist
fracture)
Sensation: Intact to light touch, propioception bilaterally
except L hand- palmar aspect of 1st-3rd digits have decreased
sensation to LT.
Propioception intact
Pertinent Results:
[**2155-10-13**] 06:13PM GLUCOSE-102 LACTATE-2.6* NA+-143 K+-3.7
CL--104 TCO2-25
[**2155-10-13**] 06:00PM UREA N-15 CREAT-1.3*
[**2155-10-13**] 06:00PM AMYLASE-134*
[**2155-10-13**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-18.7
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-10-13**] 06:00PM WBC-10.1 RBC-5.11 HGB-15.9 HCT-44.9 MCV-88
MCH-31.1 MCHC-35.3* RDW-13.1
[**2155-10-13**] 06:00PM PT-11.3 PTT-21.7* INR(PT)-1.0
[**2155-10-13**] 06:00PM PLT COUNT-295
MR L SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST
Reason: 53 Y/O MAN WITH TRAUMA POST FALL,BURST FRACTURE
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with lumbar burst fx from fall.
REASON FOR THIS EXAMINATION:
assess for spinal cord compromise
CONTRAINDICATIONS for IV CONTRAST: None.
ROUTINE MRI OF THORACIC & LUMBAR SPINE WITHOUT GADOLINIUM.
HISTORY: Known burst fracture.
Comparison is made with CT from the same date. There is a
compression fracture of the L3 vertebral body and left aspect of
L2 vertebral body as well as the left transverse process of L2.
The fracture also extends into bilateral, right greater than
left pars interarticularis and the right L2 transverse process.
There is an epidural hematoma posterior to L3 and to a lesser
extent posterior to L4 vertebral body, without significant mass
effect on the thecal sac. This is somewhat asymmetric to the
left of midline. There is evidence for ligamentous injury of the
posterior interspinous ligament from L2 through L4. Multilevel
spondylotic changes are identified.
There is a large right renal cyst which is incompletely
evaluated.
No large disc protrusion is seen. Evaluation of the thoracic
spine demonstrates no fracture, compression deformity or canal
compromise. There is no epidural hematoma or cord contusion.
There are small central disc protrusions in the mid thoracic
spine abutting the anterior aspect of the thecal sac.
IMPRESSION:
Fracture at L3 and L2 with small anterior epidural hematomas,
not causing significant compromise on the thecal sac.
Ligamentous injury of the posterior interspinous ligaments at
the fracture level.
CT C-SPINE W/O CONTRAST
Reason: ?trauma
Field of view: 25
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with fall onto head, 6feet, obvious head lac,
numbness in L arm
REASON FOR THIS EXAMINATION:
?trauma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 53-year-old gentleman with fall off a porch on to
head with numbness in left arm. Evaluate for cervical spine
injury.
COMPARISON: Head CT [**2155-10-13**].
TECHNIQUE: Multidetector helical scanning of the cervical spine
was performed in soft tissue and bone algorithm. Coronal and
sagittal reformats were displayed.
CT OF THE CERVICAL SPINE: There is no evidence of fracture or
malalignment of the cervical spine. Anterior fusion of C6-7 with
an anterior plate and interosseous screws appears intact. The
lateral masses of C1 are well seated about the dens and with
those of C2. There is no prevertebral soft tissue swelling. The
trachea is patent. Again noted are bilateral maxillary mucous
retention cysts and mild rightward deviation of the nasal
septum. The visualized lung apices are unremarkable.
IMPRESSION: No evidence of fracture or malalignment involving
the cervical spine. C6-7 fusion is intact.
CT HEAD W/O CONTRAST
Reason: ?trauma
Field of view: 25
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with fall onto head, 6feet, obvious head lac
REASON FOR THIS EXAMINATION:
?trauma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 53-year-old gentleman with fall off a porch onto
head, with obvious laceration. Please evaluate for bleed.
No prior examinations.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no acute intracranial hemorrhage, shift of
normally midline structures, or major vascular territorial
infarct. [**Doctor Last Name **]-white matter differentiation is preserved. The
ventricles are normal in size and configuration. The visualized
paranasal sinuses and mastoid air cells are clear. The external
auditory canal and middle ear cavities appear normal. There is
no calvarial fracture. Moderate-sized soft tissue laceration and
subcutaneous edema is seen in the left parietal scalp. Bilateral
maxillary sinus retention cysts and mild rightward nasal septum
deviation are noted.
IMPRESSION: Left scalp laceration, with no evidence of skull
fracture or intracranial hemorrhage.
WRIST(3 + VIEWS) LEFT
Reason: s/p closed recution L distal radius fracture, assess
positio
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with fall onto head, L arm pain, numbness in
median nerve distribution
REASON FOR THIS EXAMINATION:
s/p closed recution L distal radius fracture, assess position
HISTORY: Status post closed reduction of left distal radius
fracture.
Comparison is made to prior radiograph obtained on same date.
THREE VIEWS OF THE RIGHT WRIST.
FINDINGS: There has been marked improvement and reduction of
comminuted intraarticular distal radial fracture and distal
radioulnar articulation. Slight dorsal (perhaps 20 degree)
angulation of the distal radial articular surface persists. Soft
tissue swelling persists and osseous detail is obscured by new
overlying cast material.
IMPRESSION:
Reduction of distal radius intraarticular fracture and distal
radioulnar joint subluxation.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery/Spine was
consulted to evaluate his lumbar spine injuries further. These
were deemed nonoperative. He was measured and fitted for a
lumbar brace which is to be worn at all times when out of bed.
He will require follow up with Dr. [**Last Name (STitle) 548**] in 3 months time.
Orthopedics was also consulted for his left wrist injury;
throughout his stay his symptoms of numbness in the median nerve
distribution were self-reported to be worsening. On [**10-17**]
therefore he went to the OR with Dr. [**Last Name (STitle) **] for ORIF L distal
radius, carpal tunnel release. He tolerated it well.
On his CT abdomen it was noted: Incidentally noted 1 cm cystic
lesion within the body of the pancreas - likely either a
residual pseudocyst or incidental intraductal papillary mucinous
neoplasm (IPMN). Recommend further evaluation with MRI on a non-
emergent basis. Follow up with Dr. [**Last Name (STitle) **] has been arranged to
assess this lesion.
He was reluctant to take narcotics for pain control; only
choosing to take Tylenol prn. The narcotics remained on his
medication list in the event that he chose to take them. A bowel
regimen was also initiated.
He was evaluated by Physical therapy who have recommended that
he go home without Services. He was discharged on [**10-18**] with
follow up made. The patient was in good condition.
Medications on Admission:
aspirin 81 qd
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6hours as
needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma
Left distal radius fracture
L2-L3 spinal fractures
L3 anterior aspect of supior endplate fx
Discharge Condition:
Good
Discharge Instructions:
Continue to wear your brace when out of bed at all times.
Please resume your regular diet. You may resume your regular
medications. Take all new medications as directed. Please do
not drive while taking narcotic pain medications.
Continue to wear you TLSO back brace as directed. Wear the left
wrist splint until follow up with Dr. [**Last Name (STitle) **].
Please call or return if you have:
- Increased pain
- Fever (> 101 F)
- New weakness or numbness
- Other concerning symptoms
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**] in [**10-3**] weeks, call [**Telephone/Fax (1) 1669**] for
an appointment.
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 1228**] for an
appointment.
Follow up with Dr. [**Last Name (STitle) **] next week for removal of your head
staples; call [**Telephone/Fax (1) 6429**] for an appointment.
Follow up with your primary care doctor in the next 2-3 weeks;
you will need to call to arrange for an appointment.
|
[
"813.42",
"577.2",
"593.2",
"805.4",
"354.0",
"V45.4",
"E884.9",
"780.09",
"E849.0",
"873.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.02",
"04.43",
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
8782, 8788
|
7078, 8483
|
283, 324
|
8930, 8936
|
1724, 2309
|
9474, 9972
|
669, 686
|
8547, 8759
|
6269, 6356
|
8809, 8909
|
8509, 8524
|
8960, 9451
|
701, 1145
|
230, 245
|
6385, 7055
|
352, 550
|
1160, 1705
|
572, 611
|
627, 653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,714
| 145,070
|
47349
|
Discharge summary
|
report
|
Admission Date: [**2115-10-30**] Discharge Date: [**2115-10-31**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85F NH resident witnessed fall off of toilet. Hit head, +LOC.
Reportedly at neuro baseline.
Past Medical History:
dementia
GERD
DM
MI/CAD
h/o chronic R shoulder dislocation
Social History:
NH resident, no EtOH
Family History:
not obtained
Physical Exam:
PHYSICAL EXAM:
O: T:97.8 BP:200 /108 HR: 90 R66 O2Sats94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3 to 2 B EOMs full
Neck: in hard collar
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date during exam but
reportedly waxing/[**Doctor Last Name 688**]
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, 3to2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-24**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: symmetric
Toes downgoing bilaterally
Pertinent Results:
[**2115-10-30**] 05:30AM URINE BLOOD-MOD NITRITE-POS PROTEIN-NEG
GLUCOSE-TR KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
[**2115-10-30**] 05:30AM URINE RBC-[**3-24**]* WBC-[**3-24**] BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2115-10-30**] 05:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2115-10-30**] 05:30AM PT-12.4 PTT-26.9 INR(PT)-1.1
[**2115-10-30**] 05:30AM WBC-15.3* RBC-4.49 HGB-14.2 HCT-41.4 MCV-92
MCH-31.6 MCHC-34.2 RDW-13.5
[**2115-10-30**] 05:30AM NEUTS-89.5* BANDS-0 LYMPHS-5.7* MONOS-4.0
EOS-0.2 BASOS-0.5
[**2115-10-30**] 05:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2115-10-30**] 05:30AM PLT SMR-NORMAL PLT COUNT-293
[**2115-10-30**] 05:30AM GLUCOSE-194* UREA N-16 CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
Head CT: Left parietal acute SDH 14mm at greatest diameter
without
evidence of midline shift.There is a small minimally displaced
fracture of the left zygomatic arch. There is an air-blood level
within the left maxillary sinus. There is buckling of the left
nasal bone also consistent with a fracture.
Brief Hospital Course:
Patient was admitted to the ICU for close neurologic monitoring.
She had a repeat CT done 4 hours after the first which was
stable. Her blood pressure was maintained less than 130. She
was loaded with dilantin for seizure prophylasis which she
should maintain for one week total. Neurologically she was at
her reported baseline alternating between alert and oriented x3
to yelling out. Repeat CT done [**10-31**] was stable.
Medications on Admission:
Medications prior to admission:emablex xl 15 qd
colace
tylenol
zantac
glucerna tid
detol 4 qd
levothyroxine 75mcg qd
avapro 150 qd
fosamax 70 qwk
simvastatin 20 hs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO qd ().
8. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days: start [**11-1**] for 7 days .
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
neurologically stable
Discharge Instructions:
Monitor neurologic status.
Check dilantin level [**11-1**] - hold dilantin for level >20.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] with head CT in 4 weeks, call
[**Telephone/Fax (1) 2731**] for appt.
Completed by:[**2115-10-31**]
|
[
"E884.6",
"802.0",
"412",
"294.8",
"802.4",
"530.81",
"599.0",
"250.00",
"852.26"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4295, 4372
|
2930, 3360
|
230, 237
|
4434, 4458
|
1735, 2603
|
4596, 4742
|
496, 510
|
3575, 4272
|
4393, 4413
|
3386, 3386
|
4482, 4573
|
540, 742
|
3417, 3552
|
186, 192
|
265, 358
|
1055, 1716
|
2612, 2907
|
757, 1039
|
380, 441
|
457, 480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,109
| 167,343
|
1720
|
Discharge summary
|
report
|
Admission Date: [**2154-6-4**] Discharge Date: [**2154-6-19**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
FEVER
Major Surgical or Invasive Procedure:
Central line placement
PEG tube placement
Ultrasound guided prostate fluid collection aspiration.
History of Present Illness:
89 year old male with chief complaint of fevers of 104 degrees,
agitation, pulling at foley w/ hematuria. PMH BPH, afib, HTN,
recent episode of hemorrhagic prostatitis, primary progressive
aphasia. pt was admitted in [**State 108**] 1 mo back for hematuria and
was found to have hemorrhagic prostatitis. he was cauterized
twice. he recd lot of ativan and had to be admitted to the icu
for it. didnt get intubated. was xferred to [**Hospital **] rehab. was
doing well. last night was observed to be pulling at his foley.
also spiked to 102. was brought to the ed. found [**Last Name (un) **] febrile to
103 and SBP in 100s. satting well. tachycardic to 120s. lactate
up to 5. no wbc count elevation. UA s/o UTI. given levoflox x 1.
RIJ placed and recd 4 L NS. lactate down to 2.9.
Past Medical History:
BPH
Afib
HTN
Recent episode of hemorrhagic prostatitis
Primary progressive aphasia
Social History:
SH: no etoh, tobacco, illicits
Family History:
NC
Physical Exam:
VS: 97 131/86 76 18 94ra
GEN: friendly male, occasionally singing and humming.
HEENT: mmm, eomi.
COR: nl s1s2. rrr
PUL: poor inspiratory effort, difficult to hear posteriorly.
anteriorly cta bilat.
ABD: soft, thin, nabs, nt/nd
EXTREM: warm, no edema, cyanosis.
NEURO: cn 2-12 intact.
aphasic speech, often speaking in mix of english and yiddish
Pertinent Results:
[**2154-6-4**] 10:18PM TYPE-[**Last Name (un) **]
[**2154-6-4**] 10:18PM LACTATE-2.1*
[**2154-6-4**] 09:13PM GLUCOSE-97 SODIUM-144 POTASSIUM-3.5
CHLORIDE-119* TOTAL CO2-20* ANION GAP-9
[**2154-6-4**] 09:13PM CALCIUM-6.8* PHOSPHATE-1.9* MAGNESIUM-1.5*
[**2154-6-4**] 09:13PM WBC-14.8* RBC-2.32* HGB-7.2* HCT-21.8* MCV-94
MCH-31.2 MCHC-33.2 RDW-14.1
[**2154-6-4**] 09:13PM PLT COUNT-99*
[**2154-6-4**] 05:13PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2154-6-4**] 05:13PM LACTATE-3.2*
[**2154-6-4**] 04:49PM URINE HOURS-RANDOM UREA N-821 CREAT-100
SODIUM-54
[**2154-6-4**] 04:49PM URINE OSMOLAL-683
[**2154-6-4**] 04:49PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2154-6-4**] 04:49PM URINE [**Month/Day/Year 3143**]-MOD NITRITE-POS PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2154-6-4**] 04:49PM URINE RBC-73* WBC-753* BACTERIA-MOD YEAST-MOD
EPI-1
[**2154-6-4**] 04:49PM URINE WBCCLUMP-MANY MUCOUS-FEW
[**2154-6-4**] 04:49PM URINE EOS-POSITIVE
[**2154-6-4**] 04:45PM GLUCOSE-135* UREA N-30* CREAT-1.2 SODIUM-144
POTASSIUM-3.8 CHLORIDE-117* TOTAL CO2-20* ANION GAP-11
[**2154-6-4**] 04:45PM CALCIUM-7.1* MAGNESIUM-1.6
[**2154-6-4**] 04:45PM WBC-17.6*# RBC-2.48*# HGB-7.8* HCT-23.0*
MCV-93 MCH-31.5 MCHC-33.9 RDW-14.1
[**2154-6-4**] 04:45PM PLT COUNT-103*
ON ADMISSION:
[**2154-6-4**] 04:45PM PT-14.9* PTT-35.6* INR(PT)-1.3*
[**2154-6-4**] 09:31AM TYPE-MIX
[**2154-6-4**] 09:31AM GLUCOSE-103 LACTATE-2.2*
[**2154-6-4**] 09:31AM HGB-8.8* calcHCT-26 O2 SAT-55
[**2154-6-4**] 05:42AM LACTATE-2.9*
[**2154-6-4**] 03:40AM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2154-6-4**] 03:40AM URINE [**Month/Day/Year 3143**]-LG NITRITE-POS PROTEIN->300
GLUCOSE-100 KETONE-40 BILIRUBIN-LG UROBILNGN-4* PH-5.5 LEUK-LG
[**2154-6-4**] 03:40AM URINE RBC->50 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0
[**2154-6-4**] 03:15AM LACTATE-5.0*
[**2154-6-4**] 03:15AM HGB-11.0* calcHCT-33
[**2154-6-4**] 02:50AM GLUCOSE-120* UREA N-39* CREAT-1.5* SODIUM-143
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16
[**2154-6-4**] 02:50AM estGFR-Using this
[**2154-6-4**] 02:50AM CALCIUM-8.3* PHOSPHATE-1.3* MAGNESIUM-1.9
[**2154-6-4**] 02:50AM DIGOXIN-0.6*
[**2154-6-4**] 02:50AM WBC-6.7 RBC-3.38* HGB-10.4*# HCT-30.3*#
MCV-90 MCH-30.8 MCHC-34.3 RDW-13.8
[**2154-6-4**] 02:50AM NEUTS-94.5* BANDS-0 LYMPHS-3.7* MONOS-0.8*
EOS-0.8 BASOS-0.2
[**2154-6-4**] 02:50AM PLT COUNT-131*
[**2154-6-4**] 02:50AM PT-13.4 PTT-29.7 INR(PT)-1.1
.
ON DISCHARGE:
[**2154-6-19**] 06:15AM [**Month/Day/Year 3143**] WBC-9.0 RBC-3.14* Hgb-9.8* Hct-28.7*
MCV-92 MCH-31.2 MCHC-34.1 RDW-15.3 Plt Ct-325
[**2154-6-19**] 06:15AM [**Month/Day/Year 3143**] Glucose-121* UreaN-16 Creat-1.0 Na-136
K-4.0 Cl-100 HCO3-31 AnGap-9
[**2154-6-18**] 06:57AM [**Month/Day/Year 3143**] ALT-11 AST-22 AlkPhos-70 TotBili-0.3
[**2154-6-18**] 06:57AM [**Month/Day/Year 3143**] Calcium-8.1* Phos-1.8* Mg-2.0
WORK -UP
[**2154-6-7**] 07:05AM [**Month/Day/Year 3143**] calTIBC-212* Ferritn-244 TRF-163* IRON
-47
[**2154-6-15**] 06:40AM [**Month/Day/Year 3143**] Triglyc-113 HDL-31 CHOL/HD-3.9 LDLcalc-66
[**2154-6-13**] 08:06AM [**Month/Day/Year 3143**] TSH-4.1
[**2154-6-13**] 05:30PM [**Month/Day/Year 3143**] Vanco-20.3*
.
[**6-4**] CXR: IMPRESSION: No pneumonia.
.
[**6-4**] EKG:
Baseline artifact
Probable atrial fibrillation with rapid ventricular response
Right bundle branch block
Rightward axis - is nonspecific but cannot exclude in part right
ventricular
overload or chronic pulmonary disease
ST-T wave changes - are in part primary and are nonspecific
Clinical correlation is suggested
No previous tracing available for comparison
.
[**6-5**] Prostate Ultrasound:CONCLUSION: Marked prostatic
enlargement with an estimated volume in excess of 150 cc. No
evidence of prostate abscess on this limited study.
.
[**6-5**] Renal Ultrasound: CONCLUSION: Normal-appearing kidneys.
Massive prostate enlargement.
.
ECHOCARDIOGRAMS:
[**6-6**]:
IMPRESSION: Moderate left ventricular hypertrophy with overall
normal systolic function. Mild aortic regurgitation. Moderate to
severe mitral regurgitation. Moderate to severe tricuspid
regurgitation. No vegetation identified. If clinically
suggested, the absence of a vegetation by 2D echocardiography
does not exclude endocarditis.
[**6-11**]
GENERAL COMMENTS: A [**Month/Year (2) **] was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the [**Last Name (Titles) **].
Medications and dosages are listed above (see Test Information
section). Unsuccessful esophageal intubation.
CONCLUSION
The [**Last Name (Titles) **] probe could not be passed into the esophagus due to
patient's inability to cooperate.
[**6-11**] TTE: The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The right ventricular cavity is
dilated with normal free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The aortic valve leaflets
are mildly thickened. The aortic valve is not well seen. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is a
trivial/physiologic pericardial effusion. There is a mobile
structure in the right atrium consistent with probable
Eustachian valve (unchanged from prior).
No definte vegetation seen (cannot exclude).
Compared to the prior study of [**2154-6-6**], there is no definite
change.
CXR: RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2154-6-15**] 2:12 PM
Right PICC, 48cm via median vein.
Right PICC tip is in the right atrium, could be pulled back 6 cm
to assess its standard position at the cavoatrial junction.
Compared to prior study from [**6-5**], there is an ill-defined
increased opacity in the left lower lobe, could be atelectasis.
There is no pneumothorax or sizeable pleural effusion. Single
left transvenous pacemaker lead terminates in the right
ventricle. There is no evidence of overt CHF.
KUB: [**6-10**]
INDICATION: 89-year-old man with abdominal tenderness,
leukocytosis, question free intraperitoneal air.
COMPARISON: Abdominal radiograph dated [**2154-6-9**] and CT
abdomen and pelvis dated [**2154-6-8**]
FINDINGS: There is no evidence of free intraperitoneal air. The
supine view is markedly limited by motion artifact. Gas is seen
throughout non-dilated loops of bowel. Degenerative changes are
noted in the lower lumbar spine.
IMPRESSION: Limited study, no evidence of free intraperitoneal
air.
US RETROPER ABSCESS DRAIN PERC [**2154-6-10**] 2:19 PM
PROCEDURE: After explaining potential risks and benefits of the
procedure to the patient's daughter, [**Name (NI) **] [**Name (NI) 9834**], verbal consent
was obtained over the telephone with a witness. All questions
were answered. Thereafter, the patient's identity was confirmed
with three identifiers. A qualified nurse was present to
administer intravenous fentanyl for pain control, with
continuous appropriate monitoring.
With the patient in the left lateral decubitus position, an
endorectal probe was inserted with lidocaine gel, and the
prostate gland was scanned. Images were limited by scattered
coarse prostatic calcifications with associated dense shadowing.
However, there was an area of relative decreased echogenicity in
the right gland, corresponding to the CT abnormality. This area
was more ill defined and not compatible with a discrete fluid
collection, but more suggestive of a phlegmon. This area was
sampled with an 18-gauge 20- cm [**Last Name (un) 4300**] needle. However, given
the more solid nature of the area, sampling was difficulty.
The needle was then removed, and the sample was sent for Gram
stain and culture. The patient tolerated the procedure without
immediate complication. The procedure was performed by Dr.
[**Last Name (STitle) **] with Dr. [**Last Name (STitle) 9835**] assisting.
IMPRESSION: Patient status post ultrasound-guided aspiration of
a hypoechoic phlegmon in the right prostate gland.
-------------------
Brief Hospital Course:
89 male with benign prostatic hypertrophyu, atrial fibrillation,
hypertension, recent episode of hemorrhagic prostatitis, primary
progressive aphasia presenting with sepsis, floridly positive
urinalysis.
.
1) Bacteremia / Fungemia:
Patient was admitted hypotensive and tachycardic. IVFs were
provided for resuscitation. He was empirically started on
vancomycin and levofloxacin. [**Last Name (STitle) **] culture and urine culture
grew coag + staph and enterococcus. ID was consulted.
Antibiotics were transitioned to daptomycin / levofloxacin, and
then daptomycin alone. Once final sensitivities revealed a coag
+ staph and enterococcus which were both sensitive to
Vancomycin, the patient was started on Vancomycin and Daptomycin
was discontinued. Patient was initially in the intensive care
unit and upon starting antibiotics the patient stabilized and
was able to be transferred to the floor.
Work- up for a source for the urinary and [**Last Name (STitle) **] infections
revealed negative, but limited prostate ultrasound. CT scan was
performed to eval for abscess, prostate necrosis / abscess.
Prostate fluid collection was seen. GU was consulted, which
recommended US guided fluid extraction and drainage procedure.
This was performed, but no abscess was found; small amount of
material was extracted and sent for culture. Pacemaker pocket
was studied via ultrasound and no sign of infection seen. Two
TTEs were perfomed, which showed no vegetations on limited
study. A [**Last Name (STitle) **] was requested by ID, ans was attempted. Given his
inability to follow commands during the attempt it was deemed
safetest not to perform it. Discussions with the HCP / daughter
re: [**Name2 (NI) **] resulted in the decision to make no further attempts at
[**Name2 (NI) **]. Source was felt to be most likely prostatic given coag +
staph and bacteroides grew out of the fluid drained from the
prostate. The patient was started on metronidazole for the
bacteroides. [**Name2 (NI) **] cultures showed positive for [**Female First Name (un) **] albicans
on [**6-5**]. He was started on caspofungin and transitioned to
fluconazole. Optho evaluation was negative for retinitis.
After the prostate drainage, the patient's [**Month/Year (2) **] cultures
cleared and remained clear. A PICC line was placed for IV
antibiotics.
--- Plan to treat with 6 week course of IV vancomycin for MRSA
bacteremia ( Day 1 [**6-10**], through [**7-16**]), 2 weeks of IV
Fluconazole for [**6-5**] [**Female First Name (un) **] albicans in the [**Female First Name (un) **] ( through
[**2154-6-23**]), and 4 weeks of PO Flagyl for bacteroides (through [**7-10**])
Patient to complete 2 week course of IV fluconazole on
discharge.
--- Patient to follow-up with ID for further management [**2154-7-10**]
[**Hospital **] Medical Building [**Hospital1 18**] 10:30 AM
--- Patient to have repeat prostatic ultrasound as outpatient
for further evaluation of prosatic abscess.
--- VANCOMYCIN LEVELS: plan for trough level to be checked
weekly at Rehab. Patient needs check tomorrow [**6-20**]. Trough goals
15-20 given severity of patient infection.
.
2) Atrial fibrillation with rapid ventricular rate: Patient has
a history of atrial fibrillation and off his betablocker in the
setting of infection developed atrial fibrillation with rapid
ventricular response. The patient was continued on his digoxin
and metoprolol was uptitrated for effect. Patient remains off
coumadin since first episode of hemorrhagic prostatitis in
[**State 108**], [**Hospital 9836**] Medical Center.
--- Patient will follow-up with his primary care physician
regarding restarting coumadin.
.
3) Nutrition
Poor PO intake since admission. Pt was encouraged to eat with
multiple foods and family, but patient's POs were minimal. The
family decided it would be best to place a feeding tube to
improve his health and nutritional status in the short term,
fully aware the long term outcomes are unchanged via feeding
tubes. Patient was started on tube feeds.
4) Acute renal failure
Creatinine elevated at presentation, thought to be [**2-23**]
pre-renal. Declined wwith IVFs. Elevated again after dye load
from CT scan on [**6-8**]. Trended back to normal prior to
discharge.
.
5) BPH:
Continued finasteride. Foley catheter remained in place
initially. Patient initially failed a void trial. Plan to
attempt a second void trial as an outpatient. If fails, plan to
replace foley and follow-up with Urology as previously planned.
.
6) Primary progressive aphasia:
Family for orientation, communication.
.
7) Dementia
Unknown etiology. Cont home aricept, modafinil
.
The patient was full code during this admission. Contact was
with Daughter [**First Name4 (NamePattern1) **] [**Known lastname 9834**], MD [**Telephone/Fax (1) 9837**](cell), [**Telephone/Fax (1) 9838**](home).
Medications on Admission:
aricept
digoxin
brimonidine
latanoprost
finasteride
modafinil
trazodone
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qdaily ().
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
7. Latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at
bedtime: left eye.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 6 days: last day
= [**6-20**].
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 weeks.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1) Sepsis
2) Prostate fluid collection
3) Atrial fibrillation
.
Secondary
1) Primary progressive aphasia
2) HTN
Discharge Condition:
Not tolerating POs. Afebrile. Following simple commands.
Speaking in mix of yiddish and english.
Discharge Instructions:
You were admitted with a severe infection. This was most likely
in your prostate but did spread to the [**Hospital6 **]. You were also
found to have a fungal infection of the [**Hospital6 **]. You are being
treated with intravenous antibiotics for both bacterial and
fungal [**Hospital6 **] infections.
.
You were started on tube feeding as well given your poor diet.
.
You will require to have labs drawn 1 x / week to ensure
tolerance to the intravenous medications and tube feeding.
.
You will also have to follow up with urology and infectious
disease. You will require re-imaging of your prostate with a CT
scan to ensure that the infection has resolved.
.
Please take the following antibiotics:
1. Vancomycin 1g IV daily through [**2154-7-16**]. (total 6
weeks)
2. Flagyl 500mg orally every 8 hours through [**2154-7-10**]
(total 4 weeks)
3. Fluconazole 200mg IV daily through [**2154-6-23**] (total 2
weeks)
4. Please draw weekly CBC, Chem 7, LFT's, Vancomycin level,
ESR, and CRP and adjust vancomycin level as indicated. Results
can be sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the number below.
Followup Instructions:
Please follow up with the following appts:
.
UROLOGY
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2154-6-24**] 1:50
.
INFECTIOUS DISEASES
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**First Name (STitle) 3143**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2154-7-10**]
10:30
in [**Last Name (NamePattern1) **]. [**Hospital Unit Name **]
.
PROSTATE ULTRASOUND
You must also have a repeat ultrasound of your prostate. Please
discuss with your Urologist and Infectious Disease Doctor
regarding the scheduling of this study.
|
[
"784.3",
"294.8",
"600.00",
"601.2",
"995.92",
"401.9",
"599.0",
"008.45",
"V09.0",
"427.31",
"584.9",
"038.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"43.11",
"96.6",
"60.91"
] |
icd9pcs
|
[
[
[]
]
] |
16817, 16883
|
10366, 15205
|
223, 323
|
17039, 17140
|
1692, 3046
|
18341, 18984
|
1303, 1307
|
15328, 16794
|
16904, 17018
|
15231, 15305
|
17164, 18318
|
1322, 1673
|
4257, 10343
|
178, 185
|
351, 1132
|
3060, 4243
|
1154, 1238
|
1254, 1287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,169
| 188,181
|
38583
|
Discharge summary
|
report
|
Admission Date: [**2162-4-9**] Discharge Date: [**2162-4-17**]
Date of Birth: [**2095-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Arm weakness
Major Surgical or Invasive Procedure:
[**2162-4-12**] Removal of Left Atrial Mass with Pericardial Patch
Closure on Atrial Septum
History of Present Illness:
This is a 66 year old male who presented to outside hospital on
[**2162-4-5**] with right hand and arm weakness. He also complained on
right arm numbness which later progressed to his right leg. He
then presented to emergency room for evaluation. Brain MRI at
OSH confirmed acute infarction and underwent workup including
TEE which revealed left atrial mass and patent foramen ovale. He
was transferred to the [**Hospital1 18**] for further evaluation and
treatment.
Past Medical History:
Asthma
Gastric esophageal reflux disease
Barrett's esophagus
Prostate Cancer - s/p Radical prostatectomy
Hearing loss
Migranes
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] with cysts on the kidney and testicles
Enlarged optic nerve - ? low pressure glaucoma
Cysts in the groin removed years ago
Social History:
Last Dental Exam: 2 month ago
Lives with: spouse
Occupation: retired inspector
Tobacco: denies
ETOH: wine occassionally with dinner
Family History:
Denies premature coronary artery disease
Physical Exam:
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] midline surgical scar
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: alert and oriented x3, weakness right side - noticable
with grasp however arm strength equal
Pulses:
Femoral Right: cath site Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2162-4-9**] WBC-7.2 RBC-4.67 Hgb-13.5* Hct-38.6* Plt Ct-240
[**2162-4-9**] PT-13.0 PTT-22.8 INR(PT)-1.1
[**2162-4-9**] Glucose-82 UreaN-22* Creat-0.9 Na-137 K-4.0 Cl-104
HCO3-24
[**2162-4-9**] ALT-17 AST-17 LD(LDH)-175 CK(CPK)-33* AlkPhos-65
Amylase-42 TotBili-0.4
[**2162-4-9**] Albumin-3.9 Calcium-8.6 Phos-3.8 Mg-2.0
[**2162-4-9**] %HbA1c-5.6
[**2162-4-12**] Intraop TEE:
PREBYPASS
- The left atrium and right atrium are normal in cavity size.
- No spontaneous echo contrast is seen in the left atrial
appendage.
- No atrial septal defect is seen by 2D or color Doppler.
- Cessile mass on left side of interatrial septum measuring
0.9cm at base and 0.6cm height
- Left ventricular wall thicknesses and cavity size are 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.
- Trace aortic regurgitation is seen.
- The mitral valve leaflets are structurally normal.
- Mild (1+) mitral regurgitation is seen.
POSTBYPASS
- An interatrial patch is in place. Mass has been removed.
- LV Function remains perserved
- Small PFO found on lower aspect of interatrial septum
- Trace aortic regurgitation is seen.
- Mild (1+) mitral regurgitation is seen.
- Intact aorta.
SPECIMEN SUBMITTED: Atrial Mass.
Procedure date Tissue received Report Date Diagnosed
by
[**2162-4-12**] [**2162-4-12**] [**2162-4-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/mrr??????
DIAGNOSIS:
Left atrial mass:
Consistent with atrial myxoma with fresh hemorrhage and focal
associated fibrosis of subjacent atrial wall.
Clinical: Atrial myxoma.
Gross: The specimen is received fresh labeled with the patient's
name, "[**Known firstname **] [**Known lastname 85786**]", the medical record number and "atrial
mass." It consists of a fragment of white fibrous tissue overall
measuring 2.0 x 2.0 x 0.3 cm. Emulating from the center of the
tissue is a red raised fragment of gelatinous tissue measuring
1.0 x 0.6 cm raised 1.0 cm above the surface of the specimen. On
cut section the mass is red and hemorrhagic within the center.
The specimen is submitted entirely in cassettes A-B.
Brief Hospital Course:
Mr. [**Known lastname 85786**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation which included a
neurology evaluation. It was felt the risk of hemorrhagic
conversion of his left parietal cortical infarct was relatively
low risk, and he was cleared for surgery. On [**4-12**], Dr.
[**Last Name (STitle) 914**] performed removal of left atrial mass. For surgical
details, please see operative note. Given inpatient stay was
greater than 24 hours prior to operation, he was given
Vancomycin for perioperative antibiotic coverage. Following
surgery, he was brought to the CVICU for invasive monitoring.
Within 24 hours, he awoke neurologically intact and was
extubated without incident. His CVICU course was uneventful, and
he transferred to the telemetry floor on postoperative day one.
He was gently diuresed toward his preop weight.Went into rapid A
fib and was loaded with amiodarone. No coumadin per Dr. [**Last Name (STitle) 914**].
Chest tubes and pacing wires removed per protocol. Cleared for
discharge to home with VNA on POD #5 by Dr. [**Last Name (STitle) **].
Medications on Admission:
Medications at home: Nexium 40 mg [**Hospital1 **], Albuterol 2 puffs q4h prn
Medications at OSH: Simvastatin 10 mg qhs, Aspirin 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
Disp:*2 MDI* Refills:*1*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: 400 mg [**Hospital1 **] through [**4-22**]; then 400 mg daily
[**Date range (1) 1813**]; then 200 mg daily until cardiologist reevaluates.
Disp:*80 Tablet(s)* Refills:*0*
8. Nexium 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*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Ansdisys Home Care
Discharge Diagnosis:
Left Atrial Mass s/p Surgical Excision
Postop Atrial Fibrillation
Recent Stroke
Asthma
Gastric esophageal reflux disease
Barrett's esophagus
History of Prostate Cancer s/p Prostatectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] on [**2162-4-27**] @ 1:30 PM [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 13013**] in 6 weeks
Cardiologist Dr. [**Last Name (STitle) 39975**] in 4 weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2162-4-17**]
|
[
"V10.46",
"E849.7",
"493.90",
"782.0",
"427.31",
"530.85",
"997.1",
"E878.8",
"212.7",
"438.6",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"39.61",
"38.93",
"35.61"
] |
icd9pcs
|
[
[
[]
]
] |
7304, 7353
|
4456, 5569
|
298, 392
|
7583, 7679
|
2140, 4433
|
8220, 8619
|
1386, 1428
|
5761, 7281
|
7374, 7562
|
5595, 5595
|
7703, 8197
|
5616, 5738
|
1443, 2121
|
246, 260
|
420, 889
|
911, 1221
|
1237, 1370
|
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