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76,896
| 170,213
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36914
|
Discharge summary
|
report
|
Admission Date: [**2130-6-11**] Discharge Date: [**2130-7-4**]
Date of Birth: [**2053-9-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Cerebral Angiogram with coiling of aneurysms
External ventricular drain placement
History of Present Illness:
76yo female while at home was sitting / eating and developed and
acute constant pain behind her right eye that migrated down
right lateral posterior neck. She continued to c/o severe right
headache and was noted to have a left facial droop. She passed
out and was then lowered to the floor, EMS called, transported
to OSH where CT imaging of the brain revealed a large SAH, IVH.
She was transferred to [**Hospital1 18**] for further Neurosurgical eval
Past Medical History:
CAD, HTN, Dyslipidemia, Nonischemic Cardiomyopathy, LBBB,
CHF, Syncope, s/p Chole, Crdiac cath [**2126**](50% LAD, Non
obstructive, EF 20-25%,Implanted biventricular pacer [**2129-4-13**]
Social History:
single. Lives with daughter
Family History:
non-contributory
Physical Exam:
On Discharge:
Expired
Pertinent Results:
IMAGING:
CT/A of Head [**6-11**]:
FINDINGS: In the interval since the prior study, there has been
placement of a right ventriculostomy. The caliber of the
ventricles appears unchanged. Again seen is extensive
subarachnoid hemorrhage and intraventricular hemorrhage. There
has been re-distribution of intraventricular hemorrhage with a
larger amount now present in the right lateral ventricle. Again
seen is extensive subarachnoid hemorrhage, most prominent in the
left suprasellar cistern and middle cranial fossa. These leads
appear most related to the expected location of the posterior
communicating artery. They appear medial to the carotid
bifurcation. There is hydrocephalus, unchanged since the prior
study. Diffuse periventricular white matter hypodensity suggests
chronic small-vessel ischemia. There are calcifications of the
cavernous carotid arteries bilaterally. The CTA examination is
partially complete, but post processing has not been
performed. There is a 9 x 11 mm markedly irregular and
multilobulated
aneurysm arising from the left internal carotid artery at the
expected
location of the posterior communicating artery. The aneurysm's
size,
irregular configuration, and relationship to the distribution of
blood
suggests that this is the bleeding lesion. There is an 11 x 6 mm
lobulated aneurysm arising from the bifurcation of the left
middle cerebral artery. This points directly lateral. Although
the appearance of this aneurysm would be concerning for a
bleeding lesion, the distribution of blood does not center
around this location. There is a 4 mm aneurysm arising from the
anterior communicating artery, near its junction with the left
anterior cerebral artery. Again, the blood distribution does not
appear typical for an anterior communicating artery aneurysm.
However, there is interhemispheric hemorrhage. Limited views of
the posterior circulation demonstrate no definite aneurysm
formation. However, sensitivity is limited in the absence of the
volume-rendered images.
CONCLUSION: No evidence of new hemorrhage.
Status post right lateral ventriculostomy placement with
increased blood
within the body of the right lateral ventricle. Three left-sided
aneurysms located at the origin of the posterior communicating
artery, the left MCA bifurcation, and the junction of the left
ACA with the anterior communicating artery. A preliminary report
was generated that read "multiple intracranial aneurysms (?
related to hypertension, female sex versus systemic issues such
as fibromuscular disease, polycystic kidney disease)". 3 x 4 mm
small-neck aneurysm at junction of ACOM and A1 segments. 6 x 11
x 6 mm bilobed aneurysm at M1-M2 junction with 2-3 mm neck. 7 x
13 x 11 mm multilobulated supraclinoid left ICA aneurysm with a
2-3 mm neck. Basilar tip prominent but without frank aneurysm.
Right frontal ventriculostomy catheter in place with tip
abutting portion of parenchyma but slight decrease in size to
lateral ventricles. Appearance of diffuse subarachnoid
hemorrhage, left subdural hematoma, and intraventricular
hemorrhage is stable.
CT Head [**6-14**]:
FINDINGS: There are two aneurysm coils in the left hemisphere
which cause
extensive streak artifact limiting evaluation in this region.
Diffuse
subarachnoid hemorrhage, particularly notable in bilateral
sylvian fissures appears stable. A left temporal lobe
intraparenchymal hemorrhage with surrounding hypodensity likely
edema, also appears stable in size, as does a SDH along the
medial border of the left temporal lobe. Hyperdense material
layers in bilateral occipital horns are present in the right
lateral ventricle. The volume of intraventricular hemorrhage
appears stable. No blood is seen in the third or fourth
ventricle. The size of the ventricles appears unchanged.
Position of a right transfrontal ventriculostomy catheter is in
unchanged position, with the tip in the right frontal [**Doctor Last Name 534**].
There is trace hyperdense material surrounding the tract of the
ventriculostomy catheter (2:19), unchanged. Periventricular
white matter hypodensity is stable likely the sequelae of small
vessel microvascular infarction. There is no significant shift
of normally midline structures. A burr hole is present in the
right frontal skull. Otherwise, osseous structures appear
intact. Paranasal sinuses, ethmoid, and mastoid air cells are
well aerated. Soft tissue density material
is present in bilateral external auditory canals which may be
cerumen, but
would recommend clinical correlation. Calcifications are present
in lateral carotid siphons as well as the vertebral arteries.
IMPRESSION:
1. Stable appearance to diffuse subarachnoid, intraventricular,
left temporal lobe parenchymal and subdural hemorrhage, along
the medial border of the left temporal lobe. No new foci of
hemorrhage are identified.
2. Unchanged slight ventriculomegaly.
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2130-6-16**] 11:51 AM
Final Report
CTA CRANIAL VESSELS, WITH CONTRAST.
CT HEAD: Compared to the most recent head CT from [**2130-6-14**],
there is no change in diffuse subarachnoid hemorrhage, including
in bilateral sylvian fissures, as well as the subdural hematoma
along the medial border of the left temporal lobe, left temporal
lobe parenchymal hemorrhage and surrounding hypodensity, as well
as intraventricular extension. There is no hemorrhage seen in
the third or fourth ventricles, and the ventricular size and
configuration are stable. The position of the right transfrontal
ventriculostomy catheter is unchanged.
Extensive streak artifact in the region of left MCA and left
PCom aneurysm
severely limits evaluation of these regions. Persistent flow in
the coiled
aneurysms cannot be assessed.
There is no significant shift of normally midline structures.
Periventricular white matter hypodensity, unchanged, likely
represents sequelae of chronic small vessel infarction in a
patient of this age.
CTA: Again noted is a 3-mm aneurysm arising from the anterior
communicating artery. Extensive streak artifact limits
evaluation of vessels in the region of the coiled left MCA and
left PCom aneurysms; the presence of persistent flow into these
aneurysms cannot be assessed. However, the caliber of the major
vessels and their branches, in both the anterior and posterior
circulation appears reduced, diffusely and globally, compared to
most recent CTA of [**2130-6-11**], though the overall number of
distal branches appears similar to the prior study.
IMPRESSION:
1. Diminished caliber of the cerebral vessels, diffusely, in
both the
posterior and anterior circulation, concerning for diffuse
vasospasm.
N.B. Dedicated perfusion imaging was not requested.
2. Stable appearance to diffuse subarachnoid, intraventricular,
left temporal lobe parenchymal, and subdural hemorrhage. No new
foci of hemorrhage are identified.
3. Unchanged slight ventriculomegaly.
4. Persistent flow into the two recently-coiled aneurysms cannot
be assessed, due to extensive metallic star artifact.
5. 3mm Acom aneurysm is unchanged.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2130-6-17**] 4:33
AM
Final Report
PORTABLE AP CHEST RADIOGRAPH: ET tube tip is terminating 19 mm
above the
carina. Right central line with tip terminating in the upper
SVC. The
defibrillator biventricular pacer is unchanged in position. NG
tube is in
place with tip in the gastric fundus wall with a distended
gas-filled stomach. Unchanged left lower lobe opacity, likely
atelectasis, and slight increase in small left pleural effusion.
It is recommended that ET tube should be readjusted.
Radiology Report BILAT LOWER EXT VEINS PORT [**2130-6-18**] 10:13 AM
Final Report
FINDINGS: [**Doctor Last Name **]-scale and color Doppler imaging of the common
femoral,
superficial femoral, and popliteal veins are performed
bilaterally. Normal
compressibility, waveform, flow, and augmentation is
demonstrated in the
majority of these vessels. Compression of the right common
femoral vein is
incomplete. Color flow images of the right common femoral vein
suggest a tiny peripheral filling defect, though this is
equivocal.
IMPRESSION:
1. No left lower extremity DVT.
2. Limited compressibility of right common femoral vein may be
technical or may represent a tiny focus of chronic thrombus.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2130-6-19**] 3:51
AM
Final Report
IMPRESSION: AP chest compared to [**6-11**] through 13. Right lung
is clear,
mildly hyperinflated. Opacification at the left lung base
medially which
could be atelectasis or pneumonia is unchanged for the past
several days and small left pleural effusion may be present.
Heart size is normal. ET tube, nasogastric tube, right atrial
and left ventricular pacer and right
ventricular pacer defibrillator leads, and right internal
jugular vascular
line all in standard placements. No pneumothorax. Right clavicle
absent.
Brief Hospital Course:
Ms. [**Known lastname 83323**] came in with a large left temportal hemmorrgage
with extention into the left lateral ventricle. A EVD was placed
on admission and an four vessel angiogram showed a left PCOM, L
MCA and an ACOMM aneursym.
The Left PCOM AND MCA aneursyms were coiled, the ACOMM aneursym
was small in size and did need intervention.
The patient was moved the intensive care unit intubated. On
[**6-14**] became febrile, presumably with a VAP, full cultures were
sent and she was bronched for a sputum sample.
On [**6-16**] a CTA was performed to r/o vasospasm and it showed
diffuse vasospasm and hypertensive therapy was initiated. In
lue of her fevers she was transitioned to Keppra and weaned off
of dilantin. Lower extremity dopplers were not specific for
DVT. A family meeting was had on [**6-19**] and it was decided that
the pt would receive agressive treatment. The general surgery
team was consulted for Trach and peg placement. However, the
patient's respiratory status improved over the next two days and
she was extubated on [**6-21**] and tolerated being off the
ventilator. Neurologically she was brighter and following some
commands.[**6-22**] EVD clamped and pt failed the challenge at this
time. ICP elevated and sustained >15min. Pt did not tolerate
clamping trials and had CTA on [**6-24**] which showed mild vasospasm,
HHH therapy was continued and pan cultured due to fevers. She
was then reintubated for increased respiratory rate and
decreased SpO2. Her exam worsended no longer following commands.
Head CT was stable and was started on Vanc/Zosyn/Cipro for CSF
and PNA converage. On [**6-27**] she has spontaneous eye opening
however still not following and commands and minimal movement of
BLE. She then began extensor posturing and head CT was stable
however EVD was decreased to 10cm H2O. Cultures were resent due
to fevers and EEG was done for concern of seizures which were
later confirmed. She was then started on dual agents for seizure
addidng Keppra to regimine per Neurology. No bacteria grew from
cultures and it was deemed that Fevers were central in origin
and Abx were stopped except for drain prophylaxis.
On [**6-30**] She had a worsening exam (no eye opening, no movement to
noxious and continued seizures) A CT showed:interval evolution
of large hypodensity in the left MCA distribution, likely
reflecting evolvution of prior intraparenchymal hemorrhage with
superimposed ischemia. The increased edema causes significant
and increased
mass effect, with rightward midline shift increasing from
approximately 5 mm. An angiogram showed questionable minimal
spasm left M2 branches. Ms [**Known lastname 83323**] continued to seize
throughout the 27th and [**7-2**] with a poor exam. On [**7-3**] our team and Neurology met with the family they decided to
pursue comfort measures only to be implemented on [**7-4**](noontime)
when additional family member were present. Palliative care was
also consulted to assist with this process and hospice planning.
On [**7-4**], with family at the bedside; supportive care was
withdrawn and implemented comfort measures only. She expired at
19:03pm. The family declined an autopsy (HCP: [**Name (NI) 1785**] [**Name (NI) 83323**]).
Medications on Admission:
Protonix, Coreg, Aldactone, Zestril, Albuterol, Lovastatin
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Left Pcomm Aneurysm Rupture
Left MCA aneurysm
Anterior Communicating Artery Aneurysm
Obstructive Hydrocephalus
Intraventricular Hemorrhage
Intraparanchymal Hemorrhage
Respiratory failure
Ventilator associated Pneumonia
Coma
Protien/Calorie malnutrition
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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"348.5",
"428.0",
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"599.0",
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] |
icd9cm
|
[
[
[]
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,711
| 155,303
|
168
|
Discharge summary
|
report
|
Admission Date: [**2174-8-8**] Discharge Date: [**2174-8-17**]
Service: [**Location (un) 259**] MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
woman, a resident of [**Hospital3 **] Facility, with
end-stage dementia, diabetes mellitus, and multiple other
medical problems, who presented to [**Hospital6 649**] with a history of lethargy, cough, fever, and
shortness of breath.
According to the [**Hospital 228**] [**Hospital3 **] chart, the
patient had several recurrent temperatures to 101?????? and 102??????
over the two weeks prior to admission which were attributed
to her stage 3 sacral decubitus ulcers; the patient had been
treated with Levofloxacin and Flagyl for some time.
On the day prior to admission, the patient's Flagyl was
changed to Clindamycin. Over the few days prior to
admission, the patient exhibited increased lethargy, as well
as increased shortness of breath. The patient was
transferred to [**Hospital6 256**] for
further management.
PAST MEDICAL HISTORY: 1. Dementia. 2. Arthritis. 3.
Hypertension. 4. Coronary artery disease; status post
myocardial infarction times two; recent echocardiogram
revealed an ejection fraction of 55%. 5. Glaucoma. 6.
History of Clostridium difficile colitis. 7. Paroxysmal
atrial fibrillation. 8. Bilateral pleural effusions. 9.
Anemia of chronic disease. 10. Diabetes mellitus type 2.
11. Chronic sacral decubiti. 12. Recurrent urinary tract
infections. 13. Recurrent aspiration pneumonia. 14.
Question of chronic obstructive pulmonary disease.
ALLERGIES: CEFTRIAXONE WHICH CAUSES A RASH.
MEDICATIONS ON ADMISSION: Clindamycin 150 mg q.i.d., Motrin
400 mg p.o. q.8 hours, Apap 650 mg p.r. q.4 hours,
Multivitamin q.d., Nizatidine 150 mg q.d., Risperidone 0.5 mg
b.i.d., Zinc Sulfate 220 mcg q.d., Humulin NPH Insulin 3 U
subcue q.12 hours, Ultracal tube feeds 65 cc/hr continuous,
Amiodarone 400 mg b.i.d., Ascorbic Acid 500 mg q.d., Aspirin
325 mg q.d., Lasix 20 mg p.o. q.d., Hyoscyamine Sulfate 0.125
mg sublingual b.i.d., Levofloxacin 250 mg q.d., Bisacodyl
suppository 10 mg per rectum q.d., Ibuprofen 400 mg q.8 hours
for knee pain, Lorazepam 0.5 mg q.6 hours p.r.n. for
agitation, Magnesium Hydroxide suspension 30 ml p.r.n.,
Morphine Sulfate 2 mg sublingual q.4 hours p.r.n.
PHYSICAL EXAMINATION: Vital signs: On presentation
temperature was 104??????, heart rate 71, blood pressure 100/60,
respirations 44/min, oxygen saturation 80% on room air and
subsequently 100% after intubation on the ventilator.
General: The patient was an ill-appearing, elderly woman.
HEENT: Mucous membranes slightly dry. Pupils equal and
reactive to light. Neck: No lymphadenopathy. No jugular
venous distention. Cardiovascular: Regular, rate and
rhythm. Normal S1 and S2, though distant heart sounds.
Pulmonary: Diffuse rhonchi breath sounds bilaterally.
Abdomen: Soft, nontender, nondistended. Positive
normoactive bowel sounds. PEG tube in place. Extremities:
No edema. Wasted extremities. Vascular: Good capillary
refill. Dermatology: Large stage 3-4 sacral decubitus
ulcers with some granulation tissue present.
LABORATORY DATA: On presentation CBC revealed a white count
of 24.8, a hematocrit of 33.5, platelet count 417,000; CHEM7
revealed a sodium of 139, potassium 5.5, chloride 100, bicarb
25, BUN 45, creatinine 1.0, glucose 527; coag studies
revealed PT 14.1, PTT 24, INR 1.3; urinalysis revealed large
blood and nitrite positive, 22 red blood cells, 6 white blood
cells, occasional bacteria; blood cultures were sent with 1
out of 2 bottles coming back positive for diphtheroids, this
was presumed to be contaminant, although it would have been
covered by subsequent antibiotic treatment; ABG revealed a pH
of 7.53, pCO2 38, pO2 52.
Electrocardiogram revealed sinus rhythm in the 80s with a
normal axis, normal [**Doctor Last Name 1754**], normal intervals, U-wave, early
transition, 0.[**Street Address(2) 1755**] depression in leads II, III, and AVF.
Chest x-ray revealed right lower lobe and left lower lobe
infiltrates.
Other studies of note were a recent echocardiogram from
[**2174-6-30**], which revealed an ejection fraction of 60%,
2+ mitral regurgitation noted, as was a small to moderately
sized pericardial effusion, there were no echocardiographic
signs of tamponade, there was no significant change from a
prior echocardiogram of [**2174-6-27**].
Urine culture taken on admission later revealed growth of
Proteus mirabilis.
Wound culture from the patient's decubitus ulcer grew out
MRSA. Sputum culture from [**2174-8-8**], grew out
Proteus mirabilis and MRSA.
Stool studies from [**2174-8-8**], revealed positive
Clostridium difficile.
Blood cultures from [**2174-8-8**], were negative for any
growth.
HOSPITAL COURSE: In the Emergency Department, the patient
was noted to be in respiratory distress (please above noted
arterial blood gas), and the patient was also found to be
hypotensive with a systolic blood pressure running in the
60s. The patient was intubated emergently and started on
Dopamine after which her systolic blood pressure rose to the
90s and 100s. The patient was admitted directly into the
Medical Intensive Care Unit.
The [**Hospital 228**] medical Intensive Care Unit course is notable
for the following events:
The patient was started on Vancomycin 750 mg IV q.24 hours,
as well as Flagyl 500 mg per PEG tube q.8 hours on the
evening [**8-7**] and the morning of [**8-8**].
[**8-7**] through [**8-8**], a left IJ was placed. The
patient was weaned off pressors. The patient spiked a
temperature to 103??????.
[**8-8**] through [**8-9**], the patient's systolic
blood pressure dipped again down into the 70s, and thus she
was restarted on pressors.
[**8-9**] through [**8-10**], the patient was again
weaned off pressors. She was also ruled out for myocardial
infarction by serial enzymes. A hematocrit drop over the
previous several days from 33.5 to 27.8 to 25.9 prompted a
transfusion of 2 U of packed red blood cells with an
appropriately elevated hematocrit thereafter. The patient
also spiked a temperature to 101??????. The patient was found to
be C-diff colitis positive and was continued on Flagyl.
[**8-10**] through [**8-11**], the patient was found to
have MRSA from her decubitus ulcer culture. Sputum grew out
Proteus mirabilis and MRSA. The patient was started on
Ampicillin 2 g IV q.12 hours on [**8-11**].
[**8-11**] through [**8-12**], the patient had a brief
episode of hypotension with systolic blood pressure running
in the 80s.
On [**8-13**], the patient was extubated.
On [**8-14**], the patient had an oxygen saturation of 99%
on shovel mask and was subsequently transferred to the
Medicine floor.
While on the Medicine floor, the patient's above noted
antibiotics were continued. Also, a PICC line was placed on
the evening of [**2174-8-16**]. Subsequently the
patient's left IJ was pulled. During the patient's course on
the Medical floor, she remained afebrile, and her white count
remained in the normal range. She was noted to have some
hyponatremia to 131. Otherwise, her course was stable, and
she continued to do well on oxygenation by mask.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Sepsis.
2. Pneumonia.
3. Urinary tract infection.
4. Clostridium difficile colitis.
5. Dementia.
6. Hypertension.
7. Diabetes mellitus type 2.
8. Coronary artery disease.
9. Methicillin resistant Staphylococcus aureus positive
decubitus ulcer.
DISCHARGE MEDICATIONS: Multivitamin 1 per PEG q.d., Heparin
5000 U subcue b.i.d., Aspirin 81 mg per PEG q.d., Zinc
Sulfate 220 mcg per PEG q.d., Ampicillin 2 g IV q.12 hours to
finish on [**2174-8-25**], Vancomycin 750 mg IV q.24 hours to
finish on [**2174-8-20**], Flagyl 500 mg per PEG q.8 hours
to finish on [**2174-8-20**], Ascorbic acid 500 mg per PEG
q.d., Amiodarone 200 mg per PEG q.d., hold for systolic blood
pressure less than 90, NPH Insulin 10 U subcue q.a.m., 6 U
subcue q.p.m., regular Insulin sliding scale, for fingerstick
0-60 give 1 amp D50, call physician, 61-150 give nothing,
151-180 give 2 U subcue, 181-210 give 4 U subcue, 211-240
give 6 U subcue, 241-270 give 8 U subcue, 271-300 give 10 U
subcue, greater than 300 give 12 U subcue and call physician,
[**Name Initial (NameIs) 1756**] 5 mg per PEG q.6 hours, Risperidone 0.5 mg per PEG
b.i.d., Morphine 1-2 mg IV q.2 hours p.r.n., Prevacid 30 mg
per PEG q.d., Neutra-Phos 1 packet per PEG q.i.d.
FOLLOW-UP: The patient is to be discharged back to her
residence at [**Hospital3 **] and subsequently follow-up
with her primary care physician within the following week.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1757**], M.D. [**MD Number(1) 1758**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2174-8-16**] 19:35
T: [**2174-8-16**] 19:33
JOB#: [**Job Number 1759**]
|
[
"599.0",
"707.0",
"414.01",
"038.9",
"507.0",
"518.81",
"496",
"427.31",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7531, 8964
|
7250, 7507
|
1638, 2306
|
4791, 7195
|
2329, 4773
|
146, 997
|
1020, 1611
|
7220, 7229
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,816
| 118,864
|
52904
|
Discharge summary
|
report
|
Admission Date: [**2101-1-6**] Discharge Date: [**2101-1-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p mechanical fall, C2 fracture
Major Surgical or Invasive Procedure:
1. Open tracheostomy.
2. Percutaneous endoscopic gastrostomy.
History of Present Illness:
This is an 88 yo male s/p mechanical fall from standing 4 days
prior to presentation. He initially presented w. complaints of
neck pain and was subsequently transferred from OSH after being
diagnosed with C2 fracture and pneumonia. He was also found to
be in atrial fibrillation. No neurologic symptoms. No headache
or head injury or LOC. No SOB or palpitations or cough, although
pt was moderately confused and very poor historian.
Past Medical History:
1. Coronary artery disease s/p CABG [**2086**], MI [**2078**]
2. Benign prostatic hypertrophy s/p bladder diverticulectomy and
prostate resection.
3. Bladder diverticulum s/p bladder diverticulectomy and
prostate resection.
4. Hypertension.
5. Hypercholesterolemia.
6. Migraine
7. DM
Social History:
Smoked cigars and pipes for 40 yrs (3 per day), quit 15 yrs ago.
Occas EtOH use. Retired lawyer. Lives with his wife.
Family History:
NC
Physical Exam:
VS:
T 99 HR 59 (AF) 102/43 14 100%on 10L TM
ventilated via tracheostomy
somewhat confused
rhonchrous BS bilat
irreg irreg
1+ edema, no cyanosis, clubbing
Pertinent Results:
.
CK: 223 MB: 5 Trop-T: 0.02
.
[**2101-1-6**]
02:40a
Trop-T: 0.02
.
[**2101-1-5**]
UA Glu 1000, + ketones
.
[**2101-1-5**]
10:42p
K:3.9
Glu:287
[**2101-1-5**]
10:30p
Trop-T: 0.02
.
135 96 24 AGap=16
------------ 319
3.9 27 1.2
.
CK: 160 MB: 5
.
Ca: 9.1 Mg: 1.9 P: 2.6
13.7 ∆
11.9 --------301 ∆
40.3
N:82.5 L:12.8 M:4.0 E:0.5 Bas:0.3
PT: 11.3 PTT: 24.7 INR: 0.9
.
MICRO:
[**1-6**] MRSA: NEG
[**1-7**] Ucx: NEG
[**1-7**] RPR: pending
[**1-7**] Bcx: Pending
[**1-7**] MRSA screen: POS
[**1-10**] cath tip - NEG
[**1-10**] BAL - MRSA
.
IMAGING:
[**2101-1-6**] CT Chest: Mildly displaced left 8th-10th rib fx with
assoc. consolidation of adjacent lung, likely reflect contusion.
Small cystic spaces in right lower lobe medial basal, may
reflect pneumatoceles. T3 compression fx, likely acute
[**2101-1-6**] CT L-spine: No fx or spondylolisthesis
[**2101-1-6**] ECHO: The LA is elongated. The RA is moderately dilated.
Mild symmetric LV hypertrophy with normal cavity size. Mild
regional LV systolic dysfunction with inferior akinesis and
hypokinesis of the basal inferolateral and inferoseptal
segments. The remaining segments contract normally (LVEF =
40-45%). RV chamber size and free wall motion are normal. Mild
MR & AR.
[**1-7**] CT head: no ICH
[**1-7**] CXR: increased LLL effusion
[**1-10**] CXR: no pneumo s/p bronch, slight improvement in aeration @
bases
[**1-12**] CXR: trach in standard placement. mild bibasilar
atelectasis stable, small right pleural effusion has increased,
no pulmonary edema, heart size is normal. No pneumo. Right PIC
line passes to the edge of the right chest cage, and a leftPIC
line can be traced to the junction of the brachiocephalic veins.
Brief Hospital Course:
The patient is an 88yoM admitted to the trauma surgery service
on [**2101-1-6**] s/p mechanical fall from standing; tx'd from OSH
after being dx'd w/ C2 fracture, and pneumonia; he was initially
admitted to TICU given age and mental status, but was
re-admitted to the TICU within 1 day of tx to the floor for
respiratory distressa and bradycardia requiring intubation. Now
s/p Trach and PEG.
EVENTS:
[**1-6**] Admit to TICU. Transfer to floor.
[**1-7**]: Readmit to TICU [**12-21**] desaturations on NRB (70-80%).
[**1-8**]: Code called - atropine X 2 given, intubation for desats
and bradycardia, mucous plugging.
[**1-8**]: aline, PICC line, changed foley, intermittent bloody UOP.
following commands. intermittent brady to mid-40s.
[**1-10**]: dobhoff placement in IR, trauma line dc'ed, bronch w/ BAL
[**1-11**]: Trops neg. EKG: afib, ? LBBB. cardiology recs: Wenckebach
vs. complete heart block. no intervention at this point as BP
stable during brady episodes, atropine for Sx bradycardia, EP
consult when extubated and more stable as he likely warrants a
pacer. hypotension [**1-12**] oxycodone/hydralazine/PPF at one time,
briefly on neo.
[**1-13**]: started TFs, d/c'ed cefepime & cipro after sputum ->
+MRSA, PT/OT
Neuro: The patient was diagnoaed with C2 fracture, but was
neurologically intact. Neurosurgery spine was consulted and
recomended that the remain in [**Location (un) 2848**] J at all times for at least
4 weeks. No logroll or sugical intervention needed. The pt will
need to f/u with NS in 4 weeks with repeat C-spine CT. He also
had difficulty with altered mental status and delirium during
his hospitalization. He received oxycodone and morphine for pain
while admitted.
CV: The patient was found to be in atrial fibrillation on
admission. He also had episodes of intermittent bradycardia.
Cardiology was consulted and thought his rhythm was Wenckebach
vs. complete heart block. They additionally recommended that no
intervention be undertaken at this point as the patient's blood
pressure remained stable during bradycardic episodes, that the
patient receive atropine for symptomatic or hypotensive
bradycardia, and recommended starting aspirin. The patient will
likely place a pacemaker when his c-collar is removed.
Pulmonary: The patient's respiratory status decompensated when
transfered to the floor. At that time he was intubated. His
decompensation was thought to be due to an aspiration event as
food pieces and pills were suctioned form his lungs after
intubation. The patient was not able to extubated due to mental
status and secretions, as well as failing several SBTs. He
underwent tracheostomy placement and a PMV was ordered.
GI/GU: The patient was aggressively resuscitated as needed
during his hospitalization in order to maintain urine output.
Due to his aspiration event, the patient had a percutaneous peg
tube placed for tube feeding and he was kept strictly NPO. He
was also started on a bowel regimen to encourage bowel movement.
Foley removal was attempted but had to be replaced due to
urinary retention. Intake and output were closely monitored.
ID: The patient was initially on Levoquin after admission for
community acquired pneumonia. After his respiratory
decompensation, antibiotic coverage was broadened. Additionally,
BAL cultures were sent which grew MRSA. The patient's antibiotic
regimen was narrowed to just Vancomycin. The patient will need
14 days of therapy.
Prophylaxis: The patient received subcutaneous heparin during
this stay. PT was consulted to get the patient out of bed to a
chair.
At the time of discharge on HD#8, the patient was doing well,
afebrile with stable vital signs on TM mask, tolerating tube
feeds, foley in place and pain was well-controlled on PO pain
medication.
Medications on Admission:
asa 81', lisinopril ?, lasix 40', glipizide ?, glucophage ?,
provastatin, Fosamax 70 mg q weekly
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unites Injection TID (3 times a day).
Disp:*90 injections* Refills:*0*
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): Use only if patient is on
mechanical ventilation. .
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
Disp:*qs doses* Refills:*0*
4. Oxycodone 5 mg/5 mL Solution Sig: 5-15 mLs PO every 4-6 hours
as needed for pain: Hold for sedation, RR < 12.
Disp:*200 mLs* Refills:*0*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for SOB.
Disp:*qs * Refills:*0*
7. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for SBP < 110, HR < 60 .
Disp:*120 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP < 110 .
Disp:*30 Tablet(s)* Refills:*0*
9. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units Injection ASDIR (AS DIRECTED): per sliding scale.
Disp:*qs units* Refills:*0*
10. Vancomycin in 0.9% Sodium Cl 1 gram/250 mL Solution Sig:
1250 mg Intravenous once a day for 7 days: Last day [**1-21**] for
14 day course.
Disp:*qs * Refills:*0*
11. 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.
12. 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.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 30 days.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
88yoM s/p mechanical fall from standing
Primary: 1. type III C2 fx
2. T3 compression fx
3. L posterior [**6-28**] rib fx
4. L anterior 5th rib fx
5. Pneumonia, MRSA
6. Delirium (altered mental status)
7. Bradycardia/Atrial fibrillation
8. Aspiration
Secondary: 1. hypertension, 2. non-insulin dependent diabetes
mellitus, 3. coronary artery disease
Discharge Condition:
Mental Status: Confused - mostly
Level of Consciousness: Lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
*You were admitted to [**Hospital1 18**] trauma surgery service after a fall.
You were found to have a fracture of your C2 vertebrae as well
as multiple rib fractures.
*Your course was complicated by development of a hospital
acquired pneumonia, likely due to aspiration (breathing in of
stomach contents), with subsequent respiratory failure requiring
intubation and mechanical ventiation.
* You will need to take 14 days of IV
antibiotics--Vancomycin--to treat your pneumonia. This
antibiotic will treat the bacteria in your sputum called MRSA.
* Due to your respiratory failure, a tracheostomy was done in
the OR to allow you to breathe.
* Due to the fracture in your neck, you must wear the hard
cervical collar at all times. You will need to follow up with
Dr. [**Last Name (STitle) 739**] in 4 weeks with a repeat C-Spine CT.
* You also had multiple episodes of bradycardia (slow heart
rhythm). Cardiology was consulted to evaluate your slow heart
rhthym. They reommended that no beta blockers or calcium
channel blockers be given to you, as this could put you in the
abnormal rhthym. Additionally, if your blood pressure drops due
to this rhythm, you should receive atropine. Finally, when your
neck has healed and your c-collar removed, you will need to have
a pacemaker placed.
* You had a gastric tube placed so you can receive tube feeds to
give you nutrition, as your mental status would not permit you
to eat normally without aspirating food contents.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please take any new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 519**] in 2 weeks. You may call ([**Telephone/Fax (1) 70717**] for an appointment.
Please follow up with follow up with Dr. [**Last Name (STitle) 739**] in 4
weeks with a repeat C-Spine CT scan. Call ([**Telephone/Fax (1) 88**] for an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"428.0",
"482.42",
"401.9",
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"518.81",
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"805.02",
"414.01",
"805.2",
"V46.11",
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icd9cm
|
[
[
[]
]
] |
[
"45.13",
"31.1",
"33.24",
"96.04",
"96.6",
"38.93",
"96.72",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
8962, 9028
|
3215, 6982
|
293, 357
|
9422, 9422
|
1475, 2744
|
11776, 12206
|
1278, 1282
|
7129, 8939
|
9049, 9401
|
7008, 7106
|
9596, 11753
|
1297, 1456
|
221, 255
|
385, 819
|
2753, 3192
|
9437, 9572
|
841, 1126
|
1142, 1262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,441
| 121,195
|
32385
|
Discharge summary
|
report
|
Admission Date: [**2199-12-29**] Discharge Date: [**2200-1-3**]
Date of Birth: [**2176-1-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Multiple traumatic stab wounds
Major Surgical or Invasive Procedure:
Exploratory laparotomy
Thoracotomy
Pericardiotomy
Oversewing of lacerated right ventricle and
Hepatorrhaphy
History of Present Illness:
23 M stab victim x 3 (ant left chest, midline epigastrum, L
temple) to OR emergently for (+) FAST with pericardial effusion.
Primary repair of RV stab wound, left liver lac, and left 5th
intercostal bleed. Transfused 14u PRBC intraop, taken to TSICU
w/ stable VS.
Past Medical History:
Noncontributory
Social History:
Pt lives alone in [**Location (un) 47**], works in warehouse, has s.o. who
is also with him today. He also has younger sister who still
lives at home. Pt states he does not
remember what happened exactly.
Family History:
Noncontributory
Physical Exam:
General Appearance: WDWN 23 y/o male in NAD
Vitals: 99.2 96.8 HR 76 BP 106/52 RR 18 SAT 98/RA
HEENT: Stitches in place over eye
Cor:Nl s1, s2
Lung: CTAB
Thoracotomy incision is well healing CDI without erythema or
exudate.
Abd: s/nt/nd; well healing laparotomy incision CDI without
erythema or exudate
Extremities: no c/c/e
Pertinent Results:
[**1-2**] ECHO: Overall left ventricular systolic function is low
normal (LVEF 50-55%). There is abnormal septal motion/position.
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 borderline pulmonary artery systolic
hypertension. There is no pericardial effusion seen (limited
echo windows). Compared with the prior study (images reviewed)
of [**2199-12-29**], LVEF has improved. RV function cannot be reliably
assessed tdue to suboptimal image quality (probably improved
RVEF). There is now at least mild to moderate tricuspid
regurgitation appreciated.
.
[**1-1**] CXR: IMPRESSION: Removal of left chest tube with
unchanged small left-sided pneumothorax.
.
WBC-10.6 RBC-5.54 HGB-16.3 HCT-46.4 MCV-84 MCH-29.4 MCHC-35.1*
RDW-16.5*
[**2199-12-29**] 11:20AM PLT COUNT-125*
[**2199-12-29**] 11:16AM TYPE-ART TEMP-38.2 PO2-166* PCO2-38 PH-7.36
TOTAL CO2-22 BASE XS--3
[**2199-12-29**] 09:14AM TYPE-ART TEMP-37.6 RATES-14/0 TIDAL VOL-654
O2-50 PO2-204* PCO2-39 PH-7.38 TOTAL CO2-24 BASE XS--1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2199-12-29**] 09:14AM freeCa-1.15
[**2199-12-29**] 08:05AM TYPE-ART TEMP-35.4 PO2-304* PCO2-36 PH-7.36
TOTAL CO2-21 BASE XS--4
[**2199-12-29**] 08:05AM LACTATE-3.2*
[**2199-12-29**] 05:55AM GLUCOSE-98 UREA N-19 CREAT-1.3* SODIUM-144
POTASSIUM-4.3 CHLORIDE-114* TOTAL CO2-19* ANION GAP-15
[**2199-12-29**] 05:55AM ALT(SGPT)-129* AST(SGOT)-124* ALK PHOS-76 TOT
BILI-0.8
[**2199-12-29**] 05:55AM CALCIUM-8.1* PHOSPHATE-3.7 MAGNESIUM-2.0
[**2199-12-29**] 05:55AM WBC-13.0* RBC-5.49# HGB-16.5# HCT-48.1#
MCV-88 MCH-30.0# MCHC-34.2 RDW-16.4*
[**2199-12-29**] 05:55AM PLT COUNT-171
[**2199-12-29**] 05:55AM PT-13.3 PTT-24.3 INR(PT)-1.1
[**2199-12-29**] 05:55AM FIBRINOGE-192
[**2199-12-29**] 04:55AM TYPE-ART PO2-144* PCO2-45 PH-7.23* TOTAL
CO2-20* BASE XS--8 INTUBATED-INTUBATED VENT-CONTROLLED
[**2199-12-29**] 04:55AM GLUCOSE-148* LACTATE-5.1* NA+-138 K+-5.5*
CL--112
[**2199-12-29**] 04:55AM HGB-15.7 calcHCT-47
[**2199-12-29**] 04:55AM freeCa-1.15
[**2199-12-29**] 04:14AM TYPE-ART PO2-173* PCO2-53* PH-7.09* TOTAL
CO2-17* BASE XS--14
[**2199-12-29**] 04:14AM GLUCOSE-248* LACTATE-7.3* NA+-138 K+-5.6*
CL--107
[**2199-12-29**] 04:14AM HGB-15.1 calcHCT-45
[**2199-12-29**] 04:14AM freeCa-0.68*
[**2199-12-29**] 03:09AM UREA N-20 CREAT-1.7*
[**2199-12-29**] 03:09AM estGFR-Using this
[**2199-12-29**] 03:09AM AMYLASE-88
[**2199-12-29**] 03:09AM ASA-NEG ETHANOL-66* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2199-12-29**] 03:09AM URINE HOURS-RANDOM
[**2199-12-29**] 03:09AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2199-12-29**] 03:09AM WBC-14.6* RBC-4.08* HGB-11.0* HCT-35.4*
MCV-87 MCH-27.0 MCHC-31.1 RDW-14.5
[**2199-12-29**] 03:09AM PLT COUNT-304
[**2199-12-29**] 03:09AM PT-13.6* PTT-25.0 INR(PT)-1.2*
[**2199-12-29**] 03:09AM FIBRINOGE-239
[**2199-12-29**] 03:09AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2199-12-29**] 03:09AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2199-12-29**] 03:09AM URINE RBC-[**3-18**]* WBC-0-2 BACTERIA-FEW YEAST-OCC
EPI-0-2
[**2199-12-29**] 03:07AM GLUCOSE-133* LACTATE-10.5* NA+-145 K+-4.1
CL--105 TCO2-16*
Brief Hospital Course:
Neuro: The patient's GCS in the field an on presentation was 15.
Pt's pain was controlled with IV narcotics. Pt was placed on
dilaudid pca for pain control directly post op. When patient
transferred to the floor he was converted to PO oxycodone. Pt
remained alert and oriented throughout his hospital stay once
his sedation in the ICU wore off. Pt's stab wound to the temple
did not compromise any neurological pathways. Pt with normal
neuro exam throughout stay in hospital and no complaints of pain
at time of discharge.
.
CVS: Pt had stab wound to right ventricle. He was taken to the
OR and his pericardial effusion was evacuated. Pt received 14
units of blood in the OR to maintain hemodynamic stability. He
was taken to the T-SICU with stable vital signs. A post-op TTE
revealed an initial EF of 30-35%. Three days later, the TTE was
repeated and pt was noted to have an EF of 50-55%. Post-op EKG
showed expected pericarditis, and pt was consulted to Cardiology
with no recommended action. During hospital stay pt received
Heparin SQ TID for DVT prophylaxis. Pt to follow up with
Cardiology as outpatient.
.
Pulm: Pt presented with shortness of breath and decreased mental
status in the trauma bay. He had a left sided chest tube placed
with immediate drainage of 1100 cc's of blood.
Post-operatively, breath sounds were coarse in the upper lobes
and diminished at the bases. With a RSBI of 90, chest tube was
placed to suction. One day after admission, pt was extubated.
He was continued on nasal cannulae at 2 l/min with oxygen
saturation of 97%. Pt was encouraged to use his IS actively.
Three days into the patient's admission, his chest tube was
removed and post-pull PA/LAT CXR was clear with only a small
residual pneumothorax unchanged from prior films. At the time
of discharge Mr. [**Known lastname 805**] was 98% O2 SAT on room air.
.
Renal: Pt had foley placed in the trauma, which was discontinued
on POD2 without complication. U/O was stable during the
remainder of his say with pt's creatinine at 1.0 and his BUN of
16.
.
GI: Pt s/p midline laparotomy for stab wound with extraabdominal
fat. Pt was found to have a 2cm liver lac in the OR that was
oversewn with excellent hemostasis. Pt's midline skin incision
was closed with surgical staples which were in place without any
sign of local infection at the time of discharge. Pt with
return of bowel function, tolerating a regular diet without
nausea, vomiting, or abdominal pain out of proportion to
procedure.
.
Heme: Hematocrit was stable following OR course.
.
ID: Pt treated with peri-operative cefazolin during his hospital
stay. No cultures were taken. Pt with low grade post-op fevers
which resolved by the day of discharge.
.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 7 days.
Disp:*45 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Stab wounds to chest, abdomen, and temple.
Discharge Condition:
Stable, to home
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with trauma clinic in 1 week. Call
[**Telephone/Fax (1) 75628**] to schedule your appointment.
Please also follow up with cardiology clinic, with Drs. [**First Name (STitle) **]
[**Name (STitle) **] and [**Name5 (PTitle) 5543**] who are familiar with your case. Call
[**Telephone/Fax (1) 69442**] to make an appointment.
|
[
"873.49",
"862.39",
"864.15",
"780.6",
"860.5",
"901.82",
"E966",
"861.10",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"50.61",
"39.31",
"37.49"
] |
icd9pcs
|
[
[
[]
]
] |
7991, 7997
|
4863, 7596
|
344, 454
|
8084, 8102
|
1404, 4840
|
9216, 9560
|
1024, 1042
|
7651, 7968
|
8018, 8063
|
7622, 7628
|
8126, 9193
|
1057, 1385
|
274, 306
|
482, 747
|
769, 786
|
802, 1008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,167
| 117,923
|
9431
|
Discharge summary
|
report
|
Admission Date: [**2130-10-3**] Discharge Date: [**2130-10-4**]
Date of Birth: [**2074-8-30**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing / Codeine / Levofloxacin / Bactrim /
Nafcillin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
56YOM with h/o ESLD caused by Hep C and ETOH cirrhosis who lives
at [**Last Name (un) 4367**] [**Hospital3 **] who was found down, being transferred
to the MICU for hypotension.
The patient was reportedly in his normal state without
complaints 30 minutes prior to being found down in the bathroom
by his caretaker. The patient was reportedly very somnolent and
was not verbally responsive or following commands. He was
subsequently brought to the ED.
Of note, the patient was on the transplant list until recently,
with a previous MELD of 18 in [**2129**]. However, he was taken off
the active transplant list due to poor compliance and missing
followups in addition to inadequate social support, poor
housing, and inadequate period of sobriety.
Upon presentation to the [**Hospital1 18**] ED, the patient was found to be
somnolent and was given Narcan with improved mental status. He
was noted to have global aphasia, profound agitation, roving eye
movements, and was not blinking to threat in either visual
fields. His face was symmetric and he was moving all
extremities. A code stroke was called. The patient was
intubated with etomidate/succ for CT head and CT torso which was
negative for acute hemorrhage or infarct but limited due to
motion artifact. There was a concern for possible cerebral
edema, and neurology recommended MRI head for further
evaluation, however then the patient spiked to 104.0 and became
hypotensives to SBP 65 s/p CT scan. He was given vanc,
ceftriaxone, flagyl. Initially responded to boluses, but then
was persistently hypotensive, so R-IJ placed and neo/levophed
ggt started. He was overbreathing the vent so he was paralyzed
with vecuronium. He had difficulty maintaining BP on pressors
and 5 liters of NS boluses and therefore was given stress dose
decadron. Foley placed for low UOP. He went into A fib w RVR,
and was found to have elevated troponins. Cardiology said
demand ischemia and hypotension contributing, and recommended
trending enzymes. He was given calcium gluconate and kayexalate
for hyperkalemia with widening of QRS complex. NG placed, given
lactulose. There was also concern for trauma because of brusing
on the abdominal wall. An OG tube was placed which put out
yellow/green which progressed to dark brown concerning for GI
bleed. Protonix/octreotide ggt ordered but not hung.
.
On arrival to MICU, he was maxed out on levofed. A left femoral
arterial line was placed and was given fluids wide open (3-4L
in MICU). Initial ABG in the MICU was 7.13/69/40/24. K was
7.4, and he was given kayexalate, bicarb, calcium gluconate.
Started stooling w kayexalate, looked maroon. He was
subsequently found to have large, unreactive pupils. Neuro was
consulted and recommended CT head once more stable to evaluate
cerebral edema and possible herniation.
.
Review of systems:
Not able to be obtained as patient is intubated.
Past Medical History:
GERD
Hep C genotype 3A, cirrhosis([**2119**]) c/b EGD Grade I varices,
portal HTN with gastropathy
depression,[**2119**]
hiatal hernia, [**2121**] TIPS for variceal bleed from alcohol abuse
gun shot wound to LE
carpal tunnel syndrome
arthritis
polysubstance abuse: heroin abuse, alcohol abuse, and cocaine
abuse, hepatic encephalopathy x 3, neuropathy/chronic abd pain,
DM II,Acute interstitial nephritis [**3-1**] Nafcillin ([**2129-1-28**])
Social History:
Unable to obtain due to mental status.
Family History:
Unable to obtain due to mental status.
Physical Exam:
On Admission to MICU
General: intubated and sedated
HEENT: Bilateral 5 mm, unreactive pupils. dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, S3 present. no
murmurs, rubs, gallops
Abdomen: soft, obese, distended, small ascities
Skin: multiple areas of ecchymoses across chest
Ext: cool and cyanotic
Pertinent Results:
[**2130-10-2**] 11:20PM BLOOD WBC-9.7# RBC-5.85 Hgb-19.4*# Hct-56.7*
MCV-97 MCH-33.2* MCHC-34.3 RDW-17.1* Plt Ct-73*
[**2130-10-3**] 07:35AM BLOOD WBC-13.3* RBC-3.85* Hgb-13.0* Hct-38.6*
MCV-100* MCH-33.8* MCHC-33.8 RDW-17.8* Plt Ct-32*
[**2130-10-3**] 07:55PM BLOOD WBC-13.6* RBC-3.69* Hgb-12.7* Hct-37.5*
MCV-102* MCH-34.3* MCHC-33.8 RDW-19.6* Plt Ct-36*
[**2130-10-4**] 04:00AM BLOOD WBC-16.1* RBC-3.47* Hgb-11.9* Hct-35.9*
MCV-103* MCH-34.3* MCHC-33.3 RDW-19.6* Plt Ct-56*
[**2130-10-2**] 11:20PM BLOOD Neuts-88.2* Bands-0 Lymphs-7.8* Monos-3.2
Eos-0.4 Baso-0.5
[**2130-10-3**] 06:10AM BLOOD Neuts-79.6* Lymphs-10.6* Monos-8.4
Eos-0.7 Baso-0.7
[**2130-10-3**] 07:35AM BLOOD Neuts-83.0* Lymphs-10.3* Monos-5.6
Eos-0.6 Baso-0.4
[**2130-10-4**] 04:00AM BLOOD Neuts-65 Bands-10* Lymphs-9* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-0 NRBC-5*
[**2130-10-3**] 06:10AM BLOOD PT-28.4* PTT-85.5* INR(PT)-2.7*
[**2130-10-3**] 08:18AM BLOOD PT-44.2* PTT-136.5* INR(PT)-4.6*
[**2130-10-4**] 12:50AM BLOOD PT-27.5* PTT-60.4* INR(PT)-2.6*
[**2130-10-4**] 10:55AM BLOOD PT-38.3* PTT-50.8* INR(PT)-3.9*
[**2130-10-3**] 07:35AM BLOOD Fibrino-67*#
[**2130-10-3**] 08:18AM BLOOD Fibrino-71*
[**2130-10-3**] 08:18AM BLOOD FDP-320-640*
[**2130-10-3**] 10:44AM BLOOD Fibrino-93*
[**2130-10-4**] 10:55AM BLOOD Fibrino-126*
[**2130-10-3**] 07:55PM BLOOD ESR-2
[**2130-10-2**] 11:20PM BLOOD Glucose-116* UreaN-29* Creat-1.9* Na-146*
K-5.8* Cl-106 HCO3-13* AnGap-33*
[**2130-10-3**] 07:35AM BLOOD Glucose-175* UreaN-34* Creat-3.0* Na-147*
K-5.7* Cl-115* HCO3-17* AnGap-21*
[**2130-10-3**] 10:44AM BLOOD Glucose-60* UreaN-35* Creat-2.8* Na-149*
K-4.9 Cl-118* HCO3-14* AnGap-22*
[**2130-10-3**] 07:55PM BLOOD Glucose-255* UreaN-41* Creat-3.3* Na-144
K-5.7* Cl-106 HCO3-7* AnGap-37*
[**2130-10-4**] 10:55AM BLOOD Glucose-199* UreaN-40* Creat-4.0* Na-145
K-5.4* Cl-102 HCO3-12* AnGap-36*
[**2130-10-2**] 11:20PM BLOOD ALT-259* AST-918* LD(LDH)-1400*
CK(CPK)-[**Numeric Identifier 32171**]* AlkPhos-185* TotBili-4.3*
[**2130-10-3**] 06:10AM BLOOD ALT-203* AST-862* LD(LDH)-1335*
CK(CPK)-[**Numeric Identifier 32172**]* AlkPhos-110 TotBili-3.0*
[**2130-10-3**] 10:44AM BLOOD CK(CPK)-[**Numeric Identifier 32173**]*
[**2130-10-4**] 04:00AM BLOOD ALT-1571* AST-6577* LD(LDH)-6440*
CK(CPK)-[**Numeric Identifier 32174**]* AlkPhos-106 TotBili-6.9*
[**2130-10-2**] 11:20PM BLOOD cTropnT-0.33*
[**2130-10-3**] 06:10AM BLOOD CK-MB-70* MB Indx-0.3 cTropnT-1.19*
[**2130-10-3**] 10:44AM BLOOD CK-MB-86* MB Indx-0.4 cTropnT-1.89*
[**2130-10-3**] 07:55PM BLOOD CK-MB-248* MB Indx-0.7 cTropnT-1.93*
[**2130-10-4**] 12:50AM BLOOD CK-MB-293* cTropnT-2.11*
[**2130-10-4**] 04:00AM BLOOD CK-MB-310* MB Indx-0.7 cTropnT-1.86*
[**2130-10-2**] 11:20PM BLOOD Albumin-3.2* Calcium-10.0 Phos-2.2*
Mg-1.8
[**2130-10-3**] 06:10AM BLOOD Calcium-7.7* Phos-6.9*# Mg-1.9
[**2130-10-3**] 07:35AM BLOOD Calcium-7.4* Phos-5.9* Mg-1.7
[**2130-10-4**] 12:50AM BLOOD Calcium-6.6* Phos-9.9*# Mg-2.1
[**2130-10-4**] 10:55AM BLOOD Calcium-6.6* Phos-9.5* Mg-1.9
[**2130-10-3**] 07:35AM BLOOD Hapto-<5*
[**2130-10-3**] 08:18AM BLOOD D-Dimer-GREARTER T
[**2130-10-3**] 04:29AM BLOOD Ammonia-326*
[**2130-10-3**] 02:17PM BLOOD TSH-1.7
[**2130-10-3**] 10:44AM BLOOD Vanco-8.0*
[**2130-10-2**] 11:57PM BLOOD Type-ART Temp-38.8 Tidal V-550 PEEP-10
FiO2-100 pO2-416* pCO2-34* pH-7.39 calTCO2-21 Base XS--3
AADO2-263 REQ O2-51 -ASSIST/CON Intubat-INTUBATED
[**2130-10-3**] 01:54AM BLOOD pO2-422* pCO2-30* pH-7.36 calTCO2-18*
Base XS--6
[**2130-10-3**] 06:23AM BLOOD Type-MIX pO2-82* pCO2-62* pH-7.14*
calTCO2-22 Base XS--8
[**2130-10-3**] 07:01AM BLOOD Type-ART pO2-40* pCO2-69* pH-7.13*
calTCO2-24 Base XS--8
[**2130-10-3**] 07:41AM BLOOD Type-ART Rates-22/15 Tidal V-500 PEEP-10
FiO2-100 pO2-320* pCO2-47* pH-7.20* calTCO2-19* Base XS--9
AADO2-350 REQ O2-63 Intubat-INTUBATED
[**2130-10-3**] 08:38AM BLOOD Type-ART Rates-22/16 Tidal V-500 PEEP-10
pO2-73* pCO2-47* pH-7.18* calTCO2-18* Base XS--10
Intubat-INTUBATED Vent-CONTROLLED
[**2130-10-3**] 10:59AM BLOOD Type-MIX pO2-42* pCO2-33* pH-7.31*
calTCO2-17* Base XS--8
[**2130-10-3**] 11:06AM BLOOD Type-ART Temp-38.7 Rates-22/11 PEEP-10
FiO2-80 pO2-200* pCO2-26* pH-7.35 calTCO2-15* Base XS--9
AADO2-348 REQ O2-62 Intubat-INTUBATED Vent-CONTROLLED
[**2130-10-3**] 02:56PM BLOOD Type-ART Rates-22/13 PEEP-10 FiO2-50
pO2-145* pCO2-22* pH-7.19* calTCO2-9* Base XS--17
Intubat-INTUBATED
[**2130-10-3**] 04:00PM BLOOD Type-[**Last Name (un) **]
[**2130-10-3**] 06:19PM BLOOD Type-ART Temp-36.3 Rates-22/12 PEEP-8 O2
Flow-50 pO2-154* pCO2-20* pH-7.11* calTCO2-7* Base XS--21
Intubat-INTUBATED
[**2130-10-3**] 07:03PM BLOOD Type-[**Last Name (un) **] Temp-36.3
[**2130-10-3**] 08:13PM BLOOD Type-ART Temp-36.3 PEEP-8 FiO2-50
pO2-146* pCO2-21* pH-7.13* calTCO2-7* Base XS--20
Intubat-INTUBATED
[**2130-10-4**] 01:11AM BLOOD Type-ART Temp-37.0 PEEP-8 FiO2-50 pO2-104
pCO2-27* pH-7.06* calTCO2-8* Base XS--21 Intubat-INTUBATED
[**2130-10-4**] 02:17AM BLOOD Type-ART Temp-38.3 PEEP-8 FiO2-50
pO2-106* pCO2-28* pH-7.10* calTCO2-9* Base XS--19
Intubat-INTUBATED Comment-AXILLARY
[**2130-10-4**] 04:35AM BLOOD Type-ART pO2-91 pCO2-28* pH-7.13*
calTCO2-10* Base XS--18
[**2130-10-4**] 06:28AM BLOOD Type-ART Temp-37.7 PEEP-8 FiO2-50 pO2-90
pCO2-25* pH-7.18* calTCO2-10* Base XS--17 Intubat-INTUBATED
[**2130-10-4**] 11:07AM BLOOD Type-ART Rates-22/36 PEEP-8 FiO2-50
pO2-PND pCO2-PND pH-PND calTCO2-PND Base XS-PND -ASSIST/CON
Intubat-INTUBATED
[**2130-10-2**] 11:39PM BLOOD Glucose-103 Lactate-5.5* Na-144 K-5.8*
Cl-109* calHCO3-19*
[**2130-10-3**] 04:05AM BLOOD Lactate-4.5* K-6.9*
[**2130-10-3**] 06:23AM BLOOD Lactate-6.0* K-7.4*
[**2130-10-3**] 07:01AM BLOOD Lactate-6.1* K-6.5*
[**2130-10-3**] 07:41AM BLOOD Lactate-7.0*
[**2130-10-3**] 10:59AM BLOOD Lactate-7.5*
[**2130-10-3**] 11:06AM BLOOD Lactate-7.8*
[**2130-10-3**] 02:56PM BLOOD Lactate-11.2*
[**2130-10-3**] 06:19PM BLOOD Lactate-14.8* K-5.7*
[**2130-10-3**] 08:13PM BLOOD Lactate-14.9*
[**2130-10-4**] 01:11AM BLOOD Lactate-15.9*
[**2130-10-4**] 02:17AM BLOOD Lactate-16.0*
[**2130-10-4**] 04:35AM BLOOD Glucose-230* Lactate-15.7* Na-142 K-5.0
Cl-109*
[**2130-10-3**] 07:01AM BLOOD freeCa-0.95*
[**2130-10-4**] 04:35AM BLOOD freeCa-0.75*
[**2130-10-4**] 06:28AM BLOOD freeCa-0.77*
[**2130-10-3**] 01:30AM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.025
[**2130-10-3**] 01:30AM URINE Blood-LG Nitrite-NEG Protein-600
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-6.0 Leuks-TR
[**2130-10-3**] 01:30AM URINE RBC-76* WBC-7* Bacteri-FEW Yeast-NONE
Epi-0
[**2130-10-3**] 01:30AM URINE CastGr-28* CastHy-39*
[**2130-10-3**] 01:30AM URINE AmorphX-RARE
[**2130-10-3**] 01:30AM URINE Mucous-OCC
[**2130-10-3**] 04:50AM URINE Hours-RANDOM UreaN-661 Creat-289 Na-20
K-88 Cl-32
[**2130-10-3**] 01:30AM URINE Hours-RANDOM
[**2130-10-3**] 04:50AM URINE Osmolal-566 Myoglob-PRESUMPTIV
[**2130-10-3**] 01:30AM URINE Gr Hold-HOLD
[**2130-10-3**] 04:50AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-POS mthdone-NEG
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 56-year-old male with history of chronic
hepatitis C as well as alcohol-induced liver cirrhosis
complicated by hepatic encephalopathy, previous variceal bleeds,
status post TIPS procedure, who was admitted to the MICU for
AMS, hypotension, and fevers and who passed away on hospital day
2.
.
# Shock: Etiology was uncertain even at the time of death
although looked most likely to be septic shock given high fevers
and white count. However no clear infectious source was
identified. He received broad empiric coverage with Vanc,
cefepime, and azithromycin. Toxic ingestion such as amphetamine
overdose or serotonin syndrome was also on the differential
because he had fever, AMS, and rhabdo, however it was unclear
why he would have had hypotension if that was the explanation.
Amphetamine overdose and seratonin syndrome were considered
because he was prescribed adderall and multiple seratonergic
medications. However according to his ALF he was actively
abusing drugs in addition to adderall and therefore he could
have had almost any toxidrome. A cardiac component to his shock
was initially considered as he had elevated troponins and CK-MB
however cardiac output was [**9-6**] as measured by NICOM. ScV02 was
high. PE was considered as a possibility as TTE showed RV
dysfunction and worsened pulm HTN, but he had RV dysfunction in
the past. Bilateral LENIs were negative for DVT. He was not
stable enough for CTA or V/Q scan and was unlikely to be able to
tolerate anticoagulation given he was also in DIC with active
bleeding.
.
The patient was severely ill on arrival to the MICU and
continued to rapidly deteriorate despite aggressive
resuscitation efforts. His blood pressure was not able to be
maintained despite fluids and multiple pressors. Lactic acid was
high on presentation and continued to rise up to 16. He had
respiratory failure requiring intubation. His laboratory
findings were suggestive of DIC and he required cryo, FFP, and
blood transfusion. During the hospitalization he developed
bleeding from the rectum, bladder, and mucous membranes. He had
severe acute kidney injury and associated electrolyte
derangements. He also had evidence of shock liver.
Rhabdomyolysis was presents as well which could be explained by
toxidrome but unusual for septic shock.
.
Despite aggressive resuscitation efforts the patient continued
to decline. After discussion with the patient's son [**Name (NI) 382**] and
also his brothers it was determined that the patient would not
want prolonged intubation or resuscitation if he had a small
chance of returning to his previous level of functioning. A
decision was made to make the patient CMO and take the patient
off of the ventilator. He passed away shortly thereafter.
.
# Respiratory failure/Hypoxia: Most likely this was ARDS from
shock. CT chest showed some small peripheral wedge-shaped
infiltrates, which could have been infarcts. He was not stable
enough for VQ scan or CTA.
.
#Altered Mental Status: infection (CNS vs. pulmonary) vs.
encephalopathy vs. toxic ingestion. Has tox screen positive for
amphetamines/opioids, however he was on adderall and opioids at
home. NCHCT did not show any acute process. Neurology was
consulted and recommended MRI although patient was never
clinically stable enough to be taken for MRI.
.
# GI bleed: maroon stool, was thought to be possibly from a
watershed infarct of colon in setting of profound hypotension.
The patient also had known varices but there was only minimal
blood-tinged fluid in NG tube.
Medications on Admission:
([**First Name8 (NamePattern2) **] [**Last Name (un) **] ALF)
acetaminophen 750mg PO BID
albuterol 90mcg 1puff Q6h PRN
adderall 15mg PO BID PRN
clotrimazole 1% cream [**Hospital1 **] to feat
vit d 50,000 u Wweek
fluticasone 110mcg inh 2 puffs [**Hospital1 **]
folate 1mg Once daily
thiamine 100mg PO Daily
Tums 500mg PO BID
humalog 75/25 45 units in AM 30 units in evening
Klor-con 20meq PO Daily
MVI PO Daily
omeprazole 20mg PO daily
lactulose 30ml PO QID
sertraline 50mg PO Daily
tramadol 50mg PO TID
ibuprofen 400mg PO q6h PRN
rifaximin 550mg PO BID
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"070.54",
"728.88",
"584.5",
"250.00",
"276.2",
"557.0",
"286.6",
"038.9",
"570",
"995.92",
"571.2",
"518.81",
"785.52",
"572.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15507, 15516
|
11311, 14312
|
354, 379
|
15567, 15576
|
4325, 11288
|
15632, 15642
|
3838, 3879
|
15475, 15484
|
15537, 15546
|
14897, 15452
|
15600, 15609
|
3894, 4306
|
3247, 3298
|
292, 316
|
407, 3228
|
14327, 14871
|
3320, 3765
|
3781, 3822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,947
| 169,204
|
46720+46721
|
Discharge summary
|
report+report
|
Admission Date: [**2111-1-8**] Discharge Date:
Date of Birth: [**2057-4-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 57 year old woman with
a history of chronic obstructive pulmonary disease,
obstructive sleep apnea, diabetes mellitus, and adrenal
insufficiency. She had been admitted on [**2110-12-17**] with mental
status changes, pneumonia and liver function tests
abnormalities. She was treated with a 14 course of
Levofloxacin and Vancomycin. She also had bleeding gastric
arteriovenous malformation and fatty liver was found.
Because of increased somnolence and decreased p.o. intake,
abdominal pain and productive cough, she was brought to [**Hospital1 1444**] on [**2111-1-8**] and given Ceptaz
and Vancomycin for pneumonia and intravenous steroids for
adrenal insufficiency. Head CT for mental status change was
also negative.
Left lower lobe pleural effusion was not tapped because of
increased INR and the patient is a Jehovah Witness. The
patient received multiple fluid boluses due to decreased
urine output. She was intubated electively on [**2111-1-9**] and
then extubated and kept on Bi-Pap during the night. Pleural
fluid of the left effusion was removed on [**2111-1-11**] and was
negative. The patient developed a small hydropneumothorax.
The patient then developed heparin induced thrombocytopenia
and was found to be antibody positive and had low grade DIC.
The etiology of the liver failure was never found. The
patient had no complaints on transfer to medicine on [**2111-1-19**]
and feels she is breathing well.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease.
C-Pap requiring. Fibromyalgia. Diabetes mellitus, type II.
Gastroesophageal reflux disease. Secondary hypoadrenalism.
History of Mersa and Klebsiella. Gastric arteriovenous
malformation, leading to upper gastrointestinal bleed.
History of cholecystectomy, total abdominal hysterectomy and
left total knee replacement. HIT, antibody positive.
MEDICATIONS: Prednisone 60 mg q. day. Haldol prn. Ersadiol
300 mg twice a day. Vancomycin one gram intravenous twice a
day. Ceftazidime two grams intravenous q. eight hours.
Epogen 10,000 intermittently. KCL 40 mg q. day. Colace prn.
Albuterol nebs prn. Ferrous sulfate 320 mg q. day. Lactulose
30 mg three times a day. Miconazole powder prn. Folate one
mg intravenous q. day. Regular insulin, sliding scale.
Combivent MDI, two puffs q. six hours prn. Protonic 40 mg
intravenous q. day. Flovent MDI, two puffs twice a day.
Atrovent nebs prn.
ALLERGIES: Flexeril, Keflex, Ultram, codeine and heparin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a Jehovah's Witness. The
patient has a 35 pack year history of smoking. She quit in
[**2094**]. The patient quit alcohol in [**2093**].
PHYSICAL EXAMINATION: On transfer to medicine, vitals were
99.0 temperature; heart rate 79 to 101; blood pressure was 99
to 129 over 41 to 98; respiratory rate 10 to 27; oxygen
saturation 80 to 100% on three liters. HEAD, EYES, EARS,
NOSE AND THROAT: Positive icterus. Oropharynx dry. Neck
supple, no lymphadenopathy. Lungs clear anteriorly without
wheezes. Heart regular rate and rhythm, normal S1 and S2.
Abdomen soft, obese, nontender, nondistended. Extremities:
1+ pitting edema in upper extremities and lower extremities
bilaterally. Pneumoboots in place.
LABORATORY DATA: White count on [**1-25**] was 10.6 which had
peaked at 21.7 on [**1-20**]. Hematocrit was 26.0. Platelet count
67. Reticulocyte count on [**1-11**] was 2.7. Creatinine 0.7.
BUN 10. Potassium 3.4. Sodium 142. ALT of 47 on [**2111-1-22**].
AST 56. LD 446; alkaline phosphatase 135; total bilirubin
5.3; amylase 18; lipase 11; calcium 8.4; phosphate 1.3;
magnesium 2.1. Ammonia on [**1-9**] was 48. AFP on [**1-11**] was
4.1.
Blood cultures were no growth. Sputum culture grew
METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS and Klebsiella,
sensitive only to Meropenem an Zosyn. Stool cultures were
negative.
Chest x-ray on [**2111-1-21**] showed left pleural effusion and
bibasilar atelectasis, cannot rule out additional
consolidation in the left lower lobe, no pneumothorax.
HOSPITAL COURSE: The [**Hospital 228**] hospital course prior to
admission to medicine was summarized in the history of
present illness. After admission to medicine on [**2111-1-19**], the
patient continued on treatment for pneumonia, Ceftazidime day
ten and Vancomycin day 11 for pneumonia, as well as
continuing chest physical therapy and suctioning and
following oxygen saturations. The Ceftazidime was continued
though the Klebsiella in the sputum, approximately a week or
two prior had been resistant to Ceptaz because the patient
was clinically improving. It was felt by infectious disease
that if the Klebsiella had been a pathogen, then the patient
would not have improved.
The patient weaned down from the oxygen and remained at
baseline oxygen requirement of two to three liters with high
oxygen saturations very rapidly once on the medicine floor.
For the patient's chronic obstructive pulmonary disease, the
patient was continued on her nebs, her MDI and her Prednisone
taper. The patient continually refused her bi-pap at night.
For the hepatic insufficiency, the hepatology team followed
up in consult and stated that the patient likely had
cirrhosis and wound not benefit further from a biopsy,
especially given its risk. The patient was continued on
Lactulose and Ersadiol. The patient was somewhat non
compliant with taking her Lactulose and the importance of
this had to be discussed with her on a nearly daily basis.
The hepatology team felt that the patient should continue on
her current regimen and consider adding Flagyl at a later
date, if the patient should become more encephalopathic and
should follow-up with hepatologist.
The pulmonary staff also felt that her hypoxemia had been
secondary to VQ mismatch, decreased diffusion capacity and
congestive heart failure, which all resolved.
For the patient's anemia, the platelet count continued to
rise after the patient was taken off the heparin. The
patient continued on Epo and Ferrous sulfate to improve her
anemia. The patient also had an elevated INR which did not
respond to vitamin K. However, the INR remained at about
1.5.
The patient's electrolytes were needing almost daily
repletion, especially of the potassium and the phosphate.
The patient continually refused to take her Nutriphos and had
to be given potassium sulfate intravenously frequently. The
patient, however, remained in very good condition on the
medical floor and without complaints, no shortness of breath
and no pain. The patient was screened for rehabilitation.
The patient has been stating frequently that she wants to go
home rather than rehabilitation. However, the patient has
not yet been able to sit up in bed or ambulate at all.
The discharge medications, the date of discharge and the
discharge instructions are to be addended at a later date.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**]
Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36/D: [**2111-1-25**] 07:32/T: [**2111-1-26**] 04:19
JOB#: [**Job Number **]
Admission Date: [**2110-12-29**] Discharge Date: [**2111-1-29**]
Date of Birth: [**2057-4-5**] Sex: F
Service:
NOTE: This is an addendum to the discharge summary for the
admission starting [**2111-1-8**]. The patient was discharged on
[**2111-1-29**].
[**Hospital 14851**] HOSPITAL COURSE: The patient had stage 1 sacral
decubitus on her buttocks. This was treated with wound care
using Eucerin cream and also patient was treated with
lidocaine jelly for pain control. The patient was seen by
the wound care nurse and the decubitus ulcer was felt to be
mild, but was causing the patient a lot of discomfort and the
wound care nurse [**First Name (Titles) 3675**] [**Last Name (Titles) 99168**] lidocaine jelly.
With regard to the patient's chronic obstructive pulmonary
disease, the patient's respiratory status improved throughout
the remainder of her hospital course. The patient had no
shortness of breath or cough on discharge. The patient was
oxygenating well on her home O2 dose of 2 liters per minute.
The patient overall continued to improve, but remained
physically decompensated and the patient was transferred to
[**Hospital **] [**Hospital **] Hospital for intensive physical
therapy.
DISCHARGE MEDICATIONS are the same with the addition of
[**Hospital 99168**] lidocaine jelly to be applied to buttock prn and
[**Hospital 99168**] lidocaine swish and swallow tid prn before meals.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**]
Dictated By:[**Last Name (NamePattern1) 11117**]
MEDQUIST36
D: [**2111-1-29**] 09:56
T: [**2111-1-29**] 09:58
JOB#: [**Job Number 99169**]
|
[
"255.4",
"572.2",
"492.8",
"530.81",
"486",
"287.4",
"707.0",
"276.0",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71",
"34.91",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2620, 2638
|
7636, 9030
|
2833, 4185
|
137, 1578
|
1601, 2603
|
2655, 2810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,229
| 190,039
|
39685
|
Discharge summary
|
report
|
Admission Date: [**2107-3-18**] Discharge Date: [**2107-3-26**]
Date of Birth: [**2062-8-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
nausea, vomiting, inability to tolerate POs
Major Surgical or Invasive Procedure:
Mechanical intubation
Nephrostomy tube placement
History of Present Illness:
=========================================================
[**Hospital1 18**] ONCOLOGY MOONLIGHTER PGY-3 ADMISSION NOTE
[**Known lastname **],[**Known firstname 8207**] F [**Numeric Identifier 87461**] Age: 44 Sex: F
DATE OF ADMISSION: [**2107-3-18**]
=========================================================
.
PCP: [**Name10 (NameIs) 36023**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 36024**]
Oncologist: Dr. [**Last Name (STitle) **] [**Name (STitle) **] ([**Location (un) 2274**])
.
CC: nausea, vomiting, inability to tolerate POs
.
HPI: 44 yo F with metastatic lung cancer to brain s/p recent
chemotherapy (C2D1 of Taxotere on [**2107-3-2**]) who was transferred
from [**Location (un) 2274**] oncology clinic with persistent nausea, vomiting, and
hypotension to the 80s. Patient of note recently had a CT Torso
from [**2107-3-16**] which showed progression of her metastatic disease
including in her lungs, mediastinal lymph nodes, and new hepatic
masses. She also had a follow-up MRI brain which shows 4 new
brain metastases. There has been discussion with her outpatient
oncologist about clinical trials with TKIs but the patient needs
to off chemotherapy for one month and needs to qualify for the
study. She has stable swelling in the RUE and LUE swelling, and
continues on Lovenox. Seen by Dr. [**Last Name (STitle) **] in neuro clinic. She
continues with daily VNA pleurex drainage bilaterally was
performed today, 600cc from R catheter and, 250 cc from the left
catheter.
.
Patient reports persistent nausea and vomiting for the several
days. She did not have any nausea immmediately after her
chemotherapy. She has been vomiting up her food, but no blood.
No diarrhea, and no abdominal pain. No headache. She was finally
able to keep some food down today. She received 1 L of NS in her
clinic for an SBP of 80, decadron, zofran, and IV morphine for
her back pain in the clinic prior to transfer to the [**Hospital1 18**] ED.
States her upper extremity swelling is worse after receiving
IVFs today.
.
In ED VS were 99.1 103 97/65 20 96% 2L NC. Lab sig for Na of
128, Cre of 1.7 (baseline 1.0), WBC of 22.3 and Hct of 26.3.
Received Ativan 2 mg IV x1 and 1 L NS in the ED. VS prior to
transfer were: 97.3 98 117/70 18 100% on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied chest pain or tightness,
palpitations. Denied diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Past Medical History:
Past Oncologic History:
[**Known firstname **] was in her usual state of health up until [**2106-4-20**]
when she developed RUQ abdominal pain. She was sent to the ED by
her
PCP. [**Name10 (NameIs) **] that time she had a normocytic anemia 32.5, AST 74, ALT
148, t bili 0.2, ap 97, lipase 32. An abdominal US showed
abnormal thickening of the gallbladder and cholecystitis, w/o
intra/extra hepatic dilatation, changes c/w fatty liver disease,
and a small pleural effusion. She underwent cholecystectomy and
1 week post op developed pericardial effusion. Patient underwent
pericardiocentisis (effusion was primarily rbcs, few wbcs, and
culture negative, including AFP per report). She underwent work
up with TSH elevated to 5.6, with normal free T4 0.72, negative
[**Doctor First Name **], negative rapid strep. She had a mammogram that showed
benign microcalcifications, no radiographic evidence of
malignancy. A repeat echocardiogram [**5-26**] showed EF 60%, nl LV
thickness and wall motion, normal RV/LA, no valvular dysfunction
and no effusion.
.
1 week prior her [**Hospital1 18**] admission, patient developed swelling in
her right neck which was thought to be reactive lymphadenopathy.
She also complains of cough. Over the next two days she
developed DOE and went to [**Hospital6 **] where she was
found to have redeveloped pericardial effusion w/o tamponade.
She was therefore sent to [**Hospital1 18**] for additional
[**Hospital1 **]. Cytology from pericardiocentesis revealed
adenocarcinoma, positive for CK-7, CK-20, TTF-1, negative for
GCDFP 15 and mammoglobin. Also had multiple clots in both UEs
with multiple subsegmental PE's; received IVF filter and
enoxaparin. Hospital course was complicated by a large
abdomino/pelvic hemoperitoneum due to ruptured ovarian cyst vs.
drop metastases. IVC filter was placed. MRI head [**7-5**] showed
solitary met in left temporal lobe which she underwent SRS for
on [**7-13**] with Dr. [**First Name (STitle) **] [**Name (STitle) 3929**].
- [**2106-7-11**]: C1D1 Cisplatin/Navelbine
-[**2106-8-2**] C2D1
-[**2106-8-23**] C3D1
[**2106-9-27**]: Continued slight interval improvement of disease.
Completed six cycles of cis/navelbine (C6D8 on [**2106-11-1**])
Chemotherapy complicated with hospital admission for neutropenia
Also concern for TB initially but seen by [**Hospital1 18**] ID, TB treatment
not necessary based on subtype
[**Date range (1) 87462**]- Admitted to [**Hospital1 18**] with increase in dyspnea, facial
swelling. Pericardial tamponade requiring window and left
pleural effusion. Received chemo in hospital. Extensive clot
burden resulting in SVC syndrome, no intervention possible.
Continued on Lovenox
[**2107-2-9**]: Taxotere #1 (in hospital)
[**Date range (1) 87463**]- Readmitted with right pleural effusion, pleurex
placed.
[**2-22**]: Port placed.
[**2107-2-28**]: Neuro follow-up MRI with new brain mets. SRS planned.
[**2107-3-2**]: Taxotere #2
.
PMH:
- Lung adenocarcinoma with known mets to brain, dx [**6-/2106**];
metastatic to brain s/p cyberknife therapy, malignant pleural
and pericardial effusions s/p pericardiocentesis (see above for
further details)
- DVTs s/p IVC and SVC filters
- Malignant pleural effusion s/p drainage
- PE s/p IVF on chronic lovenox and s/p IVC filter
- Mycobacterium gordonae
- s/p CCY
- s/p pericardiocentesis
Social History:
She is originally from the [**Country 31115**] in [**2092**], lives with
husband. Married. Worked at [**Last Name (un) 59330**]. Husband works in shipping
warehouse. No smoking, alcohol, or illicit drug use
Family History:
Mother with diabetes. No family hx of cancer.
Physical Exam:
VS: 98.6 114/78 63 18 96% on 3 L NC
GA: pleasant F AOx3, NAD
HEENT: PERRLA. MM slightly dry. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: crackles at R/L lower bases BL. 2 pleurex catheters in
place bandages c/d/i BL.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema in BLLEs, 4+ pitting edema in
bilateral upper extremities.
Pertinent Results:
[**2107-3-18**] 02:15PM BLOOD WBC-22.3* RBC-2.68* Hgb-9.0* Hct-26.3*
MCV-98 MCH-33.5* MCHC-34.2 RDW-18.3* Plt Ct-353
[**2107-3-18**] 02:15PM BLOOD Neuts-97.3* Lymphs-1.8* Monos-0.7*
Eos-0.1 Baso-0.1
[**2107-3-18**] 02:15PM BLOOD Plt Ct-353
[**2107-3-18**] 02:15PM BLOOD PT-13.1 PTT-41.5* INR(PT)-1.1
[**2107-3-18**] 02:15PM BLOOD Glucose-139* UreaN-18 Creat-1.7* Na-128*
K-4.1 Cl-93* HMicrobiology:
blood culture ([**3-18**]) - pending
.
Imaging:
[**2107-3-16**]: CT Torso w/o Contrast:
IMPRESSION:
1. Interval increase in the degree of bulky supraclavicular,
axillary, and mediastinal lymphadenopathy.
2. Attenuation of the right brachiocephalic/subclavian and left
brachiocephalic veins not as well evaluated on this study due to
contrast timing.
3. Heterogeneous enhancement of the thyroid, new from the prior
study, concerning for infarction or hypoperfusion. Metastatic
infiltration is another less likely consideration.
4. Improved aeration of the lungs despite right upper lobe
bronchial
obstruction. Right upper and middle lobe masses appear enlarged
compared with the CT torso [**2107-1-17**] with bilateral
chest tubes in place and small left pleural effusion.
5. Multiple new hepatic metastases as described above with new
right and left adrenal lesions and possible development of
peritoneal disease.
6. Diffuse osseous involvement of multiple lower cervical and
upper thoracic vertebral bodies as well as focal lesions in the
L2 and L3 vertebral bodies. Irregularity of the T3 and T4
superior endplates concerning for new pathologic fractures.
.
CO3-25 AnGap-14
Brief Hospital Course:
A/P: 44 yo woman with metastatic lung cancer s/p six cycles of
cisplatin and navelbine presenting with persistent nausea,
vomiting, and hypotension presented from oncology clinic found
to have obstructive uropathy and pyelonephritis.
# Obstructive Uropathy: The patient underwent nephrostomy tube
placement by interventional radiology in attempt to alleviate
obstruction likely caused by metastatic spread of primary lung
cancer to the retroperitoneum. Procedure complicated by
hypotension and septic shock likely related to urosepsis. The
patient required mechanical intubation, multiple antibiotics and
pressor support to maintain adequate BPs. The patient's family
decided to withdraw care after improvement seemed unlikely. The
patient's family was at her bedside at the time of death.
.
#) NSCLC adeno, stage IV: Advanced disease - per primary
oncologogist the patient had worsening lymphadenopathy, liver,
brain and bony mets since most recent course of taxotere.
.
#) h/o PE: IVC filters inplace. Continued anticoagulation, held
for procedure
.
#) Stage 2 ulcer - stable
Medications on Admission:
. Oxygen
Please provide 2-4L oxygen by nasal cannula when ambulating prn
2. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain.
6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
12. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
13. morphine 15 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours as needed for pain: To be used for pain
from pleurex drainages; do not drive or operate machinery. .
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Obstructive Uropathy
Sepsis
Metastatic Lung Cancer
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2107-5-9**]
|
[
"995.92",
"198.3",
"162.3",
"518.81",
"782.3",
"593.4",
"785.52",
"V66.7",
"285.9",
"787.01",
"275.2",
"591",
"423.8",
"198.5",
"E933.1",
"196.1",
"197.6",
"584.9",
"276.2",
"197.7",
"511.81",
"276.1",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
11113, 11122
|
8687, 9773
|
355, 406
|
11216, 11226
|
7087, 8664
|
11277, 11446
|
6547, 6594
|
11086, 11090
|
11143, 11195
|
9799, 11063
|
11250, 11254
|
6609, 7068
|
2698, 2951
|
272, 317
|
434, 2679
|
2973, 6307
|
6323, 6531
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,776
| 128,531
|
33232+57842
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-1-7**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2026-3-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Acute ischemic RLE
Major Surgical or Invasive Procedure:
Perclose. [**1-9**]
Contralateral third order arteriography with abdominal
aortogram. Mechanical primary thrombectomy.Angioplasty of
femoral to popliteal bypass graft x 2.Stent placement of the
distal femoral to popliteal bypass graft.Stent placement of
proximal femoral-popliteal bypass graft.Unilateral extremity
runoff. [**1-8**]
History of Present Illness:
This 70-year-old female presented with a thrombosed and cold
ischemic foot who underwent open procedure after an angiogram
where they performed a
thrombectomy.
Past Medical History:
hypercholesterolemia
ESRD on HD (M/W/F via RUE fistula)
A-fib (on coumadin)
DM
Depression
s/p R fem-ak [**Doctor Last Name **] w/? vein 6 yrs ago
Social History:
denies smoking, EtOH, drugs
Family History:
n/c
Physical Exam:
PE: VS: BP P R O2 sats Pain
Gen- NAD, axox3
Heart- rrr, S1S2
Lungs- CTA b/l
Abd- soft, NT/ND, no AAA
Ext- RLE vac in place / wound is C/D/I
Pulses: Fem [**Doctor Last Name **] DP PT
Rt dopp dop dop -
Lt 1+ dop mono -
Pertinent Results:
[**2105-1-16**] 08:26AM BLOOD
WBC-6.3 RBC-2.78* Hgb-9.6* Hct-31.0* MCV-111* MCH-34.5*
MCHC-31.0 RDW-20.5* Plt Ct-587*#
[**2105-1-15**] 04:30AM BLOOD
PT-32.6* PTT-43.4* INR(PT)-3.4*
[**2105-1-16**] 08:26AM BLOOD
Glucose-145* UreaN-45* Creat-6.7* Na-131* K-4.8 Cl-96 HCO3-23
AnGap-17
[**2105-1-9**] 03:56PM
URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
URINE Blood-LG Nitrite-NEG Protein-100 Glucose-250 Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
URINE RBC-21-50* WBC-21-50* Bacteri-FEW Yeast-NONE Epi-[**2-18**]
TransE-0-2 RenalEp-0-2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.50 >= 0.29
Left Ventricle - Ejection Fraction: 70% to 75% >= 55%
Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *17 < 15
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave deceleration time: *275 ms 140-250 ms
TR Gradient (+ RA = PASP): *22 to 28 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MR.
Prolonged (>250ms) transmitral E-wave decel time.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension.
IMPRESSION: Near-hyperdynamic left ventricular systolic
function. Probable diastolic dysfunction. No pathologic valvular
abnormality seen. Borderline pulmonary artery systolic
hypertension. Mild dilatation of ascending aorta.
[**2105-1-9**] 9:42 AM
CHEST (PORTABLE AP)
FINDINGS: In comparison with the study of [**1-8**], the patient has
taken a much better inspiration. Although there is still some
enlargement of the cardiac silhouette, the lungs are clear, the
costophrenic angles are relatively sharp, and there is no
evidence of pulmonary [**Date Range 1106**] congestion.
EKG:
Atrial fibrillation
Low limb lead QRS voltages
Delayed R wave progression with late precordial QRS transition
Modest nonspecific precordial/anterior T wave changes
These findings are nonspecific but clinical correlation is
suggested
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 0 80 436/439 0 49 28
Brief Hospital Course:
78 F w/ RLE pain since 3 days PTA, presented to an OSH w/ a
cold and pulsless leg. She previously had a R fem-[**Doctor Last Name **] about 6
yrs ago. Denies any recent history of PVD such as rest pain,
ulcers, or claudication.
Medications on Admission:
protonix 40', renagel 2400''', coumadin 4', glyburide 1.25',
trazodone 50', cardizem 180', lipitor 10', lasix 80'
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Coumadin 1 mg Tablet Sig: Dose daily Tablet PO once a day:
Dose daily per INR until stable (Goal INR 2.5-3).
Disp:*0 Tablet(s)* Refills:*2*
14. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. lasix 80 mg PO qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
[**1-9**] Right LE ischemia s/p Perclose
[**1-8**] Contralateral third order arteriography with abdominal
aortogram. Mechanical primary thrombectomy.Angioplasty of
femoral to popliteal bypass graft x 2.Stent placement of the
distal femoral to popliteal bypass graft.Stent placement of
proximal femoral-popliteal bypass graft.Unilateral extremity
runoff.
cholesterolemia
ESRD on HD (M/W/F via RUE fistula)
a-fib (on coumadin)
DM
depression
s/p R fem-ak [**Doctor Last Name **] w/? vein 6 yrs ago
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Doctor Last Name **] and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What 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 [**1-18**]
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 [**2-17**] weeks for
post procedure check and ultrasound
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)
??????Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2105-2-10**]
8:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2106-2-11**] 9:00 Phone: [**Telephone/Fax (1) 1241**] please call the
office should you want to change/cancel this appointment
Completed by:[**2105-1-16**] Name: [**Known lastname 2706**],[**Known firstname 3989**] A Unit No: [**Numeric Identifier 12531**]
Admission Date: [**2105-1-7**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2026-3-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 270**]
Addendum:
hospital course
78 F w/ RLE pain since 3 days PTA, presented to an OSH w/ a
cold and pulsless leg. She previously had a R fem-[**Doctor Last Name **] about 6
yrs ago.
Angiogram:
1. Acute embolus to the right common femoral artery with
complete occlusion distally. There was a small amount of
flow through the profunda branch with a large amount of
clot seen in the common femoral artery and profunda.
2. Possible runoff via a popliteal artery and anterior
tibial artery but very poor visualization.
3. Completely occluded femoral to popliteal bypass.
Procedure:
1. Right groin exploration.
2. Thrombectomy of external iliac, profunda femoral,
femoral popliteal bypass.
3. Dacron patch angioplasty of the common femoral and
external iliac artery.
4. Right lower extremity 4 compartment fasciotomies.
PROCEDURE PERFORMED:
Perclose.
Foley DC / pt allowed OOB to chair / pt delined
Pt progressed with PT to meet rehab guidlines
VAC placed / change q 3 days ON DC wound is clean and dry
Heparin / coumadin bridge
Pt INR 3.2 / heparinstopped. Keep pt INR greater then 3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 4415**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2105-1-16**]
|
[
"440.20",
"272.0",
"427.31",
"250.00",
"996.74",
"585.6",
"444.22",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"39.57",
"39.95",
"00.55",
"88.48",
"88.42",
"00.46",
"83.14",
"39.50",
"86.59",
"39.49",
"00.41",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
12448, 12677
|
5485, 5717
|
332, 667
|
7886, 7895
|
1375, 5462
|
10533, 12425
|
1087, 1092
|
5881, 7252
|
7366, 7865
|
5743, 5858
|
7919, 9924
|
9950, 10510
|
1107, 1356
|
274, 294
|
695, 856
|
878, 1025
|
1041, 1071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,559
| 189,393
|
24167
|
Discharge summary
|
report
|
Admission Date: [**2117-4-24**] Discharge Date: [**2117-5-11**]
Date of Birth: [**2058-8-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Typhoid Vaccine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Sub-sternal chect pain worsening with deep inspirations and
movement.
Major Surgical or Invasive Procedure:
s/p Sternal debridment and pec flap advancement
s/p PICC line insertion
History of Present Illness:
Mr. [**Known lastname 61359**] is s/p CABG with Dr. [**Last Name (STitle) **] [**2117-4-8**] and discharge home
[**2117-4-14**]. On the morning of [**4-24**] he reports waking up with sharp
SSCP worse with deep breathing and movement. He presented to
the ED and was admitted to the [**Hospital Unit Name **] service for r/o MI.
Past Medical History:
Diabetes type 2.
Hypertension.
Silent MI.
Depression.
Anxiety.
Migraines.
Sleep apnea.
Diverticulitis s/p GI bleed in [**2116**].
Hyperlipidemia.
Strabismus, s/p many surgeries.
Elbow surgery.
Tonsillectomy.
Penile implant.
Social History:
Lives with wife and three children in [**Name (NI) 61358**], MA. Works as
credit collection manager.Tobacco: quit 12 years ago -- [**3-4**] ppd
prior. Denies ETOH use.
Pertinent Results:
[**2117-5-11**] 06:14AM BLOOD WBC-5.2 RBC-2.93* Hgb-8.7* Hct-26.0*
MCV-89 MCH-29.7 MCHC-33.6 RDW-13.6 Plt Ct-514*
[**2117-5-11**] 06:14AM BLOOD Plt Ct-514*
[**2117-4-29**] 04:54AM BLOOD PT-13.5 PTT-21.4* INR(PT)-1.2
[**2117-5-11**] 06:14AM BLOOD Glucose-114* UreaN-14 Creat-1.6* Na-138
K-4.6 Cl-103 HCO3-29 AnGap-11
[**2117-5-4**] 06:25AM BLOOD ALT-26 AST-26 LD(LDH)-206 AlkPhos-81
TotBili-0.4
[**2117-5-11**] 06:14AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.7
[**2117-5-10**] 09:15AM BLOOD Vanco-21.6*
Brief Hospital Course:
Mr. [**Known lastname 61359**] is s/p CABG with Dr. [**Last Name (STitle) **] [**2117-4-8**] and discharge home
[**2117-4-14**]. On the morning of [**4-24**] he reports waking up with sharp
SSCP worse with deep breathing and movement. He presented to
the ED and was admitted to the [**Hospital Unit Name **] service for r/o MI. His
initial CKs were negative. ON the evening of his his admission,
he spiked a fever to 101.8. Exam at that time noted erythema
and warmth at incision site with tenderness to palpation and
purulent drainage. At that time the cardiac surgery service was
consulted and pt was started on vancomycin and levofloxacin with
betadine paint and dsd to incision PRN.
On [**4-25**], a bedside incision and drainage of the sternal incision
revealed infection extending down to bone and patient was taken
to the operating room for I&D of sternal wound secondary to
dehisience. (Please see op note for full details.) Post-op he
was transferred to the CSRU with an open chest and a plastic
surgery consult was obtained for flap closure.
On POD one he remained intubated in the ICU and was successfully
weened and extubated on POD two.
On POD four he proceeded to the OR with the plastic surgery team
for flap closure.
On PODs two and six his creatinine was noted to be elevated; his
lasix was held with plans to monitor creatinine closely (no
further increase throughout stay). He was transferred to the
inpatient floor.
On PODs four and eight pt was noted to be irritable, tearful,
and with suicidal ideation -- a psychiaty consult was obtained.
His percocet was discontinued and alternate pain medication
initiated including neurontin for neuropathic pain; his celexa
was increased to his pre-op dose; haldol was ordered PRN; and a
1:1 sitter was initiated for continuous monitoring for pt
safety.
On PODs six and ten he was mentally much clearer and his 1:1
sitter was discontinued. His JP drains continued to be follow
by the plastic surgery team. And a PICC was placed by
interventional radiology for continued IV antibiotic
administration.
He continued to be stable for the next week with ongoing
evaluation by plastic surgery. Two of his three JP drains were
discontinued over this time. On PODs [**1-14**], it was decided that
he was okay to be discharged home with his one remaining JP
drain with visiting nurses to follow him closely and follow-up
with plastic surgery in one week's time.
Medications on Admission:
Aspirin 81 mg daily.
Lopressor 75 [**Male First Name (un) 239**].
Valsartan 320 daily.
Pioglitazone 45 daily.
Citalopram 40 daily.
Omeprazole 40 daily.
Hydromorphone 2 mg tabs q 4-6 hours PRN.
Colace 100 [**Hospital1 **].
Glyburide/Metformin 2.5/500 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. 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*
3. Pantoprazole Sodium 20 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*
4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Pioglitazone HCl 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Vancomycin HCl 10 g Recon Soln Sig: 1 gram Recon Soln
Intravenous Q12H (every 12 hours): thru [**2117-6-6**].
Disp:*60 Recon Soln(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
S/P sternal debridement and pec flap advancement
PMH:CABG([**4-8**]),DM2,HTN,Depression,sleep apnea, Diverticulitis,
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry.
Take all medications as prescribed
Call for any fever or drainage from wounds
Followup Instructions:
Dr [**Last Name (STitle) 61402**] in 1 week or when JP output is less than 30 cc per
day.
Dr [**Last Name (STitle) **] in [**4-2**] weeks.
Dr. [**First Name (STitle) **] in [**3-5**] weeks.
Weekly blood draws: CBC, LFTs, and vanco level, results to Dr.
[**First Name (STitle) **].
Completed by:[**2117-5-11**]
|
[
"276.7",
"584.9",
"E878.2",
"730.28",
"998.59",
"519.2",
"401.9",
"250.00",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.74",
"38.93",
"83.82",
"77.61"
] |
icd9pcs
|
[
[
[]
]
] |
6242, 6313
|
1772, 4201
|
365, 440
|
6474, 6480
|
1253, 1749
|
6633, 6945
|
4508, 6219
|
6334, 6453
|
4227, 4485
|
6504, 6610
|
256, 327
|
468, 799
|
821, 1047
|
1063, 1234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,832
| 100,619
|
45176
|
Discharge summary
|
report
|
Admission Date: [**2158-5-14**] Discharge Date: [**2158-6-23**]
Date of Birth: [**2083-7-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Fall from wheelchair
Major Surgical or Invasive Procedure:
Abdominal drain placements
Chest drain placements
Chest tube placement bilaterally
Ureteral Stent Placement
Bilateral nasal bone stabilization
Exploratory Laparotomy
History of Present Illness:
75 M on coumadin for AFib, wheelchair bound [**1-17**] cerebral palsy
fell from wheelchair onto face after accidentally driving off of
curb. C/O facial pain, No LOC, intubated for airway protection.
Pt was seen and stabilized at [**Hospital3 **] with vitK and 2
units FFP for elevated INR.
Past Medical History:
Cerebral palsy, Central Cervical Cord Contusion, BPH,
Nephrolithiasis, AFib.
Social History:
Wheelchair bound, lives at home.
Family History:
NC
Physical Exam:
100.0 99.6 99AF 114/55 26 100% PS50% 7/5 --> 410x24
NAD, trach in place
Card: Tachy, AFib
Resp: Coarse breath sounds bilaterally, CT sites clean/dry and
intact
Abd: Soft, NTND. GJ tube intact w/ G capped
Ext: Waffle boots in place.
Pertinent Results:
Microbiology:
[**5-15**] Sputum: oropharnygeal flora
[**5-15**] MRSA: neg
[**5-25**]: Sputum ecoli pan [**Last Name (un) 36**] (R ampicillin)
[**5-25**] Bcx [**12-17**]: coag +staph, pan [**Last Name (un) 36**].
[**5-26**] Ucx: neg
[**5-29**] Bcx: NGTD x2
[**5-31**] Bcx: NGTD x2
[**5-31**] Ucx: NGTD
[**5-31**] Sputum: NGTD
[**6-1**] Cdiff: Neg
[**6-2**] Ucx:NG
[**6-2**] pl Fluid:NGTD
[**6-5**] Bl Cx: neg
[**6-5**] Ucx: NG
[**6-6**] Stool clx - C. diff negative
[**6-7**] BClx - neg
[**6-7**] UClx - NG
[**6-7**] sputum cx - NGTD
[**6-8**] BAL - NGTD
[**6-8**] Bcx - NGTD
[**6-9**] Cath tip neg
[**6-9**] Abd fluid - 3+ PMNs, NGTD
[**6-9**] Abd LUQ fluid - 1+ PMNS, NGTD
[**6-10**] Pleural fluid - NGTD
[**6-10**] Ucx - neg
[**6-12**] sputum - contaminated
[**6-12**] Bclx x2 - NG
[**6-12**] Uclx - NG
[**6-13**] wound clx swab - Staph coag neg rare, 1+ PMNs
[**6-14**] pleural fluid x1 - NG
[**6-14**] pleural fluid x2 - NG
[**6-14**] pleural fluid x3 - NG
[**6-18**] sputum cx GNR
[**6-18**] Blcx - (aerobic/anaerobic) GPC in pairs/clusters, Coag neg
Staph
[**6-19**] C. diff - negative
[**6-21**] C. diff - negative
[**6-21**] BCx - P
[**6-21**] UCx - P
[**6-21**] Sputum Cx - P
Imaging:
[**5-14**] CT Cspine: severe central canal stenosis [**1-17**] severe djd
from c3-c7. fusion of c6 and c7. no acute fracture. djd can
predispose to cord injury in setting of trauma.
[**5-15**] CT torso: RLL opacification. Small left pleural effusion.
Large hiatal hernia.
[**5-25**] CT torso: Right mod-severe hydro/pyoureteronephrosis with
heterogeneous enhancement of the r kidney compatible with
pyelonephritis. Multiple obstructing distal ureteral calculi
measuring up to 7mm. Free air and contrast in the peritneal
cavity. PEG tube is not in the stomach. small contrast in the
rectum likely from video swallow from [**2158-5-17**]. While bowel
perforation can not be entirely excluded on the basis of this
study findings most likely represent injection of contrast and
air into the peritoneum through the PEG that is extraluminal.
Bowel and a drenal enhancement pattern is compatible with shock.
Small free abd.pelvic fluid. Small pericardial effusion.
cardiomegaly. dilated esophagus. Small bilat pleural eff (L>R)
and rll atx or pna. Possible left shoulder osteochondromatosis.
scoliosis. l renal small hypodensities likely cyst.
[**5-26**] CXR: Pulmonary and mediastinal vasculature are now engorged
but there is no edema. Atelectasis persists at the right lung
base. The stomach is now distended with fluid.
[**5-29**] CXR: Increased bilateral moderate pleural effusion
[**5-30**] CXR: RLL opacity is consistent with almost complete
collapse of the right lower lobe and a large hiatal hernia
[**5-31**] RUQ US: no biliary dilatation,edematous gall bladder
[**6-1**] CT head: no ICH. Increased mucosal thikcening of the
sphenoid sinuses, with persistent fluid within the ethmoid and
maxillary sinuses.
[**6-1**] CT torso w/I: no abscess.
[**6-2**]: pleural catheter right hemithorax with resolution pl eff.
Left enlargement of a moderate-to-large left pleural effusion
[**6-3**]:Large left and small right pleural effusions are similar in
size, but there has been apparent development of a small
component of loculation of the left effusion at the level of the
second left anterior rib. A confluent area of atelectasis in
this region could potentially mimic loculated pleural
fluid,however.
[**6-4**] BLE US: No DVT
[**6-5**] CXR: Moderate R pl eff and RLL collapse, and l pl eff and
LLL atelectasis all more severe
[**2158-6-11**] CXR: small to moderate pleural effusions b/l stable,
area of linear consolidation within LUL, stable
[**6-12**] CT Chest - bilateral pleural effusions.
[**6-13**] CT chest - Interval decrease in the loculated areas of
ascites. Interval decrease in R pleural effusion most likely [**1-17**]
draining. Slight interval increase in the L pleural effusion.
Still present areas of loculated fluid within the abdomen as
well as at
the hiatal junction
[**6-14**] CXR - decrease of the left pleural effusion. no evidence of
ptx, There is also new R chest tube,additional decrease R
pleural effusion
[**6-14**] post WS CXR
[**6-15**] CXR - no interval change
[**6-18**] am CXR - right pigtail catheter has been removed. Right
chest tube is seen at the base with some loculated pneumothorax
in the subpulmonic region. On the left, the chest tube has also
been pulled back somewhat and there is new subpulmonic and
medial lower lung pneumothorax on this side as well. Right IJ
catheter has been removed. Tracheostomy tube remains in place.
[**6-18**] pm CXR - post d/c of LEFT chest tube, small PTx remains.
[**6-19**] CXR - In comparison with the study of [**6-18**], there is
progressive decrease in the left pneumothorax with only a
minimal possible subpulmonic collection. Right chest tube
remains in place and persistent opacification is seen at the
right base.
[**6-19**] CT Torso - Multiple foci of loculated intraperitoneal fluid,
the largest in the left upper quadrant with 2 cm thickness, none
of which appear large enough to warrant drainage placement.
Bilateral small pneumothoraces. Resolution of right
hydronephrosis with persistent urolithiasis with stones seen in
the right collecting system and urinary bladder. One of the
stones appears to be located at the right UVJ, but none in the
distal ureter. Bilateral small pleural effusions with near right
lower lobe collapse and atelectasis in the left lower lobe.
[**6-19**] CT sinus - Redemonstration of extensive facial fractures,
thoroughly characterized on [**2158-5-14**] CT. There is pansinus
mucosal disease, though decreased compared to [**2158-6-1**].
There is hyperdense fluid seen layering in the left maxillary
and right sphenoid sinus, compatible with inspissated
secretions. No aerosolized secretions are identified. There is
fluid
opacification of the bilateral mastoid air cells. There are no
osseous changes associated with these processes. Clinical
correlation is advised to exclude acute mastoiditis. Stable
ventriculomegaly. No extra-axial fluid collections in the
visualized cranium
Brief Hospital Course:
Pt was stabilized at an OSH ([**Hospital3 2005**]) and transferred to
[**Hospital1 18**] for definitive management. He was seen and evaluated in
the Trauma Bay and found to have a LeFort I fx, for which he had
been intubated for airway protection. His other imaging was
negative for acute injury, although his CSpine was relevant for
severe central canal stenosiss from degenerative disc disease
from C3-C7. On admission to the ICU, the patient was noted to
have labile pressures, but was flluid responsive. He was started
on Unasyn with plastic surgery's recommendations for
nonoperative management of LeFort I Fracture. He was noted to be
in AFib and this was managemd with lopressor and diltiazem for
the duration of his admission, although his coumadin was held
for concern of bleeding. His left metacarpal fracture was seen
by Orthopedics and stabilized with a splint. On [**5-16**] he was
succesfully extubated and his nasal packings were removed
without evidence of rebleeding. At this time he was alert and
oriented and able to sit up in bed. On [**5-18**] the patient was
transferred to the floor. Because of his facial fractures, he
was unable to tolerate POs, and Dobhoff/NG tube placement was
contraindicated, so the patient was planned for a GTube. In the
interim the patient was nutrionally maintained on TPN. On [**5-24**]
the patient had a percutaneous gastric tube placed in the
operating room with concurrant nasal fracture reduction. At the
end of the procedure, the tube was endoscopically examined and
determined to be properly placed and secured into place with
nonabsorbable suture. His Gtube was placed to gravity prior to
initiation of tube feedings. On [**5-25**] the patient was noted to be
in rapid afib and respiratory distress for which he required
intubation. The patient was transferred to the ICU and
resuscitatied with crystalloid and maintained on neosynephrine
for unstable pressures. Cardiac enzymes were cycled and the
patient underwent both bronchoscopy and CT Torso to evaluate for
potential causes of his septic picture. His minimum pressure
prior to resuscitation was 50/30, and recovvered appropritately
with pressures and IVF resuscitation. His CT torso was reviewed
and demonstrated that PO contrast instilled through the G tube
was free within the peritoneum along with free air, and
herniation of the stomach through the hiatus of the diaphragm.
Additionally a right sided hydronephrosis [**1-17**] ureteral calculus
was identified. Urology was consulted for hydronephrosis and a
ureteral stent was placed along with a percutaneous nephrostomy
tube. Additionally the patient was noted to be in acute renal
failure for which the nephrology service was consulted and the
patient started on CRRT as tolerated by his labile blood
pressures. On [**5-26**] the patient was taken to the OR for ex-lap
and resiting of his PEG with reduction of his hiatal hernia. He
was maintained on levofloxacin, cefepime and flagyl initially
and his antibiotics tailored to known cultures for the remainder
of his admission with the help of the Infectious Disease
service. Blood cultures were positive from prior to OR. He
continued to require levophed and vasopressin for maintainance
of perfusing pressures postoperatively. On weaning sedation the
patient was noted to have significant decrease in mental status,
but was responsive to stimulus. On [**5-30**] the patient was
restarted on tube feedings without any worsening peritoneal
signs or evidence of worsening sepsis. By [**6-2**] the patient was
succesfully weaned from his pressors, but remained intubated [**1-17**]
mental status changes, and CT head and Torso obtained on [**6-1**]
indicated no intracranial hemorrhage and no abscesses
intrabdominally, but did demonstrate large bilateral pleural
effusions, for which IR was consulted and placed a R pigtail
catheter. He failed a trial extubation on [**6-4**]. On [**6-6**] he
underwent tracheostomy placement for his prolonged intubation
and this was performed without difficulty, although the patient
did have difficulty tolerating tube feeds at this time, and his
G tube was changed to a G-J by IR on [**6-7**]. He continued to have
persistent fevers and on [**6-8**] CT Torso demonstrated multiple
abdominal fluid collections for which an IR pigtails x3 were
placed with serous output. His thoracic pigtail output was noted
to be decreased oon [**6-13**] and he continued to have persistent
pleural effusions were noted, so bilateral chest tubes were
placed without difficulty. Additionally, he was noted to have a
large purulent fluid collection underlying his wound and this
was opened and packed with wet to dry dressings initially, then
converted to a wound vac. His tube feeds were advanced to goal
and his chest tubes and abdominal pig tails were allowed to
drain until they were observed to have decreased output, then
removed. His GTube was capped and the Jejunal portion remained
functional without increased residuals. Repeat imaging showed
stable fluid collections the largest of which was 2cm. On HD 40
the patient was afebrile and maintained on Vancomycin and Zosyn,
at which time he was screened and transferred to a Long Term
Acute Care facility for further management.
Medications on Admission:
1. Coumadin 2.5mg po qM-W-F-[**Doctor First Name **], 5mg po qTu-Th-Sa
2. Metoprolol XL 100mg po qd
3. Enablex daily
4. Proscar daily
5. Protonix daily
6. Tylenol prn
Discharge Medications:
1. Acetaminophen 640 mg/20 mL Suspension [**Doctor First Name **]: One (1) PO Q6H
(every 6 hours) as needed for fever, pain.
Disp:*1000 mL* Refills:*0*
2. Glucagon (Human Recombinant) 1 mg Recon Soln [**Doctor First Name **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. Bisacodyl 10 mg Suppository [**Doctor First Name **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment [**Doctor First Name **]: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes.
5. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor First Name **]: One (1)
Injection TID (3 times a day).
6. Ipratropium Bromide 0.02 % Solution [**Doctor First Name **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
7. Docusate Sodium 50 mg/5 mL Liquid [**Doctor First Name **]: One (1) PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Insulin Regular Human 100 unit/mL Solution [**Doctor First Name **]: One (1)
Injection ASDIR (AS DIRECTED) as needed for hyperglycemia.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
12. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a day.
13. Dextrose 50% in Water (D50W) Syringe [**Last Name (STitle) **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
14. 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.
15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) as needed for
pneumonia for 7 days.
Disp:*21 * Refills:*0*
16. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 7 days.
Disp:*14 Recon Soln(s)* Refills:*0*
17. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center- MACU
Discharge Diagnosis:
Sepsis
PEG placement, Dislodged PEG
Trach placement
Pulmonary Effusion
Abdominal Abscesses
LeFort I facial fracture
Left 1st metacarpal fracture
Discharge Condition:
Mental Status - Responds to stimulus
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
In addition to the below standardized instructions, the patient
will require:
IV antibiotics as ordered until [**6-28**]
Tracheostomy care/Respiratory Care - Currently maintained on
pressure support with a peep of 5 and pressure support of 5 at
50%
Wound care (Wound Vac)
General Discharge Instructions:
You have had an abdominal operation. This sheet goes over some
questions and concerns you or your family may have. If you have
additional questions, or [**Male First Name (un) **]??????t understand something about your
operation, please call your [**Male First Name (un) 5059**].
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside. But avoid traveling long distances until you
see your [**Male First Name (un) 5059**] at your next visit.
[**Male First Name (un) **]??????t lift more than 20-25 pounds for 6 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or ??????washed out?????? for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that, it??????s OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as Milk
of Magnesia, 1 tablespoon) twice a day. You can get both of
these medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
[**Male First Name (un) **]??????t take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Male First Name (un) 5059**]
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as ??????soreness.??????
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important you take this
medicine as directed. Do not take it more frequently than
prescribed. Do not take more medicine at one time than
prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please [**Male First Name (un) **]??????t take any other pain
medicine, including non-prescription pain medicine, unless your
[**Male First Name (un) 5059**] has said it is OK.
If you are experiencing no pain, it is OK to skip a dose of pain
medicine.
To reduce pain, remember to exhale with any exertion or when you
change positions.
Remember to use your ??????cough pillow?????? for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
[**Name2 (NI) 5059**]:
sharp pain or any severe pain that lasts several hours
pain that is getting worse over time
pain accompanied by fever of more than 101
a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases, you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
Worsening abdominal pain
Sharp or severe pain that lasts several hours
Temperature of 101 degrees or higher
&#[**Numeric Identifier 96557**]; My doctor:
Name:___________________________
Phone number: _
Severe diarrhea
Vomiting
Redness around the incision that is spreading
Increased swelling around the incision
Excessive bruising around the incision
Cloudy fluid coming from the wound
Bright red blood or foul smelling discharge coming from the
wound
An increase in drainage from the wound
Followup Instructions:
Please follow up in the [**Hospital 2536**] clinic in [**1-18**] weeks. Call Acute Care
Surgery [**Telephone/Fax (1) 600**] to make an appointment
|
[
"553.3",
"V58.61",
"518.81",
"427.31",
"802.0",
"584.5",
"567.22",
"038.10",
"343.0",
"815.00",
"802.4",
"788.21",
"995.92",
"998.59",
"E878.8",
"600.01",
"E884.3",
"560.89",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.72",
"21.71",
"43.11",
"96.6",
"31.1",
"46.32",
"96.72",
"96.71",
"59.8",
"54.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15153, 15209
|
7375, 12604
|
334, 501
|
15397, 15516
|
1257, 4027
|
21452, 21601
|
986, 990
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12822, 15130
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15230, 15376
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12630, 12799
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15540, 15820
|
1005, 1238
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15852, 21429
|
274, 296
|
529, 820
|
4036, 7352
|
842, 920
|
936, 970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,264
| 190,950
|
10172
|
Discharge summary
|
report
|
Admission Date: [**2169-8-28**] Discharge Date: [**2169-9-18**]
Date of Birth: [**2107-1-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Paregoric / Heparin Agents
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
dizziness w/without activity
Major Surgical or Invasive Procedure:
Aortic Valve Replacement(23 St. [**Male First Name (un) 923**] Epic), CABGx2 (LIMA-LAD,
SVG-OM)
on [**8-29**] with Dr.[**Last Name (STitle) **]
History of Present Illness:
62 yo M found to have on routine PE with his PCP, [**Name Initial (NameIs) **] new murmur.
On further work up echo revealed AS with [**Location (un) 109**] 0.7cm'2. Pt having
symptoms of dizziness, fatigue, and SOB for nearly 1 year.
Dr.[**Last Name (STitle) **] consulted for AVR.
Past Medical History:
s/p AVR (#23mm St.[**Male First Name (un) 923**] epic porcine)/CABG
x2(LIMA->LAD/SVG->OM)[**8-29**] c/w HIT +
AS
ATN
Raynaud's Syndrome
Lumbar Stenosis
Nasal polyps
Ulnar nerve release
L5-S1 Fusion'[**59**]
L4-L5 Fusion '[**68**]
(L)knee surgery
torn bicep tendon
open Appy
Social History:
married with 5 children
current 1PPD (20py hx)
lives with wife
drinks [**1-7**] ETOH daily
Family History:
nc
Physical Exam:
a/o x 3
nad
cta
rrr
abd beingn
eschar on fingertips
palp radial and ulanar pulses
sternal incision min. serous drainage and LLE mild erythema
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 33936**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 33937**]Portable TEE
(Complete) Done [**2169-8-31**] at 9:16:58 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2107-1-12**]
Age (years): 62 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: s/p AVR/CABG with poor hemodynamics in ICU.
ICD-9 Codes: 799.02, 440.0, V43.3
Test Information
Date/Time: [**2169-8-31**] at 09:16 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Findings
Conclusions
This was a directed, limited study to investigate this patient
with poor hemodynamics in ICU.
The patient had just begun a dobutamine infusion. HR is sinus at
110.
The RV is large and hypokinetic. TR is mild-moderate.
The LV is dynamic and underfilled.
There is no MR.
[**First Name (Titles) **] [**Last Name (Titles) 33938**] aortic valve is well-seated with no leak and no
AI.
There is no pericardial collection.
There is no LAA contrast.
There is no clot or dissection of the aorta.
There is no clot seen in the PA. The tip of the SGC is in the
proximal right PA.
[**2169-9-15**] 05:30AM BLOOD
WBC-8.5 RBC-3.09* Hgb-10.5* Hct-32.0* MCV-104* MCH-33.9*
MCHC-32.7 RDW-14.6 Plt Ct-217
[**2169-9-8**] 05:05PM BLOOD
Neuts-75.4* Lymphs-16.2* Monos-6.4 Eos-1.3 Baso-0.7
[**2169-9-17**] 06:35AM BLOOD
UreaN-14 Creat-0.9 K-4.3
[**2169-9-11**] 06:15AM BLOOD
Mg-1.9
[**2169-9-10**] 06:30AM BLOOD
ALT-340* AST-118* LD(LDH)-302* AlkPhos-176* TotBili-2.2*
[**2169-9-18**] 05:43AM BLOOD WBC-8.4 RBC-3.37* Hgb-11.3* Hct-34.9*
MCV-104* MCH-33.5* MCHC-32.4 RDW-14.7 Plt Ct-260
[**2169-8-28**] 12:30PM BLOOD WBC-5.0# RBC-3.43* Hgb-12.6* Hct-35.9*
MCV-105* MCH-36.6*# MCHC-35.1* RDW-13.6 Plt Ct-214
[**2169-9-18**] 08:55AM BLOOD PT-36.0* PTT-49.4* INR(PT)-3.8*
[**2169-8-28**] 12:30PM BLOOD PT-12.8 PTT-29.8 INR(PT)-1.1
[**2169-9-18**] 05:43AM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-137
K-4.5 Cl-105 HCO3-24 AnGap-13
[**2169-9-18**] 05:43AM BLOOD ALT-154* AST-109* LD(LDH)-236
AlkPhos-185* Amylase-136* TotBili-0.8
[**2169-8-31**] 03:02AM BLOOD ALT-2815* AST-4685* LD(LDH)-3502*
AlkPhos-68 Amylase-23 TotBili-1.6*
[**Known lastname 33936**],[**Known firstname **] [**Medical Record Number 33939**] M 62 [**2107-1-12**]
Radiology Report CHEST (PA & LAT) Study Date of [**2169-9-16**] 9:57 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2169-9-16**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 33940**]
Reason: ? Pneumothorax, assess sternum s/p avr and cabg
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p avr and cabg
REASON FOR THIS EXAMINATION:
? Pneumothorax, assess sternum s/p avr and cabg
Final Report
CHEST PA AND LATERAL
REASON FOR EXAM: 62-year-old man status post AVR and CABG.
Assess sternum
pneumothorax, status post AVR and CABG.
Since [**2169-9-5**], bilateral pleural effusion decreased.
Tiny residual
left pleural effusion persists. There is no overload. Lungs are
otherwise
clear. The cardiomediastinal silhouette and hilar contours are
normal. There
is no pneumothorax.
Wires of prior sternotomy are intact. Right PICC ends in the
subclavian.
Right internal jugular catheter sheath was removed. Old right
rib fractures
are unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
Approved: SAT [**2169-9-16**] 1:08 PM
Imaging Lab
Brief Hospital Course:
[**2169-8-29**] Mr.[**Known lastname **] [**Last Name (Titles) 1834**] AVR(#23mm St.[**Male First Name (un) 923**] Epic Supra
Porcine Valve)/CABG x2 (lima->Lad/SVG->OM). Please refer to
Dr[**Doctor Last Name **] operative note for further details.
XCT:84min,CPB:107minutes. He was intubated, sedated, requiring
Epi and Neo to optimize his BP and CO. Upon arrival to the
CVICU, his SVO2 dropped with associated hypotension and
elevated PA pressures. CXR revealed a right upperlobe collapse.
He was bronched at the bedside to assist reexpansion. During the
postoperative night Precedex was initiated due to Mr.[**Known lastname 33941**]
severe agitation and hemodynamic instability with waking. EPI
and neo were weaned to off with the initiation of Dobutamine.
Folate, Thiamine, and Ativan were used to treat his current ETOH
abuse hx. He remained in the ICU for 6 days postop to recover
from hemodynamic instability, weaning from the ventilator, and
shock liver with recovering LFTs. All lines and drains were
discontinued while in the CVICU. On POD#7 After PICC line
insertion for access was completed, Mr.[**Known lastname **] was doing well
and transferred to the SDU for further telemetry monitoring and
increased activity/ambulation with PT. mr. [**Known lastname **] was noted to
be thrombocytopenic and the hematology service was consulted. An
initial HIT assay was negative from [**2169-8-31**]. A PF4 antibody was
obtained and was strongly positive. Argatroban was started and
all heparin products and aspirin were discontinued. Coumadin was
started when his platelets were greater then 100,000. Argatroban
was overlapped with coumadin until his INR had been therapeutic
for three days. He did have some purpura and discomfort in his
fingertips, wound care Rn was consulted for reccommendations.
NTG topical was started, placed on necrotic fingertips. Some
recovery noted and vascular was consulted.Mr.[**Known lastname **] continued
to progress while waiting for his INR to become therapeutic. On
POD# 20 he was ready for discharge to home with VNA. His PCP,
[**Last Name (NamePattern4) **].[**Last Name (STitle) 6707**] has agreed to follow his INR and Coumadin dosing. An
appointment for follow up was scheduled for [**2169-9-19**]. As
discussed with Hematology, Coumadin is to be continued for 3
months with an INR goal [**2-5**]. A course of keflex was initiated
for an erythematous left lower leg EVH site,which is not
draining, and approximately 1cm opening on the mid sternotomy
incision, with minimal serous drainage. . Per Dr.[**Last Name (STitle) **], [**First Name3 (LF) **]
discharge today with VNA. All follow-up appointments were
advised.
Medications on Admission:
Ibuprofen 600(2)
Lisinopril 10(1)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atorvastatin 40 mg [**First Name3 (LF) 8426**] Sig: One (1) [**First Name3 (LF) 8426**] PO DAILY
(Daily).
3. Pantoprazole 40 mg [**First Name3 (LF) 8426**], Delayed Release (E.C.) Sig: One
(1) [**First Name3 (LF) 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Thiamine HCl 100 mg [**First Name3 (LF) 8426**] Sig: One (1) [**First Name3 (LF) 8426**] PO DAILY
(Daily).
5. Multivitamin [**First Name3 (LF) 8426**] Sig: One (1) [**First Name3 (LF) 8426**] PO DAILY (Daily).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-4**]
Puffs Inhalation Q6H (every 6 hours).
7. Folic Acid 1 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY (Daily).
8. Ibuprofen 400 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO Q6H (every 6
hours) as needed.
9. Metoprolol Tartrate 50 mg [**Month/Day (2) 8426**] Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 [**Month/Day (2) 8426**](s)* Refills:*0*
10. Furosemide 20 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY (Daily)
for 7 days.
Disp:*7 [**Month/Day (2) 8426**](s)* Refills:*0*
11. Potassium Chloride 10 mEq [**Month/Day (2) 8426**] Sustained Release Sig: Two
(2) [**Month/Day (2) 8426**] Sustained Release PO once a day for 7 days.
Disp:*14 [**Month/Day (2) 8426**] Sustained Release(s)* Refills:*0*
12. Warfarin 1 mg [**Month/Day (2) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM: x 3 months, INR goal [**2-5**].
Disp:*90 [**Month/Day (3) 8426**](s)* Refills:*2*
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p AVR/CABG x2
Aortic Stenosis
Hypertension
lumbar stenosis
Raynaud's disease
s/p LT knee surgery
s/p L5 fusion
Pulmonary hypertension
Heparin Induced Thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
No baths, swimming
Shower daily
No lotions, creams or powders to incisions
Take all medications as prescribed
No driving
Weigh daily and report any weight gain greater than 3 pounds
report any fever greater than 101.5 or wound drainage
Followup Instructions:
-Followup with Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
-Followup with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 6707**] ***[**2169-9-19**].Appointment at
12:30 for INR draw/Coumadin dosing.
-Followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] in 2 weeks
-Follow-up with Dr. [**Last Name (STitle) 33942**] (Hematology)4-6 weeks ([**Telephone/Fax (1) 33943**].
-Will need coumadin for 3 months, INR goal [**2-5**].
Completed by:[**2169-9-18**]
|
[
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"424.1",
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"416.8",
"496",
"414.01",
"724.02",
"443.0",
"428.0",
"570",
"998.0",
"287.4",
"E934.2",
"709.8",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"37.22",
"36.15",
"35.21",
"88.55",
"38.93",
"38.91",
"33.24",
"88.52",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10169, 10224
|
5623, 8287
|
322, 467
|
10437, 10444
|
1382, 4583
|
10772, 11311
|
1201, 1205
|
8371, 10146
|
4623, 4656
|
10245, 10416
|
8313, 8348
|
10468, 10749
|
1220, 1363
|
254, 284
|
4688, 5600
|
495, 778
|
800, 1077
|
1093, 1185
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,086
| 190,691
|
10173
|
Discharge summary
|
report
|
Admission Date: [**2144-5-1**] Discharge Date: [**2144-6-9**]
Date of Birth: [**2070-6-19**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 73 year old woman who
was transferred on [**5-1**], from [**Hospital 1474**] Hospital with
abdominal pain. She had been admitted at the outside
hospital on [**2144-4-18**], and had at that time complaints
of right sided shoulder pain and was found to have asthmatic
bronchitis, and then subsequently found to have Methicillin
resistant Staphylococcus aureus pneumonia. Also, she was
treated for Methicillin resistant Staphylococcus aureus
pneumonia with Vancomycin. She had this worsening abdominal
pain and it was decided to be transferred to the [**Hospital1 346**] for further work-up of this.
HOSPITAL COURSE: During her admission to the Medical
Service, the patient had a General Surgical consultation
which was done on [**2144-5-2**]. The initial impression was
two weeks of abdominal pain with a differential including
ischemic colitis, infectious colitis such as with C.
difficile, diverticulitis. The patient unfortunately was
unable to take intravenous contrast so her CT scans that were
obtained were all without intravenous contrast making bowel
wall and ischemia more difficulty to diagnose in her case.
The GI Service was following her very carefully as well. The
patient underwent aggressive intravenous hydration. Dr.
[**Last Name (STitle) **] was the initial surgical attending of record. Most of
her pain was in her left lower quadrant and suprapubic. She
also had some bloody diarrhea and progressive abdominal
distention, which was concerning prior to her transfer to us,
at the outside hospital. The CT scan of the abdomen that had
been obtained showed a thickened sigmoid. Barium enema
showed some mucosal ulcerations.
She, during her hospitalization up to the [**5-3**], had
been treated with antibiotics including Vancomycin, Ceptaz
and Flagyl. The patient had been passing flatus and had
liquid stools. On abdominal examination she was soft and
moderately distended. There were no palpable masses
appreciated. Her rectal examination was guaiac positive with
loose stool present. There were no palpable masses. The
patient had a variety of stool studies sent. She continued
on Levaquin and Flagyl. Levaquin was added because she was
noted to have a positive urinalysis and for Gram negative
enteric coverage as well.
HOSPITAL COURSE: The [**Hospital 228**] hospital course was basically
passing flatus and stool with low grade temperatures and
waxing and [**Doctor Last Name 688**] left lower quadrant pain. The patient
essentially had a PICC placed on [**5-4**], #5 French
dual-lumen large catheter in the right arm. She did require
a blood transfusion for decreasing hematocrit and was started
on TPN. She had a pleural fluid tap for an effusion. She
had a flexible sigmoidoscopy on the 26th.
The flexible sigmoidoscopy showed some pseudomembranes and
the patient was given Flagyl p.o. three times a day. C.
difficile toxins were sent and the final [**Location (un) 1131**] on the GI
study was an active colitis. Differential was continued
ischemic versus infectious colitis.
On [**5-6**], she had a right upper extremity ultrasound which
did not show evidence of a venous thrombosis.
All stool cultures were negative.
Of note, incidentally, the patient suffered from audio
toxicity upon her presentation to this hospitalization and it
was unclear exactly the etiology of this audio toxicity as
her hearing was markedly decreased. After multiple
discussions with the family and Dr. [**Last Name (STitle) **] in Dr.[**Name (NI) 30985**]
absence, and the GI attending, Dr. [**Last Name (STitle) 1940**] and their service,
the patient consented to an operation. Of note, on [**5-7**],
a C. difficile toxin positive but all other things were
negative for C. difficile.
She was taken to the Operating Room after a short trial of
p.o. Vancomycin after the C. difficile toxin became positive.
However, clinically her examination did not improve, so she
was taken to the Operating Room with a preoperative diagnosis
of ischemic colitis and postoperative diagnosis was
gangrenous contained perforated colitis. She underwent an
exploratory laparotomy on [**2144-5-13**], and had a subtotal
abdominal colectomy with end-ileostomy, a Hartmann's sigmoid
procedure and a splenectomy, wash-out of her abdominal
cavity, repair of some serosal injuries to the small
intestine. The patient's operative findings were that of a
gangrenous contained perforated colon, soilage frankly to the
abdomen, dead splenic flexure adherent to the spleen
requiring splenectomy.
The patient was taken to the Intensive Care Unit
postoperatively. Her postoperative course was most
remarkable for self-extubation followed by re-intubation
followed by an additional round of elective extubation and
re-intubation, and the patient had been intermittently
treated with Vancomycin for a Methicillin resistant
Staphylococcus aureus pneumonia and Methicillin resistant
Staphylococcus aureus in the sputum which she had had at the
outside hospital and was continuing on. She finally had a
tracheostomy placed for failure to wean off the ventilator.
Her early ostomy functional, patent and productive. The
patient had been on TPN and was changed to tube feeds at goal
which she tolerated well. Perioperatively, the patient was
maintained on intravenous Lopressor and gradually she was
switched over to p.o. Lopressor and p.o. Diltiazem, and of
which she had been on a calcium-channel blocker
preoperatively prior to admission. She has been followed by
Physical Therapy and Nutrition as well as Speech and
Swallowing, which helped place a Passe-Muir valve with some
vocalization but inability to tolerate p.o. and to coordinate
swallowing.
For her Infectious Disease course, she was maintained on
triple antibiotics postoperatively, of Vancomycin,
Levofloxacin and Flagyl, a ten-day course of Vancomycin and
when that was stopped, her white count increased and she
developed fevers ago. That was restarted after sputum, blood
and urine were sent. Her blood cultures had been negative.
Her urine grew out Enterococcus which was not thought to be
pathogenic at the time and her sputum continued to grow out
Methicillin resistant Staphylococcus aureus.
The patient was maintained on deep venous thrombosis
prophylaxis of subcutaneous heparin. She was on Carafate
while intubated, and then she has been on tube feeds at goal.
She is not on any further ulcer prophylaxis.
She received aggressive resuscitation and her postoperative
course involved significant diuresis with maximum of 40 twice
a day of Lasix down to 20 twice a day of NG tube Lasix and
currently she will stop Lasix as she appears to be euvolemic
and has lost all the anasarca that she had accumulated.
PAST MEDICAL HISTORY:
1. Significant for degenerative joint disease.
2. Ischemic colitis.
3. Chronic obstructive pulmonary disease.
4. Diverticulitis.
5. Clostridium difficile toxin positive.
6. Hypertension.
7. Ejection fraction of greater than 55%.
8. Two plus mitral regurgitation and two plus aortic
stenosis, secondary AV block with pacemaker placed prior to
this hospitalization and currently repaced.
9. Methicillin resistant Staphylococcus aureus bronchitis.
ALLERGIES: IVP dye and epinephrine.
MEDICATIONS AT HOME:
1. Verapamil 120 mg p.o. q. day.
2. Tiazac 120 q. day.
3. Levaquin which was started from an outside hospital.
4. Albuterol.
5. Phenergan with codeine for some cough and bronchitis that
she had been prescribed prior to hospitalization.
MEDICATIONS ON DISCHARGE FROM THIS HOSPITALIZATION:
1. Lopressor 50 mg per NG tube twice a day to be held for
heart rate less than 60 and blood pressure less than 100.
2. Diltiazem 30 mg per NG tube four times a day; hold for
systolic blood pressure less than 100.
3. Paxil 20 mg q. day.
4. Sliding scale Regular insulin.
5. Heparin 5000 Units subcutaneously twice a day.
6. Flovent 120 micrograms dosing, three puffs inhaled twice
a day.
7. Serevent one to two puffs inhaled twice a day.
8. Vancomycin 1 gram intravenous q. 12 with peak and trough
checks q. 72 hours and should be checked on [**6-10**], next.
9. Levothyroxine 75 micrograms per NG q. day.
10. ProMod with fiber, goal of 60 cc an hour.
11. Epoetin alfa 40,000 subcutaneously one time per week.
12. Iron sulfate 325 mg per NG tube three times a day,
elixir.
13. Multivitamin, Ultram, one per NG tube q. day.
14. Ativan 0.5 mg intravenously q. six p.r.n.
15. Tylenol elixir 650 mgs per NG q. six p.r.n.
SPECIAL TREATMENTS AND FREQUENCY:
1. Ostomy care.
2. Wound care; the patient has a small opening at the
inferior aspect of her wound which is not grossly infected
and is granulating well. This had been draining a small
amount of yellowish fluid and is packed very very loosely,
minimal maybe a 2 by 2, normal saline wet-to-dry three times
a day.
3. Vancomycin level checks.
4. Aspiration precautions.
5. Speech evaluation for Passe-Muir valve and swallowing
coordination.
6. Physical Therapy aggressively to regain strength, stamina
and mobility.
7. Nutrition for her tube feeds and monitoring her
nutritional status.
The patient should be continued on Vancomycin for 12
additional days after discharge.
LABORATORY: On discharge, white count is 13.3, hematocrit
27.9, platelets 367. Sodium 136, potassium 4.5, BUN 31,
creatinine 0.7, glucose 112, calcium 8.1, magnesium 2.1,
phosphorus 3.4. There is no new culture data awaiting her.
On physical examination, she was alert, awake and appears
oriented. She has a tracheostomy which is patent and secure.
She is not sedated. Her chest sounds clear. Her
cardiovascular system is regular, paced. Head and neck is
unremarkable except for the tracheostomy. Abdomen is soft,
nontender, nondistended, with a stoma that is pink and patent
in the right lower quadrant with the inferior pole of her
wound slightly opened and packed. No surrounding erythema.
No current drainage. Her extremities are warm without edema.
She has a right sided PICC line. She has Venodyne boots
placed on both lower extremities and tube feed in place, NG
tube plus pyloric feeding tube.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Status post subtotal colectomy with a poor ischemic
colitis.
2. Status post splenectomy.
3. Tracheostomy.
4. Respiratory failure on ventilator.
5. Methicillin resistant Staphylococcus aureus pneumonia.
DISPOSITION: To a Rehabilitation facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2144-6-9**] 12:28
T: [**2144-6-9**] 12:37
JOB#: [**Job Number 33944**]
|
[
"569.83",
"557.9",
"482.41",
"E870.0",
"496",
"518.5",
"008.45",
"396.2",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"46.73",
"31.1",
"45.24",
"41.5",
"38.93",
"45.75",
"33.23",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
10311, 10840
|
2452, 6869
|
7406, 10265
|
10281, 10290
|
157, 768
|
6891, 7385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,213
| 173,268
|
52453
|
Discharge summary
|
report
|
Admission Date: [**2204-8-28**] [**Month/Day/Year **] Date: [**2204-10-31**]
Date of Birth: [**2168-10-6**] Sex: F
Service: MEDICINE
Allergies:
Insulin Pork Purified / Insulin Beef / Erythromycin Base /
Codeine / Aspirin / Compazine / Peanut / Reglan / Phenergan
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Bacteremia, hypoglycemia
Major Surgical or Invasive Procedure:
Tunneled palindrome HD catheter placement ([**2204-8-31**])
R PICC line placement ([**2204-9-5**])
History of Present Illness:
Pt is a 35 y.o. African-American woman with multiple medical
problems (see below) with multiple past hospitalizations who
presents from an OSH. Pt initially presented to OSH on [**2204-8-13**]
with DKA and complaints of nausea, vomiting, and abdominal pain.
On the way to hospital pt ran over a pedestrian who also
required hospitalization. Pt was admitted to MICU, where she
was treated with IV insulin, and her symptoms resolved
completely. She was then transferred back to floor, however
again was noncompliant with her diet and again developed
hyperglycemia with BS in 500s requiring transfer back to MICU.
At this time, she was found to be bacteremic with MRSA which was
believed to be from her hemodialysis line which was removed and
pt was started on vancomycin 1gm q48hrs. The date of vancomycin
start not entirely clear, but pt had temporal femoral
triple-lumen line place on [**8-23**]. Pt had ongoing hemodialysis
with her last dialysis being [**8-27**] at OSH. Patient's symptoms
resolved and she was transferred to [**Hospital1 18**] for a mandatory
admission while guardianship is established as pt was determined
to be a threat to others. At present patient states she feels
basically at her baseline. She has some mild baseline
epigastric pain, nausea and vomiting have resolved. Pt states
she recently has had some low grade fevers to about 101. She
has some diarrhea which is normal for her. She has a slight
cough, unchanged from baseline, and non-productive. She denies
any chest pain or shortness of breath. She denies any dysuria
or urinary frequency. She has chronic leg ulcers and she has
some chronic pain and itchyness associated with these. Pt
denies any changes in apettite or sleep cycle.
Past Medical History:
1) DM1 - diagnosed initially in [**2174**]. Patient has had multiple
admissions for DKA and hypoglycemia, practically monthly.
Volatile blood sugars complicated by infections w/ recurrent
pyelonephritis, chronic diarrhea, severe gastroparesis, high and
low sugars. Poor blood sugar control has resulted in severe
diabetic neuropathy and diabetic retinopathy.
2) Gastroparesis and chronic nausea - as above [**1-4**] DM
3) ESRD - Has been on peritoneal dialysis 5x/week for
approximately past year. Patient has, in past, refused
hemodialysis. Has agreed and been started on HD during current
admission. Baseline Cr unknown as patient has had such frequent
admissions for DM1 (as above) and acute worsening of [**Month/Day (2) **]
failure due to inaccurate PD at home.
4) Seizure disorder - worked up in past by neurology. Thought to
be toxic-metabolic in nature and secondary to patient's
endocrine status (brought on by hyper or hypoglycemia)
5) Anemia - [**1-4**] ESRD. Now on procrit with HD.
6) HTN
7) Asthma
8) Chronic skin breakdown - secondary to DM1 and poor healing
due to poor vascularity. Also [**1-4**] patient scratching [**1-4**] itching
from uremia. Particularly on lower extremities bilaterally.
9) Chronic diarrhea, also with stool incontinence since removal
of absces in [**2194**]
10) Recurrent pyelonephritis
11) History of peritonitis [**1-4**] infection from peritoneal
dialysis
12) History of subdural hematoma
13) History of esophagitis/gastritis: admitted for hematemesis
in [**9-4**] - EGD revealed Grade IV esophagitis, bleeding in distal
esophagus, erythema in stomach body and fundus (consistent with
gastritis)
14) Cardiac function - last [**Date Range **] in [**6-5**] demonstrated dilated
left atrium, moderate symmetric left ventricular hypertrophy,
normal EF = 60-70%, no wall motion abnormalities
Social History:
The patient had lived [**Location 6409**] when she was admitted, but
was evicted from this residency (court ordered, prior to her
hospitalization) and was going to stay with her mother in
[**Name (NI) **] after the hospitalization. Her PCP was [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who
completed his residency and has passed along his patients to Dr.
[**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) 29958**], who has yet to meet [**Known firstname 3608**]. Per his OMR note, her
children have recently been taken by DSS. She has a long history
of medical noncompliance. She previously noted that she smokes 2
packs of cigarettes every 5 days but says that she is smoking
less now (approximately 4 pk yr history). She denies use of
alcohol or illicit drugs. Had been in abusive home relationship
but denies current abuse.
Family History:
Father with type 2 DM, CHF, CVA
Physical Exam:
Temp 99.5 BP 122/73 HR 75 RR 18 O2sat 97% on RA BS: 287 Wt: 65kg
Gen: frail, older appearing than stated age, woman, sitting in
bed
CV: RRR, III/VI systolic murmur at RUSB, radiates to carotids
Lungs: CTAB
Abd: soft, non-tender, + BS, healing sites of previous PD
catheters without signs of infection
Groin: femoral triple lumen in place, no erythema or fluctuence
Ext: wrapped in unnaboots, chronic ulcers
Skin: Numerous ulcers and scars
Pertinent Results:
CT Chest ([**2204-10-18**]):
1. Enlarged axillary lymph nodes and retroperitoneal lymph nodes
and hepatosplenomegaly, suggestive of a lymphoid disorder.
2. No discrete fluid collections are present in the left chest
wall, although evaluation is slightly limited on this non-
contrast study.
3. No pneumonia.
4. Two lower lobe pulmonary nodules. Follow-up chest CT as an
outpatient after treatment is recommended to confirm resolution.
5. Oral contrast and food debris within the esophagus. This may
be due to gastroparesis and clinical correlation is recommended.
.
CT Abdomen & pelvis ([**2204-10-10**]):
1. No evidence of fluid collections, or abnormal inflammatory
changes within groins or suprapubic territory.
2. Patchy consolidation within the left lung base concerning for
pneumonia.
3. Ground-glass opacities within bilateral lung bases,
concerning for fluid overload.
4. Anasarca.
5. Interval removal of periumbilical peritoneal dialysis
catheter with decrease in abdominal ascites.
6. Coronary artery calcifications and atherosclerotic disease.
7. Stable prominent retroperitoneal and inguinal lymph nodes.
.
Bone and soft tissue, left heel ([**2204-10-15**]):
A. Bone: Bone with active osteomyelitis, osteonecrosis and
granulation tissue.
B. Soft tissue: Skin and soft tissue with extensive necrosis and
gram (+) bacteria on Brown and Brenn stain; special stains for
acid-fast bacilli and fungi are negative for organisms with
satisfactory controls.
.
Tissue Culture ([**2204-10-15**]):
ESCHERICHIA COLI. MODERATE GROWTH.
MORGANELLA MORGANII. MODERATE GROWTH.
ENTEROCOCCUS SP.. MODERATE GROWTH.
STAPH AUREUS COAG +.
Isolated from broth culture only, indicating very low
numbers of
organisms.
_________________________________________________________
ESCHERICHIA COLI
| MORGANELLA MORGANII
| | ENTEROCOCCUS
SP.
| | |
STAPH AUREUS COA
| | | |
AMPICILLIN------------ <=2 S 16 R
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 32 R
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S 32 I
CEFUROXIME------------ 4 S
CHLORAMPHENICOL------- 8 S
CIPROFLOXACIN--------- =>4 R =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S =>16 R =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R =>8 R =>8 R
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN------------ R =>0.5 R
PIPERACILLIN---------- <=4 S =>128 R
PIPERACILLIN/TAZO----- <=4 S 32 I
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S 8 I
VANCOMYCIN------------ =>32 R <=1 S
.
Tissue Culture ([**2204-9-22**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
_________________________________________________________
STAPH AUREUS COAG +
|
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------------ <=1 S
Brief Hospital Course:
##DM type I: Pt was initially managed with an insulin regimen
from her previous admission (lantus 40mg qhs and humalog sliding
scale). However, her blood sugars were extremely difficult to
control. She had frequent episodes of both hypoglycemia and
hyperglycemia, mainly because of variability in eating patterns.
She did, however, remain without evidence of ketoacidosis. Pt
was well-known to the [**Last Name (un) **] diabetes service and they were
consulted to help with sugar management. They devised a regimen
combining lantus, NPH, and a humalog sliding scale. This
improved her blood sugar control, though she did continue to
have occasional hypoglycemic (<40) and hyperglycemic episodes
(>400). Her insulin regimen was adjusted several times during
hospitalization and she ultimately placed on 16U lantus at
lunch, 40U NPH QHS, and a humalog sliding scale QACHS.
.
##MRSA bacteremia: Pt was transferred from OSH on vancomycin for
recent hx of MRSA bacteremia. She was continued on vancomycin
for a course of 2 weeks while at [**Hospital1 18**]. The central venous
catheter from OSH was removed and tip sent for culture, which
was negative. Surveillance cultures were drawn and were
negative. However, a blood culture on [**2204-9-22**] again grew MRSA
and patient was restarted on vancomycin. She continued to
receive vancomycin dosed by levels until she was changed to
linezolid based on the results of her tissue culture obtained at
the time of her heal debridement described below.
.
##Heel osteo: Pt has chronic bilateral heel ulcers [**1-4**] diabetic
neuropathy and peripheral vascular disease. Plain films
performed early during this hospitalization did not show bony
involvement. Swab cultures of the ulcers grew a mixed bacterial
flora including MRSA and GNRs. Pt was therefore started on Zosyn
in a addition to the vancomycin she was already on for MRSA
bacteremia. Ulcers were dressed with wet to dry dressings with
Accuzyme. Pain was controlled with PO morphine. However, pt
developed worsening foot pain and follow-up films were performed
on [**2204-10-3**]. These were consistent with osteomyelitis. An attempt
was made to take the patient for an operative debridement on
[**2204-10-9**]. However, she became somnolent and hypoxic with an
oxygen saturation of 85% preoperatively. In addition, there was
concern that the patient, her mother, and guardian had not all
been consented for the procedure. She was successfully taken to
the operating room for debridement on [**2204-10-15**] with tissue
pathology and culture results detailed above. Infectious disease
was consulted to aide in selecting appropriate antibiotic
therapy. She was prescribed a 6-week course of meropenem and
linezolid, to complete on [**2204-12-2**].
.
##Pre-operative hypoxia: Pt was noted to desaturate to 85% prior
to planned debridement of her heel osteo. She recovered in the
PACU to 95-99% within minutes. ABG done was 7.36/47/70. She
was moaning but responsive. CXR done was unremarkable with
slight regression of basal infiltrates but persistent signs of
CHF. Blood cx were drawn and remained negative. EKG was at
baseline (unchanged). CBC showed baseline HCT and Troponin was
within her normal range (slightly elevated at 0.42). Anion gap
was 16, which is her baseline. Blood sugar at the time of
desaturation was 199. Neurology was consulted for her MS changes
during her desaturation. They concluded that there was not an
immediate need for EEG. The etiology of her desaturation
remained unclear.
.
##ESRD: Pt had previously been on peritoneal dialysis. However,
given her failure on PD, she was transitioned to hemodialysis on
transfer to [**Hospital1 18**]. A tunneled L subclavian HD catheter was
placed after control of her MRSA bacteremia. Pt was followed by
the [**Hospital1 **] dialysis service and received HD approximately
3x/week. She refused dialysis on several occasions, and on at
least one occasion required emergent dialysis for hyperkalemia.
Her potassium was essentially persistently elevated above 6. Her
electrolytes were monitored daily and electrocardigrams
performed as needed for hyperkalemia. She had baseline peaking
of her T waves, but consistently narrow QRS complexes. She was
also given phosphate binders to control hyperphosphatemia, which
occasionally reached double digits.
.
##Nausea: Pt has chronic nausea of unclear etiology, but likely
related to gastroparesis from diabetes. Often exacerbated
post-HD and frequently in association with narcotics in the
setting of pain. Her symptoms were relatively well controlled
with [**Name (NI) **] (she states that she has an allergy to phenergan
and compazine). Neurontin was also added, dosed post HD 200mg
.
##Diarrhea: Pt has a known h/o chronic diarrhea. However, given
her broad-spectrum antibiotics, stool samples were also sent for
C Diff toxin testing. She was given a course of metronidazole
for C Diff positive diarrhea. Follow up samples after the
completion of treatment remained negative (including 3 samples
sent the week prior to [**Name (NI) **]). Her diarrhea was controlled
symptomatically with imodium and tincture of opium. Pt also
complained of intermittent bloody stools that were guaic
positive. He has a known history of gastritis, but no previous
colonoscopy. Her hematocrit remained stable and she was
discharged with instructions to follow-up with gastroenterology
as an outpatient.
.
##Pruritus: associated self-induced ulcers from scratching,
believed to be [**1-4**] end stage [**Month/Day (2) **] disease. Dermatology was
consulted and she was treated topically with eucerin, a steroid
ointment, as well as PO benadryl, [**Doctor First Name 130**], and hydroxyzine as
needed. Pt noted slight symptomatic improvement with this
regimen. She was also then started on Neurontin 200mg PO QHD as
above.
.
##Psychiatric / Legal guardianship: Pt has a long-standing
history of noncompliance at [**Hospital1 18**]. A psychiatric evaluation
found objective memory and executive deficits. Given her h/o
noncompliance, combined with episodes of delirium, she was
thought prone to making poor decisions. It was decided to pursue
guardianship, which the patient was agreeable to. Her cousin,
[**Name (NI) **] [**Name (NI) 1968**] (tel# [**Telephone/Fax (1) 108365**]), expressed interest in being
appointed legal guardianship. A meeting was held on [**10-9**], and
paperword signed the day after. A 1 to 1 sitter was continued
for a couple weeks afterwards, as the patient has a hx of
leaving the floor, and threatening the staff in the past.
However, the pt demonstrated overall good behavior, and the
sitter was discontinued approximately 1 week prior to [**Month (only) **].
She was continued on seroquel while hospitalized.
.
##Seizures: Pt has a history of seizures, mostly in the setting
of hypoglycemia. She was continued on Keppra at 500 [**Hospital1 **].
Psychiatry initially recommended possibly switching to depakote.
EEG and MRI showed no epileptic activity. Neurology recommended
continuing with Keppra given a lower risk of drug interaction in
this pt on multiple medications.
.
##HTN: Pt was continued on metoprolol. Procardia was stopped
following episodes of hypotension after dialysis. BP was also
very labile in face of labile blood sugars.
.
##Hypercholesterolemia: Statin was continued.
.
##Anemia: Pt has baseline anemia [**1-4**] iron defficiency and
chronic dz. She was continued on iron supplements and Epogen.
.
##Access - tunnelled line cath for dialysis use only.
[**Month/Day (2) **] Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchiness.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
9. Epoetin Alfa 10,000 unit/mL Solution Sig: 40,000 units
Injection once a week.
10. Pramoxine-Hydrocortisone [**12-3**] % Cream Sig: One (1) app
Topical TID (3 times a day) as needed for itchy lesions.
11. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for itching.
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
14. Sodium Polystyrene Sulfonate 15 g/60mL Suspension Sig:
Fifteen (15) gm PO BID (2 times a day).
15. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
18. Morphine 15 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
19. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO AFTER
DIALYSIS 3X/WEEK ().
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
21. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 weeks.
23. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO Q 8H (Every 8 Hours).
24. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous once a day: at lunch.
25. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
(40) units Subcutaneous at bedtime.
26. Insulin Lispro (Human) 100 unit/mL Solution Sig: 0-20 units
Subcutaneous qachs: per sliding scale.
27. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed for nausea.
28. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q24H (every 24 hours) for 5 weeks.
29. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
[**Month/Day (3) **] Disposition:
Extended Care
Facility:
northeast specialties
[**Month/Day (3) **] Diagnosis:
Heel osteomyelitis
MRSA bacteremia
Hypoglycemia [**1-4**] Diabetes
[**Month/Day (2) **] Condition:
Stable
[**Month/Day (2) **] Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to cardiac, consistent carbohydrate, [**Name8 (MD) **] diet
Continue antibiotics through [**2204-12-2**]
Followup Instructions:
Call ([**Telephone/Fax (1) 8892**] to make an appointment with gastroenterology
for blood in your stools
Call ([**Telephone/Fax (1) 21608**] to make an appointment with [**Telephone/Fax (1) **]
Call ([**Telephone/Fax (1) 3537**] to make an appointment at the [**Hospital **] Clinic
Completed by:[**2204-10-31**]
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12,039
| 163,666
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9076
|
Discharge summary
|
report
|
Admission Date: [**2197-6-19**] Discharge Date: [**2197-6-21**]
Date of Birth: [**2112-6-19**] Sex: M
Service: SURGERY
Allergies:
Percocet / Vicodin
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
cold, pale foot x 4 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84-year-old male with severe peripheral arterial disease and
a history of left lower extremity superficial femoral artery to
dorsalis pedis bypass [**First Name3 (LF) **] in 04 complicated by vein [**First Name3 (LF) **]
stenosis requiring multiple angioplasties and most recently, in
[**2197-2-23**], a stent of the vein [**Year (4 digits) **]. He presents today with 3
days of
left 1st great toe pain and heel pain of the left foot. He
called Dr.[**Name (NI) 7446**] office this am and was instructed to
come to the ED. In the Ed patient has a cool left foot
initially
with cap refill roughly 2 seconds with a monophasic PT absent DP
(previously [**4-3**] palpable)---> that progressed to pallor. He
denies weakness or sensory deficit and rates pain as a [**3-4**]. His
most recent [**4-17**] duplex showed a patent vein [**Month/Year (2) **] with mild
restenosis w. the following velocities.
Inflow 87; proximal anastomosis 57; [**Month/Year (2) **] 57, 119 (2.0x), 117,
54, 39, 71; distal anastomosis 70; outflow 45. HE states that
he
has been therapeutic on Coumadin last check 2 weeks ago. He
denies fevers, chills, chest pain or SOB. CT scan in the ED
shows occlusion of left bypass [**Month/Year (2) **]. He is admitted to the
[**Month/Year (2) 1106**] service for further work up.
Past Medical History:
PVD, DM, HTN, hypercholesterolemia, hearing loss, CAD
PSH: Right BKA, left SFA-DP BPG ([**2190**]), vein angioplasty of BPG
for ingraft stenosis [**2194**], vein angioplasty of bpg with
stenting [**3-4**], CABG x3 ('[**89**]),Left second toe amputation, Left
hallux IP joint arthroplasty and ulcer debridement('[**90**])
Social History:
From [**Last Name (un) 31340**] [**Country 4754**] - travels from [**Country 4754**] to home in [**Location (un) 1468**],
MA several times per year. Remote history of distant TOB for
nearly 40 pack years - none currently. Drinks alcohol rarely on
social occasions. Lives with daughter
[**Name (NI) **] illicit drugs.
Family History:
Significant for [**Name (NI) 1106**] disease and heart
disease.
Physical Exam:
VSS, Afebrile
Gen: Elderly make in NAD A&Ox3
Card: RRR no m/r/g
Lungs: CTA bilat
Abd: soft, no m/t/o well healed midline incision
Ext: Right BKA, Left foot with mild pallor. Sensation and motor
function intact.
Pulses
Fem Dp PT [**Name (NI) 12924**]
R Palp ------BKA------
L Palp Absent D ( mono) Palp to distal [**11-28**] of calf.
Pertinent Results:
[**2197-6-19**] 08:30PM BLOOD WBC-6.6 RBC-3.15* Hgb-10.0* Hct-29.9*
MCV-95 MCH-31.7 MCHC-33.3 RDW-14.4 Plt Ct-233
[**2197-6-20**] 07:25AM BLOOD WBC-7.1 RBC-3.32* Hgb-10.3* Hct-31.7*
MCV-95 MCH-30.9 MCHC-32.4 RDW-14.3 Plt Ct-239
[**2197-6-21**] 09:45AM BLOOD WBC-7.3 RBC-3.33* Hgb-10.5* Hct-31.4*
MCV-94 MCH-31.4 MCHC-33.4 RDW-14.4 Plt Ct-241
[**2197-6-19**] 08:30PM BLOOD PT-15.0* PTT-29.2 INR(PT)-1.3*
[**2197-6-20**] 07:25AM BLOOD PT-15.9* PTT-125.8* INR(PT)-1.4*
[**2197-6-21**] 09:45AM BLOOD PT-14.7* PTT-39.6* INR(PT)-1.3*
[**2197-6-19**] 08:30PM BLOOD Glucose-356* UreaN-30* Creat-1.2 Na-140
K-4.1 Cl-109* HCO3-23 AnGap-12
[**2197-6-20**] 07:25AM BLOOD Glucose-102* UreaN-25* Creat-0.9 Na-143
K-4.1 Cl-111* HCO3-24 AnGap-12
[**2197-6-21**] 09:45AM BLOOD Glucose-213* UreaN-19 Creat-1.0 Na-139
K-4.7 Cl-108 HCO3-22 AnGap-14
[**2197-6-20**] 07:25AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8
[**2197-6-21**] 09:45AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
UNILAT LOWER EXT VEINS LEFT Study Date of [**2197-6-19**] 8:41 PM
FINDINGS: [**Doctor Last Name **]-scale and color Doppler ultrasonography of the
left lower
extremity demonstrates arterial flow in the proximal-most
portion of the
bypass [**Doctor Last Name **]. However, further in the proximal-to-mid portion of
the [**Doctor Last Name **]
within the upper portion of the extremity, there is abrupt
cutoff of flow with
echogenic material concerning for occlusive thrombus. Minimal
flow is
demonstrated in the distal portion of the [**Doctor Last Name **] within the left
calf.
IMPRESSION: Occlusive thrombus at the proximal-to-mid portion of
the left
arterial bypass [**Doctor Last Name **].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**6-19**] from the ED to the VICU with a
cold, mottled foot. He was started on a heparin gtt to be
therapeutically anticoagulated. A CT scan done in the ED showed
Occlusive thrombus at the proximal-to-mid portion of his the
left vein bypass [**Month/Year (2) **]. He remained on therapeutic heparin and
his foot pain resided. On HD2 his foot exam remained stable,
with palor, but good sensory and motor function. Given his
previous [**Month/Year (2) **] occlusions, the [**Month/Year (2) 1106**] team felt he was a poor
candidate for repeat angiogram with angioplasty or stenting.
His previous angio studies were reviewed and it was determined
that at this time, endovascular intervention is not an option.
Mr. [**Known lastname **] was continued on heparin and on [**6-20**] started back
on his po coumadin. He was started on pletal 100mg [**Hospital1 **]. On [**6-21**]
he had no pain, and his foot exam was again stable - with a
cool, somewhat pallored left foot, with good sensory-motor
function. His INR was 1.3 on [**6-21**], his heparin gtt was stopped
and he was started on therpeutic once daily lovenox injections.
The [**Month/Year (2) 1106**] team agreed that he was stable without any further
intervention to be done at this time and he was discharged home
with his daughter. [**Name (NI) **] will have [**Name (NI) 269**] services daily for
medication teaching/ assistance, and INR lab draws. His INR is
followed by his pcp [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**Location (un) 1468**].
Medications on Admission:
atenolol 25', atorvastatin 80', plavix 75', lisinopril 10',
metformin 1000'', warfarin 5 twice/wk, warfarin 3 5days/wk
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS (TU,TH).
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAYS
([**Doctor First Name **],MO,WE,FR,SA).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous DAILY (Daily): until INR is therapeutic 2.0 or
greater.
Disp:*10 syringes* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
four (4) hours as needed for pain.
12. PT/INR lab test
should be followed by your regular physician. [**Name10 (NameIs) 269**] can draw lab
and send results to your doctor.
Please check INR friday [**6-23**]. Pt should continue lovenox
injections until INR is 2.0 or greater
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left lower extremity ischemia
- Occlusive thrombus at the proximal-to-mid portion of the left
arterial bypass [**Hospital **]
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:
?????? Continue Plavix and coumadin. We have started you on a new
medication called pletal which you will take twice a day.
* You will need to take an injection called Lovenox until
your PT/INR is therapeutic. You will have a [**Hospital 269**] come daily to
help you with your lovenox injection.
?????? You make take Tylenol for any post procedure pain or
discomfort
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)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Hospital 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2197-7-5**] 3:45
You need to have your PT/INR checked on friday. Your [**Month/Day/Year 269**] should
be able to draw the blood and send it to the physician who
typically follows your INR, Dr. [**First Name (STitle) **] in [**Location (un) 1468**].
Completed by:[**2197-6-21**]
|
[
"E878.2",
"996.74",
"272.0",
"401.9",
"V49.75",
"444.22",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7402, 7460
|
4474, 6046
|
303, 310
|
7630, 7630
|
2808, 4451
|
8797, 9212
|
2339, 2404
|
6215, 7379
|
7481, 7609
|
6072, 6192
|
7813, 8189
|
8215, 8774
|
2419, 2789
|
239, 265
|
338, 1638
|
7645, 7789
|
1660, 1987
|
2003, 2322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,200
| 183,459
|
24638
|
Discharge summary
|
report
|
Admission Date: [**2184-5-5**] Discharge Date: [**2184-5-10**]
Date of Birth: [**2109-5-4**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Chief Complaint: found down and unresponsive
Major Surgical or Invasive Procedure:
extubated
History of Present Illness:
The patient is a 75 year old left-handed woman with a history of
osteoporosis and asthma now presenting after being found
unresponsive at home. The daughter tells me, her mother had
been going about her normal business for the day and hadn't
complained of any illness, particularly no headaches. Around
8pm, the daughter went into the the patient's bedroom to
discover her mother on the floor, lying on her side, completely
still. She was unsuccessful in arousing her mother. She called
911 and the patient was taken to an OSH where she was noted to
have a right-sided paralysis. A subsequent head CT showed a
large left
temporo-parietal bleed. She was transferred here for further
management.
Review of Systems:
-no recent fevers, chills, rashes, nausea, vomiting, or diarrhea
as per family
Past Medical History:
-osteoporosis
-asthma
Social History:
-lives with husband and at baseline is fully independent
-no significant alchohol or tobacco use
Family History:
-no h/o seizures or strokes
Physical Exam:
Physical Exam
Vitals: 99.6 132/53 68 14
General: elderly woman lying on bed, intubated
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
(patient off propofol x 15 minutes)
No response to sternal rub; eyes at midline, no doll's eye
movements; pupils sluggishly reactive 4 to 2 mm but bilateral;
slightly decreased right nlf; corneal intact b/l; weak gag;
spontaneous flexion of right leg, no other spontaneous movement;
withdraws to pain on all ext L>R; reflexes brisk throughout, toe
up on left, mute on right
Pertinent Results:
NCHCT: Comparison with the prior [**Hospital 4068**] Hospital study of [**5-4**]
reveals negligible change in the extent of the large left
temporal-parietal hemorrhage as well as moderate surrounding
edema. There may be somewhat greater quantity of blood within
the lateral ventricles, particularly on the left side, but blood
is not seen in the third ventricle at this time. The degree of
mass effect is unaltered. There is, at most, a few millimeters
rightward shift of the septum pellucidum. There is no
hydrocephalus. No other overt interval change is seen.
CXR: The endotracheal tube tip is less than 2 cm above the
carina. Heart size is at upper limits of normal. The aorta is
calcified and tortuous. Pulmonary vasculature is unremarkable.
There are low lung volumes on the exam. There is left basilar
atelectasis. Opacity at the right lower lung field may represent
atelectasis and adjacent small pleural effusion, but a somewhat
nodular contour is noted to the pulmonary component of this
opacity. Osseous and soft tissue structures are unremarkable.
CXR: 1) Nasogastric tube coiled within the stomach.
2) New patchy left lower lobe opacity which may relate to either
atelectasis or aspiration.
3) Resolved right basilar opacity with residual small right
effusion.
EEG: official report pending
[**2184-5-5**] 05:50PM TYPE-ART PO2-150* PCO2-36 PH-7.44 TOTAL
CO2-25 BASE XS-1
[**2184-5-5**] 05:29PM ALBUMIN-3.6
[**2184-5-5**] 10:58AM TYPE-ART TEMP-37.8 RATES-14/5 TIDAL VOL-500
O2-50 PO2-173* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2184-5-5**] 06:39AM TYPE-ART PO2-167* PCO2-38 PH-7.42 TOTAL
CO2-25 BASE XS-0
[**2184-5-5**] 06:39AM LACTATE-1.1
[**2184-5-5**] 06:39AM freeCa-1.11*
[**2184-5-5**] 04:47AM GLUCOSE-125* UREA N-14 CREAT-0.5 SODIUM-143
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-25 ANION GAP-12
[**2184-5-5**] 04:47AM WBC-10.4 RBC-3.48* HGB-10.8* HCT-32.5* MCV-94
MCH-31.0 MCHC-33.1 RDW-12.8
[**2184-5-5**] 04:47AM PLT COUNT-205
[**2184-5-5**] 04:47AM PT-13.3 PTT-24.7 INR(PT)-1.1
[**2184-5-4**] 11:40PM GLUCOSE-127* UREA N-16 CREAT-0.5 SODIUM-140
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2184-5-4**] 11:40PM PT-13.0 PTT-25.6 INR(PT)-1.1
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the ICU with large intraparenchymal
hemorrhage. She arrived intubated. She was started on dilantin
and blood pressure controlled. After discussions with family it
was decided to make her DNR/DNI as she is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scientist
and would not have wanted invasive interventions. On [**5-7**] after
further discussions re: dismal prognosis, patient's family
decided to make CMO and she was extubated. She was started on a
morphine drip. Pending survival, she will be trasferred to
hospice.
Medications on Admission:
-fosamax
-albuterol
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
2. Morphine Concentrate 20 mg/mL Solution Sig: [**1-11**] ML PO Q3-4H
() as needed for pain: 5-10 mg per dose.
Disp:*250 ML* Refills:*3*
3. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ML PO
Q4-6H (every 4 to 6 hours) as needed for discomfort: up to 2mg
sublingually as needed.
Disp:*60 ML* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House
Discharge Diagnosis:
intracerebral hemorrhage
Discharge Condition:
critical
Discharge Instructions:
Oral morphine & ativan for discomfort as tolerated. Scopolamine
patch for secretions.
Followup Instructions:
n/a - going to hospice
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2184-5-10**]
|
[
"431",
"518.0",
"277.3",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.14",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5465, 5524
|
4340, 4926
|
360, 371
|
5593, 5603
|
2080, 4317
|
5738, 5884
|
1376, 1406
|
4997, 5442
|
5545, 5572
|
4952, 4974
|
5627, 5715
|
1421, 1661
|
1118, 1199
|
292, 322
|
399, 1099
|
1685, 2061
|
1221, 1245
|
1261, 1360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,672
| 145,874
|
15691
|
Discharge summary
|
report
|
Admission Date: [**2108-10-23**] Discharge Date: [**2108-10-31**]
Date of Birth: [**2058-7-14**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
- cellulitis of right lower extremity
- sepsis
Major Surgical or Invasive Procedure:
- placement of RIJ CVL
- Podiatry surgery ([**2108-10-29**]) - Resection of fourth metatarsal
head osteomyelitis right foot.
History of Present Illness:
50 yo F with history of IDDM, CAD, [**Last Name (un) 24206**] [**Last Name (un) 24206**] disease and known
ulcer and cellulits of RLE presented to the ED with 2 days of
RLE cellulitis with fevers to 103 last night. The patient has
had an ulcer on the plantar aspect of her R foot since [**Month (only) 958**].
She has had recurrent episodes of cellulitis requiring treatment
on multiple occasions with Vancomycin, Daptomycin and Linezolid.
10 days prior to this admission, she had just finished a 10 day
course of daptomycin. She notes that her cellulitis infections
improve with antibiotics, but flare once she is off the
antibiotics.
.
On day of admission, the patient noted worsening erythema and
tenderness of her right leg. On arrival to the ED, her SBP 86 on
arrival and she had a lactate 3.6 and WBC 19. She denied blurry
vision, lightheadedness, CP, SOB, abdominal pain.
Past Medical History:
* Moyamoya disease
* IDDM
* HTN
* CAD, s/p CABG (LIMA to LAD, SVG to OM, SVG to PDA/PLB) on
[**2104-8-21**]; stents in SVG-OM and LCx ostium on [**2104-8-24**]
* h/o lung carcinoma of the right lower lobe.
* seizure disorder
* OSA
* s/p Ext Carotid-Int Carotid bypass [**2102**]
* s/p right CEA in [**2101**]
* multiple strokes in [**2093**], [**2094**]
* PVD
Social History:
Smokes tobacco. EtOH/drugs. Married. Has financial issues with
obtaining medication. She is on disability.
Family History:
Members with CAD and DM
Physical Exam:
On admit:
T:100.0 BP:106/51 P:94 RR: O2 sats:99% on 2L NC
Gen: Well appearing obese female in NAD
HEENT: OP clear. Chin with surgical scar
Neck: Supple
CV: +s1+s2 +SEM
Resp: CTA B/L No RRW
Abd: Benign
Ext: RLE erythema from foot to below knee. Open 0.5cm ulcer on
plantar aspect of 4th digit. + [**Year (4 digits) 17394**] DP and PT
bilaterally
Pertinent Results:
Labs from Admit:
[**2108-10-23**] 01:20PM BLOOD WBC-19.3*# RBC-3.92* Hgb-10.8* Hct-31.9*
MCV-82 MCH-27.7 MCHC-33.9 RDW-17.4* Plt Ct-268
[**2108-10-23**] 01:20PM BLOOD Neuts-90.6* Bands-0 Lymphs-7.1*
Monos-1.7* Eos-0.4 Baso-0.2
[**2108-10-23**] 01:20PM BLOOD PT-14.0* PTT-27.6 INR(PT)-1.2*
[**2108-10-23**] 01:20PM BLOOD Glucose-141* UreaN-17 Creat-1.2* Na-137
K-4.2 Cl-99 HCO3-24 AnGap-18
[**2108-10-23**] 01:20PM BLOOD ALT-11 AST-14 AlkPhos-69 Amylase-29
TotBili-0.4
[**2108-10-23**] 01:20PM BLOOD Lipase-15
[**2108-10-23**] 01:20PM BLOOD Calcium-9.0 Phos-2.4*# Mg-1.5*
[**2108-10-23**] 01:20PM BLOOD CRP-194.6*
[**2108-10-23**] 01:37PM BLOOD Lactate-3.6*
[**2108-10-23**] 04:31PM BLOOD Lactate-1.0
[**2108-10-23**] 05:21PM BLOOD Lactate-0.8
Studies:
CHEST PORT. LINE PLACEMENT [**2108-10-23**] 4:58 PM
Reason: line placement
IMPRESSION: AP chest compared to [**10-23**], 4:08 p.m.
Right PIC line has been removed, new right internal jugular line
ends in the upper SVC and a new left PIC line ends just above
the superior cavoatrial junction. Lateral aspect of the left
lower chest is excluded from the study, other pleural surfaces
are unremarkable. Heart remains top normal size and there is
mild engorgement of pulmonary vasculature but no edema or
interval mediastinal widening or indication of pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
ANKLE (2 VIEWS) RIGHT [**2108-10-23**] 4:59 PM
The ankle mortise is congruent without evidence of fracture.
Osteotomies involving the fourth and fifth metatarsals as well
as resection of the distal fourth ray are unchanged from the
previous exam. No cortical destruction is seen. There is soft
tissue swelling around the ankle and foot, likely representing
edema/cellulitis.
IMPRESSION: Soft tissue swelling likely indicating cellulitis.
No radiographic evidence of osteomyelitis.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: TUE [**2108-10-23**] 7:01 PM
ECHO [**2108-10-24**]
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 5-10 mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. A mass or vegetation on the
mitral valve cannot be excluded. There is probably moderate
valvular mitral stenosis (in part due to the significant MAC).
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of
mitral regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is severe
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2106-12-28**],
the degree of pulmopnary hypertension detected has increased. If
clinically indicated, a TEE is recommended to exclude
endocarditis and to determine the degree of valvular mitral
stenosis.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2108-10-24**] 15:52.
[**Location (un) **] PHYSICIAN:
Labs on discharge:
Brief Hospital Course:
50 yo F h/o recurrent RLE cellulitis, IDDM, CAD s/p CABG
presents with RLE cellulitis and sepsis. On presentation, SBP
was 86, with lactate 3.6, WBC 19. SBP improved to 120s w/ 2L IVF
and her lactate dropped to 1.4. After 4-5th L IVF, SBP dropped
to the 80s. Was started on pressors and abx regimen of
daptomycin and vancomycin; transferred to MICU. In MICU pressors
weaned off, minimal maint IVF started. Was continued on
daptomycin and vancomycin, which were later changed to
piperacillin-tazobactam and vancomycin. The L PICC line, which
the patient had had for 1 month, was pulled and tip sent for
culture. New PICC line placed, pt transferred out to floor.
[**Last Name (un) **] was consulted for blood sugar management. Podiatry was
consulted for surgery once cellulitis improved. ID was consulted
regarding antibiotic regimen.
.
# RLE cellulitis: Pt's erythema and tenderness resolving.
Underwent right 4th metatarsal head resection by podiatry on
[**2108-10-30**]. Bone samples were sent for microbiology and pathology
examination. Pt had bandage takedown by podiatry on POD #2,
cleared for discharge. Sent home on Vancomycin and Zosyn, to be
continued for 2 full weeks post-op, with possible extension to
4-week course pending micro/path results from biopsy specimen
sent from surgery.
.
# Recent sepsis: Pt stabilized after IVF, continued to have
stable BP while on medicine wards.
.
# CAD: Pt was without symptoms of CAD during her hospital stay.
She was continued on her home regimen of ASA, statin, BB, and
ACE-I.
.
# IDDM: Pt's FSBS were uncontrolled, likely given her infection
and then surgical course, [**First Name8 (NamePattern2) **] [**Last Name (un) **] was consulted regarding
adjustments to her home diabetes regimen. After adjustments were
made during the hospitalization, [**Last Name (un) **] recommended changing her
back to her home insulin regimen in preparation for discharge.
She had appropriate control of her FSBS on this home regimen
after her surgery and pre-discharge.
.
Medications on Admission:
Insulin: 100U glargine QAM, 60U QPM + Humalog SS
Metformin 1000mg [**Hospital1 **]
ASA 325mg daily
lyrica 150mg TID
wellbutrin 150mg [**Hospital1 **]
crestor 20mg daily
niacin 1000mg daily
diovan 150mg daily
plavix 75mg daily
allergra Prn
vicodin prn
metoprolol 12.5mg [**Hospital1 **]
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
once a day for 12 (twelve) days.
Disp:*12 bags* Refills:*0*
2. Heparin Flush 10 unit/mL Kit Sig: 10 (ten) cc Intravenous
once a day: and PRN per line care protocol.
Disp:*30 flushes* Refills:*2*
3. Saline Flush 0.9 % Syringe Sig: 10 (ten) cc Injection once a
day: and PRN per line care protocol.
Disp:*30 flushes* Refills:*2*
4. Line Care
Line Care per protocol
5. Zosyn 4.5 g Recon Soln Sig: 4.5 grams Intravenous every eight
(8) hours for 12 days.
Disp:*12 bags* Refills:*0*
6. Insulin Glargine 100 unit/mL Cartridge Sig: One Hundred (100)
units Subcutaneous qAM (every morning).
7. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units
Subcutaneous qPM (every evening).
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
11. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Niacin 1,000 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
14. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchiness.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] Home Infusion
Discharge Diagnosis:
Primary Diagnoses:
1. RLE cellulitis
2. sepsis
3. diabetes
4. PVD
Secondary Diagnoses:
- CAD s/p CABG
- h/o lung cancer
- h/o CVAs
Discharge Condition:
afebrile, vital signs stable, tolerating POs, with improving
pain and resolving infection in the right leg, bandaged and in
post-op shoe by podiatry.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2108-10-23**], for an infection of your right leg
(cellulitis). You were admitted to the MICU for low blood
pressures that required vasopressors, and you were started on
Zosyn and Vancomycin as antibiotic treatment for your infection.
In the MICU, you were weaned off the vasopressors and
maintained on IV fluids. Multiple X-rays of your right leg and
feet showed no evidence of infection in the bone
(osteomyelitis). An echocardiogram was done, which showed no
evidence of an infection in your heart (endocarditis). Your
left PICC line was changed, and podiatry was consulted for
surgery of the right foot wound once your infection improved.
You were taken to the operating room for debridement of the
wound, and the head of the 4th metatarsal bone was removed and
sent for microbiology and pathology. You continued to do well,
and were discharged on a 2-week course of Zosyn and Vancomycin
with close follow-up.
.
During your hospital stay, your blood sugars were also
poorly-controlled, so the [**Last Name (un) **] diabetes team was consulted to
help manage your blood sugars. By the time your were ready for
discharge, your blood sugars were under good control on your
home insulin regimen.
.
If you develop worsening foot pain, redness, swelling, or
warmth, or if you develop fevers or chills, you should call your
doctor immediately and return to the emergency room.
.
Followup Instructions:
You will need to have your Vancomycin trough, ESR, and CRP
checked by the VNA on [**2108-10-31**], with the results sent
to your PCP. [**Name10 (NameIs) **] will also need to have your CBC, Chem 7, and
LFTs checked once weekly while you are on these antibiotics,
with the results also to be sent to your PCP. [**Name10 (NameIs) **] will need to
follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 5164**], on Wednesday, [**11-7**], at 10:15AM.
You will also need to follow-up with your Infectious Disease
doctor, Dr. [**Last Name (STitle) **], within the next two weeks. Dr. [**Last Name (STitle) **] should
follow-up on the microbiology and pathology from [**Hospital1 18**] to make
sure that a two-week course of Zosyn or Vancomycin is sufficient
to treat your infection. Please call Dr.[**Name (NI) 24408**] office to make
this appointment tomorrow.
.
From a podiatry standpoint, you will need dressing changes every
other day by VNA, with betadyne and dressing to incision. You
should also be partial-weight-bearing on the right foot, in the
post-op shoe.
.
|
[
"V10.11",
"414.00",
"V58.67",
"V58.66",
"730.27",
"416.8",
"443.9",
"424.1",
"V45.81",
"272.4",
"458.8",
"780.57",
"518.89",
"401.9",
"731.8",
"707.15",
"995.91",
"038.11",
"437.5",
"305.1",
"V12.59",
"682.7",
"V09.0",
"250.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.88",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10050, 10117
|
6212, 8222
|
329, 456
|
10292, 10444
|
2296, 6136
|
11922, 13071
|
1889, 1914
|
8560, 10027
|
10138, 10204
|
8249, 8537
|
10468, 11899
|
1929, 2277
|
10225, 10271
|
243, 291
|
6189, 6189
|
484, 1365
|
6169, 6169
|
1387, 1748
|
1764, 1873
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,032
| 175,846
|
22331
|
Discharge summary
|
report
|
Admission Date: [**2182-7-23**] Discharge Date: [**2182-7-28**]
Date of Birth: [**2123-12-12**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
58 yo male schedulle for hernia repair preop work up showed
abnormal ECG. Cath bicuspid AV
Major Surgical or Invasive Procedure:
ascending aorta repai CABG X1
History of Present Illness:
PATINET ON PREOP HERNIA WORK UP FOUND TO HAVE ASCENDING AORTA
5.2 CM AND BYCUSPID AV EF 55% CT SURGERY CONSULTED FOR ASCENDING
AORTA REPAIR
Past Medical History:
Hypertension
Hyperlipidimia
oBESITY
Social History:
DENIES X3
Family History:
FATHER DIED OF LUNG CA
Physical Exam:
LUNGS CTA B BS
HEART RRR NM NG
ABD SOFT POS BS
CNS ORIENTD WOUND NO SX INFECTIONS STABLE MEDIASTINUM
Pertinent Results:
[**2182-7-23**]
10:16p
Source: Line-ALINE; GREEN TOP
3.9
Source: Line-ALINE
23.3
[**2182-7-23**]
6:24p
7.38 / 46 / 76 / 28 / 0
Type:Art
K:4.0 Glu:129 freeCa:1.22
O2Sat: 95
[**2182-7-23**]
4:47p
7.36 / 48 / 261 / 28 / 1
Type:Art
Na:135 K:4.4 Glu:93 freeCa:1.08
[**2182-7-23**]
4:41p
LINE: ALINE; GREEN TOP TUBE / SAMPLE SLIGHTLY HEMOLYZED
105 20
24 1.1
LINE: ALINE
102
25.0 D
LINE: ALINE
PT: 14.7 PTT: 37.9 INR: 1.4
Comments: Note New Normal Range As Of 12am Of [**2182-7-23**]
[**2182-7-23**]
4:01p
7.39 / 42 / 230 / 26 / 0
Type:Art; Intubated; Rate:8/ ; TV:800
Na:133 K:4.6 Hgb:8.5 CalcHCT:26 Glu:118 freeCa:1.04
Other Blood Gas:
Vent: Controlled
[**2182-7-23**]
3:27p
7.41 / 38 / 244 / 25 / 0
Type:Art; Intubated; Rate:8/
Na:129 K:5.1 Hgb:8.8 CalcHCT:26 Glu:122 freeCa:1.19
Other Blood Gas:
Vent: Controlled
[**2182-7-23**]
2:42p
7.50 / 29 / 181 / 23 / 0
Type:Art
K:5.4 Glu:128
[**2182-7-23**]
2:06p
7.25 / 63 / 330 / 29 / 0
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
K:5.1 Glu:121
[**2182-7-23**]
1:25p
7.29 / 64 / 422 / 32 / 2
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
K:4.4 Glu:119
[**2182-7-23**]
11:20a
7.42 / 45 / 298 / 30 / 4
Type:Art; Intubated; Rate:8/ ; TV:800
Na:136 K:4.7 Hgb:13.1 CalcHCT:39 Glu:110 freeCa:1.25
Other Blood Gas:
Vent: Controlled
Brief Hospital Course:
PATIENT WITH UNCOMPLICATED POST UP COURSE POST OP #2 WAS DC FROM
CRSU TO FLOOR. CHEST TUBES REMOVED WITH OUT COMPLICATIONS
AFEBRILE STABLE
Medications on Admission:
DYAZIDE, LIPITOR, ATENOLOL
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) **] VNA
Discharge Diagnosis:
HTN
CAD
s/p CABG/repair of ascending aortic aneurysm
post op atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
do not drive for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**12-14**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**12-14**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in [**2-14**] weeks
Completed by:[**2182-7-27**]
|
[
"427.31",
"441.2",
"746.4",
"401.9",
"E878.2",
"997.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3723, 3779
|
2292, 2432
|
404, 435
|
3904, 3910
|
869, 2269
|
4218, 4450
|
707, 731
|
2509, 3700
|
3800, 3883
|
2458, 2486
|
3934, 4195
|
746, 848
|
274, 366
|
463, 604
|
626, 664
|
680, 691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,069
| 150,715
|
1169
|
Discharge summary
|
report
|
Admission Date: [**2140-8-25**] Discharge Date: [**2140-9-20**]
Date of Birth: [**2102-2-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Severe Pancreatitis
Major Surgical or Invasive Procedure:
Placement of left IJ CVL
Intubation
Mechanical Ventilation
History of Present Illness:
This is a 38yo M with h/o paranoid schizophrenia who initially
presented to [**Hospital6 7472**] in [**Location (un) 5583**] on [**8-18**]
with new DKA and then developed severe pancreatitis/bandemia
with possible HCAP with bilat lower lobe infiltrates s/p
intubation now transferred here for further management. Pt was
intially treated for DKA however bc of persistent abdominal pain
and fevers, a CT scan was obtained on [**8-19**] which revealed
finsing consitent with pancreatitis. On [**8-20**], pt was found to
be obtunded and O2sats were in mid80s so pt was intubated for
airway protection and presumed aspiration. Pt has been
hemodynamically stable, requiring no pressors. A central line
has been placed in his right IJ. Pt was started on Vanc/Zosyn,
which was then changed to Vanc/Doripenem. Vanc was then dc'd
however given increasing bandemia today, was added back on. Pt
had normal lactate. Pt is on insulin gtt for hyperglycemia.
Repeat CT scan on [**8-23**] showed no discrete abscess or pancreatic
necrosis but there was worsening fluid surrounding the tail of
pancreas. CT chest that today showed progressive lower lobe
consolidation (atelectasis vs infiltrate) with small bilat
pleural effusions. Sputum cx at OSH grew GPCs in chains/pairs
and beta hemolytic strep not group A.
.
On arrival to the ICU, pt was intubated and sedated. Pt's OGT
was pulled out during transport. O2 sats were 85% on arrival.
RT performed recruitment maneuver and O2 sats improved to 98% on
AC TV of 550cc, RR of 14, PEEP of 10, FiO2 100%. TV was then
decreased to 450cc bc peak pressures were getting high. Pt is
noted to be tachypnic, breathing up to 30. ABG was pH 7.43 pCO2
42 pO2 101 and his vent settings were further adjusted to TV 450
RR 26 PEEP 15 FiO2 80%. Then, bc was still tachypnic and TV
was ~500.
.
Review of systems:
unable to obtain
Past Medical History:
paranoid schizophrenia
polysubstance abuse
hypertension
hypercholesterolemia
Social History:
denies T/E at OSH. has h/o IVDU
Family History:
No family hx of pancreatitis
Physical Exam:
Physical Exam on Admission to MICU
General: intubated, sedated, obese
HEENT: ETT in place, PERRL
Neck: supple, unable to assess JVP due to body habitus
Lungs: diminished breath sounds bilaterally
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, distended, non-tender, no rebound tenderness or
guarding
Ext: warm, well perfused, trace bilat LE edema
Pertinent Results:
Labs on Admission:
[**2140-8-25**] 10:07PM GLUCOSE-207* UREA N-21* CREAT-0.8 SODIUM-146*
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-28 ANION GAP-12
[**2140-8-25**] 10:07PM ALT(SGPT)-33 AST(SGOT)-62* LD(LDH)-329*
CK(CPK)-1083* ALK PHOS-71 TOT BILI-0.4
[**2140-8-25**] 10:07PM LIPASE-142*
[**2140-8-25**] 10:07PM ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-4.2
MAGNESIUM-1.9
[**2140-8-25**] 10:07PM TRIGLYCER-343*
[**2140-8-25**] 10:07PM WBC-11.6*# RBC-2.92*# HGB-9.3*# HCT-26.7*#
MCV-92 MCH-31.9 MCHC-34.8 RDW-14.3
[**2140-8-25**] 10:07PM NEUTS-62 BANDS-13* LYMPHS-17* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-4*
[**2140-8-25**] 10:07PM PT-15.6* PTT-26.3 INR(PT)-1.4*
[**2140-8-25**] 10:23PM TYPE-ART TEMP-38.8 TIDAL VOL-500 PEEP-10
O2-100 PO2-101 PCO2-42 PH-7.43 TOTAL CO2-29 BASE XS-2 AADO2-571
REQ O2-94 -ASSIST/CON INTUBATED-INTUBATED VENT-CONTROLLED
.
Micro
Blood cx 8/25,[**8-26**]: pending
Urine cx [**8-26**]: pending
.
Imaging
.
TTE [**8-26**]:
The left atrium is normal in size. No intracardiac shunt is
suggested after intravenous saline injection at rest. 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. Right ventricular chamber size and free wall
motion are grossly normal. The ascending aorta is mildly dilated
at the sinus level. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy with gossly normal biventricular cavity sizes and
global systolic function. No intracardiac shunt identified.
.
CXR [**8-26**]:
FINDINGS: In comparison with study of [**8-25**], the endotracheal
tube lies
approximately 5.4 cm above the carina. Right IJ catheter extends
to the mid portion of the SVC. Continued low lung volumes may
account for much of the prominence of the transverse diameter of
the heart. Atelectatic changes and effusion are seen at the left
base. No definite vascular congestion.
.
RUQ US [**8-26**]:
Only portions of the pancreatic neck and head are visualized and
demonstrate normal echotexture. The liver is also normal in
echotexture without focal lesions. There is no intra- or
extra-hepatic biliary dilatation. The portal vein is patent with
appropriate hepatopetal flow. The gallbladder is unremarkable
without stones or wall edema. The common bile duct is not
dilated measuring 3 mm.
The right kidney measures 12.7 cm. The left kidney measures 14.7
cm. There
are no stones or hydronephrosis. The spleen is enlarged
measuring 15.6 cm. There is a small amount of intra-abdominal
ascites. In addition, there are three fluid collections anterior
to the right kidney with one of the largest measuring 5.4 x 3.9
cm. These demonstrate no peristalsis and may represent
non-peristalsing bowel or pseudocysts.
IMPRESSION:
1. Ascites, consistent with known pancreatitis.
2. Pseudocysts versus non-peristalsing bowel anterior to the
right kidney.
3. Splenomegaly.
Portable abdomen X-ray [**8-26**]:
FINDINGS: One abdominal radiograph in supine position was
obtained. Quality of the film is compromised due to exclusion of
pelvic area and right peridiaphragmatic region. Normal bowel gas
pattern, without evidence of free air. No abnormal
calcifications.
IMPRESSION: Unremarkable abdominal radiograph.
CT CHEST W/CONTRAST Study Date of [**2140-9-5**] 2:31 PM
IMPRESSION:
1. Similar appearance to acute pancreatitis with fluid
surrounding the tail of the pancreas and extending inferiorly
along anterior perirenal fascia. This is slightly more better
contained when compared with [**2140-8-23**], but no significant change
from [**2140-8-29**].
2. Unchanged bilateral pleural effusions with bilateral lower
lobe dependent consolidation which most likely represents
atelectasis though infection is not excluded.
3. Endotracheal tube 6.7 cm from the carina. This should be
advanced.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2140-8-29**] 5:33 PM
IMPRESSION:
1. No evidence of retroperitoneal or other hematoma.
2. Intra-abdominal free fluid and peripancreatic stranding
consistent with
the provided history of pancreatitis.
3. Increase in small pleural effusions bilaterally.
4. Splenomegaly.
Brief Hospital Course:
38M with h/o schizophrenia p/w severe pancreatitis c/b acute
respiratory failure requiring intubation, increased abdominal
pressures, and acute kidney injury.
# Acute Pancreatitis: Etiology unclear, but may be related to
hypertriglyceridemia which, in turn, may have been caused by
Zyprexa or clozapine. OSH CT scans showed no evidence of
gallstones, and LFT's were not suggestive of obstruction, making
gallstone pancreatitis unlikely. Patient denies history of
recent ETOH abuse, and lack of elevated transaminases upon OSH
admission argued against recent ETOH abuse. Pancreatitis was
severe given complications mentioned above but reimaging did not
show any abscess formation, pseudocysts, necrosis. Patient
eventually started tolerating enteral feeds and is now eating a
normal diabetic diet without abdominal pain.
# Acute Respiratory Failure:
-likely secondary to healthcare acquired pneumonia (as seen on
CT), pulmonary edema (patient +28L fluid balance at one point),
atelectasis, and possibly ARDS as well from pancreatitis.
Patient was treated for a hospital acquired pna, persistently
diuresed, with improvement in lung function. Patient did well
with gradual weaning of sedatives and was started on PSV several
times prior to becoming fully extubated.
-He received a 8 day course of Vanc/Zosyn which was completed on
[**9-15**].
#Acute Kidney Injury due to Acute Interstitial Nephritis (AIN)
-creatinine had normalized as of [**2140-9-10**] (to 1.0); rose to 1.5
to 1.6 on [**2140-9-17**]
-did not improve with IV fluids. patient actually takes good PO.
-Nephrology felt patient developed Acute Interstitial Nephritis,
possibly due to Zosyn used for the PNA. He has elevated urine
and serum eosinophils
-Per our nephrologists, if no significant change in his
creatinine (i.e. stays below 2.0), no intervention is necessary.
If creatinine rises above 2.0 nephrology should be consulted and
it is possible at that point that he may need a renal biopsy
and/or steroids.
-He has an appointment with our nephrologist Dr. [**Last Name (STitle) 7473**] on
[**9-26**] which we would like for him to keep
# Paranoid Schizophrenia:
-followed by psych here, with med adjustments
-has auditory hallucinations, but not visual
-Clozapine 200 qhs; also given Haldol for agitation in the ICU.
-Haldol dose was decreased as tolerated and weaned off methadone
10 q8h
-QT interval was within range but should continue to follow
while on haldol
-Will need to continue monitoring CBC while on clozapine due to
possibility of developing agranulocytosis
-should be followed by psychiatry while at the LTAC and after
discharge
-has persistent mouth/jaw movements which may represent tardive
dyskinesia
.
#Anemia
-Received 3 PRBC transfusions in MICU
-Hct stable
-no evidence of bleeding or hemolysis
.
# Diarrhea
- now resolved
- C. Diff negative x 2.- as C.Diff negative I see no
contraindication to anti-motility agents (Imodium)
.
# HTN and Sinus Tachycardia:
- sinus tach chronic, asymptomatic, thought initially to be
vbolume related
- in the setting of hypertension (on [**Last Name (un) **]) will add Atenolol,
which will also help with the tachycardia
.
## Diabetes mellitus, uncontrolled, no complications
- new diagnosis for this patient
- DKA on admission, resolved
- HbA1c 8.6
- started on Glargine [**Hospital1 **] plus Humalog ISS qid
- good control currently on this regimen
.
# Mother has guardianship in [**State 2690**] - not fully consistent with
MA laws - MA guardianship application initiated by our attorneys
- mother willing to remain his guardian (due to antipsychotics
will need [**Doctor Last Name 7474**])
.
#Following critical care illness and prolonged hospitalization
patient is very weak and will need inpatient rehab stay in an
LTAC or a rehab hospital. There, his active medical issues of
acute renal failure, uncontrolled hypertension, diabetes, and
psychosis can be managed and he can receive the physical and
occupational therapy he needs which cannot be provided at an
acute hospital
.
Full code
Medications on Admission:
Home Medications:
Depakote
Zyprexa
Atenolol
Gemfibrozil
.
Meds on transfer:
Lansoprazole 30mg NG daily
Captopril 25mg [**Hospital1 **]
Doripenem 500mg IV q8h
Valproic acid 1250mg q12h
Tylenol 650mg q6h PRN
Versed drip 6mg/hr
Combivent q6h 8puffs
Lacri-Lube every 2 hours
Chlorhexidine 15ml q12h
Fentanyl drip 12.5mcg/hr
Lovenox 40mg q24h
Clozapine 200mg daily
Insulin regular drip
Insulin Glargine
D5W at 100ml/hr
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for Constipation.
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Agitation.
6. clozapine 50 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
7. ipratropium bromide 0.02 % Solution Sig: One (1) unit dose
Inhalation Q6H (every 6 hours).
8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. insulin glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous qam.
10. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
- Acute Pancreatitis - resolved
- Healthcare Acquired PNA - resolved
- Encephelopathy (toxic-metablic)- resolving
- Paranoid Schizophrenia - chronic
- Diabetes mellitus with DKA
- Acute Interstitial Nephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital in the setting of an acute
pancreatitis flare. Subsequently you were diagnosed with a
pneumonia. In the setting of infection you were confused.
.
Check your blood glucose level four times a day (before each
meal and at bedtime) and call your physician if the result is
less than 70 or greater than 200.
You were admitted to the hospital in the setting of an acute
pancreatitis flare. Subsequently you were diagnosed with a
pneumonia. In the setting of infection you were confused.
.
Check your blood glucose level four times a day (before each
meal and at bedtime) and call your physician if the result is
less than 70 or greater than 200.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2140-9-26**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Specialty: Nephrology
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
**Please have a semi-full bladder upon arrival to this
appointment**
|
[
"787.91",
"507.0",
"272.4",
"514",
"V49.87",
"E939.3",
"997.31",
"285.9",
"E930.0",
"250.02",
"E879.8",
"518.0",
"349.82",
"427.89",
"273.8",
"272.1",
"401.9",
"577.0",
"295.32",
"458.9",
"580.89",
"276.0",
"305.90",
"728.88",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"38.97",
"96.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12735, 12806
|
7323, 11354
|
291, 352
|
13078, 13078
|
2826, 2831
|
13963, 14410
|
2410, 2440
|
11819, 12712
|
12827, 12827
|
11380, 11380
|
13261, 13940
|
2455, 2807
|
11398, 11438
|
2225, 2243
|
232, 253
|
380, 2206
|
12846, 13057
|
2845, 7300
|
13093, 13237
|
2265, 2344
|
2360, 2394
|
11456, 11796
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,502
| 111,915
|
10968
|
Discharge summary
|
report
|
Admission Date: [**2178-10-20**] Discharge Date: [**2178-10-25**]
Date of Birth: [**2114-8-15**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Adhesive Tape
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac Cath [**10-20**] with 2 BMS placed
Cardiac Cath [**10-21**]
History of Present Illness:
This 64 year old woman with a prior history of breast cancer s/p
XRT, hypertension and hyperlipidemia who has been experiencing
chest discomfort with exertion for the past three years. She
describes chest tightness with exertion while either walking
quickly
or starting up an incline. Over the past three months this
exertional angina has wrosened. She has not had angina at rest.
She denies shortness of breath, lightheadedness, dizziness,
PND, Orthopnea, palpitations, snycope, edema, or claudication.
She has been followed by Dr.[**Name (NI) **] and had a stress MIBI
done in [**2175**] which was remarkable for Moderate, partially
reversible septal and apical wall perfusion defect. Global
hypokinesis with EF of 48%. Since then, she has been medically
managed, however more
recently she was enrolled in a study looking at heart disease
and
lifestyle modification. As part of the study, she underwent a
coronary CT which demonstrated significant calcium in the
proximal part of the LAD.
.
She has also recently had an exercise stress test, done on
[**2178-6-26**]. She exercised for 6 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and
was
stopped for marked ST changes. Negative for symptoms. At peak
exercise, the patient had 3.5 to 4mm St segment depression in
the
inferolateral leads as well as 1.5 -2mm St segment elevation in
V1-V2. These changes are in the setting of baseline prominent
voltage repolarization abnormalities. They resolve with rest by
minute 8 of recovery.
.
Prior to admission to the CCU, she underwent an elective
catheterization for CAD. She was given pre-hydragion and had
320 cc of contrast. During the procedure she had an estimated
100 cc blood loss, with no angiographic evidence of CAD in her
LMCA. Her LAD had a diffuse proximal 90% and mid vessel
calcific disease, origin D1 with 50% stenosis at origin. LCX:
Mild luminal irregularities into OM1 with mild vessel 60%
stenosis into OM2. RCA: Proximal 50% stenosis. She had chest
pain during the procedure and was transfered to the CCU.
.
Upon arrival to the CCU the patient was chest pain free,
although she complained of some nausea. She had been given 8 mg
of Zofran, and was given a one time dose of 10 mg Compazine.
Her vitals were: 76 123/72 11 and 100 RA.
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Breast cancer [**2140**] s/p left radical mastectomy, radiation
therapy
-Back surgery 2 yrs ago for spinal stenosis
-GERD
-Osteoporosis
-Remote GIB -[**2157**]
Social History:
-Retired dental hygenist, and business manager for family
practice
-retired
-non-smoker
-no ETOH
Family History:
Paternal Grandfather with Stroke
Father with MI
Physical Exam:
Exam on Discharge:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CARDIAC: Regular Rate Rhytm with normal S1, S2. No S3 or S4.
II/VI Systolic crescendo decrescendo murmur at RSB radiating to
carotids. LSB II/VI murmur radiating to the apex.
LUNGS: Scar across R breast. No accessory muscle use, no labored
breathing, CTA- anteriorly, no crackles, wheezes or rhonchi
appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No LE edema
Pertinent Results:
STUDIES:
Catherization [**2178-10-20**]: (prelim report)
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel coronary artery disease. The LMCA was
free of
angiographically apparent disease. The LAD had diffuse,
calcific
proximal and mid-vessel stenosis of 90%. The origin of the
first
diagonal branch had a 50% ostial stenosis. The LCx had mild
luminal
irregularities into OM1 with mid vessel 60% stenosis into OM2.
The RCA
had a proximal 50% stenosis.
2. Limited resting hemodynamics revealed normotension.
3. Successful cutting balloon/rotablation/PTCA/stenting of the
mid LAD
with a Taxus Liberte Atom 2.25x16 mm drug-eluting stent (DES)
followed
by a more proximal Taxus Liberte 2.5x12 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5177**] at 12
atm and 15
atm respectively. We then stented the more distal mid LAD
disease with a
Taxus Liberte 2.5x16 mm DES at 10 atm. Final angiography
revealed normal
flow, no angiographically apparent dissection and 0% residual
stenosis
in the stents with an ostial 60% DIAG branch vessel stenosis
with TIMI 2
flow. (see PTCA comments)
4. R 6Fr radial artery sheath removed and Terumo TR band placed
without
complications.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful cutting balloon/rotablation/PTCA/stenting of the
mid LAD
with a Taxus Liberte Atom 2.25x16 mm drug-eluting stent (DES)
and then a
more proximal Taxus Liberte 2.5x12 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5177**] at 12 and 15
atm
respectively. We then stented the more distal mid LAD disease
with a
Taxus LIberte 2.5x16 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5177**] at 10 atm. (see PTCA
comments)
3. ASA indefinitely
4. Plavix (clopidogrel) 75 mg daily for at least 12 months
5. Integrilin (eptifibatide) gtt for 18 hours
6. Secondary prevention for coronary artery disease
7. R 6Fr radial artery Terumo TR band placed without
complications.
Catheterization [**2178-10-21**]:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographtically
apparent disease. The LAD had widely patent stents in the
proximal and
mid portion of the vessel. There was TIMI 2 flow in D1 that was
of
similar appearance/ unchanged from films taken on [**2178-10-20**]. The
Cx had a
50% distal stenosis that was unchanged from films taken on
[**2178-10-20**].
2. Limited resting hemodynamics revealed a central aortic
pressure of
118/66 mmHg.
3. The right femoral arteriotomy site was successfully closed
with a 6
French angioseal device.
4.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease that is unchanged from
[**2178-10-20**].
2. Successful closure with angioseal device.
ECHO [**2178-10-21**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the mid to distal anterior
wall, anterolateral wall, distal inferior wall and apex. The
remaining segments contract normally (LVEF = 40-45 %). Right
ventricular chamber size and free wall motion are normal. The
study is inadequate to exclude significant aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Focused views. Focal left
ventricular regional dysfunction c/w CAD. Mild aortic
regurgitation. Probable mild aortic stenosis.
Brief Hospital Course:
64 year old woman with a prior history of breast cancer s/p XRT,
hypertension and hyperlipidemia who has been experiencing
worsening exertional angina who presented for an elective cath
procedure and had rotational atherectomy of the LAD, DES in the
LAD who required a relook cath for chest pain. This second
procedure was complicated by diagonal perforation. There was no
clinical evidence of tamponade after this perforation and it was
thought to be healed upon discharge.
.
# Decreased EF: Last ECHO in [**2178-5-5**] with normal EF of 55%
without any changes in wall motion abnormalitiy. ECHO performed
during this hospitalization after known ischemia showed EF
40-45%. Afterload reduction with Lisinopril was started. Of
note, patient had known mild AS prior to admission, also seen on
ECHO here with mild AR.
.
# CAD: Diffuse Coronary disease with intervention to proximal
LAD with 3 DES. No interval change upon re-cath. The patient
was maintained on medical management with the following agents:
Prasugrel (out of concern for interaction w/ PPI), ASA,
Metoprolol, Simvastatin, Lisinopril. ASA dose was increased and
Imdur was held on discharge.
.
# Sinus Tachycardia: The patient developed tachycardia after the
catheterization procedures that was thought to be likely due to
decreased EF. HR was well controlled with increase in Metoprolol
prior to discharge. Resting HR 80s, ambulatory HR 110.
.
# Apical hypokinesis: Seen on Echo (see Echo report.)
Initiation of anticoagulation necessary to prevent accumulation
of thrombus. Patient started bridge from heparin to coumadin in
patient and was continued on Lovenox outpatient.
.
# Anemia: Stable throughout hospitalization.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth once a day in the morning
BUTALBITAL-ACETAMINOPHEN-CAFF - 50 mg-325 mg-40 mg Tablet - [**1-3**]
Tablet(s) by mouth every 6 hr as needed for HA
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 0.5 (One half) Tablet(s) by
mouth once daily
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet -
Tablet(s) by mouth
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider;
OTC) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth once a day
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 mL Subcutaneous Q12H
(every 12 hours): Total dose 70mg or 0.7mL. Discard the
remainder of the syringe.
Disp:*10 Syringes* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take 1 every 5 minutes up to 3 tabs, then call your doctor/911.
Disp:*30 Tablet, Sublingual(s)* Refills:*5*
6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Do not miss a dose.
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
Disp:*240 Tablet(s)* Refills:*2*
12. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: Dosage will change based on blood levels, to be
directed by Dr.[**Doctor Last Name 35583**] office.
Disp:*90 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
Please Draw INR on [**10-25**] and fax results to Dr.[**Name (NI) 35583**]
office, attention [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 26695**].
Office Phone:([**Telephone/Fax (1) 2037**]
Office Fax:([**Telephone/Fax (1) 35584**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnoses:
Coronary artery disease s/p cath x2
Heart failure ef 45%
Secondary Diagnoses:
Sinus Tachycardia
Apical hypokinesis
Anemia
Aortic Stenosis
Hypertension
Dyslipidemia: As above
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have been admitted to the hospital after an elective
catheterization procedure to look at the arteries in your heart.
While you were here, you received 2 stents to help keep open
your arteries. In addition, we have noted some decrease in your
heart function. This puts you at risk for clots that could
cause a stroke. As a result, we have started a medicine called
Warfarin to keep your blood thin, and another called Lovenox
(the injection) to protect you while Warfarin takes effect.
There have been several changes to your medication:
-Start Prasugrel 10mg once daily to protect your
stents/arteries, it is important that you do not miss a dose of
this medicine.
-Start Warfarin 7.5mg (3 pills) once daily to thin your blood.
There will be lab monitoring associated with this medicine.
-Start Lovenox (injection) twice daily until told by your doctor
to stop. This will thin your blood while the warfarin takes
effect.
-Increase your Aspirin to 325mg daily
-Start lisinopril 2.5mg to help your heart/blood pressure
-Stop Atenolol. Instead take Metoprolol as directed to control
your heart rate. This dose will likely be decreased over time.
-Stop Isosorbide (Imdur) and only take nitroglycerin as needed
for chest pain and as directed.
Followup Instructions:
On Tuesday [**10-27**], please have your blood drawn at [**Hospital1 **]-[**Location (un) 1439**].
The results should be communication to Dr.[**Doctor Last Name 3733**]. This is
important as it affects your Coumadin(warfarin) dosing.
Follow up:
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2178-11-3**]
10:20
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81,893
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Discharge summary
|
report
|
Admission Date: [**2142-1-30**] Discharge Date: [**2142-2-7**]
Date of Birth: [**2078-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
Intubation, Hemodialysis
History of Present Illness:
63 yo M with diabetes, CKD, paroxysmal atrial fibrillation s/p
recent ablation ([**11/2141**]) found down by family members for
uncertain duration. Altered, hypotensive, bradycardic, and with
fingerstick of 134 with EMS.
.
Upon arrival to the ED vitals were: T 96.7, HR 38, BP 125/73, RR
13, O2Sat 100% NRB. Had sinus brady upon arrival with QRS of
168. Got calcium and multiple amps of bicarb. Was intubated with
8.0 tube, though difficult intubation. With 5+ bicarb pushes,
QRS narrowed and HR increased. Because of these findings,
patient placed on bicarb drip. Toxic ingestion was entertained
and toxicology consult was called. Given hypotension and
bradycardia, patient started on dopamine at 10 mcg. Given
hypotension, was given 4L NS, had RIJ central line place, and
Vanc/Zosyn for epiric treatment of sepsis. 600 mg aspirin given
for potential MI. Patient had multiple imaging studies in ED
including CT head, CT c-spine, CT chest/abd/pelvis, all had
essentially and CXR. Vitals prior to transfer to the MICU were:
HR 70, BP 162/67, RR 23, O2Sat 100% on AC 550 by 20 with PEEP 5
and FiO2 100%.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2134**] PTCA/stenting of
PDA
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-
Past Medical History:
Diastolic dysfunction
Hypertension, severe
Diabetes mellitus, type II c/b retinopathy, nephropathy, and
neuropathy
Chronic infected diabetic ulcer
PAF on coumadin
OSA
Peripheral edema
Hyperlipidemia
BPH
Obesity
GERD
Social History:
Lives with girlfriend. Retired; formerly worked as bus driver
with [**Company 2318**]. Denies alcohol, tobacco, or illicit drug use.
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Brother with diabetes mellitus.
Physical Exam:
VS: T 95.2, HR 68, BP 174/89, O2Sat 95% 550x24, PEEP 8, FiO2 70%
GEN: intubated, sedated
HEENT: right surgical pupil, left pupil 3 mm and reactive, ET
and OG tube in place
NECK: large circumference, RIJ triple lumen and LIJ dialysis
cath in place
PULM: CTAB anteriorly with transmitted vent sounds
CARD: Bradycardia, nl S1, nl S2, no M/R/G
ABD: BS+, distended, tympanic,
EXT: BLE edema with skin changes as below
SKIN: BLE with icthyosis and RLE with verrucous skin changes and
ulceration
NEURO: Withdraws to pain, does not spontaneously open eyes or
follow commands
Pertinent Results:
Admission Labs:
[**2142-1-29**] 10:40PM BLOOD WBC-9.0 RBC-3.89* Hgb-10.8* Hct-35.7*
MCV-92# MCH-27.7 MCHC-30.2* RDW-17.1* Plt Ct-165
[**2142-1-29**] 10:40PM BLOOD Neuts-73.1* Lymphs-19.8 Monos-4.7 Eos-1.9
Baso-0.5
[**2142-1-29**] 10:40PM BLOOD PT-19.0* PTT-31.8 INR(PT)-1.7*
[**2142-1-29**] 10:40PM BLOOD Glucose-137* UreaN-150* Creat-7.3*#
Na-134 K-8.6* Cl-105 HCO3-8* AnGap-30*
[**2142-1-29**] 10:40PM BLOOD ALT-23 AST-31 CK(CPK)-383* AlkPhos-104
TotBili-0.1
[**2142-1-29**] 10:40PM BLOOD Lipase-93*
[**2142-1-29**] 10:40PM BLOOD cTropnT-0.08*
[**2142-1-29**] 10:40PM BLOOD CK-MB-10 MB Indx-2.6
[**2142-1-29**] 10:40PM BLOOD Albumin-4.3 Calcium-8.6 Phos-12.5*#
Mg-2.6
[**2142-1-29**] 10:40PM BLOOD Osmolal-344*
CXR:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Low lung volumes. Perihilar opacities may relate to pulmonary
edema,
although underlying aspiration cannot be excluded.
3. Enlarged cardiac silhouette. Prominent superior mediastinum,
may relate
to supine, AP technique. Recommend clinical correlation and
consider CT as
clinically warranted.
CT Chest:
1. Moderate bibasilar dependent atelectasis with focal
consolidations, which
may represent aspiration. Enlarged pretracheal lymph node,
likely reactive.
2. Numerous mesenteric and paraaortic lymph nodes.
3. Small sacular aneurysm of the infrarenal portion of the
aorta, measuring
2.6 cm in transverse diameter (on coronal image). Follow-up
ultrasound in 6
months can be performed to assess stability, given the lack of
comparison
studies.
4. Small hiatal hernia.
5. Fat-containing left inguinal hernia.
TTE:
IMPRESSION: stiff left ventricle with impaired relaxation and
preserved ejection fraction; moderate pulmonary hypertension
with a dilated hypocontractile right ventricle
Renal U/S: Normal renal ultrasound as described.
Brain MRI:
IMPRESSION:
1. A small focus of subacute hemorrhage seen in the right
occipital lobe not visualized on CT but seen as T1
hyperintensity on MR images with restricted diffusion in the
center on diffusion-weighted images.
2. Moderate-to-severe changes of small vessel disease and brain
atrophy seen.
3. Chronic infarcts in cerebellum and pons.
4. No MRI signs of posterior reversible encephalopathy syndrome.
Brief Hospital Course:
This is a 63 year old gentleman with diabetes, CKD, paroxysmal
atrial fibrillation s/p recent ablation ([**11/2141**]) found down by
family members for uncertain duration. Altered, hypotensive,
bradycardic, found to be acidemic, hyperkalemic on admission.
.
# ACIDEMIA/ACUTE ON CHRONIC RENAL FAILURE: On admission, patient
was tested for ingestion, and had negative serum ethanol,
methanol, aspirin and ethylene glycol. Etiology of renal
failure felt to be acute on chronic in the setting of
over-diuresis due to recent increase in dose to 160mg [**Hospital1 **] from
120 qAM, 80qPM. Renal was consulted on admission and placed a
temporary L IJ dialysis line. Renal ultrasound was normal. His
renal failure, hyperkalemia gradually resolved without dialysis.
Patient maintained good urine output throughout his ICU stay.
His renal function continued to improve with creatinine on
discharge 2.8. He was discharged on 80mg [**Hospital1 **] lasix.
.
# RESPIRATORY FAILURE: Intubated for airway protection in ED
given obtunded state. He was weaned from the ventilator and
extubated without complication. He was completeley weaned off
oxygen by discharge.
.
# Uremic Metabolic Encephalopathy: On admission neurology was
consulted. EEG was consistent with metabolic encephalopathy
and MRI demonstrated mp evdidence of PRES. It is thought that
his acute change in mental status was most likely secondary to
uremia. As his renal failure returned to his baseline, his
mental status improved. A small focus of subacute hemorrhage was
seen in right occipital lobe was visualized and on review by
neurology felt to be chronic. Chronic small vessel disease and
brain atrophy also noted.
.
# ATRIAL FIBRILLATION: While in the ICU, a 20-minute episode of
A-fib with RVR to 180s initially, then > 150s sustained. BP
initially fell to 90s but then rebounded without intervention.
The patient received 5mg IV metoprolol and returned into normal
sinus rhythm and was countinued on coumadin and restarted on
oral metoprolol.
.
# HYPERTENSION: The patient's extubation complicated by
significant hypertension with systolic blood pressures into the
220s. His home dose of hydralazine was increased and metoprolol
uptitrated.
.
# Elephantiasis verrucosa nostra: Dermatology was consulted and
recommended AmLactin lotion [**Hospital1 **] and leg wraps.
.
# HYPERNATREMIA: Patient was initially hypernatremic to the 150s
consistent with over diuresis. This resolved with IV D5W.
.
# TROPONIN ELEVATION: Troponin T was elevated at 0.23 secondary
to demand ischemia. Echocardiogram demonstrated diastolic
dysfunction, but no focal wall motion abnormalities of the LV.
.
# DIABETES MELLITUS TYPE 2: The patient was treated with insulin
sliding scale while admitted. He was discharged on his home
dose of novalog and nph. He was instructed to regularly check
his fingersticks and to call his physician if his blood sugar
was 60.
.
TRANSITIONAL ISSUES
# Medical Mangagement: Increased hydralazine to 75mg tid, lasix
80mg [**Hospital1 **], recommend outpatient evaluation of sleep apnea
# Code Status: Full
Medications on Admission:
1. simvastatin 160 mg Tablet
2. calcium acetate 667 mg Tablet tid with meals.
3. Vitamin D 50,000 unit Capsule Sig: qweek
4. furosemide 80 mg Tablet 1 [**Hospital1 **]
5. hydralazine 50 mg Tablet 1 Tablet PO Q8H
6. Humalog 100 unit/mL ISS
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-26**]
8. isosorbide mononitrate 30 mg Tablet SR qdaily
9. metoprolol succinate 100 mg SR [**Hospital1 **]
10. omeprazole 20 mg Capsule, qdaily
11. warfarin 5 mg Tablet qdaily on weekdays and 4mg on weekends
12. aspirin 81 mg Tablet, qdaily
13. NPH insulin Fourteen (14) units Subcutaneous qdaily : Take
before breakdast, take 10 units of NPH before dinner.
Discharge Medications:
1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. calcium acetate 667 mg Tablet Sig: One (1) Tablet PO three
times a day: with meals
.
3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
4. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. hydralazine 50 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Disp:*135 Tablet(s)* Refills:*2*
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: One
(1) Inhalation once a day as needed for shortness of breath or
wheezing.
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. warfarin 2 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
11. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. ammonium lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*2*
13. Compression Stockings
Please provide patient with compression stockings.
Diagnosis: Elephantiasis Verrucosa Nostra
14. Outpatient Lab Work
Reminder!! Please have your electrolytes and INR checked at your
next clinic appointment.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
Subcutaneous once a day: Take 16 units before breakfast and
dinner.
16. Novolog 100 unit/mL Solution Sig: Take 12 units with each
meal Subcutaneous three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Acute Renal Failure (diuretic overdose)
2. Diabetes Type 2, Chronic Kidney Disease, Elephantiasis
Verrucosa Nostra
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation of loss of consiousness. You
were found to be in profound renal failure which caused a build
up of toxins and likely contributed to your altered mental
status. You were intubated to protect your respiratory function
and a hemodialysis catheter was placed to clean your blood. The
breathing tube was ultimately taken out and you were transferred
back to the floor for further management where you did well and
your kidney function continued to improve. While it is unclear
why you developed acute kidney failure, it may be have occurred
in the setting of a recent increase in your daily lasix dose.
You had an episode of elevated blood pressure and atrial
fibrillation while hospitalized. Your daily hydralazine dose was
increased.
Your legs were evaluated by our dermatologists who determined
you had elephantiasis verrucosa nostra. A new cream was
prescribed, AmLactin which should be applied twice daily.
Compression stockings should prevent further progression of
these skin changes.
Please continue your insulin regimen that you were taking at
home. No changes were made to these medications. Please discuss
your diabetes managment with your primary care physician. [**Name10 (NameIs) 357**]
continue to check your blood sugars. If you have a blood sugar <
60, please stop taking your medications and call your physician
[**Name Initial (PRE) 2227**].
The following medication changes were made:
1. DECREASE Coumadin to 3mg daily
2. INCREASE Hydralazine to 75 mg three times daily
3. DECREASE Lasix to 80mg twice a day
4. START Lactic Acid 12% Lotion (AmLactin), apply twice daily to
your legs
5. START Compression stockings as tolerated
Please follow up with your primary care physician next week to
have a blood pressure check, an electrolyte check and to have
your INR checked.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 28551**]
Appointment: Tuesday [**2142-2-13**] 10:20am
You appointment for Friday [**2142-2-9**] has been cancelled
and was rescheduled with the appointment above.
**You need to become established with a Dermatologist and make
an appointment within 1 month. Please discuss this with your
primary care physician at this appointment.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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icd9cm
|
[
[
[]
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] |
[
"38.91",
"96.71",
"96.04",
"38.95",
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icd9pcs
|
[
[
[]
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] |
10590, 10647
|
5131, 8219
|
311, 338
|
10809, 10809
|
2870, 2870
|
12933, 13570
|
2119, 2268
|
8930, 10567
|
10668, 10788
|
8245, 8907
|
10992, 12910
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2283, 2851
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1573, 1679
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263, 273
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366, 1469
|
2886, 5108
|
10824, 10968
|
1710, 1712
|
1734, 1952
|
1968, 2103
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,673
| 158,971
|
28982
|
Discharge summary
|
report
|
Admission Date: [**2166-4-14**] Discharge Date: [**2166-4-18**]
Date of Birth: [**2104-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
stage IV thymoma with metastatic disease
Major Surgical or Invasive Procedure:
[**2166-4-14**]:
1. Left thoracotomy.
2. Parietal pleurectomy.
3. Thymectomy, en bloc wedge resection of left upper lobe.
4. Resection of nodule on left hemidiaphragm with primary
repair of diaphragm.
History of Present Illness:
The patient is a 61-year-old male with stage IV thymoma with
metastatic disease to the diaphragm and parietal pleura. He
underwent chemotherapy
with excellent radiographic response and was admitted for
resection of all gross residual disease.
Past Medical History:
1) Chronic active HBV (HBsAg low positive, HBsAb borderline,
HBcAb positive, HBeAg negative, HBeAb positive -> negative, HBV
VL detected, <40 IU/mL)
2) Iron deposition liver disease: HFEF negative, elevated
ferritin, normal transferrin, [**2162**] biopsy with significant iron
overload and fatty change, grade 2 inflammation, stage 2
fibrosis. S/p periodic therapeutic phlebotomies, last [**9-30**].
Last ferritin 174 on [**2165-8-24**]
3) Nephrolithiasis - [**2163**], spontaneously passed. Did not
capture, so composition unknown
4) Lactose intolerance
Social History:
Originally from [**Country 651**], has lived in US for many years, first in
[**State **], then moved to the [**Location (un) 86**] area. He owns a restaurant in
[**Hospital1 2436**]. He is a lifelong non-smoker, and drinks alcohol
rarely. He is married with a son.
Family History:
Mother: Hepatocellular carcinoma
Grandfather: Stomach cancer
Physical Exam:
General 61 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopath
Card: RRR
Resp: decreased breath sounds on left with faint basilar
crackles, no wheezes
Right clear
GI: benign
Extr: warm no edema
Incision: left thoracotomy site clean, dry intact margins well
approximated no erythema
Neuro: awake alert oriented.
Pertinent Results:
[**2166-4-17**] WBC-3.1* RBC-2.83* Hgb-9.0* Hct-26.3* MCV-93 MCH-31.9
MCHC-34.3 RDW-13.9 Plt Ct-147*
[**2166-4-14**] WBC-2.3* RBC-3.47* Hgb-11.1* Hct-32.0* MCV-92 MCH-31.8
MCHC-34.6 RDW-13.6 Plt Ct-120*
[**2166-4-16**] Glucose-137* UreaN-14 Creat-0.8 Na-138 K-4.4 Cl-102
HCO3-32
[**2166-4-14**] Glucose-163* UreaN-21* Creat-0.7 Na-141 K-3.9 Cl-106
HCO3-27
[**2166-4-15**] CK(CPK)-1167* [**2166-4-15**] CK(CPK)-1179* [**2166-4-15**]
CK(CPK)-1001*
[**2166-4-15**] CK-MB-6 cTropnT-0.04* [**2166-4-15**] CK-MB-7 cTropnT-0.06*
[**2166-4-15**] CK-MB-8 cTropnT-0.04*
[**2166-4-16**] Mg-2.0
CXR:
[**2166-4-17**]: PA AND LATERAL CHEST: In comparison to prior study,
left basilar chest tube has been removed, as has an epidural
catheter. There is no enlarging pneumothorax, though minimal
lucency at the left apex persists. A small persistent right
pleural effusion with multifocal bibasilar atelectasis is again
noted. There are extensive post-surgical changes in the
mediastinum. There is no further interval change.
[**2166-4-16**]: Left-sided chest tube in unchanged position. No
pneumothorax.
[**2166-4-14**]: The cardiomediastinal silhouette demonstrates cardiac
enlargement and mediastinal widening most likely related to
prior surgery and possible character of the study. Bilateral
chest tubes are in place. There is questionable right and left
basal pneumothorax that should be closely followed. There is
also extensive amount of subcutaneous air on the left. There is
no appreciable pleural effusion. Bibasilar atelectasis is most
likely related to recent surgery.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted [**2166-4-14**] following Left thoracotomy.
Parietal pleurectomy.
Thymectomy, en bloc wedge resection of left upper lobe.
Resection of nodule on left hemidiaphragm with primary repair of
diaphragm. He was extubated in the operating room, transfer to
the TSICU for closer monitoring.
Respiratory: aggressive pulmonary toilet, nebs, incentive
spirometer and good pain control he titrated off oxygen with
oxygen saturations of 95% RA
Chest tube: 2 left chest-tubes were placed. [**Doctor Last Name 406**] drain into
the right chest from the left side which was removed on
[**2166-4-15**]. The right angle and apical tubes were placed to
water-seal and subsquently removed on [**4-16**] & 26.
Chest films: serial films showed Bibasilar atelectases, no
pneumothorax or effusions
Cardiac: cardiac enzymes mildly elevated with diffuse [****]
EKG consistent with pericarditis.
GI: PPI & bowel regime
Nutrition: tolerated a regular diet
Renal: foley removed following epidural removal with good urine
output. Electrolytes were replete as needed
Pain: Bupaviacane Epidural managed by the Acute pain service was
removed. The PO pain were titrated to good pain control
Dispositon: he was seen by physical therapy who deemed him safe
for home. He was discharged on [**2166-4-18**] with his family and
[**Location (un) 86**] VNA. He will follow-up with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
LAMIVUDINE 100 mg Tablet daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take with narcotics.
2. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: take with food and water.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Stage [**Doctor First Name 690**] thymoma s/p 6 cycles
chemo(Cisplatin,Adriamycin,Cytoxan) completed [**2-/2165**]
HBV
Hemachromatosis w hx phlebotomies 2x/month until ~[**3-/2165**],
Lactose intolerance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Left thoracotomy incision develops drainage
-Chest tube site cover with a bandaid until healed
-Should chest tube site drain cover with a clean dry dressing
and change as needed to keep site clean and dry
Pain:
-Oxycodone 5-10 mg every 4-6 hours as needed for pain
-Ibuprofen 400-600 mg every 8 hours of pain. Take with food and
water
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lifting greater than 10 pounds until seen
-No driving while taking narcotics
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Followup Instructions:
Follow-up with Dr.[**First Name (STitle) **] [**0-0-**] [**2166-5-6**] 10:00 on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Completed by:[**2166-4-23**]
|
[
"198.89",
"070.32",
"275.03",
"164.0",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"07.82",
"32.29",
"37.31",
"34.81",
"04.03",
"34.59"
] |
icd9pcs
|
[
[
[]
]
] |
5751, 5808
|
3773, 5213
|
350, 557
|
6056, 6056
|
2180, 3750
|
7029, 7324
|
1711, 1773
|
5295, 5728
|
5829, 6035
|
5239, 5272
|
6207, 7006
|
1788, 2161
|
270, 312
|
585, 831
|
6071, 6183
|
853, 1412
|
1428, 1695
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,171
| 131,318
|
840
|
Discharge summary
|
report
|
Admission Date: [**2121-3-18**] Discharge Date: [**2121-3-26**]
Date of Birth: [**2086-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Nsaids / Levaquin
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Pulmonary vein isolation / ablation
History of Present Illness:
Ms. [**Known lastname **] is a 34 yo female with hypertrophic cardiomyopathy,
obesity, anxiety, multifocal atrial tachycardia, atrial
fibrillation, left atrial tachycardia, and AVNRT. She was
admitted after pulmonary vein isolation complicated by atrial
tachycardia requiring cardioversion and SOB from pulm edema
requiring post-procedure re-intubation.
The patient was admitted for elective pulmonary vein isolation.
Both groin veins were accessed for the procedure. At the end of
the procedure, she developed atrial tachycardia with 2:1 block
at a rate of approximately 100. This atrial tach was not ablated
though she was cardioverted back to NSR. She was successfully
extubated after cardioversion. She had received an estimated
4.5L of fluid during the procedure. She developed shortness of
breath after extubation. Exam and CXR were concerning for
pulmonary edema. She responded well to 40mg IV lasix x2 with an
estimated 3L urine output. Nonetheless, the patient's shortness
of breath worsened, saturating 92% on NRB and speaking in short
sentences. She required re-intubation and received propofol and
vecuronium during intubation.
She has been hospitalized several times over the past 1-2 months
with symptoms of palpitations and dyspnea associated with atrial
arrhythmias.
Past Medical History:
Hypertrophic cardiomyopathy on transplant list
Intermittent atrial fibrillation
s/p cardiac arrest at age of 16yo
s/p MVA
Chronic back pain
Asthma
COPD
Bipolar
Anxiety
s/p appendectomy
multiple cardiac caths
s/p cardioversion
.
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, - Hypertension
.
Cardiac History:
The patient initially presented with syncope at age of l2. At
l3, the patient was seen at [**Hospital3 1810**] for history of
syncope, chest pain and progressive exercise intolerance. She
was found to have hypertrophic cardiomyopathy. She was
subsequently cathed. Left
ventricular end diastolic pressure was found to be 20. She was
then started on chronic Verapamil therapy. At age l6, she
experienced cardiac arrest secondary to complex tachycardia. She
was successfully resuscitated. Repeat catheterization showed
left ventricular end diastolic pressure of 36-40 without outflow
tract obstruction. EP showed inducible atrial flutter with a
rapid ventricular blood pressure. She was felt to have a rapid
antegrade
conduction and possible pre-excitation. She was started on
Norpace. Since then, the patient has been stable on Verapamil
and Norpace with occasional palpitations, chest pain and light
headedness.
.
Social History:
Currently on disability. 40 pack-year smoker (2ppd x20 years)
quit since recent bronchitis. No EtOH. Regular marijuana use.
Family history remarkable for hypertrophic cardiomyopathy and
congenital aortic stenosis s/p cardiac surgery during infancy.
No family history of sudden cardiac death or premature CAD.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mom has DM, HTN. Her son has aortic stenosis
and hypertrophic cardiomyopathy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2-99.2 60-80 100-120/40-60 SIMV RR 10 Vt 650 FiO2 60 PEEP
8 99%
Gen: Obese. Intubated and sedated.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Coarse breath sounds bilaterally in part due to upper
airway congestion.
Abd: Soft, nontender. No organomegaly or masses.
Ext: No edema. Bilateral palpable 1+ pulses distally. Bilateral
femoral cath sites clean and dry without palpable hematoma or
audible bruit.
Neuro: Sedated.
Integumentary: No rashes or lesions.
Pertinent Results:
ADMISSION LABS:
[**2121-3-18**] 09:00AM BLOOD WBC-12.5* RBC-3.54* Hgb-11.4* Hct-33.6*
MCV-95 MCH-32.1* MCHC-33.9 RDW-13.9 Plt Ct-268
[**2121-3-19**] 09:14PM BLOOD Neuts-89.0* Bands-0 Lymphs-6.4* Monos-3.9
Eos-0.5 Baso-0.3
[**2121-3-18**] 09:00AM BLOOD PT-14.2* INR(PT)-1.2*
[**2121-3-18**] 09:00AM BLOOD Plt Ct-268
[**2121-3-18**] 07:58PM BLOOD Glucose-98 UreaN-8 Creat-0.8 Na-143 K-3.9
Cl-107 HCO3-25 AnGap-15
[**2121-3-18**] 07:58PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7
[**2121-3-18**] EKG:
Sinues bradycardia at 58. Leftward axis. Normal intervals.
Slightly wide QRS. No acute ST or T wave changes. Compared to
prior dated [**2121-3-1**] the patient is no longer in an atrial
tachycardia. EKG obtained during EP procedure today reveals
episode of atrial tachycardia to rate of 99.
[**2121-3-18**] CXR:
Portable AP chest radiograph compared to [**2121-2-28**].
Marked cardiomegaly is grossly unchanged, although slight
increase in the
heart diameter cannot be excluded allowing to the differences in
the technique of the exam and the lung volumes. Increase in
bilateral perihilar haziness continuing towards the lung bases
suggest worsening of pulmonary edema. Small bilateral pleural
effusions cannot be excluded. There is no pneumothorax or
pneumomediastinum.
[**2121-3-19**] and [**2121-3-20**] Sputum Cultures:
KLEBSIELLA PNEUMONIAE
SENSITIVITIES: |
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**3-19**], [**3-20**], and [**2121-3-21**] Blood Cultures: NGTD
[**2121-3-20**] Urine cultures: NGTD
Brief Hospital Course:
(1) Respiratory Failure
Ms. [**Known lastname 5854**] respiratory failure was secondary to pulmonary
edema in the setting of
COPD/bronchitis and acute Klebsiella pneumonia. Sputum cultures
grew pan-sensitive Klebsiella pneumoniae, and she was placed on
a ten day course of Bactrim DS [**Hospital1 **]. She was diuresed and placed
on her home regimen of albuterol, ipratropium and montelukast.
She was extubated on [**2121-3-22**] and dishcarged on room air,
breathing comfortably.
(2) Cardiac Arrhythmias
On [**2121-3-18**], she underwent a pulmonary vein isolation procedure.
Per telemetry after the procedure, she continued to have atrial
tachycardia with multiple morphologies. She was restarted on
aspirin and warfarin after the procedure and was continued
continued on her verapamil and amiodarone. She was discharged
on amiodarone 200 mg TID with close follow-up scheduled with the
[**Hospital **] clinic.
PENDING ISSUES FOR FOLLOW-UP:
(1) She needs an INR check on [**2121-3-28**]. Upon discharge, her INR
was 4.2, so coumadin was held. She was told to restart it
according to her PCP's instructions on [**2121-3-28**].
(2) Patient was sent home with out-patient PT for
deconditioning.
Medications on Admission:
Albuterol inhaler as needed
Amiodarone 200mg Daily
Klonazepam 1mg QID
Furosemide 80mg Daily
Singulair 10mg every evening
Trazodone 200mg every evening
Verapamil 240mg Daily
Wellbutrin 74mg Daily
Zoloft 150mg Daily
Vitamin D Daily
Tums Daily
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain, fever.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. Verapamil 180 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q24H (every 24 hours).
11. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
PRIMARY
Pneumonia
Atrial tachycardia
Discharge Condition:
Hemodynamically stable, saturating well on room air, ambulatory
Discharge Instructions:
You were admitted to the hospital so that a special procedure
could performed that could help prevent your heart rate from
going to rapidly. After the procedure, you experienced a rapid
decrease in blood oxygen levels and required intubation. You
developed a pneumonia and have been agressively treated for it.
You have improved significantly and will be able to complete
treatment with antibiotics by mouth.
If you experience new chest pain, shortness of breath, nausea,
vomiting, diarrhea, dizziness, or any other symptom that
concerns you, please seek medical attention.
Followup Instructions:
You have the following appointments:
(1) You need to have your INR checked on [**2121-3-28**] and reviewed by
your primary care doctor. They will make any changes to your
coumadin dose that are needed. Please call your PCP [**Last Name (NamePattern4) **]
[**0-0-**] to set up a time to have your blood drawn.
(2) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 285**]
Date/Time:[**2121-4-2**] 2:00
(3) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2121-4-18**] 2:20
PENDING ISSUES FOR FOLLOW-UP:
(1) She needs an INR check on [**2121-3-28**]. Upon discharge, her INR
was 4.2, so coumadin was held. She was told to restart it
according to her PCP's instructions on [**2121-3-28**].
(2) Patient was sent home with out-patient PT for
deconditioning.
|
[
"427.89",
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"300.00",
"482.0",
"494.0",
"507.0",
"518.81",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.27",
"37.28",
"37.34",
"96.07",
"96.04",
"96.71",
"99.61",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
8464, 8515
|
5833, 7035
|
315, 353
|
8596, 8662
|
3944, 3944
|
9285, 10211
|
3258, 3418
|
7327, 8441
|
8536, 8575
|
7061, 7304
|
8686, 9262
|
3458, 3925
|
263, 277
|
381, 1668
|
3960, 5810
|
1690, 2916
|
2932, 3242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,550
| 176,519
|
9390
|
Discharge summary
|
report
|
Admission Date: [**2159-11-22**] Discharge Date: [**2159-11-27**]
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86yo man with extensive CAD history (multiple MI with CABG x 2
and
multiple PCI) and history of gastric cancer. He had a Billroth
II procedure in [**7-26**],
and presented to outside hospital ([**Hospital3 **]) with
abdominal pain, nausea/vomiting and [**11-13**] EGD demonstrating
esophagitis and gastritis. On
[**11-20**], he was taken to the OR for a conversion of his Billroth
II to a roux-en-y for bile reflux gastritis. On [**11-21**], he
suffered an episode of shortness of breath with chest pain
radiating down his right arm. No diaphoresis, n/v,
palpitations. This pain was relieved with SL NTG and morphine.
He was also reported to have had desaturaation to 80% on 6L nc,
which improved after lasix and nebs.
.
He was transferred to [**Hospital1 18**] CCU for futher management. On
admission, he had no EKG changes and he was chest pain free. He
was medically managed with ASA, plavix, beta blocker, ACE-I, and
statin. He subsequently ruled in for NSTEMI by cardiac enzymes.
He was felt to be a poor candidate for catheterization
secondary to his complicated coronary anatomy with multiple
previous interventions. Cardiac enyzymes were followed, and he
was medically managed.
Additionally, he was noted on [**11-22**] to have slurred speech
and slight left facial droop.
A non-contrast CT was obtained, which demonstrated a hypodense
lesion in the right fronto-parietal region with associated edema
and slight mass effect; there was no associated hemorrage.
Past Medical History:
CAD s/p MI (first MI age 46; STEMI [**11-27**])
CABG [**2143**], redo [**2151**] (LIMA->LAD, SVG->OM, SVG->rPDA)
Multiple PTCA
HTN
Hyperlipidemia
Pacer placement for ?SSS, WAP, bradycardia, high degree AV block
Mult CVA (last [**2156**])
s/p bilateral CEA (L [**2154**], R [**2148**])
Stage II Gastic Cancer s/p partial gastrectomy and Billroth II
[**7-26**]
GERD
?COPD
EF 40%, mod LV HK (echo [**12-28**])
Status post nephrectomy for renal cell carcinoma
Status post left common iliac stent x 2.
History of right femoral AV fistula and right femoral
bruit.
**************
CATH HISTORY(2.5 x 18 mm, 2.5 x 15 mm, and 2.5 x 15 mm) treated
in the past with brachytherapy, [**2158-2-1**] LMCA atherectomy and
placement of 3.0 x 13 mm Zeta stent, [**2158-12-23**] with SVG -> rPDA
with 3.0 x 18 mm Hepacoat proximally and 3.0 x 23 mm Hepacoat
distally, [**2159-3-21**] with 3.0 x 28 mm Taxus and 3.0 x 24 mm Taxus
in the SVG -> rPDA as well as balloon angioplasty for LCx
in-stent restenosis using a 2.5 mm balloon, and finally
[**2159-8-8**] treatment of LMCA into LCx with 3.5 x 13 mm Cypher
with rescue of jailed LAD using a 2.5 mm balloon and SVG -> RCA
with 3.5 x 18 mm Cypher distally and 3.5 x 23 mm Cypher
proximally; [**2159-8-21**]: placement of cypher to SVG to RPDA
anastamosis. [**2159-9-7**] with Cypher stent to OM1 c/b LCx
dissection with successful tamponade to the area.
Social History:
Lives with his wife of 66 years; Retired police officer ([**2118**])+
Tobacco (3ppd x 35 years); quit 40 years ago+ heavy ETOH; quit
60 years ago; Denied IVDU
Family History:
+ premature CAD/MI: Father and 4 uncles all died before the age
of 50
+ HTN
- DM
Physical Exam:
96.6, 73, 140/48, 18, 92% RA
gen: elderly man in bed in no acute distress
heent: perrla, eomi; mucous membranes dry
cv: RRR with 2/6 systolic murmur throughout precordium
no JVD
resp: ispiratory crackles ?????? way up lung fields
abd: soft, NT, normoactive bowel sounds
midline incision with staples; no erythema
extr: no c/c/e
Pertinent Results:
CXR - Evidence of cardiac failure.
.
CT HEAD -
.
1. Hypodense in the right frontoparietal region preserves the
[**Doctor Last Name 352**]- white matter and is concerning for vasogenic edema since
there is a small amount of mass effect associated with it. There
is a small round area within it and it is unclear whether this
represents [**Doctor Last Name 352**] matter or a mass. Comparison with prior studies
is recommended. If no comparisons are available, MRI with
gadolinium is recommended.
.
2. There is no acute intracranial hemorrhage.
.
ECG - Cardiology Report ECG Study Date of [**2159-11-23**] 8:38:06 AM.
Sinus rhythm with atrial premature beats and ventricular paced
rhythm. Since
the previous tracing of [**2159-10-20**] probably no significant change.
Brief Hospital Course:
Right fronto-parietal brain mass - [**11-22**] the patient was noted
to develop a left facial droop w/ slurred speech. CT scan
showed a right fronto-parietal brain mass. Pt was started on
decadron. Neurology was consulted and found lesion to be most
c/w metastases vs. primary brain tumor. Neurosurgery consult
was considered but deferred as pt and family desired no further
interventions. They instead opted for hospice care.
.
NSTEMI - The patient was initially seen by cardiology upon
admission. Since he was deemed as a poor candidate for
catheterization he was managed conservatively. He was not
anticoagulated due to the large risk for bleed in light of his
recent surgery. Serial ECGs were obtained. The patient was
maintained on ASA, plavix, and beta-blocker. On [**11-22**], the
patient's cardiac enzymes began to rise with a CK 85 -> 340 and
troponin .02 -> .56. Enzymes were followed and conservative
management continued.
.
CHF - Pt had recently had an echo performed in [**8-26**] that
showed an EF of 40%. Pt had a CXR that showed him to be in mild
failure. He was diuresed with IV lasix with good response. He
was also maintained on an ACE inhibitor for afterload reduction.
.
Acute on chronic renal failure - pt went into mild renal failure
with a creatinine of 2.1 likely secondary to
hypovolemia/aggressive diuresis . His creatinine improved to
baseline of 1.8 with light hydration.
Bandemia - pt was initially found to have a bandemia with a
normal wbc count on admission. It was thought to be stress
related to surgery vs. infection. His UA was significant for
pyuria and the patient was started on ciprofloxacin.
.
Post-operative day #4 from conversion to roux-en-y - surgery was
consulted to follow patient based on his recent abdominal
surgery. There were no surgical issues that arose during the
hospitalization.
.
Hospice Care - On [**11-26**] a family meeting was held between the
family, palliative care service, and the medical team. At this
meeting the patient requested no further medical interventions
and arrangements were made for hospice care at the patient's
home. The patient was given prescriptions for symptomatic
treatment of his condition and all other extraneous medications
were discontinued.
Medications on Admission:
Temazepam 30HS
MVI
Lescol 20mg qD
Aciphex 20mg [**Hospital1 **]
Plavix 75mg qD
ASA 325mg qD
Zantac 300mg po qD
Cholestyramine [**Hospital1 **]
Toprol xl 50mg qD
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: [**4-11**] PO
q1hour:prn as needed for pain.
Disp:*1 * Refills:*0*
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for ANXIETY.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest/arm
pain.
Disp:*20 Tablet, Sublingual(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Zantac 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Gastric cancer
gastritis s/p roux-en-y
Myocardial Infarction
Brain metastasis
Hypertension
Discharge Condition:
stable
Discharge Instructions:
If you experience headache, chest pain, shortness of breath,
abdominal pain, intractable nausea or vomiting, seizures - tell
your hospice nurse and they will make a decision on whether to
call your doctor.
Followup Instructions:
none
|
[
"V10.04",
"997.1",
"599.0",
"V66.7",
"584.9",
"V45.81",
"414.00",
"410.71",
"348.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8275, 8343
|
4602, 6863
|
227, 234
|
8478, 8486
|
3808, 4579
|
8740, 8748
|
3347, 3429
|
7075, 8252
|
8364, 8457
|
6889, 7052
|
8510, 8717
|
3444, 3789
|
177, 189
|
262, 1746
|
1768, 3155
|
3171, 3331
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,016
| 102,057
|
1180+55265
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-8-11**] Discharge Date: [**2144-8-26**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is an 85 [**Hospital **] nursing
home resident with a history of cerebrovascular accident,
coronary artery disease, status post coronary artery bypass
graft who presents with shortness of breath and respiratory
distress. The patient has been a nursing home resident for
two years, is wheel chair bound times eight months prior to
admission according to his son, had a fever and shortness of
breath earlier the week prior to admission. The patient was
started on Levofloxacin on [**8-7**] at the nursing home
and Flagyl was also added. The morning prior to admission
the patient was noted to have increased respiratory distress,
diaphoretic, complaining of shortness of breath. This was
the morning of [**2144-8-11**]. The patient's O2 sats in
the Emergency Room were found to be in the low 70s on 4
liters nasal cannula. The patient was felt to be in severe
respiratory distress and was intubated emergently in the
Emergency Room. According to the physician, [**Name10 (NameIs) **] patient was
alert prior to intubation.
Subsequently after intubation the patient's blood pressure
decreased and the patient was started on Dopamine and his
heart rate increased into the 150s. The pressures were
changed to Neosinephrine with significant decrease in blood
pressure without any excessive tachycardia associated with
it. The patient was given Vanco, Ceftriaxone, Flagyl in the
Emergency Room. An nasogastric lavage was performed in the
Emergency Room, which was significant for coffee ground,
which were OB positive. The patient was also grossly OB
positive from below.
The patient was transferred to the MICU sedated, intubated
with a left groin catheter.
PAST MEDICAL HISTORY: 1. History of cerebrovascular
accident in [**2141-8-1**] with associated left sided
weakness. 2. Dementia. 3. Coronary artery disease status
post four vessel coronary artery bypass graft in [**2136**]. 4.
Diabetes mellitus type 2. 5. Peptic ulcer disease. 6.
Atypical psychosis. 7. Prostate cancer. 8.
Hypercholesterolemia. 9. Mild congestive heart failure with
an EF between 40 and 50% and an echocardiogram in 9/98
showing left ventricular hypertrophy and moderate aortic
stenosis, moderate mitral regurgitation with global decrease
in contractility. 9. Aortic insufficiency status post AVR.
MEDICATIONS ON ADMISSION: 1. Cardura 4 mg q.o.d. 2.
Glipizide 5 mg q day. 3. Lipitor 10 mg q.d. 4. Norvasc 5
mg q.d. 5. Prevacid 15 mg q day. 6. Dulcolax 5 mg b.i.d.
7. Depakote 500 mg b.i.d. 8. Lopressor 25 mg b.i.d. 9.
Ultram 50 mg b.i.d. 10. Risperdal 0.25 mg q.h.s. 11. Senna
two tablets q day. 12. Vitamin E. 13. Allopurinol 100 mg
q.d. 14. Coumadin 0.5 mg q.d. 15. Levofloxacin. 16.
Flagyl.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has been living at [**Hospital3 7511**] for two years. The patient denies any tobacco or
alcohol use.
PHYSICAL EXAMINATION: The patient's vital signs on arrival
temperature 97.0. Pulse 104. Blood pressure 112/52.
Respiratory rate 17. Generally, this is an elderly, thin
male, intubated, sedated. HEENT examination normocephalic,
atraumatic. Pupils are equal, round and reactive to light
from 2 mm down to 1 with light. ET tube is in place and
attached. Nasogastric tube is also in place. Neck is
without lymphadenopathy. JVP was difficult to assess, but
was not appreciated. The patient had course breath sounds
bilaterally throughout. Heart was regular rate and rhythm
with normal S1 and S2. No murmurs, rubs or gallops were
appreciated. Abdomen was soft, nontender, nondistended with
normal abdominal bowel sounds. Extremities without edema.
The patient had no clubbing, cyanosis or edema. Neurological
examination was difficult to perform given that the patient
was sedated.
LABORATORY ON ADMISSION: A white blood cell count of 9.1,
hematocrit 30.9, platelets 509, sodium 159, potassium 3.7,
chloride 123, bicarb 16, BUN 5, creatinine 1.7, glucose 297,
CPK was 132, ABG obtained in the Emergency Room was 7.23 with
a CO2 of 47 and a PAO2 of 367. The patient had a chest
x-ray, which showed a right lower lung infiltrate and a
questionable mild congestive heart failure and
electrocardiogram was obtained, which showed the patient to
be in atrial fibrillation at a rate of 123 without any acute
changes.
HOSPITAL COURSE: 1. The patient was admitted to the MICU
with the presumptive diagnosis of an aspiration pneumonia
secondary to worsening dementia and nursing home bound.
According to the family prior to this admission the patient
has had a gradual decline in mental status and was not
responding appropriately prior to this recent insult. The
patient was initially placed on vent settings of assist
control with a tidal volume of 700, respirations of 10 and a
FI2 of 60%. Arterial blood gases were sent, which stayed
within that range with a resolving respiratory acidosis. The
patient's antibiotics of Vancomycin, Levofloxacin and
Ceftriaxone were continued for broad spectrum coverage. A
sputum culture was sent, which was consistent with
oropharyngeal flora. The patient remained afebrile with a
right lower lobe infiltrate on chest x-ray. Therefore
Vancomycin was continued for gram positive coverage, Flagyl
was continue for anaerobic coverage, and Ceftriaxone was
changed to Levofloxacin for further gram negative and
atypical coverage. A legionella and urinary antigen was
checked, which was negative.
Throughout the course of the hospital stay the patient became
afebrile and his white count decreased and was within normal
limits at the time of discharge. The patient, however, did
not seem to be appropriately improving his right lower lobe
pneumonia with serial chest x-rays obtained. A bronchoscopy
was performed by the pulmonary fellow, which did not find any
focus of infection or any masses. Only mucous was noted.
The patient's vent settings were weaned slowly and eventually
the patient tolerated pressure support of 5 with a PEEP of 5
on FIO2 of .4. The patient was stable on this level for one
week prior to extubation. The patient was optimize with
suctioning of secretions prior to extubation and was
successfully extubated on [**2144-8-25**].
2. The patient was felt to be in possible mild congestive
heart failure at the time of admission. The patient was
diuresed aggressively with Lasix and oxygenation improved as
well as resolution of his congestive heart failure. The
patient was found to be in atrial fibrillation at the time of
admission. The patient was placed on Lopressor and titrated
up to Lopressor 50 mg po t.i.d. with good control of his
supraventricular tachycardia. The patient was ruled out for
a myocardial infarction with a negative troponin and multiple
negative CK. Cardiac issues have been stable throughout the
hospital stay.
3. The patient had some decreased urine output during his
hospital stay, which was felt to be secondary to prerenal
azotemia in the setting of possible sepsis verses decreased
cardiac output secondary to heart failure. At the time of
discharge the patient's renal functions had improved and is
stable.
4. ID. The patient initially was stable and cultures were
all negative. Blood cultures, urine cultures and sputum
cultures were nonspecific and did not show any source of
infection. As a result antibiotics were initially stopped.
However, after stopping the antibiotics the patient dropped
his blood pressure with a systolic in the 70s and the patient
became febrile with a temperature of 103.7. The patient was
restarted on Vancomycin, Levofloxacin and Flagyl for presumed
sepsis. The patient underwent a fourteen day course and at
the completion of the course the patient is currently
afebrile with no increase in white count. The patient's
blood pressure has also been stable and it was felt that the
patient had a transient sepsis, which was corrected with a
fourteen day course of broad spectrum antibiotics.
Throughout the hospital stay the patient has not grown out
any positive cultures except for the patient did have some
positive cultures secondary to central lines as well as A
lines. However, all blood cultures were negative and those
were felt to be contaminants.
6. Code status, the patient's code status was readdressed
with the family given his presentation. The family was
informed that the patient would be unlikely to improve from a
neurological standpoint. The patient had been decreasing
mentally prior to this admission and it was felt that this
admission added additional anoxic insult, which the patient
would not likely recover from. A neurological consult was
obtained during this hospital admission and they agreed with
our prognosis and the family is informed of these studies.
Throughout the hospital stay the patient was pretty much
unresponsive even as his pulmonary status improved. It was
felt that the patient would be unlikely to ever return to his
baseline status and if extubated would not respond to his
family. The patient's family was informed of all of this and
after discussing with the rest of their family they felt that
they still wanted everything done for the patient. Therefore
the patient will remain full code. The patient was also
given a PEG tube for enteral feedings. In the future if the
patient were to aspirate again and be reintubated, the
patient's family would like a tracheostomy to be performed.
At this time a tracheostomy was not performed as the patient
was successfully extubated.
DISCHARGE CONDITION: Unresponsive, but stable from
cardiovascular and pulmonary standpoint. The patient is
likely at optimal baseline, although he is not responsive.
DISCHARGE STATUS: The patient will be discharged to [**Hospital3 7511**] or other rehab facility for management.
DIAGNOSES:
1. Dementia.
2. Aspiration pneumonia.
3. Congestive heart failure.
4. Sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**]
Dictated By:[**Name8 (MD) 2402**]
MEDQUIST36
D: [**2144-8-26**] 14:21
T: [**2144-8-26**] 14:29
JOB#: [**Job Number 7513**]
Name: [**Known lastname 956**], [**Known firstname 957**] Unit No: [**Numeric Identifier 958**]
Admission Date: [**2144-8-11**] Discharge Date: [**2144-8-27**]
Date of Birth: [**2059-2-13**] Sex: M
Service:
ADMITTING DIAGNOSIS: Pneumonia.
DISCHARGE DIAGNOSIS: Pneumonia treated.
ADDENDUM: Status post transfer to the floor on [**8-26**], the
patient's condition remained stable with no events, no
respiratory distress, no decompensation in his status. On
the day of discharge the patient's vital signs were
temperature current 98.6 with temperature max of 100.8, pulse
rate 88, blood pressure 156/80, respirations 18, satting 96%
on a 35% scoop face blow by mask.
HOSPITAL COURSE: As previously dictated, the patient is an
85-year-old Russian speaking only male resident of [**Hospital3 959**] with baseline dementia who presented to [**Hospital1 960**] with acute respiratory distress
secondary to presumed aspiration pneumonia. The patient was
intubated and treated with IV antibiotics in the MICU
empirically, although repeated blood cultures and sputum
cultures failed to grow an identifiable pathogenic organism.
The patient improved, was successfully extubated and remained
stable. The patient also was guaiac positive with a frank GI
bleed and coffee ground emesis on admission which stabilized
as well. Serial hematocrits in the 29-30 range and then
shortly after admission the patient was considered to be
stable and deemed appropriate for discharge to [**Hospital3 901**]
to resume subacute care.
DISCHARGE DIAGNOSIS:
1. Aspiration pneumonia.
2. Dementia.
3. Sepsis.
4. Diabetes mellitus type 2.
5. Coronary artery disease.
6. Status post CVA in the remote past.
7. Congestive heart failure with an ejection fraction of
40%.
8. Peripheral vascular disease.
9. Prostate cancer.
10. Increased cholesterol.
11. Status post AVR.
DISCHARGE MEDICATIONS: The patient is on Lipitor 10 mg q
h.s., Neutra-Phos one packet tid with tube feeds, Norvasc 5
mg q day, Lopressor 50 mg tid, Colace 100 mg [**Hospital1 **], Prevacid 30
mg qid, NPH 80 units q a.m., 40 units q h.s. with regular
insulin sliding scale, Dulcolax q d, Haldol 1 gm q 4 hours
prn, Dilantin 100 mg tid, titrate to therapeutic level,
Flagyl 500 mg per J tube tid times 10 days from date of
discharge, Levaquin 500 mg per J tube q day times 10 days.
The patient is stable on discharge.
Active issues regarding the patient's care include:
1. Pulmonary: The patient should receive aggressive
pulmonary toilet with chest PT at minimum tid. Attempt
should be made to wean the patient from oxygen as usual from
30% to nasal cannula, continued on the patient's respiratory
status, i.e. mouth breathing. [**Month (only) 412**] require continued mouth
ventilation, supplemental O2 via scoop mask.
2. Neurologic: Patient was evaluated by the neurology staff
at [**Hospital1 536**] during his stay.
Assessment was that patient had baseline dementia with
seizure disorder made worse by hypoxic insult secondary to
hypovolemia with its presentation. Recommendation is to
treat therapeutic levels of Dilantin. The patient is on
Dilantin and was on the outpatient medications and should be
monitored to maintain therapeutic levels and assess for
improvement in his mental status.
3. Hematologic: The patient presented with a GI bleed.
Coumadin was held at that time and has now been restarted
secondary to concerns for a bleed. It should be assessed in
the future as to whether patient should be restarted as well
as be monitored for evidence of acute bleed in the future
which is unlikely considering the patient's stability over
the last week in the hospital.
4. Pneumonia. The patient should be continued on the Flagyl
and Levaquin as prescribed and the outpatient medications
listed above.
5. Decubitus sacral ulcer should be changed with appropriate
precautions, Duragel dressing.
6. Patient requires a wet to dry dressing change to the left
heel [**Hospital1 **] and sheepskin protected precautions for the left
heel.
7. Cardiovascular: Patient has known coronary artery
disease and had some episodes of tachycardia earlier in his
hospital stay as per the previous hospital course summary.
The patient has been stable on his Lopressor 50 mg tid and
would recommend continued monitoring of patient's status with
his drug dose as well as prophylaxis for patient's incidental
finding of a 7 cm abdominal aortic aneurysm.
DISPOSITION: Was discussed with family. Case manager
discussed patient's disposition with both family and
receiving facility - [**Hospital3 901**]. All parties are in
agreement with the current plan of management concerning the
patient. The patient remained a full code at this time per
the wishes of the family. The patient remains a full code
except in the event of ruptured abdominal aortic aneurysm.
DISCHARGE CONDITION: Stable to [**Hospital3 901**].
DISCHARGE STATUS: Patient is to be discharged upon
completion of this discharge summary for transport with the
patient.
DISCHARGE DIAGNOSIS:
1. Aspiration pneumonia.
2. Dementia.
3. Sepsis.
4. Diabetes type 2.
5. Coronary artery disease.
6. CVA in the remote past.
7. Congestive heart failure.
8. Peripheral vascular disease
9. Prostate cancer.
10. Hyperlipidemia, status post AVR.
[**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 290**], M.D. [**MD Number(1) 291**]
Dictated By:[**Doctor Last Name 961**]
MEDQUIST36
D: [**2144-8-27**] 14:00
T: [**2144-8-27**] 14:09
JOB#: [**Job Number 962**]
|
[
"707.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.21",
"43.11",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15144, 15298
|
12170, 15122
|
15319, 15839
|
2450, 2886
|
10978, 11808
|
3042, 3923
|
119, 1789
|
3938, 4443
|
10518, 10530
|
1812, 2423
|
2903, 3019
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,107
| 108,863
|
9416
|
Discharge summary
|
report
|
Admission Date: [**2178-12-2**] Discharge Date: [**2179-1-3**]
Date of Birth: [**2123-8-27**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 32137**]
Chief Complaint:
wheezing, malaise
Major Surgical or Invasive Procedure:
mechanical ventilation
bronchoscopy
thoracentesis
History of Present Illness:
55 YOF c/o SOB and cough for one week. It is accompanied by
myalgias and chest pain on right side as well as some back pain.
Had URI symptoms first, with nasal congestion, headache. Cough
is non-productive, but feels chest congestion. Husband has been
sick for 1 month with cough. She denies fevers, chills, nausea,
vomiting, abdominal pain. She felt light headed when standing
and SOB with ambulation. No dysuria, leg swelling or pain. No
h/o CHF or clots. Recently traveled to [**State 108**]. No exotic pets
or [**Location (un) **] exposures.
In ED T 97.5 104 90/51 16 99 RA then dropped toBP 70/40 RR 30
with 92 on RA. She was given 2 L NS and BP came up to 90/50.
Her CXR showed a RLL, and her wheezing improved with neb
treatment. She was administered levofloxacin and ceftriaxone.
Past Medical History:
Depression
Acne
Social History:
Non smoking, occasional EtOH, no ilicit drug use. Married.
Employed as a work book editor. Swims long distance at
baseline.
Family History:
Father AAA
Physical Exam:
Vitals 97.8 109 89/47 38 97 % NRB
General Pleasant middle aged woman tachypneic in mild
respiratory distress
HEENT sclera white conjunctiva pink mmm
neck no jvd
cv regular s1 s2 no m/r/g
pulm lungs with coarse bs right base +egophony +dull
abd soft nontender +bowel sounds
extrem warm no edema +palpable distal pulses
neuro alert and awake
derm mild facial flushing
Pertinent Results:
Admission labs:
[**2178-12-2**] 02:35PM PT-13.3 PTT-26.6 INR(PT)-1.1
[**2178-12-2**] 02:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
BURR-1+ TEARDROP-1+
[**2178-12-2**] 02:35PM NEUTS-53 BANDS-24* LYMPHS-9* MONOS-7 EOS-1
BASOS-0 ATYPS-1* METAS-4* MYELOS-1*
[**2178-12-2**] 02:35PM WBC-2.1*# RBC-3.61* HGB-10.8* HCT-29.9*
MCV-83 MCH-29.9 MCHC-36.1* RDW-13.9
[**2178-12-2**] 02:35PM TOT PROT-5.3* ALBUMIN-2.6* GLOBULIN-2.7
[**2178-12-2**] 02:35PM CK-MB-NotDone
[**2178-12-2**] 02:35PM cTropnT-<0.01
[**2178-12-2**] 02:35PM LIPASE-12
[**2178-12-2**] 02:35PM ALT(SGPT)-21 AST(SGOT)-11 CK(CPK)-10* ALK
PHOS-111 TOT BILI-0.5
[**2178-12-2**] 02:35PM GLUCOSE-144* UREA N-27* CREAT-0.9 SODIUM-134
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-14
[**2178-12-2**] 02:38PM LACTATE-3.1*
[**2178-12-2**] 03:09PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2178-12-2**] 03:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2178-12-2**] 04:42PM TYPE-ART TEMP-36.7 PO2-83* PCO2-38 PH-7.36
TOTAL CO2-22 BASE XS--3 INTUBATED-NOT INTUBA
[**2178-12-2**] 07:06PM TYPE-ART TEMP-36.6 O2-100 PO2-99 PCO2-35
PH-7.39 TOTAL CO2-22 BASE XS--2 AADO2-592 REQ O2-95
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
.
Other labs:
[**2178-12-8**] 03:17PM BLOOD Ret Aut-1.9
[**2178-12-10**] 03:52AM BLOOD Fibrino-520*
[**2178-12-8**] 03:17PM BLOOD Hapto-411*
[**2178-12-5**] 04:08AM BLOOD calTIBC-142* VitB12-GREATER TH Folate-5.3
Ferritn-301* TRF-109*
[**2178-12-5**] 04:08AM BLOOD PEP-NO SPECIFI IgG-974 IgA-149 IgM-99
[**2178-12-18**] 06:50AM BLOOD HIV Ab-NEGATIVE
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IGG 1 [**Telephone/Fax (3) 32138**] MG/DL
IGG 2 143 L 241-700 MG/DL
IGG 3 23 22-178 MG/DL
IGG 4 11 4-86 MG/DL
IGG 1[**Telephone/Fax (1) 32139**] MG/DL
.
Micro:
[**2178-12-2**] 2:15 pm BLOOD CULTURE 1ST SET VENIPUNCTURE.
**FINAL REPORT [**2178-12-15**]**
Blood Culture, Routine (Final [**2178-12-15**]):
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
ADDITIONAL SENSITIVITIES REQUESTED PER DR. [**Last Name (STitle) **]
#[**Numeric Identifier 32140**]
[**2178-12-9**]. TYPE F: Identified by State Laboratory.
RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON
RECEIPT OF
WRITTEN REPORT.
SENSITIVITIES PERFORMED BY FOCUS DIAGNOSTICS INC..
CEFUROXIME = SENSITIVE ( <= 0.5 MCG/ML ).
CHLORAMPHENICOL = SENSITIVE ( <= 0.5 MCG/ML ).
CLARITHROMYCIM = SENSITIVE ( 2 MCG/ML ).
Levofloxacin = SENSITIVE ( <= 0.03 MCG/ML ).
MEROPENEM = SENSITIVE ( <=0.06 MCG/ML ).
SULFA X TRIMETH = SENSITIVE ( <= 0.06 MCG/ML ).
IMIPENEM = SENSITIVE ( <= 0.5 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
HAEMOPHILUS INFLUENZAE,
BETA-LACTAMASE NEGATIVE
|
AMPICILLIN------------<=0.12 S
AMPICILLIN/SULBACTAM-- <=1 S
CEFTRIAXONE-----------<=0.03 S
CEFUROXIME------------ S
LEVOFLOXACIN---------- S
MEROPENEM------------- S
TETRACYCLINE----------<=0.25 S
TRIMETHOPRIM/SULFA---- S
Aerobic Bottle Gram Stain (Final [**2178-12-5**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 5647**] [**2178-12-5**] 1000.
PLEOMORPHIC GRAM NEGATIVE ROD(S).
.
Imaging:
[**12-2**] CXR: There are bibasal effusions with infiltrates at both
lung bases, more marked
on the right. The cardiomediastinal silhouette is unremarkable.
CONCLUSION:
Infiltrates at lung bases, highly suggestive of consolidation.
Please ensure
followup to clearance.
.
US liver: Sludge-filled gallbladder with tiny gallstones. No
evidence of acute
cholecystitis.
.
[**12-5**] CT chest: Diffuse bilateral airspace consolidation
predominantly involving
the lower lobes, but also involving the upper lobes more
focally. Diffuse
ground-glass attenuation of the aerated portions of the lungs,
with relative
sparing of the lung apices.
,
[**12-5**] CT sinuses: Pansinusitis. No evidence of erosive bone
changes.
,
Echo: Suboptimal image quality. Mild mitral regurgitation
without discrete vegetation. Mild aortic valve sclerosis. Normal
biventricular cavity sizes with excellent global and normal
regional biventricular systolic function.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
[**12-13**] CT chest: 1. Increased bilateral nonhemorrhagic layering
pleural effusion, now
moderate-to-large and increased multifocal consolidation and
ground-glass
opacity, more widespread and more dense, could be worsening of
multifocal
pneumonia, alveolar hemorrhage, or developing ARDS, should be
correlated with
labs.
2. Signs of anemia.
3. Gallstone.
[**12-21**] LENIs:
IMPRESSION:
No evidence of DVT.
[**12-21**] RUQ U/S:
IMPRESSION:
1. Sludge and stone-filled gallbladder with no definite evidence
of acute
cholecystitis, though the gallbladder does appear moderately
distended. If
clinical concern for cholecystitis persists, recommend further
evaluation with
a HIDA scan.
2. Unchanged echogenic nodule at hepatic dome.
[**12-23**] CTA CHEST/CT ABD/CT PELVIS:
IMPRESSIONS:
1. Diffuse pulmonary consolidations and ground-glass opacities
are increased in density and extent compared to [**2178-12-13**].
2. Anasarca. Moderate right greater than left pleural effusions
are also
slightly increased.
3. No evidence of pulmonary embolism.
4. Mildly prominent mediastinal lymph nodes, non-specific and
unchanged.
5. Cholelithiasis, without CT evidence for acute cholecystitis.
No acute
intra- abdominal pathology seen to account for the patient's
symptoms.
[**12-23**] CT SINUS:
Marked improvement in chronic sinus disease. No evidence of
abnormal
enhancing lesions or osseous destruction.
[**12-25**] Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
[**12-25**] ECHO:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Mild tricuspid regurgitation with normal valve
morphology. Moderate pulmonary artery systolic hypertension.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Compared with the
prior study (images reviewed) of [**2178-12-8**], the estimated
pulmonary artery systolic pressure is higher. The other findings
are similar.
[**2178-12-28**] Bronchial washings:
NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
55 YOF otherwise healthy c/o malaise and cough for 1 week which
likely represents pneumonia.
# Bilateral Pneumonia/ARDS: Likely pathogen H flu, as bacterial
suprainfection following viral infection, as grown from blood
cultures on the day of admission. Initially, the patient was
started on vancomycin, ceftaz and azithromycin. The antibiotic
regimen was changed on [**2178-12-5**] when blood cultures positive, to
ceftaz and azithro only. The same day the patient was becoming
more tired with increased tachypnea and was intubated. The
patient continued to have fevers through ceftaz treatment, so an
Echo was done on [**2178-12-7**] to rule out endocarditis, no evidence
of vegetations noted. At that time, the CXRs showed more volume
overload, so the patient was diuresed with IV lasix of 40mg [**Hospital1 **]
with good volume removal. As the patient was unable to be
weaned off the mechanical ventilator, CT scan was done which
showed large pleural effusions. A thoracentesis was performed
on [**2178-12-13**] which showed a transudative effusion, likely
secondary to volume overload. As she continued to spike fevers
with ceftaz treatment, the regimen was changed to meropenem and
vancomycin on [**2178-12-13**], vancomycin stopped on [**2178-12-15**], per ID
meropenem should continue for a total of 3 weeks. The patient
was successfully extubated on [**2178-12-14**]. She was able to maintain
reasonable O2 sats on nasal cannula for the next two days and
was sent to the floor.
.
Mrs [**Last Name (un) 32141**] was transfered to the medical floor on [**12-16**]
sating 94% on 5L NC. Over the next 4 days she became
increasingly tachypnic with progressive oxygen requirement. Her
leukocystosis rose to 21 despite no additonal culture data and
continuation of meropenem. On [**12-19**] she was transfered back to
the MICU for tachypnea and desaturations to the 70s.
.
Although the patient's profound sickness and long recovery is
typical for H flu pneumonia her young age and lack of
immunocompromise were atypical for getting this infection.
Investigation for immunocompromise was undertaken. HIV was
negative, SPEP and UPEP for normal. IGG subtyping showed
isolated deficiency of IGG 2 of unclear significance. She had no
evidence of diabetes and no reason to be functionally asplenic.
.
There was a possibility raised by the ICU team that she may have
underlying lung disease prior to her pneumonia. It is possible
that she may have pulmonary venoocclusive disease, pulm HTN, or
small distal PEs not seen on CTA. This will need to be addressed
in the future by her pulmonologist.
.
Patient has documented dead space of 84%. Patient had completed
a course of treatment for known H. flu bacteremia with
azithromycin, 7 day empiric course of meropenem. After worsening
around [**12-20**], patient was started on vanc/zosyn. On [**12-24**] and [**12-25**]
[**Female First Name (un) 576**] was done bilaterally for concern of empyema but did not
reveal a source of infection. Patient was trached on [**12-25**].
Patient continued to be tachypneic in the 30-40s with an element
of anxiety. Multiple bronchs have been done and there does not
appear to be a current PNA. Concern for inflammatory causes less
in the setting of no bronchial fluid or peripheral
eosinophillia. Differential includes infectious cause vs. BOOP.
There has been a poor response to antbiotics and no secretions
on bronch argues against PNA. Patient's peribronchovascular
pattern could be consistent with BOOP over typical ARDS picture.
BOOP would require treatment with steroids and until clear
diagnosis is made difficult to justify steroids in the setting
of possible infectious cause. Differentiation of the etiologies
of the ARDS would require tissue bx. This would require VATS but
the patient does not have enough lung reserve to take down one
lung for the procedure. The patient??????s clinical resp pattern is
consistent with pulmonary fibrosis vs. rind. IP did not feel
thoracentesis would be beneficial. Patient got PMV valve placed
on [**12-30**], resp status improving. Over the next couple of days pt
progressively tolerated longer trials of CPAP/PSV, PMV trials
and eventually trach mask. Pt was seen by S&S and recommended a
formal exam when the pt was able to tolerate the trach mask/PMV
for a more consistent period of time.
.
# Fever/Leukocytosis: After being readmitted to the MICU for
hypoxia the pt had a persistent leukocytosis and fever. Finally
defervesced [**2178-12-29**]. Pt had extensive w/u for source of
infection including negative BALs, LENIs, bilateral
thoracentesis, CT Sinuses/Chest/Abdomen/Pelvis, blood cxs, urine
cxs, stool cxs and ECHO. Pt grew VRE from urine cx from [**2178-12-22**]
but ID did not feel that this was causing her infection,
however, given her persistent fever and leukocytosis Linezolid
was given [**Date range (1) 19594**]. Pt seen by Dermatology for rash on back
which was cutaneous candidiasis and treated with Fluconazole
[**Date range (1) 28307**]. No other sources of infection were identified. Pt
remained with resolving ARDS.
# Hypotension: The patient became more hypotensive on the day
after intubation, likely secondary to sedating medications and
infection. Fluid resuscitated and required levophed at that
time. Central and arterial lines placed. The patient was
taking spironolactone at home for unknown reasons, was held in
the setting of low blood pressures. Pt continued to have MAPs
55-65 throughout the admission but maintained adequate urine
output and normal mental status.
.
# Anemia: Previous baseline HCT in [**2176**] of 35, since admission
she has been less than HCT 30. The HCT was as low as 21
requiring transfusion of 2 units of blood. Iron studies were
consistent with anemia of chronic disease. No evidence of DIC,
B12 and folate normal. Management should continue as an
outpatient.
.
# Depression: Her home oral medications, geodon and prozac,
were initially held while the patient was sedated and restarted
after 1st extubation. Ritalin held during hospitalization. Pt
then restarted on prozac 80mg Qdaily and ziprasidone 40mg [**Hospital1 **].
Pt was seen by outpatient psychiatrist and recommended
continuing with current therapies.
.
FEN: vegetarian diet, Replete lytes
Prophy: Heparin SQ
Access: 2 PIV
Code: full
Communication: with patient
Medications on Admission:
Meds
Prozac 40 QD
Ritalin
Geodon
Spironolactone
.
Allergies
clindamycin-face swelling
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: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
6. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
7. Ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
10. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
14. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Lidocaine HCl 40 mg/mL (4 %) Solution Sig: One (1)
Injection tid () as needed for prn cough.
17. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day).
18. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed.
19. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed for air hunger.
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 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Haemophilus influenzae pneumonia
Acute respiratory distress syndrome
Anemia
.
Secondary diagnosis:
Depression
Anxiety
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for shortness of breath. You
were found to have a severe pneumonia, requiring admission to
the intensive care unit and intubation as well as tracheostomy.
You were treated with antibiotics with slow improvement of your
symptoms and resolution of the infection. You still have
underlying inflammation in your lungs that may take months to
resolve completely.
.
Please follow up with your doctors as detailed below.
.
If you become short of breath, have fevers or chills, cough up
blood, have chest pain, abdominal pain or diarrhea, difficulty
urinating, or any other worrisome symptoms please call your
doctor and go to the emergency room.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 2205**]
Completed by:[**2179-1-3**]
|
[
"E879.8",
"285.29",
"790.7",
"458.9",
"780.60",
"564.09",
"999.89",
"112.3",
"311",
"276.6",
"482.2",
"511.9",
"041.5",
"518.81",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.24",
"00.14",
"34.91",
"38.93",
"33.22",
"31.1",
"96.04",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
18050, 18116
|
9475, 15820
|
290, 341
|
18278, 18287
|
1781, 1781
|
19009, 19123
|
1367, 1379
|
15956, 18027
|
18137, 18215
|
15846, 15933
|
18311, 18986
|
1394, 1762
|
233, 252
|
369, 1168
|
18236, 18257
|
1797, 3145
|
1190, 1207
|
1223, 1351
|
3157, 9452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,556
| 133,277
|
24020
|
Discharge summary
|
report
|
Admission Date: [**2149-2-25**] Discharge Date: [**2149-2-28**]
Service: MEDICINE
Allergies:
Penicillins / Prednisone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 year old caucasian female with CHF, CAD, basal artery
stenosis, hiatal hernia, esophageal ulcer, MR transferred from
[**Last Name (un) 4068**]. She has history of CHF, CAD with basal artery
insuffiency/?stenosis (since [**2123**]), balance difficulty (walks
with walker), hiatal hernia, esophagel ulcer, MR, who presents
s/p mechanical fall OOB. Patient's grandadaughter went to live
w/ her s/p her husband's death a month ago (husband was main
health caregiver). She overreached something on table @ 3am and
fell out of bed. Intially EMT called, only slight tenderness in
L hip. Therefore EMT left @ 3am. and pt was back in bed over the
course of the morning. Pt's lower extremity became extremely
[**Location (un) 620**]. She had XRAY of pelvis and LE, and CT of head which
showed no ICH, no LE fracture. There was no bed @ [**Last Name (LF) 620**], [**First Name3 (LF) **]
she was transferred to [**Hospital1 18**] instead. At [**Hospital1 18**] ED, she had MRI
hip that r/o fracture.
She also had some paranoia episode (according to daughter,
always have that in hospital, especially since husband's death).
Patient was also very agitated in the ED. She was also noted to
be hypoxic in ED.
Past Medical History:
CHF
CAD
basal artery stenosis
hiatal hernia
esophageal ulcer
MR
Social History:
lives in own apt. usually taken care by husband when passed away
on [**12-28**]. Now she cared for by her granddaughter, who lives with
her and has home aids twice a week.
Family History:
non-contributory
Physical Exam:
on Admission:
T 98.3 BP 100/P?, P 51, R 20, O2 92-95%
Gen: NAD
HEENT: unremarkable, dry mucus membrance
CV: RRR, II/VI SEM apex to axilla
Resp: CTAB
Abd: S, NT/ND +BS
Ext: DP 1+ b/l, LLE calf area ++ bruise, very swollen, large
bulla on anterior aspect of LE, skin not tense, bruised area
very warm, both foot warm to touch. passive and active motion
seen ok. ( pt non-cooperative)
neuro: moves all ext, CN II-XII intact, A&0X2
Pertinent Results:
[**2149-2-25**] 04:20PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
[**2149-2-25**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2149-2-26**] 06:02PM BLOOD WBC-13.5* RBC-3.27* Hgb-8.5* Hct-27.4*
MCV-84 MCH-26.1* MCHC-31.2 RDW-16.1* Plt Ct-170
[**2149-2-27**] 01:03AM BLOOD PT-15.4* PTT-42.1* INR(PT)-1.5
[**2149-2-27**] 01:03AM BLOOD Fibrino-224 D-Dimer-1056*
[**2149-2-27**] 04:00AM BLOOD Glucose-130* UreaN-20 Creat-0.8 Na-145
K-4.5 Cl-110* HCO3-27 AnGap-13
[**2149-2-27**] 04:00AM BLOOD CK(CPK)-602*
[**2149-2-26**] 06:02PM BLOOD ALT-22 AST-170* LD(LDH)-441* CK(CPK)-847*
AlkPhos-78 TotBili-3.5*
[**2149-2-26**] 04:37AM BLOOD ALT-11 AST-79* LD(LDH)-371* CK(CPK)-547*
AlkPhos-71 TotBili-2.0*
[**2149-2-27**] 04:00AM BLOOD CK-MB-116* MB Indx-19.3* cTropnT-1.69*
[**2149-2-26**] 06:02PM BLOOD CK-MB-172* MB Indx-20.3* cTropnT-1.36*
[**2149-2-26**] 04:37AM BLOOD CK-MB-110* MB Indx-20.1* cTropnT-0.57*
proBNP-5350*
[**2149-2-27**] 04:24AM BLOOD Type-ART FiO2-40 pO2-146* pCO2-35
pH-7.47* calHCO3-26 Base XS-2
[**2149-2-26**] 04:53AM BLOOD Type-ART Temp-36.1 O2 Flow-2 pO2-75*
pCO2-38 pH-7.48* calHCO3-29 Base XS-4 Intubat-NOT INTUBA
Vent-SPONTANEOU
Ct head: IMPRESSION: No acute hemorrhage or mass effect.
Ct leg:
IMPRESSION: Large hematoma in the left calf.
ECHO [**2149-2-26**]
Conclusions:
The left atrium is dilated. The left ventricular cavity size is
normal.
[Intrinsic left ventricular systolic function may be more
depressed given the severity of valvular regurgitation.] Resting
regional wall motion
abnormalities include inferolateral hypokinesis. Estimated left
ventricular ejection fraction ?45%. Right ventricular chamber
size is normal. Right ventricular systolic function is normal.
The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The mitral regurgitation jet is eccentric. The tricuspid valve
leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded
CT chest w/o contrast [**2149-2-27**]
IMPRESSION:
1) Minimal interstitial pulmonary edema and small bilateral
pleural effusions, consistent with mild or resolving congestive
heart failure.
2) Large posterior diaphragmatic hernia of Bochdalek, which
accounts for the left-sided lucencies on previous chest
radiographs.
3) Numerous small shotty mediastinal lymph nodes, probably
reactive. .
4) 3-mm nonobstructing stone versus granuloma in the right
kidney. Multiple calcified liver and spleen granulomas.
Brief Hospital Course:
A/P 86 year old with CAD, CHF, basal artery insuffiency came in
s/p fall, admitted for further evaluation of leg pain.
1) S/P mechanical fall
-CT head neg for intracranial bleed. X-rays of the pelvix and
lower extremity were negatve for fracture from OSH reports. MRI
hip was done in the ED at [**Hospital1 18**] ED which r/o fracture. Ct of
leg on [**2-26**] confirmed the development of a left calf hematoma
#Psych
-give haldol 1-2mg PRN for agitation, hold nortryptylline per
psych, Continue prozac
-A psych consult was called on admission due to pateint's
history of agitation/confusion and visual/auditory
hallucinations s/p recent passing of her husband. Pt thought to
have delerium +/- depression
#CV-
Overnight from [**Date range (1) 61132**], she had an episode of hypotension
(systolic 60-70's) (pt's BP in the ED the day previously was
130/60) and received 1-2 L of fluid boluses with minimal
improvement of her hypotension; ABG w/ PO2 75. This AM,
hypotensive (MAP ~low 60's, systolic 70-80's) hypoxic again to
sats in hi 70's to lo 80's (ABG x2 were likely venous w/ PO2 29,
32) which improved with 100% NRB. Incidentally her BP improved
on the NRB as well. Hct this AM 24.7 from 28 (at [**Last Name (un) 4068**]) without
dilution of CBC or completion of blood transfusion. Levaquin and
Vanco were given to cover for possibility of infection. Pt was
transferred to ICU for closer monitoring and managment. Cardiac
enzymes were sent which ruled in strongly for myocardial
infarction. A CXR showed evidence of congestive heart failure
and ? LLL opacity. A CT chest without contrast was done which
showed evidence of pulmonary edema and large posterior
diaphragmatic hernia of Bochdalek, which accounts for the
left-sided lucencies on previous chest radiographs. CT of
patient's left leg was done as this showed edema and echhymosis.
A large calf hematoma and edema was observed. As pt had
evidence of myocardial infarction and CHF, an echo was done
which showed EF?45%, mod pul art systolic HTN, 2+MR,
infero-lateral HK. A cardiology consult was obtained for
management of NSTEMI. Family was clear that aggressive measures
were not to be taken and DNR/DNI status was confirmed. Medical
managment of MI was requested. The cardiology service
recommened the following: 1) HCT > 30
2) ASA 3) Plavix once bleeding issue is resolved 4)
Metoprolol, titrate up as tolerated 5) ACE 6) Lipitor 7) Hold
off heparin given bleeding concerns. These recommendation were
followed.
On [**2-27**], a family meeting occurred and comfort was decided to be
the primary goal of the patient's care from that point forward
given her critical status and recent deterioration in overall
condition. A morphine gtt was started on [**2-27**] and the patient
expired at 9:13 am on [**2-28**].
[**Name (NI) **] pt was covered with Vanc/levofloacin out of concern for
hospital acquired pneumonia +/- sepsis given pt hypoxia and
hypotension. Blood and urine cultures showed no growth. No
further evidence of infection was identified. NSTEMI accounted
for HD changes/
HEME- given hematocrit drop leading to demand ischemia. Pt was
trasfused with PRBC's from [**2-26**] to [**2-27**].
# Neuro
-known basal artery insuffiency/stenosis
-has balance difficulty; usually walks with walker
# [**Name (NI) 61133**] Pt has h/o hiatal hernia and h/o esophageal ulcer. Avoided
NSAIDS given bleeding concerns. Sucralafate and pepcid
continued.
#endo-RISS for blood sugar control
#FEN
-DAT
-will give fluid boluses as tachcardia, and decreased BP, poor
fluid intake
-put on maintenance fluids until po intake satisfacotry
-nutirition for poor intake
# PPX-continue sucrafate, pepcid
#code: DNR/DNI (d/w pt's family & HCP)
#access- PIV. A central line was attempted on [**2149-2-26**] but was
not successful due to patient intolerance of the procedure.
Family requested on no further attempts on the night of [**2149-2-26**]
# communication
-HCP -daughter in SF ([**Telephone/Fax (3) 61134**]
-daughter [**Name (NI) **] [**Name (NI) 61135**] (lives with mom) [**Telephone/Fax (1) 61136**]
family is very involved.
Medications on Admission:
sulcrafate
pepcid 20 [**Hospital1 **]
nortripline 25 daily
prozac 30 daily
asa 81
toprol
trazodone 25 qhs
no nebs at home
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2149-4-30**]
|
[
"435.0",
"719.7",
"396.0",
"584.9",
"398.91",
"924.10",
"785.51",
"518.84",
"440.0",
"414.01",
"E884.4",
"410.51",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9383, 9392
|
5060, 9178
|
255, 261
|
9443, 9617
|
2262, 3507
|
1781, 1799
|
9351, 9360
|
9413, 9422
|
9204, 9328
|
1814, 1814
|
200, 217
|
289, 1488
|
3516, 5037
|
1828, 2243
|
1510, 1576
|
1592, 1765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,511
| 166,843
|
43283
|
Discharge summary
|
report
|
Admission Date: [**2147-8-21**] Discharge Date: [**2147-8-29**]
Service: MEDICINE
Allergies:
Morphine / Mirtazapine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
ICD firing for VTach
Major Surgical or Invasive Procedure:
Your ICD was interrogated on [**2147-8-21**], and you were shocked for
Ventricular Tachycardia by your AICD once during this admission.
History of Present Illness:
The patient is a 86 yo man with h/o CAD s/p MI and CABG in [**2136**],
chronic AFib with V-pacing, chronic systolic CHF with EF 20%,
who presents with recurrent ICD firing in the setting of
sustained VTach. The patient states that he was in his normal
state of health until this afternoon, when he was "shocked" at
his nursing home. Per the nursing home, the patient was shocked
by his ICD at approximately 3 PM. He then had [**6-21**] subsequent
episodes of ICD firing. He became unresponsive for 5-10 seconds
during these episodes but regained consciousness with ICD
firing. The patient denies recent lower extremity swelling,
shortness of breath, orthopnea, PND. He does endorse a feeling
of chest fullness after the repeated shocks. The patient was
brought to the ED for further evaluation.
In the ED, the patient's VS were T 98.1, P 74, BP 118/80, R 16,
O2 96% on RA. EP was consulted and the patient's pacemaker was
interrogated. The patient's programmed anti-tachycardia pacing
settings were decreased, and the number of Joules for firing was
increased from 20 to 35. He was thought to be fluid overloaded,
so he was given Lasix 80 mg IV x1. He was then given a
Lidocaine bolus of 100 mg IV and started on Lidocaine 2 mg gtt.
On arrival to the floor, the patient had another episode of VT,
for which he was shocked after approximately 15 seconds. The
patient was unresponsive during this episode but regained
consciousness when his ICD fired.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He does endorse recent constipation for the past two days. All
of the other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion (though poor exercise capacity), paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations.
Past Medical History:
MI X2 (inferior and anteroseptal)
- CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 112**] [**2136**])
- Afib w/o anticoag (fall risk)
- Sustained VTach in [**2146**] s/p admission
- PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to
[**Company 1543**] Concerto in [**2145**].
3. OTHER PAST MEDICAL HISTORY:
- legally blind secondary to glaucoma
- Hiatal hernia
- Hepatic cysts/hemangioma and lipoma in hepatic flexure
- s/p Lt BKA (WWII trauma [**2078**])
- BPH s/p suprapubic prostatectomy ([**2131**])
- s/p cholecystectomy ([**2110**])
- Chronic low back pain
- Osteoarthritis
- Positive PPD in past
- Depression and anxiety
Social History:
The patient immigrated from [**Country 532**] 20 years ago; lives at [**Hospital1 100**]
Senior Center w/ wife. Former oncology surgeon w/ one daughter
and grandaughter in [**Name (NI) 86**]
-Tobacco history: None currently
-ETOH: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 97.9, P 80, BP 123/72, R 16, O2 97% on RA
GENERAL: Elderly man, blind, pleasant and anxious, in NAD.
HEENT: Decreased visual acuity bilaterally. Sclera anicteric.
PERRL, No pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bronchial breath sounds
in right middle lobe. No crackles appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. RUQ scar
EXTREMITIES: s/p Left leg BKA. 1+ edema in RLE.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2147-8-21**] 06:15PM
139 | 105 | 20 / 130
3.7 | 23 | 1.1\
CALCIUM-9.0 PHOSPHATE-3.2 MAGNESIUM-2.1
COAGs: PT-14.1* INR(PT)-1.2*
13.0
9.9 >---< 247
39.8
[**2147-8-21**] 06:15PM cTropnT-0.02, CK(CPK)-42
[**2147-8-22**] 01:57AM Trop 0.03 CK 46
[**2147-8-21**] 10:18PM DIGOXIN-0.2*
TSH:0.30 Free-T4:1.3
U/A: Small bili, trace protein, few bacteria, no leuk esterase,
[**7-26**] hyaline casts
========================================
DISCHARGE LABS:
[**2147-8-29**] 06:30AM BLOOD WBC-12.0* RBC-4.50* Hgb-12.3* Hct-39.1*
MCV-87 MCH-27.4 MCHC-31.5 RDW-15.3 Plt Ct-264
[**2147-8-29**] 06:30AM BLOOD Glucose-148* UreaN-29* Creat-1.0 Na-137
K-3.6 Cl-99 HCO3-26 AnGap-16
[**2147-8-26**] 04:15AM BLOOD ALT-33 AST-25 LD(LDH)-260* AlkPhos-80
TotBili-3.1*
[**2147-8-25**] 04:04AM BLOOD %HbA1c-6.1*
========================================
RELEVANT STUDIES:
CXR ([**2147-8-21**]): Wet read: low lung volumes result in
bronchovascular crowding, likely account for right infrahilar
opacity. vascular congestion, new retrocardiac opacity.
CXR ([**2147-8-25**]): Interval worsening of the left basal
consolidation that might represent infectious process versus
atelectasis.
EKG ([**2146-8-24**]): Ventricularly paced at rate of 79 bpm. Left
axis deviation. RBBB with LAFB. Q waves in II, III, AVF.
2D-ECHOCARDIOGRAM ([**2146-8-22**]): Left atrium is markedly dilated.
Left ventricular wall thicknesses are normal. Left ventricular
cavity is moderately dilated. Severe regional left ventricular
systolic dysfunction with severe hypokinesis of nearly all
segments. Estimated cardiac index is depressed (<2.0L/min/m2).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
Aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. Aortic valve leaflets (3)
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. Mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. Tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be quantified. There is no
pericardial effusion. IMPRESSION: Moderate left ventricular
cavity enlargement with extensive regional systolic dysfunction
and depressed cardiac index c/w multivessel CAD or other diffuse
process. Right ventricular cavity enlargement with free wall
hypokinesis. Moderate mitral regurgitation. Dilated thoracic
aorta.
Brief Hospital Course:
# Ventricular Tachycardia: The patient had approximately 8
episodes of VTach the day of admission, for which his ICD fired.
He became unresponsive for approximately 5-10 seconds during
these episodes and regained consciousness with ICD firing. It
appears that the patient was not taking Amiodarone at [**Hospital 100**]
Rehab. On discussion with staff and Dr. [**Last Name (STitle) 73**], it seemed
that Amiodarone was discontinued since patient had not had VT or
ICD firing from [**Month (only) **] to [**2147-6-16**], and it was felt pt would be
stable off Amiodarone. Interrogation of his pacemaker on
admission showed over 20 shocks delivered for VT in the past few
weeks. The most likely etiology for these recurrence episodes is
lack of effective medication and electrolyte disturbances were
thought to have played a secondary role.
Patient was treated with Lidocaine and amiodarone drip in the
CCU and transitioned to Amiodarone PO after a 10 gram load. He
is currently on Amiodarone 400 mg daily. He has had many
episodes of Slow VT (rates 120's) in which the BP has been
stable and pt has been asymptomatic. His ICD was adjusted so
that a shock is delivered only for VF or VT at a very high rate.
It is also set to pace him out of faster rhythms as a primary
response, before giving a shock. It is hoped that the
resumption of amiodarone with prevent further VT. The
consideration of further therapy, including other antiarrhythmic
medications and possible VT ablation, was extensively discussed
by the Cardiology staff. Given his co-morbid conditions and
overall functional status, it was determined that the risks of
these therapies do not outweigh the benefits and are therefor
not medically indicated in this patient.
Baseline thyroid function and liver function tests were normal
except for total bilirubin of 4.0 (repeat total bili 2.8,
indirect 0.7), and should be repeated in 3 months.
#. Acute on Chronic Systolic CHF: The patient appeared fluid
overloaded on physical exam and ICD device also indicated
overloaded state. No obvious overload on admission CXR. He
received IV Lasix prn to obtain daily fluid balance goals. Home
dose of Lasix PO was uptitrated according to patient's daily
intakes. He should continue on Lasix 120 mg twice daily at his
nursing facility. Repeat TTE on [**2147-8-22**] showed EF 20-25%,
worsened MR (mod-severe), mod-severe pulmonary HTN. Outside
records showed that patient had been on lisinopril 5 mg daily
after hospitalization 1 year ago, but he is no longer written
for ACEIs at [**Hospital1 100**]. He was started Captopril 6.25 mg PO TID. He
was discharged on Captopril and should be transitioned to a long
acting ACE such as Lisinopril when his blood pressures
stabilizes. He should continue to get daily weights and Lasix
adjustment when his weight increases more than 3 pounds in 1 dy
or 6 pounds in 3 days with a 2 gram Na diet.
#. Coronary Artery Disease: The patient has a history of CAD
s/p MI and CABG in [**2136**]. On admission, he had chest pain in the
setting of ICD firing, but had no further chest pain during
hospital course. Cardiac biomarkers were trended although there
was low suspicion that VT had ischemic etiology. Troponin was
slightly elevated at 0.03 and trended down to 0.02, CK was WNL.
No acute ST-T wave changes were appreciated on ECG. Patient was
monitored on telemetry and daily EKG's were followed. He was
continued on home doses of ASA, Zocor, Nitroglycerin. Atenolol
and Imdur were decreased. He was started on Captopril.
# HYPONATREMIA: Patient developed hyponatremia as low as 127.
This was thought to be secondary to polydipsia and large free
water intake with low solute intake. Patient appeared euvolemic.
He was encouraged to drink fluids with electrolytes, Ensure and
broth, and free water was restricted with good effect. Sodium
trended back to normal limits (137) by [**2147-8-29**].
# LEUKOCYTOSIS: Patient developed new leukocytosis to 14.7 on
[**2147-8-23**] from unclear etiology. He remained afebrile, CXR WNL. UA
was equivocal but culture was negative. Blood culture was still
pending upon discharge but no growth to date. Repeat CXR on
[**2147-8-26**] suggestive of increased atelectasis whereas [**2147-8-27**]
showed stable changes. Leukocytosis trended down starting
[**2147-8-27**] and pt continues to have a clear urinalysis without any
evidence of localized infection.
# Question Sleep Apnea: Patient had recurrent episodes of oxygen
desaturation to 80's% while sleeping, and apneic pauses were
noted. Patient received O2 by nasal cannula while sleeping, as
he did not tolerate face mask, to good effect. He should
continue this at rehab until a formal sleep study can be
obtained.
#. Blindness / Glaucoma: The patient has a history of blindness
secondary to glaucoma. He was continued on Alphagen, Trusopt,
and Xalatam eye gtts.
#. Delirium: Patient was alert and oriented upon admission. He
was continued on Ativan 1.5 mg QHS and Lorazepam 0.5 mg q4h prn
for anxiety. On [**8-26**], he became acutely delirious as marked by
agitation and visual hallucinations. 1:1 sitter was employed, no
restraints used; pt given Zyprexa 5mg SL with good effect
although pt was very somnolent throughout the next day, waking
only for dinner. Somnolence improved with discontinuation of all
sedatives and benzodiazepines. Upon discharge, he is able to
eat and drink with assist. Patient does not appear to be
infected and no other source of sedation aside from medications
was identified.
# Depression: Continued home dose of Lexapro.
# Urinary Retention: Pt had 2 episodes of urinary retention
during his delirious state with residuals of 1000 cc and
overflow incontinence. His Foley was replaced and a voiding
trial should be done once mental status and alertness improve.
If patient continues to have urinary retention, would recommend
a urology evaluation.
# Hyperglycemia: Patient was noted to have hyperglycemia upwards
of FS 200 in the 1-2 days prior to discharge. As above, he was
evaluated for infectious source and none was found. HgbA1c 6.1
as checked during admission. Given his co-morbid conditions, we
recommend he have continued monitoring for this upon discharge
by his primary care physician [**Name Initial (PRE) **]/or rehab staff. [**Month (only) 116**] need
continued fingerstick monitoring and possible initiation of
diabetic medication, despite his normal HgbA1c.
# Superficial Thrombophlebitis: Thrombophlebitis of left
antecubital area was noted [**2147-8-27**]. No peripheral IV in place.
Started warm compresses and ibuprofen 400mg q6hrs PRN with
resolution of symptoms.
During this hospitalization, Mr. [**Known lastname **] chose to be a DNR-DNI but
did request external defibrillation for VFib/Vtach should his
ICD not fire appropriately. This was extensively discussed with
both Mr. [**Known lastname **] and his family during the admission.
Medications on Admission:
Confirmed with [**Hospital 100**] Rehab
Aspirin 81 mg daily
Atenolol 12.5 mg [**Hospital1 **]
Alphagan 0.2 1 drop both eyes [**Hospital1 **]
Digoxin 0.125 mg qod
Trusopt 1 gtt both eyes [**Hospital1 **]
Lexapro 20 mg daily
Lasix 80 mg PO daily
Imdur 90 mg daily
Xalatam 1 gtt each eye qhs
Ativan 1.5 mg qhs
Miralax powder daily
Zocor 20 mg daily
Nitroglycerin 0.3 mg Tablet SL PRN
Lorazepam 0.5 mg q4hrs PRN anxiety
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO twice a day.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO twice a day.
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for agitation.
11. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
Ventricular Tachycardia
Acute on Chronic Systolic Congestive Heart Failure
Coronary Artery Disease
Urinary Retention
Hyperglycemia
Delerium
Secondary:
Anxiety
Discharge Condition:
Improved. The patient is currently V-paced. His vital signs
are stable.
Discharge Instructions:
You were admitted to the hospital because you were found to be
in an abnormal heart rate and your ICD fired multiple times.
While you were here, we discovered that you were not taking
Amiodarone, a medication which is very important for your heart
rhythm, as previously thought. We thus restarted this
medication to correct your dysrhythmia. While you were here,
you were also found to be slightly fluid overloaded secondary to
your CHF. We gave you Lasix IV and diuresed you as you
tolerated.
.
While you were here, we made the following changes to your
medications:
1. We STARTED you on Amiodarone for your abnormal heart rhythm.
It is very important that you take this medication as directed
(400mg daily).
2. We STARTED Captopril 6.25 mg three times a day
3. We DECREASED your Atenolol dose to once daily instead of
twice daily.
4. We INCREASED your Lasix from 80mg daily to 120mg twice daily
5. We CHANGED your Imdur 90mg daily to 30mg daily
6. You were continued on your eyedrops,
Alphagan/Trusopt/Xalatan
7. You were continued on aspirin 81mg daily, Lexapro 20mg daily
8. Please resume your nitroglycerin 0.3mg SL PRN and Miralax.
Please take all medications as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider if you
experience shortness of breath, chest pain, increasing
confusion, increasing swelling in your leg, recurrent shocks
from your ICD, fevers, chills, or any other concerning symptoms.
weight increases by more than 3 ilbs between two days. Please
adhere to a low sodium (<2 gm/day) diet each day.
Followup Instructions:
You have an appointment in the DEVICE CLINIC for [**2147-9-11**]
at 1:30pm. You can reach their office at:[**Telephone/Fax (1) 62**]
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 93239**] [**Hospital Ward Name 23**] Clinical Center,
[**Location (un) 436**] Date/time: [**12-27**] at 2:20pm.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,295
| 182,164
|
41733
|
Discharge summary
|
report
|
Admission Date: [**2200-8-16**] Discharge Date: [**2200-8-23**]
Date of Birth: [**2160-11-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Respiratory distress
.
Reason for MICU transfer: Critical tracheal stenosis
Major Surgical or Invasive Procedure:
Tracheostomy
Rigid Bronchoscopy
History of Present Illness:
39 yo WF with a hx of CAD s/p 5 vessel CABG in [**7-10**] complicated
by cardiogenic shock requiring IABP, LV systolic dysfunction (EF
35%), HTN, HLD, DM who presented with to an OSH 3 days ago with
dyspnea and was intubated and transferred to the [**Hospital1 18**] for
further evaluation.
.
Her respiratory problems date back to her hospitalization for
her CABG on [**2200-7-8**], after which she was intubated for 7 days for
cardiogenic shock, successfully extubated and discharged on
[**7-19**]. However, she re-presented to an OSH on [**7-21**] with chest
pain and dyspnea and was found to have MRSA PNA and was treated
with Vanc/Moxi. During that hospitalization, she was also noted
to have upper airway stridor and hoarseness [**1-1**] tracheal
stenosis found on CT-Chest that was treated with steroids and
transferred to [**Hospital1 18**] on [**7-31**]. During that hospitalization, the
patient had a rigid bronchoscopy which revealed mucoid
concretions that were obstructing the tracheal lumen and given a
presumptive diagnosis of tracheitis. Tissue culture grew out
corynebactrium however BALs were negative. She was covered
empirically with vancomycin, clindamycin, and aztreonam, as well
as micafungin for possible fungal infection and Bactrim for PCP
prophylaxis given her course of steroids. Post-bronch, her
breathing was unlabored with no evidence of inspiratory stridor
or hypoxia. CT-chest also demonstrated LAD thought to be
secondary to her infection. She was subsequently discharged home
on [**2200-8-8**].
.
Most recently, she presented to an OSH three days ago with
worsening dyspnea was intubated and transferred to [**Hospital1 18**]. Here,
she had another rigid bronchoscopy that revealed tracheal
stenosis with friable/necrotic tracheal mucosa obstructing ~80%
of her tracheal lumen that was subsequently removed. She
ultimately underwent tracheostomy and was admitted to the MICU.
CT-Chest revealed a small amount of mediastinal air thought to
be iatrogenic, LAD which was increased in size from prior, and
diffuse ground glass opacities consistent with aspiration. She
was started on vanc+cipro on [**8-16**] for recurrent tracheitis and
clinda was added on [**8-17**]. She had also been diuresed ~1.5L while
in the MICU. Prior to transfer, ID recommended discontinuation
of Vanc and Cipro and continuation of IV clindamycin for 10
days.
.
Prior to transfer, the patient states that she is still short of
breath, unable to take deep breaths, but feels better than when
she came in. She also describes a periodic cough productive of
small amounts of green-yellow sputum. She continues to have
pain over both her tracheostomy site and her sternotomy site.
She denies any fevers, chills, abdominal pain, or change in her
bowel habits.
Past Medical History:
Anterior NSTEMI s/p 5 vessel CABG [**2200-7-8**] (one note of this
actually being a STEMI in the DC paperwork)
CHF (EF 35-40% on TTE [**2200-8-4**])
Type 2 Diabetes Mellitus
Crohns disease
Hypertension
Hyperlipidemia
Asthma
Depression
Fibromyalgia
S/p ventral hernia repair
S/p appendectomy
S/p cholecystectomy
S/p C-section with tubal ligation
Social History:
Lives with husband in [**Name (NI) **].
- Tobacco: Smokes 2ppd x >14 years.
- Alcohol: Social drinker.
- Illicits: No drug use.
Family History:
No family history of coronary artery disease
Physical Exam:
Admission Physical Exam:
General: Intubated and sedate, not arousable to verbal stimuli.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
Vitals: 98.1, 92/66, 89, 20 99 Trach Mask FSBS 135-264
General: sitting up in bed in NAD
Neck: Trach tube in place
Heart: RRR, nml S1/S2. No m/r/g
Lungs. Respirations unlabored. CTAB with transmitted upper
airway sounds
Abdomen: Soft, NT/ND. +BS
Extremities: WWP, mild LE edema
Pertinent Results:
On admission:
[**2200-8-16**] 10:33PM BLOOD WBC-13.0* RBC-3.35* Hgb-10.0* Hct-30.0*
MCV-90 MCH-29.8 MCHC-33.3 RDW-16.5* Plt Ct-299
[**2200-8-16**] 10:33PM BLOOD Neuts-87.0* Lymphs-9.5* Monos-3.1 Eos-0.3
Baso-0.1
[**2200-8-16**] 10:33PM BLOOD PT-12.6 PTT-19.7* INR(PT)-1.1
[**2200-8-16**] 10:33PM BLOOD Glucose-301* UreaN-9 Creat-0.4 Na-139
K-4.1 Cl-103 HCO3-28 AnGap-12
[**2200-8-16**] 10:33PM BLOOD ALT-22 AST-14 LD(LDH)-238 CK(CPK)-32
AlkPhos-88 TotBili-0.3
[**2200-8-16**] 10:33PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2382*
[**2200-8-16**] 10:33PM BLOOD Albumin-3.1* Calcium-9.0 Phos-1.9* Mg-1.6
[**2200-8-16**] 12:51PM BLOOD Type-ART Temp-37.5 Rates-15/ FiO2-100
pO2-220* pCO2-51* pH-7.34* calTCO2-29 Base XS-0 AADO2-461 REQ
O2-77 -ASSIST/CON Intubat-INTUBATED
[**2200-8-16**] 12:51PM BLOOD Lactate-1.9
Other Relevant Labs:
[**2200-8-18**] 03:26AM BLOOD ESR-62*
[**2200-8-18**] 03:26AM BLOOD CRP-48.1*
Imaging
1. New tracheostomy with air visualized in the soft tissue
spaces of the neck and tracking down to the mediastinum. No CT
evidence of tracheal perforation or mucosal tear (trachea above
the tube is opacified with secretions and this section is not
fully assessed) These findings are likely post-procedural.
However, correlation with physical exam and continued clinical
monitoring is recommended.
2. Extensive bilateral opacities with bilateral ground-glass
opacities with sparing of the periphery and more focal
parenchymal opacities at bilateral bases. These findings are
concerning for edema overlying aspiration pneumonia. Edema may
be cardiogenic or noncardiogenic and an early ARDS picture
cannot be excluded.
3. Nodal mass at the level of the right bronchus intermedius
extending to the level of the takeoff of the superior segment of
the right lower lobe superior segment bronchus appears more
prominent.
Prior to discharge:
[**2200-8-20**] 07:00AM BLOOD WBC-7.2 RBC-3.68* Hgb-10.8* Hct-32.2*
MCV-88 MCH-29.4 MCHC-33.6 RDW-15.9* Plt Ct-351
[**2200-8-21**] 08:20AM BLOOD Glucose-152* UreaN-11 Creat-0.6 Na-139
K-5.0 Cl-98 HCO3-33* AnGap-13
[**2200-8-21**] 08:20AM BLOOD Calcium-9.5 Phos-4.9* Mg-1.8
Brief Hospital Course:
Primary Reason for Hospitalization: This is a 39 year old female
with h/o CAD s/p CABG [**2200-7-8**] complicated by cardiogenic shock
with IABP, EF 30%, possible Dressler's syndrome, pneumonia, and
recent admission for tracheal stenosis who was transferred to
[**Hospital1 18**] for management of respiratory failure in the setting of
tracheal stenosis.
.
Active Issues:
.
#. Respiratory Failure: Presented to an OSH with dyspnea and was
intubated and transferred to the [**Hospital1 18**] for further evaluation.
In the ED, her ETT appeared to be obstructed, Anesthesia was
emergently consulted, and ultimately she went to the OR with IP
?????? rigid bronch was performed which revealed tracheal stenosis
with friable tracheal mucosa for which she underwent cryotherapy
and forceps removal of the necrotic-appearing respiratory
mucosa; she ultimately underwent a tracheostomy with a long tube
[**Last Name (un) 295**] (terminating ~2cm above the carina). She was admitted to
the MICU for further evaluation. She was able to be weaned off
positive pressure ventilation down to 40% FIO2 with trach mask.
She was then able to be transitioned to the floor and continued
to improve with regards to her oxygen requirement. She was
weaned to a high flow trach mask and was cleared by PT to go
home. She was taught how to manage her trach by respiratory
therapy and demonstrated an understanding of how to manage her
secretions. Case management was able to coordinate the
appropriate home devices (suction, humidified air, oxygen tanks,
and hospital bed) and she was setup to follow-up with
interventional pulmonology as an outpatient.
.
#. Tracheitis/Tracheal Stenosis(s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] long trach): The
exact etiology is still unclear. [**Name2 (NI) **] likely this was a
bacterial superinfection over already weakened/necrotic mucosa
(patient had tracheal trauma from prior intubation). She was
initially treated with broad empiric coverage but this was
narrowed to Clindamycin after cultures on this admission grew
mixed oral flora. Alternatively it could be related to Crohn??????s
or another inflammatory process however this is less likely
given she recently received high dose steroids. Her tracheal
tissue was noted to have grown fungal elements that were not
treated and thought to be a contamination. Final tracheal biopsy
results were still pending. Pt continues to have mild pain in
the throat and on the skin about the incision site which was
well controlled with MS Contin and MSIR. She will need to follow
up with Interventional Pulmonology clinic after discharge. Per
ID recommendations she will continue clindamycin for a total of
10 day course. She was unable to tolerate Passey Muir valve
prior to discharge given her current degree of stenosis. It is
hoped, however, with Speech evaluation at home and an
appointment at [**Hospital1 18**] on [**9-2**] for follow up that with a few
weeks of healing that the patient will be able to communicate
via speech through a Passey Muir valve.
** Please note: Shortly after discharge, was called by a Rite
Aide pharmacy in [**State 350**] who endorsed concern re: this
patient obtaining narcotics. They have "red flagged" her file
and those of her husband and sister in the past for possible
narcotic dependence/abuse as they have frequently purchased
large quantities of various narcotics, paying out of pocket,
from multiple hospitals and clinics. The sister was requesting
this Rite Aide fill only the narcotic medications, none of the
antibiotics, nebulizers, other medications. We requested that
the patient's antibiotics also be filled - her narcotic
prescriptions we provided are of limited quantity (~35 tablets
each).
.
#. Pulmonary Edema: CT scan on admission showed diffuse ground
glass opacities that were thought to be most likely pulmonary
edema. The etiology was suspected to be CHF vs negative pressure
pulmonary edema from inspiration against narrowed trachea. She
diuresed well with IV lasix. On the floor, she demonstrated a
mild increase of her lower extremity edema and was effectively
diuresed with PO lasix and did not have any worsening in her
respiratory status.
.
Chronic Issues:
.
# CAD s/p CABG: no acute evidence suggestive of ACS. She was
continued on her home dose of aspirin, Plavix, metoprolol and
statin. Given her cardiac risk, a low-dose ACE inhibitor was
added on to her home regimen.
.
# T2DM: Her home regimen was initially held because she was NPO.
She was then transitioned back to her home dose of Lantus 30u
daily with sliding scale to cover. Given a sliding scale insulin
requirement, her daily Lantus was increased to 35 units with
minimal subsequent sliding scale requirement.
.
# Crohn's: stable for now. She will continue her home dose of
mesalamine
.
# Depression: She will continue her home paroxetine and seroquel
.
TRANSITIONAL ISSUES for PCP:
.
#. Tracheostomy Care: The patient underwent tracheostomy
teaching. The cuff should NOT be inflated as this may cause
further tracheal trauma. She could not tolerate a Passey Muir
valve because of the degree of tracheal narrowing. She may be
able to be transitioned to a smaller trach in the future. She
will follow up with Interventional Pulmonology clinic for
further management.
#. Lymph Nodes on CT: She will need to follow up with
Interventional Pulmonology for possible biopsy after resolution
of her acute illness
#. Studies still pending at the time of discharge: Final
Tracheal Biopsy pathology
#. Please follow-up pain management as patient was given enough
pain medication to cover her until her PCP [**Name Initial (PRE) 648**]
#. Please follow-up her blood pressure as she was started on
lisinopril 2.5mg daily
#. Please follow-up her blood sugars as her insulin regimen was
changed will inpatient.
Medications on Admission:
1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 5 days.
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 6 days.
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-1**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. insulin detemir 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous at bedtime.
11. insulin aspart 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: Take with meals.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 10
days.
14. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 4 days.
Discharge Medications:
1. hospital bed Sig: One (1) bed ongoing: Diagnosis: Tracheal
stenosis/tracheitis s/p tracheostomy. Needs [**Hospital **]
hospital bed. Pt unable to lay flat and needs to change
positions quickly.
Disp:*1 bed* Refills:*2*
2. portable suction Sig: Two (2) suctions ongoing : Dx:
Tracheitis, tracheal stenosis s/p tracheostomy.
Disp:*2 suctions* Refills:*2*
3. Home oxygen Sig: One (1) unit ongoing: Dx: Tracheitis,
tracheal stenosis s/p tracheostomy. Pt needs O2 50% with trach
mask, humidified air.
Disp:*1 unit* Refills:*2*
4. catheter 14 Fr Misc Sig: Five (5) catheters Miscellaneous
ongoing: 14 French suction catheters Dx: Tracheitis, tracheal
stenosis s/p tracheostomy.
Disp:*5 catheters* Refills:*2*
5. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. quetiapine 25 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
solution Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
Disp:*25 nebulizer solution* Refills:*0*
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer solution Inhalation Q6H
(every 6 hours) as needed for shortness of breath or wheezing.
Disp:*25 nebulizer solution* Refills:*0*
11. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*1*
16. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*35 Tablet Extended Release(s)* Refills:*1*
17. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical QID (4
times a day) as needed for Pain.
Disp:*1 tube* Refills:*2*
18. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
19. insulin lispro 100 unit/mL Cartridge Sig: Sliding Scale
units Subcutaneous with meals: per insulin sliding scale that is
printed.
Disp:*1 bottle* Refills:*2*
20. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 7 days.
Disp:*1 tube* Refills:*0*
22. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
23. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO three
times a day for 4 days.
Disp:*26 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
City of [**Hospital **] Home Health
Discharge Diagnosis:
Primary:
Tracheal Stenosis
CHF
Pneumonia
Secondary:
CAD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. [**Known lastname **],
Thank you for allowing us to participate in your care. You were
admitted to the hospital because you were having significant
trouble breathing. In the emergency room, you were intubated,
and subsequently had a procedure known as a bronchoscopy, where
the pulmonary physicians were able to look down your airway and
see what was causing your shortness of breath. They found that
your airway was narrowed due to ongoing inflammation. Given your
difficulty breathing, you had a tracheostomy tube placed and
were transferred to the medical intensive care unit. There, you
were treated with antibiotics and pain medications, which
continued when you were transferred to the general medical
floor. Your breathing subsequently improved and your pain was
managed and you will be discharged home with appropriate
respiratory services.
Please note the following changes in your medications:
-START CLINDAMYCIN 600mg by mouth three times a day for the next
four days
-START METOPROLOL 12.5mg by mouth twice a day
-START LISINOPRIL 2.5mg by mouth daily
-START INSULIN GLARGINE 35 units at bedtime
-START INSULIN LISPRO per the sliding scale we print out
following your blood sugars with meals
-START MORPHINE (EXTENDED RELEASE) 60mg by mouth twice a day
-START MORPHINE (INTERMEDIATE RELEASE) 15mg by mouth every [**3-5**]
hours as needed for pain
-START LIDOCAINE OINTMENT around your trach site as needed every
4 hours
-START PANTOPRAZOLE 40mg by mouth twice daily
-START MUCINEX 600mg by mouth twice daily
-START MICANAZOLE cream and apply to vaginal area
-START IPRATROPIUM-BROMIDE NEBULIZER every 4-6 hours as needed
for shortness of breath
-START ALBUTEROL NEBULIZER every 4-6 hours as needed for
shortness of breath
-Continue your home atorvastatin, aspirin, plavix, mesalamine,
paroxetine, quetiapine
Please bring this paper work with you to your doctors
[**Name5 (PTitle) 4314**] [**Name5 (PTitle) **] that they are aware of your recent
hospitalization.
Followup Instructions:
Name: [**Last Name (un) **],[**Last Name (un) **] L.
Location: COOS COUNTY FAMILY HEALTH SERVICES
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 90671**]
Phone: [**Telephone/Fax (1) 90673**]
Appointment: Wednesday [**2200-8-28**] 10:15am
Department: RADIOLOGY
When: TUESDAY [**2200-9-2**] at 9:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2200-9-2**] at 11:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: VOICE SPEECH & SWALLOWING
When: TUESDAY [**2200-9-2**] at 1 PM
With: [**Doctor First Name **] BAARS [**Telephone/Fax (1) 3731**]
Building: Span Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] [**Apartment Address(1) 37858**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,999
| 139,839
|
1527
|
Discharge summary
|
report
|
Admission Date: [**2175-9-22**] Discharge Date: [**2175-9-24**]
Date of Birth: [**2111-12-22**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
referred for hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 63 year old male with PMH significant for CAD s/p 4
vessel CABG in [**2158**], s/p PCI with DES to occluded graft
(SVG->PDA) in [**2174-4-18**], s/p recent admission for NSTEMI [**7-28**]
that was medically managed, hypertension, moderate to severe
COPD, OSA on CPAP, right upper lobe CT findings suggestive of
bronchoalveolar carcinoma, and now presenting with hypotension
with systolics in the 70s in the setting of starting
spironolactone and isosorbide last week. He was scheduled to get
CT guided biopsy, but prior to the procedure, he was found to
have SBPs in the 70s. He did not have his procedure and was sent
to the ED.
.
In the ED, vitals were T=97.4, HR=67, BP=97/58, RR=18, POx=95%
2L NC. He was given 3 Liters of IVFs with persistent BPs in 80s.
On arrival to the MICU, his BPs were in the 100s.
Past Medical History:
-CAD s/p CABG in [**2158**] to 4 distal vessels with l arterial and 3
venous conduits: Left internal mammary artery to left anterior
descending coronary artery, saphenous vein graft to the first
and second obtuse margins, saphenous vein graft to the distal
right coronary artery.
-s/p PCTA in [**2174-4-18**] with DES to occluded graft (SVG->PDA)
-NSTEMI [**7-28**] medically managed
-persistent RUL infiltrate concerning for bronchoalveolar
carcinoma pending biopsy
-COPD
-Obstructive sleep apnea
-Hypertension
-Hyperlipidemia
-Hip replacement [**10-26**]
-? PAF not on coumadin
-Right ear deafness
Social History:
Married, wife is nurse, three children. Smoked 2ppd x 20 yrs,
quit 20 yrs ago. Drinks 2 glasses of wine or beer/night. Owner
and works for country store business.
Family History:
Family History:
Mother- died in her late 90s
Father- died at age 84 of prostate CA
[**Name (NI) 8962**] brother died of MI age 65, had first MI at age 47
Physical Exam:
ADMISSION
VS: Temp: 97.8, BP: 118/69 HR: 67 RR: 21 O2sat: 98% 2LNC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
RESP: CTA b/l with good air movement throughout
CV: distant heart sounds, RRR
ABD: +b/s, soft, nt/nd
EXT: no c/c/e
SKIN: no rashes/no 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
DISCHARGE:
VS: 97.8 130/78 66 18 97%RA
GEN: middle-aged male, pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, OP clear
RESP: CTA b/l, no wheezes, rales, ronchi
CV: RRR, distant heart sounds, no mrg
ABD: Soft, nt/nd naBS, no rebound/guarding
EXT: 2+ radial/DP pulses, no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3, CNII-XII intact, 5/5 strength throughout
Pertinent Results:
Blood Counts:
[**2175-9-22**] 08:00AM BLOOD WBC-8.8 RBC-5.17 Hgb-15.1 Hct-44.8 MCV-87
MCH-29.2 MCHC-33.7 RDW-14.1 Plt Ct-216
[**2175-9-22**] 09:35AM BLOOD Neuts-79.3* Lymphs-13.1* Monos-5.4
Eos-1.7 Baso-0.5
[**2175-9-24**] 07:00AM BLOOD WBC-7.5 RBC-4.85 Hgb-14.2 Hct-43.1 MCV-89
MCH-29.3 MCHC-33.0 RDW-14.0 Plt Ct-193
Chemistry:
[**2175-9-22**] 09:35AM BLOOD Glucose-115* UreaN-33* Creat-1.3* Na-141
K-4.8 Cl-104 HCO3-28 AnGap-14
[**2175-9-24**] 07:00AM BLOOD Glucose-96 UreaN-16 Creat-1.0 Na-139
K-4.0 Cl-101 HCO3-32 AnGap-10
Cardiac:
[**2175-9-22**] 09:35AM BLOOD cTropnT-0.02*
[**2175-9-22**] 09:35AM BLOOD Digoxin-1.8
[**2175-9-22**]
EKG: Sinus rhythm. Inferior myocardial infarction, age
undetermined. Lateral ST-T wave abnormalities. Since the
previous tracing of [**2175-8-9**] ST-T wave abnormalities may be less
prominent.
[**2175-9-22**]
CXR: No acute intra-thoracic process. Minimal residual right
upper lobe
opacity.
Brief Hospital Course:
This is a 63 year old male with PMH significant for CAD s/p 4
vessel CABG in [**2158**], s/p PCI with DES to occluded graft
(SVG->PDA) in [**2174-4-18**], s/p recent admission for NSTEMI [**7-28**]
that was medically managed, and now presenting with hypotension
to SBPs of 70 in the setting of starting spironolactone and
isosorbide last week.
.
#. Hypotension. The patient was found to be hypotensive with a
systolic in the 70s in pulmonary clinic in the setting of
recently being started on sprironolactone and isosorbide. He
Since being started on these meds he has noted that he has had
symptoms of lightheadedness and dizziness at home especially
when he stood up laying down or sitting. On admission to the
ICU, the team considered several etiologies for the patient's
hypotension, including infectious, cardiogenic,
medication-effect. There were no changes on EKG, and the
patient's CE were negative x1. There were no focal signs on
physical exam or laboratory values to suggest infection.
Digoxin level was wnl. Antihypertensives were initially held
with improvement in symptoms. Overnight the patient remained
stable with SBPs rising to the 140s. The patient was transfered
to the floors, where he remained stable with SBPs in the
130s-140s. The patient was started on half-doses of his
lisinopril (20mg daily) and carvedilol (12.5mg [**Hospital1 **]). He
remained stable overnight with SBPs in the 120s-130s. The
patient was restarted on a reduced dosing of his lasix (40mg
daily) that morning. With stable SBPs in the 120s-130s, the
patient was discharged with a presciption of a blood pressure
cuff and instructions to take his blood pressure every morning
and to call his PCP if his pressures were <100 or >170. The
patient reported he had follow-up scheduled with his PCP [**Name Initial (PRE) **]
[**9-26**]. His PCP's office was verbally alerted regarding
circumstances of this admission to ensure proper follow-up
occurred.
.
#. [**Last Name (un) **]. The patient was admitted with a Cr of 1.5. It was
thought that this was likely prerenal in the setting of diuresis
with furosemide and newly started spironolactone. His
creatinine resolved to baseline 1.0 with IV and PO rehydration.
.
#. Persistent lung infiltrate. Patient is awaiting biopsy to
rule out bronchoalveolar carcinoma. He was instructed to
discuss rescheduling a biospy with his primary care doctor.
.
#. CAD. Patient is s/p CABG in [**2158**] with recent PCI for [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 5175**] to occluded graft in [**4-26**] as well as NSTEMI managed
medically in [**7-28**]. Dixogin, Lipitor, and ASA continued. As
discussed above, beta blocker and ACEI were initially held, then
restarted at decreased dosages. His spironolactone and
isosorbide were held at discharge pending further discussion
with his PCP and cardiologist.
#COPD: The patient was continued on his home regimen of
fluticasone-salmeterol, tiotropium, and albuterol as needed.
.
#HLD: The patient was continued on home Atorvastatin.
.
#OSA: The patient was continued on his home CPAP regimen w/o
issue.
.
The patient remained full code for the duration of this
admission
Medications on Admission:
-Albuterol Inhaler Sig: Two puffs Inhalation Q6H (every 6 hours)
as needed for dyspnea.
-Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
1 puff inhaled Disk with Device Inhalation [**Hospital1 **] (2 times a day).
-Furosemide 40 mg every other day
-Furosemide 80 mg every other day
-Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
-Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
-Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
-Aldactone 25mg daily
-Isosorbide 30mg daily
Discharge Medications:
1. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) dose Inhalation [**Hospital1 **] (2 times a day).
5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
9. Blood Pressure Cuff Misc Sig: One (1) cuff Miscellaneous
take pressure daily.
Disp:*1 cuff* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Hypotension
SECONDARY
Coronary Artery Disease
Right Lung Upper Lobe Infiltrate of [**Last Name (un) 5487**] significance
COPD
Obstructive Sleep Apnea
Hyptertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 8963**],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted with low blood pressures.
This was likely due to too many blood pressure medications. We
decreased your blood pressure regimen and your blood pressure
stabilized. You are now ready for discharge.
During this hospitalization your medications were changed as
follows:
-STOPPED IC isosorbide
-STOPPED aldactone
-DECREASED lisinopril
-DECREASED carvedilol (coreg)
Please weigh yourself every morning. If you weight increases by
5lbs over 3 days, please call your primary care doctor.
Please check your blood pressure every morning. If your
systolic pressure (the top number) is less than 100, please call
your primary care doctor. If your systolic pressure (the top
number) is greater than 170, please call your primary care
doctor.
Please see below for your follow-up appointments.
Congratulations on the birth of your grandchild.
Please note, the patient was discharged without being seen by
myself, the attending, on the day of discharge. He was seen in
the ICU by the intensivists on the first 2 hospital days. I did
review discharge instructions with the housestaff and concur
with the plan.
Followup Instructions:
PRIMARY CARE:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 8964**] within 1 week of discharge. It will be important to
discuss your blood pressure regimen and how it can best be
co-managed between your cardiologist and primary care doctor.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
|
[
"793.1",
"412",
"276.51",
"458.29",
"272.4",
"401.9",
"V45.81",
"414.00",
"496",
"E947.8",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8799, 8805
|
3977, 7150
|
299, 305
|
9037, 9037
|
3019, 3954
|
10424, 10890
|
1990, 2129
|
7945, 8776
|
8826, 9016
|
7176, 7922
|
9188, 10401
|
2144, 3000
|
235, 261
|
333, 1155
|
9052, 9164
|
1177, 1778
|
1794, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,494
| 170,109
|
787
|
Discharge summary
|
report
|
Admission Date: [**2155-8-3**] Discharge Date: [**2155-8-17**]
Date of Birth: [**2090-9-8**] Sex: M
Service: CSURG
Allergies:
Atenolol / Vasotec / Shellfish
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
redo AVR/MVR
History of Present Illness:
This is a 64yo M who presented with c/o progressive SOB for 6
weeks. He has documented significant dysfunction of AV over the
past year, with planned AVR and possible MVR (not scheduled
yet). Presents with 6 weeks of progressive dyspnea with acute
worsening over past 24 hrs. New orthopnea. No CP. Mild failure
on CXR
Past Medical History:
1.Hypercholesterolemia
2.3V CABG [**2144**]
3.Endocarditis s/p Bioprosthetic in 96AVR,
4.HTN,
5.DM-2,
6.Gout,
7.Carotid Stenosis- 40-50% stenosis of R carotid artery in 97,
8.Renal Artery Occlusion
9.Toxic Thyroid Nodule s/p RAI
10.trigger finger release
[**2144**]: IPMI , [**2144**] CABG with LIMA to LAD, [**Year (4 digits) 5659**] to OM1 and OM2
[**11/2147**]: endocarditis
[**2148-2-9**] cardiac catheterization [**Hospital1 18**] for exertional arm
discomfort (similar to pre-bypass angina). Widely patent bypass
grafts/native 3vd. Moderate-severe MR [**First Name (Titles) **] [**Last Name (Titles) **], moderate to severe
diastolic dysfunction.
[**2148-2-14**] right retinal artery occlusion, possibly due to aortic
valve associated embolic event.
[**2148-3-4**]: AVR [**Hospital6 **]
[**2155-6-17**]: Ruled out for PE. Troponin 0.14. CK's
flat. Diagnosed with CHF, captopril initiated. Diuresed.
[**2154-6-17**] echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated, RA mildly dilated, mild
symmetric LVH. Aortic root, ascending aorta and arch mildly
dilated. 1+ AI. [**12-6**]+ MR, significant pulmonic regurgitation.
LV inflow pattern suggestive of a restrictive filling
abnormality, elevated left atrial pressure.
[**2155-7-3**] echo: ef 60%, la with mild dilation, aortic root with
mod dilation, EF 55%, 3+ AR, 2+ MR.
[**7-3**] cath: [**1-7**]+ AR on aortogram. 2+ MR. [**Name14 (STitle) 5659**] open to OM1 but not
OM2. LIMA open. Aortic pulse pressure 40, LVEDP 36, PCW mean
29, Aortic diastolis 40, significant V wave, Fick CO 4.8, CI 2.4
Social History:
Marries, ex Librarian, rare ETOH, no tobacco- quit 40 years ago.
Family History:
Father was [**Name2 (NI) 1818**] and died with Lung Cancer
Maternal Grandfather with [**Name2 (NI) 499**] cancer
Physical Exam:
BP 99/37 P 71 R20
Gen- looks tired
HEENT-unremarkable
CVS-nl S1/S2, no S3/S4, 2/6 systolic flow murmur with no
radiation, [**3-11**] diastolic murmur ar USB, no pedal edema, DP
1+bilaterally, JVP 10cm
resp- crackles bibasilar, no wheezes
GI-nl BS, nontender
neuro- A+O X 3, move all 4 limbs
Pertinent Results:
[**2155-8-3**] 03:30PM GLUCOSE-124* UREA N-28* CREAT-1.3* SODIUM-139
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-26 ANION GAP-11
[**2155-8-3**] 03:30PM CK(CPK)-34*
[**2155-8-3**] 03:30PM cTropnT-<0.01
[**2155-8-3**] 03:30PM CK-MB-NotDone
[**2155-8-3**] 03:30PM WBC-6.1 RBC-4.29* HGB-13.4* HCT-39.7* MCV-93
MCH-31.3 MCHC-33.8 RDW-15.1
[**2155-8-3**] 03:30PM NEUTS-75.8* LYMPHS-17.1* MONOS-3.6 EOS-3.1
BASOS-0.4
[**2155-8-3**] 03:30PM PLT COUNT-173
[**2155-8-3**] 03:30PM PT-12.8 PTT-26.4 INR(PT)-1.0
Brief Hospital Course:
-Echo [**7-4**]:
Overall left ventricular systolic function is normal (LVEF>55%).
The aortic root is moderately dilated.The aortic valve leaflets
are mildly thickened. The aortic valve appears to be a
homograft. Moderate to severe (3+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
-cath [**2155-7-4**]
LMCA had no significant angiographically significant disease.
LAD was 100% occluded at the mid level, filled by LIMA. Lcx 100%
occluded in OM1, OM2 had diffuse 80% proximal disease. L-PDA had
diffuse 70% lesion. RCA was non-dominant, and was 100% occluded
at the mid level.Coronary angiography of the bypass grafts
showed widely patent LIMA to LAD. [**Month/Day/Year 5659**] to OM1 and OM2 was widely
patent to OM1 (small vessel), jump
segment to OM2 was occluded. Left vetriculography demonstrated
mild anterolateral and inferior hypokinesis with contrast
estimated EF of 60%. There was 2+ mitral
regurgitation. Resting hemodynamics demonstrated normal left
sided filling pressure
of mRA 9mmHg. There was wide aortic pulse pressure (40 mmHg)
with
marked elevation of LVEDP (36 mmHg) to near aortic diastolic
level (40
mmHg), consistent with severe aortic insufficiency. PCW pressure
was
elevated with a mean of 29 mmHg. Significant v wave was present
(40
mmHg), indicative of significant MR. There was no gradient
across the
aortic valve. Fick calculated cardiac ouput and cardiac index
were 4.8
l/min and 2.4 l/min/m2, respectively. On [**8-4**] Cardiac Surgery
was consulted and on [**2155-8-8**] patient underwent redo AVR/MVR with
21mm St. [**Male First Name (un) 923**] Mechanical Aortic valve and 27mm St. [**Male First Name (un) 923**]
mechanical mitral valve. Patient was transfered to CSRU in
stable condition. Patient was extubated on POD1 and was
transfused 1 U of PRBC's for a crit of 28. On POD 2 pt had
bouts of AFib where he was treated with lopressor and Amio bolus
then amio po. Pt had milrinone weaned off on POD 2 and was
tranfered to the floor on POD 3. Pt did well on the floor,
however, it took several days to make his INR therapeutic. INR
became therapeutic on [**8-17**] and pt was discharged. Pt was
cleared by PT and his PCP was notified for INR checks.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p redo MVR/AVR
Discharge Condition:
good
Completed by:[**2155-8-17**]
|
[
"424.1",
"429.4",
"593.9",
"428.0",
"427.31",
"424.0",
"401.9",
"V58.61",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"35.22",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5621, 5679
|
3329, 5598
|
290, 304
|
5739, 5774
|
2797, 3306
|
2356, 2470
|
5700, 5718
|
2485, 2778
|
247, 252
|
332, 653
|
675, 2257
|
2273, 2340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,769
| 126,444
|
54572
|
Discharge summary
|
report
|
Admission Date: [**2198-6-9**] Discharge Date: [**2198-6-11**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 81-year-old male with a
history of rectal cancer status post sigmoid colectomy in
[**2192**], presents with melena and left foot cellulitis. The
patient states that he has been short of breath x 2 weeks
with worsening symptoms in this past week. In his usual
state of health, he would walk his dogs 2-3 times a day. In
the past week he stopped walking his dogs, found that he
cannot walk to his door nor walk up the stairs without
feeling tired. He also notes that his stools were darker
than usual (2 stools per day, intermittent black) for the
past 7-10 days, but did not think much of it. At this time,
he also developed redness and tenderness in his left middle
toe. He went to [**Hospital 1263**] Hospital for evaluation of his left
foot cellulitis, when the doctor noticed that he was short of
breath (CBC showed a hematocrit of 22). Positive for nausea
(dry heaves), lightheadedness with positional change,
ethanol, and generalized malaise. Negative for fever,
chills, vomiting, hematemesis, epistaxis, syncope, BRBPR,
history of XRT in the esophagus region, history of PUD,
history of GERD. The patient decided that he wanted to be
admitted to the [**Hospital3 55759**] Center at this point.
EMERGENCY DEPARTMENT COURSE: Temperature 99.5 degrees, pulse
113, blood pressure 143/61, respiratory rate 16, 97 percent
on room air, and hematocrit 23. RECTAL EXAM: Guaiac
positive. NG lavage: Coffee ground with 500 cc lavage.
EGD: Several nonbleeding erosions in body of stomach but
duodenum/esophagus within normal limits. Received 4 units of
packed red blood cells. Started on clindamycin 600 mg x1 for
cellulitis. The patient was then transferred to the SICU.
SICU COURSE: T-max ?, pulse 80, blood pressure 127/45,
respiratory rate of 16, 99 percent on room air, hematocrit of
26.6 to 29.0 to 31.8. Was started on Augmentin for
cellulitis.
PAST MEDICAL HISTORY:
Type 2 diabetes.
Hypertension.
Gout.
Rectal carcinoma status post sigmoid colectomy on [**2-/2192**].
Chronic renal insufficiency.
Status post appendectomy.
Skin cancer.
Asthma.
SOCIAL HISTORY: The patient lives at home alone, drinks [**1-19**]
glasses of wine per day, stopped smoking 44 years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lisinopril.
2. Lasix 20 q.d.
3. Flovent.
4. Wellbutrin.
5. Allopurinol.
6. Aspirin.
7. Glyburide 7.5 units q.a.m./5units q.p.m.
8. Metformin 500 mg q.d.
9. Singulair q.d.
10. Prazosin 1 tablet q.d.
PHYSICAL EXAMINATION: On initial exam, patient had a T-max
of 98.4 degrees, pulse of 64, blood pressure of 122/60,
respiratory rate of 22, 97 percent on room air. The patient
had diffuse wheezing with resolving left foot erythema. The
remainder of the exam was unremarkable.
LABORATORY DATA: Chem-10 was significant for a BUN of 32,
creatinine of 1.4, which had decreased from 1.8, calcium of
7.5, with an albumin of 3.2. Hematocrit was 31.8, initially
at 29. PT, PTT and INR all within normal limits.
IMPRESSION: An 81-year-old male with a history of rectal
carcinoma status post sigmoid colectomy admitted for upper
gastrointestinal bleed and left foot cellulitis.
Upper gastrointestinal bleed. Unclear source.
Esophagogastroduodenoscopy revealed only erosion. The
patient was monitored by serial hematocrits, 4 units of blood
was transfused in the ED. The patient was started on clears
and IV Protonix b.i.d. was given. Once hematocrit was stable
greater than 30, Protonix was switched to p.o. and patient
was restarted on his medications withholding aspirin.
Cellulitis. Left toe erythema was improving once the patient
was on the floor. The patient was continued on Augmentin for
a 7-day course. Cultures remained negative during this time
frame.
DISCHARGE MEDICATIONS: Same as admission with the addition
of,
1. Augmentin 500/125 mg 1 tab q.d. for the remaining 5 days.
2. Protonix 40 mg p.o. q.d.
3. Colace.
4. Aspirin was withheld.
DISPOSITION: To home.
DISCHARGE STATUS: The patient was ambulating, mentating,
eating and drinking normally.
DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary
to erosion within the stomach and duodenum.
DISCHARGE FOLLOWUP: The patient was asked to follow up with
his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within the week.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**]
Dictated By:[**Last Name (NamePattern1) 56096**]
MEDQUIST36
D: [**2198-6-13**] 08:36:15
T: [**2198-6-13**] 10:14:23
Job#: [**Job Number 111629**]
|
[
"535.41",
"532.40",
"788.20",
"V10.06",
"280.0",
"496",
"250.00",
"274.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
3874, 4154
|
4176, 4261
|
2602, 3850
|
4282, 4644
|
117, 1988
|
2010, 2196
|
2213, 2579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,112
| 157,539
|
51721
|
Discharge summary
|
report
|
Admission Date: [**2105-5-31**] Discharge Date: [**2105-6-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with BMS to mid LAD
History of Present Illness:
Ms. [**Name14 (STitle) **] is a [**Age over 90 **] yo M w/PMHx sx for HTN, hyperlipidemia and
IDDM who presented [**2105-5-31**] with a bilateral chest sensation
which she describes as "terrible burning", with radiation to the
back, starting at 10 am and lasting until she arrived in the ED
at 11:30 am. Patient had associated nausea and vomiting as well.
Her daughter called EMS, and prior to arrival in the ED, patient
received nitro SL x 3 and ASA 325.
<br>In the ED, patient's initial VS were: 96.1 HR 50 BP 135/75
RR 12 O2sat 100%, and she was found to have STE in V3-V5 on EKG,
and was taken emergently to cardiac catheterization, where she
was found to have a focal 90% mid LAD lesion with TIMI II flow,
and a BMS was placed. She received integrillin bolus,
atorvastatin 80 mg, Plavix 600 mg, and heparin gtt.
<br>Reviewing her recent history with her daughters (one of whom
lives with her, and the other of whom lives downstairs), Ms
[**Known lastname 60285**] has been dependent on them for most ADLs including
cooking, showering and most other household chores, as well as
administering her three-times-daily insulin. She can do basic
self-care including bathing. She has been significantly hampered
by her neuropathy which makes walking and using stairs
difficult. In terms of recent symptoms, they have only noticed
that she appears to have been progressively more fatigued over
the last 1-2 months with a more marked fatigue over the last 2
weeks. They also think she may have had some left sholder pain
over the last week or two.
<br>She had been prescribed nitroglycerin in the past but her
daughters report that she was using it whenever she felt poorly
and as a result was often getting light-headed, "practically
passing out" so she is not using this now.
<Br>On review of symptoms, she denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She has a possible--but ambiguous--history of
TIAs. She denies recent fevers, chills or rigors; or exertional
buttock or calf pain. All of the other review of systems were
negative.
<br>Cardiac review of systems is notable for prior chest pain.
She denies dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
<br><b>CCU course:</b> patient went to the CCU for observation
after the intervention as the floor did not have available beds.
While in the CCU she did have new onset afib for which she was
placed on hep gtt and then spontaneously converted. She also had
left sided systolic heart failure with and echo showing EF of
30% and a requiring 4L NC. She was diuresed with 10mg IV lasix
and responded well, putting out 1.7L and weaning to 2L NC. On
arrival to floor she denied any SOB or chest pain. She reported
feeling tired.
Past Medical History:
1) Type 2 diabetes
2) Peripheral neuropathy
3) Right mastectomy for breast cancer in [**2086**]
4) Osteoarthritis
5) GERD
6) Coronary artery disease
7) Hypertension
8) Hypothyroidism
Social History:
Widow, lives with daughter, no smoking, no alcohol.
Family History:
Mother died at age 88 with "heart disease"
Physical Exam:
VS: T 90.7, BP 124/76, HR 82, RR 16, O2 98% on 2L
Gen: well appearing female in NAD, HOH, pleasant, appears
younger than stated age. Asleep but arousable. Alert and
oriented.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR. I/VI SEM at RUSB. No murmurs or rubs.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles.
Abd: Obese, soft, distended. No HSM. No abdominal bruits.
Ext: No c/c/e. No femoral bruits. No ecchymoses or hematoma.
Skin: + stasis dermatitis bilaterally. No ulcers, scars, or
xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
INRs:
[**5-31**] 1.3
[**6-1**] 1.4 PM got 5mg coumadin
[**6-3**] 1.5 PM 5mg coumadin
[**6-4**] 2.2 day of discharge, should get 3mg.
[**2105-5-31**] 11:45AM BLOOD WBC-6.7 RBC-4.38 Hgb-15.6 Hct-44.0
MCV-101* MCH-35.7* MCHC-35.5* RDW-13.3 Plt Ct-161
[**2105-5-31**] 11:45AM BLOOD Glucose-338* UreaN-27* Creat-0.6 Na-135
K-4.3 Cl-100 HCO3-23 AnGap-16
[**2105-5-31**] 11:45AM BLOOD cTropnT-0.02*
[**2105-5-31**] 11:45AM BLOOD CK(CPK)-69
[**2105-5-31**] 11:45AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
CXR ([**2105-5-31**]):
Heart size is enlarged. The aorta is tortuous. The hilar
contours are normal. No pneumothorax is visualized. Diffuse
prominence of the interstitial marking which is more prominent
in the perihilar region and upper lobes are consistent with a
mild pulmonary edema. No focal consolidative process is noted.
Small left pleural thickening/effusion is unchanged. The
compression deformity of mid thoracic vertebra is relatively
unchanged compared to the prior study.
IMPRESSION
1. No pneumothorax or focal consolidative process is visualized.
Mild pulmonary vascular congestion is noted.
2. Unchanged small left pleural thickening/effusion.
3. Compression deformity of the mid thoracic vertebra.
ECHO [**2105-5-31**]
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy. There is moderate to severe regional left
ventricular systolic dysfunction with mid to distal anterior,
septal hypokinesis and apical akiensis (LVEF= 30 %). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The aortic valve is not well
seen. No aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. No mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2103-9-19**], LV
systolic dysfunction is new.
Cardiac Catherization [**2105-5-31**]
COMMENTS:
1. Selective coronary angiography of this right dominant vessel
revealed 2 vessel coronary artery disease. The LMCA had no
angiographically apparent flow limiting epicardial coronary
artery
disease. The LAD had a 90% mid-LAD lesion with TIMI 2 flow. The
LCx had
a 40% mid-vessel lesion of a major OM. The RCA had a 70%
stenosis in
the mid-PDA, with otherwise minimal disease.
2. Resting hemodynamics revealed mild systemic arterial
systolic
hypertension.
3. Successful PTCA/stenting to mid LAD with a 2.5x15mm Vision
stent and
posted with a 2.75mm NC balloon. Excellent result with normal
flow down
vessel and no residual stenosis.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Mild systemic arterial systolic hypertension.
3. Acute anterior myocardial infarction.
4. Successful PCI/stent to mid LAD with bare metal stent.
Brief Hospital Course:
Ms. [**Known lastname 60285**] is a [**Age over 90 **] yo F w/PMHx sx for HTN, IDDM,
hyperlipidemia who is admitted for a STEMI, now s/p BMS to LAD
.
CAD/STEMI: Patient with ST elevations in anterior distribution
seen on EKG, positive troponis. She was a code STEMI in the ED
and taken directly to the cardiac catherization lab. She was
found to have a mid-LAD lesion on catheterization and is now s/p
BMS stent placement. Her CKs peaked at 1366. While here, she was
started on metoprolol 25mg [**Hospital1 **], plavix 75mg [**Hospital1 **], aspirin 325 mg
while here and discharged on 81mg daily. She was also started on
Atorvastatin 80mg. Her Lisinopril was increased to 40mg daily,
one dose. Her isordil was discontinued. Her lipid panel showed
choles 153, tri 237, HDL 36, LDL 70. She should continue on
plavix until her cardiologist tells her its ok to stop. She was
chest pain free following the cardiac catherization.
.
Acute Systolic Heart Failure: Patient has post-event heart
failure and initially required 4L oxygen by nasal canula, She
was diuresed intially 20mg IV lasix and out out about 2L to that
and was subsequently weaned off O2. She still had crackles when
transferred to the floor and was given 10mg IV lasix and started
on 10mg PO lasix daily. Her ECHO showed EF 20% echo with apical
akinesis. Because of this apical akinesis, as well as the atrial
fibrillation, described below, she was continued on heparin
while here and started on coumadin. Her INR was 2.2 the day of
discharge. Her INR should be followed closely with a goal of
[**2-14**].5.
- she recieved 5mg of coumadin on [**6-2**] and [**6-3**]. She is being
discharged on 3mg daily. Please follow INR closely and INR goal
close to 2.
.
Atrial Fibrillation/3-5s Pauses: Patient with temporary atrial
fibrillation intially, in the CCU, put on heparin gtt. She
convered sponteneously back into sinus that day, but on the
night of transfer to floor ([**6-2**]), she went back into a fib and
until about 2pm [**6-2**], and has been in sinus until discharge. She
was intially treated with metoprolol IV 5mg, which controlled
her rate. She is discharged on 25mg metoprolol [**Hospital1 **] for rate
control. Patient was also having symptomatic transitional pauses
on [**6-2**] from 3-5 seconds, but had not had any since noon that
same day day. Given pauses, should hold back on AV nodal
blockade, but needs rate control for RVR.
The Electrophysiology team was consult who suggested monitoring
her and limiting metoprolol. She was also started on coumadin
for the apical akinesis and atrial fibrillation to prevent
stroke. Her Goal INR is 2-2.5.
.
HTN: She was hypertensive during the hospitization, improved
with increase in lisinopril dose
- Metoprolol 25mg [**Hospital1 **]
- Lisinopril was increased to 40mg AM
.
Hyperl.ipidemia. Continue statin. Check lipid panel.
DMII: Well-controlled at baseline. A1c average 6's. a1c 6.8.
Continue home insulin regulin.
.
Neuropathy: could all be from DM, but given good control and MCV
of 101 would consider other ddx. continue neurontin
Medications on Admission:
ATENOLOL 25MG--[**1-14**] every day
ATIVAN 1MG--One four times a day as needed for for anxiety
ELAVIL 10MG--One at bedtime
GLYBURIDE 2.5MG--Take one twice a day with meals
HUMULIN 70/30 70-30 U/ML--3 u at dinner
ISDN 10 MG--One three times a day
LISINOPRIL 20 mg--1 tablet(s) by mouth once a day
NEURONTIN 300MG--Take one in the morning and one in the evening
NITROGLYCERIN 0.4 MG--As needed for for angina
PLAVIX 75 mg--1 tablet(s) by mouth once a day
SOFTCLIX --As directed
SYNTHROID 50MCG--One every day
ZOSTRIX 0.025%--Apply four times a day to feet
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO Daily on
sunday throught Friday: Give 150mcg once daily on Saturday.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Humalog 100 unit/mL Solution Sig: Four (4) untis
Subcutaneous 15 minutes before dinner.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous every morning.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eleven
(11) units Subcutaneous every evening.
15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Please check INR on [**2105-6-6**].
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
19. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**]
Discharge Diagnosis:
Coronary artery disease: s/p STEMI
Paroxysmal Atrial fibrillation: currently in normal sinus
rhythm.
Acute systolic heart failure
Hyperlipidemia
Diabetes type 2
Discharge Condition:
Labs: BUN 19, creat .6, HCT 41, INR 2.2, plt 130, WBC 5.5
VS: 98.6, 80, 20, 136/85 96% RA.
Right groin tender, small hematoma palpable but no bruit or
signs of acute bleeding.
Discharge Instructions:
You were admitted to the hopital with chest pain and were found
to have a Hear Attack. You had a cardiac catheterization and
stent placed in your left coronary artery. Your chest pain
resolved
You had an ECHO that showed that the apex of your heart is not
functioning as it should. For this reason, you need to start
taking coumadin every day. Coumadin is a medication that
prevents thrombus formation, which in turn prevents stroke.
While you were here your heart was temporarily in an abnormal
rhythm and had pauses lasting up to 5 seconds. This is not
unusual after a heart attack, and usually resolves within
several days. Your heart has been in a normal rhythm since
[**2105-6-2**]. If you feel lightheaded, and your sugar is normal,
please call your doctor or return to the hospital.
You need to take Plavix daily for 1 month and possibly longer.
Do not stop taking Plavix unless your cardiologist tells you to.
You have an appt with Dr. [**Last Name (STitle) 120**] next week. You were started on
coumadin for to decrease your risk of stroke. Your coumadin
level will need to be followed closely.
Please call your doctor or return to the hospital if you have
lightheadedess, shortness of breath, chest pain, or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:
[**6-10**] at 10:30am
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2105-9-2**] 10:30
Completed by:[**2105-6-4**]
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79,178
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41088
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Discharge summary
|
report
|
Admission Date: [**2163-1-10**] Discharge Date: [**2163-1-29**]
Date of Birth: [**2085-7-4**] Sex: M
Service: MEDICINE
Allergies:
Septra / Shrimp
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
MRSA pneumonia, bacteremia
Major Surgical or Invasive Procedure:
Intubation x2
Tracheostomy placement
G-tube placement
History of Present Illness:
This is a 77yo M with PMH significant for a left pontine CVA
with residual right-sided hemiperesis, prior subarachnoid
hemorrhage, severe HTN, HL, CKD (baseline Cr 2.0) and asthma who
was originally admitted to OSH with 3 weeks of progressive SOB
and was found to have extensive left-sided MRSA pneumonia and
bacteremia. Of note, pt was recently in Phillipenes, returned to
the U.S. on [**1-1**]. Pt was initially treated with Zosyn, CTX,
Azithro and streoids. He subsequently deteriorated requiring
admission to the ICU, intubation and addition of Vanc for MRSA
coverage. Cultures eventually grew MRSA in sputum and blood and
CXR contineud to show progressive consolidation of the left lung
and his fevers persisted. Pt was changed to Linezolid due to
concern for toxin-producing community-acquired MRSA with
necrotizing pna and CT scan showed consolidaiton throughout left
lung and left sided pleural effusion as well as narrowing in the
left main stem bronchus. He underwent a bronchoscopy on [**1-8**]
which showed blood clot which completely occluded takeoff to LUL
and extended into left main stem and it could not be suctioned
off via flexible bronchoscopy. Pt was then transferred to [**Hospital1 18**]
for rigid bronchoscopy. ID team recommended switching back to
Vancomycin given the bacteremia. Current vent settings on
transfer were AC 40% TV 400 RR 12 PEEP 5. VS were 160s-180s
70-80s CVP 8-10 Tmax 103.6.
.
Of note, pt's course was complicated by AF with RVR on evening
of [**1-8**] requiring Diltiazem drip. He has reportedly now been rate
controlled and in NSR since 0600 on [**1-9**]. At baseline, PERRL,
does not follow commands, nonenglish speaking. UOP has been
45-100cc/hr. Hospital course also complicated by episode of
twitching on [**1-8**] with abnormal tongue movements. Head CT was
performed and was negative.
.
Upon arrival to the ICU, pt is sedated, unresponsive. Appears
comfortable.
Past Medical History:
Left pontine CVA with right hemiparesis
s/p TIAs
s/p SAH
HTN
HL
R CEA
Asthma
CKD (baseline Cr 2)
GERD
Gout
Anxiety with panic attacks
s/p bilateral cataract surgeries
Hemorrhoidectomy
Social History:
smoked in past, quit in [**2129**]. no alcohol, drugs. from the
Phillipines.
Family History:
children with asthma
Physical Exam:
Admission Exam:
VS: Temp: 100.7 BP: 153/72 HR: 139 RR: 15 O2sat 99% on AC
GEN: intubated, sedated
HEENT: anicteric, ETT in place
RESP: +rhonchi bilat
CV: RRR, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ bilat edema
SKIN: no rashes/no jaundice
NEURO: sedated, unresponsive, does not open eyes
Discharge Exam:
VS: afebrile, 124-170/60-84, 66-76, 20@100% on TM at 50% FiO2
GEN: ill-appearing male, NAD, trach mask in place, understanding
simple commands and able to nod head yes/no
HEENT: EOMI, PERRLA, no dentition, dry MMM
CV: II/VI systolic murmur at RUSB, nonradiating, RRR
Pulm: decreased BS on left, ronchi bilaterally
Abd: soft, tenderness around PEG site, mildly distended,
tympanic on percussion, +BS
Ext: RUE > LUE edema, strength assessed only by hand grip on L
and [**3-8**]
Neuro: CNII-XII grossly intact, R sided hemiparesis and
anesthesia
Pertinent Results:
[**2163-1-10**] 10:00AM BLOOD WBC-20.2* RBC-2.45* Hgb-7.7* Hct-22.8*
MCV-93 MCH-31.5 MCHC-33.7 RDW-15.8* Plt Ct-163
[**2163-1-11**] 03:59AM BLOOD WBC-18.9* RBC-2.49* Hgb-7.9* Hct-23.5*
MCV-94 MCH-31.6 MCHC-33.5 RDW-16.2* Plt Ct-157
[**2163-1-12**] 03:56AM BLOOD WBC-16.8* RBC-2.70* Hgb-8.4* Hct-25.0*
MCV-93 MCH-31.2 MCHC-33.7 RDW-16.4* Plt Ct-188
[**2163-1-13**] 03:52AM BLOOD WBC-12.5* RBC-2.39* Hgb-7.4* Hct-22.4*
MCV-94 MCH-30.9 MCHC-32.9 RDW-17.0* Plt Ct-218
[**2163-1-14**] 04:43AM BLOOD WBC-10.5 RBC-2.16* Hgb-6.8* Hct-20.4*
MCV-95 MCH-31.3 MCHC-33.2 RDW-17.0* Plt Ct-216
[**2163-1-14**] 03:38PM BLOOD WBC-10.7 RBC-2.87*# Hgb-9.0*# Hct-26.4*#
MCV-92 MCH-31.4 MCHC-34.1 RDW-16.8* Plt Ct-207
[**2163-1-15**] 05:56AM BLOOD WBC-10.5 RBC-2.73* Hgb-8.6* Hct-25.2*
MCV-92 MCH-31.6 MCHC-34.2 RDW-16.7* Plt Ct-214
[**2163-1-16**] 03:12AM BLOOD WBC-9.9 RBC-2.69* Hgb-8.3* Hct-24.8*
MCV-92 MCH-30.9 MCHC-33.5 RDW-16.6* Plt Ct-183
[**2163-1-10**] 10:00AM BLOOD Neuts-90.8* Lymphs-6.7* Monos-0.9*
Eos-1.2 Baso-0.3
[**2163-1-13**] 03:52AM BLOOD Neuts-90.8* Lymphs-6.5* Monos-1.3*
Eos-1.3 Baso-0.1
[**2163-1-18**] 03:46AM BLOOD Neuts-84.6* Lymphs-7.6* Monos-2.1
Eos-5.6* Baso-0.1
[**2163-1-10**] 10:00AM BLOOD PT-13.0 PTT-26.4 INR(PT)-1.1
[**2163-1-13**] 03:52AM BLOOD PT-13.6* PTT-32.1 INR(PT)-1.2*
[**2163-1-14**] 04:43AM BLOOD PT-13.0 PTT-29.1 INR(PT)-1.1
[**2163-1-15**] 05:56AM BLOOD PT-12.2 PTT-30.1 INR(PT)-1.0
[**2163-1-16**] 03:12AM BLOOD PT-12.9 PTT-31.6 INR(PT)-1.1
[**2163-1-17**] 03:03AM BLOOD PT-12.7 PTT-31.3 INR(PT)-1.1
[**2163-1-18**] 03:46AM BLOOD PT-13.3 PTT-35.3* INR(PT)-1.1
[**2163-1-10**] 10:00AM BLOOD Glucose-70 UreaN-73* Creat-1.8* Na-149*
K-3.9 Cl-118* HCO3-24 AnGap-11
[**2163-1-11**] 03:59AM BLOOD Glucose-106* UreaN-72* Creat-1.9* Na-150*
K-4.2 Cl-120* HCO3-21* AnGap-13
[**2163-1-11**] 08:31PM BLOOD Glucose-155* UreaN-63* Creat-1.9* Na-150*
K-3.5 Cl-121* HCO3-21* AnGap-12
[**2163-1-12**] 03:56AM BLOOD Glucose-192* UreaN-58* Creat-1.8* Na-148*
K-3.6 Cl-117* HCO3-21* AnGap-14
[**2163-1-12**] 05:21PM BLOOD Glucose-155* UreaN-52* Creat-1.7* Na-148*
K-3.5 Cl-118* HCO3-22 AnGap-12
[**2163-1-13**] 03:52AM BLOOD Glucose-112* UreaN-50* Creat-1.8* Na-148*
K-3.6 Cl-119* HCO3-22 AnGap-11
[**2163-1-13**] 01:54PM BLOOD Glucose-196* UreaN-49* Creat-1.8* Na-149*
K-4.1 Cl-120* HCO3-22 AnGap-11
[**2163-1-14**] 04:43AM BLOOD Glucose-149* UreaN-45* Creat-1.8* Na-150*
K-3.6 Cl-121* HCO3-23 AnGap-10
[**2163-1-14**] 03:38PM BLOOD Glucose-159* UreaN-40* Creat-1.6* Na-145
K-4.5 Cl-117* HCO3-21* AnGap-12
[**2163-1-15**] 05:56AM BLOOD Glucose-108* UreaN-37* Creat-1.7* Na-143
K-4.0 Cl-114* HCO3-24 AnGap-9
[**2163-1-16**] 03:12AM BLOOD Glucose-121* UreaN-31* Creat-1.6* Na-143
K-4.2 Cl-112* HCO3-25 AnGap-10
[**2163-1-10**] 10:00AM BLOOD ALT-39 AST-27 LD(LDH)-320* CK(CPK)-70
AlkPhos-79 TotBili-0.5
[**2163-1-10**] 10:00AM BLOOD Albumin-2.3* Calcium-8.4 Phos-5.3*
Mg-2.9*
[**2163-1-11**] 03:59AM BLOOD Calcium-8.5 Phos-5.1* Mg-2.9*
[**2163-1-11**] 08:31PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.8*
[**2163-1-12**] 03:56AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.7*
[**2163-1-12**] 05:21PM BLOOD Calcium-8.5 Phos-2.4* Mg-2.6
[**2163-1-13**] 03:52AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.6 Iron-58
[**2163-1-13**] 01:54PM BLOOD Calcium-8.2* Phos-2.4* Mg-2.7*
[**2163-1-14**] 04:43AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.7*
[**2163-1-14**] 03:38PM BLOOD Calcium-7.6* Phos-2.3* Mg-2.6
[**2163-1-15**] 05:56AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4
[**2163-1-16**] 03:12AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.3
[**2163-1-13**] 03:52AM BLOOD calTIBC-155* VitB12->[**2151**] Folate->20
Ferritn-795* TRF-119*
[**2163-1-11**] 03:59AM BLOOD Triglyc-287*
[**2163-1-15**] 05:56AM BLOOD Vanco-21.6*
[**2163-1-14**] 04:43AM BLOOD Vanco-22.1*
[**2163-1-13**] 03:52AM BLOOD Vanco-22.1*
[**2163-1-11**] 03:59AM BLOOD Vanco-18.6
[**2163-1-10**] 10:00AM BLOOD Vanco-27.4*
[**1-10**] Cytology: DIAGNOSIS: Left Pleural Fluid:
NEGATIVE FOR MALIGNANT CELLS.
[**1-10**] CXR:
The ET tube tip is 6 cm above the carina. The left internal
jugular line tip is at the level of junction of the left
brachiocephalic vein and SVC. The NG tube tip is in the stomach.
There is large left upper lung consolidation with minimal air
bronchogram that might represent the known necrotizing pneumonia
mentioned in the requisition. There is also left lower lobe
consolidation that most likely represents a combination of
pleural effusion and consolidation. Right lung is essentially
clear, but there is questionable opacity in the right lower
lobe, faint, that might represent developing infectious process.
Correlation with prior imaging obtained in outside facility
would be beneficial.
[**1-10**] CT Chest: IMPRESSION:
1. Strong suspicion for large left lower lobe pneumonia.
2. Adequately drained partly organized pleural effusion on the
left.
3. More recent ground-glass opacities in both the right and the
left lung,
suggestive of recent infection.
4. Calcified thyroid nodes, cholelithiasis, atherosclerotic
disease, coronary calcifications, left posterior superior rib
sclerotic focus.
[**1-12**] CXR: IMPRESSION: Significant increase in large right upper
lung density consistent with pneumonia, effusion or
consolidation.
[**1-13**]: TTE: Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild left ventricular wall thickness with normal
cavity size and preserved biventricular global and regional
biventricular systolic function. No clinically significant
valvular disease. Mild pulmonary artery systolic hypertension.
[**1-13**] CXR: The current study shows opening of the left lung with
minimal left atelectasis still present. The consolidation in the
left mid lateral portion of the lung is redemonstrated. No
pneumothorax is seen.
[**1-15**] CXR: FINDINGS: The left hemithorax is completely opacified,
similar in appearance to [**1-12**] with a worsened appearance compared
to [**1-13**] where there has been some interval clearing. This
opacity is due to a combination of infiltrate, volume loss, and
effusion. In the right lung, there is pulmonary vascular
redistribution with some hazy vasculature suggesting an element
of fluid overload. The NG tube and left-sided PICC line are
unchanged.
IMPRESSION: Worsened appearance of the left lung.
[**1-15**] CT Head: IMPRESSION:
1. No evidence of acute hemorrhage.
2. Brain atrophy.
3. White matter disease predominantly on the right side. Given
the
asymmetric nature of the white matter disease, a CTA or MRA of
the neck would help for further assessment to exclude unilateral
carotid disease if
clinically indicated and if there are no prior studies to
evaluate this
abnormality.
4. Chronic lacune in the left thalamus.
5. Small size of the pons could be related to previous infarct.
A small
slightly hyperdense area is seen in the left side of the midline
of the pons which could be related to prior infarct.
6. If there is clinical concern for acute infarct, MRI can help
for further assessment as clinically indicated.
[**1-16**] CXR: Compared to the study from the prior day, there is no
significant interval change.
Brief Hospital Course:
This is a 77 yo M with PMH significant for a left pontine CVA
with residual right-sided hemiparesis, prior subarachnoid
hemorrhage, severe HTN, HL, CKD (baseline Cr 2.0) and asthma who
was originally admitted to an OSH with 3 weeks of progressive
SOB and was found to have extensive left-sided MRSA pneumonia
and bacteremia transferred to [**Hospital1 18**] for a rigid bronchoscopy
after finding a blood clot in LUL and left mainstem bronchus
during a flexible bronch whose hospital course was complicated
by extubation failure requiring tracheostomy and PEG tube
placement with clinical deterioration and transition to
palliative care.
ACTIVE ISSUES:
#. Hypoxia/Necrotizing MRSA Pneumonia
a) MICU COURSE
Patient has MRSA necrotizing pulmonary infection and bacteremia.
Was initially on broad spectrum abx prior to narrowing to vanco
after MRSA was diagnosed. On admission, had pleural effusions
drained with pigtail catheters by IP. He was extubated once,
but failed extubation and was re-intubated in about 48 hrs. A
trach was placed after his second intubation. Around [**1-17**] he
started spiking fevers through the vanco. He was switched to
linezolid and Zosyn was added. All cultures and workup was
negative for other superinfection, so Zosyn was discontinued
after 48 hrs. He remained afebrile on linezolid and his goal
was 2 weeks of treatment since he was afebrile. He was able to
wean to trach mask, his mental status improved and he was called
to the floor.
b) MEDICINE FLOOR COURSE:
Patient's clinical status remained tenuous while on floor. He
spiked a fever requiring restarting Zosyn. Given extent of
pneumonia, ID was consulted who recommended that linezolid be
changed to vancomycin for 6 week total course. Zosyn was
discontinued. Repeat CT chest revealed that the left lung had a
large burden of necrotic tissue and a small effusion. The
effusions that were noted were thought to be too small for
drainage by the interventional pulmonary team. Surgical consult
was offered to the patient's family however given overall
prognosis and significant co-morbidities, consultation was
declined. Subsequent goals of care are discussed below. Plan is
to continue with vancomycin for 6 week total course. He will
need weekly CBC, LFTs, and Chem-7 to be followed up by primary
provider.
# Goals of care: Given significant clinical decline and overall
poor prognosis, several discussions were held with health care
proxy (daughter - [**Name (NI) 1785**] [**Name (NI) **]) and family. Decision was made to
make patient DNR/DNI with no escalation of care, no transfers to
the ICU, no unnecessary procedures and with eventual transition
to palliative/hospice care if he did not improve on antibiotics.
In keeping with their wishes, the medical team kept with
antibiotics and other medications that would keep the patient
comfortable. Given distance from family, patient was transferred
back to [**Hospital 8641**] hospital for remainder of treatment.
#. Hemoptysis/Bloody tracheal suctionings: Patient had several
episodes of hemoptysis and bloody tracheal suctionings secondary
to known MRSA necrotizing infection. Patient had 2
bronchoscopies which showed active bleeding. Hemostasis was
achieved with cold saline. Patient required 4 units of pRBCs
while admitted. Serial hematocrits were monitored. No further
interventions were needed. In keeping with goals of care (see
above), no further interventions should be pursued.
#. Hypertension: Patient was markedly hypertensive while
admitted which attributed to pulmonary edema on several
occasions. After review of prior records, patient's systolic BP
must be between 140-170 given h/o CVA. Patient was better
controlled on 5 agents including labetalol, Lasix, clonidine,
amlodipine, and captopril. Given goals of care, hypertension
control should continue in setting of reducing symptoms from
hypertension.
TRANSITIONAL ISSUES
1) Code status: DNR/DNI (see goals of care discussion)
2) Discharge plan: Patient will continue on vancomycin for 6
weeks and should ultimately transition to hospice care. He is
being transferred back to [**Hospital 8641**] Hospital to be closer to his
family.
Medications on Admission:
Medications at home:
Clonidine 0.3mg TID
Allopurinol 100mg daily
Lasix 40mg daily
ASA 325 daily
Prozac 20mg daily
Labetelol 600mg [**Hospital1 **]
Captopril 50mg daily
Amlodipine 10mg daily
Omeprazole 20mg daily
MVT daily
Oxybutynin 10mg daily
Colace 100mg [**Hospital1 **]
Proscar 5mg daily
Hytrin 2mg daily
Senna PRN
Vit D daily
Valium PRN
Advair 250/50 [**Hospital1 **]
Albuterol PRN
.
Meds on transfer:
Propofol gtt
Fentanyl gtt 50mcg/hr
Vancomycin 1250mg q24h
MVT daily
Labetalol 600mg q8h
Glargine 15U + ISS
Solumedrol 40mg q12h
Nicardipine gtt 6mg/hr
Miralax
Hytrin 2mg qhs
Clonidine 0.3mg TID
ASA 325 daily
Protonix 40mg daily
Tylenol PRN
Allopurinol 100mg daily
Lipitor 10mg daily
Albuterol PRN
DuoNeb q6h
Zosyn 2.25mg q6h
Zofran PRN
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
4. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
DAILY (Daily) as needed for constipation.
5. terazosin 1 mg Capsule [**Hospital1 **]: Two (2) Capsule PO HS (at
bedtime).
6. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
9. therapeutic multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
10. amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 130.
11. clonidine 0.1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3
times a day): Hold for SBP < 130.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. labetalol 200 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO TID (3 times
a day): Hold for SBP < 130. Tablet(s)
15. captopril 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day): Hold for < 100.
16. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
17. furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
19. Vancomycin 1000 mg IV Q 24H
20. Morphine Sulfate 0.5-1.0 mg IV Q6H:PRN pain Start: [**2163-1-27**]
Please give prior to suctioning.
21. heparin (porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection TID (3 times a day): DVT Prophylaxis.
22. insulin glargine 100 unit/mL Solution [**Month/Day/Year **]: Five (5) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital
Discharge Diagnosis:
Primary Diagnosis:
MRSA Pneumonia
.
Secondary Diagnosis:
Hypertension
Hyperlipidemia
Prior CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Patient has tracheostomy tube and PEG tube.
Discharge Instructions:
You were admitted to the hospital for a very bad pneumonia.
This was due to a infection from MRSA. Because of this you
required help from a breathing machine. You are going to require
a very long course of antibiotics to help treat this.
.
After some time you still had difficulty with breathing without
the machine and so a breathing tube placed at the base of your
neck to help you breath. After some time you were able to come
off the breathing machine but still require the tube to help
your breath.
.
Because of the extent of your infection, you and your family
decided that aggressive treatments would not be pursued. Your
family voiced their interest in getting hospice involved.
.
Because your family is so far away from you, we are transferring
you back to [**Hospital 8641**] hospital where you will likely go to a long
term care facility and having discussions about hospice and
palliative care.
.
Please see the attached list for all of your medications.
Followup Instructions:
You are being transferred back to [**Hospital 8641**] Hospital. You will
likely go to a long term care facility where you and your family
can talk to palliative care and hospice experts.
Completed by:[**2163-1-31**]
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28,865
| 179,255
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44976
|
Discharge summary
|
report
|
Admission Date: [**2158-10-8**] Discharge Date: [**2158-10-14**]
Date of Birth: [**2082-5-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Vancomycin
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
abdominal pain, dizziness, nausea, malaise x4 days
Major Surgical or Invasive Procedure:
EGD [**10-12**]
History of Present Illness:
HPI: Patient is a 76 y/o m hx of CAD s/p CABG w/ a four day hx
of dizziness, nausea and constipation, w/ gen malaise, poor po
intake over the past few weeks. Recent episoded of diarrhea
followed by constipation over the past week. Poor PO intake,
because angina worse with eating, has led to avoidance of food.
Patient has severe angina that is refractory to maximal medical
management per recent notes in OMR, 2-3 episodes per day per
patient. Denies syncope or claudication. Pt states angina is not
becoming more frequent or severe. Angina is relieved by SlNTG
.
Originally presented to [**Hospital **] Hospital [**10-8**] w/ c/o
lightheadedness, CP x2 episodes similar to angina, which was
relieved by NTG. At OSH SBP in 80s then drop to 60s. Responded
to SBP in 100s after given NTG. Noted to be guaic positive.
patient hypotensive there but responed to nitro and fluids.
Transferred to [**Hospital1 18**] for further management.
Patient was hypotensive to 60s responded to several fluid
boluses, w/ BP responding to SBP 137, then having CP, [**6-25**] that
was relieved w/ NTG sublingual. Transferred to MICU given
hypotension
.
MICU Course: Patient remained stable in MICU. No episodes of
hypotension. No use of pressors. cardiac enzymes negative x3. No
ischemic changes on ECG. TTE showed worsening AS, now severe.
Past Medical History:
CAD s/p CABG [**2148**]
DM
Bradycardia s/p dual chamber [**Year (4 digits) 4448**]
BPH
Total knee replacement
Arthritis
Social History:
SH: lives alone, has 2 daughters in the area. retired fine arts
teacher, current theater clinic. quit tob 45 yers abo no etoh
Family History:
FH: [**Last Name (un) **] DM 75 died'
Mom MI [**26**]
Dad MI [**14**]
Pertinent Results:
p-MIBI: Mild, fixed perfusion defect involving the basilar
portion of the inferior wall, unchanged from prior study. 2.
Mild left ventricular enlargement with calculated EF of 67%.
.
[**10-9**] TTE:
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is [**5-25**]
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Right ventricular chamber
size and free
wall motion are normal. The aortic valve leaflets are moderately
thickened.
There is severe aortic valve stenosis (area 0.7cm2). Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. An
eccentric, anteriorly directed jet of mild (1+) mitral
regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial
effusion.
.
[**10-9**] EKG: Sinus bradycardia
Ventricular pacer spikes in pattern of pseudofusion complexes
suggested
First degree A-V delay
Intraventricular conduction delay - probably left bundle branch
block
Since previous tracing of [**2158-10-8**], probably no significant
change
.
[**10-12**] CTA: Abdomen to evaluate for ? mesenteric ischemia
Impression: Altherosclerotic disease involving aorta and vessels
of major tributaries. However there is no focal stenosis or
post-stenotic dilatation of any of the vessels, all vessels are
patent. No secondary signs to suggest mesenteric ischemia.
.
[**10-12**] EGD: Gastric and duodenal erosions. Gastric ulcer. Biopsy
taken.
Brief Hospital Course:
Briefly this is a 76M with CAD s/p 4vCABG [**2148**] presenting with
poor po intake, 30 lb weight loss, abdominal discomfort and
angina found to be hypotensive, admitted initiallo to MICU for
monitoring and resucsitation.
.
1. Hypotension: BP improved with fluids. TTE showed severe AS,
which in a volume depleted person who is pre-load dependent was
thought to be the likely etiology of pt's hypotension. On date
of discharge pt's BP is stable and he has tolerated
re-initiation of home antihypertensives.
.
2. CAD: with chronic stable angina that is refractory to maximal
medical therapy per outpatient cardiology notes. Ruled out with
CEs, EKG. Likely etiology for angina is severe AS.
.
3. AS. Pt was seen by cardiothoracic surgery who recommended a
full pre-operative work-up in anticipation of AVR with possible
CABG: including cardiac catheterization, and GI consult. Pt
received part of work up in house including GI consult and b/l
carotid ultrasounds. Pt will return in ~2 weeks for elective
outpatient catheterization and will be in touch with CT surgery
regarding bypass surgery scheduling and expectations.
.
4. Abdominal discomfort:Pt presented with symptoms of abdominal
pain and angina with eating. He also was guaiac positive and
anemic. Of note pt had recently been incompletely treated for
an assumed h. pylori infection. He had received 2 weeks of a
three week course of antibiotics before self discontinuing the
medications due to diarrhea. Pt had a history of a recent
colonoscopy in [**2157**] which was significant only for grade 2
internal hemorrhoids. Pt underwent an EGD on [**10-12**] which showed
gastric and duodenal erosions and a gastric ulcer. Pt continued
on PPI. Biopsy taken, will return in a week, if remains H.
Pylori positive, pt's PCP will contact the pt re: starting
prevpac. Pt also underwent a CTA of the abdomen to evaluate for
mesenteric ischemia in light of his symptoms of post-prandial
pain, this study showed no evidence for any occluded bowel
vessels.
.
5. Diabetes: RISS and metformin continued, metformin held for 48
hours after administration of CTA dye load.
.
6. BPH: Pt initially experienced urinary retention requiring
foley which was shortly thereafter discontinued, on the day
prior to discharge pt again experirenced an episode of retention
requiring foley replacement, this was again weaned prior to
leaving the hospital. Pt continued on proscar and doxazosin.
Plan to follow up with outpatient urology if retention remains
an active issue. Pt initally emperically treated for UTI with
cipro, whis was d/c'd when culture results returned negative.
Pt will contact his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**] for a
follow up appointment within a week after discharge. He will
also be following up with cardiothoracic surger regarding
completion of pre-op workup including outpatient cardial
catheterization, dental clearance, and potential vein mapping.
Will need repeat EGD prior to OR given risk of bleeding with
surgery/anticoagulation. Pt/PCP to follow up EGD biopsy results
in 1 week post discharge for result of h. pylor test, if postive
to complete prevpac treatment. Pt to return to Dr. [**First Name (STitle) 679**] for
repeat EGD in [**6-27**] weeks.
Medications on Admission:
Home MEDS:
Medications:
Atenolol 50mg daily
Lasix 20mg dialy
lisinopril 10mg daily
proscar 5mg daily
lipitor 10mg daily
metformin 500mg po bid
mvi
fosamax 70mg daily
glucosamine
.
Transfer MEDS:
Lisinopril 5 mg PO DAILY
Aspirin 81 mg PO DAILY
MetFORMIN (Glucophage) 500 mg PO BID
Atorvastatin 10 mg PO DAILY
Metoprolol 12.5 mg PO BID
Doxazosin 1 mg PO HS
Multivitamins 1 CAP PO DAILY
Finasteride 5 mg PO DAILY
Nitroglycerin SL 0.3 mg SL PRN
Heparin 5000 UNIT SC TID
Pantoprazole 40 mg PO Q24H
Insulin SC
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP <100.
Disp:*30 Tablet(s)* Refills:*3*
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*3*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation.
Disp:*60 Capsule(s)* Refills:*3*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*3*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for HR<55, SBP <100.
Disp:*30 Tablet(s)* Refills:*3*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-17**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*3*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Start next dose on [**10-15**].
Disp:*60 Tablet(s)* Refills:*3*
10. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*3*
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Moderate to Severe Aortic Stenosis
Gastric ulcer
BPH related urinary retention
Discharge Condition:
Fair
Discharge Instructions:
Please take all medications as prescribed. Please attend all
scheduled follow up appointments.
Call your doctor or return to the emergency room if you
experience chest pain not responsive to nitroglycerin,
increasing shortness of breath, abdominal pain, loss of
consciousness, intractable abdominal pain, nausea,vomiting,
blood in stool/vomit or black stool.
Followup Instructions:
You have the following scheduled appointments in the [**Hospital1 18**]
system.
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2158-11-7**]
10:15
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-2-6**]
2:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2159-4-12**]
2:00
Please call your primary care physician for [**Name Initial (PRE) **] follow up
appointment within 1 week of discharge:
Dr. [**Last Name (STitle) 58**] [**Telephone/Fax (1) 3329**]
|
[
"280.0",
"272.0",
"276.52",
"V45.81",
"V45.01",
"531.40",
"414.00",
"401.9",
"250.00",
"424.1",
"600.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8838, 8893
|
3637, 6916
|
336, 354
|
9016, 9023
|
2101, 3614
|
9431, 10003
|
2011, 2082
|
7470, 8815
|
8914, 8995
|
6942, 7447
|
9047, 9408
|
246, 298
|
382, 1708
|
1730, 1851
|
1867, 1995
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,049
| 125,393
|
38964
|
Discharge summary
|
report
|
Admission Date: [**2113-10-17**] Discharge Date: [**2113-10-23**]
Date of Birth: [**2051-6-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / hazelnut / lidocaine
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
Patient is a 62 year old male s/p Whipple resection for
pancreatic adenocarcinoma poorly differentiated T3N1MX on
[**2113-8-21**] who is also s/p port-a-cath placement on [**2113-9-14**] now
undergoing chemotherapy with gemcitabine, last received [**2113-9-27**].
Presented to [**Hospital1 18**] [**Location (un) 620**] today with 2 days rigors,malaise,
with blood sugars 600, T 104. Pt had poor appetite, so had not
taken his lispro since Saturday. At [**Hospital1 18**] [**Name (NI) 620**], pt
hypotensive, with lactate 2.5 after 4L ns.Exam revealed
dehiscence of port. Started on vanc 1g, aztreonam 1g(pen
allergy) for port infection. Also received insulin 10U for blood
sugar 600. Transfered to [**Hospital1 18**] for further care.
In the ED intial VS were T: 98.0 65 102/55 20 96%.Dropped to
84/54, initially on peripheral levophed 4mcg/kg/min, RIJ placed,
Got 1L IVF, improved to 114/62. Venous lactate 2.1 Cr 1.9
(baseline 1.2) .HCT 28.1 baseline 33.6. CXR ? LLL infiltrate.
Dehisced portacath.
Seen in [**Hospital1 18**] [**Location (un) 620**] heme/onc clinic for day 21 gemcitabine on
[**2113-10-14**], held due to leukopenia, day 8 chemo held due to noted
open right upper corner port incision, also T to 102. Received
kelfex x4 days without adverse event, continued with port. Also
with increased Cr so lisinopril held.
On arrival to the MICU, patients VSS stable, mentating well.
Review of systems:
(+) Per HPI
(-) Denies 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:
MEDICAL HISTORY:
DM2 - followed at [**Hospital1 **] by Dr. [**First Name8 (NamePattern2) 10827**] [**Last Name (NamePattern1) **]
-poorly controlled with complications
-on insulin
Hypertension
Dyslipidemia - refusing treatment
basal cell carcinoma
reports UTD colon ca screening - c-scope [**6-12**] yrs ago, "normal"
SURGICAL HISTORY:
basal cell carcinoma resection
hemorrhoidectomy
Social History:
Lives with: wife
Alcohol: rarely
Tobacco: none
Drugs: none
retired Mt. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1688**] computer science professor but would
like to go back to work
Family History:
denies FH of liver or pancreatic malignancy
Father had throat cancer, but was heavy smoker
Physical Exam:
Admission Examination
Vitals: T: 98.1 BP: 107/61 P:68 R: 18 O2: 99
General: Alert, oriented, no acute distress
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. Left chest with protrusion of port-acath, site mildly
erythematous, non tender, no frank pus/exudate
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.
Skin: left leg with capillaritis, right leg uninvolved
Discharge exam:
VS - Tmax 99.5 118-120/66-70 78-86 95%/RA
FSG: 194 218 247 165 262
GEN: NAD, AAOx3
Neck: Bandage on at sight of right IJ clean, intact, dry, no
hematoma
PULM: CTAB no RRW
CV: RRR normal S1/S2, no mrg
ABD: Soft, non-tender, nondistended
EXT: WWP 2+ pulses palpable bilaterally, no edema, no
splinters/nodules of the hands, venous stasis changes in L leg
Pertinent Results:
[**2113-10-17**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-10-17**] 12:00AM PT-15.9* PTT-34.4 INR(PT)-1.5*
[**2113-10-17**] 12:00AM WBC-4.1 RBC-3.42* HGB-9.4* HCT-28.4* MCV-83
MCH-27.4 MCHC-33.0 RDW-15.0
[**2113-10-17**] 12:00AM NEUTS-84.4* LYMPHS-10.3* MONOS-5.0 EOS-0.1
BASOS-0.2
[**2113-10-17**] 12:00AM GLUCOSE-313* UREA N-32* CREAT-1.9* SODIUM-135
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-11
[**2113-10-17**] 12:01AM GLUCOSE-283* LACTATE-2.1*
[**2113-10-17**] 12:01 am BLOOD CULTURE # 2.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +. PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- R
Aerobic Bottle Gram Stain (Final [**2113-10-17**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2113-10-17**] 2:50PM.
Anaerobic Bottle Gram Stain (Final [**2113-10-17**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2113-10-17**] URINE URINE CULTURE-FINAL
[**2113-10-17**] 1:40 pm FOREIGN BODY Source: port.
WOUND CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
62 y/o M with history of pancreatic cancer s/p whipple currently
on chemotherapy with gemcitabine with port in place, presenting
with fevers and hypotension.
Active issues:
# MRSA Bacteremia: Pt transferred from OSH to [**Hospital1 18**] given
persistent hypotension and elevated lactate despite 4L IV
fluids. Central line placed in [**Hospital1 18**] ED with further fluid
boluses delivered. He briefly needed pressor support with
levofloxacin, which was discontinued shortly after arrival to
the ICU as he was maintaining MAPs above 65 and mentating well.
He had evident dehiscence of his left chest port, with this
compromise of the skin barrier the suspected source for an
infection. He was started on vancomycin and cefepime, with the
port removed by surgery and port culture growing MRSA. Blood
cultures from [**Hospital3 **] and [**Hospital1 18**] were positive for MRSA,
so he was continued on vancomycin alone. He improved clinically
and was discharged from the ICU to the regular floor. Blood
cultures were negative from [**10-18**]. TTE and TEE showed no signs of
endocarditis. PICC placed [**10-21**]. He will complete 3 week course
of vancomycin dated from first negative blood culture.
# Acute kidney injury: Cr elevated to 1.9 on admission from
baseline of 1.0, improved somewhat with hydration but did not
return to baseline (1.4-1.5 range).
# Diabetes: Patient with hyperglycemia on admission, but no
anion gap. Home dose of Humalog 75/25 up-titrated during
admission, with improvement in blood sugar control.
# Pancreatic adenocarcinoma: poorly differentiated T3N1MX
pancreatic adenocarcinoma s/p Whipple resection [**2113-8-21**],
recently treated with gemcitabine.
# Hypertension: home lisinopril held on admission due to
hypotension, acute kidney injury.
Transitional issues:
- Follow up with surgery
- Follow up with Infectious Disease clinic. Will have weekly
labs drawn (CBC, Chem 10, vancomycin levels)
- Follow up with the PEVA service 2 weeks after discharge for
serial blood culture monitoring and evaluation for possible port
replacement given his continued need for chemotherapy.
- He will also follow up with his Oncologist, Dr [**Last Name (STitle) 3274**].
Thrombocytopenia noted is suspected to be a side effect of
gemcitabine and should continue to be trended.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. HumaLOG Mix 75-25 *NF* (insulin lispro protam & lispro) 100
unit/mL (75-25) Subcutaneous [**Hospital1 **]
22 units with breakfast, 12 units at dinner
2. Lisinopril 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Stool Softener *NF* (docusate calcium;<br>docusate sodium)
unknown Oral daily
5. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
6. Aspirin 81 mg PO DAILY
7. Ascorbic Acid 500 mg PO DAILY
Discharge Medications:
1. Humalog 75/25 28 Units Breakfast
Humalog 75/25 19 Units Dinner
2. Docusate Sodium 100 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. 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.
5. Vancomycin 1250 mg IV Q 24H
RX *vancomycin 500 mg 1250mg daily Disp #*14 Unit Refills:*0
6. Ascorbic Acid 500 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
MRSA bacteremia
Port infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with fevers and found to have
a blood infection due to an infection of your port. Your port
was removed and you were started on antibiotics. An
echocardiogram showed no signs of infection of your heart.
Changes to your home medications include:
-START vancomycin 1250mg daily (last day will be [**11-7**])
-INCREASE insulin dose to Humalog 75/25 28 units at breakfast
and 19 units at dinner, please continue to check your blood
sugars at home 3-4 times a day and call your doctor if your
blood sugar is in excess of 300.
-STOP lisinopril 5mg, your primary care doctor will tell you
when to resume, probably after you finish your antibiotics
You will need to have labs drawn every week- the infectious
disease doctors [**Name5 (PTitle) **] follow up on your vancomycin levels. You
will also need daily wound care and dressing changes.
It was a pleasure taking care of you during your
hospitalization, and we wish you all the best going forward.
Followup Instructions:
-Please call Dr.[**Name (NI) 32613**] office at [**Telephone/Fax (1) 86425**] to schedule a
follow-up appointment with surgery.
-Please call Dr.[**Name (NI) 3279**] office in [**Location (un) 620**] to schedule a
follow-up appointment in 2 weeks.
-You will follow up with the Infectious Disease outpatient
antibiotic management clinic. They will call you with an
appointment time in the next day or 2. If you do not hear from
them or have any concerns, please call [**Telephone/Fax (1) 457**]
-please call your primary care doctor, Dr. [**Last Name (STitle) 16412**] at
[**Telephone/Fax (1) 75256**] to schedule an appointment within 2 weeks of
discharge.
Completed by:[**2113-10-29**]
|
[
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"038.12",
"998.30",
"E879.8",
"285.9",
"401.9",
"E849.0",
"V10.83",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"86.05",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
9744, 9789
|
6218, 6377
|
309, 340
|
9864, 9864
|
4167, 4771
|
11053, 11741
|
2873, 2966
|
9159, 9721
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10015, 11030
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3794, 4148
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8021, 8522
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1786, 2228
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258, 271
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6392, 8000
|
6176, 6195
|
368, 1767
|
9879, 9991
|
2250, 2637
|
2653, 2857
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,085
| 115,300
|
39496
|
Discharge summary
|
report
|
Admission Date: [**2182-10-30**] Discharge Date: [**2182-11-26**]
Date of Birth: [**2122-3-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Actos / Percocet / Cephalosporins
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Epigastric pain and shortness of breath
Major Surgical or Invasive Procedure:
Intubated
IABP
RIJ
History of Present Illness:
Mr. [**Known lastname **] is a 60 y.o male with a history of nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD who
presented to [**Hospital6 **] with epigastric chest
pain and shortness of breath. At [**Hospital1 487**], he was found to have
a left bundle branch block that was not known to be old and as
such was taken to the cath lab. The LBBB was later noted to be
old, however during cath he was noted to have a total occlusion
to the OM2 as well as 2 tight lesions in the RCA. Of note, the
patient had been found to have inferior septal ischemia on a
stress test during outpatient workup.
In the cath lab, the patient subsequently developed acute
shortness of breath, at which point he was given 100mg of lasix
and started on a nitroglycerin drip. His symptoms did not
improve, at which point he was intubated and an intra-aortic
balloon pump was placed through right femoral access. He also
received angiomax and 300mg of clopidogrel. A swan was placed
which showed elevated pulmonary artery pressures and wedge
pressures between 37-44. Laboratory exam at [**Hospital1 487**] was
significant for Na 129, K 4.1, BUN 53, Cr 1.3, hemoglobin 16.6
and platelets of 135. Her PT was 19.4 and INR was 1.8. Dig level
of 0.8, and cardiac enzymes significant for CK of 135, MB of 7
and Troponin of 0.08 which was negative in their reference
range.
.
Review of systems could not be obtained due to intubation.
Past Medical History:
CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.
-PACING/ICD: VVI AICD implated on [**2180-4-26**]
3. OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropahty
Hypertriglyceride
CHF
Afib
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Past surgical history:
Appy
Chole
Epigastric hernia repair
Tonsillectomy
AICD/pacemaker implanted [**2180-4-8**]
.
Social History:
-Tobacco history: Former smoker
-ETOH: no etoh
Is not married.
Family History:
Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T=97.5 BP= 87/38 HR=89 RR=16 O2 sat=100% on 500/18/5/40
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
CARDIAC: Fast, irregular, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Diffusely rhonchorous with crackles throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace lower extremity edema. Right femoral sheath
introducer sheeth and swan in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Radial, DP 2+ bilaterally.
.
Pertinent Results:
Admission Labs:
[**2182-10-30**] 11:04PM BLOOD WBC-12.7* RBC-4.68 Hgb-15.5 Hct-44.1
MCV-94 MCH-33.1* MCHC-35.1* RDW-17.0* Plt Ct-157
[**2182-10-30**] 11:04PM BLOOD Neuts-83.9* Lymphs-10.4* Monos-4.5
Eos-0.6 Baso-0.6
[**2182-10-30**] 11:53PM BLOOD PT-33.4* PTT-150* INR(PT)-3.4*
[**2182-10-30**] 11:04PM BLOOD Plt Ct-157
[**2182-10-30**] 11:04PM BLOOD Glucose-243* UreaN-54* Creat-1.6* Na-133
K-4.4 Cl-96 HCO3-29 AnGap-12
[**2182-10-30**] 11:04PM BLOOD ALT-22 AST-31 LD(LDH)-313* CK(CPK)-126
AlkPhos-89 TotBili-0.3
[**2182-10-30**] 11:04PM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.17*
[**2182-10-30**] 11:04PM BLOOD Calcium-7.9* Phos-5.3* Mg-1.9
[**2182-10-30**] 11:04PM BLOOD TSH-3.9
.
STUDIES:
CHEST (PORTABLE AP) Study Date of [**2182-10-30**]
Large right upper lobe opacity is consistent with a right upper
lobe collapse. The NG tube tip is in the distal right mainstem
bronchus. The aortic balloon pump tip is 2.4 cm from the aortic
arch. ET tube tip is 2.3 cm above the carina. Swan-Ganz catheter
from inferior approach is in the main right pulmonary artery.
Left transvenous pacemaker lead terminates in the standard
position in the right ventricle. There is moderate-to-severe
cardiomegaly. Left perihilar and left upper lobe opacities
could be atelectasis or infection. There is gastric distention.
There is mild shifting of the cardiomediastinum towards the
right side.
.
Portable TTE (Complete) Done [**2182-10-31**]
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF = 15
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with normal free wall contractility. The aortic valve
leaflets are mildly thickened (?#). There is mild aortic valve
stenosis (valve area 1.5 cm2). The aortic stenosis is likely the
"low flow/low gradient" type. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT Ab/Pelvis [**2182-11-13**]
1. Findings suggestive of mild-to-moderate pulmonary edema. More
focal small nodular opacities within the lungs as described
above may represent focal regions of underlying
pneumonitis/pneumonia, possibly aspiration related in this
patient with distal trachea secretions. Small right simple
pleural effusion. Follow up CT chest in [**4-13**] months recommended
to confirm nodular opacity resolution.
2. No definite source of infection noted within the
abdomen/pelvis. No
biliary ductal dilatation.
3. Moderate sized right piriformis collection, probably
intramuscular
hematoma, particularly in the setting of anticoagulation
(infected collection cannot be excluded).
4. Dense atherosclerotic calcifications involving the aorta and
coronary
tree. Cardiac enlargement dilatation of both the left ventricle
and left
atrium.
.
CARDIAC CATH [**2182-11-21**]
1.Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA was
free of
angiographically-apparent disease. The LAD was heavily
calcified with
mild luminal irregularities. The LCx had a short total
occlusion in the
mid CX into the OM2 which filled via collaterals from the OM1
and LAD.
The RCA had severe diffuse calcific diesease with calcific
70-80%
stenoiss in the proximal vessel, distal 50% stenosis adn 99%
calcific
stenosis at the RPDA/RPL bifurcation.
2.Resting hemodynamics revealed normal right and left sided
filling
presures with RVEDP 13 mmHg and PCWP 12 mHg. The cardiac index
was
preserved at 2.6 l/min/m2. There was mild systolic hypotension
SBP 87
mmHg.
3. Left ventriculography was deferred.
4. Successful PCI of RCA lesions with rotablation and DES via R
radial
approach and balloon pump support
5. Unsuccessful PCI of the OM.
6. Secondary prevention of CAD
7. Plavix 75mg daily for 12 months
8. Monitor for signs of left leg ischemia
9. Follow creatinine and HCT
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PCI to RCA with rotablation and IABP support.
3. Unsuccessful PCI of the OM.
4. Successful removal of IABP.
.
DISCHARGE LABS:
Na 134, K 4.8, BUN 35, Creat 1.2, WBC 3.7, HCT 27, HGB 8.9, plt
116, INR 1.6
.
ECHO [**11-25**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. There is severe global left ventricular hypokinesis
with near akinesis of the inferior septum, inferior, and
inferolateral wall. The anterior wall and anterior septum
contracts best, but are hypokinetic. Global systolic function is
severely depressed. (LVEF = 20 %). 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 mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images unavailable for review) of
[**2182-10-31**], left ventricular systolic function is similar. Mild
mitral regurgitation is now seen.
.
Micro data: (unless noted positive, result is negative)
[**2182-11-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2182-11-12**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2182-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-9**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2182-11-9**] CATHETER TIP-IV WOUND CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE
NEGATIVE} INPATIENT
[**2182-11-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-8**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram Stain-FINAL
INPATIENT
[**2182-11-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL INPATIENT
[**2182-11-7**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2182-11-7**] Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
[**2182-11-7**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2182-11-7**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG
SEROLOGY-FINAL INPATIENT
[**2182-11-7**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2182-11-7**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV
IgM ANTIBODY-FINAL INPATIENT
[**2182-11-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-5**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-3**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2182-11-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Brief Hospital Course:
60 year old man who presented to an outside hospital emergency
room with epigastric pain and shortness of breath, who was
subsequently taken to the cath lab after being found to have a
LBBB which was later demonstrated to be old. The patient
subsequently became dyspneic in the cath lab, was intubated,
became hypotensive, and an IABP was placed with phenylephrine
started. He was subsequently transferred to the [**Hospital1 18**] CCU for
further care.
.
# Shock and Dyspnea: The patient initially had elevated
biventricular elevated filling pressures, increased cardiac
output and low SVR. He was therefore thought to have
distributive shock with potential sepsis. Our initial chest
x-ray after new OG tube placement showed a collapsed right upper
lobe of his lung which later resolved after replacement of the
OG tube. He was pan-cultured and started on broad spectrum
antibiotics including Vancomycin and Zosyn, later switched to
Vancomycin, Cefepime, and Ciprofloxacin. His pressors remained
marginal, and he required levophed to maintain MAPs >65. Due to
persistently adequate cardiac output readings from his Swan, his
intra-aortic balloon pump and Swan were removed. Repeat chest
x-rays showed pulmonary edema and acute exacerbation of his
systolic congestive heart failure. Extubation was attempted on
[**2182-11-1**], but afterwards his oxygenation decreased acutely most
likely secondary to flash pulmonary edema. He failed a trial of
BiPAP and became acutely agitated, requiring emergent
re-intubation. He was subsequently aggressively diuresed with
IV boluses of furosemide in addition to a furosemide drip with
metolazone. After the initial diuresis, he was transitioned to
Torsemide PO and developed hyponatremia. The Torsemide dose was
adjusted to 10 mg and he appears to be at his dry weight today
of 200 pounds. He is ambulating on RA with O2 sats in high 90's,
no peripheral edema and clear lung sounds. Given his very low
EF, he should be started in spironolactone and digoxin as his BP
allows. Please weight daily and adjust diuretics to maintain
weight at 200 pounds. He is being considered for a heart
transplant and transplant workup was started during this
hospital stay. He will follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP here for continued workup and evaluation.
.
# Coronary artery disease: The patient had evidence of a
reperfusion defect on recent SPECT stress test and evidence of
tight lesions in RCA from his cardiac catheterization at the
outside hospital. His troponins were mildly elevated which could
have represented demand ischemia and/or congestive heart
failure, but less likely acute coronary syndrome. His ECG
showed a LBBB that remained unchanged throughout his CCU stay.
He was medically managed with 48 hours of a heparin drip, full
dose aspirin, atorvastatin 40mg daily, loaded with 300mg plavix
and then given plavix 75mg daily. He underwent catheterization
prior to discharge with stenting of an RCA lesion (see cath
report.) Note that in the setting of a heparin gtt, the patient
developed a piriformis hematoma; his HCT remained stable.
.
# Atrial fibrillation and Ventricular Tachycardia: The patient
was persistently in atrial fibrillation and had several episodes
of ventricular tachycardia prompting firing of his ICD. His
beta blocker was held secondary to his hypotension requiring
pressors. He was seen by our electrophysiology team and
received a AV nodal ablation following by a BiV pacer upgrade.
He has been restarted on his betablocker at a lower dose and
amiodarone was loaded. He has had no further VT within the last
4-5 days and he is [**Age over 90 **]% AV paced on telemetry.
.
# Acute renal failure: This was most likely secondary to poor
forward flow in the setting of an acute on chronic systolic CHF
exacerbation. His lisinopril was held, medications were renally
dosed and his renal function improved with diuresis. ACEi was
restarted before discharge at lower dose.
.
# Diabetes mellitus type 2: The patient was maintained on
glargine and an ISS without complications. Metformin was d/c'ed
because of his CHF. His glargine may need to be uptitrated as
his appetite improves. Please continue to do fingerstickes
before meals with Humalog insulin coverage per sliding scale.
.
#Transaminitis: LFTs trending down. Thought to be secondary to
poor forward flow with CHF exacerbation. Statin has been
restarted.
.
# Anemia: Hct has slowly trended down during hospital stay. He
has no evidence of acute bleeding at present and piriformis
hematoma development did not seem to drop his hct precipitously.
It is thought that anemia a combination or phlebotomy, ARF and
critical illness. His hct should be monitored and iron studies
sent if hct/hgb continues to drop. Stools should be Guiaiced.
.
# Hyponatremia: now resolved. Thought secondary to overdiuresis.
Torsemide dose has been adjusted and should be titrated to
maintain dry weight of 200 pounds.
.
# Social: Patient lives alone with an elderly aunt and uncle as
[**Name2 (NI) **] supports.He was functionally independent before admission
and goal is to return to this.
Medications on Admission:
Home medications
Aspirin 81mg daily
lipitor 40mg daily
lisinopril 40mg qd
lopressor 150mg [**Hospital1 **]
digoxin 0.375mg MWF, 0.25mg TTSS
furosemide 160mg [**Hospital1 **]
metolazone 2.5 qweek
Gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lantus 48 units qd
multivitamin
coumadin 5mg TWFSS, 7.5mg MT
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not skip doses or stop taking unless Dr. [**Last Name (STitle) **] says
it is OK.
Disp:*30 Tablet(s)* Refills:*11*
6. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 70.
11. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
12. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: before meals.
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X per week
(Sun, Tues, Wed, Fri): Please check INR on Thursday [**11-28**].
14. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/week
(Mon, Thurs, Sat).
15. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. multivitamin Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
[**Last Name (un) 6267**] check IR, PT, CBC and Chem 7 on [**2182-11-28**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Atrial fibrillation s/p AV node ablation
Acute on chronic systolic congestive heart failure
Anemia
Hypothyroidism
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you in the hospital. You were
admitted for heart failure and required a lengthy stay in the
ICU. During your time in the ICU you were intubated and had
pneumonia. Also, three important procedures were performed.
First, you had an AV nodal ablation which allowed your heart to
beat more slowly. Second, you had a revision to your pacer to
help your heart work better. Finally, you had a catheterization
of your heart during which stents were placed to open blocked
vessels.
You should make the following changes to your medications:
CHANGE THE FOLLOWING DOSES:
- Change aspirin 81 mg daily to aspirin 325 mg daily
- Change Lisinopril 40 mg daily to Lisinopril 5 mg daily
- Change Metoprolol 150 mg [**Hospital1 **] to Toprol XL 12.5 mg daily
- Change Furosemide to torsemide 10 mg daily
STOP THE FOLLOWING MEDICATIONS:
- Digoxin, Metolozone, metformin, spironolactone
START THE FOLLOWING NEW MEDICATIONS:
- Plavix to keep the stents open. You will need to take this
medicine every day for at least one year with a 325 mg aspirin.
Do not stop taking these medicines unless Dr. [**First Name (STitle) 437**] tells you it
is OK.
- Start Amiodarone to control your heart rhythm
- Start Trazadone to help you sleep
- start senna as needed if you get constipated.
- Ranitidine to protect your stomach from the Plavix and
aspirin.
Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Please go to all of the recommended followup appointments that
are listed below.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2182-12-16**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 63252**] when you get out of
rehab to schedule appts.
Completed by:[**2182-11-27**]
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29,796
| 191,989
|
30907
|
Discharge summary
|
report
|
Admission Date: [**2125-7-3**] Discharge Date: [**2125-7-7**]
Date of Birth: [**2065-6-10**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 y/o M with PMHx of SSS s/p PCM & vertrobasilar insufficiency.
p/w recurrent syncopal episode yesterday where he sustained an
arm fracture. He was at his nursing home where he developed
sudded LOC and a fall. He was found by the nursing home staff
on the floor. There was neither loss of bowel or bladder. Prior
the the event he felt lightheaded, but denied diaphoresis, chest
pain or palpitations. He presented to [**Hospital1 **] for
evaluation and was found to have a right humeral fracture. He
had a CT that was negative for ICH or mass. He was referred to
[**Hospital1 18**] after he had a telemetry strip that was a WCT at ~100.
During that initial episode, he became transiently hypotensive
(vitals not documented) and he received a total of 2L of NS.
.
Upon arrival to the [**Hospital1 18**] ER his intial vitals signs were 98.7
80 120/68 22 99RA. While in the ER he had another 2 runs of
WCT ~115 bpm with RBBB morphology. Per the ER nursing note he
had a tele recording of HR 22O and had a percordial thump
following which the patient returned to a sinus rhythm at 96bpm.
He was given 2 doses of 150 mg of amiodarone IV.
.
Of note he just had his pacemaker interrogated in early [**Month (only) **]
[**2125**] (per patient report at [**Hospital **] Hospital) and the device was
functioning and detected no WCT. He presented to that hospital
for a fall as well and was told that he had had a TIA but had
negative CT head.
.
On review of symptoms, he denies any prior deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
- hemorrhagic stroke [**2119**]; with residual right sided weakness;
thinks he might have had x2 strokes prior to that (x1 = loss of
vision in both eyes; second = vision split)
- DMII
- depression(requiring inpatient hospitalization in past)
- Peripheral vascular disease with known occlusion of both
carotid arteries with collaterals from the vertebrals.
- Diastolic heart failure based on C.Cath [**11-9**] showing impaired
filling, 30% diffuse narrowing LCx. - no intervention; Mild
cardiomyopathy with ejection fraction 43%, but normal
coronary arteries.
- Past polysubstance abuse and hx suicide attempts
- Hyperlipidemia
- Hypertension
- s/p Guidant pacemaker for sick sinus syndrome [**2121**]
- COPD
- s/p C5-6 laminectomy
- seizures (?): has trialed neurontin in the past--> no help
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
Social History:
Social history is significant for smoking 10 cigarettes per
day. There is a history of heavy alcohol abuse ([**1-3**] pint to 1
pint per day of vodka x 10 years), but he stopped drinking about
heavily 5 years ago. His last drink was 2 weeks ago. He lives in
a nursing home ([**Hospital 169**] Center [**Location (un) 1411**]) and used to be in
[**Hospital3 **]. He walks with a cane.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died of MI at 86. Mom died of MI at
72.
Physical Exam:
VS: T 95.4, BP 102/45, HR 82, RR 12, O2 100% on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL (3->2mm bilat), EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 6cm with patient flat
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: chest wrap with sling. defib pads in place. Resp were
unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. right humerus tender to
palpation. right hand with normal sensation and capillary
refill.
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
Neuro:
MS: alert and oriented x3. coherent response to interview, CN
II-XII intact motor, nl tone/bulk. [**5-7**] to hand grip/ plantar and
dorsiflex bilat
[**Last Name (un) **]; light touch intact over face/hands/feet
Pertinent Results:
[**2125-7-3**] 04:10AM CK-MB-NotDone cTropnT-<0.01
[**2125-7-3**] 04:18PM CK-MB-3 cTropnT-<0.01
[**2125-7-3**] 04:10AM GLUCOSE-105 UREA N-12 CREAT-0.7 SODIUM-142
POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-16* ANION GAP-16
[**2125-7-3**] 05:00AM WBC-13.3* RBC-3.39* HGB-11.1* HCT-34.1*
MCV-100* MCH-32.8* MCHC-32.7 RDW-15.4
[**2125-7-3**] 05:00AM PLT COUNT-290
[**2125-7-3**] 04:10AM CALCIUM-7.5* PHOSPHATE-2.8 MAGNESIUM-1.6
[**2125-7-3**] 04:10AM PT-12.4 PTT-31.1 INR(PT)-1.0
Brief Hospital Course:
Mr. [**Known lastname 73100**] is a 60 year old man with a history of recurrent
syncope, sick sinus syndrome s/p DDD pacemaker, bilateral
carotid stenosis, COPD, DM2, h/o hemorrhagic stroke, who
presented with recurrent syncope complicated by R humeral
fracture.
.
Syncope:
Head CT from [**Hospital1 **] [**Location (un) 620**] showed no acute bleed, only hypodense
areas consistent with old infarction or injury.
Electrophysiology was consulted and his pacemaker was
interrogated, showing episodes of pacemaker mediated tachycardia
and some rate-drop episodes but no history of tachyarrhythmias.
He was thought to have vagal/reflex syncope. He could not be
started on a volume expander due to his hypertension. The rate
drop response was turned off to evaluate how he would do without
it but as there was no difference, it was reinstated. He was
also started on a beta blocker, which may have some marginal
benefit. However, it is likely that he will continue to have
syncopal episodes, as his type of neurocardiogenic syncope
cannot be well managed by either pacemaker or medications. Pt
is at high risk of another fall [**2-3**] syncope and will need PT
evaluation at NH for [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 73101**]. Followup was
scheduled with Dr. [**First Name (STitle) **] in Cardiology.
.
R Humeral Fracture:
X-rays demonstrated R humeral fracture. Seen by orthopedic
trauma service. It was determined that no operative management
was warranted for the injury. He was fitted with a humeral
fracture brace. Ortho's physical therapy recommendations are:
1) Pt's right arm is non-weightbearing. 2) Pt will need to
perform flexion/extension exercises twice daily of right hand &
wrist. He will need to continue receiving heparin SC for DVT
prophylaxis as long as he is not ambulating. Follow-up was
scheduled with Dr. [**Last Name (STitle) **] on [**7-26**] at 8:20AM. Would
recommend DEXA scan as outpatient to evaluate for osteoporosis
as patient has been on long-standing steroids.
.
Pain control:
Pain management was a significant issue throughout
hospitalization. He was initially on a dilaudid PCA, but with
poor effect. The pain service was consulted and he was started
on oxycontin 20mg [**Hospital1 **], dilaudid 4-8mg Q3-4H PRN, acetaminophen
650mg Q6H, gabapentin 100mg QHS with little improvement per
patient. There was concern about drug-seeking behavior. Of
note, pt has a history of suicidal attempt after sequestering
pain medications. However, he was observed by the nurse to be
taking his medications. He developed constipation and was c/o
abdominal pain as he was initially refusing bowel regimen. He
was started on a more intensive bowel regimen with subsequent
resolution and will need to continue the bowel regimen as long
as he is taking pain meds.
.
Epigastric pain:
Pt was complaining of epigastric burning. In light of his
cardiac history, an EKG done which was unchanged from baseline
with no ST-T changes. Likely gastritis, not surprising as he
has been on ASA and prednisone. Started on GI prophylaxis with
no further complaints.
.
COPD:
He was breathing comfortably throughout the hospitalization with
good oxygen saturation and without evidence of acute
exacerbation of COPD. He was continued on his Spiriva and
Advair at his home doses and provided with albuterol nebs PRN.
As there was no indication for a standing dose of prednisone 20
mg, we began slowly weaning his dose to 10 mg. He will need to
taper it off slowly per the following schedule: Prednisone 10 mg
x 12 days, then Prednisone 5 mg x 14 days.
.
DM2:
He experienced no active issues. Metformin was held, and he was
provided with sliding scale insulin with good glucose control.
.
Seizure disorder:
He has a history of seizure disorder but recent episodes were
not thought to represent seizure disorder. He was continued on
Keppra and scheduled for outpatient followup with Dr.
[**Last Name (STitle) 623**] on [**7-17**], at 11:40am.
Medications on Admission:
Keppra 1,000 mg [**Hospital1 **]
Lisinopril 5 mg DAILY
Tiotropium Bromide 18 mcg DAILY
Metformin 500 mg SR daily
Docusate 100 mg [**Hospital1 **]
Simvastatin 80 mg DAILY
Thiamine HCl 50 mg daily
Dipyridamole-Aspirin 200-25 mg Cap, [**Hospital1 **]
Hydromorphone 2 mg [**Hospital1 **]
Folic Acid 1 mg daily
Insulin (regular) sliding scale
acetaminophen 325-650 mg q4prn
advair diskus 250/50 1 puff [**Hospital1 **]
maalox 30cc q6prn
lactulose 30mL qhs prn
imodium 2 mg qid prn
compazine 25 mg PR prn
albuterol neg QID
prilosec 20 mg [**Hospital1 **]
prednisone 20 mg daily
reglan 5 mg TID with meals
seroquel 25 mg hs
seroquel 25 mg q4prn: agitation
zolpidem 5 mg qhs prn: insomnia
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
18. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed for pain for 21 days.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
21. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
22. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 28 days: Continue 10mg daily through [**7-20**], then
decrease to 5mg daily through [**8-3**] then stop.
23. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritis.
24. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
25. Seroquel 25 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for agitation.
26. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
hr Sig: One (1) Cap, Multiphasic Release 12 hr PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center, [**Hospital1 1501**]
Discharge Diagnosis:
Primary:
1. Reflex (Vagal) Syncope
2. Right humeral fracture
Secondary:
1. Sick sinus syndrome s/p pacemaker placement
2. Vertebrobasilar insufficiency
3. Bilateral carotid stenosis
4. Hx of hemorrhagic stroke [**2119**]
5. Recurrent syncope
6. Diabetes type 2
7. Depression
8. Diastolic heart failure
9. Past polysubstance abuse and hx of suicide attempts
10. Hyperlipidemia
11. Hypertension
12. COPD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the [**Hospital1 18**] after losing consciousness at
your nursing home, leading to a fall and a broken right arm.
While you were here at [**Hospital1 18**], we checked your pacemaker and
found that it was functioning properly. You were seen by
orthopedic surgery who felt that you did not need surgery for
your broken arm. You will need physical therapy at your nursing
home and outpatient follow-up with neurology, cardiology, device
clinic, and orthopedic surgery.
You were started on the following medications: for pain relief,
you were started on oxycontin 20mg twice a day, dilaudid 4-8mg
every 3-4 hrs, acetaminophen (Tylenol) 650mg every 6 hrs,
gabapentin 100mg every night. You have been started on
Metoprolol 12.5mg TID.
.
The following medications were changed: we decreased your
prednisone dosage to 10mg daily with plan for a slow taper.
.
Please take all medications as prescribed.
If you have chest pain, chest pressure with jaw or arm pain,
loss of consciousness, or any other concerning symptoms, please
call 911 or come to the ER.
.
Please do not smoke. Information regarding smoking cessation was
given to you at discharge.
Followup Instructions:
You are scheduled for the following appointments:
Neurology: Dr. [**Last Name (STitle) 623**] in [**Hospital Ward Name **] 5 on [**7-17**] at 11:40am.
.
Device Clinic: Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2125-7-24**] 10:30
.
Orthopedics: You have a follow up appointment with Dr. [**Last Name (STitle) **]
8:20AM on [**7-26**]
.
Cardiology: You have a follow up appointment with Dr. [**First Name (STitle) **] on
[**7-10**] at 1:40PM.
Please keep all follow up appointments.
|
[
"428.30",
"438.89",
"276.2",
"780.79",
"E849.7",
"414.01",
"496",
"789.06",
"E888.9",
"401.9",
"780.2",
"812.21",
"250.00",
"V53.31",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.54"
] |
icd9pcs
|
[
[
[]
]
] |
12630, 12706
|
5363, 9384
|
274, 280
|
13153, 13162
|
4854, 5340
|
14379, 14868
|
3534, 3665
|
10115, 12607
|
12727, 13132
|
9410, 10092
|
13186, 14356
|
3680, 4835
|
227, 236
|
308, 2235
|
2257, 3116
|
3132, 3518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,918
| 115,437
|
25530
|
Discharge summary
|
report
|
Admission Date: [**2181-6-25**] Discharge Date: [**2181-7-5**]
Date of Birth: [**2119-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
- recurrent L malignant pleural effusion [**3-16**] metastatic gastric
cancer
Major Surgical or Invasive Procedure:
- thoracentesis
- Pleurodesis
- placement of chest tube
History of Present Illness:
62 M with metastatic gastric cancer now with c/o shortness of
breath and recurrant pleural effusion
Past Medical History:
PMH: gastric adenoCa-s/p chemo, HTN, MPE, ^lipidemia
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
on discharge
vitals: 99.1 106 126/69 24 97% 2.5 L (needs to be updated)
WD, cachectic, NAD
alert and oriented, moves all extremities
tachy, regular rate/rhythm
bilateral slight decrease BS at bases, CTA otherwise
soft, nt, nd, nabs
no c/c/e; bilateral lower extrem warm
Pertinent Results:
[**2181-7-3**] 12:30PM BLOOD WBC-8.2 RBC-3.06* Hgb-9.3* Hct-28.0*
MCV-92 MCH-30.5 MCHC-33.3 RDW-17.3* Plt Ct-336
[**2181-7-3**] 12:30PM BLOOD Neuts-80.9* Lymphs-5.5* Monos-9.2
Eos-4.3* Baso-0.1
[**2181-7-3**] 12:30PM BLOOD Plt Ct-336
[**2181-6-27**] 05:38PM BLOOD PT-14.6* PTT-29.5 INR(PT)-1.3*
[**2181-7-3**] 12:30PM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-32 AnGap-11
[**2181-7-1**] 04:55AM BLOOD ALT-10 AST-18
[**2181-7-1**] 04:55AM BLOOD proBNP-428*
[**2181-7-3**] 12:30PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
[**2181-7-1**] 04:55AM BLOOD Albumin-2.4* Calcium-8.2*
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2181-7-4**] 2:47 PM
History of pleural effusion with pleurodesis and chest tube
removal.
Since the previous study of [**2181-7-3**], the left chest tube has
been removed. There is consistent small left pleural effusion
and loculated hydropneumothorax anteriorly in the left lower
hemithorax, unchanged since the prior film. The diffuse
bilateral interstitial densities and right pleural effusion are
also unchanged.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: WED [**2181-7-4**] 4:15 PM
Brief Hospital Course:
The pt. was admitted to the oncology service on [**6-25**] with
complaints of recurrant pleural effusions related to his
metastatic gastric cancer. For the past week prior to admission
the pt. had been suffering from progressive shortness of breath.
A CXR was done on admission showing and expanding pleural
effusions. The IP team was contact[**Name (NI) **] and the pt. was set up for
pleurodesis and pleurex catheter placement. On HD 2 the pt.
went to the IP suite and pleurodesis was attempted. The pt.
became bradycardic to the 20s and a code was called. The pt.
was immediately intubated and bronched -> a large mucous plug
was extracted and the patient's vitals immediately improved.
With the pt. intubated the pleurodesis was completed. A left
side chest tube was placed and the pt. was transferred to the
ICU. The pt. was extubated overnight and transferred to the
floor with telementry. The pt. did well for the next several
days. On PPD2 the pt. had an aspiration event during which his
O2 sats dropped briefly and he became tachycardic. This
resolved with nebulizers, cough medicine, and lopressor. The
pt. did well for the next two days. His chest tube remained on
suction until PPD3 at which time it was placed to water seal. A
post-water seal cxr was unchanged and on the morning of PPD 4
the ct was clamped. A four hour post cxr showed no change and
the chest tube was pulled. Post pull CXR was again stable with
no evidence of a new pneumothorax. By HD 11 the pt. was doing
well post pull and ready for discharge. He was still requiring
supplemental oxygen and arrangements were made for a VNA to
visit and check the pt.s oxygen saturation as well as chest tube
site. He was tolerating a regular diet, was given instructions
regarding follow-up appoinments, medications, and post-procedure
care. He understood this information well and was ready for
discharge.
Medications on Admission:
compazine
zofran
ativan
hyzaar
lipitor
Discharge Medications:
1. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
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:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain: - do not drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*0*
8. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
- Metastatic gastric cancer
- Malignant pleural effusion
- s/p pleurodesis and chest tube placement
Discharge Condition:
- good
Discharge Instructions:
- you may shower; no soaking in a bath tub, swimming pool, or
hot tub for several weeks
- you should eat a regular diet as tolerated
- you should take pain medications as needed
- do not drive while taking pain medications
- every day you take pain medication you should take a stool
softener: colace, senna, or dulcolax are all good options
- you should continue to use supplemental oxygen during the day
- the chest tube site dressing may come off on Saturday morning
- please call the Interventional Pulmonology clinic at
[**Telephone/Fax (1) 10084**] if T>101.5, nausea, emesis, redness or smelly
drainage from chest tube site, shortness of breath, swelling in
your extremities, or any other concern.
Followup Instructions:
**it is very important that you call to confirm the following
appointments**
Provider [**Name9 (PRE) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) **]:[**0-0-**]
Date/Time:[**2181-7-3**] 1:00
.
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-7-3**] 2:00
.
Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) **], [**Name Initial (PRE) **].D.
Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2181-7-12**] 2:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-7-11**] 2:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"934.1",
"197.2",
"427.89",
"518.81",
"401.9",
"V10.04",
"507.0",
"272.4",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"33.22",
"38.93",
"34.91",
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5579, 5650
|
2222, 4120
|
396, 454
|
5794, 5803
|
1026, 2199
|
6556, 7304
|
704, 717
|
4209, 5556
|
5671, 5773
|
4146, 4186
|
5827, 6533
|
732, 1007
|
279, 358
|
482, 583
|
605, 659
|
675, 688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,673
| 158,560
|
55030
|
Discharge summary
|
report
|
Admission Date: [**2118-3-29**] Discharge Date: [**2118-4-4**]
Date of Birth: [**2031-7-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
[**3-29**] Right Craniotomy resection of RF mass
History of Present Illness:
This is an 86 year old Spanish Speaking woman who presented to
[**Hospital1 18**] with two months of dizziness and episodic vomiting. She
was seen here at [**Hospital1 18**] last week and a Brain MRI demonstrated a
large right frontal mass and a left vestibular schwannoma.
Surgical intervention was recommended. Risks and benefits were
discussed and patient wished to proceed. She was discharged and
return [**3-29**] for surgical intervention
Past Medical History:
PVD
cataracts
Dizziness
Right frontal mass
left vestibular schwannoma
Social History:
Non smoker
Family History:
non-contributory
Physical Exam:
On Admission:
WD/WN, comfortable, NAD.
HEENT: OP clear
CV: RRR
PULM: CTAB
ABD: soft, NT, ND
EXT: no edema
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-19**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Discharge exam:
Awake, Alert, oriented x 3 in Spanish, No drift, MAE with good
strength. Sutures were clean and dry.
Pertinent Results:
MRI Brain [**2118-3-29**]:
The previously noted right frontal tumor, with small component
extending
across the midline on to the left side is redemonstrated for
surgical
planning. There is no significant change in the overall size
and shape of the lesion. The lesion measures 5.4 x 5.4 cm.
This is in close proximity to the adjacent venous tributaries
and the inferior sagittal sinus as seen on the prior study.
There is indentation on the right lateral ventricle, better seen
on the prior study. An enhancing lesion in the left CP angle and
IAC is again seen. No new lesions are noted.
Head CT [**2118-3-29**]:
IMPRESSION:
1. Status post recent right frontal craniotomy with
postoperative changes
including subcutaneous air, small amount of hemorrhage and edema
in the
surgical bed, as well as extensive bifrontal pneumocephalus,
measuring up to 23mm and exerting mass effect on the adjacent
frontal lobes. Close continued followup is recommended.
2. Known extra-axial mass in the left cerebellopontine angle is
better-
demonstrated on dedicated enhanced MRI from [**2118-3-29**].
NOTE ADDED IN ATTENDING REVIEW: As above, there is a large
amount of
post-operative pneumocephalus, with air in the anterior
interhemispheric
fissure and effacement of the subjacent frontal gyri, giving
rise to the
so-called "Mt.Fuji sign," as may be seen with tension
pneumocephalus.
Also noted is a relatively small region, roughly 3.3 cm (AP) of
likely
cytotoxic edema, at the operative bed in the right paramedian
frontovertex
(2:24-30), not present previously. This may represent a small
region of
injury/infarction.
MRI Brain [**2118-3-30**]:
IMPRESSION:
1. Status post right frontovertex craniotomy and tumor
resection, with large amount of residual subdural pneumocephalus
with mass effect as well as post-operative subdural fluid
collections and pachymeningeal enhancement.
2. Circumferential slow diffusion at the margins of the
resection bed, with only low-level enhancement, suggestive of
peri-operative ischemia.
3. Expected appearance of the post-surgical cavity with
residual blood
products, but no definite evidence of residual tumor.
4. Grossly patent principal dural venous sinuses, including the
superior
sagittal sinus.
Chest X-ray [**2118-3-30**]
Lung volumes are low exaggerating the cardiac silhouette.
Mediastinum is
unremarkable. Lungs are essentially clear. No appreciable
pleural effusion or pneumothorax is seen.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to Neurosurgery and was taken to the OR
on [**3-29**] with Dr. [**Last Name (STitle) 739**] for a right craniotomy for tumor.
She tolerated the procedure well and was extubated and taken to
the SICU. Post op head CT showed post operative changes.
Brain MRI post op showed expected post-op changes with no
residual tumor. There is a question of ischemia in the surgical
bed. She was extubated in the ICU on [**3-30**].
On [**3-31**], she was transfered to the floor. She remained stable on
the floor on [**4-1**] while working with PT and OT in order to
determine the best disposition status for her.
On [**4-2**], The patient was neurologically intact. The incision
was clean, dry and well approximated. The patient magnesium and
phosphorus were repleated.
Foley was removed in routine fashion and pt voided without
incident. On [**4-3**] she remained neurologicall stable and was
ambulating well with nrursing and family. On [**4-4**], PT declared
that patient was safe to be discharged home with home services.
She was discharged in stable condition.
Medications on Admission:
1. ketorolac 0.5 % Drops Sig: One (1) drop Ophthalmic TID (3
times a day): OU.
2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID (3 times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Discharge Medications:
1. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*90 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. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid () for 2
days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Right Frontal Mass
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:
?????? Keep your sutures clean and dry until they are removed.
?????? Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
?????? Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
?????? Exercise should be limited to walking; no lifting >10lbs,
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.
?????? DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this when cleared by the neurosurgeon.
?????? You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; you will not require blood work
monitoring.
?????? Do not drive until your follow up appointment.
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:
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with one
of the Physician Assistant in 10 days from the time of surgery
for suture removal.
Please follow up with Dr. [**Last Name (STitle) 739**] in 1 month. This
appointment can be scheduled by calling [**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2118-4-20**] at 1pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2118-4-4**]
|
[
"225.2",
"443.9",
"707.13",
"348.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
6996, 7079
|
4529, 5629
|
285, 336
|
7142, 7142
|
2065, 4506
|
8874, 9719
|
951, 969
|
6453, 6973
|
7100, 7121
|
5655, 6430
|
7325, 8851
|
984, 984
|
1944, 2046
|
236, 247
|
364, 813
|
1299, 1928
|
998, 1098
|
7157, 7301
|
835, 906
|
922, 935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,373
| 146,764
|
20724
|
Discharge summary
|
report
|
Admission Date: [**2129-5-15**] Discharge Date: [**2129-5-17**]
Date of Birth: [**2071-9-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Naproxen
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 y.o. M with metastatic melanoma to liver, now p/w bilater LE
edema, R>L and decreased urine output. Patient is a confused
historian, thus most of history is obtained from the daughter.
Daughter states patient was improving from his last admission
for C. Diff diarrhea. Over last 3 days he had progressive
worsening of LLE edema, along with a chronically swollen RLE.
The daughter was concerned of water oozing out of his leg.
Patient also had sudden worsening of mental status. over last 24
hours with more severe short term memory changes and inability
to follow commands; Patient prior to that oriented to year,
month, but not to date. Patient also complained of increased
intermittent urinary retention x 3 days. He denied any increased
thirst, but having dry mouth x 3 days, polydipsia. Patient has
been given gatorade/gingerale. He had a normal dinner and a
cinnabun this AM with some coughing after food for last 24
hours. Patient denied any recent f/c, no cough, no cp, no sob,
no palpitations, he did mentioned increased burping. Patient
does have chronic abomdinal pain for which he takes morphine ATC
and it appears it may have worsened over last few days. His
diarrhea resolved and he had a formed soft stool yesterday. At
baseline he is about 100 lbs.
.
In Ed: Patient was given 1L NS bolus (unclear how much he
received), 500 mg IV levaquin, morphine IV. Patient initially
afebrile (96.2), tachycardic to 116, with SBP 97/79, 18, 95 %
Past Medical History:
Metastatic melanoma with known liver mets
s/p traumatic splenectomy [**2108**]
s/p right ankle melanoma excision as above [**9-11**]
s/p right inguinal LN biopsy [**2126**], but inability to excise due
to close proximaty to vasculature
s/p L5-S1 discectomy [**2121**]
s/p resection SCC left arm [**2125**]
s/p R hip Fx repair [**4-16**]
C. Diff [**4-16**]
Social History:
Lives with his wife and daughter, works as a mechanic
[**Name (NI) **]: 1.5ppd x 40yrs
EtOH: no h/o abuse; none x3months
Illicits: none
Daughter [**Name (NI) 1785**] works from home for excavation company
Wife recently diagnosed with breast cancer.
Family History:
Mother d. diabetes and Alzheimer's dz. no fam h/o melanoma
Physical Exam:
95.5 105 104/71 13 92% on RA IV 20 gage
HEENT: NC, AT, diffusely icteric with dry MMM, and suggestion of
thrus
Neck: no LAD, + JVD, average size thyroid
CV: RRR, nl s1, s2, 2/6 SEM @ apex with a click
Lungs: scant crackles @ bases
Abd: decreased BS, diffuse anasarca, with hepatomegaly
Ext: + 2 pitting edema, scrotal edema
+ 2 DP b/l, no leg pain
Pertinent Results:
EKG: Sr 109, nl axis, low voltage,
.
CXR [**5-15**]: Bilateral small pleural effusions.
.
RLE u/s [**5-15**]: No evidence of deep venous thrombosis in the right
lower extremity.
.
CT head [**5-15**]: No evidence of hemorrhage or mass effect. To
exclude more subtle metastatic disease, an MR [**First Name (Titles) 151**] [**Last Name (Titles) **]
could be helpful if clinically indicated.
.
Abd u/s [**5-16**]:
1. Multiple focal liver lesions that represents metastasis.
2. Obstructing thrombosis of the infrahepatic portion of the
IVC. Portal vein has normal appearance.
3. Moderate bilateral pleural effusion.
Brief Hospital Course:
A/P: 57 y.o. M with metastatic melanoma with known liver
metastases, recent C. Diff infection who present with altered
mental status, b/l lower edema, anasarca and severe
hyponatremia.
.
Patient has a history of hyponatremia, serum sodium of 133
documented 10 days prior to admission. Serum sodium was 111 on
initial presentation, with serum Osm 245, no osmolar gap. Urine
specific gravity 1.014 consistent with hyperconcentration. He
was admitted to the ICU for further management. Etiology of
hyponatremia is likely multifactorial, but acute change was
likely due to combined polydypsia and fulminant hepatic failure.
Nephrology was consulted and recommended treatment with 3%
hypertonic saline and lasix. However, given severity and
chronicity of his condition, goals of care were transitioned to
comfort measures only as the result of extensive discussion with
ICU team and Palliative Care consult tream. Patient was
subsequently transferred from the ICU to the Oncologic Medicine
service where he received IV Morphine boluses as needed for pain
control. Prior to discharge, peripheral IV was no longer
functional and was discontinued. Per patient's request, a new
IV was deferred and his pain was managed with MS Contin 20 mg q
12 hours, plus MSIR 15-30 mg q 1 hour PRN breakthrough pain. He
was discharged to home on the morning of [**5-17**] in the care of
his family and hospice services.
Medications on Admission:
1. Metronidazole 500 mg PO TID - for a total of 14 days - 3 more
days left.
2. Furoseminde 20 mg PO QD
3. Morphine 30 mg PO Q12H
4. Morphine 15 mg PO q4 prn
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: [**1-11**] mL PO q1 hour
as needed for pain.
Disp:*100 cc* Refills:*0*
2. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*10 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Metastatic melanoma
Hyponatremia
Hepatic failure
Discharge Condition:
Critical
Discharge Instructions:
You are being discharged home with hospice care for comfort
measures. Please call Dr. [**Last Name (STitle) 24699**] office if you have any
questions or concerns about the care you are receiving at home:
([**2129**].
Followup Instructions:
N/A
|
[
"V10.83",
"782.3",
"453.2",
"197.7",
"572.8",
"276.7",
"276.1",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5459, 5550
|
3544, 4951
|
306, 313
|
5643, 5654
|
2902, 3521
|
5920, 5927
|
2458, 2518
|
5159, 5436
|
5571, 5622
|
4977, 5136
|
5678, 5897
|
2533, 2883
|
245, 268
|
341, 1795
|
1817, 2175
|
2191, 2442
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,976
| 142,575
|
50648+50649
|
Discharge summary
|
report+report
|
Admission Date: [**2115-3-27**] Discharge Date: [**2115-4-19**]
Date of Birth: [**2034-6-29**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Ace Inhibitors / Morphine / IV Dye, Iodine Containing
Contrast Media
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
Tunnelled dialysis catheter placement
Pulmonary intubation
History of Present Illness:
80M history of systolic heart failure with an ef of 25%, s/p BiV
pacer, CABG x2 with saphenous vein harvesting who is presenting
with left lower extremity swelling and rash. Recently, the
patient had been admitted to [**Hospital1 **] for renal failure where he
received ultrafiltration. He was subsequently discharged to
[**Hospital1 **] for one week of rehab. He was recently discharged from
[**Hospital1 **] and without incident yesterday he noticed a painful
swollen rash on his left leg over the site of his SVG. He said
that the pain was a "stinging" [**7-5**] of ten. It was not relieved
with OTC pain medications, but the pain resolved with time. The
patient decided to wait one day to see if the the rash resolved.
When it it did not he decided to come into to the [**Hospital1 **] for
evaluation. He reports a general malaise. He denies fevers,
chills, night sweats, chest pain, chest pressure, palpitations,
orthopnea. He reports severe shortness of breath on exertion
however, this is his baseline. He also notes a chronic cough
which he says is from "fluid overload." He denies nausea,
vomiting, or change in his bowel or bladder habits. He does note
that he is incontinent at baseline and has to wear a diaper. He
denies dysuria. He denies any pain.
In the ED, initial vs were: 98.0 69 101/48 18 99% RA. Labs were
remarkable for a creatinine of 3.1 which is his baseline. Also
an INR of 1.5 (not on anticoagulation). Patient was given
vancomycin 1 gram IV. He received lower extremity ultrasound to
rule out DVT. Vitals on Transfer: 97.6 71 18 96/53 99%ra
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies . Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
HL
HTN
DMII
CAD s/p CABG - [**2083**] (SVG-distal LAD, distal LCx, distal RCA),
re-do in [**2088**]
pAF
ventricular tachycardia s/p [**Company 1543**] biventricular ICD ([**2104**])
and s/p VT ablation ([**10/2115**])
Infarct-related cardiomyopathy with significant coronary
disease, (EF 20-25%, left ventricular systolic dysfunction with
akinesis of the inferior septum, inferior wall, and
inferolateral wall)
Atrial tachycardia s/p ablation ([**2104**], [**2105**])
Atrial flutter s/p ablation
AVNRT s/p slow pathway modification
h/o CVA ([**2088**], [**2108**]) - mild residual visual disturbance and
unsteady gait
Prostate cancer s/p TURP
Chronic renal insufficiency (baseline 2.0-2.3, more recently
3s)
h/o nephrolithiasis
Intermittent vertigo history
Mild insomnia (sleeps 2-3 hours nightly)
s/p Tonsillectomy (at age 40)
s/p Mastoidectomy
Social History:
Patient lives at home alone in [**Hospital1 3494**], MA. Patient is
independent in his ADLs. Has a walker. Retired nurse. [**First Name (Titles) 4084**] [**Last Name (Titles) 105388**] or used illicits. Usually has 1 glass of wine with dinner
but none in past 9 months. Has VNA at home and is getting a home
help aid.
Family History:
Patient is adopted. Unaware of biological family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:97.4 BP:114/57 P:71 R:16 O2:99
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, poor dentition
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: Pt with LLE swelling x1 day. Red areas around knee and up
thigh. +cellulitis. Vanco 1g given. Left leg swollen more than
right. Atrophic skin with dark venous stasis changes. 3+ pitting
edema to the thigh. Pulses 2+
Skin: Venous stasis changes b/l LE.
Neuro: II-XII grossly intact. AAOx3.
Gait deffered.
DISCHARGE EXAM:
GENERAL: 80 yo M, extubated, AAOx3 (not date but oriented to
year and president)
CHEST: no wheezes, BB rales slightly worse on left, no rhonchi,
CV: S1 S2 Normal in quality and intensity RRR, 2/6 systolic
murmur at apex.
ABD: soft, non-tender, distended, BS normoactive. no
rebound/guarding.
EXT: wwp, trace edema in LE. PT's 1+, DP's trace. Chronic venous
stasis changes, no edema.
NEURO: AAOx3 as above, conversant
SKIN: see above
Pertinent Results:
Admission Labs:
[**2115-3-27**] 03:06PM BLOOD WBC-10.6 RBC-3.45* Hgb-9.1* Hct-29.9*
MCV-87 MCH-26.3* MCHC-30.3* RDW-18.1* Plt Ct-138*
[**2115-3-27**] 03:06PM BLOOD Neuts-80.6* Lymphs-14.4* Monos-4.3
Eos-0.5 Baso-0.1
[**2115-3-27**] 03:06PM BLOOD PT-16.3* PTT-37.0* INR(PT)-1.5*
[**2115-3-27**] 03:06PM BLOOD Glucose-153* UreaN-60* Creat-3.1* Na-136
K-3.5 Cl-95* HCO3-27 AnGap-18
[**2115-3-29**] 03:00PM BLOOD ALT-40 AST-64* LD(LDH)-220 AlkPhos-236*
TotBili-1.0
[**2115-3-29**] 09:39AM BLOOD CK-MB-4 cTropnT-0.11*
[**2115-3-28**] 05:40AM BLOOD Calcium-8.4 Phos-5.3*# Mg-2.4
[**2115-3-28**] 05:40AM BLOOD Vanco-12.7
Urine:
[**2115-3-30**] 07:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2115-3-30**] 07:47PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.0 Leuks-MOD
[**2115-3-30**] 07:47PM URINE RBC-2 WBC-40* Bacteri-FEW Yeast-NONE
Epi-0
[**2115-3-30**] 07:47PM URINE Hours-RANDOM UreaN-383 Creat-87 Na-21
K-50 Cl-11
[**2115-3-30**] 07:47PM URINE Osmolal-328
REPORTS:
CXR [**4-2**]: As compared to the previous radiograph, there is no
relevant
change. The monitoring and support devices are constant. There
is moderate cardiomegaly with retrocardiac atelectasis. The
mild perihilar opacity on the right is unchanged. No evidence
of larger pleural effusions. The diameter of the vascular
structures might indicate mild fluid overload, as observed on
[**2115-4-1**], 4:15 a.m.
No newly appeared parenchymal opacities
CXR [**4-1**]:Compared to the previous radiograph, the film focuses on
the upper
abdomen. The tip of the esophageal tube projects over the left
upper
quadrant. A wet read was entered into the system.
With the given technical limitations, there are no other
changes. Moderate cardiomegaly with extensive retrocardiac and
mild right perihilar opacity. No larger pleural effusions.
UEs US/Mapping [**4-9**]:
1. No indirect evidence of arterial insufficiency to either
upper extremity or indirect evidence of central venous stenosis
involving either upper extremity.
2. Patent bilateral cephalic and basilic veins.
3. Note of no arterial calcifications; however, paired right
brachial
arteries.
EEG [**4-11**]:
Abnormal EEG due to the very low voltage background
activity, no definite activity of cortical origin. These
findings are
indicative of a severe encephalopathy. The most common causes of
such
encephalopathies are anoxia and substantial sedating
medications. Of
note, this recording was not done in order to evaluate presence
or
absence of cortical activity and so cannot be used for
prognosis. There
were no focal abnormalities but encephalopathies can obscure
focal
findings. There were no epileptiform features.
CT head [**4-12**]:
FINDINGS: There is no acute intracranial hemorrhage, edema,
mass, mass
effect, or infarction. There is cystic encephalomalacia of the
right
occipital lobe consistent with old infarction. Prominence of
the ventricles and sulci is consistent with age-related
involutional changes. A focus of hypoattenuation in the right
putamen is consistent with an old lacunar infarct.
Periventricular and subcortical white matter hypodensities are
suggestive of chronic small vessel ischemic disease. There is
no fracture. The visualized paranasal sinuses are clear. There
is chronic and likely developmental underpneumatization of the
right mastoid air cells which are nevertheless clear. The left
mastoid air cells and bilateral middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
CXR [**4-13**]:
ET tube is in standard placement. Severe cardiomegaly is
unchanged. There is no longer any pulmonary edema. There is
probably small volume of pleural fluid bilaterally, particularly
on the left because of the persistent left lower lobe collapse.
No pneumothorax. Dual-channel right supraclavicular dialysis
catheters end in the low SVC and upper right atrium
respectively. Atrio-biventricular pacer defibrillator leads are
also unchanged in their positions. Nasogastric tube ends in the
stomach which is not distended. No pneumothorax or free air
below the diaphragm.
DISCHARGE LABS:
[**2115-4-19**] 04:41AM BLOOD WBC-6.8 RBC-3.32* Hgb-8.8* Hct-28.5*
MCV-86 MCH-26.5* MCHC-30.9* RDW-21.0* Plt Ct-103*
[**2115-4-18**] 05:08AM BLOOD PT-16.7* PTT-39.2* INR(PT)-1.6*
[**2115-4-19**] 04:41AM BLOOD Glucose-84 UreaN-19 Creat-3.6*# Na-143
K-3.9 Cl-104 HCO3-28 AnGap-15
[**2115-4-18**] 05:08AM BLOOD ALT-16 AST-23 LD(LDH)-230 AlkPhos-108
TotBili-0.6
[**2115-4-19**] 04:41AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1
Brief Hospital Course:
MICU COURSE
Patient presented to the ICU with altered mental status and
respiratory distress unable to protect his airway. Saturations
were in the mid 80's on room air with improvement to the 90's on
NRB. Noted to be hypotensive to the high 80's/low 90's
systolic. Addditionally, having jerking movements concerning
for seizure activity. Given respiratory distress, was intubated
on admission to the ICU and a R IJ CVL was placed for BP
support. A-line was placed for BP monitoring. Continued to
have worsening urine output, but improved mental status while
holding cefepime, mexilitine, and quinidine.
CCU COURSE #1
The patient was transferred to the CCU on [**2115-4-5**]. The patient
was transferred out of the CCU on [**2115-4-8**]. In summary, the pt is
an 80y/o gentleman with CAD s/p CABG x2, sCHF EF 25%,
VT/AT/AVNRT s/p ICD and ablation, CKD, DM2 and chronic venous
stasis who initially presented with LLE cellulitis, course
complicated by worsening CHF unresponsive to diuresis, [**Last Name (un) **]
progressing to uremia requiring HD, AMS with myoclonus requiring
intubation for airway protection, and superimposed pustular MSSA
cellulitis, who was subsequently extubated with gradually
improving mental status and transferred to the CCU due to
hemodynamically stable monomorphic VT.
#. Monomorphic VT: Pt has a history of VT/AT/AVNRT. He went into
VT on the floor and was transferred to CCU. He was
hemodynamically stable throughout VT on CCU course #1. He is s/p
multiple procedures and ICD for his various arrythmias. Likely
mechanism of his VT was thought to be re-entry from
ischemia-related scar. Reason for recurrence was thought to be
mild ischemia at HD on the day of transfer due to his
anti-arrhythmics being held. Quinidine was restarted as well as
his home dose of mexiletine. He was also started on a lidocaine
drip which was quickly weaned. He had a few rare episodes of VT
in the CCU that were self-terminating. He remained asymptomatic
and hemodynamically stable throughout CCU course #1. He has an
ICD for additional rhythm control. Of note, quinidine must be
dosed AFTER dialysis or it will get removed (see below).
#. Altered mental status: pt had continued AMS on arrival to CCU
during CCU #1, but this resolved during his CCU course. No focal
neuro deficits. Blood cultures were negative.Initially AMS was
accompanied by myoclonus which resolved during CCU course: per
neuro this was probably [**12-27**] uremia. Also had LP given vesicular
rash with concern for viral encephalitis: HSV/VZV PCR negative
and no e/o infection in CSF. Also had EEG which was negative per
neuro. Likely AMS was toxic-metabolic in nature with multiple
contributing causes including uremia and infection. He was
treated for cellulitis with antibiotics and initiated on HD for
renal failure. With these interventions, he became AAOx3
(oriented to year and president but not date) and improved, but
not at his previous baseline. This is likely his new baseline,
which can be characterized as responsive to questions,
appropriate, but sluggish, with somewhat slurred speech, and
alert. He was reluctant to participate in activities but agreed
to with frequent prompting.
#. LLE cellulitis: Initially dx with non-purulent cellulitis,
which he is at increased risk for given chronic BLE venous
stasis. In ICU developed superimposed vesicular rash
(non-dermatomal pattern) for which derm consult was consulted:
no HSV/VZV in CSF or vesicular swab. Vesicular bacterial swab
did grow out MSSA pan-sensitive to antibiotics. He was on Vanco
dosed per HD protocol and completed a 10d course of this with
resolution of his cellulitis. He remained afebrile without
leukocytosis after stopping abx and his rash did not recur.
#. [**Last Name (un) **] on CKD: Patient has been hospitalized multiple times for
renal failure and required UF once in the past. This time his
renal failure worsened on the floor in the setting of volume
overload, then was refractory to diuretics [**12-27**] poor forward
flow. Also complicated by severe right heart failure causing
preload dependence which made volume status management
difficult. Started temporary HD via tunneled line during this
hospitalization. He will likely need permanent dialysis in the
long run. PPD placed and was negative. Added on hepatitis
serologies which were neg for HAV and HCV but c/w past infection
to HBV. Obtained vein mapping and baseline PTH.
#. sCHF [**12-27**] ischemia: EF 25%. Has ischemic CM including right
heart failure causing significant preload dependence.
Hypervolemic on exam on CCU admission. Removed several liters of
volume with HD. Held ACE/[**Last Name (un) **] given renal failure. If pt HD
dependent, can restart these, but for now held off in case pt
recovered some renal function. Likely pt will not benefit from
long-term effects of these so there is low urgency to start
these. Started isosorbide dinitrate 10mg po BID and hydralazine
10mg QID to reduce preload and afterload.
# PAF: Pt is on aspirin 325mg daily for PAF per dr. [**Last Name (STitle) **]. no
other anticoag b/c of prostate bleeding history. continued this.
#. C. diff: pt developed loose stools prior to CCU transfer. He
also had lower abdominal tenderness. Checked stool c.diff and it
was positive. He was initiated on IV flagyl and and his diarrhea
and abdominal tenderness improved. He never had leukocytosis or
fever but was recently treated with multiple abx including
vanco, clinda, cefepime, and zosyn. He was switched to po flagyl
and should complete his course on [**2115-4-22**].
CCU COURSE #2
# PEA ARREST: The patient was transferred to the CCU on [**2115-4-11**]
s/p PEA arrest. Overnight, on the floor, he had an episode of
chest pain and tachypnea at approximately 12:30am, although he
was saturating well (> 95% on room air). EKG was unchanged from
prior, V-paced. Troponin mildly elevated, in the setting of
dialysis dependent renal injury. CXR was unchanged from prior.
At approximately 4:20am, code blue was called for patient
unresponsive and pulseless. Rhythm appeared to be PEA on
monitor. Compressions were started immediately. Patient was
intubated, received two doses of epinephrine, calcium and sodium
bicarb. The patient recovered a pulse and was transferred to
the CCU and was intubated. Patient was started on norepinephrin
0.2mcg/kg/min. Patient??????s family was notified of the event. Mr.
[**Known lastname **] was extubated and weaned off of pressors successfully. He
was initially quite altered, but then became oriented to self,
[**Hospital1 18**] and was able to carry on a conversation, responding
approprpriately. He confirmed his desire to be full code and
proceed with dialysis. Head CT was obtained and did not show any
ICH or edema. His renal function continued to be poor, but
dialysis was difficult to initiate in the setting of tenuous
blood pressures (80s to 90s) and the worry that SBPs would drop
with large fluid shifts. Patient did have dialysis in house and
tolerated it well. Of note, quinidine must be dosed AFTER
dialysis or it will get removed. Mexilitine is not dialysed and
can be dosed by the usual regimen. Alternatively, it is also
possible to give BOTH mexilitine and quinidine AFTER HD if this
is more convenient and will avoid confusion. The above issues
mentioned in first CCU course remained stable.
TRANSITIONAL ISSUES:
- finish c. diff course (last dose [**2115-4-22**])
- continue HD
- dose quinidine after HD session
- pt's sluggish response to questions and flat affect appear to
be a new baseline for him, perhaps as a result of anoxic brain
injury. He is, however, alert and responds to questions at
baseline. AAOx3 (oriented to year and president but not date).
ADDENDUM - PATIENT WAS TRANSFERRED TO [**Hospital3 **] HOSPITAL
IN [**Hospital1 **]. ON ARRIVAL THERE, THE PATIENT WAS FELT TO BE
CONFUSED AND WAS THEREFORE TRANSFERRED BACK TO THE [**Hospital1 18**]
EMERGENCY ROOM.
Medications on Admission:
atorvastatin 20 mg qhs
quinidine gluconate 324 mg q8h
isosorbide dinitrate 20 mg TID
nitroglycerin 0.3 mg SL prn chest pain
ascorbic acid 1,000 mg daily
aspirin 325 mg daily
cholecalciferol 2,000 unit daily
cod liver oil 1 tbsp daily
folic acid 400 mcg daily
mineral oil 2 tbsp daily
multivitamin 1 tablet daily
vitamin E 400 unit daily
B Complex 1 tablet daily
mexiletine 150 mg q8h
metoprolol succinate 50 mg daily
torsemide 60 mg daily
Lantus 16 units qhs
Discharge Medications:
1. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed as needed for chest pain.
3. heparin (porcine) 1,000 unit/mL Solution Sig: [**2102**]-8000 units
Injection PRN (as needed) as needed for dialysis.
4. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days: Last day [**4-22**].
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
6. quinidine sulfate 200 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours: dose AFTER hemodialysis .
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
cellulitis
acute on chronic kidney injury necessitating hemodialysis
acute on chronic systolic congestive heart failure
ventricular tachycardia
diabetes mellitus
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 came to the hospital because you had cellulitis. You had a
lot of complications during your treatment, including worsening
of your heart failure and kidney function and inability to
manage your fluid status, which led to initiationg of
hemodialysis. On discharge, you will continue to have dialysis.
You also developed confusion from your kidney failure and
infection and you were intubated to protect your breathing.
After dialysis and treatment with antibiotics, you improved and
the breathing tube was removed. You were transferred for the
cardiac ICU for an irregular heart rhythm (ventricular
tachycardia) but this improved by putting you back on your home
medications.
During the hospitalization, your heart stopped. You were
resuscitated with CPR and you were intubated. You recovered
after this episode.
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.
Multiple changes were made to your medications. Your new
medication list is attached and should be followed as directed.
Do not continue to take any other medications, including old
medications, unless they are listed.
Followup Instructions:
Dr. [**Last Name (STitle) **] will arrange for cardiology follow up.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-5-7**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2115-6-5**] at 3:00 PM
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
Admission Date: [**2115-4-19**] Discharge Date: [**2115-5-1**]
Date of Birth: [**2034-6-29**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Ace Inhibitors / Morphine / IV Dye, Iodine Containing
Contrast Media
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80-year-old male with history of CAD s/p CABG x2, chronic
systolic heart failure with EF of 25%, s/p BiV pacemaker with
very recent admission with cellulitis complicated by renal
failure and HD inititiation, PEA arrest, with resultant short
term memory loss and delirium who presents from rehab with
delirium.
The patient was discharged [**4-19**] with a discharge status of
delirium with visual hallucinations and short term confusion who
presented to rehab and was immediately sent back to [**Hospital1 18**] for
concern of mental status. Per report he was given a piece of
paper and attempted to sign it with his finger. For full details
on the prior admission please see the discharge summary from
[**4-19**].
In the ED, initial vitals were: T 98, HR 70, BP 109/54, RR 20,
SvO2 99% on RA. A code stroke was called due to confusion and
slight assymetry on face. The CCU team and neurology evaluated
the patient and thought consistent with delirium and prior
deficits from CVAs. CT head was done and was negative for acute
intracranial process (on prelim read). CXR with edema but no
infiltrate. UA with many WBCs. Per report looks like pus. He was
given CTX and 1L of NS. Vitals on transfer were: HR 80, BP
99/54, RR 20, SvO2 95% RA. Access: power picc, HD.
Currently, he states that he does not feel well, however, he
cannot describe this further.
REVIEW OF SYSTEMS: Unable to obtain. Patient confused. He denies
any pain or shortness of breath.
Past Medical History:
HL
HTN
DMII
CAD s/p CABG - [**2083**] (SVG-distal LAD, distal LCx, distal RCA),
re-do in [**2088**]
pAF
ventricular tachycardia s/p [**Company 1543**] biventricular ICD ([**2104**])
and s/p VT ablation ([**10/2115**])
Infarct-related cardiomyopathy with significant coronary
disease, (EF 20-25%, left ventricular systolic dysfunction with
akinesis of the inferior septum, inferior wall, and
inferolateral wall)
Atrial tachycardia s/p ablation ([**2104**], [**2105**])
Atrial flutter s/p ablation
AVNRT s/p slow pathway modification
h/o CVA ([**2088**], [**2108**]) - mild residual visual disturbance and
unsteady gait
Prostate cancer s/p TURP
Chronic renal insufficiency (baseline 2.0-2.3, more recently
3s)
h/o nephrolithiasis
Intermittent vertigo history
Mild insomnia (sleeps 2-3 hours nightly)
s/p Tonsillectomy (at age 40)
s/p Mastoidectomy
Social History:
Patient lives at home alone in [**Hospital1 3494**], MA. Patient is
independent in his ADLs. Has a walker. Retired nurse. [**First Name (Titles) 4084**] [**Last Name (Titles) 12627**] or used illicits. Usually has 1 glass of wine with dinner
but none in past 9 months. Has VNA at home and is getting a
home help aid. [**Last Name (LF) **], [**Name (NI) **] [**Name (NI) 111**] is involved in care. HCP
[**Name (NI) 2048**] [**Name (NI) 68568**].
Family History:
Patient adopted. Unaware of biological family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T= 98.1 BP= 112/54 HR= 83 RR= 17 O2 sat= 95% RA
GENERAL: Chronically ill appearing elderly male, AOx2.
HEENT: atraumatic, poor dentition, EOMI, PERRL.
Neck: Middle JVD, no rigidity
CARDIAC: Soft sounds, S1, S2, no m/r/g appreciated.
LUNGS: CTAB, anterior examination, no accessory muscle use
ABDOMEN: Soft, NTND. No suprapubic tenderness.
EXTREMITIES: Chronic venous stasis changes, no edema.
SKIN: No ulcers or xanthomas. Warm.
NEURO: slight asymetry to face when smiling. Limited exam. CN
II-XII grossly intact. Normal tone. Poor short term memory. See
neurology consult note for additional details.
Discharge Physical Exam:
Patient [**Name (NI) **]
Pertinent Results:
ADMISSION LABS:
[**2115-4-18**] 05:08AM BLOOD WBC-8.2 RBC-3.41* Hgb-8.9* Hct-29.7*
MCV-87 MCH-26.0* MCHC-29.9* RDW-21.1* Plt Ct-141*
[**2115-4-19**] 04:41AM BLOOD WBC-6.8 RBC-3.32* Hgb-8.8* Hct-28.5*
MCV-86 MCH-26.5* MCHC-30.9* RDW-21.0* Plt Ct-103*
[**2115-4-19**] 03:45PM BLOOD WBC-6.9 RBC-3.42* Hgb-9.0* Hct-29.5*
MCV-86 MCH-26.2* MCHC-30.4* RDW-21.0* Plt Ct-104*
[**2115-4-20**] 05:20AM BLOOD WBC-7.4 RBC-3.29* Hgb-8.8* Hct-28.5*
MCV-87 MCH-26.7* MCHC-30.8* RDW-21.1* Plt Ct-110*
[**2115-4-18**] 05:08AM BLOOD PT-16.7* PTT-39.2* INR(PT)-1.6*
[**2115-4-19**] 03:45PM BLOOD PT-16.8* PTT-43.3* INR(PT)-1.6*
[**2115-4-20**] 05:20AM BLOOD PT-16.9* PTT-39.2* INR(PT)-1.6*
[**2115-4-18**] 05:08AM BLOOD Glucose-109* UreaN-38* Creat-5.5*# Na-142
K-4.1 Cl-103 HCO3-28 AnGap-15
[**2115-4-19**] 04:41AM BLOOD Glucose-84 UreaN-19 Creat-3.6*# Na-143
K-3.9 Cl-104 HCO3-28 AnGap-15
[**2115-4-20**] 05:20AM BLOOD Glucose-90 UreaN-27* Creat-4.6* Na-141
K-4.0 Cl-102 HCO3-28 AnGap-15
[**2115-4-18**] 05:08AM BLOOD ALT-16 AST-23 LD(LDH)-230 AlkPhos-108
TotBili-0.6
[**2115-4-19**] 04:41AM BLOOD proBNP-[**Numeric Identifier 105389**]*
[**2115-4-19**] 03:45PM BLOOD CK-MB-3
[**2115-4-19**] 03:45PM BLOOD cTropnT-0.16*
[**2115-4-20**] 05:20AM BLOOD CK-MB-2 cTropnT-0.17*
[**2115-4-19**] 03:49PM BLOOD Glucose-118* Na-140 K-4.0 Cl-100
calHCO3-42*
URINE:
[**2115-4-19**] 05:44PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2115-4-19**] 05:44PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2115-4-19**] 05:44PM URINE RBC-25* WBC->182* Bacteri-NONE Yeast-NONE
Epi-0
MICRO:
Urine ([**4-19**]): NGTD
Blood ([**4-19**] x4): NGTD
STUDIES:
CT Head non-con ([**4-19**]):
INDINGS: There is no acute hemorrhage, edema, mass effect, or
acute
territorial infarction. The ventricles and sulci are prominent
consistent
with generalized atrophy. There is a large area of
encephalomalacia in the right occipital lobe, unchanged from
prior CT. Old right lenticular lacune is noted. There is no
fracture. Again noted are underpneumatized right mastoid air
cells. The visualized paranasal sinuses, left mastoid air
cells, and middle ear cavities are clear.
IMPRESSION: No evidence of acute intracranial process.
CXR ([**4-19**]):
IMPRESSION: Status post extubation. Findings suggesting mild
pulmonary
edema. Persistent left basilar opacification, but somewhat
improved.
Brief Hospital Course:
80-year-old male with history of CAD s/p CABG x2, chronic
systolic heart failure with EF of 25%, s/p BiV pacemaker with
very recent admission with cellulitis complicated by renal
failure and HD inititiation, PEA arrest, with resultant short
term memory loss and delirium who presented from rehab with
delirium with concern of sepsis with urinary tract infection. He
continued to decline during his hospitalization with worsening
of his delirium. After discussion with his health care proxy,
the decision was made to transition his care to comfort measures
only, and Mr. [**Known lastname **] [**Last Name (Titles) **] on [**2115-5-1**].
# Altered mental status: There were likely multiple etiologies
including anoxic brain injury, delirium and possible infection.
The anoxic brain injury is not treatable at this time. The
delirium is likely precipitated by his prolonged recent ICU stay
including intubation. We tried to maintain normal sleep/wake
cycle, frequent reorientation, limit tethering. We obtained
blood and urine cultures and started him initially on vancomycin
and ceftriaxone. The cultures were negative for 36 hours at
which time they were discontinued. The patient remained afebrile
during his hospitalization. Head CT and CXR did not show any
acute proscess. There was evidence of old occipital infarcts.
Delirium continued to worsen in the context of hypotension
associated with hemodialysis and then worsening metabolic state
after HD was discontinued. He received Haldol, Ativan, and
olanzapine for agitation, which became more frequent,
particularly at night, over the course of his hospital
admission.
.
# Hypotension: Patient tolerated pressures in the 90s during
hemodialysis, but may have ultimately exacerbated his delirium.
Hemodialysis was discontinued when decision was made for comfort
measures only, and his pressures improved. Patient had a history
of requiring substantial preload and gentle IVF was provided prn
to maintain volume status.
.
# Ventricular tachyarrhythmia: Patient was continued on
quinidine and mexilitine until CMO. BiV ICD was stopped at that
time but pacer was kept on until patient [**Year (4 digits) **].
# CAD: s/p CABG. Admitted on aspirin and as per neurology, we
initially increased his dose to 325. Discontinued ASA when CMO.
.
# Systolic CHF: Breathing on room air at time of admission, but
oxygen requirement increased over the course of the admission.
Crackles were observed intermittently on pulmonary exam, but JVD
was not observed until HD was stopped and patient received fluid
bolus. Mr. [**Known lastname **] developed an increasing oxygen requirement,
initially by nasal cannula, then face mask, as secretions
worsened. These were treated with a scopolamine patch and
glycopyrrolate with limited effect.
.
# h/o CVA: Per neuro consult note recommend warfarin for INR >2.
However due to concern for risk of falls or bleeding, we
increased aspirin to 325mg and started him on a statin to
minimize future strokes. These were discontinued when
transitioned to CMO.
.
# Renal failure: Admitted on HD, which caused hypotension and
may have contributed to low volume status exacerbating delirium.
HD was discontinued as care was transitioned to an emphasis on
comfort.
.
# Nutrition: Patient was tolerating POs at time of admission,
but his PO intake decreased as his delirium worsened.
Medications on Admission:
- mexiletine 150 mg PO Q8H
- nitroglycerin 0.3 mg Tablet Sublingual as directed as needed
for chest pain
- heparin (porcine) 1,000 unit/mL Solution Sig: [**2102**]-8000 units
Injection PRN (as needed) as needed for dialysis
- metronidazole 500 mg PO Q8H Last day [**4-22**]
- aspirin 81 mg PO daily
- quinidine sulfate 200 mg PO every eight (8) hours: dose AFTER
hemodialysis
- Nephrocaps 1 mg PO daily
Discharge Medications:
-
Discharge Disposition:
[**Month/Year (2) **]
Discharge Diagnosis:
-
Discharge Condition:
Patient [**Month/Year (2) **].
Discharge Instructions:
-
Followup Instructions:
-
Completed by:[**2115-5-19**]
|
[
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"276.2",
"438.89",
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"682.6",
"427.5",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.97",
"39.95",
"38.95",
"96.6",
"99.60",
"96.04",
"03.31",
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] |
icd9pcs
|
[
[
[]
]
] |
31268, 31291
|
27435, 28083
|
21367, 21373
|
31336, 31368
|
24980, 24980
|
31418, 31450
|
24208, 24263
|
31242, 31245
|
31312, 31315
|
30815, 31219
|
31392, 31395
|
9108, 9526
|
24303, 24910
|
4502, 4937
|
16921, 17488
|
22776, 22857
|
21306, 21329
|
2026, 2431
|
21401, 22757
|
24996, 27412
|
28098, 30789
|
22879, 23727
|
23743, 24192
|
24935, 24961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,368
| 109,685
|
45341+58809
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-9-10**] Discharge Date: [**2191-9-15**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Hemorrhage of LUE AVF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 y.o. M with ESRD on HD via LUE AVF presented to [**Hospital 4068**] Hosp
with hemorrhage of LUE AVF after dialysis.Gets HD at [**University/College **]
on a Mon and [**University/College 2974**] only schedule. Started using AVF about 2
weeks ago. Infiltrated at HD on [**Name6 (MD) 2974**] [**Name8 (MD) **] RN immediately took
needles out and used catheter. He was sent home. He noted some
bleeding at AVF, pain then felt diaphoretic and weak. EMS found
him with BP of 60/palp. Hypotensive with SBP in 60's, ptt >150.
He was given protamine/6L of NS/3 units of PRBC who developed a
large left anterior chest hematoma. EKG showed NSTEMI with a
troponin of 0.131. T waves were inverted anteriorly. He did not
have chest pain. Transferred to [**Hospital1 18**] SICU for close monitoring
on [**9-10**]. Admitted to SICU B with Hct 25.
Past Medical History:
PMH: CAD, Bladder CA, HTN, Renal Failure on HD via LUE AVF
PSH: Cystectomy 25 [**Last Name (un) **], CABG [**98**] [**Last Name (un) **], Corneal tx 8 [**Last Name (un) **], LAVF 3
mo ago
Social History:
lives with [**Age over 90 **] y.o. wife
Family History:
N/C
Physical Exam:
aaO x3, pale, NAD
RRR, no MRG
Rales on left side, right clear to auscultation. L chest wall
obviously expanded. tight chest skin. no active evidence of
expansion
soft, NT/ND/+BS
Lue stitch intact at small needle hole intact. severee
ecchymosis of LUE. palp thrill of avf, palp radial pulse. +
neuro exam throughout pin prick
Pertinent Results:
[**2191-9-15**] 06:50AM BLOOD WBC-8.6 RBC-3.00*# Hgb-9.3* Hct-27.8*
MCV-93 MCH-31.1 MCHC-33.6 RDW-18.5* Plt Ct-152
[**2191-9-14**] 06:10AM BLOOD WBC-9.0 RBC-2.39* Hgb-7.8* Hct-23.0*
MCV-96 MCH-32.6* MCHC-33.8 RDW-17.6* Plt Ct-151
[**2191-9-15**] 06:50AM BLOOD Glucose-87 UreaN-46* Creat-4.0* Na-140
K-3.9 Cl-102 HCO3-24 AnGap-18
[**2191-9-15**] 06:50AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.7
Brief Hospital Course:
He arrived via med flight to ED awake and alert. In ED noted to
have expanding hematoma tracking up arm from fistula into the
chest wall with a very large amt of blood in the chest wall. A
CT torso at [**Last Name (un) 4068**] was negative for aortic abnormality or
retroperitoneal bleed. Three liters of fluid and 2 units of PRBC
were given at [**Last Name (un) 4068**] then he received aother unit of PRBC here
at [**Hospital1 18**] as well as 2 units of FFP and a six pack of platelets.
A small needle hole was noted in AVF. A single stitch was placed
with hemostasis. HCT slowly trended down each day to 23.4 on
[**9-12**]. Epogen was given at dialysis. He was admitted to the SICU
for monitoring with serial hematocrits drawn. An U/S was done to
assess for active bleeding. This was a limited study due to
extensive hematoma. No pseudoaneurysm was visualized. His arm
was kept elevated. Tylenol was given for comfort. On [**8-14**], Hct
decreased to 23. He was transfused with 2 units of PRBC while in
hemodialsyis. Hemodialsyis was done via the R tunnelled HD line.
Upon admission, cardiac enzymes were cycled for previously noted
T wave changes. These were negative for MI. He was dialyzed via
the tunnelled HD line on [**9-12**] for 1.5 liters and again on [**9-14**].
Vital signs remained stable. The LUE arm circumference measured
12 inches with extensive bruising. Sensation was intact.
Diet was advanced and tolerated. Ileo conduit was draining well.
PT and OT evaluated him given that his wife reported that he had
fallen at home and that she was not strong enough to assist him
to get up. PT recommended rehab. He will be discharged to
[**Location (un) 582**] at [**Location (un) 620**], [**Telephone/Fax (1) 63378**].
Medications on Admission:
aspirin 81mg qd, zocor 80mg qd, niacin 500mg qd, lasix 20mg qd,
hctz 50mg qd, atenolol 50mg qd, felodipine 2.5mg qd, predforte
1% every other day
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO prn: 4 hours if
needed for pain as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
while taking percocet to prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Niacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic every other day.
9. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
ESRD
Bleeding of LUE AVF
LUE/L chest hematoma
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if increased
swelling, bruising/bleeding of left arm/chest or if malfunction
of dialysis line
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2191-9-29**]
9:00
Completed by:[**2191-9-15**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15401**]
Admission Date: [**2191-9-10**] Discharge Date: [**2191-9-15**]
Date of Birth: [**2101-9-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2648**]
Addendum:
correction: HCTZ dose is 50mg po qd
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 176**] Of [**Location (un) 407**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2191-9-15**]
|
[
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"585.6",
"275.41",
"V45.81",
"V10.51",
"287.5",
"V44.59",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6189, 6423
|
2218, 3958
|
283, 290
|
5339, 5348
|
1806, 2195
|
5562, 6166
|
1441, 1446
|
4154, 5149
|
5270, 5318
|
3984, 4131
|
5372, 5539
|
1461, 1787
|
222, 245
|
318, 1156
|
1178, 1368
|
1384, 1425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,924
| 142,313
|
3197
|
Discharge summary
|
report
|
Admission Date: [**2194-10-27**] Discharge Date: [**2194-11-12**]
Service: MEDICINE
Allergies:
Amoxicillin / Sulfonamides / Penicillins
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
-Open reduction internal fixation of right hip
-Closed reduction of right distal radius with manipulation.
-Endotracheal Intubation
-Placement of a Right Internal Jugular Central Venous Line
History of Present Illness:
Ms. [**Known lastname 15011**] is an 87 year old woman with past medical history of
HTN, glaucoma, OA, and recently diagnosed pancreatic/[**Known lastname 499**] CA
with ?liver mets who presented s/p unwitnessed fall at her
[**Hospital3 **] facility. She was found on the ground by her
aide complaining of severe right hip pain.
In the ED, the patient was found to have low HCT 23.6. She was
crossmatched 4 units and consented. She was placed in a C-collar
and had a CT C-spine. Xray showed right hip fracture. She was
given IV Morphine for pain control.
Overnight, the patient was transfused 2 units of pRBCs. She was
unable to answer questions appropriately [**1-13**] to pain. She does
not remember anything from the fall. The daughter reports that
the patient is ambulatory at baseline and relies on her aide for
all ADLs.
Past Medical History:
-newly discovered likely pancreatic, [**Month/Day (2) 499**] ca with liver mets
(pt unaware)
-HTN
-glaucoma
-OA
-?Rheum dx
-LBP
Social History:
Pt lives at [**Hospital3 **], aide helps with all ADLs. No
smoking, ETOH, drug use.
Family History:
No history of [**Hospital3 499**] cancer, IBD, breast cancer, CAD, diabetes,
rheumatic diseases, asthma.
Physical Exam:
(Per Admitting Resident)
Vitals:T.98.2, BP 150/83, HR 108, RR 16, sat 97% on RA.
General: sleeping comfortable, C-collar in place. Family
requests no distruptions.
HEENT:nc/at, MMM,
Neck: C-collar in place.
Lungs: Clear to auscultation anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, +3/6 systolic
crescendo/decrescendo murmur loudest in aortic area.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 1+pitting edema.
neuro: unable to assess.
Pertinent Results:
ADMISSION LABS [**2194-10-27**]:
BLOOD
[**2194-10-27**] 09:00PM WBC-13.1* Hgb-6.9* Hct-23.6* Plt Ct-468*
[**2194-10-27**] 09:00PM Neuts-81.9* Lymphs-11.2* Monos-3.9 Eos-2.8
Baso-0.2
[**2194-10-27**] 09:00PM PT-11.5 PTT-19.5* INR(PT)-1.0
[**2194-10-27**] 09:00PM Glucose-187* UreaN-29* Creat-1.2* Na-136 K-4.4
Cl-102 HCO3-26 AnGap-12
[**2194-10-27**] 09:00PM CK(CPK)-49
[**2194-10-27**] 09:00PM CK-MB-3 cTropnT-0.07*
U/A
[**2194-10-28**] 02:33AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2194-10-28**] 02:33AM Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2194-10-28**] 02:33AM RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1
[**2194-10-28**] 02:33AM Mucous-RARE
MICROBIOLOGY:
[**2194-10-28**], [**2194-10-29**] 2 Urine Cx grew e. coli
[**2194-10-30**], [**2194-11-3**] 2 Urine Cx Negative
[**2194-11-6**], [**2194-11-8**] 2 Urine Cx grew yeast
C.Diff negative x 2
Blood Cx negative x 5 (2 pending at d/c)
BAL Respiratory Viral Cx Negative; BAL Gram Stain Negative
Sputum Cx ([**2194-10-30**]): 3+ GRAM NEGATIVE DIPLOCOCCI.; 1+ MULTIPLE
ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.; Resp Cx grew out
yeast (sparse growth)
RADIOLOGY:
CT C-Spine ([**2194-10-27**]) -IMPRESSION:
1. No acute fracture of the cervical spine.
2. Minimal anterolisthesis of C4 over C5 and C7 over T1 and
minimal retrolisthesis of C5 over C6 of indeterminate age, but
could be degenerative. Clinical correlation advised. Severe
osteopenia and degenerative changes. MRI is a more sensitive
modality to evaluate for ligamentous or spinal cord injury.
3. Sub-cm right thyroid nodule. 1.3 x 0.9 cm nodule posterior to
the right lobe of the thyroid may represent a parathyroid
adenoma versus a thyroid nodule. Correlation with thyroid
ultrasound on a non-emergent basis suggested.
CT Head ([**2194-10-27**]) - IMPRESSION: No acute intracranial
abnormality.
Hip X-Ray ([**2194-10-27**]) - IMPRESSION:
1. Intertrochanteric-subtrochanteric fracture of the femur
extending to the lesser trochanter with varus angulation.
2. Severe osteopenia.
Wrist X-Ray ([**2194-10-28**]) - IMPRESSION:
1. Right wrist -- Colles fracture with dorsal angulation of the
distal radial articular surface. Question acute or subacute.
2. Left wrist -- findings essentially representing SLAC wrist
(scapholunate advanced collapse), unlikely to be acute. No acute
fracture identified. No chondrocalcinosis.
3. Bilateral severe osteopenia and osteoarthritis.
CXR ([**2194-10-29**]) - IMPRESSION: New left lower lobe atelectasis
with pleural effusion could be due to aspiration. Early followup
chest radiograph recommended.
CXR ([**2194-10-29**]; at time of MICU transfer) - As compared to the
previous radiograph, there is no relevant change. Borderline
size of the cardiac silhouette, moderate retrocardiac
atelectasis. Presence of minimal left-sided pleural effusion
cannot be excluded. No evidence of overhydration. No focal
parenchymal opacity suggesting pneumonia. No pneumothorax.
CXR ([**2194-11-3**]; at time of MICU callout) - IMPRESSION:
Significant interval improvement in multifocal airspace
opacities.
Echo ([**2194-10-30**]) - The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.2 -1.9cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
DISCHARGE LABS ([**2194-11-11**]):
[**2194-11-11**] 05:30AM BLOOD WBC-16.9* RBC-3.34* Hgb-9.3* Hct-29.7*
MCV-89 MCH-27.8 MCHC-31.2 RDW-18.1* Plt Ct-771*
[**2194-11-11**] 05:30AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-141
K-4.2 Cl-109* HCO3-25 AnGap-11
[**2194-11-11**] 05:30AM BLOOD ALT-36 AST-38 LD(LDH)-332* AlkPhos-256*
TotBili-0.7
[**2194-11-11**] 05:30AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
[**2194-11-11**] 05:30AM BLOOD CRP-37.0*
[**2194-11-11**] 05:30AM BLOOD ESR-24*
Brief Hospital Course:
87 year old female with recently diagnosed pancreatic/[**Month/Day/Year 499**]
cancer with liver metastases, hypertension, osteoarthritis who
presented on [**2194-10-27**] with right hip and wrist fractures after
an unwitnessed fall.
# Unwitnessed Fall, Right Hip and Wrist Fractures - The patient
presented with right hip and wrist fractures after an
unwitnessed fall. On arrival to [**Hospital1 18**], she received one liter
of normal saline and morpine 4 mg IV x 2. CT-c-spine was without
fracture. CT head was without acute process. Hip xray showed a
right intertrochanteric-subtrochanteric fracture of the femur
extending to the lesser trochanter with varus angulation. She
was admitted to the medical service for further management. She
underwent open reduction and internal fixation of right hip
fracture and closed reduction or right distal radius fracture.
She tolerated the procedure well but had agitation
post-operatively which was treated with IV haldol. On POD#1 she
was noted to have acute hypoxia, tachypnea and tachycardia. She
was ultimately transferred to the MICU for further management
(see below). While in the MICU, she had an echo which showed
mild atrial stenosis, mild mitral regurgitation, severe
pulmonary artery hypertension, and an EF of 75%. After she was
called out to the floor, PT and OT were consulted. At the time
of discharge, PT recommendations included transfer training,
balance training, and bed mobility. The patient was ultimately
discharged to a rehabilitation facility.
# Hypoxia, respiratory distress - At approximately 2 PM on POD#1
she was noted to have acute hypoxia, tachypnea and tachycardia.
She was initially 80% on RA and this improved to low 90s on
facemask and high 90s on a non-rebreather. Repeat CXR showed no
acute cardiopulmonary process. ABG on a non-breather was
7.34/34/170. EKG showed sinus tachycardia but no other changes
compared to priors. She was transferred to the MICU for further
management. CTA did not show evidence of pulmonary embolism.
Also, bilateral lower extremity ultrasounds showed no evidence
of DVT. While in the MICU, the patient was intubated. She was
also found to have a pneumonia (in addition to a previously
known UTI, which was being treated with ciprofloxacin). She was
started on vancomycin and cefepime. She was ultimately
extubated on [**2194-11-2**]. She was called out to the floor on
[**2194-11-3**]. The patient also had some episodes of delirium /
agitation upon transfer to the MICU and while she was in the
MICU. By the time the patient was transferred to the floor,
this had improved. Sedating medications were avoided after she
was called out to the medicine floor. A right internal jugular
CVL was also place while the patient was in the MICU. This was
removed after the patient was called out to the floor.
# Anemia - On admission, the patient's hematocrit was 23.6 with
iron studies notable for low iron and ferritin. It was felt
that this could be related to the patient's colonic malignancy
(see below). She received three units of PRBCs. Her hematocrit
was trended. She was also kept on pantoprazole. At the time of
her call out from the MICU on [**2194-11-4**], the patient's hematocrit
was stable. After she was called out to the floor, the
patient's family requested that she receive no more blood
transfusions.
# Leukocytosis / Thrombocytosis - On [**2194-11-8**], as the patient
was approaching discharge, she was noted to have rising white
blood cell and platelet counts. At that time, she had already
completed a 7 day course of vancomycin and cefepime for a
pneumonia. Her mental status was noted to be improving, and she
remained afebrile despite her rising white count. A urinalysis
showed bacteriuria; however, two urine cultures grew out yeast
alone. She was started on ciprofloxacin again for possible UTI,
and she was started on fluconazole for the yeast in her urine.
Her Foley [**Last Name (un) **] was discontinued but restarted secondary to
urinary retention. Two stool cultures were negative for c.diff.
Blood cultures also were drawn and did not grow out anything by
the time of discharge. A chest x-ray did not show signs of
infection. LFT's showed elevated LDH and alkaline phosphatase,
which could be consistent with her underlying malignancy. This
was discussed with the heme/onc fellow, and it was felt that
that the patient's leukocytosis and thrombocytosis were
consistent with an inflammatory state secondary to her recent
PNA and UTI as well as her mailgnancy. It was discussed with
the patient's family that the next step in the workup of her
leukocytosis would include bone marrow biopsy. This was not
consistent with their goals of care (see below). At the time of
discharge, the patient's WBC was trending down.
# Pancreatic/[**Name (NI) **] Cancer - Pt had recently been diagnosed with
adenocarcinoma of the [**Name (NI) 499**] on biopsy. She has suspicious liver
lesions as well as a mass in the head of the pancreas concerning
for second primary. At the time of admission, she had not been
told yet, as her family wanted to withhold the information until
after the [**Holiday 1451**] holiday. Social work and palliative
worked with the patient's family throughout her hospitalization.
As explained above, the patient had leukocytosis and
thrombocytosis towards the end of her hospitalization with a
negative infectious work-up. It was discussed with the
patient's family that further work-up of this would include a
bone marrow biopsy. Furthermore, if any abnormalities were
found on bone marrow biopsy, treatment of the patient's [**Holiday 499**]
and pancreatic cancer would need to be addressed first. This
was not consistent with the family's goals of care. At the time
of discharge, the family's goal of care were to move the patient
to a rehab facility, where she could build her strength.
Telling the patient of her diagnosis can also be addressed
during that time. As the patient's disease progresses, the
family plans to progress towards hospice care.
# Hypertension - The patient did have some episodes of
hypertension. While in the MICU, she was on IV metoprolol QID.
This was switched to PO metoprolol [**Hospital1 **]. After the transition to
PO metoprolol, the patient's blood pressure was better
controlled.
# Polymyalgia Rheumatica - The patient's home regimen of
prednisone was not entirely clear. While in the MICU, she was
on stress doses of steroids. However, after call out to the
floor, she was transitioned to a regimen of 5 mg prednisone
daily.
# Of note, a speech and swallow evaluation on [**2194-11-4**]
recommended nectar thick liquids and pureed foods, with the
patient's meds being crushed in puree. Repeat speech and
swallow done on the day prior to discharge cleared the patient
for a regular diet.
Medications on Admission:
Lorazepam 0.5 mg Tab QID
Aciphex 20mg [**Hospital1 **]
Ibuprofen 800 mg Tab Oral daily
Duloxetine 60 mg daily
Metoprolol Tartrate 25 mg Tab Oral [**Hospital1 **]
Prednisone 5 mg daily
Ultram 50 mg Tab Oral QID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Right hip and wrist fractures s/p unwitnessed falls
Pneumonia
Urinary Tract Infection
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital after you had an unwitnessed
fall at your [**Hospital3 **] facility. You were found to have
fractures in both your right hip and your right wrist. You were
admitted and taken to the OR to repair these fractures. You
post-operative course was complicated by respiratory distress,
ultimately requiring transfer to the ICU and intubation. You
were ultimately extubated and transferred back to the medical
floor.
Also, during your hospital course, you were found to have a
urinary tract infection as well as a pneumonia. These were
treated with antibiotics. We also tried removing your foley
catheter but you had difficulty urinating after. This will be
removed as possible at your rehab facility.
MEDICATION CHANGES:
-CHANGE Lorazepam to 0.5 mg at night as needed for anxiety
-STOP Aciphex; START Pantoprazole 40 mg twice a day
-STOP Ibuprofen
-STOP Lexapro; START Duloxetine 40 mg daily
-CHANGE Metoprolol Tartrate to 50 mg twice a day
-CHANGE Prednisone to 5 mg daily
-STOP Ultram
THE FOLLOWING MEDICATIONS WERE ADDED:
-Milk of Magnesia 30 mL twice a day as needed for upset stomach
-Bisacodyl 10 mg PO/PR daily as needed for constipation
-Docusate Sodium 100 mg twice a day
-Enoxaparin Sodium 40 mg injection daily
-Acetaminophen 650 mg every 6 hours as needed for pain
-Miconazole Powder 2% three times a day
-Fluconazole 200 mg daily (to complete a 7 day course, ending on
[**11-14**])
-Senna 1 tab twice a day
-Lidocaine 5% Patch daily (apply for 12 hours and then keep off
for 12 hours)
-Amlodipine 5 mg daily
Please return to the emergency room or call 911 if you
experience any further falls, chest pain, shortness of breath,
fevers greater than 101.5, severe nausea with inability to
tolerate food or liquids by mouth, confusion, or any other
concerning symptoms.
It was a pleasure taking part in your medical care.
Followup Instructions:
You should call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], and make a
follow-up appointment with her within 2 weeks of discharge. The
telephone number for Dr.[**Name (NI) 15012**] office is [**Telephone/Fax (1) 133**].
You also need to follow-up with orthopedic surgery in 4 weeks.
To set up this appointment, please call [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 15013**] at
[**Telephone/Fax (1) 1228**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"157.0",
"518.81",
"518.0",
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"197.7",
"599.0",
"780.09",
"820.21",
"416.8",
"153.9",
"E885.9",
"507.0",
"813.42",
"715.90",
"401.9",
"365.9",
"725",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"79.35",
"79.02",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13683, 13755
|
6588, 13423
|
258, 451
|
13885, 13920
|
2273, 6565
|
15835, 16464
|
1577, 1683
|
13776, 13864
|
13449, 13660
|
13944, 14679
|
1698, 2254
|
14699, 15812
|
210, 220
|
479, 1309
|
1331, 1460
|
1476, 1561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,264
| 150,855
|
1186
|
Discharge summary
|
report
|
Admission Date: [**2180-1-9**] Discharge Date: [**2180-1-21**]
Service: NEUROSURGERY
Allergies:
Reglan / Compazine / Levofloxacin / Phenothiazines
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
Craniotomy and subdural hemorrhage evacuation, Trach placement,
PEG placement
History of Present Illness:
84y/o male w/ hx of dementia, no hx of stroke, ICH prior,
presented with fall in the nursing home, change in MS (more
lethargic, poor responsive). He fell in the facility, hit his
head. His baseline was following simple command, no
conversation, no hemiplegia. He was brought into OSH, there CT
showed L-SDH. Transfer to [**Hospital1 18**] ED. He was intubated after exam
due to loss of airway protection and repeated vomiting. Hx was
obtained from old MR [**First Name (Titles) 767**] [**Last Name (Titles) **] Hosp.
Past Medical History:
Alzheimer Disease
HTN
Peripheral vasc disease
No hx of stroke, ICH
Bladder outlet obstruction
Social History:
Lives in [**Location 7533**]. Retired business man.
ETOH, Smoking, Drug
Family History:
Not contributory. Colon ca. No hx of stroke, tumor.
Physical Exam:
Vitals: 97.8 HR 81, reg BP 182/78 RR 19 SaO2 92% r/a
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums
clear.
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: soft, ? tenderness?
Ext: No arthralgia, no cyanosis/edema
Neurologic examination:
Limited exam due to lethargy. Opened eyes w/o stimuli,
?following
grasping, but not releasing.
No following at eye, but corneal reflexes pos bilaterally,
doll's
sye positive. Bil pupil R 4mm, left 3mm, surgical (or
presurgical
for glaucoma), nonreactive. Fundus invisible due to glaucoma.
R facial droop, WFH symmetrical.
Motors: No purpousful movement. Withdrawal for 4limbs. Less
spontaneous movement at right UE and LE.
DTR: brisk, symmetrical. Planter toes going down. No clonus.
Pertinent Results:
[**2180-1-18**] 10:52AM BLOOD WBC-7.8 RBC-2.88* Hgb-8.8* Hct-26.7*
MCV-93 MCH-30.6 MCHC-33.1 RDW-14.5 Plt Ct-410
[**2180-1-9**] 07:00PM BLOOD Neuts-89* Bands-0 Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2180-1-18**] 10:52AM BLOOD Plt Ct-410
[**2180-1-18**] 10:52AM BLOOD Glucose-168* UreaN-13 Creat-0.4* Na-138
K-4.3 Cl-104 HCO3-23 AnGap-15
[**2180-1-10**] 03:14AM BLOOD ALT-18 AST-26 LD(LDH)-179 AlkPhos-71
TotBili-0.1
[**2180-1-18**] 10:52AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.9
[**2180-1-10**] 03:14AM BLOOD calTIBC-209* Ferritn-132 TRF-161*
[**2180-1-15**] 02:11AM BLOOD TSH-0.97
[**2180-1-15**] 02:11AM BLOOD T4-4.9
Cspine CT: No evidence of cervical spine fracture or
malalignment.
Multilevel degenerative changes as described.
[**1-9**] Head CT: Large left-sided subdural hematoma causing
subfalcine and uncal
herniation. Small right parafalcine subarachnoid hemorrhage
anteriorly.
T and L spine: 1. No definite evidence of thoracolumbar spine
fracture. Multilevel degenerative changes. CT would have
increased sensitivity for detection of a fracture if clinical
suspicion warrants. 2. Mild degenerative changes of the hips
bilaterally.
[**1-18**] Head CT: Stable size of left subdural collection status
post craniotomy with evidence of evolving hemorrhage. Decrease
in the degree of pneumocephalus. Evolving right subdural
collection involving the anterior and middle cranial fossa, most
of which appears to represent old blood, however, a linear focus
of high attenuation likely represents newer blood. 6 mm of
right subfalcine herniation and stable appearance of the basilar
cisterns.
[**2180-1-20**] 10:00AM BLOOD WBC-9.8 RBC-2.88* Hgb-8.8* Hct-26.9*
MCV-94 MCH-30.4 MCHC-32.5 RDW-14.4 Plt Ct-479*
[**2180-1-21**] 11:00AM BLOOD Glucose-170* UreaN-12 Creat-0.4* Na-133
K-5.0 Cl-102 HCO3-24 AnGap-12
[**2180-1-21**] 11:00AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.1
[**2180-1-19**] 09:20AM BLOOD ALT-13 AST-24 AlkPhos-75 Amylase-43
TotBili-0.2
[**2180-1-19**] 09:20AM BLOOD Lipase-22
[**2180-1-20**] 12:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
Patient had fallen at his nursing home and sustained a left
sudural bleed. Because of the change in mental status as well
as right hemiplegia, he was taken to the OR for a craniotomy and
evacuation. He was also loaded with Dilantin. After the
surgery, he has been difficult to arouse and occasionally
opening his eyes and moving his upper extemities. Because of
that, he could not be extubated and the family made the decision
to place a trach and PEG. He was weaned off the ventilator and
placed on a trach mist mask. Currently, he will move his upper
extremities purposefully, however, he has no promixal lower
extremity movement but will wiggle his toes. He will
occasionally open his eyes to voice but does not follow any
commands. He is tolerating his tube feeds, his staples were
removed from his head and the incision was well healing. On
[**1-21**] General surgery removed the staples from G tube incision
and placed steri-strips at the site.
He was noted to have a right arm cellulitis so he was started on
Keflex. He had some low grade temperatures. A CBC did not show
any evidence of a leukocytosis and UA was negative. Because he
has been sedentary, lower extremity dopplers were obtained,
which did not show any evidence of DVT. Urine and blood
cultures are pending. The low grade temperatures are likely
secondary to the cellulitis.
Patient has also had low calcium and phosphorus, which has been
repleted. Please check a set of electrolytes in one week after
discharge. He should also have a Dilantin level repeated on
Tuesday.
Medications on Admission:
ASA 81mg daily
Glucophage
MVI
Metamucil
Keflex
Flomax
Effexor XR
Namenda
Aricept Mg
Zyprexa
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO TID (3
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
11. Cephalexin 250 mg/5 mL Suspension for Reconstitution Sig:
10ml PO Q12H (every 12 hours) as needed for cellulitis R Arm
for 4 days.
12. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale units Subcutaneous QAC and HS: 121-140 2 units, 141-160 4
units, 161-180 6 units, 181-200 8 units, 201-220 10 units,
221-240 12 units, 241-260 14 units, 261-280 16 units, 281-300 18
units, 301-320 20 units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
SDH, Alzheimer Disease, HTN, Peripheral vascular disease,
Bladder outlet obstruction.
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed and attend your
follow up appointments.
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], in 4 weeks with a head CT. PLEASE
CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.
|
[
"852.21",
"600.91",
"518.5",
"331.0",
"263.9",
"443.9",
"E888.9",
"401.9",
"250.00",
"682.3",
"285.9",
"342.80",
"294.10",
"599.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"01.31",
"99.05",
"96.6",
"96.72",
"96.04",
"99.07",
"31.1",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7195, 7275
|
4190, 5751
|
265, 344
|
7405, 7414
|
2022, 2784
|
8556, 8698
|
1116, 1169
|
5893, 7172
|
7296, 7384
|
5777, 5870
|
7438, 8533
|
1184, 1494
|
222, 227
|
372, 893
|
3212, 4167
|
1518, 2003
|
915, 1010
|
1026, 1100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,915
| 133,798
|
12972+56413
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-11-24**] Discharge Date: [**2133-12-1**]
Date of Birth: [**2064-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tegretol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2133-11-26**] Coronary Artery Bypass Graft x 4 LIMA->Left anterior
descending, RSVG-> Diagonal 1, Obtuse marginal, and posterior
descending artery, 28 mm MV ring, PFO closure
[**2133-11-24**] cardiac catheterization
History of Present Illness:
69 year old man presented to [**Hospital3 **] ED with chest
pain(heartburn) and shortness of breath. Patient has been having
intermittent episodes of discomfort since [**Holiday 1451**]. Pain
worse with exertion and associated w/diaphoresis and dyspnea.
EKG with new anterolateral EKG changes.
Transferred to [**Hospital1 18**] for cardiac catheterization
Past Medical History:
Coronary artery disease
DM
HTN
Hyperlipidemia
Arthritis
Malignant melanoma
Renal calculi s/p lithotripsy-Left
Gout
Social History:
Lives with: single
Occupation: retired Administrator at [**University/College 5130**]
Cigarettes: Smoked no [x] yes []
Other Tobacco use: none
ETOH: 1 drink/week
Illicit drug use: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death
Physical Exam:
T Pulse: 82 Resp: 16 O2 sat:
B/P Right: Left:
Height: 5'7" Weight: 210lbs
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] Murmur - no
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, A&O x3 [x]
Pertinent Results:
[**2133-11-26**] TTE
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. The left ventricular cavity is moderately dilated.
There is moderate to severe regional left ventricular systolic
dysfunction with mid to distal severely hypokinetic anterior,
[**Last Name (un) **]-septal and lateral wall and akinetic apex.. Right
ventricular chamber size and free wall motion are normal. 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 leaflets are moderately thickened. Moderate to severe (3+)
mitral regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Improved left ventricular global and focal LV systolci
function with inotropic support.
2. Preserved RV systolci function
3. A partial annuloplasty band is visualized in the mitral
postion. Well seated and stable with good leaflet excursion.
Trace to mild MR [**First Name (Titles) **] [**Last Name (Titles) 8751**] by PHT = >2 cm2.
4. No left to right flow could be demonstrated on the IAS with
CFD.
[**2133-11-29**] 09:50AM BLOOD WBC-14.1* RBC-3.66* Hgb-10.3* Hct-31.7*
MCV-87 MCH-28.1 MCHC-32.5 RDW-14.5 Plt Ct-152
[**2133-11-29**] 01:57AM BLOOD WBC-12.8* RBC-3.35* Hgb-9.5* Hct-28.8*
MCV-86 MCH-28.4 MCHC-33.1 RDW-14.5 Plt Ct-113*
[**2133-11-29**] 09:50AM BLOOD Glucose-239* UreaN-49* Creat-2.0* Na-128*
K-4.5 Cl-94* HCO3-22 AnGap-17
[**2133-11-29**] 01:57AM BLOOD Glucose-152* UreaN-47* Creat-2.1* Na-129*
K-4.5 Cl-98 HCO3-23 AnGap-13
[**2133-11-28**] 08:47PM BLOOD Glucose-193* UreaN-44* Creat-2.0* Na-127*
K-4.6 Cl-95*
[**2133-11-30**] 08:50AM BLOOD WBC-11.4* RBC-3.68* Hgb-10.4* Hct-31.5*
MCV-86 MCH-28.4 MCHC-33.2 RDW-14.5 Plt Ct-212
[**2133-11-30**] 08:50AM BLOOD Plt Ct-212
[**2133-11-30**] 05:50AM BLOOD Glucose-113* UreaN-46* Creat-1.8* Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
[**2133-11-25**] 06:00AM BLOOD CK(CPK)-70
[**2133-11-30**] 05:50AM BLOOD Mg-2.5
Brief Hospital Course:
He was transferred in from outside hospital and underwent
cardiac catheterization, due to coronary artery disease cardiac
surgery was consulted. On [**11-26**] he went to the operating room
and underwent a CABG x 4, MV ring, PFO closure. See operative
note for full details. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support
with epinephrine weaned off on POD1. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. Baseline creatinine was 1.6 and peak creatinine post
operatively was 2.3. His renal function was slowly improving at
the time of discharge. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating with assistance, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged to [**Doctor First Name 391**] [**Hospital **] rehab in good condition with
appropriate follow up instructions. Of note, the patient needs
repeat CT chest to f/u on pulmonary nodules in 6 months.
Medications on Admission:
MVI
Lorazepam 0.5 [**Hospital1 **]/PRN
Flonase 2 sprays each nostril daily/prn
KCL 20 meq daily
Allopurinol 300 daily
ASA 81 daily
Crestor 10 daily
Amlopidine 5 daily
Metformin 1000 [**Hospital1 **]
Glyburide 10 [**Hospital1 **]
Diovan 160 daily
Fish Oil 1000 TID
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puff Inhalation four times a day.
2. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puff Inhalation four times a day.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation q2h as needed for
shortness of breath or wheezing.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day.
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
15. insulin sliding scale
Insulin SC Sliding Scale - humalog
Breakfast Lunch Dinner Bedtime
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-199 mg/dL 4 Units 4 Units 4 Units 1 Units
200-239 mg/dL 6 Units 6 Units 6 Units 2 Units
240-280 mg/dL 8 Units 8 Units 8 Units 3 Units
16. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Coronary Artery Disease
Acute systolic heart failure
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Arthritis
Malignant melanoma
Renal calculi s/p lithotripsy-Left
Gout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema +1 bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2133-12-30**] at 1:30
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] [**Telephone/Fax (1) 4475**] on [**12-23**] at 10:45am
**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:[**2133-11-30**] Name: [**Known lastname 7162**],[**Known firstname **] Unit No: [**Numeric Identifier 7163**]
Admission Date: [**2133-11-24**] Discharge Date: [**2133-12-1**]
Date of Birth: [**2064-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tegretol
Attending:[**First Name3 (LF) 741**]
Addendum:
dischrge was delayed on [**2133-11-30**] due to temp of 101. Has been
afebrile since. D/c to [**Doctor First Name 1726**] [**Hospital **] rehab today.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 1726**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 3983**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2133-12-1**]
|
[
"E947.8",
"V10.82",
"428.21",
"458.29",
"V45.89",
"428.0",
"401.9",
"285.9",
"272.4",
"250.00",
"276.1",
"584.9",
"410.01",
"716.90",
"745.5",
"424.0",
"414.01",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"35.33",
"36.13",
"35.71",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10005, 10250
|
3998, 5509
|
287, 507
|
7914, 8158
|
1786, 2694
|
8999, 9982
|
1251, 1337
|
5824, 7553
|
7717, 7893
|
5535, 5801
|
8182, 8976
|
1352, 1767
|
237, 249
|
535, 893
|
915, 1032
|
1048, 1235
|
2704, 3975
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,785
| 108,509
|
41287
|
Discharge summary
|
report
|
Admission Date: [**2180-3-29**] Discharge Date: [**2180-4-13**]
Date of Birth: [**2110-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea, Acute Renal Failure
Major Surgical or Invasive Procedure:
Temporary Dialysis Catheter Placement
Tunneled Dialysis Catheter Placement
Central Venous Line Placement
History of Present Illness:
Mr. [**Known lastname **] is a 69 yo M with h/o CKD stage IV, HTN, DM2,
Hyperlipidemia presented to [**Location (un) **] ED with weakness, nausea for
several days. Also noted poor appetite, shortness of breath
worsened by exertion, chest pain and cough prodcutive of clear
sputum. Also with two loose stools and abdominal pain. reported
fever to 103.
At [**Location (un) **] VS T 98.4, pulse 77, RR 18, BP 167/77, O2 sat 93%/RA.
CXR demonstrated RLL/RML infiltrate. Given vanc 1g, ceftriaxone
1g and levofloxacin 500mg IV for PNA. ABG 7.24/31/63/88,
admitted to ICU and intubated. Put on vent at AC Vt 600, RR 20,
FiO2 50, PEEP 5, on propofol for sedation. Lytes demonstrated Cr
8.8, BUN 133, K 5.7. ECG demonstrated no peaked T waves. Given
calcium gluconate, kayexalate. Given 200mg IV lasix and put out
200cc urine. OG output "coffee grounds materials" and he was
started on pantoprazole 40mg IV q12. Transferred to [**Hospital1 18**] for
consideration of urgent hemodialysis.
Past Medical History:
- HTN
- DM2
- CKD Stage IV (Baseline Cr 4.55)
- Atrophic left kidney
Social History:
Lives with partner in [**Name (NI) 22022**] MA, current smoker. Denies EtOH,
illicit drugs.
Family History:
Noncontributory
Physical Exam:
Admission
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 62 (59 - 65) bpm
BP: 114/57(72) {112/57(72) - 114/59(73)} mmHg
RR: 25 (22 - 25) insp/min
SpO2: 95%
Heart rhythm: SB (Sinus Bradycardia)
Height: 72 Inch
General Appearance: Well nourished, intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: RML)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
On discharge:
Tmax: 97.6
Tcurrent: 97.6
HR: 82 (68-82) bpm
BP: 144/83 {136/80 - 152/86} mmHg
RR: 18 (18 - 20) insp/min
SpO2: 96% RA
Heart rhythm: Irregular
Height: 72 Inch
General Appearance: Obese, edematous, but aware and appropriate
Eyes / Conjunctiva: PERRL
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), GII holosystolic
murmur RUSB
Pulmonary: no increased work of breathing, wheezes at upper lung
[**Last Name (un) 8434**], good movement of ir throughout.
Abdominal: Protuberant, soft, Non-tender, Bowel sounds present
Extremities: Diffuse edema but decreased from yesterday,
strength 4/5 throughout.
Pertinent Results:
Admission Labs:
[**2180-3-29**] 12:00AM BLOOD WBC-31.6* RBC-3.35* Hgb-10.6* Hct-31.1*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.4 Plt Ct-267
[**2180-3-29**] 12:00AM BLOOD PT-15.3* PTT-31.9 INR(PT)-1.3*
[**2180-3-29**] 12:00AM BLOOD Glucose-176* UreaN-137* Creat-9.7*
Na-130* K-5.6* Cl-97 HCO3-13* AnGap-26*
[**2180-3-29**] 12:00AM BLOOD ALT-34 AST-57* AlkPhos-85 TotBili-0.7
[**2180-3-29**] 12:00AM BLOOD Albumin-2.4* Calcium-8.9 Phos-11.7*
Mg-2.3
[**2180-3-29**] 01:00AM BLOOD Type-ART Temp-36.8 Rates-14/13 Tidal
V-500 PEEP-5 FiO2-50 pO2-87 pCO2-34* pH-7.21* calTCO2-14* Base
XS--13 Intubat-INTUBATED
Legionella Antigen positive - [**2180-3-30**]
Imaging:
CXR on admission:
An endotracheal tube lies with its tip approximately 4 cm from
the carina. An NG tube lies with its tip below the diaphragm
although the tip is not
visualized on this study. There is increased opacity at the
right base with homogenous opacification consistent with a
pleural effusion. This makes assessment of the right lung base
difficult. There are air bronchograms evident in the right lower
lung; however, this may be related to either compressive
atelectasis or pneumonia
CT Abdomen:
1. Endotracheal tube is seen 5 cm above the carina. The right
internal
jugular line is seen with the distal tip in the proximal
superior vena cava. The nasogastric tube is seen coiled with
the tip within the antrum of the stomach.
2. Complete opacification of the right lower lung lobe with a
moderate-sized pleural effusion. There is a smaller
consolidation and tiny pleural effusion at the base of the left
lung.
3. No intra-abdominal or intrapelvic source of infection. There
is
perinephric stranding seen around the right kidney as well as
free fluid
within the pelvis from likely from aggressive hydration or poor
nutritinoal status.
4. Several hypodensities seen bilaterally and a soft tissue
density lesion
seen in the inferior pole of the right kidney. This right kidney
lesion can be further evaluated with ultrasound after the
patient's acute clinical condition resolves.
CT Chest:
1. Endotracheal tube is seen 5 cm above the carina. The right
internal
jugular line is seen with the distal tip in the proximal
superior vena cava. The nasogastric tube is seen coiled with
the tip within the antrum of the stomach.
2. Complete opacification of the right lower lung lobe with a
moderate-sized pleural effusion. There is a smaller
consolidation and tiny pleural effusion at the base of the left
lung.
3. No intra-abdominal or intrapelvic source of infection. There
is
perinephric stranding seen around the right kidney as well as
free fluid
within the pelvis from likely from aggressive hydration or poor
nutritinoal status.
4. Several hypodensities seen bilaterally and a soft tissue
density lesion
seen in the inferior pole of the right kidney. This right kidney
lesion can be further evaluated with ultrasound after the
patient's acute clinical condition resolves.
Pertinent labs on discharge:
Hemoglobin 7.5 Hct 22.6. Final urine culture on [**2180-4-11**] was
negative for growth.
Brief Hospital Course:
Mr. [**Known lastname **] is a 69 y/o M with Stage IV CKD (Cr 4.5), HTN, DM2, p/w
weakness & SOB x 3 days, found to have RML/RLL PNA and acute on
chronic renal failure, transferred for consideration of urgent
hemodialysis.
#. Hypoxemia/Pneumonia: Patient arrrived intubated and sedated
on mechanical ventilation. He was treated initially for
community acquired pneumonia with azithromycin and ceftriaxone,
but switched to vancomycin and cefepime as he did not intially
improve. Urine legionella antigen was positive and antibiotics
were narrowed to levofloxacin. His WBC count continued to rise,
infectious disease was consulted and coverage was broadened to
tigecycline on [**2180-3-31**]. He was extubated initially on [**2180-4-3**],
but became acute hypoxic due to mucous plugging and suffered PEA
arrest. He was emergently reintubated, and put back on the
ventilator. On [**2180-4-7**], he passed a spontaneous breathing trial
and was extubated without complication. His white count trended
down to 12 on transfer to the floor. He was continued on
levofloxacin with a planned total course of 21 days (Day #15 at
discharge).
# Cardiac Arrest: On [**2180-4-3**] patient was extubated, became
acutely hypoxic and suffered PEA arrest. Chest compressions
were started promptly, he received epinephrine, atropine and
received one electrical defibrillation for ventricular
fibrillation. He received adenosine for SVT, then switchedinto
atrial fibrillation with RVR. Restoration of sponteous
circulation was achieved in 8 minutes.
He was give amiodarone 150mg IV, followed by an infusion at
1mg/hr for six hours, then 0.5 mg/hr for 18 hours. His rate was
stable in the 80s.
#. Sepsis: On hospital day 2, patient became progressively
tachycardic and hypotensive responsive to fluid boluses and
briefly required norepinephrine.
#. Acute on Chronic Renal Failure: On arrival patient had
increased BUN and creatinine (4.5 -> 8.8) from baseline, mild
hyperkalemia (5.7) and metabolic acidosis. He was initially
treated with kayexalate, and IV bicarbonate. A temporary
dialysis catheter was placed and CVVH was initiated. His
electrolyte abnormalities gradually improved. A left internal
jugular tunneled catheter was placed, and he was started on
intermittent hemodialysis. He was started on Aluminum
Hydroxide, this was changed to calcium acetate on discharge.
Mr. [**Known lastname **] will likely require longterm hemodilaysis from this
point on. He was noted to be severely anemic (Hct 22-25) and
possibility of transfusion was discussed, but patient refused.
# Atrial Fibrillation. On hospital day two, patient was noted
to be in atrial fibrillation. Anticoagulation was initially
held. After completing his course of amiodarone post arrest, he
was started on diltiazem 30mg PO qid with fair to good rate
control (80s to 100s). He was started on a heaprin drip and
warfarin. As his platelets trended down from 267 to 110, there
was concern for HIT. Heparin dependent antibodies were sent and
he was initially switched to argatroban; antibodies returned
negative. Once his INR was > 2.0, argatroban was stopped. INR
was initially therapeutic on 4 mg warfarin, but then became
supratherapeutic. Dose was decreased to 2.5 mg on [**2180-4-11**] and
should be held on [**2180-4-13**]. He will require INR checks on [**2180-4-14**]
and [**2180-4-17**] with further adjustments as needed. He should follow
up with his PCP at discharge to discuss cardiology referral for
evaluation/management of his atrial fibrillation. His blood
pressures have been very stable on his current dose of
diltiazem, which may be titrated up if his heart rate persists
above 90s. If he maintains good rate control, a long-acting form
of diltiazem may be appropriate at discharge from rehab to aid
with compliance.
# Abdominal Pain: Patient had tenderness to palpation of the
abdomen on exam. Given rising white count and question of
perinephric fluid collection on the outside CT, an abdominal
ultrasound was performed that were unremarkable. He was treated
empirically for possible abodminal infection with tigecycline
from [**2180-3-31**] to [**2180-4-6**] and his pain resolved.
#. DM2: Fingerstick blood glucose was checked daily. Mr. [**Known lastname **]
did not require insulin therapy upon discharge.
# Elevated Alkaline Phosphatase: Alk phos increased after
admission to 500s. This was thought to be secondary to
levofloxacin therapy.
TRANSITIONAL CARE ISSUES:
- Patient will need nephrology follow up after discharge from
rehab, either with his prior nephrologist or a new provider.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] will need to arrange for regular INR checks while on
warfarin after discharge. He should see his PCP to discuss
cardiology referral for his atrial fibrillation.
- Patient will need INR monitored tomorrow and Monday and
warfarin dose adjusted accordingly.
- Patient will need to be monitored for heart rate control
(diltiazem may be increased as needed).
- Patient will complete his course of levofloxacin after 3
additional doses Q48H (next dose [**2180-4-14**]).
- CBC/hematocrit should be checked on Monday (patient may
require transfusion for Hct < 21).
Medications on Admission:
Atenolol 50mg PO daily
Lasix 40mg PO daily
Sodium Bicarbonate 2 tabs PO bid
minitran patch
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain, fever.
Disp:*90 Tablet(s)* Refills:*0*
4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: PLEASE HOLD TODAY [**2180-4-13**] for INR of 4.6.
Disp:*30 Tablet(s)* Refills:*2*
5. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
Disp:*3 Tablet(s)* Refills:*0*
6. PhosLo 667 mg Capsule Sig: As directed Capsule PO twice a
day: Take 1 tab after breakfast, 1 tab after lunch, 2 tab after
dinner.
Disp:*120 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Hospital rehab
Discharge Diagnosis:
Primary:
Legionella pneumonia
Acute renal failure necessitating dialysis
Pulseless electrical activity cardiac arrest
Atrial fibrillation/flutter (new)
Anemia
Secondary:
Type II diabetes
Hypertension
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 **] you presented to the [**Hospital1 18**] on [**2180-3-29**] in severe
respiratory distress due to pneumonia illness. This illness
required an admission to the medical intensive care unit and for
you to be intubated and placed on a respirator. During this time
you were diagnosed with pneumonia due to legionella infection
and were begun on Levofloxacin IV antibiotics. However, during
this time you stopped making urine and required dialysis. Your
ICU course was complicated by an arrhythmia called atrial
flutter/fibrillation. You were started on warfarin
anticoagulation therapy to minimize your risk of stroke. This
will require following INR on a regular basis. You also had an
episode where your heart stopped (lost pulse) and you required
rescusitation, which was successful.
You improved on antibiotics and were transfered to the medical
floor where your respiratory status improved and you defervesed.
You were continued on dialysis 3x per week. You also
demonstrated significant weakness likely due to the long
admission in the intensive care unit. However your strength
improved somewhat during your stay.
Your renal failure requires hemodialysis at this time. You will
need to copntinue hemodialysis as an outpatient with a renal
physician following your care.
We have made the following changes to your medication regimen:
- STOP TAKING atenolol while using the diltiazem.
- STOP TAKING minitran patch while using the diltiazem.
- STOP TAKING furosemide until/unless instructed to resume by
your doctors.
- STOP TAKING sodium bicarbonate until/unless instructed to
resume by your doctors.
- BEGIN TAKING diltiazem 30 mg PO every 6 hours for heart rate
control (your doctor may wish to change you to a once-daily
formula once you are stable on this regimen)
- BEGIN TAKING warfarin 2.5 mg PO daily (your doctor will need
to monitor your INR and may need to adjust your dose)
- BEGIN TAKING Phos-Lo to control your phosphate levels (total 4
tablets daily or as directed by your nephrologist)
- BEGIN TAKING aspirin 81 mg PO daily
- TAKE AS NEEDED acetaminophen for fever or pain
- COMPLETE COURSE of levofloxacin (antibiotic) for your
pneumonia (3 more doses over 6 days)
Please continue to take your medications as prescribed.
Followup Instructions:
Please have make an appointment with your primary care physician
on discharge from rehab. You should review your medications with
your doctor and discuss referral to a cardiologist for your
atrial fibrillation. You will also need to have your INR
monitored regularly while on anticoagulation therapy with
warfarin.
You will need to follow up with a nephrologist at discharge from
rehab (either your prior nephrologist or a new provider) to
monitor your kidney function and need for dialysis.
Completed by:[**2180-4-13**]
|
[
"359.81",
"427.5",
"599.0",
"427.31",
"585.4",
"427.32",
"753.12",
"250.40",
"587",
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"038.9",
"V45.11",
"785.52",
"250.50",
"995.92",
"584.9",
"362.01",
"403.91",
"276.2",
"272.4",
"285.9",
"585.6",
"287.5",
"482.84",
"518.81",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"39.95",
"38.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12435, 12501
|
6276, 10725
|
329, 436
|
12746, 12746
|
3196, 3196
|
15216, 15740
|
1664, 1681
|
11626, 12412
|
12522, 12725
|
11510, 11603
|
12922, 15193
|
1696, 2526
|
2540, 3177
|
261, 291
|
10751, 11484
|
6163, 6253
|
464, 1446
|
3212, 3852
|
3866, 6144
|
12761, 12898
|
1468, 1539
|
1555, 1648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,310
| 139,038
|
47350
|
Discharge summary
|
report
|
Admission Date: [**2183-7-26**] Discharge Date: [**2183-7-29**]
Date of Birth: [**2134-8-16**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Terbutaline / Morphine / Iodine; Iodine Containing /
Adhesive Tape
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
48 year old woman with chronic back, leg pain, on multiple meds
for pain syndrome who was found by her daughter on [**7-25**] to be
somnolent. Called EMS and in ED found to be lethargic in setting
of taking [**7-18**] Vicodin and an unknown amount of trazadone,
Seroquel, and Neurotin. Due to slurred speech and somnolence in
ED, patient was intubated for airway protection. Before being
intubated, she denied suicidal ideation, although per patient's
sister, history of suicidal ideation. In the ED, temperature
97, HR 116, BP 140/87, RR 17, and oxygen saturation 98% on room
air. Tylenol level was 80 and her urine was positive for
benzodiazepines, opiates, and amphetamines. Her EKG was
unremarkable. She had minimal response to 0.4mg of Narcan, given
twice. She received 50 mg of charcoal and was started on 13gm
(14mg/kg) of NAC by mouth.
Past Medical History:
-Status post gastric bypass surgery in [**2176**]
-Hypothyroid
-Asthma, with normal PFTs in [**2178**]
-Status post subtotal colectomy
-History of lower back pain, leg pain, foot pain
-Suicidal ideations, per sister
Social History:
Stay at home mom. Daughter 17yo. [**Name2 (NI) **] tob/etoh/IVDU.
Family History:
colon cancer in grandmother, uncle
Physical Exam:
Physical exam on admission:
T:98.5 BP:147/86 HR:104 RR:23 O2saturation:94%
Gen: Overweight, intubated middle aged woman.
HEENT: Pupils equal round and reactive. 6-->2mm. No conjunctival
pallor. No icterus. Moist mucous membranes.
NECK: Supple. No cervical lymphadenopathy. No JVD.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. No wheezes, crackles,
or rhonci appreciated.
ABD: Protuberant. Normal active bowel sounds in all four
quadrants. Soft. Nontender and nondistended. No guarding or
rebound. Liver edge not palpated.
EXT: Warm and well perfused. No clubbing or cyanosis. No lower
extremity edema, bilaterally. 2+ dorsalis pedis and radial
pulses, bilaterally.
NEURO: Intubated and sedated. Movements not purposeful. Responds
to noxious stimuli.
Pertinent Results:
Laboratory studies on admission:
[**2183-7-25**]
WBC-7.2 HGB-10.6* HCT-30.9* MCV-91 RDW-15.9* PLT COUNT-400
NEUTS-31* BANDS-0 LYMPHS-52* MONOS-9 EOS-8* BASOS-0
GLUCOSE-136* UREA N-18 CREAT-1.0 SODIUM-137 POTASSIUM-4.0
CHLORIDE-104 TOTAL CO2-24
ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-90 TOT BILI-0.1
Utox: bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG
amphetmn-POS mthdone-NEG
Stox: ASA-NEG ETHANOL-NEG ACETMNPHN-80.6* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
Laboratory studies on discharge:
[**2183-7-29**]
WBC-9.4 Hgb-12.2 Hct-37.0 MCV-94 RDW-15.6* Plt Ct-307
Glucose-111* UreaN-16 Creat-0.6 Na-141 K-3.5 Cl-102 HCO3-22
Other labs:
Iron-103 calTIBC-464 VitB12-415 Folate-18.1 Ferritn-15 TRF-357
TSH-2.0
EKG [**7-25**]: Sinus tachycardia, rate 103. Since the previous
tracing of [**2183-3-31**] the heart rate is faster. Technical artifacts
are present. Minimal increase in ST-T wave abnormalities is
present
Radiology:
[**7-25**] CXR: An ET tube has been placed with tip 6.3 cm above the
carina, above the level of the clavicular heads. The tube could
be advanced approximately 3 cm to ensure proper positioning. An
NG tube traverses below the diaphragm with tip off the field of
view. The lungs are grossly clear and there is no evidence of
consolidations or edema. The cardiac silhouette is enlarged
compared to the prior exam, though this may be due to technique.
Mediastinal and hilar contours are unremarkable. There is no
evidence of pneumothorax.
[**7-26**] Head CT w/o contrast: There is no intracranial hemorrhage.
There is no mass effect, shift of normally midline structures,
hydrocephalus, or acute vascular territorial infarct. The
density values of the brain parenchyma are normal, and the
ventricles and basal cisterns are unremarkable. Fluid secretions
within the posterior nasopharynx and oropharynx are likely
related to patient's intubated status. Visualized paranasal
sinuses and mastoid air cells are otherwise normally aerated.
[**7-27**] CXR: Comparison with the previous study done [**2183-7-26**]. The
lungs remain clear. The heart and mediastinal structures are
unremarkable. The left hemidiaphragm is mildly elevated. An
endotracheal tube and nasogastric tube have been removed.
Brief Hospital Course:
48 year old female with chronic pain (back, leg, foot) initially
admitted [**7-26**] to [**Hospital Unit Name 153**] after being found somnolent in the setting
of multiple drug ingestion (Vicodin, trazodone, Seroquel,
Neurontin).
1) Polysubstance overdose: Patient is on multiple psychiatric
meds (see admission med list), in addition to Vicodin and
neurontin. Urine tox screen was positive for amphetamines,
opiates, and benzodiazepines, and serum tox was notable for a
Tylenol level of 80. A toxicology consult was obtained and the
patient was started on N-acetylcysteine for Tylenol overdose and
a dose of charcoal. She was intubated in the emergency room and
transferred to the intensive care unit. She was extubated on
[**2183-7-26**] without difficulty. Her liver function tests remained
normal, and N-acetylcysteine was discontinued. She was
transferred to the general medical floor on [**2183-7-28**]. Psychiatry
followed the patient closely throughout her hospital stay.
Although the patient denies intentional overdose, she
acknowledges multiple recent social stressors and passive
suicidality, raising concern that this overdose represented a
suicide attempt. Psychiatry therefore recommended section 12 and
psychiatric admission.
2) Bipolar disorder: As recommended by psychiatry, all of the
patient's psychiatric medications were discontinued. Her
psychiatric medications will be re-started/titrated once she is
transferred to a psychiatric facility.
3) Hypothyroidism: The patient was continued on levothyroxine;
recent TSH wnl
4) Asthma: The patient has a chronic cough attributed to asthma.
CXR was without infiltrate. She was continued on flovent and
albuterol and was started on atrovent. She may benefit from
outpatient PFTs (last obtained in [**2178**]).
5) Anemia: At time of discharge, the patient's hematocrit was
stable. Although ferritin was low at 15, iron/TIBC were normal.
This should be monitored as an outpatient and further work-up of
occult bleeding pursued at the discretion of the patient's
primary care physician. [**Name Initial (NameIs) **] B12 and folate were normal.
6) Disposition: The patient is medically stable for transfer to
psychiatric facility.
Medications on Admission:
-Percocet
-Neurontin
-MVI
-Vicodin
-Albuterol 90 mcg INH [**2-11**] q6HR PRN
-Xanax XR 3mg daily
-Synthroid 100mg daily
-Lamictal 100 mg daily
-Prilosec 20mg [**Hospital1 **]
-Topiramate 50 mg [**Hospital1 **]
-Sertraline 100 mg daily
-Trazodone 200 mg qHS
-Quetiapine 300 mg qHS
-Flonase 50 mcg INH 2puffs [**Hospital1 **]
-Flovent HFA 220 mcg INH 2-4 puffs [**Hospital1 **]
-Imitrex 50 mg PO q1h PRN (maximum 4 per day)
-Acetaminophn-Isometh-Dichloral 325-65-100 mg TWO capsules [**Hospital1 **]
PRN
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for nausea.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: polysubstance overdose
Secondary: bipolar disorder, asthma, anemia
Discharge Condition:
The patient is medically stable for transfer to a psychiatric
facility
Discharge Instructions:
You were admitted with a polysubatance overdose. You are now
being transferred to a psychiatric facility for further
treatment.
1) Please follow-up as indicated below
2) Please see your primary care physician or come to the
emergency room if you develop abdominal pain, nausea, vomiting,
or other symptoms that concern you.
Followup Instructions:
1) Primary Care:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2183-10-21**] 10:20
2) Orthopedics
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2183-9-9**] 3:05
3) Psychiatry: Please follow-up as directed following
psychiatric admissions
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2183-7-29**]
|
[
"285.9",
"965.4",
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"244.9",
"969.7",
"965.00",
"518.81",
"E950.3",
"969.4",
"V45.86",
"296.80",
"338.4",
"784.5",
"780.09",
"E950.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8437, 8452
|
4803, 7003
|
363, 389
|
8572, 8645
|
2567, 2586
|
9017, 9585
|
1604, 1640
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7555, 8414
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8473, 8551
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7029, 7532
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8669, 8994
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1655, 1669
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3058, 3189
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300, 325
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417, 1263
|
2600, 3044
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1285, 1502
|
1518, 1588
|
3201, 4780
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,328
| 145,963
|
26766
|
Discharge summary
|
report
|
Admission Date: [**2106-3-23**] Discharge Date: [**2106-4-1**]
Date of Birth: [**2040-9-11**] Sex: M
Service: MEDICINE
Allergies:
Remicade / Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Hypotension s/p CCY
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
65M h/o DM2, diastolic CHF, COPD on home O2, admitted to OSH
with atypical chest pain on [**2106-3-21**]. Was at home in bed
developed left-sided chest pain without radiation x a few
minutes, which repeated a few times. No nausea, vomiting, SOB.
Has a baseline cough that was unchanged. No fever, abdominal
pain, dysuria, headache.
.
At the OSH, he ruled out for MI with negative enzymes and
underwent dobutamine nuclear stress with small partially
reversible inferior defect. He did have a recent presentation to
ED with abdominal pain and found to have gallstones, planned for
elective CCY [**9-1**], so decided to proceed with elective
procedure and underwent lap chole yesterday. Intraoperatively
develeped hypotension associated with reported dynamic
inferolateral STD on ECG. Given 2L NS and started on peripheral
neo gtt. Extubated at end of surgery but required reintubation
shortly. CE's flat. Hct stable. CXR with bibasilar infiltrates
and pleural effusions, concern for pneumonia and sepsis, started
on levofloxacin and flagyl. Transferred to [**Hospital1 18**] for further
management and consideration of cath given ECG changes.
.
Unable to perform review of symptoms other than noted above, as
patient is intubated and sedated.
Past Medical History:
CHF (EF>55%, diastolic dysfunction)
Cor pulmonale (clinical diagnosis)
Pulmonary hyptertension
CKD (baseline Cre 1.5-2.0)
DM2
HTN
COPD on 2L home O2 (no hx PFTs, chest CT [**10-1**]: emphysema, V/Q
scan [**10-31**]: negative for PE)
Arthritis with chronic pain syndrome
Psoriasis
Depression
Hyperlipidemia
OSA
Narcotic dependence
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
Social History:
Social history is significant for the presence of current
tobacco use (current 1 ppd, 40-60 pack-year history). There is
no history of alcohol abuse. There is no known family history of
premature coronary artery disease or sudden death. Currently
disabled [**12-26**] difficulty walking.
Family History:
noncontributory
Physical Exam:
VS: T 96.9, BP 117/62, HR 76, RR 16, O2 93% on 100%/500/16/5
Gen: Obese male in NAD, sedated, intubated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, unable to assess JVP due to habitus.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored and diminished throughout. No crackles, wheeze,
rhonchi anteriorally.
Abd: Obese, soft, NTND, No HSM or tenderness. Absent bowel
sounds. No abdominial bruits. Lap chole surgical sites on
abdomen.
Ext: No c/c/e. No femoral bruits.
Skin: +stasis dermatitis and psoriasis. No 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:
[**2106-3-23**] 10:39PM TYPE-ART PO2-149* PCO2-64* PH-7.32* TOTAL
CO2-34* BASE XS-4
[**2106-3-23**] 09:05PM TYPE-ART PO2-88 PCO2-65* PH-7.28* TOTAL
CO2-32* BASE XS-1
[**2106-3-23**] 09:05PM LACTATE-0.8
[**2106-3-23**] 09:05PM O2 SAT-96
[**2106-3-23**] 09:05PM freeCa-1.03*
[**2106-3-23**] 08:35PM GLUCOSE-160* UREA N-34* CREAT-1.5* SODIUM-139
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
[**2106-3-23**] 08:35PM estGFR-Using this
[**2106-3-23**] 08:35PM ALT(SGPT)-21 AST(SGOT)-32 LD(LDH)-201
CK(CPK)-24* ALK PHOS-101 AMYLASE-27 TOT BILI-0.8
[**2106-3-23**] 08:35PM LIPASE-11
[**2106-3-23**] 08:35PM CK-MB-NotDone cTropnT-0.04*
[**2106-3-23**] 08:35PM ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-5.1*
MAGNESIUM-1.8
[**2106-3-23**] 08:35PM WBC-7.0 RBC-3.71* HGB-10.4* HCT-31.5* MCV-85
MCH-28.0 MCHC-33.0 RDW-15.0
[**2106-3-23**] 08:35PM NEUTS-95.1* BANDS-0 LYMPHS-3.4* MONOS-1.1*
EOS-0.3 BASOS-0.2
[**2106-3-23**] 08:35PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
STIPPLED-OCCASIONAL TEARDROP-1+
[**2106-3-23**] 08:35PM PLT SMR-NORMAL PLT COUNT-184
[**2106-3-23**] 08:35PM PT-12.4 PTT-28.1 INR(PT)-1.0
.
.
MEDICAL DECISION MAKING
.
EKG demonstrated NSR, 70bpm, normal axis and intervals, no ST-T
changes with no significant change compared with prior dated
[**2104-1-14**].
.
.
2D-ECHOCARDIOGRAM performed on [**2104-1-14**] demonstrated:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is probably normal (LVEF>55%). Right ventricular
chamber size and free wall motion are probably normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
.
Dobutamine SPECT performed on [**2106-3-22**] demonstrated:
Small reversible inferior wall defect. EF 56%.
.
LABORATORY DATA: [**3-23**] @ OSH
WBC 10.3, Hct 31.7, Plt 216
BUN 41, Cre 1.8
CK 30 -> 28 -> 34 -> 28
Tn 0.06 -> 0.06 -> 0.06 -> 0.06
INR 1.3
Brief Hospital Course:
#Hypotension - Patient was initially transfered on a neo drip
and nitro paste. Both medications were quickly discontinued and
his [**Known lastname **] pressure stablized. Cardiac enzymes were flat and
EKGs done here were not suggestive of cardiac ischemia. He was
restarted on his [**Known lastname **] pressures meds. The exact cause of his
hypotension is not know. There was a concern with the history
of positive stress and some dynamic EKG changes seen at the OSH
that it might be cardiac. These tracings were not available to
use but the evidence does not suggest a cardiac cause. It is
also possible that he was transiently bacteremic during the
surgical procedure leading to the brief hypotension. [**Known lastname **]
cultures drawn here did not grow any organisms and he did
complete a course of levo/flagyl. He was discharged on bactrim
for possible local wound infection (see below).
.
Respiratory Failure - It seems that the patient failed initial
extubation at the OSH. He was transfered on a ventilator.
Chest xrays were suggestive of a possible pneumonia and he was
treated with a 7 day course of levo/flagyl. He was intially
difficult to wean and extubate. From his records, he has
underlying pulmonary disease. He also appeared to be volume
overloaded. He was diuresed and extubated. After extubation,
he was noted to have oxygen saturations in the mid to upper 80s
consistently, at times dipping to the low 80s. Per the
patient's report, this is typical for him, and he is on home
oxygen therapy. There does not seem to be formal documentation
of PFTs. We suggest that PFTs be obtained by his PCP after
discharge.
.
CAD - The patient had a positive SPECT stress at the OSH showing
a small reversible inferior wall defect. Theses images were not
available to us. He was initially transfered for a
consideration of cardiac catheterization. His cardiac enzymes
were flat and EKGs not suggestive of ischemia here. Cardiac
Cath was defered after discussion with the patient and
considering his renal function at this time. He was told to
follow up with a cardiologist after discharge for possible
further evaluation in the future. He was maintained on ASA, BB,
Statin, and ACEI. He was on plavix during the hospitalization,
but was not continued on this as an out patient. ACE-I was
discontinued due to acute renal failure while in the hospital.
This should be restarted as an outpatient when Cr improves, if
BP tolerates.
.
Post Lap Chole - Patient had surgery performed on [**2106-3-23**].
While intubated, he seemed to have significant abdominal pain
and some redness was noted. The general surgery team was
consulted and they followed him while in house. CT ABD/Pelvis
as well as RUQ US did not suggest acute pathology. He will
complete a 10 day course of Bactrim for a possible surgical
wound infection. His sutures should be removed 2 weeks post op
on [**2106-4-6**]. This can be done at either rehab or by his PCP.
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 41912**] was contact[**Name (NI) **] prior to discharge and stated that Mr
[**Known lastname **] does not need a follow up appoinment with Dr [**Last Name (STitle) 41912**] post
operatively. He will be seen by his PCP.
.
CKD - Per report, base line Cr is 1.5-2.0. It rose to 1.9 on the
morning of [**3-30**] and then to 2.6 in the evening of [**3-30**], in the
context of having been diuresed significantly. Additionally his
urine output declined. Pt's urine output improved with fluids
and Cr was stable at 2.5 at the time of discharge. It should be
monitored while at rehab to ensure it continues to improve. His
ACEI was held. It can be restarted when his Cr improves if his
BP tolerates
.
Chronic Pain - he was restarted on his outpatient pain
medications. These should be titrated by his PCP.
.
Diabetes - Patient was on glyburide as an outpatient. He was
maintained on a sliding scale in house with minimal insulin
requirement. He was not discharged on glyburide. His [**Known lastname **]
sugars should be followed and treatment restarted if necessary.
Care should be taken with glyburide given this patient's renal
insufficiency.
Medications on Admission:
ASA 81mg daily
Metoprolol 50mg [**Hospital1 **]
Prinivil 10mg [**Hospital1 **]
Lasix 40mg daily
Lipitor 80mg daily
Zetia 10mg daily
Nitro patch 0.2mg/hr q12h
Nitro sl prn
Wellbutrin 100mg [**Hospital1 **]
Zoloft 100mg [**Hospital1 **]
Triamcinolone spray prn
Halobeasol cream
Prilosec 20mg daily
FeSO4 325mg daily
Neurontin 100mg tid
Dilaudid 4mg q3h prn
MS Contin 60mg [**Hospital1 **]
Glyburide 10mg [**Hospital1 **]
Advair 500/50 1 puff [**Hospital1 **]
Spiriva daily
Albuterol prn
.
TRANSFER MEDICATIONS:
Hydrocortisone 100mg IV Q8h
Levaquin 500mg IV daily
Flagyl 500mg IV Q8h
Neosynephrine 0.1mcg/kg/min
.
ALLERGIES: Remicaide, PCN
Discharge Medications:
1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a
day.
8. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times
a day.
9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
10. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): last day [**2106-4-7**].
14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
15. please check fingersticks QACHS
16. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
17. Outpatient Lab Work
Draw electrolytes on Friday [**4-2**], including creatinine, to
ensure return of renal function.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p cholecystectomy
respiratory failure
pneumonia
Discharge Condition:
stable, patient seems to be at his baseline pulmonary status
Discharge Instructions:
You were transfered to [**Hospital3 **] Hospital after your surgery
because of concern for your heart. You were intubated when
transfered to the hospital. You completed a treatment for
pneumonia. There was no evidence of an acute event to your
heart. Cardiac catheterization was not performed during this
hospitalization.
.
Please follow up with all of your appointments listed below.
Dr. [**Last Name (STitle) 41912**] was contact[**Name (NI) **] before your discharge and he does not
need to see you back in his office. The stitches from your
surgery should be removed on [**2106-1-6**]. This can either be done
at rehab or by your PCP. [**Name10 (NameIs) **] you have any concerns of questions,
Dr. [**Last Name (STitle) 41912**] can be contact[**Name (NI) **] at ([**Telephone/Fax (1) 65914**].
.
Likely because of dehydration during your hospitalization, your
kidney function was somewhat decreased compared to usual. Your
rehab facility should follow-up on kidney labs to make sure that
your kidney function is improving.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on Tuesday [**4-6**] at 10:00
am. His office number is [**Telephone/Fax (1) 11376**].
.
You will need to be seen by a cardiologist after discharge.
Please either have your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] set up an appointment
for you or you can call Dr. [**Last Name (STitle) 11493**] who saw you at [**Hospital3 18201**] at ([**Telephone/Fax (1) 64781**].
.
Draw labs per discharge orders.
|
[
"518.81",
"416.8",
"428.0",
"486",
"428.32",
"585.9",
"496",
"276.51",
"403.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12081, 12155
|
5658, 9828
|
302, 315
|
12249, 12312
|
3257, 5635
|
13395, 13874
|
2326, 2343
|
10516, 12058
|
12176, 12228
|
9854, 10341
|
12336, 13372
|
2358, 3238
|
242, 264
|
10363, 10493
|
343, 1586
|
1608, 2004
|
2020, 2310
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,015
| 117,676
|
25857
|
Discharge summary
|
report
|
Admission Date: [**2188-5-31**] Discharge Date: [**2188-6-1**]
Date of Birth: [**2134-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
Central venous line
Diagnostic Paracentesis
Endotracheal Intubation and ventilation
History of Present Illness:
53M Hep C cirrhosis, smoldering myeloma, here with hypoglycemia.
Recently discharged one week prior with the following issues: 1)
liver failure secondary to Hep C Cirrhosis, 2) new diagnosis of
smoldering myeloma ([**1-17**] anemia), 3) esophageal candidiasis, 4)
suicidal ideation.
Now presents initially with hypoglycemia (fs 20), mental status
changes. Found to have profound metabolic acidosis with bicarb
of 9, AG of 20 (corrected to 27, albumin 1.1), Lactate of 15.4.
Treated empirically with vanco/levo/flagyl. Subsequently, SBP
fell to 90s, then to 50s, and required 7L IVF, started on
levophed. However, MAPs apparently persistently in 50s despite
levophed. Diagnostic paracentesis notable for 2300 WBC,
28%neuts, 21%lymphs, 1% bands, but 6125 RBCs. Began to
experience respiratory distress secondary to volume overload and
was intubated.
On arrival, pt noted to be moving all four extremities, with
livedo, intubated.
Past Medical History:
1. Hepatitic C cirrhosis- Genotype 1. Pt was previously treated
with intron A and Rebetron. He is currently on the transplant
list with a MELD score of 14 as of [**2-20**]-- in speaking with the
liver fellow, it is now increased to around 20. Pt with Grade 1
varices on EGD from 05/[**2187**]. Etiology of hepatitis C felt to be
intranasal cocaine versus tatoos.
2. Early encephalopathy
3. Recurrent abdominal ascites
4. Thrombocytopenia
5. Splenomegaly
6. Cholelithiasis
7. Duodenal ulcer- EGD [**2188-4-24**]. Pt was treated with triple
therapy fo H pylori. Pt reports that he was supposed to start on
protonix following completion of this medication but has not yet
done so.
8. Anemia
9. Obesity
Social History:
Pt is married and lives with his wife. Denies tobacco use. Prior
ETOH use but quit 5-6 years ago. Smoked marijuana 30-40 years
ago--- no current illicit drug use. Worked as a schoolteacher
(teaches shop).
Family History:
NC
Physical Exam:
VS 81 85/33 31 78%
GENERAL: Intubated, sedated
HEENT: PERRL, EOMI, intubated
NECK: Supple, L IJ
CARDIOVASCULAR: S1, S2, reg, tachy
LUNGS: L base rhonchorous, o/w clear
ABDOMEN: Distended, nontender, hypoactive bowel sounds.
EXTREMITIES: Cool, livedo present
NEURO: Intubated and sedated.
Pertinent Results:
[**2188-5-31**] 10:40PM LACTATE-13.3*
[**2188-5-31**] 10:40PM O2 SAT-95
[**2188-5-31**] 10:11PM PLEURAL WBC-2300* RBC-6125* POLYS-28* BANDS-1*
LYMPHS-21* MONOS-24* EOS-26*
[**2188-5-31**] 09:22PM LACTATE-12.2*
[**2188-5-31**] 08:18PM URINE HOURS-RANDOM
[**2188-5-31**] 08:18PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2188-5-31**] 08:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2188-5-31**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-8.8
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-5-31**] 07:00PM PT-35.8* PTT-64.3* INR(PT)-3.9*
[**2188-5-31**] 06:55PM AMMONIA-132*
[**2188-5-31**] 06:55PM LACTATE-15.4* K+-4.6
[**2188-5-31**] 06:50PM GLUCOSE-58* UREA N-27* CREAT-3.1*#
SODIUM-125* POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-9* ANION GAP-24*
[**2188-5-31**] 06:50PM ALT(SGPT)-98* AST(SGOT)-130* CK(CPK)-285* ALK
PHOS-72 AMYLASE-43
[**2188-5-31**] 06:50PM LIPASE-12
[**2188-5-31**] 06:50PM ALBUMIN-1.1* CALCIUM-8.2* PHOSPHATE-8.3*#
MAGNESIUM-2.2
[**2188-5-31**] 06:50PM CORTISOL-38.2*
[**2188-5-31**] 06:50PM CRP-49.2*
[**2188-5-31**] 06:50PM WBC-2.0* RBC-2.72* HGB-10.4* HCT-33.3*
MCV-123*# MCH-38.3* MCHC-31.2 RDW-19.4*
[**2188-5-31**] 06:50PM NEUTS-5* BANDS-18* LYMPHS-1* MONOS-0 EOS-4
BASOS-0 ATYPS-1* METAS-3* MYELOS-2* NUC RBCS-7* OTHER-66*
[**2188-5-31**] 06:50PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2188-5-31**] 06:50PM PLT SMR-VERY LOW PLT COUNT-69*
[**2188-5-31**] 06:50PM GRAN CT-340*
Head CT:
No evidence of acute intracranial hemorrhage or change from
prior study. MRI with diffusion-weighted images more sensitive
in the evaluation for acute ischemia/infarct.
CXR:
Lungs are much lower in volume, accounting for some interval
increase in heart size. The azygos vein is distended and there
is a suggestion of mild edema in the right lung, but the
combination of hypotension and large heart raises concern for
pericardial effusion and cardiac tamponade. There is no
appreciable pleural effusion. Lateral aspect of the left chest
is excluded from the examination. Other pleural surfaces give no
indication of pneumothorax.
Brief Hospital Course:
53M hep C cirrhosis, smoldering myeloma, here with catastrophic
metabolic acidosis, likely secondary to renal failure and
sepsis.
* Goals of care: On arrival to MICU, discussed with wife. Pt
would wish to have death with dignity, therefore, it was decided
that labs would be drawn to determine if pt had further
decompensated despite full aggressive care. If so, would
proceed to comfort measures only. In the intervening time, pt
was made DNR.
* Shock: Most likely secondary to sepsis, secondary to bacterial
peritonitis. Volume resuscitated with crystalloid to CVP>12.
Maxed out on levophed immediately on arrival to MICU and started
on neosynephrine with only modest effect. MAPs could not be
maintained above 60. Initially planned to start vasopressing
and then dobutamine to maximize cardiac output, however, given
above goals of care and discussion with family, no further
escalation of care was undertaken.
* Acidosis: Most likely secondary to combination of liver, renal
failure, and sepsis. Given shock, given two amps of bicarb
stat, then started bicarb infusion to maximize effect of
pressors.
* Sepsis: Vanco/levo/flagyl given empirically. Subsequent to
death of patient, gram stain of peritoneal fluid was found to
contain heavy GNR along with PMNs, suggesting that most likely
source of overwhelming sepsis was bacterial peritonitis,
although primary reason for this was unclear.
On reevaluation of laboratory values, pt was found to have
continued profound acidosis, profound coagulopathy, continued
failure of gluconeogenesis, other liver dysfunction, as well as
rising potassium. Therefore, given continued dismal prognosis
and patient's wishes, care was withdrawn. Death was declared at
0350.
Medications on Admission:
1. Furosemide 20 mg
2. Spironolactone 50mg [**Hospital1 **]
3. Lactulose (30) ML PO TID
4. Pantoprazole 40 mg Q12H
5. Magnesium Oxide
6. Nystatin 100,000 unit/mL Suspension
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Overwhelming Sepsis
Acute Liver Failure
Bacterial peritonitis
Metabolic Acidosis
Livedo
Acute Renal Failure
Hyperkalemia
Hypoxic respiratory failure
Septic shock
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"518.81",
"286.7",
"995.92",
"251.2",
"203.00",
"276.7",
"584.9",
"785.52",
"567.29",
"070.70",
"276.2",
"038.9",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.17",
"54.91",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6891, 6900
|
4913, 6639
|
326, 411
|
7106, 7116
|
2660, 4250
|
7168, 7174
|
2332, 2336
|
6863, 6868
|
6921, 7085
|
6665, 6840
|
7140, 7145
|
2351, 2641
|
274, 288
|
439, 1372
|
4259, 4890
|
1394, 2094
|
2110, 2316
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,544
| 175,858
|
8231
|
Discharge summary
|
report
|
Admission Date: [**2164-2-24**] Discharge Date: [**2164-2-25**]
Date of Birth: [**2115-12-1**] Sex: M
Service: MEDICINE
Allergies:
Methadone / Levofloxacin / Penicillins
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] is a 48 yo male with PVD, ESRD on HD, currently
undergoing treatment for c. difficile found by his VNA with
diarrhea, fatigued, BPs in 80's and down to 60's while standing.
He was reported to have intermittent altered mental status. He
was sent to [**Hospital3 7362**] where T 97, HR 68, RR 16, BP 83/52,
SpO2 100%. He was found to have WBC 15.1 with 35% bands,
lactate 2.0. He received NS 500 cc, IV azithromycin 500 mg IV
and rocephin 1 gram IV, as empiric therapy for possible
infiltrate on CXR. He was started on a dopamine drip for SBP
persistently in the 70's for approximately two hours.
He was transferred to the [**Hospital1 18**] ED via [**Location (un) **] on a dopamine
drip. In our ED, T 100, HR 80, BP 101/42, RR 16, SpO2 100% on
NRB. RIJ was placed. Patient received 2L NS, vancomycin 1 gram
IV, and dopamine gtt was transitioned to leveophed gtt. On
examination in ED, patient was reported to be confused and
somnolent, requiring sternal rub to arouse. When aroused,
complained of abdominal pain with palpation. Abdomen was noted
to be distended and firm, without rebound or peritoneal signs.
CT abdomen/pelvis was peformed and general surgery, [**Location (un) 1106**]
surgery were called.
Past Medical History:
PMH:
1. Insulin dependent diabetes mellitus, diagnosed age thirteen.
2. ESRD on HD
3. Hypertension.
4. Gastroesophageal reflux disorder.
5. Hiatal hernia.
6. Renal transplant, [**2154**], with chronic rejection.
7. Depression.
8. Peripheral [**Year (4 digits) 1106**] disease.
9. Chronic pain.
10. Lactose intolerance.
.
PSH:
1. Bilateral third finger amputations.
2. Left second and third toe amputations.
3. Left hand sympathectomy.
4. Left below knee popliteal to posterior tibial bypass with
non reverse saphenous vein graft.
5. Right inguinal hernia.
6. Renal transplant, [**2154**].
7. Bilateral lower extremity angiogram with angioplasty of
left distal graft and angioplasty of right posterior
tibial ([**2161-1-2**]).
8. Left knee incision and drainage [**9-16**]
Social History:
lives w/ father, denied ETOH , quit tob in [**2147**]
Family History:
Non-contributory
Pertinent Results:
.
EKG: sinus rhythm, rate 80, normal axis, normal intervals. +
1-[**Street Address(2) 1766**] elevations in V1-V3, also seen on prior EKG dated
[**2163-12-4**].
.
CXR [**2-23**]: Lung volumes are now quite low with new patchy
opacity at the right more than left lung base, likely
atelectasis. Allowing for this, the heart size and pulmonary
vessels are likely within normal limits, and there is no
significant pleural effusion.
.
CT ABDOMEN PELVIS [**2-23**]:
1. Moderate ascites may be secondary to third spacing, but can
also be seen secondary to more significant pathologies. Bowel
ischemia cannot be excluded.
2. Moderately distended gallbladder. Acalculous cholecystitis
is possible.
3. Stool distended colon.
4. Bibasilar atelectasis and superimposed pneumonia.
[**2164-2-23**] 08:10PM BLOOD WBC-16.3*# RBC-4.50* Hgb-10.9* Hct-38.0*
MCV-84 MCH-24.2* MCHC-28.7* RDW-16.8* Plt Ct-255
Neuts-68 Bands-17* Lymphs-7* Monos-5 Eos-3 Baso-0 Atyps-0
Metas-0 Myelos-0
[**2164-2-24**] 10:45AM BLOOD Glucose-28* UreaN-44* Creat-5.3* Na-144
K-4.2 Cl-104 HCO3-30 AnGap-14
[**2164-2-23**] 08:10PM BLOOD ALT-38 AST-37 LD(LDH)-292* CK(CPK)-36*
AlkPhos-204* TotBili-0.5 [**2164-2-23**] 08:10PM BLOOD Lipase-9
[**2164-2-23**] 08:10PM BLOOD cTropnT-0.38*
.
[**2164-2-24**] 01:55AM BLOOD CK(CPK)-34*
[**2164-2-24**] 01:55AM BLOOD cTropnT-0.36*
.
[**2164-2-24**] 10:45AM BLOOD CK-MB-7 cTropnT-0.34*
[**2164-2-24**] 10:45AM BLOOD CK(CPK)-91
.
[**2164-2-24**] 10:45AM BLOOD Calcium-8.9 Phos-5.0* Mg-1.8
[**2164-2-23**] 08:10PM BLOOD Albumin-2.4* Calcium-9.2 Phos-4.8* Mg-1.8
[**2164-2-23**] 08:10PM BLOOD Cortsol-32.8*
[**2164-2-24**] 08:31AM BLOOD Type-MIX FiO2-100 pO2-59* pCO2-56*
pH-7.34* calTCO2-32* Base XS-2 AADO2-613 REQ O2-98
[**2164-2-24**] 05:10AM BLOOD Type-ART pO2-80* pCO2-29* pH-7.51*
calTCO2-24 Base XS-0
[**2164-2-23**] 09:28PM BLOOD Type-MIX pO2-148* pCO2-56* pH-7.34*
calTCO2-32* Base XS-3 Comment-GREEN TOP
[**2164-2-23**] 08:22PM BLOOD Glucose-95 Lactate-2.7* K-3.7
[**2164-2-24**] 05:04AM BLOOD Glucose-105 Lactate-2.0
[**2164-2-24**] 10:55AM BLOOD Lactate-1.3
Brief Hospital Course:
Pt presented with hypotension, thought in ICU to be possibly due
to sepsis. He also was markedly sedated, and responded to
narcan. Please see hard copy of medical record for detailed
discussion between ICU attending, Dr. [**Name (NI) 4507**], pt, and family,
regarding pt's decision to discontinue dialysis and have comfort
measures only. Palliative care consulted and pain and
aggitation management as per their recommendations. Pt was
transferred to medical floor. Pt passed away less than 24 hours
after transfer to medical floor, family at bedside.
Medications on Admission:
Vancomycin 250 mg PO q 6 hours
Amlodipine 10 mg Tablet daily except dialysis days
Clopidogrel 75 mg Tablet daily
Gabapentin 300 mg daily
Ambien 10 mg qHS PRN
Sensipar 60 mg daily w/ dinner
Hydromorphone 4 mg Q 4 PRN pain
Lantus 23 units SQ qHS
Humalog SSI
Metoprolol 50 mg [**Hospital1 **]; skip AM dose on HD day
Metronidazole 500 mg [**Hospital1 **]
MSContin 30 mg [**Hospital1 **]
Naprosyn 500 mg [**Hospital1 **]
Nortriptyline 100 mg qHS
Omeprazole 20 mg [**Hospital1 **]
Sevalamer 3200 mg with meals, 1600 mg with snacks x 2
Simvastatin 40 mg daily
ASA 81 mg daily
B-complex vitamin
Renaltab II MVI daily
Discharge Disposition:
Expired
Discharge Diagnosis:
na
Discharge Condition:
na
Discharge Instructions:
na
Followup Instructions:
na
Completed by:[**2164-3-1**]
|
[
"995.92",
"338.29",
"403.91",
"530.81",
"038.9",
"486",
"250.01",
"008.45",
"443.9",
"785.52",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5869, 5878
|
4649, 5208
|
312, 318
|
5924, 5928
|
2551, 4626
|
5979, 6011
|
2514, 2532
|
5899, 5903
|
5234, 5846
|
5952, 5956
|
260, 274
|
346, 1629
|
1651, 2426
|
2442, 2498
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,846
| 134,334
|
6080+55731
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-3-29**] Discharge Date: [**2138-3-30**]
Date of Birth: [**2074-2-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 63yo F living at [**Hospital3 2558**] with multiple
medical problems including DM, HTN, diastolic CHF,
hyperlipidemia, pulm HTN, ESRD on HD, h/o AV graft infections,
morbid obesity, lower extremity DVT, b/l IJ vein thromboses on
coumadin, and OSA. She has recently been admitted several times
to [**Hospital1 18**] for tachycardia and chest pain, most recently on [**10-25**]
to the [**Hospital Unit Name 196**] service for chest pain that was deemed
musculoskeletal.
.
Today, she presents directly from HD at [**Location (un) **]. After an unkonwn
amount of fluid removal there (although patient states her
weight dropped 7 kg), BP was noted to be persistently in the 60s
systolic. Patient complained of headache and seeing spots in her
vision. She was transferred to [**Hospital1 18**] ED.
.
In the ED, initial VS: BP 86/55, HR 82, RR 26, O2 100%, T 97.6
Patient denied light-headedness but complained of chronic pain
in L leg and arm. Without any intervention, SBP rose to 90s and
then up to 110, but then fell into 70s for 1 hour. Patient was
mentating well without light-headedness. She given ~1 L NS. With
those fluids, BP rose to mid 90s. 2 20-guage peripheral IV were
placed. Labs, CXR, and EKG were unremarkable.
VS prior to transfer were HR 81, BP 93/62, RR 14, O2 99% on 2L
.
Upon arrival to the ICU, patient complains of gassiness and L
arm and leg pain that is unchanged for the past 6 months. She
denies light-headedness, dizziness, chest pain, palpitations,
shortness of breath, abdominal pain. Review of systems was
otherwise negative.
Past Medical History:
atrial tachycardia: seen by Dr. [**Last Name (STitle) **] in [**10-24**] and felt to
be atrial tachy [**2-18**] illness, no indication for ablation
- hemorrhagic pericardial effusion
- Bilateral internal jugular thromboses, restarted on coumadin
[**8-24**]
- h/o bilateral lower extremity DVT's
- ESRD on HD T, Th, Sat
- IDDM
- Diastolic heart failure
- Pulmonary hypertension
- Hypercholesterolemia
- OSA, noncompliant with CPAP as outpatient
- OA
- h/o C. Diff
- GERD
- Depression
- Morbid obesity
- Fibroid uterus; vaginal bleeding
- h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc
- h/o Multiple line infections
**[**2135-12-17**]: Providencia, treated with 4 wk course of
aztreonam
**[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin
and gentamicin
**[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks
**[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz
and vanc
.
PAST SURGICAL HISTORY:
- L forearm radial-basilic AV graft, s/p infection, thrombosis
and abandonment ([**12-21**])
- Multiple lines in L upper arm with AV graft
- 1/07 L femoral PermaCath placed
- L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**])
- [**4-23**] Excision of left upper arm infected AV graft; associated
MRSA bacteremia treated with 6 weeks vancomycin.
- Right upper extremity AV fistula creation [**10-23**] s/p revision
- [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring
and IVC filter removed
Social History:
Patient denies tobacco, alcohol or illicit drug use. She lives
in a nursing home ([**Hospital3 2558**]). She is separated from her
husband. She has 5 children in [**Location (un) 86**] [**Doctor Last Name **] area.
Family History:
Two children with asthma. Otherwise non-contributory.
Physical Exam:
VS BP 92/64, HR 93, RR 18, O2 Sat 100% on 2L NC
General: calm, obese, friendly; no teeth;
Lungs: few expiratory crackles at bases; no wheezes appreciated
Cardio: distnat heart sounds, regular, no murmurs
Abd: + BS, soft, obese, + midline hernia no HSM
Extremities: warm, trace bilateral pitting edema
Neuro: alert, oriented, cranial nerves grossly intact.
LABS: see below
Pertinent Results:
Admission labs:
[**2138-3-29**] 12:30PM WBC-5.0 RBC-4.05* HGB-12.6 HCT-41.8 MCV-103*
MCH-31.0 MCHC-30.0* RDW-15.8*
[**2138-3-29**] 12:30PM NEUTS-82.0* LYMPHS-11.2* MONOS-2.4 EOS-4.3*
BASOS-0.2
[**2138-3-29**] 12:30PM GLUCOSE-183* UREA N-14 CREAT-2.9*# SODIUM-143
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-30 ANION GAP-14
[**2138-3-29**] 04:14PM LACTATE-0.7
CXR:
No evidence of pneumonia. Mild vascular congestion without
pulmonary edema. Possible trace right pleural effusion.
Brief Hospital Course:
Ms. [**Known lastname **] is a 63 yoF with multiple medical problems who
presented with hypotension after dialysis.
.
#. Hypotension: Improved prior to arrival in MICU, patient
mentating well. Baseline SBP 105-120. Hypotension was most
likely secondary to volume removal at HD. She currently has no
signs to suggest sepsis or cardiogenic shock, but given history
of multiple infections CXR and blood cultures were done and
showed no evidence of infection. Of note, repeated blood
pressure measurements varied widely over short time intervals,
indicating likely false cuff readings. Leg cuff measurements
seemed to be more accure.
.
#. History of atrial tachycardia: Currently NSR in the 80s.
Tachyarrhythmia was likely secondary to her pulmonary
hypertension. Amiodarone was continued at home dose.
.
# diastolic CHF and pulmonary artery hypertension: Patient
appeared euvolemic and required only her home 2L NC O2.
.
#. history of DVT: On chronic anticoagulation for numerous upper
and lower DVTs. Admission INR therapeutic. Coumadin was
continued at home dose.
.
#. L arm and leg pain: chronic, unclear etiology. Patient states
tylenol q4h has helped. LFTs were checked and were normal.
Tylenol was continued. Xrays of the L hip and left shoulder were
done and will need to be followed up by
.
#. ESRD, [**2-18**] DM: on HD T-Th-Sat; likely over dialyzed the day of
admission Patient states that weight fell from 131 to 126kg
during dialysis, but this may be an exaggeration. Renal was
consulted and will discuss limitation of future volume removal
with [**Location (un) **]. Sevelamer was continued.
.
#. DEPRESSION: Paxil was continued.
.
#. GERD: PPI was continued.
.
#. DM: Home insulin regimen was continued. ASA and statin for
primary prevention were continued.
.
Full code status was confirmed with patient.
.
Medications on Admission:
acetaminophen 1 g qid
albuterol dfa prn
amiodarone 200 mg daily
B-Complex vitamin daily
Bactrim DS 800 mg-160mg 2 tabs qHD
Bisacodyl suppository daily
cepacol prn
docusate [**Hospital1 **]
duoneb q6h prn
folate 2 mg daily
insulin NPH 20 units qAM
Novolog SS
omeprazole 40 mg daily
paroxetine 30 mg daily
senna 8.6 mg daily
sevelamer 1600 mg tid
simvastatin 10 mg daily
warfarin 4 mg daily
.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
5. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO at HD.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
nebulizer Inhalation q8h:prn as needed for shortness of breath
or wheezing.
8. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO once a day.
9. Insulin
Please continue your previous insulin regimen of NPH 20 units
qam and Novolog SS.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
primary: hypotension
secondary: ESRD, DM2
Discharge Condition:
stable, normal mental status, not ambulatory secondary to leg
pain
Discharge Instructions:
You came to the hospital because of low blood pressure after
dialysis. This was likely because too much fluid was removed
during dialysis. You received IV fluids, and your blood
pressure improved. You also complained of shoulder and hip
pain. Xrays were done. These will need to be followed up by
your primary care doctor.
None of your medications was changed. Please resume all of your
home medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 608**] to arrange a follow up
appointment in approximately 1-2 weeks. You can discuss your
chronic shoulder and leg pain at that time.
Completed by:[**2138-3-30**] Name: [**Known lastname **],[**Known firstname 1194**] Unit No: [**Numeric Identifier 4084**]
Admission Date: [**2138-3-29**] Discharge Date: [**2138-3-30**]
Date of Birth: [**2074-2-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone
Attending:[**First Name3 (LF) 1015**]
Addendum:
On initial discharge summary, discharge information indicated
"to home" as destination. In fact, this patient was sent back to
[**Hospital3 901**]. This was changed in final paperwork and page 1
was completed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**]
Completed by:[**2138-3-30**]
|
[
"V45.11",
"428.0",
"403.91",
"458.29",
"250.00",
"416.0",
"585.6",
"V58.61",
"V12.51",
"428.30",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9808, 10037
|
4635, 6463
|
297, 303
|
8362, 8431
|
4128, 4128
|
8981, 9785
|
3664, 3719
|
6905, 8181
|
8295, 8341
|
6489, 6882
|
8455, 8958
|
2888, 3415
|
3734, 4109
|
246, 259
|
331, 1916
|
4145, 4612
|
1939, 2865
|
3431, 3648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,800
| 102,587
|
31058
|
Discharge summary
|
report
|
Admission Date: [**2193-5-6**] Discharge Date: [**2193-5-7**]
Date of Birth: [**2128-4-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
65yo M h/o HTN, DM, CAD s/p CABG [**2189**], Afib on coumadin who went
to church in his usual state of health this morning but was
found down Sunday evening at 8:30pm by his wife, unresponsive
with mild shaking of his body. The patient was taken to an OSH
where a large right ICH was found with extension into the
ventricles with associated left midline shift and subfalcine
herniation.
At [**Location (un) 620**], he received vitamin K, 2 units of FFP and mannitol.
In our ED, he received dilantin 1g IV x 1, mannitol 250mg bolus
x 2, profilnine 2 vials.
Past Medical History:
hypertension
diabetes
coronary artery disease s/p CABG 3yrs ago on coumadin
mild chronic obstructive pulmonary disease
Social History:
lives at home with wife; occ smoker, nonETOH drinker
Family History:
noncontributory
Physical Exam:
T:97 BP: 157/93/ HR:116 R 16 O2Sats 98%
Gen: unresponsive, intubated and sedated.
HEENT: Pupils: equally round at 6mm, nonreactive; + corneal
reaction bilat; No doll eye movement; EOMs full
Neck: supple
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft.
Neuro:
Mental status: nonresponsive, intubated and sedated.
Cranial Nerves:
I: Not tested
II: Pupils equally round equally round at 6mm, nonreactive.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No withdrawal of extremities to noxious bilaterally.
Sensation: no grimace to noxious stimuli.
Reflexes: diminished bilaterally.
Toes upgoing bilaterally
Pertinent Results:
Labs:
[**2193-5-6**]
CBC: WBC-21.0* RBC-4.55* Hgb-14.1 Hct-41.3 MCV-91 MCH-31.0
MCHC-34.2 RDW-14.9 Plt Ct-200
Diff: Neuts-92.2* Bands-0 Lymphs-4.6* Monos-2.6 Eos-0.3 Baso-0.2
Coags: PT-18.9* PTT-23.5 INR(PT)-1.8*
Chem: Glucose-200* UreaN-25* Creat-1.0 Na-139 K-4.4 Cl-102
HCO3-26 AnGap-15 Calcium-9.8 Phos-4.3 Mg-2.5
STox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
ABGs:
[**2193-5-7**] 03:47AM pO2-75* pCO2-61* pH-7.31* calTCO2-32* Base XS-1
[**2193-5-7**] 06:08AM pO2-75* pCO2-38 pH-7.45 calTCO2-27 Base XS-2
Other:
CK-MB-5 CK(CPK)-113 cTropnT-0.01
[**2193-5-7**] Coags: PT-15.8* PTT-27.7 INR(PT)-1.4*
Ucx negative
Bcx, sputum cx NGTD
Imaging:
CT OSH [**2193-5-5**]: large right intraparenchymal hemorrhage, tracking
into ventricles, with leftward MLS 17mm and subfalcine
herniation; possible brain stem hemorrhage as well.
Brief Hospital Course:
65yo man with PMH significant for HTN who presents with large
intracerebral hemorrhage with intraventricular extension
admitted with signs of herniation. His neurologic exam on
admission was notable for coma with loss of pupillary and
oculocephalic reflexes, with preserved corneal and gag reflexes.
Options were discussed with the family and it was determined (in
conjunction with the neurosurgery service) that surgical
intervention was not desired. He was admitted to the neurology
ICU. The patient's ICU course was complicated by probable
development of DI, with urine output of one liter over one hour.
He received treatment with DDAVP and fluid replacement. In the
meantime, deliberations continued among the family about goals
of care and whether to initiate comfort measures. Family
meetings involving the patient's wife, sons, as well as other
relatives and friends, took place involving the house staff,
social worker, and nurse.
On [**2193-5-7**] in the morning, Mr. [**Known lastname 73345**] was noted to have a
rapidly falling blood pressure. He was started on multiple
pressors but was not able to regain a viable blood pressure.
Within approximately 30 minutes, he had a cardiac arrest and
died. His son was at the bedside. The rest of the family was
called. His wife declined autopsy.
Medications on Admission:
Diltiazem 30 QID
Lipitor 40
Isordil 30
Coumadin 7.5mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage with intraventricular extension
Likely brain herniation
Cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"414.00",
"280.9",
"518.81",
"253.5",
"V45.81",
"427.31",
"401.9",
"780.01",
"496",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4196, 4205
|
2754, 4058
|
331, 355
|
4344, 4353
|
1873, 2731
|
4405, 4411
|
1170, 1187
|
4168, 4173
|
4226, 4323
|
4084, 4145
|
4377, 4382
|
1202, 1483
|
275, 293
|
383, 941
|
1552, 1854
|
1498, 1536
|
963, 1084
|
1100, 1154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,646
| 120,537
|
21777
|
Discharge summary
|
report
|
Admission Date: [**2185-1-18**] Discharge Date: [**2185-1-23**]
Date of Birth: [**2121-6-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 23673**]
Chief Complaint:
Bleeding, difficulty swallowing, hoarse voice x 1 day
Major Surgical or Invasive Procedure:
Angiogram with stenting of vertebral artery.
History of Present Illness:
63 y/o female s/p C4 vertebrectomy, C3-5 ACDF on [**2185-1-7**]
presents for eval of feeling of "throat swelling/constriction",
hoarseness x 1 day. Also admits to swelling of R side of neck x
1 day. Pt denies neck pain, weakness, fever, CP/SOB.
Past Medical History:
Rheumatoid Arthritis
Cancer of appendix x 3 years
Myocardial infarction
Diabetes
HTN
Physical Exam:
EXAM: AAOx3
PERRLA EOMI
Neck: Clear incision on R anterior/lateral neck with ?
edema/hematoma
Chest:CTA bilat
Heart:RRR No murmurs,rubs
Abd:Soft NTND +BS
Neuro:Cranial nerves II-XII grossly intact
Repetition intact
Strength: [**3-31**] throughout upper & lower ext
Senstion intact throughout
Reflexes full (3) throughout
Pertinent Results:
CT: Prevertebral hematoma
Brief Hospital Course:
63 y/o female who s/p ACDF presented to ER c/o neck fullness,
hoarsness x 1 day. CT revealed hematoma & pt taken to Angio for
eval. Found to have pseudoaneurysm at site of L vert. Cervical
stent placed with no complications. Pt had swallow eval post op
which was neg for aspiration. Pt also received 2 units of blood
for decreased HCT of 24.9 post op. Repeat HCT improved to 35.3
Remainder of hospital course unremarkable
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for severe pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Neck hematoma
vertebral artery dissection
Discharge Condition:
stable
Discharge Instructions:
[**Name8 (MD) **] MD for temp >101.5, redness or drainage from groin or neck
wounds, persistent pain, or any other questions. Please wear
hard collar at all times.
Followup Instructions:
With Dr. [**Last Name (STitle) 1132**] in 1 week. Please call for appt. [**Telephone/Fax (1) 1669**].
Follow-up with Dr. [**Last Name (STitle) 1327**] as scheduled.
Completed by:[**2185-1-23**]
|
[
"443.24",
"599.0",
"401.9",
"E878.8",
"714.0",
"250.00",
"998.12",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"99.04",
"00.64"
] |
icd9pcs
|
[
[
[]
]
] |
2358, 2364
|
1216, 1639
|
374, 421
|
2450, 2458
|
1166, 1193
|
2671, 2868
|
1662, 2335
|
2385, 2429
|
2482, 2648
|
821, 1147
|
281, 336
|
449, 695
|
717, 806
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,442
| 135,608
|
45038
|
Discharge summary
|
report
|
Admission Date: [**2191-9-14**] Discharge Date: [**2191-9-16**]
Date of Birth: [**2109-3-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Percocet / Vicodin /
Sulfa (Sulfonamide Antibiotics) / Clindamycin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 year old woman with past medical history of MI ([**2146**]), last
coronary catheterization in [**2185**] with clean coronaries,
diabetes, hypertension, hyperlipidemia, Pulmonary Embolism in
[**2140**]/[**2190**] taken off coumadin 2 months ago by cardiologist due to
course completion, presented with 3 weeks of dyspnea and chest
pressure/pain. She was referred by PCP for HR 160s with chest
pain.
.
ED course admission vitals: HR 160, BP 90/57, RR 26 Sat97%RA. BP
range SBP 90s - 120. Transient BP 72/54 after administration of
SL nitroglycerin. EKG showed HR 160s. She was given adenosine
which revealed atrial flutter. Also given diltiazem 20mg IV,
30mg PO with good response. CTA chest showed left lower lobe
segmental PE. Guaiac negative. She was started on a heparin
drip. She was given 2+ liters NS and transferred to ICU.
Past Medical History:
- PE [**11/2190**]
- Diabetes
- Dyslipidemia
- Hypertension
- Hx MIs in [**2140**]
- Diastolic CHF, EF>=60% on [**2187-9-27**]
- Bipolar disorder/Depression
- Remote history of upper GI bleed from ulcer
- History of PE and DVT following an appendectomy [**2140**]'s
- irritable bowel syndrome.
- GERD and hiatal hernia s/p repair
- Hypothyroidism
- Headaches
- vertigo
- Anemia
- Macular degeneration
- Reports being on home O2 for Angina
Social History:
Lives with her husband. Rare alcohol. Never used tobacco, or
drugs. Has 17 steps in her home. Uses a walker to get around
outside her home, no aides in home. Used to work as a legal
secretary but is now retired. She has 2 sons (live in Mass) and
3 grandchildren.
Family History:
Her brother died from a MI in his late 30s. Her father died from
a MI in his 80s. Her brother died from a MI in his late 80s. Her
mother died from a cerebral aneurysm.
Physical Exam:
ICU Admission Physical exam
Vitals: T: 98.3 BP:123/53 P:64 R:18 O2: 97/RA
General: Alert, oriented, no acute distress elderly female lying
in bed, pleasant and conversational
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular rhythm, normal rate, prominent RV heave, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, mild pain to palpation of LE wo tenderness over calves
.
Floor Discharge physical exam:
Vitals: T 98, BP 165/50, HR 52, RR 13, Sat 98% RA
General: Alert, oriented x3, no acute distress elderly female
lying in bed, pleasant and conversational
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 4-5 cm above sternal angle, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular rhythm, normal rate, 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
Pertinent Results:
CBC:
[**2191-9-14**] BLOOD WBC-13.7*# RBC-4.58# Hgb-14.6# Hct-42.4# MCV-93
MCH-31.8 MCHC-34.4 RDW-12.8 Plt Ct-424#
[**2191-9-16**] BLOOD WBC-5.3 RBC-3.11* Hgb-9.7* Hct-29.1* MCV-94
MCH-31.3 MCHC-33.5 RDW-12.8 Plt Ct-264
.
COAGULATION:
[**2191-9-14**] BLOOD PT-12.4 PTT-23.4 INR(PT)-1.0
[**2191-9-16**] BLOOD PT-13.4 PTT-51.5* INR(PT)-1.1
.
BLOOD CHEMISTRY:
[**2191-9-14**] BLOOD Glucose-127* UreaN-19 Creat-1.1 Na-138 K-4.9
Cl-97 HCO3-26 AnGap-20
[**2191-9-16**] BLOOD Glucose-91 UreaN-5* Creat-0.7 Na-143 K-3.8
Cl-114* HCO3-23 AnGap-10
[**2191-9-14**] BLOOD ALT-15 AST-23 LD(LDH)-176 CK(CPK)-63 AlkPhos-71
TotBili-0.3
[**2191-9-14**] BLOOD Calcium-10.5* Phos-4.7* Mg-2.4
[**2191-9-16**] BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
.
LIPASE:
[**2191-9-14**] BLOOD Lipase-1250*
[**2191-9-15**] BLOOD Lipase-184*
[**2191-9-16**] BLOOD Lipase-30
.
CARDIAC MARKERS:
[**2191-9-14**] BLOOD proBNP-4512*
[**2191-9-15**] BLOOD CK-MB-4 cTropnT-0.01 proBNP-2079*
[**2191-9-14**] BLOOD CK-MB-4 cTropnT-0.02*
[**2191-9-14**] BLOOD cTropnT-0.02*
.
OTHERS:
[**2191-9-14**] BLOOD Triglyc-126
[**2191-9-14**] BLOOD TSH-4.9*
[**2191-9-14**] BLOOD Lithium-0.7
[**2191-9-14**] BLOOD Lactate-0.7
.
URINE:
[**2191-9-14**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
.
[**2191-9-14**] 11:44 pm URINE Source: Catheter.
URINE CULTURE (Final [**2191-9-16**]): NO GROWTH.
.
EKG:
[**2191-9-14**]: tracing # 1: Narrow complex tachycardia. It is unclear
whether this is sinus. Diffuse ST-T wave changes likely due to
repolarization abnormalities. Cannot exclude ischemia. Compared
to the previous tracing of [**2190-11-13**] narrow complex tachycardia
is seen and there are ST-T wave changes.
[**2191-9-14**] Ectopic atrial rhythm with ventricular premature beats
and premature atrial contractions. Non-specific lateral T wave
changes. No diagnostic interim change.
.
IMAGING:
CTA [**2191-9-14**] IMPRESSION:
1. Segmental and subsegmental PE affecting the posterior basal
segments of
the left lower lobe. Probable additional subsegmental PE
involving the right upper lobe apical segment.
2. Stable pulmonary nodules, for which no additional followup is
needed.
Echo [**2191-9-15**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral and tricuspid regurgitation. Moderate pulmonary
hypertension.
Portable CXR [**2191-9-15**]:
FINDINGS: As compared to the previous radiograph, there is
unchanged moderate cardiomegaly and moderate tortuosity of the
thoracic aorta. No evidence of focal parenchymal opacity
suggesting pneumonia. No pleural effusions. No pulmonary edema.
Unremarkable hilar and mediastinal contours.
Liver/gallbladder US [**2191-9-15**]:
FINDINGS: The gallbladder is mildly distended but no gallstones
are
identified. There is no gallbladder wall edema and no
pericholecystic fluid
is identified. No biliary dilatation is seen and the common duct
measures 0.5 cm. No focal hepatic abnormality is identified on
limited views of the liver. The spleen is unremarkable measuring
8.9 cm. No ascites is seen in the upper abdomen.
IMPRESSION: No gallstones and no biliary dilatation identified.
Brief Hospital Course:
82 year old woman with history of CAD, dCHF, last cath [**2185**] with
clean coronaries, Diabetes, hypertension, hyperlipidemia, prior
PE recently completed 6 month course of anticoagulation
presented with new PE and atrial flutter, discharged in stable
condition on anticoagulation.
.
# PE: Recurrent. Unclear why she had her prior (second) PE for
which she received a course of 6 months coumadin. She was
stabilized in the ICU after her BP dropped s/p SL GTN in the ED
and transferred to the floor. She was started on heparin drip
upon presentation to the hospital which was then shifted to
lovenox injection 60 mg twice daily, first dose given the
evening of the discharge day. She was hemodynamically stable
upon transfer from the ICU as well as during her stay on the
medical floor. Most likely she will need a lifelong
anticoagulation. Aspirin was held and not continued on discharge
due to bleeding risk per patient. Coumadin 5 mg daily was
started upon discharge. Prescription was provided to check her
INR and will be followed by her PCP Dr [**Last Name (STitle) 12646**]. She will call
to have a close follow up appointment. Given recurrent PE, age
appropriate work up for malignancy would be suggested.
.
# Atrial Flutter: No history of arrhythmia per OMR. Outpatient
cardiologist is not aware of any history of arrhythmia in the
past. According to the patient she was told by her visiting
nurse 2 weeks prior to presentation that her pulse was not
regular. Initially in the ED after adenosine administration it
was showed that she has atrial flutter. Subsequent EKG showed
ectopic atrial rhythm with PAC's and PVC's. Her HR was well
controlled by diltiazem and metoprolol, however given her low
borderline BP upon transfer to the floor with bradycardia,
diltiazem dose was reduced to 15 mg twice daily while we
continued metoprolol at 12.5 mg twice daily. Echo showed mild
symmetric left ventricular hypertrophy with normal global and
regional biventricular systolic function in addition to Mild
mitral and tricuspid regurgitation and moderate pulmonary
hypertension. This was similar to an echo in [**2190**].
.
# Hypertension: Due to initial hypotension, home regimen
diltiazem, metoprolol and lasix were held. Subsequently upon
improvement, her diltiazem and metoprolol were restarted, while
lasix was still held due to low borderline blood pressure. Her
home diltiazem dose was halved given her bradycardia rate of
50's. We continued to hold lasix upon discharge. Her BP on
discharge was 165/50 with HR of 52.
.
# Chest pain: Pleuritic per history. Likely related to
underlying PE but given extensive cardiac history (despite clean
coronaries [**2185**]) there was an initial concern of an ischemic
event. She had 3 sets of cardiac enzymes which were negative.
Her chest pain resolved in the ICU and remained without chest
pain during the rest of her stay in the hospital.
.
# Elevated Lipase: Unclear why. Initially pancreatitis was a
concern given her abdominal pain and elevated lipase which was
initially ~ 1200 that trended down to 30. She had a lipase of
100 in [**2189**]. Her abdominal pain resolved upon having a large
bowel movement. No further work up was pursued.
# Leukocytosis: Likely related to PE. She was afebrile. There
was no concerning symptoms for infectious etiology. No
antibiotics were given. UA was mildly positive but asymptomatic.
Resolved spontaneously.
.
# DM: Her home medication metformin was held while in the
hospital and placed on insulin sliding scale. metformin was
restarted upon discharge.
.
# Depression/bipolar disorder: Lithium level was within normal
limits. She was continued on home dose lithium, risperdal, and
mirtazapine.
# Hypothyroidism: continued home dose levothyroxine. TSH
slightly elevated but likely related to stress of
hospitalization and sick euthyroid.
.
.
___________________
Transitional issues:
1. Please check INR [**9-19**], [**9-21**], [**9-23**] of which the results will
be faxed to her PCP
2. Please ensure patient is taking lovenox until informed
otherwise
3. Please consider age appropriate malignancy work up due to
recurrent PE.
4. Please consider restarting lasix if needed and as appropriate
to her HR and BP
Medications on Admission:
CURRENT MEDICATIONS: Confirmed with patient
- caltrate 600mg-400u po daily
- vitamin B12 1000 mcg IM q month
- diltiazem HCl 30 mg po bid
- fluticasone 50 mcg spray [**Hospital1 **]
- lasix 40 mg po bid
- levothyroxine 88 mcg po daily
- lithium 150 mg po bid
- metformin 500 mg po daily
- mirtazapine 30 mg po qhs
- nitroglycerin 0.3 mg sl prn chest pain, used occ
weekly/monthly
- omeprazole 20 mg po daily
- KCl 10 mEq po bid
- asa 81 mg po daily (held while on coumadin)
- tylenol 500 mg po bid prn pain
- [**Doctor First Name 130**]
- risperidone 0.5 mg qAM, 1mg qPM
- metoprolol 12.5 mg po BID
- miralax 17 gram po daily
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 14 days.
Disp:*28 injection* Refills:*0*
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
3. Caltrate-600 Plus Vitamin D3 600 mg(1,500mg) -400 unit Tablet
Sig: One (1) Tablet PO once a day.
4. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) inj Injection
once a month.
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
pray Nasal twice a day.
6. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO
twice a day.
8. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
9. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 min as needed for chest pain: maximum 3
tablets total.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. acetamenophen 500 mg Sig: One (1) tablet twice a day as
needed for pain.
13. [**Doctor First Name **] Oral
14. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO once a day:
every morning.
15. risperidone 1 mg Tablet Sig: One (1) Tablet PO once a day:
at evening.
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Miralax 17 gram Powder in Packet Sig: One (1) dose PO once a
day as needed for constipation.
18. diltiazem HCl 30 mg Tablet Sig: [**1-2**] Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
19. Outpatient Lab Work
Please check your coumadin level (INR) on Monday [**2191-9-19**],
Wednesday [**2191-9-21**], and Friday [**2191-9-23**]. These results should be
faxed to Dr. [**Last Name (STitle) 12646**] at [**Telephone/Fax (1) 92693**]. The coumadin dose should
be adjusted at her appointment with her PCP.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Pulmonary Embolism
Atrial Flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs [**Known lastname **],
.
You were admitted to [**Hospital1 18**] due to chest pain and shortness of
breath. Upon imaging your chest, it was found that you have a
clot in one of your lung vessels. You had low blood pressures
requiring you to be admitted to the ICU where your blood
pressure was stabilized. You were transferred to the floor for
further management. During your stay, you were kept on heparin
drip for your clot. Prior to discharge, you received one dose of
Lovenox injection (another form of heparin).
.
During your stay, we noticed you had abnormal heart rhythm.
Given the abnormal heart rhythm and the repeated clotting, we
recommend that you stay on coumadin to reduce the risk of
further clots in the future.
.
We made the following changes in your medication list:
Please HOLD Lasix
Please HOLD Potassium supplement
Please HOLD Aspirin
Please START lovenox injection 60 mg every 12 hours until you
are told to stop the injections, (when your coumadin level is
appropriate)
Please START Coumadin 5 mg daily at 4 pm
Please START Diltiazem 15 mg twice daily (changed from Diltiazem
30 mg twice daily)
.
Please continue the rest of your home medications the way you
were taking them at home prior to admission.
.
Please check your coumadin level (INR) on Monday [**2191-9-19**],
Wednesday [**2191-9-21**], and Friday [**2191-9-23**]. These results should be
faxed to Dr. [**Last Name (STitle) 12646**] at [**Telephone/Fax (1) 92693**].
.
Please follow up with your appointments as illustrated below.
Followup Instructions:
Department: [**Telephone/Fax (1) **]
When: WEDNESDAY [**2192-5-9**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 43**] & MCLLUDUFF [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please call the number below on Monday to schedule appointment
with your primary care physician
[**Name Initial (PRE) 7274**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Address: [**Street Address(2) **],STE 4W, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 4615**]
|
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"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14308, 14363
|
7525, 11379
|
402, 408
|
14460, 14460
|
3520, 7502
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436, 1270
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14403, 14439
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14475, 14619
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1292, 1733
|
1749, 2015
|
2920, 3501
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,707
| 161,993
|
31324
|
Discharge summary
|
report
|
Admission Date: [**2150-8-4**] Discharge Date: [**2150-8-7**]
Date of Birth: [**2104-4-7**] Sex: M
Service: MEDICINE
Allergies:
Sevoflurane / [**Location (un) **] Juice
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
hypertensive urgency, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 73843**] [**Known lastname **] is a 46 y/o man with type I DM, ESRD on HD,
and hypertension who presented to the ED on [**8-4**] with
nausea/vomiting and dizziness per report of personal care
attendant. The attendant contact[**Name (NI) **] the patient's sister earlier
today to report symptoms. When the patient's sister spoke with
him on the phone, he comlained of "difficulty breathing" and
"feeling sick" but would not further elaborate. He did not take
his morning labs per his sister due to vomiting. At that time,
he was taken to the ED.
.
On arrival to the ED, the patient's initial vitals were T 97.1,
HR 92, BP 235/107, RR 18, O2 91%. Symptoms in the ED included
left-sided chest pain (which patient denied on our exam),
nausea/vomiting, and abdominal pain. Reportedly completed
dialysis yesterday per usual schedule though they were unable to
achieve a dry weight yesterday. Patient's care attendant noted
that patient was more somnolent than usual on the day after
dialysis. Left EJ was placed for access. He was treated with
zofran 4 mg IV X 1. He was then placed on a nitroglycerin gtt
for SBPs over 200. He also took hydralazine 25 mg PO X 1. BP
improved to 178/97 and the patient was taken to dialysis.
.
At dialysis, the patient's temperature increased to 99.8. Blood
cultures were sent. Blood pressure at dialysis was labile,
ranging from 130s-180s systolic, and nitroglycerin gtt was
turned on & off. Three kg were removed at dialysis to achieve a
weight of 65.8 kg (dry weight reportedly 65 kg). On our arrival,
the patient notes ongoing abdominal pain and nausea. Denied
chest pain or shortness of breath. Denied dizziness. Would not
otherwise answer questions reliably.
.
As for his mental baseline, the patient's sister states that he
is typically oriented to self, date of birth, day of dialysis, &
those people he knows. He does have baseline confusion since
last year in [**Month (only) 216**] (after his PEA arrest). He does not
typically know month/year but can tell you what type of building
he is in (i.e., hospital but not [**Hospital3 **]). Of note, the
patient has had multiple recent admissions for hiccups (etiology
unclear) as well as recent admission [**2154-7-29**] for syncope thought
secondary to dehydration following dialysis.
Past Medical History:
1. Diabetes mellitus, type I , c/b retinopathy (legally blind
on left), neuropathy and nephropathy , gastroparesis
2. chronic kidney disease stage V, on HD Tues/Thurs/Sat; s/p
AVG placement [**8-7**]
3. chronic systolic heart failure, EF 40-45% ([**2149-9-6**])
4. Hypertension
5. Pulmonary hypertension
6. Glaucoma
7. s/p surgical debridement of left arm fistula ([**5-25**]) and
ruptured aneurysm repair ([**6-25**])
8. History of PEA arrest ([**6-25**])during AV fistula repair
9. History of positive PPD, s/p one year of treatment
Social History:
Originally from [**Male First Name (un) 1056**]. Separated, with five healthy
children. Not currently working, but has worked for a security
guard in the past. He just moved from [**Location (un) 7349**] to permanently stay in
[**Location (un) 86**] with his brother. [**Name (NI) **] [**Name (NI) **] current tobacco use (quit
several years ago). He [**Name (NI) **] EtOH or illicit drug use. History
of homelessness, but currently lives in [**Location **] in an apartment.
Family History:
Multiple siblings with HTN and diabetes. Two sisters with a
"[**Last Name **] problem." No known early coronary disease or kidney
disease.
Physical Exam:
vs: T 97.4, BP 151/84, P 80, RR 13, 96% on RA
gen: alert and responsive to voice though inattentive, answers
questions with appropriate (but at times wrong) answers
heent: L surgical pupils, sclerae injected bilaterally, right
pupil small but reactive, face symmetric, speech clear
lungs: no wheezes or rhonchi, slight crackles at bilateral bases
CV: RRR, normal S1, S2,
abd: distended with hypoactive bowel sounds, tympanitic to
percussion, reports tenderness diffusely with palpation though
no rebound or voluntary guarding
ext: no peripheral edema
skin: healed ulcers on shins
neuro: alert, oriented to person but not place or time
("sister's house" and will not answer time), face symmetric,
tongue midline, left surgical pupil, will hold right leg off bed
to gravity, will not voluntarily move left leg with increased
stiffness left leg compared to right, no withdrawal to pain
bilateral lower extremities, bilateral hand grip [**3-23**], holds both
arms flexed to gravity with some drift of the left arm after
seconds, reflexes 1+ at bilateral biceps and right patella, no
patellar reflex on left, toes downgoing bilaterally
Pertinent Results:
Trop-T: 0.17
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
STOX ADDED [**8-4**] @ 19:57
145 103 44
---------------< 173
4.6 30 7.8 D
CK: 64 MB: Notdone
Ca: 9.9 Mg: 2.1 P: 3.5
ALT: 42 AP: 179 Tbili: 0.4 Alb:
AST: 25 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 26
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
90
7.1 > 10.7 < 212
33.0
N:82.8 L:11.6 M:3.2 E:2.0 Bas:0.4
CXR: (prior to dialysis) single portable AP upright view of the
chest was obtained. Cardiomegaly is stable. Indistinctness and
cephalization of pulmonary vasculature and interstitial
prominence are consistent with pulmonary interstitial edema. No
focal airspace consolidation or large effusion is seen on this
single frontal view. Osseous structures are unremarkable.
IMPRESSION: Stable cardiomegaly. Pulmonary interstitial edema.
.
Head CT: There is no intra- or extra-axial hemorrhage, mass
effect, shift of normally midline structures or hydrocephalus.
Ventricles, basal cisterns, and sulci are normal in
configuration. [**Doctor Last Name **]-white matter differentiation is normally
preserved. Visualized paranasal sinuses and mastoid air cells
are well aerated. Increased soft tissue thickening of the left
posterior globe and increased attenuation of the lens are
stable. By report, the patient has a history of glaucoma and
left eye blindness. IMPRESSION: No acute intracranial
abnormality. Stable left globe abnormalities.
.
EKG: sinus rhythm at 75, normal axis, LVH, prolonged PR (200
ms), upsloping elevated ST segments in V2-6, biphasic p wave in
V1
.
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2150-8-5**]
9:25 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MICU [**2150-8-5**] SCHED
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 73856**]
Reason: r/o PRES or stroke
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with CKD, on HD, HTN, DM p/w MS changes in
the context of HTN
emergency
REASON FOR THIS EXAMINATION:
r/o PRES or stroke
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: [**First Name9 (NamePattern2) 73857**] [**Doctor First Name **] [**2150-8-6**] 3:52 PM
No acute pathology including no evidence of infarction or PRES.
Unchanged
FLAIR signal intensity in the left corona radiata, likely a
small DVA.
Unchanged left retinal hemorrhage.
Final Report
INDICATION: 46-year-old with chronic renal disease,
hypertension, diabetes,
and mental status changes in the setting of a hypertensive
emergency. Evaluate
for PRES or stroke.
COMPARISON: MRI of the brain [**2149-6-28**].
TECHNIQUE: Sagittal T1, axial T2, GRE, and DWI are performed.
MRI OF THE BRAIN WITHOUT IV CONTRAST: There is no evidence of
acute
hemorrhage, edema or infarction, and no change from [**2149-6-28**]. Again
seen is a small area of T2 and FLAIR hyperintensity within the
left corona
radiata, extending into the left ependymal region and likely
representing a
small developmental venous anomaly. There may be an associated
capillary
telangiectasia to explain the FLAIR abnormality. Additional mild
periventricular FLAIR hyperintensities likely represent chronic
microvascular
ischemic disease. There is no restricted diffusion or abnormal
signal
intensity within the remainder of the brain parenchyma. High T2
signal within
the left retina is again consistent with hemorrhage and the left
globe is
atrophied. The intracranial flow voids are unremarkable.
IMPRESSION:
1. No evidence of infarction, PRES, or other acute pathology.
2. Unchanged FLAIR hyperintensity within the left corona radiata
again likely
represents a small developmental venous anomaly, probably with
an associated
capillary telangiectasia. This could be confirmed with
gadolinium, however,
given the lack of change over one year and the patient's
end-stage renal
disease, this may not be necessary.
3. Unchanged left retinal hemorrhage.
.
Brief Hospital Course:
# Malignant Hypertension: Pt with labile blood pressures at
baseline, and history of gatroperesis and chronic
nausea/vomiting, which may have contributed to poor PO
[**Year (4 digits) 4085**] compliance. Systolic blood pressure 230's on arrival
and given patient's altered mental status as possible end organ
dysfunction, this was considered malignant hypertension. The
patient was sent for emergent hemodialysis and then transferred
to the ICU and started on a nitroglycerin drip. Patient was
weaned from nitro drip with SBP goals 150-190. This range
chosen given need to maintain sufficient CNS perfusion after
hypertensive emergency in a patient with baseline anoxic
encephelopathy. Patient was transferred to the floor and started
on his home metoprolol and losartan. His blood pressure
remained 150-180 so on the day of discharge his home hydralazine
was also started for goal SBP 120. Erythromycin was started for
gastroparesis/motility and nausea controlled with prn zofran. He
did not have nausea or vomiting during his hospitalization.
# Acute Delerium: Patient's presentation was consistent with
delirium given that he seemed to wax & wane. CT head in ED
without acute pathology. Neuro exam initially had focal
abnormalities, but on reassessment, just generalized weakness
and poor mental status/attention/effort. Clinical picture felt
to be most likely [**12-20**] metabolic/renal and polypharmacy from
Baclofan, Reglan, Phenergan, Amitryptiline, Thorazine, with a
poor baseline mental status from previous PEA arrest. Ischemic
disease was excluded (no EKG changes, cardiac enzymes flat 0.21,
0.17) and infection was unlikely (blood cultures negative,
patient afebrile, leukocytosis). Neurology consult evaluated
concluded she had an encephalopathy of most likely metabolic
origin, with HTN possibly playing a critical role. MRI was
ordered and showed no sign of PRES or other acute abnormality.
Patient's was at baseline neurologic status on transfer to the
floor, alert and orientedx3 with sluggish but appropriate
responses.
# Type 1 diabetes Uncontrolled with complications,
gastroparesis, retinopathy, nephropathy: Patient was on 3 U
lantus and SSI with humalog. He had one hypoglycemic episode
where BS was 30, but responded to juice and [**11-19**] amp D5. The
patient will follow up with [**Last Name (un) **].
# End Stage Renal Disease, hemodialysis dependent: Renal
consulted in ED and sent for emergent hemodialysis due to likely
volume overload contributing to hypertension. Had
ultrafiltration done [**8-4**], [**8-5**] and [**8-6**]. Continued lanthanum
and sevalemer. Was at dry weight on day of discharge, should
continue his HD schedule MWF as before.
# Hiccups: Came in on thorazine, baclofen. Concern for these
medications causing altered mental status so they were held, but
hiccups worsened. Once back to baseline mental status, was
started on lower dose of baclofen (20 [**Hospital1 **]) and he tolerated this
well with no change in MS, but improvement in hiccups.
# Chronic systolic heart failure, compensated: Continued on Beta
Blocker and [**Last Name (un) **]. Hemodialysis for volume control, patient is
anuric.
#Depression: Held Amitryptiline in the setting of altered mental
status, but restarted when back to baseline. Continued
citalopram. No suicidal ideation or worsening mood during the
hospitalization.
Medications on Admission:
HOME MEDS: (per prior d/c summary)
1. Docusate Sodium 100 mg PO BID
2. Amitriptyline 25 mg PO HS (at bedtime)
3. Aspirin 81 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Lanthanum 1000 mg PO TID W/MEALS
6. Metoprolol Succinate 150 mg daily
7. Citalopram 20 mg PO DAILY
8. Metoclopramide 5 mg PO QIDACHS (4 times a day (before meals
and at bedtime)).
9. Hydralazine 25 mg PO TID
10. Losartan 50 mg PO DAILY
11. Furosemide 20 mg PO BID
12. Bisacodyl 10 mg PO DAILY as needed.
13. Chlorpromazine 25 mg PO every 4-6 hours as needed for
hiccups.
14. Baclofen 5 mg PO three times a day.
Discharge Medications:
1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for
hiccups.
6. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
11. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Insulin Glargine 100 unit/mL Solution Sig: 6 Units units
Subcutaneous once a day: Please resume previous insulin regimen
of 6U every morning.
14. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) unit
Subcutaneous three times a day: Please take 1 unit after each
meal (as per your regular insulin regime).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Maliganant Hypertension
Acute Delirium
Diabetes Mellitus type 1 w/complications, gastroparesis,
retinopathy
Gastroparesis
Chronic Hiccups
End Stage Renal Disease, hemodialysis dependent
Chronic Systolic Heart Failure, EF >55%
Depression
Discharge Condition:
Stable.
Discharge Instructions:
You came to the hospital with nausea, vomiting and confusion.
We believe this was because your blood pressure was very high.
We treated you for your high blood pressure with
antihypertensive medications and hemodialysis in the ICU. Your
mental status improved as your blood pressure came down.
.
We made the following changes to your medications:
STOPPED Chlorpromazine
CHANGED Baclofen 5 mg PO two times a day
.
Please follow up with your PCP, [**Name10 (NameIs) 151**] your social worker as
described below. Please take all your medications as directed.
.
If you have any nausea, vomiting, headache, fever, chills,
increasing confusion, high blood pressure or any general change
in your condition please call your PCP or come to the emergency
department.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4131**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-8-12**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23482**], LICSW Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-8-13**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-8-13**] 1:00
|
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10,799
| 153,183
|
49567
|
Discharge summary
|
report
|
Admission Date: [**2160-9-1**] Discharge Date: [**2160-9-8**]
Date of Birth: [**2088-11-7**] Sex: M
Service: MEDICINE
Allergies:
Tape / Lipitor
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
lightheadedness & weakness
Major Surgical or Invasive Procedure:
blood transfusions
History of Present Illness:
71yo man with a history of CAD s/p CABG, s/p mechanical [**First Name3 (LF) 1291**] on
coumadin, s/p ICD for VT/CHB/afib, CHF w/ EF 25-30%, Lupus (in
remission), CKD, chronic anemia on Aranesp, h/o recurrent GIB,
who presents with lightheadedness & generalized wkness over [**2-10**]
days. The hx comes from both pt and his wife. Pt had been in
his USOH, until about 3 days ago, when his wife noted the
patient to be more fatigued & sleeping more than usual. The
patient reports that he began feeling lightheaded w/ standing
(though no syncope) and generally weak during that time. He
notes that he has had some dark/"black" stools over the past [**3-11**]
days, though reports no abd pain, N/V/D. (Of note, his hct had
been 34 on routine check 5 days ago. His INR was
supratherapeutic at that time at 4.29; his coumadin was dose
reduced from 3mg MWF/2mg TTHS to 2mg daily.) He reports
baseline SOB is stable. Pt did have an episode of SSCP the day
PTA, which occurred at rest & resolved with nitro. The pain was
similar to that which he has on a nearly daily basis. The
patient's symptoms of LH & generalized wkness/fatigue continued
to progress, so he asked his wife to bring him to the [**Name (NI) **] for
eval.
.
In ED: VS T 98, 112, 116/69, 19, 100% on NRB. His HR dropped
into the 60-70s after triage. He had one BP of 76/30 & improved
to 117/66 w/o intervention. Developed SSCP in ED. ASA, nitro,
and fentanyl were give. Pain resolved. EKG reportedly stable &
not evolving. CE w/ trop 0.07 & CK 44. Other labs notable for
drop in hct from 33.9-->28 over ~6 days. INR 4.5. Stool was
"dark" & guaiac +. Not NG lavaged. Crt 2.9 increased from
baseline 1.5-1.7. HCO3 16. UA negative. Glucose 33 on chem 7 &
Recheck 130s. Given 1L NS. Pt being admitted to ICU for mgt &
eval of possible GIB & ARF.
ROS: He reports no fevers, chills. ?wt loss (unsure am't)
Chronic SOB. Some constipation. No diarrhea, BRBPR. + chronic
angina uses 2SL mult days a wk. Pain occurs at rest usually.
No cough/hemoptysis. No change in vision, hearing. No HA. No
hematuria, dysuria, LE swelling. No numbness, tingling, falls.
Past Medical History:
1) Coronary artery disease status post coronary artery bypass
graft (CABG). The last catheterization was in [**2156**], currently
being medically managed, followed by Dr. [**Last Name (STitle) **].
(2) Status post St. [**Male First Name (un) 923**] aortic valve replacement and then a
redo in
[**2148**] and in [**2151**].
(3) He has CHB, afib, ventricular tachycardia status post
pacemaker implantable cardioverter-defibrillator (ICD)
implantation.
(4) He has a history of GI bleeds, has had gastritis and
duodenal
noted in the past.
(5) He has CHF with an ejection fraction of 25-30%
(6) Hypertension.
(7) Gout.
(8) Lupus with a history of lupus nephritis.
(9) Hypothyroidism.
(10) Anemia.
(11) He also has thrombocytopenia and a mildly reduced white
count for which he is being followed in Hem/[**Hospital **] Clinic.
(12) H/o abnl chest CT: 1.5 cm precarinal lymph node, as well as
a few of lung nodules. Seen by Dr. [**Last Name (STitle) **] in pulm clinic.
(13) Emphysema: Pulmonary function tests done in the office
today were reviewed. He has an FEV1 of 2.1 liters, which is 78%
of predicted and an FVC of 3.24 liters, which is 84% of
predicted, and an FEV1/FVC ratio of 62%. This is consistent
with a very mild obstructive deficit.--per pulm note in OMR
Social History:
He lives with his wife. [**Name (NI) **] is a retired truck driver. He
drinks occasional alcohol. He smoked 1.5 packs a day for 28
years and quit in [**2132**]. He has been exposed to asbestos in the
past. He reports that he worked in shipyards and was spraying
asbestos paint.
Family History:
His mother, father and sister all died of liver failure. His
father was an alcoholic, his sister had lupus. There is no
family history of lung disease.
Physical Exam:
VS: 97.2 128/72 72 20 100% RA
GEN: Well-appearing man who appears younger than his stated age.
NAD, sitting bed.
SKIN: Cool, dry. Multiple ecchymoses on hands, arms. No rashes.
HEENT: NC/AT, EOMs intact, PERRLA. Oral mucosa pink and moist.
No lymphadenopathy.
CARD: Normal rate, regular rhythm. S1, S2 intact. II/VI systolic
murmur at the RUSB with mechanical closing sound.
PULM: CTAB. Good aeration bilaterally. No wheezes, rales, or
rhonchi.
ABD: Soft, obese, NT. Bowel sounds present. No masses.
EXT: Warm, 2+ pulses, 1+ edema R>L.
NEURO: A&Ox3, CNII-XII intact. 5/5 strength, light touch,
temperature sensation intact throughout. Reflexes 2+ throughout.
Pertinent Results:
Admission Labs:
[**2160-9-1**] WBC-8.5# RBC-3.29* HGB-9.2* HCT-28.0* MCV-85 MCH-27.8
MCHC-32.6 RDW-17.4* NEUTS-69.0 LYMPHS-23.4 MONOS-6.6 EOS-0.7
BASOS-0.4
GLUCOSE-105 UREA N-130* CREAT-2.2* SODIUM-139 POTASSIUM-5.8*
CHLORIDE-107 TOTAL CO2-17* ANION GAP-21*
.
[**2160-9-1**] 07:35AM BLOOD CK-MB-NotDone proBNP-3394*
[**2160-9-1**] 12:22PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2160-9-2**] 11:38AM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2160-9-3**] 07:03PM BLOOD CK-MB-6 cTropnT-0.14*
.
Admission CXR:
No acute cardiopulmonary process identified. Unchanged
emphysema.
.
Echo ([**2160-9-2**])
The left atrium is mildly dilated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-45 %); no definite regional wall motion
abnormality is identified although views are technically
suboptimal. The right ventricular cavity is dilated with normal
free wall contractility. The aortic root is moderately dilated
at the sinus level. A bileaflet aortic valve prosthesis is
present. The transaortic gradient is upper normal for this
prosthesis. Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. The motion of the tricuspid
prosthetic leaflets appears normal. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Discharge Labs:
[**2160-9-7**] 08:12PM BLOOD WBC-3.4* RBC-3.42* Hgb-9.8* Hct-29.8*
MCV-87 MCH-28.7 MCHC-32.9 RDW-17.1* Plt Ct-107*
[**2160-9-7**] 08:12PM BLOOD PT-21.5* PTT-110.7* INR(PT)-2.0*
[**2160-9-7**] 08:12PM BLOOD Glucose-93 UreaN-57* Creat-1.7* Na-133
K-4.6 Cl-101 HCO3-21* AnGap-16
[**2160-9-7**] 08:12PM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8
Brief Hospital Course:
71 yo man w/ CAD s/p CABG, s/p mechanical [**Month/Day/Year 1291**], afib, EF 25-30%,
h/o GIB, chronic anemia, CKD second to lupus nephritis, who
presents with lightheadedness and fatigue in the setting of a
drop in his hematocrit and acute renal failure found to have
guiac positive stools.
# Acute on chronic anemia, acute blood loss: The pt was felt to
have a slow UGIB. He was transfused a total of six units pRBCs
with a Hct goal of approximately 30; although his HCT initially
failed to bump appropriately, it did stabilize. The GI service
was consulted and, based on the pt's comorbidities and prior
negative endoscopies, conservative medical managment was pursued
with IV PPI x 72 hours. The pt's home anticoagulation was
reversed with vitamin K; when his INR dropped below 1.5 he was
started on a heparin gtt given his mechanical valve. On transfer
out of the MICU to the medicine floor, the pt's Hct was stable
in the 30s and his INR was 1.5. He was continued on his heparin
to coumadin bridge. Patient's hematocrit remained stable and
required no further transfusions on the medical [**Hospital1 **]. His stools
lightened and patient was switched to po protonix [**Hospital1 **]. Coumadin
was restarted and INR of 2 acheived on the day prior to
discharge. It is recommended by the GI team that he undergo a
capsule enteroscopy as an outpatient to complete the workup of
GIB.
# Status post mechanical aortic valve replacement: The pt's
home INR goal is 2.0-3.0 He was supratherepeutic at the time
admission (5.3) and his anticoagulation was reversed as above.
When INR was below 1.5, the pt was treated with a heparin gtt.
He continued on a heparin gtt while receiving 2mg of coumadin
daily until INR >2. Patient was discharged home with a plan for
repeat INR check on [**9-9**] and appropriate follow up with his PCP
who manages his INR.
# Acute on chronic renal failure: At the time of admission, the
pt was thought to be pre-renal due to GIB/poor PO intake. His Cr
improved with IVF and pRBCs. The pt's home Lasix and [**Last Name (un) **] were
held at the time of admission but added back at the time of
discharge. His [**Last Name (un) **] dose was decrease by half due to persistent
borderling hypotension while on the floor. Patient's creatinine
was at baseline of 1.7 at the time of discharge.
# CAD: The pt complained of CP several times during admission,
however this was similar to his baseline. His home BB was
continued; his ASA was briefly held in the setting of his GIB.
Cardiac biomarkers were checked and were flat; no ECG changes
were ever noted. Patient was discharged home on aspirin and BB.
#Hyponatremia: Pt with mild hyponatremia at the time of
admission. This was thought to have occured in the setting of
probably decreased blood volume/relative hypovolemia. This
corrected with fluid administration and improved PO intake.
# Hypertension: The pt's home anti-hypertensives were initially
held in the setting of acute bleeding, but were restarted by the
time of discharge as above.
# Hypothyroidism: Stable. Home levothyroxine continued during
his stay.
Medications on Admission:
COUMADIN - 2MG Tablet daily (just reduced)
FUROSEMIDE [LASIX] - 40 mg Tablet once a day
LEVOXYL - 125MCG Tablet - ONE BY MOUTH EVERY DAY
LOPID - 600MG Tablet - ONE BY MOUTH once A DAY
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg once a day
NITROGLYCERIN [NITROQUICK] - 0.4 mg Tablet, Sublingual - 1
Tablet(s) sublingually prn as needed for cp
OXYCODONE - 5 mg Tablet - [**1-9**] Tablet(s) by mouth every four (4)
hours as needed for pain & at bedtime
PROTONIX - 40MG ONE BY MOUTH TWICE A DAY
VALSARTAN [DIOVAN] - 160 mg Tablet - once a day
ASPIRIN - 81 mg Tablet - once a day
FOLIC ACID - (OTC) - 1 mg once a day
LORATADINE [CLARITIN] - (OTC) - Dosage uncertain
PYRIDOXINE [VITAMIN B-6] - (OTC) - 50 mg Tablet - 1 Tablet(s)
by
mouth once a day
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please use as directed.
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
13. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
14. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day.
15. Outpatient [**Month/Day (2) **] Work
Please draw INR on [**9-9**] and fax results to:
Dr. [**Last Name (STitle) **]
FAX# [**Telephone/Fax (1) 12540**]
16. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Upper Gastrointestinal Bleed
Acute blood loss anemia
Chronic kidney failure stage IV
Iatrogenic Coagulopathy
.
Secondary diagnosis:
Coronary artery disease
St. [**Male First Name (un) 923**] aortic valve replacement
Complete heart block
History of GI bleeds
Congestive heart failure
Hypertension
Gout
Lupus with a history of lupus nephritis
Hypothyroidism
Thrombocytopenia
Leukopenia
Emphysema
Discharge Condition:
Hemodynamically stable, hematocrit stable at baseline,
creatinine stable at baseline, therapeutic INR
Discharge Instructions:
You have been admitted for lightheadedness and dizziness. Prior
to admission, your INR had been supratherapeutic at 4.29. You
had also noticed dark, black stools prior to admission. We
believe your dizziness and lightheadedness was due to an upper
GI bleed. You were medically managed in the medical ICU for your
upper GI bleed. Coumadin, aspirin, lasix, and valsartan were
held and you were transfused 5 units of packed red blood cells.
Your hematocrit or blood level was stabilized after initiation
of protonix and you were started on a heparin to coumadin bridge
for anticoagulation for your mechanical heart valve. It is
recommended that you continue on twice daily oral protonix to
prevent further gastrointestinal bleeding. It is also
recommended that you undergo an outpatient capsule study to look
for sources of bleeding in your small bowel.
.
Please continue your coumadin at 2 mg PO daily with an INR check
next week on [**9-9**] at your usual [**Month/Day (2) **] facility. Please continue all
other medications with the exception of aspirin and oxycodone
which have been discontinued and valsartan which has been cut in
half. Please discuss resuming aspirin with Dr. [**Last Name (STitle) **] at
follow up. Also, please discuss referral for outpatient capsule
study with Dr. [**Last Name (STitle) **].
.
If you develop any chest pain, shortness of breath, dizziness,
lightheadedness, or any other general worsening of condition,
please call your PCP or come directly to the ED.
Followup Instructions:
Please have your INR checked on [**9-9**] and have the results faxed
to Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **].
You have an appointment with radiology for a CT scan on [**2160-9-10**]
at 3 PM. If you are unable to keep this appointment, please call
[**Telephone/Fax (1) 327**] to reschedule. Thank you.
.
You have an appointment with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] on [**2160-9-12**] at
9:15 AM. If you are unable to keep this appointment, please call
[**Telephone/Fax (1) 9347**] to reschedule. Thank you.
.
You have an appointment at the Pulmonary Function [**Telephone/Fax (1) **] on [**2160-9-17**]
at 1 PM. If you are unable to keep this appointment, please call
[**Telephone/Fax (1) 609**] to reschedule. Thank you.
|
[
"V45.81",
"583.81",
"428.0",
"403.90",
"414.00",
"428.22",
"455.0",
"537.82",
"V58.83",
"427.31",
"274.9",
"V15.84",
"280.0",
"276.1",
"287.5",
"585.4",
"244.9",
"V43.3",
"578.9",
"790.92",
"584.9",
"562.10",
"V58.61",
"710.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12404, 12410
|
6971, 10068
|
301, 322
|
12867, 12972
|
4946, 4946
|
14511, 15315
|
4096, 4251
|
10861, 12381
|
12431, 12431
|
10094, 10838
|
12996, 14488
|
6612, 6948
|
4266, 4927
|
235, 263
|
350, 2489
|
12582, 12846
|
4962, 6595
|
12450, 12561
|
2511, 3779
|
3795, 4080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,978
| 197,890
|
31925
|
Discharge summary
|
report
|
Admission Date: [**2121-8-22**] Discharge Date: [**2121-8-30**]
Date of Birth: [**2060-11-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2121-8-25**] cabg x5 (LIMA to LAD, SVG to DIAG, SVG to ramus
sequentially to OM2, SVG to PDA)
History of Present Illness:
60 yo male present to outside ER with 48 hours of jaw pain, and
numbness in fingers and hand. EKG changes lead to cath which
revealed EF 40-50%, LAD 100%, 70-80% prox. CX, RCA 100%.
Transferred to [**Hospital1 18**] for CABG.
Past Medical History:
obesity
( no health care for 10 years)
Social History:
lives with girlfriend
current [**Name2 (NI) 1818**] 1 ppd x 40 years
[**7-11**] drinks per week
retired banker
Family History:
brother with MI at 70
Physical Exam:
NAD lying in bed
MAE, alert and oriented x 3, nonfocal exam
PERRL, anicteric, MMM, nl. buccal membrane
neck supple, no lymphadenopathy/thyromegaly
RRR S1 S2 no m/r/g
CTAB
abd obese, soft, NT, +BS
extrems, warm, well-perfused, palpable distal pulses
no varicosities or edema
T 98 HR 69 SR RR 22 154/84 98% 2L NC 68" 119 kg
Pertinent Results:
[**2121-8-28**] 05:45AM BLOOD WBC-9.9 RBC-2.85* Hgb-8.9* Hct-26.7*
MCV-94 MCH-31.3 MCHC-33.5 RDW-13.9 Plt Ct-233
[**2121-8-28**] 05:45AM BLOOD PT-12.6 PTT-33.7 INR(PT)-1.1
[**2121-8-28**] 05:45AM BLOOD Plt Ct-233
[**2121-8-28**] 05:45AM BLOOD Glucose-103 UreaN-13 Creat-0.8 Na-139
K-3.9 Cl-99 HCO3-29 AnGap-15
[**2121-8-27**] 03:48AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.4
Cardiology Report ECHO Study Date of [**2121-8-25**]
PATIENT/TEST INFORMATION:
Indication: Intraop CABG. Evaluate Aortic Atheroma, Ventricular
Function, Valve status
Height: (in) 68
Weight (lb): 262
BSA (m2): 2.29 m2
BP (mm Hg): 135/70
HR (bpm): 70
Status: Inpatient
Date/Time: [**2121-8-25**] at 09:28
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.4 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.6 cm
Left Ventricle - Fractional Shortening: *0.13 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 45% to 55% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.7 cm (nl <= 3.4 cm)
Aorta - Arch: 3.0 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm)
Mitral Valve - Peak Velocity: 0.7 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 140 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous
hypertrophy of the
interatrial septum. No ASD or PFO by 2D, color Doppler or saline
contrast with
maneuvers.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mild regional
LV systolic dysfunction. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
normal; anterior apex - hypo; apex - hypo; remaining LV segments
contract
normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. No atheroma in ascending aorta. Normal aortic arch
diameter. Complex
(>4mm) atheroma in the aortic arch. Normal descending aorta
diameter. Complex
(>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic
(normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure. No TEE related
complications.
Suboptimal image quality - body habitus. The patient appears to
be in sinus
rhythm.
Conclusions:
Pre bypass: The left atrium is moderately dilated. Left
ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is
mild regional left ventricular systolic dysfunction with distal
and apical
anterior hypokinesis. Overall left ventricular systolic function
is mildly
depressed (LVEF= 45-50 %). The remaining left ventricular
segments contract
normally. Right ventricular chamber size and free wall motion
are normal.
There are simple atheroma in the aortic arch and the descending
thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation
is seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post bypass: Patient is av paced, then a paced on phenylepherine
infusion. LV
wall motion appears imrproved to normal. LVEF 55%. Normal RV
function. MR is
still mild. Aortic contours intact. Remaining exam is unchanged.
All findings
discussed with surgeons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2121-8-25**] 11:20.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 74840**])
Brief Hospital Course:
Admitted [**8-22**] and pre-op workup completed over the weekend.
Underwent cabg x5 with Dr. [**First Name (STitle) **] on [**8-25**]. Transferred to the
CVICU in stable condition on phenylephrine and propofol drips.
Extubated that evening and transferred to the floor on POD #2 to
begin increasing his activity level. Chest tubes and pacing
wires removed without incident. Pt works with pt / PT cleares
for home with VNA. Foley DC'd without incident.
Medications on Admission:
none at home
at transfer:
ASA 325 mg dialy
lopressor 12.5 mg [**Hospital1 **]
protonix 40 mg daily
nicotine patch 21 daily
IV heparin
IV integrilin
plavix 75 mg daily
thiamine 100 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
10. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] vna
Discharge Diagnosis:
CAD s/p cabg x5
obesity
Discharge Condition:
good
Discharge Instructions:
SHOWER DAILY and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 2603**] in [**1-4**] weeks [**Telephone/Fax (1) 6256**]
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
PLEASE GET AN APPT. WITH A PRIMARY CARE in [**12-3**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2121-8-30**]
|
[
"305.1",
"285.9",
"410.41",
"414.01",
"278.00",
"V17.3",
"401.9",
"493.20",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"88.72",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
7847, 7898
|
5933, 6386
|
328, 428
|
7968, 7975
|
1279, 1704
|
8232, 8576
|
889, 912
|
6627, 7824
|
7919, 7947
|
6412, 6604
|
7999, 8209
|
1730, 5837
|
927, 1260
|
282, 290
|
456, 683
|
5872, 5910
|
705, 745
|
761, 873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,020
| 195,422
|
5560+5561
|
Discharge summary
|
report+report
|
Admission Date: [**2142-7-6**] Discharge Date: [**2142-7-31**]
Date of Birth: [**2072-12-5**] Sex: F
Service: SURGERY
Allergies:
Cardizem / Codeine / Optiray 300
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
[**2142-7-6**]- Endovascular repair of abdominal aortic aneurysm with
bilateral femoral endarterectomies complicated by left external
iliac artery avulsion s/p left iliac stent graft to left CFA,
bilateral femoral endartectomies and rt.
CFA patch angioplasty [**2142-7-7**]
RT. groin washout [**2142-7-8**]
History of Present Illness:
69 y.o female with AAA, which has grown from 4 cm to 6.5 cm.
Past Medical History:
1. CAD s/p CABG [**2138**] LIMA-->LAD, VG-->OM, VG--->RCA. Exercise
MIBI ([**3-3**]): Interval development of moderate, reversible distal
anterior wall and apical perfusion defect, involving the
expected LAD territory. Stable, moderate, predominantly fixed
perfusion defect involving the lateral wall and lateral portion
of the inferior wall. Normal left ventricular cavity size.Mildly
depressed left ventricular function with hypokinesis ofthe apex
and septal akinesis, the latter being consistent with prior
CABG. EF 46%.
[**4-30**] Echo: mild LAE, mild LV sys fcn, focal hypokinesis w/ basal
inf/lat wall
2. DM2
3. cryptogenic cirrhosis (?NASH) c/b esophgeal varicies
4. pancytopenia
5. CRI (1.9)
6. h/o PUD
7. h/o LGIB (AVM)
8. AAA: [**3-3**] Abd MRI- infrarenal AAA 5 x 6 cm with diffuse
atherosclerotic change
9. MI [**2122**]
10. s/p R cataract surgery
Social History:
Patient denies any significant etoh history. She used to smoke
cigarettes but quit 18 years ago. No tattoos. No IVDU. She is
Irish/Lebanese.lives with son. 2 Daughters work at [**Hospital1 18**] in
PACU.
Family History:
Her mother had non-alcoholic liver cirrhosis.
Her father had diabetes.
Physical Exam:
Elderly female, NAD
NCAT, PERRL, EOMI
neg lesions nares, oral pharnyx, auditory
supple, farom
neg lymphandopathy or supraclavicular nodes
[**Hospital1 **]-basilar crackles at bases
rrr without murmers
Right groin / JP drain / neg erythema noted
palpable pulse b/l le
Pertinent Results:
[**2142-7-31**]
WBC-2.8* RBC-3.57* Hgb-10.4* Hct-31.1* MCV-87 MCH-29.2 MCHC-33.5
RDW-18.2* Plt Ct-70*
[**2142-7-27**]
PT-14.4* PTT-32.5 INR(PT)-1.4
[**2142-7-31**]
Glucose-116* UreaN-13 Creat-1.3* Na-136 K-4.0 Cl-102 HCO3-28
AnGap-10
[**2142-7-31**]
Calcium-7.6* Phos-2.8 Mg-1.7
[**2142-7-11**]
freeCa-1.03*
[**Month/Day/Year 706**] Final Report
CHEST (PA & LAT) [**2142-7-28**] 5:52 PM
CHEST (PA & LAT)
Reason: please eval tip of picc. thanks
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with AAA, recurrent CHF,CAD with baslar
crackles and JVD.
REASON FOR THIS EXAMINATION:
please eval tip of picc. thanks
This is a two view chest dated [**2142-7-28**].
INDICATION: PICC line placement.
Comparison is made to previous study of [**2142-7-23**].
A left PICC line is present, terminating within the superior
vena cava. The cardiac silhouette is mildly enlarged. There is
upper zone [**Year (4 digits) 1106**] redistribution, mild perihilar haziness, and
subtle interstitial opacities in the perihilar and basilar
regions. Small pleural effusions are noted as well as a small
amount of fluid within the fissures.
IMPRESSION:
1. Left PICC line in satisfactory position.
2. Congestive heart failure, which has worsened compared to the
recent radiograph.
Cardiology Report ECG Study Date of [**2142-7-26**] 10:11:22 AM
Sinus bradycardia, rate 57. Left anterior hemiblock. T wave
inversion in
lead VI suggestive of ischemia. Non-specific repolarization
changes in the
lateral standard and precordial leads. Possible old inferior
wall myocardial
infarction. Cannot exclude anterior myocardial infarction of
indeterminate age.
Compared to the previous tracing of [**2142-7-25**] T waves are more
deeply inverted in
leads V2 and aVL suggesting an ongoing acute ischemic process.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
57 132 104 486/478.58 24 -44 100
Cardiology Report ECHO Study Date of [**2142-7-18**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. H/O cardiac surgery.
Height: (in) 66
Weight (lb): 164
BSA (m2): 1.84 m2
BP (mm Hg): 144/43
HR (bpm): 77
Status: Inpatient
Date/Time: [**2142-7-18**] at 16:30
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W272-1:13
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1111**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.35 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 1.27
Mitral Valve - E Wave Deceleration Time: 170 msec
TR Gradient (+ RA = PASP): *52 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2141-5-23**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV
systolic dysfunction. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior
- hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is mild regional left ventricular
systolic
dysfunction. Overall left ventricular systolic function is
mildly depressed.
Resting regional wall motion abnormalities include inferolateral
hypokinesis.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2141-5-23**], the
estimated
pulmonary artery ysystolic pressure is now higher. Left
ventricualr systolic
function appears similar.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2142-7-18**] 18:58.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]
[**Name Initial (NameIs) 706**] Final Report
CTA ABD W&W/O C & RECONS [**2142-7-16**] 3:41 PM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
Reason: ENDOVASCULAR REPAIR AAA
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman s/p endovascular AAA repair
REASON FOR THIS EXAMINATION:
We need CTA of Abdomen
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 69-year-old woman status post endovascular abdominal
aortic aneurysm repair.
COMPARISON: [**2142-5-16**].
TECHNIQUE: Multiple axial images of the abdomen and pelvis were
obtained both prior to and following the administration of 150
cc of Optiray. In addition, reconstructed images in the coronal
and sagittal planes were obtained.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Few images
through the lung bases demonstrate small bilateral pleural
effusions with associated bibasilar atelectasis, left greater
than right. There are small paracardial lymph nodes measuring up
to 7 mm in diameter.
There is a large amount of ascites, surrounding the liver and
spleen. The spleen is enlarged. There are splenic artery
calcifications seen. No focal liver lesions are identified. Both
kidneys are slightly atrophic. There are bilateral symmetric
nephrograms . The adrenal glands are unremarkable. There are
calcified gallstones in the gallbladder.
The free fluid surrounding the liver and spleen tracks into the
pelvis, surrounding the bladder.
The celiac, superior mesenteric, and renal arteries are patent.
There is an infrarenal aortic aneurysm, unchanged in size
compared to [**2142-5-24**]. However, in the interim, there has
been a placement of aorto- bilateral iliac stent grafts.
Within the left posterior pararenal space, there is a large
collection with attenuation values ranging between 40-29
Hounsfield units measuring approximately 9.8 (transverse)x 4.9
(anterior-posterior) x 10.3 cm in the craniocaudad dimension.
This displaces the left kidney anteriorly. These are best
visualized on the coronal reconstructed images, and the inferior
aspect of this hematoma abuts the left limb of the stent graft.
However, no active extravasation is identified.
CT PELVIS WITH IV CONTRAST: There is diverticulosis without
diverticulitis. There is a large amount of free fluid in the
pelvis. There is air in the bladder presumably from recent
instrumentation. There are bilateral groin skin staples. There
is slight asymmetry of the left groin musculature with small low
attenuation fluid, which could be secondary to postoperative
procedures.
RECONSTRUCTED IMAGES: Reformatted images in the coronal and
sagittal planes confirmed the presence of the left posterior
pararenal space hematoma, which displaces the left kidney
anteriorly. The value grade of these images is 4.
Findings were communicated to Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] on [**2142-7-16**].
IMPRESSION:
1. Left posterior pararenal space hematoma displacing the left
kidney anteriorly. No active extravasation is identified.
2. Marked amount of ascites.
3. Bilateral pleural effusions and bibasilar atelectasis.
4. Splenomegaly.
[**2142-7-26**] 12:40 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2142-7-26**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2142-7-26**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2142-7-18**] 7:30 pm BLOOD CULTURE
**FINAL REPORT [**2142-7-24**]**
AEROBIC BOTTLE (Final [**2142-7-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2142-7-24**]): NO GROWTH.
[**2142-7-9**] 9:06 am SWAB Site: RECTAL RECTAL.
**FINAL REPORT [**2142-7-13**]**
MRSA SCREEN (Final [**2142-7-11**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2142-7-13**]):
No VRE isolated.
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- 1 S
PENICILLIN------------ 2 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
Pt admitted [**2142-7-6**] AAA
Pt underwent a endovascular abdominal aortic aneurysm repair,
repair of left external iliac artery avulsion, bypass from left
iliac stent graft to left common femoral artery, and bilateral
femoral endarterectomy and patch angioplasty of
right common femoral artery. Pt remained intubated post
procedure. She was transfered to SICU in fair condition.
Pt experienced a iliac artery rupture intra - op.
[**2142-7-7**] - [**2142-7-15**] - SICU status
Pt experience blood loss intra procedure. Pt had multiple blood
transfusions / BP / HR / HCT were followed.
Pt was on and off IV blood pressure medications for BP support.
Pt also experienced high grade temps Vanco / Zosyn started
Pt extubated [**2142-7-13**]
[**Last Name (un) **] consult put in for the patient.
[**2142-7-16**] - [**2142-7-18**]
Pt transfered to the floor in stable condition. Pt diet advanced
as tolerated. PT consult is obtained.
Pt still has significant drainage from groin incision. Pt gets
CTA ( no endo leak ). Zosyn is DC'd. Pt remains on Vancomycin.
Cefazolin started.
Pt experiences chest pain. Pt ruled out for MI by CK, but pt had
inrease in troponin level. Given the patients difficult hospital
course to date a cardiology consult was obtained. They suggested
that the pt recently had MI, but probable not related to this
hospital course.
Pt beta blocker increases / asa continued
[**2142-7-19**] - [**2142-7-24**]
Pt recieves surface echo. EF 45% / found to have mild chf, pt
recieves lasix. Lytes replenished.
Cx show e-coli / staph coag neg. from groin, Cefazolin dc'd. Pt
put on Zosyn. C/W Vancomycin.
Groin continues to drain.
Epogen restarted
[**2142-7-25**] - [**2142-7-26**]
Pt goes back to the OR for lymphatic leak from right groin. She
undergoes an excision and debridement of right groin wound and
secondary primary closure. Pt recieves a JP drain. She tolerates
the procedure well. There are no complications. This is done by
MAC. She is transfered to the PACU in stable condition.
After recovery from anesthesia transfered to the floor in stable
condition.
[**2142-7-27**] - [**2142-7-30**]
Pt recieves PICC line. Case management is involved for home VNA
services. Pt consult is obtained.
[**2142-7-31**]
Pt is stable on DC. She is urinating / taking PO / pos BM.
She leaves with VNA services for:
1. IV antibiotics
2. daily weights
3. lytes / vanco dosing - labs
4. JP drain monitering
She is to follow-up with Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **] in one week
Medications on Admission:
ASA 81', Lipitor 20', Iron 325'' Imdur 90', Lasix 40'', Protonix
40', Univasc 15', nadolol 60', Norvasc 10', Lantus 31HS, Humulin
SS, Epogen
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
Disp:*100 cc* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: as directed
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*1 vial* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Nadolol 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
13. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for for loose bowel
movements.
Disp:*30 Tablet(s)* Refills:*0*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
15. glargine Sig: Ten (10) units at bedtime.
16. Vancomycin HCl 1000 mg IV Q 24H
please check trough at 3rd dose
HOLD FOR VANCO TROUGH >15
17. Outpatient Lab Work
[**Hospital1 **], bun/cr and trough weekly. call results to Dr.[**Name (NI) 5695**]
office [**Telephone/Fax (1) 3121**]
18. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: AC scale:
glucoses <100 no insulin
glucoses 101-150/4u
glucoses 151-200/5u
glucoses 201-250/6u
glucoses 251-300/7u
glucoses 301-350/8u
glucoses 351-400/9u
glucoses >400 [**Name8 (MD) 138**] md
Bedtime scale:
glucoses <150,no insulin
glucoses 151-200/2u
glucoses 201-250/3u
glucoses 251-300/4u
glucoses 301-350/5u
glucoses 351-400/5u
glucoses >400 [**Name8 (MD) 138**] Md.
19. ampicillan Sig: One (1) 500 mg four times a day for 6
weeks.
Disp:*60 500mg* Refills:*3*
20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Status post abdominal aortic aneurysm repair, postoperative
blood loss anemia ,transfused
DM2 insulin dependant,uncontrolled
Postoperative CHF, compensated
HX CAD w angina, controlled
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Also
call if you loose more then 5 lbs.
Adhere to 2 gm sodium diet
Moniter cbc,bun,cr, vanco trough weekly.
Continue antibiotics for total of 6 weeks started [**7-9**]-continue
thru [**8-19**]
You have a JP drain, please moniter the output and empty daily.
Call if your surgical wound becomes red, drains, or has
discharge. Also call if you experience fever and or chills.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-8-2**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2142-9-11**] 1:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2143-1-23**] 9:00
Provider: [**Name10 (NameIs) 1111**],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3121**] Follow-up
appointment should be in 1 weeks.
You have an appointment already with Dr [**Last Name (STitle) **]. Please schedule
another appointment when you leave. Schedule the appointment for
one week. He can be reached at [**Telephone/Fax (1) 5003**]
Completed by:[**2142-7-31**] Unit No: [**Numeric Identifier 22375**]
Admission Date: [**2142-7-6**]
Discharge Date: [**2142-7-31**]
Date of Birth: [**2072-12-5**]
Sex: F
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old female who
was initially evaluated by Dr. [**Last Name (STitle) **] in an office visit
on [**2142-4-30**] for a known abdominal aortic aneurysm.
Patient was encouraged by her daughter to seek followup and
evaluation. The aneurysm was 1st noted 4 years ago at the
time of her coronary artery bypass by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
It was found to be in a 4 cm range. This is progressively
enlarged and it is now at 6.5 cm in maximal diameter. She
does admit to having intermittent episodes of chest pain and
had a nuclear medicine scan which showed a small area of
reversible ischemia and larger fixed defect with a mildly
reduced ejection fraction. Patient has had episodes of
congestive failure in the past.
Patient is known to have a chronic anemia related to GI
bleeds of uncertain origin. Hematocrit usually ranges between
25 and 32. Patient also is known to have hepatic cirrhosis of
undetermined etiology, and she has been followed by Dr. [**First Name (STitle) **]
[**Name (STitle) **] in the past. Her albumin is 3. Her PT is approximately
14. Her platelet count is 70-80 range. She has not undergone
a repeat coronary angiography because of her inability to
tolerate Plavix secondary to her GI bleeding. Patient does
admit to chronic low back pain and denies any other specific
symptoms.
PAST MEDICAL HISTORY: Past medical history is significant
for hypertension, type 2 diabetes x18 years and insulin
dependent, does admit to history of gallstones, asymptomatic,
history of spinal canal stenosis, history of angina, coronary
artery disease.
PAST SURGICAL HISTORY: Past surgical history includes CABG
and tonsillectomy.
ALLERGIES: Cardizem - manifestations not documented. Plavix
- GI bleed.
PHYSICAL EXAMINATION: She is a well appearing, elderly lady
in no acute distress. Blood pressure is 150/80, pulse 58.
HEENT exam was unremarkable. Chest was clear to auscultation.
Heart is regular rate and rhythm. Abdominal exam is soft.
There is no shifting dullness or fluid wave. Her aneurysm is
faintly palpable. Her abdomen is slightly protuberant and is
nontender. Pulse exam: She has palpable femorals bilaterally.
Popliteal pulses are nonpalpable. She has strongly palpable
right DP and a very diminished left DP.
Patient now was admitted for elective abdominal aortic
repair.
HOSPITAL COURSE: Patient was admitted to the preoperative
holding area on [**2142-7-6**]. She underwent an endovascular
abdominal aortic aneurysm repair with repair of the left
external iliac avulsion with a bypass from the left iliac
stent graft to the common femoral artery. She had bilateral
femoral endarterectomies and a patch angioplasty to the right
common femoral. Patient tolerated the procedure well and was
transferred to the PACU in stable condition.
Patient was transferred to the SICU for continued care.
Patient returned on [**2142-7-8**] to the OR for a right groin
washout. She remained in the SICU for vasopressor support and
ventilation. Patient was transferred to regular nursing floor
on [**7-12**].
On [**7-23**], patient had an episode of shortness of breath.
This was very consistent with congestive heart failure.
Patient was diuresed with improvement in her symptoms.
Patient was followed by [**Last Name (un) **] during her hospitalization for
glycemic management. Patient returned to the OR on [**2142-7-25**] for a right groin wound washout and primary closure.
PICC line was placed on [**2142-7-26**] for long-term
antibiotics.
Patient's wound culture grew E. coli and Staph-coag negative
MRSA. Patient was continued on vancomycin and levofloxacin.
The patient's wound showed continued improvement. Patient
will be discharged to home with IV antibiotics for a total of
6 weeks. Antibiotics were started on [**7-9**], will continue
through [**8-20**]. Patient should follow up with Dr. [**Last Name (STitle) **]
as directed.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm status post endovascular repair,
iliac avulsion left status post bypass graft from iliac
stent to common left femoral artery, status post bilateral
femoral endarterectomies with a right femoral artery
angioplasty.
2. Blood loss anemia corrected.
3. Type 2 diabetes, insulin dependent controlled.
4. Coronary artery disease with congestive failure
postoperatively compensated.
5. Right groin seroma with infection treated.
6. Hypertension controlled.
DISCHARGE MEDICATIONS: Acetaminophen 325 mg tablets [**1-28**] q.4-
6h. p.r.n., Protonix 40 mg daily, Sarna lotion to effected
areas daily, aspirin 81 mg daily, oxycodone/acetaminophen
5/325 tablets [**1-28**] q.4-6h. p.r.n., nitroglycerin sublingual
0.3 mg tablets p.r.n., Epogen 4000 units subcutaneously every
Monday, Wednesday, and Friday, isosorbide mononitrate 90 mg
daily, atorvastatin 20 mg daily, ferrous sulfate 325 mg
daily, moexipril 7.5 mg daily, nadolol 60 mg daily,
diphenoxy/atropine 2.5/0.25 mg tablets 2 q.6h. p.r.n. for
bowel movements, calcium carbonate 500 mg q.i.d. p.r.n., and
Bicillin 500 mg q.6h. times a total of 1 week, glargine 10
units at bedtime, Humalog insulin before meals and at bedtime
as directed, vancomycin 1 gram q.24h. for a total of 6 weeks.
This will be continued through [**2142-8-20**].
DISCHARGE INSTRUCTIONS: Patient should follow up with Dr.
[**Last Name (STitle) **] as directed. The wound should continue with dry
sterile dressings. If there is increasing drainage, erythema,
or if patient develops fever, they should call the office
sooner. Outpatient lab work includes a CBC, BUN, creatinine,
and vancomycin trough weekly. These results should be called
to Dr.[**Name (NI) 5695**] office.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2142-7-31**] 10:28:05
T: [**2142-7-31**] 11:01:22
Job#: [**Job Number 22376**]
|
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"250.50",
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"280.0",
"456.21",
"285.1",
"369.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
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"39.25",
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icd9pcs
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[
[
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] |
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|
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|
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|
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|
21104, 21234
|
1911, 2181
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21257, 21822
|
19415, 19443
|
8056, 12028
|
19472, 20824
|
7647, 7944
|
20847, 21080
|
1597, 1808
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,757
| 193,966
|
32987
|
Discharge summary
|
report
|
Admission Date: [**2112-12-31**] Discharge Date: [**2113-1-1**]
Date of Birth: [**2033-2-12**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
[**2112-12-31**]-Uneventful placement of infrarenal OptEase IVC filter
from the right common femoral venous approach.
History of Present Illness:
Mr. [**Known lastname **] is a 79 y/o male with a PMHx of Alzeimers Dz, HTN,
Hyperlipidemia, GERD and diabetes who was found down,
unresponsive at his [**Hospital3 **] facility. He was brought by
EMS to the ED where he was noted to be hypotensive, with an
oxygen requirement.
.
Past Medical History:
Alzeimers disease
HTN
GERD
DM
Hyperlipidemia
Headaches
Social History:
Wife states pt is not a smoker, drinker, or drug user. He lives
in [**Hospital3 **].
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.6 BP:86/60 HR: NSR 71 RR:18 O2sat 97%
GEN: Confused, thinks he is at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] unable to answer
questions appropriately
HEENT: PERRL, EOMI, anicteric, op without lesions
NECK: no jvd, no carotid bruits,
RESP: CTAB except L base crackles
CV: RR Distant Heart Sounds no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: Cold distal extremities, no edema, 1+ dorsalis pedis, post
tib1+ bilat
SKIN: no rashes/no jaundice
NEURO: confused. Cn II-XII intact.
Pertinent Results:
ADMISSION LABS
[**2112-12-30**] 08:16PM BLOOD WBC-18.90* RBC-4.14* Hgb-12.7* Hct-36.7*
MCV-89 MCH-30.6 MCHC-34.6 RDW-14.6 Plt Ct-123*
[**2112-12-30**] 08:16PM BLOOD Neuts-72* Bands-1 Lymphs-19 Monos-4 Eos-0
Baso-0 Atyps-4* Metas-0 Myelos-0
[**2112-12-30**] 08:16PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Burr-2+
[**2112-12-30**] 08:16PM BLOOD PT-13.7* PTT-25.5 INR(PT)-1.2*
[**2112-12-30**] 08:16PM BLOOD Glucose-500* UreaN-37* Creat-2.1* Na-140
K-5.0 Cl-104 HCO3-19* AnGap-22*
[**2112-12-30**] 08:16PM BLOOD CK(CPK)-207*
[**2112-12-30**] 08:16PM BLOOD CK-MB-8
[**2112-12-30**] 08:16PM BLOOD cTropnT-0.02*
[**2112-12-31**] 05:04AM BLOOD CK-MB-8 cTropnT-0.03*
[**2112-12-30**] 08:16PM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8
[**2112-12-31**] 02:55AM BLOOD Acetone-NEGATIVE Osmolal-320*
[**2112-12-30**] 09:50PM BLOOD Type-ART pO2-183* pCO2-21* pH-7.39
calTCO2-13* Base XS--9 Intubat-NOT INTUBA
Lactate trend
[**2112-12-30**] 08:30PM BLOOD Lactate-5.8*
[**2112-12-30**] 09:31PM BLOOD Lactate-4.7*
[**2112-12-30**] 11:41PM BLOOD Lactate-5.7*
[**2112-12-31**] 12:35AM BLOOD Lactate-5.3*
[**2112-12-31**] 02:25AM BLOOD Lactate-4.7*
[**2112-12-31**] 09:52AM BLOOD Lactate-3.0*
IMAGING
CXR [**2112-12-30**]
Relatively stable examination with no definite acute pulmonary
process
.
CT C spine [**2112-12-30**]
No acute traumtic injury. Degenerative changes as above.
.
CT head [**2112-12-30**]
Small amount of right frontal subarachnoid hemorrhage. Gven size
and distribution and given history, post traumatic etiology
suspected. No mass effect.
.
MRI head 2/2.08
1. Acute subarachnoid hemorrhage along the sulci in the right
frontal lobe at the site of hypodensity seen on CT.
2. Extensive bifrontal and right medial parietal superficial
siderosis.
3. Moderate-to-severe brain and medial temporal atrophy.
4. Mild-to-moderate changes of small vessel disease
5. No evidence of acute infarct.
.
CT abdomen [**2112-12-31**]
1. Saddle pulmonary embolism with relatively greater clot burden
on the right. Echocardiography may be useful as clinically
indicated to assess for right heart strain.
2. Renal cysts some of which are greater density than simple
fluid, probably due to protein content.
3. Small amount of free pelvic fluid is nonspecific.
.
IVC filter placement [**2112-12-31**]
Uneventful placement of infrarenal OptEase IVC filter from the
right common femoral venous approach.
.
ECHO [**12-31**]/-08
The left atrium is normal in size. The right atrium is dilated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 60%). There is no ventricular septal defect. The
right ventricular cavity is dilated with severe global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic arch
is mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The supporting
structures of the tricuspid valve are thickened/fibrotic.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate-to-severe pulmonary artery systolic hypertension.
There is no pericardial effusion. Suboptimal image quality -
patient unable to cooperate.
IMPRESSION: dilated, severely hypocontractile right ventricle;
moderate-to-severe pulmonary hypertension
Brief Hospital Course:
In the ED the patients vitals were Tmax 99.8, HR 70-77, BP SBP
(82-119)/(43-84), RR 28-40, Sat 88% on 4L, then 100% on
Non-rebreather. He received 5 Liters of NS, levofloxacin 750mg
x1, ceftriaxone 1gm x1, flagyl 500mg IV x 1, and 8 units of
regular insulin. Insulin drip was started at 6 units/hour. He
was started on levophed titrated up to 0.09mcg/kg. Finger stick
prior to CT scan was 401. Peak glucose of 500. Patient had a
lactate that peaked at 5.8.
.
In the [**Name (NI) **] pt was pan-scanned. He had a head CT which was
questionable for a small SAH. It was read as such by the ED
radiologist Dr. [**Last Name (STitle) 2026**] and Dr. [**Last Name (STitle) **]. Neurosurgery was
consulted. Neurosurgery resident and neurosurgery attending Dr.
[**Last Name (STitle) 548**] felt that there was no SAH, and what was seen was
artifact. Neurosurg signed off, because they felt there was no
bleed.
.
Pt was found to have large saddle embolus when scanning abdomen
for possible ischemic bowel.
.
Unable to send pt for repeat head CT as he did received contrast
for his CT chest. At time of admission still discussing final
decision and further head imaging for patient.
.
Pt was confused and unable to answer questions. Unable to obtain
ROS.
.
Impression: Mr. [**Known lastname **] is a 79 y/o man found down, noted in
the ED to be hypotensive, w/ desat, AG of 17, BG 500, w/ renal
failure Acute vs. Chronic, noted to have CT read of head w/
debate of artifact vs. SAH, found to have massive pulmonary
embolus on CT scan. He was transferred from ED on
Non-rebreather, levophed for BP, and Insulin drip, DNR/DNI.
.
# Saddle Pulmonary Embolus: Pt had massive pulmonary embolism,
that has lead to ms changes, LOC, hypoxia, hypotension, elevated
lactate, leukocytosis, and likely stress response causing
glucose elevation.
Pt was hemodynamically unstable from pulmonary embolism. There
is debate as to whether or not pt had SAH bleed on head CT,
radiology says maybe, neurosurg states it is an artifact.
Discussed final read with all parties. Unable to repeat head CT,
because CT chest dye load would interfere with ability to tell
if SAH occurred. head imaging showed bleed (confirmed by MRI),
no heparin, placed IVC filter
pending consensus no head bleed, planned to give intra-pulm cath
thrombolytics becaue the benefit of lytics likely outweighs risk
at this point in time.
TTE was done for right heart strain, with results as reported.
Fluid bolus were given PRN, as he is preload dependent, kept CVP
15-20.
.
#: Altered Mental Status: Patient found down unconscious, he had
an underlying baseline of alzeimers. Unclear what caused LOC.
Initially felt to be secondary to metabolic or infectious
etiology given finding concerning for DKA (glucose 500s, ketones
in urine, AG=17) and Sepsis(leukocytosis 18, elevated lactate
5.8, hypotension, desat). Finding of massive saddle PE, explains
all of the above finding, severe cardiac compromise, can lead to
the lactic acidosis in the setting of pt taking glucophage. Poor
perfusion can cause this patient with baseline dementia to have
a worsened mental status. He was continued on his namenda and
aricept. He did not recover his mental status and was made CMO
after discussion with his wife, subsequently expired.
.
# Anion Gap Acidosis: ph 7.39, Lactate is 5.3. The lactate could
be secondary to glucophage use, in setting of hypoperfusion.
Sepsis is very unlikely, better explanations hypoperfusion from
PE. DKA also possibility but not as likely.
Continued insulin drip and checked frequent K.
.
# Infectious Etiology: clean UA, blood cx pending, no signs of
meningitis. No abd signs of infection on exam or CT. Pt received
levoquin 750 IV, flagyl 800mg IV, and ceftriaxone 1gm in ED.
Only thing he is not adequetly covered for is gram positives.
Infection as etiology is very unlikely given how story fits with
PE, but will still cover for gram positives for 24 hours.
Vancomycin was started then discontinued after CMO.
.
# ROMI: Patients ECG showed Twave inv v1-v3, otherwise normal.
No reported history of chest pain, but w/ DM need to consider
MI. Also looking for strain and trop leak.
First Trop 0.02, CK 207, MB 8
.
# Renal Failure: No current records on patient. Unclear if this
is acute or chronic renal failure. Felt to be likely from
pre-renal CV compromise.
.
# Hyperlipidemia: Cont Lipitor 20mg
.
# HTN: Hx of hypertension and propanolol use.
.
# DM: Check Hemoglobin HgA1C in am. Insulin drip initially then
long acting and sliding scale.
held glucophage.
.
# Pain control: tylenol for now.
.
# F/E/N: IVF. Replete lytes PRN. NPO.
.
# PPx: Bowel regimen, PPI, sq Heparin
.
# Access: Right Fem line
.
.
# Communication: [**Known lastname **],[**Name (NI) 539**] Wife [**Telephone/Fax (1) 76718**]
Medications on Admission:
Lipitor 20mg daily
Gabapentin 400mg daily (Headaches)
Propranolol 160mg Daily
Aricept 10mg [**Hospital1 **]
Omeprazole ?
Metformin 1gm [**Hospital1 **]
Namenda 10mg [**Hospital1 **]
Cosopt L eye [**Hospital1 **]
xalatan eye drops both eyes QHS
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
none
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2113-5-11**]
|
[
"401.9",
"331.0",
"250.00",
"530.81",
"276.2",
"272.4",
"294.10",
"453.41",
"430",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
10394, 10403
|
5304, 7829
|
307, 426
|
10451, 10457
|
1523, 5281
|
10510, 10671
|
930, 948
|
10365, 10371
|
10424, 10430
|
10097, 10342
|
10481, 10487
|
963, 1504
|
257, 269
|
454, 734
|
7844, 10071
|
756, 812
|
828, 914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,539
| 184,930
|
860
|
Discharge summary
|
report
|
Admission Date: [**2167-1-30**] Discharge Date: [**2140-3-14**]
Date of Birth: [**2125-10-11**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname 5923**] is a 41-year-old female
with past medical history of questionable chronic obstructive
pulmonary disease and asthma with two recent hospitalization
for asthma / chronic obstructive pulmonary disease flares
complicated by pneumonia. Patient presents with five days of
URI symptoms, sore throat and fatigue, three days of
shortness of breath with inhaler use with moderate relief,
two day history of cough, dry and nonproductive and
subjective fevers and chills. Patient denies myalgias,
headache, chest pain, rash, diarrhea, abdominal discomfort,
or hemoptysis. Current symptoms are identical to prior
admission. Patient's last admission was on [**11-15**]. Patient
has one lifetime history of intubation. Patient had a lung
biopsy in [**9-15**], past reports suggestive of interstitial
pulmonary fibrosis.
On presentation to the Emergency Department, patient had a
temperature of 101.9 F, heart rate of 126, blood pressure
156/85, breathing rate of 28, saturating at 83% on room air.
Patient was put on oxygen. Patient received a chest x-ray
which showed questionable early left lower lobe infiltrate
with atelectasis. EKG showed patient in sinus tach with poor
R wave progression, left axis deviation, no signs of
ischemia. Patient was started on antibiotics, steroids, nebs
and admitted.
PAST MEDICAL HISTORY:
1. Interstitial pulmonary fibrosis.
2. Adult onset asthma with one lifetime intubation, multiple
hospitalizations.
3. History of VRE and MRSA.
4. Schizoaffective disorder.
5. Depression.
6. Multiple suicide attempts.
7. Temporal lobe epilepsy.
8. Meningitis.
9. History of positive PPD status post six month treatment
with INH and Rifampin.
10. Gastroesophageal reflux disease.
11. History of TDs in the setting of ETOH withdraw.
12. Exploratory laparotomy for abdominal mass versus uterine
cyst.
13. Noninsulin dependent diabetes mellitus.
ALLERGIES:
1. Patient has insensitivity to Codeine which gives her GI
upset.
2. True allergy to Penicillin for which she gets a rash.
3. Erythromycin for which she also gets a rash.
MEDICATIONS:
1. Prozac 60 mg p.o. q. day.
2. Neurontin 1200 mg p.o. t.i.d.
3. Clozaril 100 mg q. AM, 400 mg q. PM.
4. Flovent two puffs b.i.d.
5. Albuterol nebs p.r.n.
6. Risperdal 2 mg p.o. q.h.s.
SOCIAL HISTORY: Patient smokes one to two packs of
cigarettes per day and has a history of medical noncompliance
and poor follow up. Patient has been sober for greater than
10 years. Also prior use of LSD, cocaine and heroin use, but
none in the recent past. Patient lives alone.
PHYSICAL EXAMINATION: On arrival to the medical floor, the
patient had a temperature of 98.3 F, blood pressure 120/68,
pulse of 100, respirations 22, saturating 94% on 10 liter
mask. In general patient is an obese white female in mild
distress, able to speak in full sentences. Normocephalic,
atraumatic. Pupils equal, round and reactive to light.
Extraocular movements intact. Oropharynx is clear. Neck was
supple without tenderness or rigidity. No jugular venous
distention was appreciated. Lungs: Decreased breath sounds
in the right base with mild wheezing. Cardiovascularly:
Patient was tachycardic, S1, S2, no murmurs. Abdomen was
obese, soft, nontender, nondistended with normoactive bowel
sounds. Extremities: 1+ pitting edema lower extremities to
the knee. Cranial nerves II through XII intact. Normal
strength and sensation, equal bilateral extremities. No
clubbing or cyanosis with minimal pitting lower extremity
edema.
LABORATORY: White count 21.4, hematocrit 40.3, platelets
322. Urinalysis was negative. Sodium 137, potassium 4.0,
chloride 102, bicarbonate 24, BUN 10, creatinine 0.7, glucose
of 197.
HOSPITAL COURSE: Patient was admitted to the Medical Floor.
Patient received oxygen via face mask to keep saturations
greater than 92%. Patient received q. three hour standing
Albuterol and Atrovent neb treatments. Patient was started
on Levofloxacin 500 mg p.o. q. day and patient was also
started on Solu-Medrol 80 mg IV q. eight hours. Patient was
managed on this course until the second hospital day when
patient was found to be increasingly somnolent. ABG was
performed at this time that showed a pH of 7.35, pCO2 of 58,
pO2 of 132. Because of this, the patient was taken to the
ICU for observation.
In the ICU, the patient continued to slowly improve.
Steroids, nebulizer treatments and antibiotics were continued
as on the floor. Patient received cardiac echo for
evaluation of possible congestive heart failure. Patient had
left ventricular wall thickness. Cavity size and systolic
function were all normal with a left ventricular ejection
fraction of greater than 55% and normal left ventricular
region wall motion unchanged in the interval from previous
echo of [**2163-5-6**]. The patient returned to the floor after
two days of observation in the ICU in improved condition.
Patient had chest x-ray at this time which showed interval
resolution of patient's pulmonary opacities.
Pulmonary consult was obtained for more input on patient's
worsening respiratory status who advised patient receive
chest CT Scan. The chest CT Scan was consistent with
worsening interstitial lung disease. Patient's sedation is a
possible contribution of patient's psychiatric regimen was
considered and psych consult was obtained. They recommended
it was reasonable to hold sedating psychiatric medications,
but continuing patient on low dose Clozaril. All other
psychiatric medications were stopped.
Throughout this time, the patient slowly continued to improve
in respiratory status requiring less frequent nebs and
decreased O2. The patient was transitioned from mask to
nasal cannula where she continued to improve. The patient
was also started on Bactrim for PCP prophylaxis and other
follow up chest x-ray showed no evidence of focal
consolidation. Patient completed a course of Levofloxacin
which was stopped prior to discharge.
Fingersticks were checked on patient during the hospital stay
and slowly started to trend upward. Patient was put on
sliding scale insulin. At time of discharge, the patient is
saturating about 92% on two liters nasal cannula. The
patient will be discharged to pulmonary rehab prior to
discharge home.
CONDITION ON DISCHARGE: Stable and improved.
DISCHARGE DIAGNOSIS: As per admission in addition to recent
admission for asthma exacerbation with questionable pneumonia
in the setting of interstitial lung disease and likely
steroid induced hyperglycemia.
DISCHARGE MEDICATIONS:
1. NPH insulin 8 units at breakfast, five units at dinner.
2. Risperdal 2 mg p.o. q.h.s.
3. Diabetic diet.
4. Neurontin 600 mg p.o. t.i.d.
5. Clozapine 100 mg p.o. q. AM, 400 mg p.o. q.h.s.
6. Fluticasone 112 micrograms two puffs b.i.d.
7. Lansoprazole 30 mg p.o. q. day.
8. Prednisone 60 mg q. day times 30 days then 15 mg q. day
for three days than 40 mg q. day times three days, 30 mg q.
day for three days, 20 mg q. day for three days, 10 mg q. day
for three days then stop.
9. Guaifenesin 5 to 10 ml p.o. q. six hours p.r.n.
10. Tylenol 650 mg p.o. q. six hours p.r.n.
11. Albuterol and Atrovent nebs q. four hours p.r.n.
12. Alendronate 70 mg p.o. q. Sunday.
13. Calcium Carbonate 500 mg p.o. t.i.d.
14. Vitamin D 400 units p.o. q. day.
15. Bactrim single strength tabs, one tab p.o. q. day.
16. Prozac 60 mg p.o. q. day.
17. Heparin 5000 units subcutaneous q. 12 hours.
FOLLOW UP APPOINTMENTS:
1. Patient advised to follow up with Dr. [**Last Name (STitle) 5817**] from
Pulmonary Service in four weeks. To call [**Telephone/Fax (1) **] for
appointment.
2. Patient advised to see primary care provider in one week
for follow up and especially to discuss smoking cessation
which is imperative in this patient with underlying lung
disease.
3. Patient also advised to see psychiatrist in one week for
follow up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2167-2-9**] 14:22
T: [**2167-2-9**] 15:57
JOB#: [**Job Number 5925**]
|
[
"251.8",
"493.22",
"E932.0",
"295.70",
"515",
"311",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6703, 7590
|
6492, 6680
|
3887, 6423
|
2755, 3869
|
7614, 8308
|
157, 1483
|
1505, 2447
|
2464, 2732
|
6448, 6470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,195
| 162,127
|
31290
|
Discharge summary
|
report
|
Admission Date: [**2159-3-14**] Discharge Date: [**2159-3-16**]
Date of Birth: [**2129-7-21**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
29 year old Female with a 15 year history of uncontrolled Type I
Diabetes, including previous hospitalization for DKA in [**Month (only) **],
ESRD on PD, who was referred from clinic with orthostasis,
glucose in the 400s and ketones on U/A after missing several
doses of insulin.
In clinic, she had a finger stick showing a blood glucose of
512. 2 days prior to admission she had finger sticks showing
glucoses in the 200s but highly variable. On day of admission,
she was seen in clinic and noted to be orthostatic with a blood
sugar over 500 and ketones in her urine, and was sent to the ED.
She has also noted recent increased thirst, nausea, increased
fatigue, lightheadedness, as well as some blurred vision. She
also notes a headache several days ago which has since resolved.
She has had no urinary symptoms, no abdominal pain, no changes
in bowel movements, no vomiting and no changes in mental status.
She was diagnosed with diabetes mellitus type I at age 14, and
has had numerous complications including diabetic retinopathy in
her left eye, gastroparesis, and diabetic neuropathy. She has a
history of poor compliance with her insulin regimen as she finds
the injections painful, and does not consistently check her
blood sugars. She was hospitalized in [**2158-7-9**] for DKA
following several days of increased fatigue, and polyuria. Her
glucoses ranged from 300-500 during her hospitalization and was
started on an insulin drip requiring up to 430 units/hour.
Hospitalization was also complicated by line infection and MRSA
bacteremia, abdominal peritonitis, worsening renal failure,and
ARDS.
In the [**Hospital1 18**] ED she was afrebrile, with temperature of 98.7,
149/103, 15, 97% on room air. Her finger stick showed a blood
sugar of 399. She was given 1L of normal saline and started on a
second liter with 20mEq of potassium and received 10 units of IV
insulin and started on an insulin drip at 6 units/hr.
Past Medical History:
-DM1 (last A1c 10.7%) c/b neuropathy, nephropathy, retinopathy
w/ left eye blindness (followed by Dr. [**Last Name (STitle) **] at [**Last Name (un) **])
-ESRD on PD (seen by Dr. [**Last Name (STitle) **]
*** [**Last Name (STitle) 1326**] w/u per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - Her pretransplant
workup is complete. She is O positive. CMV and EBV positive,
hepatitis A, B, C and HIV are negative. She has 0% PRA. She had
a normal Pap, normal EKG. Stress test with no reperfusion.
Cardiac echo demonstrated normal EF of 50-60% with some
diastolic dysfunction in left ventricle with no valvular
disease.
-Hypertension
-Hyperlipidemia; TG in the 4000s
-Depression
Social History:
Initially from [**Male First Name (un) 1056**], moved to US 12 years ago. She lives
with boyfriend and her 11-year-old daughter. She does not work
outside the house. She quit smoking over a year ago but has
restarted and is smoking [**2-9**] ppd. She and denies alcohol or drug
use.
Family History:
Her parents are both alive and have diabetes and hypertension.
She has one sister who is obese and has hypertension. Her
9-year-old girl is healthy.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss, + polydipsia, + polyuria
EYES: - Photophobia, - Visual Changes, + Blindness
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: Af, 151/100, 82, 18, 99%RA
GEN: NAD, Obese
Pain: 0/0
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT, PD Site CDI
EXT: - CCE
NEURO: CAOx3, Non-Focal other than blindness
Pertinent Results:
[**2159-3-15**] 05:41AM BLOOD WBC-6.6 RBC-3.17* Hgb-9.8* Hct-27.6*
MCV-87 MCH-30.9 MCHC-35.5* RDW-16.2* Plt Ct-199
[**2159-3-14**] 10:25AM BLOOD WBC-7.4 RBC-3.58* Hgb-11.3* Hct-31.4*
MCV-88 MCH-31.6 MCHC-36.1* RDW-16.2* Plt Ct-234
[**2159-3-14**] 10:25AM BLOOD Neuts-61.9 Lymphs-30.6 Monos-3.9 Eos-2.7
Baso-0.9
[**2159-3-15**] 05:41AM BLOOD Glucose-155* UreaN-58* Creat-6.4* Na-134
K-3.5 Cl-104 HCO3-18* AnGap-16
[**2159-3-14**] 06:55PM BLOOD Glucose-104 UreaN-62* Creat-6.5* Na-133
K-3.3 Cl-100 HCO3-19* AnGap-17
[**2159-3-14**] 03:02PM BLOOD Glucose-134* UreaN-61* Creat-6.1* Na-133
K-5.9* Cl-105 HCO3-18* AnGap-16
[**2159-3-14**] 11:50AM BLOOD Glucose-327* UreaN-65* Creat-6.7* Na-132*
K-4.8 Cl-100 HCO3-18* AnGap-19
[**2159-3-14**] 10:25AM BLOOD Glucose-406* UreaN-65* Creat-6.7*#
Na-132* K-3.9 Cl-95* HCO3-20* AnGap-21*
[**2159-3-14**] 03:02PM BLOOD ALT-9 AST-7 LD(LDH)-155 AlkPhos-74
TotBili-0.2
[**2159-3-14**] 10:25AM BLOOD CK(CPK)-75
[**2159-3-14**] 10:25AM BLOOD cTropnT-0.01
[**2159-3-15**] 05:41AM BLOOD Calcium-8.4 Phos-6.2* Mg-1.9
[**2159-3-14**] 06:55PM BLOOD Calcium-8.0* Phos-4.8* Mg-1.8
[**2159-3-14**] 03:02PM BLOOD Albumin-3.4 Calcium-7.5* Phos-4.1 Mg-1.7
[**2159-3-14**] 03:02PM BLOOD Acetone-NEGATIVE
[**2159-3-15**] 05:41AM BLOOD Cortsol-9.0
[**2159-3-13**] 02:50PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2159-3-13**] 02:50PM BLOOD HIV Ab-NEGATIVE
[**2159-3-13**] 02:50PM BLOOD HCV Ab-NEGATIVE
[**2159-3-14**] 12:16PM BLOOD K-3.8
[**2159-3-14**] 10:33AM BLOOD Glucose-399*
[**2159-3-14**] 12:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2159-3-14**] 12:55PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-3-14**] 12:55PM URINE RBC-1 WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-25
[**2159-3-14**] 12:55PM URINE Hours-RANDOM Na-59 K-11 Cl-39 HCO3-LESS
THAN
[**2159-3-14**] 12:55PM URINE Osmolal-300
[**2159-3-14**] 11:28PM OTHER BODY FLUID WBC-2* RBC-0 Polys-16*
Lymphs-9* Monos-74* Macro-1*
[**2159-3-14**] 11:28 pm DIALYSIS FLUID
GRAM STAIN (Final [**2159-3-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
[**2159-3-15**] 5:41 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
CHEST (PORTABLE AP) Study Date of [**2159-3-14**] 10:56 AM
CONCLUSION: No acute cardiopulmonary process.
Brief Hospital Course:
1. Diabetic Ketoacidosis, Type 1 Diabetes Uncontrolled with
Complications
- Patient missed insulin dosing due to social reasons
- Basic infectious and cardiac reasons ruled out
- Continue on standing and sliding scale insulin
- [**Last Name (un) **] consult
- Anion-gap closed
- Electrolytes stable within parameters of ESRD patient
- Pioglitazone for insulin sensitization due to very high
insulin requirement
2. ESRD on Peritoneal Dialysis
- Continue PD
- Renal consultation
- Calcitriol and Renagel
- Sevelamer
- Pre-[**Last Name (un) **] labs were sent
3. Benign Hypertension
- Atenolol, Lasix
4. Hyperlipidemia
- Crestor
5. Peripheral Neuropathy
- Lyrica, Nortriptyline
6. Anxiety/Depression
- trazadone, Nortriptyline
Medications on Admission:
ATENOLOL - 25 mg Tablet - [**2-9**] tab Tablet(s) by mouth once a day
CALCITRIOL - 0.5 mcg Capsule - once a day
DARBEPOETIN ALFA IN POLYSORBAT - 200 mcg/0.4 mL Syringe - SQ
every week
FUROSEMIDE - 40 mg Tablet - twice a day
INSULIN ASPART [NOVOLOG] - 12 units sc at breakfast and dinner
INSULIN REGULAR HUM U-500 CONC - 24 units sc at lunch and qhs
METOCLOPRAMIDE - 5 mg Tablet - 1 Tablet(s) qid for nausea as
needed
NORTRIPTYLINE - 10mg at breakfast and lunch, 30mg qhs
ONDANSETRON HCL - 8 mg Tablet -1 Tablet(s) by mouth q 8 hrs prn
nausea
OXYCODONE-ACETAMINOPHEN - 5mg-325 mg Tablet - 1 Tablet(s) by
mouth prn for pain
PERMETHRIN - 5 % Cream - massage into skin from head to feet.
leave on [**9-21**] hr, wash off. Repeat in 14 days.
PIOGLITAZONE [ACTOS]- 30 mgTablet - 1 Tablet(s) by mouth once a
day
PREGABALIN [LYRICA] - 150 mg Capsule - 1 Capsule(s) by mouth at
bedtime
ROSUVASTATIN [CRESTOR] - 20 mg Tablet - 1 Tablet(s) by mouth
once a day
SEVELAMER HCL [RENAGEL] - 400mg Tablet - 1 Tablet(s) by mouth
with meals
TRAZODONE - 100 mg Tablet - 1Tablet(s) by mouth qhs as needed
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
3. Nortriptyline 10 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
4. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
6. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
8. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Novolog 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at breakfast and dinner.
13. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig:
Twenty Four (24) units Injection at lunch and QHS.
14. Darbepoetin Alfa In Polysorbat 200 mcg/0.4 mL Pen Injector
Sig: One (1) injection Subcutaneous once a week.
15. Permethrin 5 % Cream Sig: One (1) application Topical 14
days after last application.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Type 1 Diabetes Uncontrolled with Complications
ESRD on Peritoneal Dialysis
Benign Hypertension
Hyperlipidemia
Peripheral Neuropathy
Anxiety/Depression
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with nausea/vomitting, inability to eat,
inability to take your insulin.
If you are experiencing increased thirst, increased urination,
fever or chills, to contact your PCP [**Name Initial (PRE) 2227**].
It is very important that you take your insulin as stopping it
is life threatening.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-3-21**] 1:00
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2159-3-23**] 11:20
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-4-5**]
9:00
|
[
"403.11",
"536.3",
"250.63",
"300.4",
"250.13",
"250.53",
"362.01",
"272.4",
"357.2",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
9830, 9836
|
6692, 7422
|
290, 296
|
10053, 10059
|
4258, 6427
|
10420, 10947
|
3301, 3451
|
8557, 9807
|
9857, 10032
|
7448, 8534
|
10083, 10397
|
4020, 4239
|
6561, 6669
|
229, 252
|
324, 2257
|
2279, 2983
|
2999, 3285
|
6457, 6526
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,234
| 131,961
|
52142
|
Discharge summary
|
report
|
Admission Date: [**2182-12-18**] Discharge Date: [**2182-12-19**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Resident admit note reviewed and appreciated. Information
presented here largely gleaned from that source given non-verbal
status of patient. 83 yo m w/ vascular dementia, recently
admitted to NEBH for R cerebellar stroke w/ subsequent g-tube
placement. On 1day of admission, pt noted to be tachypnic w/ o2
sat to 84% and moderately thick whitish secreations. Pt
suctioned w/ improvement to 94%. Febrile to 102.
In ED given vanc, ceftriaxone and azithro, started on sepsis
protocol w/ lac 5.0
Past Medical History:
PUD
s/p R AKA [**7-5**]
dementia
CVA
GIB (on coumadin)
h/o DVT
Echo at NEBH [**7-5**]: LVEF 55%, trace MR.
Social History:
nh resident since [**2174**].
Family History:
nc
Physical Exam:
t 99.8, bp 111/44, p 115, r 18, 98% 10L NRB
Minimally arousable, localized pain.
Pupils pinpoint.
OP- midline lesion of upper hard palate, generally yellow and
discolored.
Dry MMM.
Regular s1,s2. no m/r/g
b/l coarse rhonchi w/ assoc upper airway sounds.
+bs. PEG site clean/dry, minimal erythema surrounding. mildly
distended. soft.
R BKA, amputions site C/D/I.
L w/o le edema, poor foot hygiene.
trace dp pulse
skin: by report, sacral decubitus.
Pertinent Results:
CBC
[**2182-12-17**] 10:33PM BLOOD WBC-3.4* RBC-4.23* Hgb-12.6* Hct-34.5*
MCV-82 MCH-29.8 MCHC-36.5* RDW-15.1 Plt Ct-340
[**2182-12-17**] 10:33PM BLOOD Neuts-55 Bands-22* Lymphs-4* Monos-14*
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-1*
Coags:
[**2182-12-17**] 11:40PM BLOOD PT-14.1* PTT-32.7 INR(PT)-1.3
Chemistries:
[**2182-12-17**] 11:40PM BLOOD Glucose-108* UreaN-21* Creat-0.8 Na-142
K-3.7 Cl-106 HCO3-26 AnGap-14
[**2182-12-17**] 11:40PM BLOOD ALT-6 AST-20 LD(LDH)-180 CK(CPK)-743*
AlkPhos-68 Amylase-63 TotBili-0.6
[**2182-12-17**] 11:40PM BLOOD cTropnT-<0.01
[**2182-12-17**] 11:40PM BLOOD Albumin-2.4* Calcium-8.0* Iron-PND
[**2182-12-17**] 11:40PM BLOOD Cortsol-PND
Blood Gas:
[**2182-12-18**] 03:25AM BLOOD Type-ART Temp-38.8 pO2-133* pCO2-47*
pH-7.34* calHCO3-26 Base XS-0
[**2182-12-18**] 01:06AM BLOOD Lactate-3.0*
[**2182-12-18**] 02:01AM BLOOD Lactate-3.3*
[**2182-12-18**] 03:02AM BLOOD Lactate-4.6*
Urine
[**2182-12-17**] 11:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2182-12-17**] 11:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2182-12-17**] 11:40PM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
Micro:
[**2182-12-18**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending
[**2182-12-17**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending
[**2182-12-17**] URINE EMERGENCY [**Hospital1 **] Pending
ECG: 100bpm, nl axis, nl intervals, no st-tw changes.
CXR: 1. Suboptimal positioning of central venous catheter
within the mid-right
atrium. This should be withdrawn by 5 cm.
2. Increasing parenchymal opacities at the left lung base.
This likely
represents asymmetric edema. Alternatively, this could be a
manifestation of
aspiration.
KUB: Diffusely dilated loops of small bowel with
air-filled colonic
loops. These findings could represent ileus or early
small bowel obstruction.
ABG:7.34/47/133 on NRB
Brief Hospital Course:
83 yo m w/ h/o recent cva and g-tube placement who p/w new onset
hypoxia, w/ rhonchi on exam, LLL opacity on cxr, elevated
lactate on MUST protocol.
1) MUST- Lactate remains elevated despite high svo2. BPs stable
so no indication for pressors/inotropes. Pt rec'd 4L NS in ED
so adequately volume resuscitated by criteria. Cortisol stim
test pending. Does not meet criteria for APC given recent CVA
and low APACHE score (11). Likely etiology is infectious given
significant bandemia, most probable is pulmonary given LLL
findings and lung exam. PNA vs aspiration. Other possibilities
included enteric given findings on KUB and recent surgical
placement of PEG tube. Covered w/ vanc/ceftriaxone/azithro, no
indication for additional pseudomonal coverage w/ cefepime. Used
NS boluses to maintain cvp>8 and patient was continued on MUST
protocol. Hospital course as below.
2) PNA-presumptively treating for, pt rec'd
vanc/azithro/ceftrixone/cefepime/clindamycin in ED. Simplified
regimen to include vanc/ceftriaxone/azithro. Sputum culture grew
out e.coli and klebsiella. Over the hospital course the
patient's respiratory status deteriorated. In d/w family,
patient's goals of care were changed to CMO given his ongoing
decompensation. Patient passed away on HD2 of respiratory
failure.
3) illeus- also possible that pt may have transmigrated bacteria
secondary to illeus. covered for gram neg on admission.
4) glucose- RISS, QID fs
5) prophylaxis- maintained on gi, hep sc, pneumoboots
(aggressive given h/o DVT)
6) contact: [**Name (NI) **], [**First Name3 (LF) **] h:[**Telephone/Fax (1) 107888**], w:[**Telephone/Fax (1) 107889**]
Medications on Admission:
Prevacid 30mg pgt daily
Metoprolol 25 mg po
Duonebs
Bowel regimen
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
sepsis
pna
Discharge Condition:
expired
Discharge Instructions:
.
Followup Instructions:
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"V49.76",
"437.0",
"438.11",
"285.9",
"486",
"038.9",
"443.9",
"995.91",
"V44.1",
"518.82",
"V12.51",
"290.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5237, 5313
|
3437, 5093
|
260, 265
|
5367, 5376
|
1473, 3414
|
5426, 5566
|
986, 990
|
5209, 5214
|
5334, 5346
|
5119, 5186
|
5400, 5403
|
1005, 1454
|
213, 222
|
293, 792
|
814, 923
|
939, 970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,837
| 184,409
|
48796
|
Discharge summary
|
report
|
Admission Date: [**2104-11-7**] Discharge Date: [**2104-12-12**]
Date of Birth: [**2037-9-3**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Endotracheal Intubation [**2104-11-7**] and [**2104-11-28**]
Percutaneous endoscopic gastrostomy (PEG)
History of Present Illness:
Mr. [**Known lastname **] is a 67 year old male with history HIV on HAART and
colitis who presented to the ED on [**2104-10-28**] with severe
abdominal pain for 3 days, was admitted to the surgical service
for perforated diverticulum and is now s/p sigmoid colectomy,
who represented for fever [**2104-11-7**] and was found to have
multifocal PNA and was transferred to the MICU on [**2104-11-7**] with
respiratory distress. He was intubated and underwent BAL which
was not revealing. He was treated for 14 days with linezolid,
meropenem, and cipro and was extubated [**11-21**]. His MICU course was
complicated by delirium after extubation and he developed
diarrhea (neg for c. diff), was transferred to the floor on
[**11-23**]. His status declined and he was re-admitted to the MICU on
[**11-26**] and reintubated on [**2104-11-28**]. He was extubated on [**12-1**] and
had PEG placed for nutritional support on [**12-2**]. The patient was
stable on nasal cannula and therefore was called out to the
floor in the afternoon on [**12-2**]. Vital signs prior to transfer
were 96.5 99/75 81 32 97% 2L NC
.
On arrival to the floor patient denies any pain in chest,
abdomen, extremities or elsewhere. He denies nausea or vomiting
Past Medical History:
CAD with MI s/p stent in [**2097**]
HIV since [**2077**] (last CD4 was 540 (2 wks prior to admission) and
viral load was <75)
Crohn's vs. lymphocytic colitis diagnosed 6 month ago on
colonoscopy
Esophagitis
Adrenal suppression
Primary open angle glaucoma
MV insufficiency
Arthroscopic knee surgeries
Ankle sprain early [**Month (only) **]
Sacral decubitus ulcer since last admission
Cataract surgery
Social History:
15 pack-year smoking quit 35yrs ago, social ETOH 10 drinks/wk,
occ marijuana. Lives independently in [**Hospital1 778**], however had been
in rehab since last hosp. Retired from engineering supply
business.
Family History:
father with DM, panc cancer, mother with [**Name2 (NI) 499**] cancer, CHF
Physical Exam:
Admission physical exam:
=========================
Vitals: T:99.7 BP:116/72 P:93 R:33 O2: 95% on 70% high flow
General: Alert, oriented, no acute distress, some tachypnea and
difficulty finishing sentences
HEENT: Sclera anicteric, MMM, high flow mask in place, crusted
abrasion on L face
Neck: supple, JVP not elevated, no LAD
Lungs: exp wheezes throughout, bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: open abd wound, with granulation tissue, no e/o
drainage or errythema. Colostomy bag in place. Mild TTP on R
side
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ edema to the mid calf
bilaterally, no calf tenderness. Bruising around L ankle.
Petechial rash on R foot
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
SKIN: dressed decubitus ulcer
Discharge Physical Exam:
========================
97.6 140/70 101 24 97% on 2L NC
General: A+OX1-2. Patient with frequent periods of confusion
with garbled speech. Weak phonation but speech intelligible when
patient is oriented and mouth appropriately lubricated.
HEENT: Sclera anicteric, MMM, NC in place
Neck: supple, JVP not elevated, no LAD
Lungs: faint scattered crackles. Tachypneic with rapid shallow
breaths 20-30 times per minute.
CV: Tachycardic, hyperdynamic heart sounds. normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: PEG in place. Colostomy bag in place. Surgical wound
clean. NABS, no TTP
Ext: warm, well perfused, 2+ pulses,
SKIN: dressed sacral decubitus ulcer
Pertinent Results:
Admission labs:
[**2104-11-6**] 06:15PM WBC-4.5 RBC-3.04* HGB-9.9* HCT-28.5* MCV-94
MCH-32.6* MCHC-34.8 RDW-13.6
[**2104-11-6**] 06:15PM NEUTS-76.1* LYMPHS-20.0 MONOS-3.3 EOS-0.3
BASOS-0.3
[**2104-11-6**] 06:15PM PLT COUNT-207
[**2104-11-6**] 06:15PM PT-14.4* PTT-25.3 INR(PT)-1.2*
[**2104-11-6**] 06:15PM GLUCOSE-122* UREA N-17 CREAT-0.5 SODIUM-135
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-10
[**2104-11-7**] 06:50AM ALBUMIN-1.8* CALCIUM-6.2* PHOSPHATE-2.4*
MAGNESIUM-1.7
[**2104-11-7**] 09:03AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.041*
[**2104-11-7**] 09:03AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2104-11-7**] 09:03AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
CT torso [**2104-11-6**]:
IMPRESSION:
1. Multifocal opacities in the upper and lower lungs, consistent
with diffuse pneumonia. New irregular gas containing cavities
concerning for necrotizing pneumonia in the previously seen area
of right lower lobe consolidation.
2. Small bilateral pleural effusions, left greater than right.
3. Moderate amount of free fluid in the abdomen with
indeterminate
attenuation values, likely representing post-surgical fluid. No
confined
collection within the abdomen or pelvis to suggest abscess.
4. Normal post-surgical appearance of the Hartmann's pouch and
[**Month/Day/Year 499**]. No
evidence of obstruction, perforation, or leak.
[**2104-11-8**] Echo:
IMPRESSION: No echocardiographic evidence of endocarditis,
however cannot exclude due to subooptimal image quality.
Moderate focal left ventricular systolic dysfunction consistent
with inferior/inferolateral infarction. Mild mitral
regurgitation.
[**2104-11-13**] CT torso:
IMPRESSION:
1. Interval worsening alveolar pulmonary opacities with
crazy-paving pattern, which could be related to worsening
pneumonitis versus pulmonary edema and developing adult
respiratory distress syndrome. More organized and
necrotic-appearing right lower lobe necrotizing pneumonia.
Worsening pleural effusions.
2. New moderate bilateral pleural effusions.
3. Slight interval increase in abdominal and pelvic ascites.
4. Worsening anasarca.
5. Status post sigmoid colectomy and diverting colostomy.
[**2104-12-4**] CT abdomen:
1. Interval decrease in the size of a necrotic pneumonia in the
right lung
base measuring 3.5 x 3 cm today.
2. Consolidation in the left lower lobe consistent with
aspiration or
pneumonia.
3. Left greater than right moderate nonhemorrhagic effusions.
4. Nonhemorrhagic ascitic fluid with foci of free air, likely
related to
recent PEG insertion.
Micro data:
[**11-6**]: Blood Culture, Routine (Final [**2104-11-12**]): NO GROWTH
[**11-6**] URINE CULTURE (Final [**2104-11-8**]): NO GROWTH.
[**11-7**] SPUTUM: GRAM STAIN (Final [**2104-11-7**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2104-11-9**]):
MODERATE GROWTH Commensal Respiratory Flora.
[**11-8**]: DIRECT INFLUENZA A ANTIGEN TEST (Final [**2104-11-9**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2104-11-9**]):
Negative for Influenza B.
[**11-11**] Sputum:
GRAM STAIN (Final [**2104-11-11**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2104-11-13**]): NO GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2104-11-12**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Stool Culture:
Source: Stool.
**FINAL REPORT [**2104-12-1**]**
MICROSPORIDIA STAIN (Final [**2104-12-1**]): NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final [**2104-11-27**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2104-11-28**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2104-11-28**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2104-11-27**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2104-11-28**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2104-11-28**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2104-11-28**]):
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2104-11-28**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2104-11-27**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
BRONCHIAL LAVAGE LINGULA.
**FINAL REPORT [**2104-12-1**]**
Respiratory Viral Culture (Final [**2104-12-1**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2104-11-29**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
RAPID PLASMA REAGIN TEST (Final [**2104-12-9**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2104-11-28**] 10:45 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE
RLL.
GRAM STAIN (Final [**2104-11-29**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2104-11-30**]):
~7000/ML Commensal Respiratory Flora.
YEAST. ~5000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
LEGIONELLA CULTURE (Final [**2104-12-5**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2104-11-29**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2104-11-29**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2104-12-12**]):
YEAST.
ACID FAST SMEAR (Final [**2104-12-1**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2104-12-2**]):
TEST CANCELLED, PATIENT CREDITED.
FURTHER [**Location (un) **] OF THE CULTURE WILL BE PERFORMED ON
REQUEST ONLY.
Refer to CMV early antigen test result for further
information.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2104-12-2**]):
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 102541**] [**2104-12-2**]
2:39PM.
POSITIVE FOR CYTOMEGALOVIRUS.
Early antigen detected by immunofluorescence.
Discharge Labs:
================
[**2104-12-12**] 06:03AM BLOOD WBC-9.5 RBC-2.95* Hgb-8.8* Hct-27.5*
MCV-93 MCH-29.9 MCHC-32.1 RDW-15.0 Plt Ct-313
[**2104-12-12**] 06:03AM BLOOD Neuts-69.1 Lymphs-24.6 Monos-4.7 Eos-1.3
Baso-0.3
[**2104-12-10**] 05:29AM BLOOD PT-11.6 INR(PT)-1.1
[**2104-12-12**] 06:03AM BLOOD Glucose-115* UreaN-16 Creat-0.4* Na-143
K-3.5 Cl-108 HCO3-29 AnGap-10
[**2104-12-12**] 06:03AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.9 Mg-2.0
Brief Hospital Course:
Primary Reason for Hospitalization:
====================================
Mr. [**Known lastname **] is a 67 yo gentleman with history of HIV on HAART,
last CD4 ct >500 and VL undetectable, s/p recent colectomy on
[**2104-10-29**] for perforated diverticulum who presented on [**2104-11-7**]
with fever and was found to have multifocal PNA on CT requiring
intubation and an ICU course that was complicated by delirium
and malnutrition.
.
ACTIVE ISSUES:
===============
# Acute Respiratory failure: Due to bilateral, multifocal
necrotizing pneumonia, worst in the RLL. He was intially given
Vanc/Levaquin. However, after CT scan results, he was broadened
to vanc/cipro/meropenem given his recent hospitalization.
Shortly after transfer to the MICU, the patient had worsening
respiratory distress requiring intubation [**2104-11-8**]. He was
maintained on ARDS net ventilation settings. Antibiotic regimen
was adjusted to Linezolid/Cipro/meropenem. [**11-11**] he had
worsening oxygenation, with bronchoscopy showing a lot of thick
yellowish secretions. Sputum and BAL cultures were all negative.
Viral DFA negative, legionella urine antigen negative. Acid-fast
smears were negative x3. On [**11-13**] patient found on repeat CT
scan to have worsening bilateral R>L pleural effusions. 700cc of
light-coloured fluid drained from the left side, with elevated
LDH to suggest exudative effusion, but was considered to be
transudative given bland cell count and gross appearance. On
[**2104-11-20**] He was successfully extubated. He completed his
antibiotic course on [**2104-11-22**]. On [**11-26**] pt had respiratory
decompensation and increased O2 requirement. He went from 99%
on 1L the evening of [**11-25**] to 85% on 3L the AM of [**11-26**]. He
received nebs and lasix but continued to require 6L O2 on floor
and had labored breathing with audible breath sounds at bedside.
CXR showed diffuse hazy opacities bilaterally. EKG without
ischemia or right axis dev but ?Q wave in lead III. He was
transferred to MICU for continued work of breathing and nursing
concern. Restarted vanc/[**Last Name (un) 2830**]/cipro for suspicion of recurrent
pneumonia. He was reintubated [**11-28**] for increased work of
breathing. He was extubated on [**12-1**] and had PEG placed for
nutritional support on [**12-2**]. Since that time he has had a
consistent 1.5 to 2 liter oxygen requirement. He continues to
breath 20-30 times per minute with rapid shallow breathing,
however this has been stable for over a week. The source of his
continued breathing difficulties appears to be a combination of
severe necrotizing pneumonia which is slow to heal as well as a
possible component of respiratory muscle weakness due to
cachexia. The neccessary duration of treatment for necrotizing
pneumonia is not well established and depends on response to
therapy. In consultation with thoracic surgery, a 6 week course
of antibiotics was planned to be completed [**2103-12-26**]. If the
patient continues to have respiratory difficulties at that point
a repeat CT scan of the chest should be considered. Because a
causative organism was never identified he will require
continued broad spectrum coverage with Vancomycin, Meropenem,
Ciprofloxacin, and Micafungin. Interventional Pulmonology
considered a tap of pleural fluid but felt that it was too risky
given the small amount of fluid.
.
#. HCAP/Fevers/chills: Thought to be due to necrotizing
pneumonia. All blood and urine cultures were negative. Recent
CD4 ct >500 therefore unlikely opportunistic infection. Given
recent surgery were initially concerned for intra-abdominal
infection, however no evidence of focal collection; moderate
free-fluid in abdomen likely represents normal post-surgical
changes. The surgery team followed along, but did not feel this
was a post-surgical infection. TTE did not show endocarditis.
The ID team was consulted. Because of persistent fevers,
fluconazole was added [**11-11**]. Urine crypto antigen negative and
galactomannan negative. Beta-glucan and HHV8 were positive
however this was not considered clincially relevant by the
infectious disease service given improving clinical status.
[**11-12**], given continued fevers, vanco stopped and linezolid
started. The cytology from his pleural effusion fluid showed
"vesicular chromatin, irregular nuclear membranes and some
plasmacytoid cell", raising the possibility of malignancy
causing his continued fevers. The oncology team was consulted,
who recommended multiple viral markers, but felt that his lung
mass would be very atypical for a malignancy. CMV was positive
in the BAL. Ultimately because of response to therapy, it was
concluded that the fevers had been due to the pneumonia. The
patient was afebrile for over 10 days prior to discharge with
stable white count.
.
#. Malnutrition, severe: patient has recent history of chronic
diarrhea and weight loss from possible Crohn's vs microscopic
colitis. On admission had albumin 1.8, trended down to 1.2
despite initiating tube feeds. He was fed via dobhoff but he was
displaced several times. There was difficulty replacing it even
with endoscopy and he had a PEG placed on [**2104-12-1**]. With tube
feeds, albumin had trended up to 2.4 prior to discharge. Urine
protein to creatinine ratios were checked to look for an
alternative explanation for hypoalbuminemia. These were elevated
but not in nephrotic range and results can be falsely elevated
in the setting of cachexia. No other evidence of synthetic
dysfunction was found to suggest hepatic origin.
-- If persistently hypoalbuminemic despite treatment of
infection and appropriate nutritional support then should
consider further GI workup to investigate protein losing
enteropathy.
.
# Acute metabolic encephalopathy: Most likely related to
prolonged severe illness. No evidence of CNS infection. VBG
ruled out CO2 narcosis. Patient has many obligate tethers. TSH
and RPR are normal.
- [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 102542**]
- Small dose of trazodone QHS to help sleep wake cycle.
.
# Possible Zenker's seen on EGD:
- video speech and swallow when patient improved from
respiratory standpoint
.
# s/p Colectomy: Patient had wound dehiscence, however the wound
remained clean and dry with granulation tissue and evidence of
adequate wound healing.
- Pouch change 2 x a week: Monday/Thursday
- Cleanse skin with warm water
- Pat dry
- Cut wafer to fit template pattern with supplies
- Apply [**Last Name (un) **] seal to back of wafer
- Center pouch over stoma and apply to abdomen and hold in place
x 2 minutes
.
# Sacral decubitis: Seen by wound care, has sacral coccygeal
ulcer measuring 4 x 3 cm that is covered with a black eschar.
Treated with special bed and dressing changes.
.
#. Anemia: lower than recent baseline, however pt does have
anemia at baseline. [**Month (only) 116**] be in part due to blood loss during
surgery. Studies were checked which showed anemia of chronic
disease. He had brown guaic postive stools. Endoscopy showed
Schatzki ring and non-bleeding duodenal ulcer. He was started on
pantoprazole. His HCT then trended up and has remained stable
for several days.
.
CHRONIC ISSUES:
===============
# HIV: continued home antiretrovirals, RiTONAvir 100 mg PO BID
and Darunavir 600 mg PO BID
.
# HLD: continued rosuvastatin
.
# CAD s/p NSTEMI in [**2097**]: rate well controlled. metoprolol held
in setting of hypotension, but later restarted. Continued
aspirin and rosuvastatin.
.
# Glaucoma: continued eye drops
.
TRANSITIONAL ISSUES:
====================
-- 6 week total course of antibiotics planned, which is to be
completed [**2103-12-26**]. If the patient continues to have respiratory
difficulties at that point a repeat CT scan of the chest should
be considered.
-- Video swallow when medically appropriate before starting
anything PO and also to investigate possible Zenker's
Diveriticulum.
-- GI follow-up outpatient to investigate protein losing
enteropathy
-- Questions about ostomy should be referred to Acute Care
Surgery (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] did the sigmoid Colectomy)
Medications on Admission:
Medications at rehab:
Nystatin s&s
dorzolamide-timolol drops
brimonidine eye drops
Darunavir 600mg [**Hospital1 **]
RiTONAvir 100mg [**Hospital1 **]
calcium carbonate
aspirin 325
MV
Metoprolol Succinate XL 12.5 daily
Tylenol
oxycodone PRN pain
.
Medications on transfer:
-Piperacillin-Tazobactam 4.5 g IV Q8H
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
-Aspirin 325 mg PO/NG DAILY
-Budesonide 3 mg PO DAILY
-Rosuvastatin Calcium 20 mg PO DAILY
-Ciprofloxacin 400 mg IV Q12H
-RiTONAvir 100 mg PO BID
-Darunavir 600 mg PO BID
-Metoprolol Succinate XL 12.5 mg PO DAILY
-Vancomycin 1000 mg IV ONCE
-Niacin 500 mg PO BID
-Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. rosuvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. niacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
3. ritonavir 80 mg/mL Solution [**Hospital1 **]: One Hundred (100) mg PO BID
(2 times a day).
4. darunavir 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
5. dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
8. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for itchiness.
9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB/wheeze.
12. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze.
13. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.25 Tablet PO HS (at bedtime).
16. vancomycin in D5W 1 gram/200 mL Piggyback [**Last Name (STitle) **]: 1000 (1000)
mg Intravenous Q 12H (Every 12 Hours) for 13 days: Last dose
[**2103-12-26**].
17. meropenem 500 mg Recon Soln [**Month/Day/Year **]: Five Hundred (500) mg
Intravenous Q6H (every 6 hours): Last dose [**2103-12-26**].
18. micafungin 100 mg Recon Soln [**Month/Day/Year **]: One Hundred (100) mg
Intravenous Q24H (every 24 hours): Last dose [**2103-12-26**].
19. ciprofloxacin 750 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
twelve (12) hours for 13 days: Last dose [**2103-12-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary:
- Necrotizing Pneumonia
- Acute on Chronic Systolic Heart Failure (EF 30-35%)
- Malnutrition
- Anemia
- Aspiration
Secondary:
- Coronary Artery Disease
- HIV
- Hyperlipidemia
- Glaucoma
Discharge Condition:
Respiratory rate 24-32 and SpO2 in mid 90s on 1.5-2 L oxygen at
recent baseline, stable for over one week.
HR 80s to 100s stable for over 1 week
Mental Status: Confused - always.
Speech: Garbled and Hypophonic. Improves with lubrication of
oral cavity.
Level of Consciousness: Alert
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname **], it was a pleasure taking care of you here at [**Hospital1 18**].
You were admitted to the hospital on [**11-7**] because you
were having fevers at rehab after your surgery. You were
diagnosed with a very severe pneumonia and on two occassions you
required a breathing tube to help you breathe. On [**12-1**]
you were able to be taken off of the breathing machine. You have
been receiving a long course of multiple strong antibiotics. You
will continue to receive these antibiotics when you go to rehab.
Followup Instructions:
Questions about ostomy should be referred to Acute Care Surgery
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] did the sigmoid colectomy).
If patient's breathing not improving after completing antibiotic
course, consider repeating CT of the chest.
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50,480
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50213
|
Discharge summary
|
report
|
Admission Date: [**2135-1-21**] Discharge Date: [**2135-1-31**]
Date of Birth: [**2085-2-3**] Sex: F
Service: NEUROLOGY
Allergies:
Hurricaine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Called by Emergency Department as a Code Stroke for Left-sided
weakness and aphasia
Major Surgical or Invasive Procedure:
IV-tPA
MERCI clot retrieval
History of Present Illness:
NIH Stroke Scale score was 0: 17
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 2
3. Visual fields: 2
4. Facial palsy: 2
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 1
HPI:
Ms. [**Known lastname 104742**] is a 49 y/o woman with a PMH significant for
myelodysplastic syndrome, HTN and hypothyroidism, who presents
with left sided weakness. She reportedly went to bed in her
normal state of health at 2300. Her partner heard her thrashing
in bed at 0130 and at that time, he noted her speech to be
slurred and her left side to be weak, though apparently still
able to move. As it seems that the thrashing likely was around
the time of onset of the stroke, we considered 0130 to be the
last known well time. She was initially taken to OSH, where she
had a CT head that was negative for hemorrhage; it was there
determined that she was "out of the tPA window" and she was
transferred to [**Hospital1 18**] for further care.
Full ROS unable to be obtained as patient very agitated and
seemingly confused when providing her own history. However, she
does not appear to have any recent febrile illnesses and there
is
no current chest pain, shortness of breath, palpitations or
abdominal pain.
Past Medical History:
-HTN
-gout
-hypothyroidism
-myelodysplastic syndrome
-alcohol abuse
-lumbar surgery (exact nature of surgery unknown)
Social History:
She was previously employed as a hairdresser,
though says she hasnt worked in 4 years. Not reported by
patient,
but there is apparently a history of alochol abuse.
Family History:
unknown
Physical Exam:
on admission:
Vitals: T: 97 P: 67 BP: 138/49 SaO2: 99% NC
General: Awake, agitated
HEENT: no oral lesions
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, S1S2
Abdomen: soft, +BS
Extremities: warm, well perfused
Neurologic:
-Mental Status: Alert, oriented to person, "hospital", and year
but not month. Naming generally intact, with some errors on low
frequency objects. Left sided neglect.
-Cranial Nerves: PEERL 6-->4 mm b/l. Gaze deviation to right.
Left sided hemianopia. Would not cross midline to commands but
is
able to track acorss midline. Left facial droop. Sensory loss
left face.
Motor: L hemiparesis- no antigravity ability at all on left.
Right sided strength full.
Sensory: Light touch intact at times when testing sensation, but
sometimes she would not realize when someone was holding her
left
arm, indicating a possible sensory componenent. Dimimihed
pinprick on left.
Reflexex: Patellar reflexes 2+ b/l. Biceps reflex 2+ on right,
remaining reflexes 1+. Toe upgoing on left and mute on right.
Coordination: finger-nose intact on right
Pertinent Results:
[**2135-1-21**] 06:20PM TYPE-ART PO2-104 PCO2-33* PH-7.45 TOTAL
CO2-24 BASE XS-0
[**2135-1-21**] 05:02PM TYPE-ART TEMP-37.1 RATES-/25 TIDAL VOL-500
PEEP-5 O2-40 PO2-148* PCO2-30* PH-7.47* TOTAL CO2-22 BASE XS-0
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2135-1-21**] 05:02PM GLUCOSE-82 K+-3.7
[**2135-1-21**] 05:02PM freeCa-1.08*
[**2135-1-21**] 10:44AM TYPE-ART TEMP-35.0 RATES-15/ TIDAL VOL-500
PEEP-5 PO2-139* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0
[**2135-1-21**] 10:44AM GLUCOSE-124*
[**2135-1-21**] 10:44AM freeCa-1.07*
[**2135-1-21**] 08:39AM TYPE-ART PO2-187* PCO2-34* PH-7.44 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2135-1-21**] 08:39AM HGB-9.5* calcHCT-29
[**2135-1-21**] 07:38AM TYPE-ART PO2-169* PCO2-36 PH-7.44 TOTAL
CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2135-1-21**] 07:38AM GLUCOSE-146* LACTATE-1.5 NA+-135 K+-3.0*
CL--101
[**2135-1-21**] 07:38AM HGB-10.2* calcHCT-31
[**2135-1-21**] 07:38AM freeCa-1.10*
[**2135-1-21**] 04:35AM GLUCOSE-119* UREA N-24* CREAT-1.4* SODIUM-138
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
[**2135-1-21**] 04:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-1-21**] 04:35AM URINE HOURS-RANDOM
[**2135-1-21**] 04:35AM WBC-11.3* RBC-4.08* HGB-11.7* HCT-36.2 MCV-89
MCH-28.6 MCHC-32.3 RDW-17.7*
[**2135-1-21**] 04:35AM PLT COUNT-523*
[**2135-1-21**] 04:35AM PT-12.2 PTT-21.3* INR(PT)-1.0
[**2135-1-21**] 04:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2135-1-21**] 04:35AM URINE BLOOD-TR NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2135-1-21**] 04:35AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0-2
CTA head/neck [**1-21**]:
Occlusion of the right middle cerebral artery near its origin.
Likely retrograde collateral flow present, reconstituting more
distal branches of this vascular distribution. Evolving infarct
within the right basal ganglia region.
CT head [**1-21**]:Hyperdense regions within the head of the right
caudate nucleus and right lentiform nucleus. The findings are of
concern for either hemorrhagic transformation of the infarct,
versus extravascular accumulation of contrast material. A
followup MR study may be of help in differentiating between
these two entities.
rpt CT head [**1-22**]:
1. Evolving right basal ganglia hemorrhage with underlying
infarct with
intraventricular extension of hemorrhage and 3 mm leftward
shift.
2. Persistent moderate left subgaleal hematoma, felt to be due
to
anticoagulants on earlier studies- correlate clinically.
3. Paranasal sinus disease.
rpt CT head [**1-23**]:
1. No new foci of acute intracranial hemorrhage.
2. Expected interval evolution of the known right basal ganglia
hemorrhagic conversion, with interval decreased attenuation of
the hyperdense hemorrhagic foci but increase of peri-hemorrhagic
edema.
3. Essentially unchanged mild leftward shift of normally midline
structures, with persistent effacement of the right frontal
[**Doctor Last Name 534**].
4. Unchanged trace intraventricular hemorrhagic extension at the
right
occipital [**Doctor Last Name 534**] without developing hydrocephalus.
5. Interval decreased soft tissue swelling and hematoma in the
left temporal and frontal region.
6. Paranasal sinus disease as described above.
[**1-26**]: attempted MRI
Incomplete examination due to lack of patient cooperation. Right
basal
ganglia hemorrhage/hematoma is again noted.
Brief Hospital Course:
Initial Assessment:
Ms. [**Known lastname 104742**] is a 49 y/o woman with a PMH significant for
myelodysplastic syndrome, HTN and hypothyroidism, who presents
with sudden onset left sided weakness. On her exam, her NIHSS is
17 and she has a dense left sided hemiparesis as well as right
gaze deviation, left hemianopia and neglect. Her imaging shows
an
occlusion of R MCA near its origin. Her history, exam and
imaging
are consistent with acute embolic stroke in R MCA. The time of
onset was taken to be 0130; the time of her thrashing, and so
when she was seen here, she remained within the window for IV
tPA. The decision was made to proceed with the IV tPA. The plan
at this time is to proceed with tPA infusion and if clinical
exam
remains unchanged in 30 minutes, then plan is to proceed with
angio for IA tPA vs. Merci.
Neuro:
Ms. [**Known lastname 104742**] was admitted to the neurology ICU, attending Dr.
[**Last Name (STitle) **].
There was no improvement with tPA, and she developed hematomas
of the right knee, left scalp, and left clavicular area, so IV
TPA was stopped. The team proceeded with angio and MERCI device
was used. This resulted in opening of inferior division of the
right MCA, but opening of the superior division was
unsuccessful. She was monitored in the ICU and then was
transferred to the step down unit, then to the floor for further
management. She was started on Aspirin 81mg and Lovenox 40mg
daily (given possible MDS/malignancy.) Her CT scans showed
hemorrhagic conversion in the Right striatum and white matter.
An MRI was attempted, but she was unable to tolerate this.
There was no need to attempt repeating this MRI, per Dr. [**First Name (STitle) **]
stroke attending. Imaging otherwise as above.
CVR:
Blood pressure was controlled metoprolol 25mg TID and as needed
hydralazine. Her metoprolol was increased to 50mg TID prior to
discharge. She had an transthoracic echocardiogram which showed
no ASD or LV thrombus. There was normal global and regional
biventricular systolic function. There was mild pulmonary
hypertension. A bubble study was not done. A transesophageal
echocardiogram was attempted, however Ms. [**Known lastname 104742**] developed
methemoglobinemia (level 29) after receiving benzocaine spray.
She received Methylene blue 140mg IV by anesthesia and had rapid
clinical improvement. Her methemoglobinemia level was zero
before returning to the neurology floor. A transthoracic echo
with bubble was later done which showed No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. She had lower extremity doppler
studies which were negative for DVT. Hypercoagulable work up is
pending at the time of discharge: antithrombin 3, prothrombin
gene mutation, factor v leiden.
Heme: Due to her myelodysplastic syndrome and bleeding with tPA,
heme-onc was consulted, and they did not believe there were any
restrictions on her stroke management due to her MDS.
Additionally, the team spoke with her outpatient hematologist
who confirmed no need for epo or aranesp while in the hospital.
Her HCT was stable during her hospitalization.
FEN/GI: She was initially NPO. She was followed closely by
speech and language team and was started on NGT feeds. When
able, a regular diet was initiated and advanced. At the time of
discharge she was tolerating a regular diet with nectar-thick
liquids. Her electrolytes were monitored carefully, and
repleted as necessary.
She received Famotidine for GI prophylaxis.
Psych/ETOH: Initially Ms. [**Known lastname 104742**] had significant alcohol
withdrawal. She was on a CIWA scale and received multiple doses
of Ativan in addition to Valium q12. She also received thiamine
and folate. CIWA was discontinued and she had no further
symptoms prior to discharge. She received Trazadone for sleep.
MSK: Ms. [**Known lastname 104742**] had intermittent pain, especially in left
shoulder. She had an XR which showed no evidence of cortical
disruptions suggestive of fracture or AC separation. Pain was
treated with tylenol and oxycodone.
Medications on Admission:
-amlodipine 5mg daily
-omeprazole 20mg daily
-atenolol 50mg daily
-levothyroxine 50mcg daily
-vit B-12 1000mcg daily
-vit B1 100mg [**Hospital1 **]
-folic acid 1mg daily
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) MG
Subcutaneous DAILY (Daily).
2. senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2
times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
-Stroke (Right PCA+MCA-territory infarction)
Secondary diagnoses:
- EtOHism / withdrawal
- chronic LBP
- chronic mild anemia, possible MDS
- methemoglobinemia secondary to benzocaine spray.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you had a large stroke. You
initially received TPA in attempt to break up the clot in your
brain, however this did not improve your symptoms and you
developed bruising. You then had a MERCI retrieval which was
able to open up part of your blood vessels. You were started on
medication, Lovenox, and Aspirin, to prevent further clots and
strokes. You were also started on a blood pressure medication.
You had multiple tests including head CT scans, attempted brain
MRI, echocardiograms, and ultrasounds of your legs to determine
the cause of your stroke. Additionally, multiple laboratory
tests were sent which are still pending.
While you were in the hospital you were treated for alcohol
withdrawal. You also developed a reaction to benzocaine spray,
called methemoglobinemia, in which you developed breathing
problems requiring treatment in the ICU.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2135-3-14**] 1:30
The following tests are pending at the time of discharge:
antithrombin 3, factor v leiden, prothrombin gene mutation.
|
[
"274.9",
"342.82",
"E879.8",
"238.75",
"368.46",
"781.8",
"998.12",
"E938.5",
"289.7",
"291.0",
"285.9",
"303.90",
"719.16",
"401.9",
"781.94",
"724.2",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.74",
"99.10",
"88.72",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12121, 12191
|
6781, 10884
|
363, 392
|
12445, 12445
|
3253, 6758
|
13551, 13858
|
2131, 2141
|
11105, 12098
|
12212, 12212
|
10910, 11082
|
12623, 13528
|
2582, 3234
|
2156, 2156
|
12298, 12424
|
240, 325
|
420, 1791
|
12231, 12277
|
2171, 2397
|
12460, 12599
|
1813, 1933
|
1949, 2115
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,672
| 165,902
|
3338
|
Discharge summary
|
report
|
Admission Date: [**2191-10-7**] Discharge Date: [**2191-10-16**]
Date of Birth: [**2124-2-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
1) open g-tube placement [**10-12**]
2) emergent EGD [**10-7**]
History of Present Illness:
This is a 67 year old male with a history of recently diagnosed
adenocarcinoma of the esophagus. The patient, over the past few
months, had had increased difficulty in swallowing and on
[**2191-10-3**] underwent upper endoscopy which revealed a large mass in
the lower third of the esophagus. Biopsy revealed this mass as
adenocarcinoma of the esophagus. The patient has continued to
have poor oral intake but today attempted to eat a regular meal.
At 5 PM today, he began coughing up blood. Per patient and
relative, he coughed up roughly 500 cc of blood. Coughing
associated with abdominal pain. He denied lightheadedness or
dizziness. He went to ED where he was tachycardic in 110-120,
with BP in 140-145 range. O2 saturation nl on room air with
normal respiratory rate. He coughed up more blood in ED. Hct
41.3 2 large bore PIV placed and 4 units typed and crossed. GI
[**Name (NI) 653**], admitted to ICU where he is to undergo upper
endoscopy and possible stenting of mass.
On ROS, denies CP or dyspnea. Reports worsened appetite and 20
lb weight loss over past few months. No diarrhea.
Past Medical History:
1) Esophageal adenocarcinoma
2) Prostate cancer, s/p radical retropubic prostatectomy
Social History:
Patient does not drink or smoke. He is married, wife is health
care proxy.
Family History:
Notable for brother who has multiple myeloma.
Physical Exam:
VS: T 97.3 BP 131/69 HR 81 RR 19 O2 96 on 2L
Gen: WD/WN male Caucasian in NAD
Eyes: Sclerae anicteric
Mouth: No blood seen, MMM
Neck: Supple, no LND, no bruits
Chest: CTA b/l good air movement
Heart: RR, S1S2 nl without murmur
Abdomen: Mild epigastric tenderness to palpation. Otherwise
non-tender. Non-distended. Bowel sounds absent.
Ext: No edema, distal pulses normal.
Pertinent Results:
[**2191-10-7**]: Upper endoscopy:
Esophagus:
Contents: Clotted blood was seen in the esophagus at 30 cm from
the incisors, occluding theh esophagus. No active bleeding was
seen. Exam was interrupted due to the extent of the clot and
proximity to the airway..
Stomach:
Other Not examined.
Duodenum:
Other Not examined.
Impression: Blood clot in the esophagus at 30 cm from the
incisors. Exam interrupted at this point.
CBC trend:
[**2191-10-7**] 07:35PM BLOOD WBC-11.5* RBC-5.03 Hgb-15.1 Hct-41.3
MCV-82 MCH-30.0 MCHC-36.5* RDW-12.9 Plt Ct-391
[**2191-10-7**] 10:05PM BLOOD Hct-37.8*
[**2191-10-8**] 04:07AM BLOOD WBC-8.8 RBC-4.40* Hgb-13.0* Hct-36.8*
MCV-84 MCH-29.6 MCHC-35.3* RDW-12.9 Plt Ct-315
[**2191-10-8**] 09:55AM BLOOD Hct-36.1*
[**2191-10-8**] 04:33PM BLOOD Hct-37.6*
[**2191-10-9**] 03:30AM BLOOD WBC-7.9 RBC-4.40* Hgb-13.1* Hct-36.2*
MCV-82 MCH-29.8 MCHC-36.1* RDW-13.1 Plt Ct-284
[**2191-10-9**] 03:07PM BLOOD Hct-36.3*
[**2191-10-10**] 04:00AM BLOOD WBC-9.8 RBC-4.35* Hgb-13.0* Hct-36.2*
MCV-83 MCH-29.9 MCHC-36.0* RDW-12.8 Plt Ct-264
[**2191-10-11**] 06:00AM BLOOD WBC-8.0 RBC-4.21* Hgb-12.6* Hct-34.6*
MCV-82 MCH-30.0 MCHC-36.5* RDW-13.1 Plt Ct-298
RLE ultrasound: Negative for DVT.
PET-CT: [**2191-10-5**]:
There is focal abnormal uptake of FDG in the thickened
esophagus, liver and multiple nodes including aortocaval
consistent with metastatic disease.
There are FDG-avid right paraesophageal (SUVmax 12.9), right
paratracheal (SUVmax 8.9), right hilar (SUVmax 5.5) and
subcarinal nodes (SUVmax 15.2). The esophagus shows FDG-avid
extensive wall thickening (SUVmax 18.3) and there is retention
of contrast proximally and a fluid level.
There are FDG-avid lymph nodes in the abdomen: right retrocrural
(SUVmax 7.6), lesser curve of the stomach (SUVmax 7.3),
paraortic ( SUVmax 11.7), and aortocaval (SUVmax 5.9).
There is an FDG-avid hepatic focus (SUVmax 6.7)
Physiologic uptake is seen in the brain, heart and GI and GU
tracts.
There is a small non-FDG-avid right middle lobe nodule.
IMPRESSION: Findings are consistent with esophageal cancer with
a hepatic metastasis and extensive FDG-avid nodes in the chest
and abdomen including the aortocaval.
Brief Hospital Course:
This 67 year old gentleman with recently diagnosed
adenocarcinoma of esophagus presented to the ED with several
episodes of hematemesis. On presentation he was hemodynamically
stable, with respiratory status at baseline. Hematocrit was
also at baseline. He was admitted to MICU as the likely source
of bleed is tumor was not resolving. In the MICU he underwent
urgent upper endoscopy; however, this procedure was terminated
as a large clot was visualized in the proximal esophagus. He
was monitored for 3 more days in the MICU for any signs of
rebleeding, pt remained was aggressively controlled with
antiemetics along with IV protonix to prevent any vomiting or
reflux which may have led to rebleeding (which in turn would
have required intubation). He had no episodes of bleeding in
the MICU. His hct trended slowly downward but the patient
remained hemodynamically stable Hematology/Oncology was
consulted and a PET-CT revealed metastatic disease. As pt had
to remain NPO, surgery was consulted for G-tube placement. The
G-tube was placed on [**10-12**] and tube feeds were started on [**10-13**].
The patient was discharged in stable condition and tolerating
tube feeds, with an outpatient follow up appointment with Dr.
[**Last Name (STitle) 3274**] (oncology) on [**10-20**].
Medications on Admission:
None.
All/ADR's: None known.
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO DAILY
(Daily) as needed.
Disp:*450 mL* Refills:*3*
2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg suspension PO twice a day.
Disp:*1 month* Refills:*2*
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*1 month* Refills:*3*
4. Compazine 5 mg/5 mL Syrup Sig: Five (5) mL PO every four (4)
hours as needed for nausea.
Disp:*1 month* Refills:*0*
5. Morphine 10 mg/5 mL Solution Sig: 0.5-1 mL PO every four (4)
hours as needed for pain.
Disp:*1 month* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1) upper GI Bleeding
2) Esophageal adenocarcinoma
Discharge Condition:
stable and tolerating g-tube feeds
Discharge Instructions:
You were admitted with esophageal bleeding. Please take all of
your medications as prescribed. Please do not take anything
other than thin liquids by mouth unless instructed to do so by
your doctor.
.
If you experience nausea, vomiting, dark stool, dizziness,
fainting, abdominal pain, pain, infection or redness around the
site of the g-tube, chest pain or shortness of breath or any
other concerning symptoms please seek medical attention
immediately.
Followup Instructions:
Please keep your appointment with Dr. [**Last Name (STitle) 3274**]. His office phone
is [**Telephone/Fax (1) 15512**] in case you need to reschedule.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2191-10-20**] 10:30
|
[
"719.06",
"196.2",
"285.1",
"578.9",
"197.7",
"V10.46",
"276.52",
"150.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.19",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
6367, 6425
|
4391, 5682
|
327, 393
|
6519, 6556
|
2189, 4368
|
7058, 7337
|
1734, 1781
|
5761, 6344
|
6446, 6498
|
5708, 5738
|
6580, 7035
|
1796, 2170
|
276, 289
|
421, 1516
|
1538, 1626
|
1642, 1718
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,056
| 116,491
|
50528
|
Discharge summary
|
report
|
Admission Date: [**2180-3-13**] Discharge Date: [**2180-3-25**]
Date of Birth: [**2113-2-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hmg-Coa Reductase Inhibitors (Statins)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Redo-Coronary Artery Bypass Graft x
4(SVG-LAD,SVG-OM1,SVG-OM2,SVG-PDA), Mitral Valve repair (28 mm
band) [**3-13**]
History of Present Illness:
67 yo M s/p CABG in [**2172**] and PCI in [**2178**], now s/p admission for
acute pulmonary edema and cardiac catheterization showing 2
occluded grafts. Referred for redo surgery.
Past Medical History:
- CAD with 5vCABG in [**2172**]
- MI with PCI [**2172**], PCI in [**5-/2179**] (DES to RCA)
- left renal artery stenosis on [**2180-1-10**], nuclear scan showed 82%
function on R and 16% function on L. 99% stenosis on renal
angiogram with BMS X 1
- CRI ([**2180-1-18**] Cr 2.2)
- HTN
- hemmorhoids
- hypercholesterolemia (LDL 98)
- PVD
- h/o liver lesions
- s/p rectal prolapse repair
- known carotid disease 16-49% stenosis on R, 50-79% on left
- s/p herniorrhaphy
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2172**] anatomy as follows: LIMA->LAD,
SVG to PDA, OM1, OM2, and diag.
.
Percutaneous coronary intervention, in [**2177**] anatomy as follows:
total occlusion of native vessels and LIMA, with patent SVG to
diag which backfilled LAD. 40% stenosis in SVG to OM.
.
Social History:
Social history is significant for current tobacco use (52 pack
year smoking history). There is no history of alcohol abuse.
Family history was not elicited.
Family History:
NC
Physical Exam:
hr 61 BP 115/72 RR 16
NAD
Lungs CTAB
Well healed sternal incisions
Heart RRR, HSM
Abdomen Benign
Pertinent Results:
[**3-13**] [**Month/Year (2) **]: PRE-BYPASS: 1. The left atrium is [**Month/Year (2) 5660**] dilated.
No atrial septal defect is seen by 2D or color Doppler. 2. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
moderate hypokinesis of the inferior and inferolateral walls. An
area of akinesis is also seen in the mid to basal inferior wall.
Overall left ventricular systolic function is [**Month/Year (2) 5660**]
depressed (LVEF= 40%). 3. Right ventricular chamber size and
free wall motion are normal. 4. There are focal calcifications
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 leaflets are mildly thickened. An eccentric,
postero-lateral directed jet of Severe (4+) mitral regurgitation
is seen. POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and
epinephrine and is being paced. 1. A well-seated mitral
annuloplasty ring is seen with normal leaflet motion (mean
gradient = 5 - 7 mmHg). There is no valvular systolic anterior
motion ([**Male First Name (un) **]). Trivial mitral regurgitation is seen. 2. RV
function is slightly depressed, LV function is [**Male First Name (un) 5660**]
depressed. Specifically the inferior wall appears akinetic. 3.
Aorta is intact post decannulation.
[**3-23**] CXR: Allowing for patient positional differences, the
right-sided pleural effusion distributes in a different pattern,
however, the overall extent of the pleural effusion is not
significantly changed from prior. Smaller left pleural effusion
is also again identified. Median sternotomy wires, cardiac and
mediastinal contours appear unchanged. No new focal
consolidations are identified.
[**2180-3-13**] 12:32PM BLOOD WBC-17.1*# RBC-2.28*# Hgb-6.9*#
Hct-19.4*# MCV-85 MCH-30.1 MCHC-35.4* RDW-15.2 Plt Ct-174
[**2180-3-16**] 03:54AM BLOOD WBC-21.2* RBC-3.11* Hgb-9.2* Hct-27.9*
MCV-90# MCH-29.6 MCHC-33.0 RDW-16.6* Plt Ct-114*
[**2180-3-24**] 05:25AM BLOOD WBC-13.3* RBC-3.07* Hgb-9.1* Hct-27.9*
MCV-91 MCH-29.6 MCHC-32.5 RDW-16.1* Plt Ct-347
[**2180-3-13**] 12:32PM BLOOD PT-15.7* PTT-59.0* INR(PT)-1.4*
[**2180-3-13**] 02:06PM BLOOD UreaN-31* Creat-2.2* Cl-116* HCO3-22
[**2180-3-16**] 03:54AM BLOOD Glucose-193* UreaN-60* Creat-4.4* Na-138
K-6.1* Cl-105 HCO3-19* AnGap-20
[**2180-3-24**] 05:25AM BLOOD Glucose-116* UreaN-76* Creat-3.5* Na-144
K-4.6 Cl-106 HCO3-26 AnGap-17
[**2180-3-14**] 12:52AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.7*
[**2180-3-21**] 08:40AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.7*
Brief Hospital Course:
Mr. [**Known lastname 105222**] was a same day admit after having a cardiac cath and
surgical work-up in late [**Month (only) 958**]. He was taken to the operating
room on [**2180-3-13**] where he underwent a redo-sternotomy, CABG x 4
and MV Repair. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Postoperatively he had asystole
followed by complete heart block. He remained intubated for
acidosis and was extubated the morning of post-op day two,
neurologically intact. He was restarted on Plavix for his renal
stent. Chest tubes and epicardial pacing wires were removed per
protocol. He continued to have some episodes of heart block and
nodal agents were held. He then had rapid atrial fibrillation
which converted with amiodarone. He was started on Coreg. He was
seen by renal for oliguria and hyperkalemia. His urine output
improved as did his creatinine with time and holding diuretics.
He was transferred to the telemetry floor on post-op day seven
for further management. Over the next several days he worked
with physical therapy for strength and mobility. His creatinine
trended down and he appeared to be suitable for discharge on
post-op day ten with the appropriate follow-up appointments.
Medications on Admission:
Alprazolam, Plavix 75', Fenofibrate 45', Metoprolol 100",
Nifedipine 30', ASA 325', Iron 325'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*0*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please take 200mg [**Hospital1 **] for 7 days. Than 200mg QD until
stopped by cardiologist.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease, Mitral Regurgiataion now s/p
Redo-Coronary Artery Bypass Graft x 4, Mitral Valve Repair
Acute on chronic renal failure
PMH: Coronary Artery Disease s/p PCI-RCA, Chronic Renal
Insufficiency, Hypertnesion, Hypercholesterolemia, Peripheral
Vascular Disease
PSH: CABG '[**72**], L renal stent, hernia repair, Prolapse Rectum
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 3236**] 2 weeks
Cariologist in [**12-19**] weeks
Dr. [**Last Name (STitle) **] 4 weeks
Nephrologist in [**12-19**] weeks
Completed by:[**2180-3-25**]
|
[
"427.5",
"414.01",
"403.90",
"584.9",
"427.31",
"426.0",
"424.0",
"997.1",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.14",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7157, 7206
|
4538, 5840
|
315, 432
|
7595, 7601
|
1804, 4515
|
7914, 8172
|
1668, 1672
|
5984, 7134
|
7227, 7574
|
5866, 5961
|
7625, 7891
|
1687, 1785
|
265, 277
|
460, 641
|
663, 1478
|
1494, 1652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,623
| 134,319
|
33525
|
Discharge summary
|
report
|
Admission Date: [**2151-2-26**] Discharge Date: [**2151-3-5**]
Date of Birth: [**2106-8-16**] Sex: M
Service: MEDICINE
Allergies:
Linezolid
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal distension, lethargy
Major Surgical or Invasive Procedure:
Paracentesis, Perihepatic fluid collection drainage
History of Present Illness:
44 yom with hx of Hep C Cirrhosis recently admitted for CCY on
[**1-/2151**] c/b bacterial peritonitis who now presents with
increased lethargy, abdominal pain and jaundice. Patient reports
increasing lethargy over the last few days. he does not feel
confused and is AAOx3. He also reports increasing abdominal pain
which is similar to when he was diagnosed with peritonitis on
last admission. He has had poor PO intake but has been taking
lactulose at home. He has NOT been taking his Linezolid since
discharge as his pharamacy has not filled the medication. He
denies any recent fevers but does report chills. +Nausea but no
vomiting. +diarrhea but is on lactulose, no BRBPR, no melena. He
denies any chest pain, sob, cough or dysuria
.
In the ED: Temp 98.1, BP 117/56, HR 73, RR 18, 97% RA. CT scan
done which showed no abcess at CCY site. Transplant surgery
consulted and believed no surgical issue at this time. Liver
fellow consulted and decided to admit to Med.
Past Medical History:
HCV Cirrhosis
Gall stone pancreatitis, s/p ERCP [**9-21**],
Splenectomy
CCY
.
HOME MEDICATIONS: (per last d/c summary)
Linezolid 600mg PO q12h (not taking)
Levothyroxine 75mcg daily
Clotrimazole 10 Troch PRN 5 times daily
Oxycodone 5mg q4h PRN pain
Lactulose 30mg PO TID
Methadone 10mg daily
Docusate
Senna
Midodrine 5mg TID
Atenolol 50mg daily
Furosemide 40mg [**Hospital1 **]
Social History:
Married, lives in [**Location **], has children. Denied current
EtOH or IV drug use.
Family History:
N/C
Physical Exam:
VS: Temp 97.5, BP 114/60, HR 79, RR 20 97% RA
GEN: Middle-aged man in NAD, extremely jaundiced, lethargic,
AAox3
HEENT: EOMI, PERRL, sclera icteric, OP moist
NECK: Supple, no JVD, no LAD
CV: Reg rate, normal S1, S2. +SEM II/VI LUSB
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, +mild distension, +TTP of entire abdomen, no rebound,
no guarding, +healing scar in RUQ from site of CCY, no discharge
from wound
EXT: +2 pitting edema of b/l LE, +asterixis
SKIN: +jaundice, +spider angiomata
Pertinent Results:
Labs on admission:
[**2151-2-25**] 09:20PM BLOOD WBC-14.7*# RBC-UNABLE TO Hgb-8.4*
Hct-27.5* MCV-UNABLE TO MCH-UNABLE TO MCHC-35.7* RDW-UNABLE TO
Plt Ct-124*
[**2151-2-25**] 09:20PM BLOOD Neuts-82.6* Bands-0 Lymphs-14.3*
Monos-2.2 Eos-0.9 Baso-0.1
[**2151-2-25**] 10:53PM BLOOD Glucose-90 UreaN-62* Creat-0.9 Na-132*
K-5.3* Cl-102 HCO3-20* AnGap-15
[**2151-2-25**] 10:53PM BLOOD ALT-92* AST-141* AlkPhos-65 TotBili-38.0*
[**2151-2-25**] 10:53PM BLOOD Albumin-3.0* Calcium-9.9 Phos-5.0*
Mg-3.3*
[**2151-3-3**] 07:20AM BLOOD Albumin-4.1 Calcium-11.7* Phos-6.0*
Mg-4.1*
[**2151-2-28**] 05:15AM BLOOD Hapto-<20*
[**2151-2-25**] 09:20PM BLOOD Ammonia-63*
[**2151-3-2**] 01:37PM BLOOD PTH-29
[**2151-2-25**] 09:57PM BLOOD Lactate-2.9*
[**2151-3-3**] 07:14AM BLOOD Lactate-12.9*
[**2151-3-3**] 05:10AM BLOOD freeCa-1.44*
.
Labs prior to death:
.
[**2151-3-5**] 11:26AM BLOOD WBC-12.4* RBC-3.21* Hgb-10.5* Hct-29.0*
MCV-90 MCH-32.6* MCHC-36.0* RDW-17.1* Plt Ct-37*
[**2151-3-5**] 11:26AM BLOOD PT-36.7* PTT-59.9* INR(PT)-3.9*
[**2151-3-5**] 11:26AM BLOOD Glucose-114* UreaN-101* Creat-3.5*
Na-151* K-4.1 Cl-106 HCO3-8* AnGap-41*
[**2151-3-5**] 03:18AM BLOOD ALT-231* AST-506* AlkPhos-58
TotBili-47.3*
[**2151-3-5**] 11:26AM BLOOD Calcium-10.3* Phos-8.8* Mg-4.0*
[**2151-3-5**] 11:51AM BLOOD Type-ART pO2-118* pCO2-25* pH-7.13*
calTCO2-9* Base XS--19 Intubat-INTUBATED
[**2151-3-5**] 11:51AM BLOOD Glucose-102 Lactate-18.8* K-3.9
.
[**2151-3-4**] 01:16PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2151-3-4**] 01:16PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-0.2 pH-5.0 Leuks-NEG
[**2151-3-4**] 01:16PM URINE RBC-282* WBC-0 Bacteri-NONE Yeast-MANY
Epi-3
[**2151-3-4**] 01:16PM URINE Hours-RANDOM UreaN-87 Creat-50 Na-96
.
Microbiology:
.
BCx - negative, ascitic fluid negative, fluid collection showing
VRE, UCx initially negative, then growing yeast. Sputum Cx with
budding yeast, 3+ 2 days prior to death.
.
Imaging/Studies:
.
CT abd/pelvis: [**2-25**]
.
IMPRESSION:
1. Increased bibasilar consolidation/atelectasis.
2. Interval removal of JP drain. The subhepatic collection is
decreased in
size, now measuring 5.4 cm in greatest dimension.
3. Moderate ascites. This may represent reaccumulation of
ascites in the
setting of liver disease though bile leak not excluded given the
provided
history. If there is clinical concern for bile leak, consider
MRCP with a
hepatobiliary [**Doctor Last Name 360**] (Gd-BOPTA or EOVIST) which may demonstrate a
leak if
present, although hepatic excretion may be reduced in the
setting of
cirrhoisis.
4. Cirrhotic liver, unchanged.
5. Mild bilateral hydronephrosis, unchanged.
6. Interval decrease in size of right cardiophrenic lymph node,
now 1.8 x 1.0
cm.
.
CXR [**2-25**]:
.
CHEST, TWO VIEWS: Band-like linear density of the left lung base
corresponds
to atelectasis seen on subsequent CT of the abdomen and pelvis.
There is no
evidence of pneumonia or pulmonary edema. Cardiac size is
normal. No
subdiaphragmatic free air is identified.
IMPRESSION: Bibasilar atelectasis
.
ECHO [**3-2**]:
.
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Transmitral Doppler and
tissue velocity imaging are consistent with normal LV diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Hyperdynamic left
ventricular function (EF>75%). No vegetations seen.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2150-7-10**], the
ventricular rate is now faster, the ventricular function is now
hyperdynamic and moderate pulmonary artery hypertension is now
present.
.
CXR [**3-3**], MICU transfer day:
.
There are bibasilar opacities partially retrocardiac, but also
continuing
towards the more lateral aspect of the chest that appears to be
worsening
atelectasis, although underlying infection cannot be excluded.
Small
bilateral pleural effusion is demonstrated. Upper lungs are
clear. The
cardiomediastinal silhouette is unchanged.
.
KUB [**3-3**]:
.
IMPRESSION: No ileus, obstruction or free air.
.
CTA abd/pelvis [**3-3**];
.
IMPRESSIONS:
1. Bibasilar consolidation slightly more than that seen on
[**2151-2-25**], likely
representing atelectasis although infection cannot be excluded.
2. Percutaneous transhepatic drain in place, with adjacent small
bubble of
gas. Given history of recent procedures and perihepatic
infection, multiple
new small hypodensities in the liver are concerning for liver
abscesses.
3. Increasing ascites and anasarca.
4. Diffuse colonic mucosal wall thickening and thumbprinting,
non-specific,
but infectious/inflammatory etiology such as C. difficile
colitis is favored.
No secondary or vascular findings to suggest ischemic colitis.
.
ECHO [**3-4**]:
.
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular
systolic function is hyperdynamic (EF>75%). The estimated
cardiac index is high (>4.0L/min/m2). 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. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. The mitral valve leaflets are structurally
normal. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: No vegetations seen. Hyperdynamic systolic function,
consistent with low systemic vascular resistance
.
CXR [**3-4**]:
.
FINDINGS: As compared to the previous examination, there is no
relevant
change. The position of the monitoring and support devices is
constant.
There is unchanged moderate overhydration with minimally
increasing bilateral
areas of hypoventilation. No newly appeared focal parenchymal
opacity
suggestive of pneumonia, no evidence of pneumothorax
Brief Hospital Course:
44 yom with hx of Hep C Cirrhosis recently admitted for CCY on
[**1-/2151**] c/b bacterial peritonitis and perihepatic fluid
collection who now presents with increased lethargy, abdominal
pain, elevated WBC and jaundice after non-compliance with
antibiotics at home. His bilirubin continued to rise during the
admission. Dx Paracentesis was negative. Fluid collection
drain was placed under IR guidance and produced purulent
material. Patient was treated with broad spectrum antibiotics
including linezolid for previous intraabdominal VRE infection as
well as Zosyn. Paracentesis was repeated on [**3-1**] and was
negative. Pt. had decreasing HCTs, requiring 2U daily for
maitnenance at stable level of uncear source and was scheduled
for EGD the morning of ICU transfer (Please see below for ICU
course).
.
# Abdominal pain/lethargy/WBC elevation/Hyperbili. Was felt to
be most likely [**3-8**] infection: source was unclear at time of ICU
transfer, but suspected intraabdominal fluid collection as the
source. The BCx were pending at time of transfer to MICU, UCx
were negative to date, there was no SBP and fluid collection
preliminary cultures were negative, however smear was with 4+
PMNs. Pt. was not tachycardic on admission, however, had
progressively increasing HR which was felt to be due to either
worsening infection vs. GIB. Patient was followed by ID and
Surgery transplant team while on the floor. WBC was stable,
patient was started on Zosyn empirically for a presumed
intraabdominal infection and restarted on Linezolid. Serial
exams showed worsening ascites and increasing lethargy and
weakness. ECHO was obtained to assess for Cx negative
endocarditis as a possible source due to worsening murmur on
exam, no vegetations were noted. Patient had a progressively
increasing AG on Chem 7 felt to be due to worsening acidosis and
renal failure. He had a developing hypercalcemia. On day of
MICU transfer, patient was noted to be increasingly tachypneic,
more lethargic and encephalopathic. His ABG was 66* 34* 7.14*4
12, showing severe acidosis and hypoxemia. Lactate was 12.4.
Patient received 2 amps of Na HCO3, IVF and was transferred to
the MICU for further care (see below).
.
# Anemia. Patient had a slowly dropping HCT during first 3 days
of admission, then continued to remain aroudn 22, despite 2U
daily. Baseline 27-30. No EGD reports in OMR, but per GI notes,
EGD from [**2151**]8 did not show varices. Concern for GIB given
sharp drop, eg. gastrophaty, vs. new varices. Patient with
chronic anemia at baseline so hemolysis less concerning and most
of bili is direct, however difficult to assess given liver
failure. Stools guiac positive. He was treated with IV PPI [**Hospital1 **].
Patient was scheduled for EGD on morning of ICU transfer.
.
# ARF. Baseline 0.6 - 0.8, Na < 10 in urine. Cr was 0.9 on
admission, however increased to 1.5 by HD4. It improved to 1.0
w/ 2U PRBCs and 50g albumin x2. Etiology was felt to be
pre-renal given suspected sepsis, but pt. was also hyperdynamic
on exam, and did not respond to an initial fluids challenge,
thus concern for hepatorenal. U/A was unremarkable. Patient had
slight hydronephrosis on CT [**2-13**].
.
# Hep C Cirrhosis: Patient's home fursemide and atenolol were
held in setting of infection. MELD was 34 on [**3-2**]. Patient
remained on transplant list prior to entering MICU. He was
continued on home midodrine, lactulose, rifaximiin, and
cholestyramine for pruritis.
.
# Hypothyroidism: Patient was continued on home levothyroxine.
.
MICU Course:
.
The patient was transferred to the MICU for hemodynamic
instability and elevated lactate. During his initial survey and
access placement he developed a lower GI bleed. Central line
was placed, the patient was intubated and blood rapidly
transfused. He was stabilized with continually elevating
lactate. Surgery, GI, Renal & Infectious disease were consulted
to provide recommendations to comment on refractory acidosis,
pancolitis (C. Diff), oliguric renal failure, worsening liver
failure and persistant hypotension. Fluid collection cultures
eventually grew VRE. BCx were negative and Sputum and Urine
showed budding yeast. Patient was treated with broad spectrum
antibiotics. He was found to be a non-operative or endoscopic
candidate and hemodialysis was not offered. He was maintained
on levophed, neosynephrine and vasopressin while sedated and
intubated. Over his 3 days in the MICU several family meetings
were held and the patient was first made DNR/DNrI then CMO. He
passed on [**3-5**] at approximately 6:30pm.
Medications on Admission:
Linezolid 600mg PO q12h (not taking)
Levothyroxine 75mcg daily
Clotrimazole 10 Troch PRN 5 times daily
Oxycodone 5mg q4h PRN pain
Lactulose 30mg PO TID
Methadone 10mg daily
Docusate
Senna
Midodrine 5mg TID
Atenolol 50mg daily
Furosemide 40mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to hemodynamic collapse and sepsis.
Discharge Condition:
Death
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2151-3-16**]
|
[
"789.59",
"578.9",
"571.5",
"287.5",
"041.04",
"070.44",
"518.81",
"276.2",
"998.59",
"285.9",
"790.92",
"276.0",
"275.42",
"572.3",
"567.22",
"584.9",
"244.9",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"54.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14104, 14113
|
9210, 13794
|
300, 353
|
14202, 14209
|
2458, 2463
|
14262, 14297
|
1873, 1878
|
14134, 14181
|
13820, 14081
|
14233, 14239
|
1893, 2439
|
1470, 1754
|
230, 262
|
381, 1352
|
2477, 9187
|
1374, 1452
|
1770, 1857
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,627
| 167,626
|
2876+2894
|
Discharge summary
|
report+report
|
Admission Date: [**2115-3-31**] Discharge Date: [**2115-4-10**]
Service: C-Medicine
CHIEF COMPLAINT:
Questionable nonsustained ventricular tachycardia in setting
of low left ventricular ejection fraction, status post hip
arthroplasty.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
female with a history of coronary artery disease, status post
myocardial infarction with three vessel disease (100% right
coronary artery, 90% proximal left anterior descending
artery, 90% obtuse marginal one), hypertension, chronic
atrial fibrillation, status post cerebrovascular accident
with left hemiplegia, peripheral vascular disease, poorly
controlled noninsulin dependent diabetes mellitus, and left
ventricular ejection fraction of 15% who, on [**2115-3-31**],
lost her balance while walking without assistance of her cane
and sustained a displaced left subcapital femur fracture.
The patient was admitted and was initially hyperglycemic with
an INR of 5. She was admitted to the medicine service and
reversed with fresh frozen plasma. She underwent cardiology
evaluation which revealed moderate to high risk (10% to 15%)
of surgery given her reversible inducible anterior and
inferior defects on Persantine Cestimibi. Her left
ventricular ejection fraction was 15% (she has three vessel
disease per last cardiac catheterization).
The patient underwent a left hip bipolar hemiarthroplasty on
[**2115-4-2**]. Her hospital course was complicated by a
fever to 103.3 ([**4-3**]), atrial fibrillation
80s to 120s and, most recently, has had two runs of seven to
nine beats of what appears to be either nonsustained
ventricular tachycardia or atrial fibrillation with
aberrancy. These occurred on [**2115-4-5**]. Given the
patient's low left ventricular ejection fraction, this may be
an indication for electrophysiologic evaluation although, in
this patient, social issues and quality of life must be taken
into consideration. The patient is being transferred to the
C-Med service over the weekend for observation, electrolytes
repletion and medical management until further decision
regarding electrophysiologic study plus/minus pacemaker
versus medical management or observation is to take place.
The patient is comfortable, without chest pain, shortness of
breath, palpitations or syncope.
PAST MEDICAL HISTORY: 1. Coronary artery disease, status
post myocardial infarction; cardiac catheterization in
[**2112-1-17**] showed a wedge of 20, dilated left ventricle,
left ventricular ejection fraction 28%, diffuse hypokinesis,
mild mitral regurgitation, proximal right coronary artery
100% occlusion, apical akinesis and apical thrombus, 90% left
anterior descending artery, proximal obtuse marginal one of
90%. 2. Hypertension. 3. History of right cerebrovascular
accident with left-sided weakness, upper extremity greater
than lower extremity. 4. Peripheral vascular disease. 5.
Chronic atrial fibrillation. 6. Noninsulin dependent
diabetes mellitus ([**2111**]).
MEDICATIONS ON ADMISSION: Digoxin 0.125 mg p.o.q.d.,
atenolol 25 mg p.o.q.d., Coumadin 5 mg p.o.q. Monday and 2.5
mg all other days, Captopril 50 mg p.o.b.i.d., aspirin 325 mg
p.o.q.d., Glipizide 10 mg p.o.q.d., sublingual nitroglycerin
p.r.n., diltiazem 50 mg p.o.b.i.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is from [**Country **]. She lives with
her daughter, son-in-law and granddaughter. She does not use
alcohol or tobacco.
FAMILY HISTORY: The patient's had asthma, her mother
hypertension and history of cerebrovascular accident. A
brother has asthma and diabetes mellitus.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 100.2, blood pressure 130/80, heart rate
77 to 113, respiratory rate mid-20s and oxygen saturation 96%
in room air. Fingersticks are 210, 229 and 215, input and
output 2,865 and 864 today. General: Patient was in no
acute distress. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, extraocular movements intact,
pupils equal, round, and reactive to light and accommodation,
oropharynx clear. Neck: Supple no jugular venous
distention, no bruit. Cardiovascular: Irregularly irregular
with rate in the 90s. Chest: Clear to auscultation
bilaterally. Abdomen: Nontender, slightly distended,
positive bowel sounds. Extremities: 1+ edema bilaterally,
left hip neurovascularly intact, dressing clean, dry in
intact, left upper extremity with edema on the left.
Neurologic examination: Alert and oriented times three,
cranial nerves II through XII intact, motor [**3-21**] in left upper
extremity, 4-/5 in left lower extremity, [**4-20**] otherwise, deep
tendon reflexes brisk in left upper extremity and left lower
extremity, right toe downgoing, left toe upgoing.
LABORATORY DATA: Electrocardiogram showed atrial
fibrillation to the 60s, right axis, poor R wave progression,
Q waves in V1 through V3, I and AVL, left posterior
fascicular block, T wave inversions in AVF and laterally.
[**2115-4-2**] x-ray showed left displaced femoral neck
fracture, status post left hip bipolar hemiarthroplasty.
Persantine Cestimibi on [**2115-4-1**] showed a fixed
perfusion defect in the apex with Persantine induced
abnormalities involving anterior and inferior walls, left
ventricular ejection fraction 15%, hypokinesis except for at
the lateral anterior wall; electrocardiogram showed just
baseline ST-T wave changes without any changes.
White blood cell count was 8.8, hematocrit 29.1, platelet
count 114,000, prothrombin time 14.8, partial thromboplastin
time 43.2, INR 1.5, sodium 133, potassium 3.7, chloride 101,
bicarbonate 22, BUN 10, creatinine 0.9, glucose 188,
magnesium 1.5, calcium 7.8, hemoglobin A1c 13.3, albumin 4.3,
phosphorous 2.5, and digoxin level 0.8. [**2115-4-4**]
arterial blood gases 7.47, 36 and 156. Blood cultures times
two on [**2115-4-3**] were negative. Sputum culture on [**2115-4-3**] was unremarkable. Urine culture on [**2115-4-3**]
showed 7,000 per ml of yeast and 1,000 per ml of
Staphylococcus.
HOSPITAL COURSE: The patient is an 81 year old female with
three vessel coronary artery disease, status post myocardial
infarction, hypertension, chronic atrial fibrillation, status
post right cerebrovascular accident, peripheral vascular
disease, and noninsulin dependent diabetes mellitus, who
presents with seven to nine beats of wide complex tachycardia
which was reviewed by cardiology and deemed to be either
nonsustained ventricular tachycardia or atrial fibrillation
with aberrancy status post hip replacement.
1. Cardiovascular: From a cardiovascular standpoint, the
patient was maintained on aspirin and a beta blocker as well
as an ACE inhibitor and digoxin. She remained in atrial
fibrillation, as she is chronically. Her diltiazem was
eventually weaned off and, instead, her beta blocker was
increased for rate control. The patient was later admitted
to the C-Medicine service and had no further events of
nonsustained ventricular tachycardia (versus aberrant rapid
atrial fibrillation).
The case was reviewed with the electrophysiology service and,
based on the uncertainty of the rhythm, no history of syncope
or pre-syncope, and the invasive nature of the associated
procedures (cardiac catheterization/electrophysiology study),
and unlikely mortality benefit in this elderly patient with a
history of cerebrovascular accident, cardiomyopathy with
three vessel disease, it was decided that ICD placement was
not recommended.
Empiric amiodarone for nonsustained ventricular tachycardia,
with a goal of potential cardioversion from atrial
fibrillation, was considered to be reasonable although it was
unlikely to provide mortality benefit. After discussion with
Dr. [**Last Name (STitle) 11528**], it was decided not to pursue the use of
amiodarone.
2. Orthopedics: Postoperatively, the patient was
weightbearing as tolerated. She can have her staples
discontinued two weeks postoperatively and will need
follow-up with orthopedics in four weeks. She will need
aggressive physical therapy and has posterior hip precautions
(i.e., should not cross left leg over right leg in front of
her body).
3. Endocrine: The patient was started back on glipizide and
sliding scale insulin, with good blood sugar control.
4. Fever: The patient had no further fevers while on the
C-Medicine service. The brief fever that she had
postoperatively may have been due to atelectasis. She had no
elevated white blood cell count or evidence of infection
anywhere and had no fevers during the rest of her hospital
stay.
5. Disposition: The patient will need to be anticoagulated
because of her chronic atrial fibrillation. At present, her
INR is subtherapeutic, but she will be receiving subcutaneous
Lovenox until her INR is between 2 to 3.
DISCHARGE DIAGNOSES:
Nonsustained ventricular tachycardia versus atrial
fibrillation with aberrancy times two on [**2115-4-5**]
(medical management).
Chronic atrial fibrillation.
Coronary artery disease with three vessel disease, status
post myocardial infarction.
Left hip fracture on [**2115-3-31**], status post left hip
replacement on [**2115-4-2**].
Hypertension.
Status post right cerebrovascular accident with residual
left-sided weakness.
Peripheral vascular disease.
Noninsulin dependent diabetes mellitus.
Decreased left ventricular ejection fraction of 15%.
DISCHARGE MEDICATIONS:
Coumadin started on [**2115-4-8**], initially given 5 mg but
may eventually need 2.5 mg p.o.q.d.; this will be adjusted as
needed.
Lopressor 100 mg p.o.t.i.d.
Lovenox 80 mg s.c.b.i.d. until INR between 2 and 3.
Captopril 50 mg p.o.t.i.d.
Digoxin 0.125 mg p.o.q.d.
Aspirin 81 mg p.o.q.d.
Glipizide 10 mg p.o.q.d.
Regular sliding scale insulin.
Percocet one p.o.q.6h.p.r.n.
FOLLOW-UP: The patient is to follow up with Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) 8499**], her primary care physician, [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 13954**], in
two to four weeks. The patient is to follow up with
orthopedic surgery four weeks from her surgery date which was
[**2115-4-2**], with Dr. [**Last Name (STitle) 13955**] or Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) **].
Two weeks postoperatively, the patient's staples should be
discontinued. She should be on posterior hip precautions
(not allowed to cross left leg over body) and will need
aggressive physical therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], M.D.
[**MD Number(1) 11525**]
Dictated By:[**Name8 (MD) 13956**]
MEDQUIST36
D: [**2115-4-9**] 13:55
T: [**2115-4-9**] 15:35
JOB#: [**Job Number 13957**]
Admission Date: [**2115-3-31**] Discharge Date: [**2115-4-18**]
Service:
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 4223**] is an 81-year-old
female who on [**4-4**] fell at home resulting in a left femur
fracture. She was admitted to the hospital and underwent a
bipolar hemiarthroplasty. She had multiple medical problems.
She was initially admitted to the Medical Service and you can
refer to their notes for their evaluation. Her orthopedic
course was significant for: She was cleared for the
Operating Room after an evaluation from Cardiology. On [**2115-4-3**], she had a left bipolar hemiarthroplasty.
Postoperatively, she required cardiac inotropes. She was
admitted to the Intensive Care Unit. She had a mild drop in
her saturations. There was concern about her pulmonary
status. She was evaluated by the Surgical Intensive Care
Unit and the Pulmonary Team. She subsequently had a CT
angiogram and was treated with heparin. She was noted to
have a small bleed into her stomach. Her heparin was
discontinued. She was subsequently, after multiple days in
the Intensive Care [**Hospital 14010**] transferred to the floor. Her
postoperative course was unremarkable from that time. She
was subsequently transferred to rehabilitation.
Postoperative plan is to follow-up in the office.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 14011**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2115-6-26**] 09:53
T: [**2115-6-26**] 09:53
JOB#: [**Job Number 14012**]
|
[
"518.0",
"820.8",
"425.4",
"427.31",
"250.00",
"E888",
"401.9",
"997.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
3497, 3634
|
8850, 9399
|
9422, 10796
|
3027, 3328
|
6086, 8829
|
3657, 4495
|
113, 248
|
10825, 12330
|
4520, 6068
|
2337, 3000
|
3345, 3480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,792
| 131,562
|
30705
|
Discharge summary
|
report
|
Admission Date: [**2120-5-17**] Discharge Date: [**2120-6-6**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Bile duct injury s/p lap chole on [**2120-5-16**]
Major Surgical or Invasive Procedure:
[**2120-5-17**] ERCP
[**2120-5-21**]: cholangiogram
[**2120-5-21**] Pigtail drain placement
[**2120-5-27**]: Exploratory laparotomy, hepaticojejunostomy, removal of
transhepatic tube, repair transgastric gastrotomy, suture
ligation right hepatic artery.
[**2120-5-31**] T Tube cholangiogram
History of Present Illness:
Patient s/p lap chole on [**2120-5-16**] at OLH for "inflamed
gallbladder". He developed a bile leak following procedure. He
denies fever, chills, nausea, vomiting. HIDA scan was performed
which did reveal a bile leak, bile noted in JP bulb drainage.
Patient sent for consult with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Past Medical History:
AFib (Cardioverted x 2 [**2110**])
HTN
PTSD (Veteran WWII)
h/o ETOH abuse, last [**2088**]
Rosacea
Lap CCY
Umbilical hernia repair
Cataract surgery
Social History:
Wife deceased, lives alone
Tobacco 1PPD
2 children
Family History:
NC
Physical Exam:
VS: 99.6, 92, 115/64, 20, 97%RA
Gen: A+O, NAD, face flushed, anicteric sclera
Lungs: CTA bilaterally
Card: RRR
Abd: +BS, soft, appropriately tender, JP in RUQ with bilious
appearing drainage
GU: Foley in place draining clear yellow urine
Extr: No C/C/E
Neuro: Strength 5/5
Pertinent Results:
On Admission: [**2120-5-17**]
WBC-8.3 RBC-3.47* Hgb-11.3* Hct-34.0* MCV-98 MCH-32.7* MCHC-33.4
RDW-14.8 Plt Ct-185
PT-14.3* PTT-26.3 INR(PT)-1.3*
Glucose-102 UreaN-8 Creat-0.9 Na-140 K-3.9 Cl-104 HCO3-30
AnGap-10
ALT-30 AST-48* AlkPhos-98 Amylase-47 TotBili-0.9
Albumin-3.7 Calcium-9.0 Phos-2.1* Mg-2.0
Brief Hospital Course:
Patient admitted for bile leak s/p chole.
ERCP on [**2120-5-17**] demonstrated: A complete obstruction seen at the
middle third of the common bile duct. Two surgical clips were
found at the level of the obstruction. No contrast was noted in
the duct above the level of the obstruction.
A moderate pressure occlusion cholangiogram was performed, no
contrast was seen above the level of bile duct obstruction. No
filling of the upper third of the bile duct or bifurcation was
found.
Impression: The major papilla was normal.Complete bile duct
obstruction was found.
CT Abd done [**2120-5-18**] as follow-up to HIDA and ERCP assessing for
fluid collections. This showed mild intrahepatic biliary ductal
dilatation, predominantly affecting the left lobe.
On [**5-20**], attempted placement of PTC was unsuccessful due to lack
of biliary dilation (decompressed system).
On [**5-21**] PTC placement was again attempted. This resulted in
successful placement of left 8 French modified biliary tube
extending from the left system and into the right with pigtail
in the right main biliary duct and side holes draining the right
and left main biliary ducts. The catheter is attached to a bag
for external drainage. The pull-back cholangiogram demonstrated
complete transection at the level of the confluence of the
biliary ducts, questionable 0.5 cm of the common bile duct
remaining at this level. There was normal appearing right-sided
biliary ducts and moderate dilation of the left-sided biliary
ducts.
On [**5-22**] a liver U/S was performed demonstrating patent vessels.
This was done in response to slight bump in AST/ALT which
resolved.
On [**5-27**] the patient was taken to the OR for Exploratory
laparotomy, hepaticojejunostomy, removal of transhepatic tube,
repair of transgastric gastrotomy, suture ligation right hepatic
artery. PLease see the operative note for further details. He
was briefly placed in the SICU. He was transferred back to the
regular surgical floor.
Increased bilious output was noted on POD 2. A CT scan was done
to evaluate for fluid collections, however none were seen.
The following day he underwent a T-tube cholangiogram that
demonstrated patent hepatojejunostomy anastomosis. The T- tube
drains the right biliary system. No contrast was noted within
the left biliary system. there was a small amount of leakage
noted at the site of hepatojejunostomy site. It was decided that
no further surgical intervention would be attempted.
CT exam of abdomen was repeated on [**6-6**] which showed no
abnormal intra-abdominal fluid collections identified status
post hepaticojejunostomy. The JP drain which had been placed
earlier in the hospitalization was pulled and the PTC was
capped.
Blood and bile cultures remain oending at the time of discharge.
Medications on Admission:
Coumadin 5'hs, Atenolol 25', Clonazepam 1'hs, Lorazepam 1 [**Hospital1 **]
PRN, Remeron 15'hs, Tricor
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take while taking pain medication (dilaudid). stop if loose
stool or diarrhea. .
Disp:*60 Capsule(s)* Refills:*2*
3. Outpatient [**Name (NI) **] Work
PT/INR Friday [**6-7**]. Fax to PCP
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Home Care
Discharge Diagnosis:
bile leak s/p lap chole
Discharge Condition:
Good
Discharge Instructions:
Please call Dr [**Last Name (STitle) 9411**] office at [**Telephone/Fax (1) 673**] if you experience
increased abdominal pain, increase in the amount of drainage or
if drainage appears bloody or foul smelling.
Drain and record output at least daily and more often as needed.
Bring this record with you to your clinic visit.
Monitor for fevers, chills, nausea, vomiting, diarrhea, [**Male First Name (un) 1658**]
colored stool or bright red blood at rectum, call the office if
these occur.
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2120-6-13**] 2:20
Call to schedule f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72744**] [**Telephone/Fax (1) 28262**]
Completed by:[**2120-6-7**]
|
[
"327.23",
"576.2",
"576.8",
"401.9",
"427.31",
"998.2",
"997.4",
"695.3",
"E878.6",
"751.69",
"902.22",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.59",
"87.51",
"51.10",
"45.91",
"38.86",
"51.43",
"87.54",
"46.39",
"51.37",
"44.61",
"54.4"
] |
icd9pcs
|
[
[
[]
]
] |
5554, 5615
|
1874, 4651
|
309, 601
|
5683, 5690
|
1547, 1547
|
6227, 6530
|
1235, 1239
|
4803, 5531
|
5636, 5662
|
4677, 4780
|
5714, 6204
|
1254, 1528
|
220, 271
|
629, 980
|
1561, 1851
|
1002, 1151
|
1167, 1219
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,154
| 147,020
|
10181
|
Discharge summary
|
report
|
Admission Date: [**2161-12-28**] Discharge Date: [**2162-1-4**]
Date of Birth: [**2118-1-10**] Sex: F
Service: Cardiothoracic Surgery Service
CHIEF COMPLAINT: Tracheomalacia
HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old
female with a history of congenital dwarfism and
tracheomalacia who was has had progressively worsening
respiratory problems since the early [**2138**].
She had a tracheoplasty on a previous admission in [**Month (only) **]
and was admitted on [**2161-12-28**] after spiking a
temperature at home with a productive cough.
She was brought up for a follow-up bronchoscopy on [**12-28**]
under LMA. During the procedure, there was noted to be a
postoperative residual swelling of the trachea and main stem
bronchus which resulted in significant subglottic stenosis
and mucous plugging. Her stent was able to be cleared, but
postoperatively she required intubation and pressure support
with phenylephrine. She was sent to the Medical Intensive
Care Unit for further care.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Tracheomalacia.
2. Congenital dwarfism.
3. Chronic bronchitis.
4. Lumbar spinal stenosis.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Levofloxacin 500 mg by mouth once per day.
2. Vioxx 150 mg by mouth once per day.
3. Mucomyst nebulizer treatment at hour of sleep.
4. Paxil 10 mg by mouth once per day.
5. Oral contraceptive pills.
ALLERGIES: She has no known drug allergies.
FAMILY HISTORY: Her family history is of normal stature.
No history of respiratory difficulties.
SOCIAL HISTORY: She works as an actress in [**Last Name (un) 33963**]. She
denies any history of smoking.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
afebrile, her blood pressure was 90/52, her heart rate was
97, her respiratory rate was 25, and her oxygen saturation
was 100% on assist-control with a positive end-expiratory
pressure of 5, and a FIO2 of 50%. In general, the patient
was a well-developed and well-nourished female on a
ventilator in no apparent distress. Head and neck
examination revealed normocephalic and atraumatic. The
pupils were equal, round, and reactive to light and
accommodation. The sclerae were anicteric. The neck was
supple. No lymphadenopathy. No stridor. Cardiovascular
examination revealed a regular rate and rhythm. No murmurs,
rubs, or gallops. The lung examination revealed coarse
breath sounds bilaterally. She did have inspiratory wheezes
bilaterally. The abdomen was soft, nontender, and
nondistended. Extremity examination revealed no clubbing,
cyanosis, or edema. On neurologic examination, she was able
to follow commands.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her admission
laboratories revealed a white blood cell count of 18.6, her
hematocrit was 34.4, and her platelets were 501. The SMA-7
revealed her sodium was 135, potassium was 3.5, chloride was
97, bicarbonate was 27, blood urea nitrogen was 9, creatinine
was 0.4, and her blood glucose was 101. Her arterial blood
gas was 7.36/49/135.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed
no signs of acute ischemia.
Her chest x-ray showed the endotracheal tube 5 cm above the
carina in the left main stem bronchus in place with no
pneumothorax, and also showed a right middle lobe
collapse/consolidation.
BRIEF SUMMARY OF HOSPITAL COURSE: She was transferred to the
Thoracic Surgery Service on hospital day two after being
extubated, and she was in good care there. She was using 35%
face mask and saturating about 98%.
Her floor care required frequent racemic epinephrine
nebulizers for her wheezing, but her need for this soon
decreased during this admission. In addition, to the
bronchoalveolar lavage from this bronchoscopy, it ended up
growing out Aspergillus fumigatus. An Infectious Disease
consultation was obtained and the patient was started on by
mouth voriconazole instead of Zosyn. Her diet was quickly
advanced, and by [**1-4**] she was ready to go.
Her physical examination on discharge revealed she was alert
and oriented times three and in no apparent distress. She
had good air entry bilaterally with some wheezing, but her
lungs were clear to auscultation bilaterally. She was
saturating 100% on room air. Her abdomen was soft,
nontender, and nondistended. Her extremities were without
any clubbing, cyanosis, or edema.
DISCHARGE DISPOSITION/CONDITION: She was discharged to home
in good condition.
MEDICATIONS ON DISCHARGE:
1. Racemic epinephrine nebulizer treatments.
2. Voriconazole 100 mg by mouth twice per day as needed.
3. Dilaudid by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was recommended
to follow up with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in three months and with
her primary care physician in the next one to two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2162-1-4**] 13:14
T: [**2162-1-6**] 07:17
JOB#: [**Job Number 33966**]
|
[
"259.4",
"117.3",
"491.9",
"996.69",
"518.81",
"724.02",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1508, 1590
|
4503, 4645
|
1205, 1490
|
4679, 5161
|
3385, 4477
|
177, 193
|
222, 1025
|
1048, 1178
|
1607, 3356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,433
| 143,337
|
53407
|
Discharge summary
|
report
|
Admission Date: [**2178-4-21**] Discharge Date: [**2178-5-4**]
Date of Birth: [**2129-10-5**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril
/ Naprosyn / Bactrim DS / Phenytoin / Nitrofurantoin / Sulfa
(Sulfonamide Antibiotics) / Zofran / IV Dye, Iodine Containing /
Latex
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
pain, swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 48-year-old female with PMHx of spina bifida, HTN, MR,
paraperesis, non-epileptic [**First Name3 (LF) 54422**], and urostomy with chief
complaint of body swelling and pain.
.
Her symptoms began about 4 days ago with lower extremity and
abdominal swelling. She also reports diffuse body tenderness in
addition to nausea, vomiting, and subjective chills. She took
her temperature prior to coming to the hospital but said it was
less than 100.0F. The patient reports a vague chest discomfort
that comes and goes. She is bedbound at baseline.
.
On arrival to the ED, she complained of shortness of breath. She
was placed on a NRB with CXR showing mild pulmonary vascular
congestion (no edema) with mild atelectasis. She was weaned off
oxygen and was satting 93% on RA but the patient requested NC
for comfort reasons. Of note, she is an asthmatic. Pain was
controlled with morphine. A d-dimer came back positive but the
patient cannot get a CTA due to a contrast allergy. CT abdomen
was stable from prior. Troponin was negative x 1. She was
admitted to medicine for further evaluation. Transfer vitals
were HR- 71, BP- 120/84, RR- 16, SaO2- 93% on RA, 95% on 2L.
.
On arrival to the floor, vital signs were T- 97.6, BP- 112/77,
HR- 66, RR- 20, SaO2- 99% on 3L. The patient continued to
complain of diffuse body pain and swelling in her legs and
abdomen. She denied chest pain but continued to have minimal
shortness of breath. She denies change in her urine quality, RUQ
pain, rash, or cough.
.
Past Medical History:
1. Asthma/COPD
2. Hypertension
3. GERD
4. Urostomy
5. h/o VRE pyelonephritis
6. Spina bifida (myelomengiocele)
7. Paraplegia (documented, though patient can walk)
8. Depression
9. Mild mental retardation
10. Psychogenic dysarthria and tremor
11. [**First Name3 (LF) **] vs. pseudoseizures
- EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular
bifrontal sharp delta activity although the clinical events
which occurred during the record were not associated with EEG
change
12. Atopic dermatitis
13. Back pain
14. Genital herpes
15. Uterine fibroid
16. Uterine prolapse
17. Diverticulosis
18. External hemorrhoids
19. [**Doctor Last Name **]-[**Known lastname **] syndrome in [**1-9**].
Social History:
Lives alone in an apartment in [**Location (un) 86**]. She is able to transfer
w/ wheelchair. Reports [**Location (un) 269**] assistance once a week in her home.
Tobacco: 1 PPD EtOH: Drinks 2-3 beers a day. Illicits: Denies
IVDU ever. History of smoking crack cocaine, claims to have
stopped using cocaine 3 years ago.
Family History:
3 healthy children. Mother - died of lung cancer. Father -
killed by his girlfriend. Not in contact with her brother and
sister.
Physical Exam:
ADMISSION PHYSICAL:
GENERAL: Obese female resting in NAD
HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear. NC in
place
NECK: Supple, difficult to assess JVD given body habitus.
LUNGS: Bilateral wheezes with good respiratory effort.
HEART: RRR, no MRG, nl S1-S2.
ABDOMEN: Obese. Soft, non-distended with tenderness to palpation
throughout. No rebound.
EXTREMITIES: Trace edema bilaterally, 2+ peripheral pulses.
Tender to palpation throughout lower extremities
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, sensation
grossly intact throughout. Gait deferred as patient is bedbound.
LABS: See below.
.
DISCHARGE PHYSICAL:
VS: Tm 98.2, Tc 97.9, BP 107/86 (98-162/76-94), 73 (70-83),
97%RA I/O:
GENERAL: Obese female, NAD, pleasant, A&Ox3
HEENT: sclerae anicteric, dry MM, no scleral injection
LUNGS: no use access mm, clear posteriorly without wheezes or
crackles
HEART: distant heart sounds, RRR, no MRG, nl S1-S2.
ABDOMEN: +BS, Obese, Soft, distended, non-tender, no rebound
EXTREMITIES: pedal edema bilaterally, non-pitting, unchanged
compared to last several days
NEURO: Awake, A&Ox3, answers questions appropriately, CNs II-XII
grossly intact.
SKIN: Thickened, hardened skin on legs and arms, and back, no
longer peeling, greatly improved, hands with erythema and some
skin sloughing, but greatly improved
Pertinent Results:
ADMISSION LABS:
[**2178-4-21**] 08:00PM URINE HOURS-RANDOM
[**2178-4-21**] 08:00PM URINE UCG-NEG
[**2178-4-21**] 08:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2178-4-21**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2178-4-21**] 06:33PM D-DIMER-835*
[**2178-4-21**] 05:15PM GLUCOSE-86 UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
[**2178-4-21**] 05:15PM estGFR-Using this
[**2178-4-21**] 05:15PM cTropnT-<0.01
[**2178-4-21**] 05:15PM proBNP-40
[**2178-4-21**] 05:15PM WBC-9.4 RBC-4.06* HGB-12.8 HCT-38.3 MCV-94
MCH-31.6 MCHC-33.5 RDW-14.2
[**2178-4-21**] 05:15PM NEUTS-53.1 LYMPHS-36.5 MONOS-3.8 EOS-5.4*
BASOS-1.1
[**2178-4-21**] 05:15PM PLT COUNT-219
[**2178-4-21**] 05:15PM PT-11.6 PTT-27.2 INR(PT)-1.0
.
DISCHARGE LABS:
Na 135 K 4.5 Cl 101 HCO3 25 BUN 12 Cr 0.9
Hct 34.3 Hgb 10.8 WBC 10.7 Plt 389
.
STUDIES:
CXR [**2178-4-21**]:
IMPRESSION: Mild bibasilar atelectasis.
.
CTAP [**2178-4-21**]:
IMPRESSION:
1. No acute abdominal pathology, especially no retroperitoneal
bleed.
2. Status post urinary diversion with ileal conduit with
prominent lower
ureters, unchanged since the prior study. Stable right renal
scarring.
3. Fibroid uterus.
4. Spina bifida with sacral meningocele, unchanged.
.
LUNG SCAN [**2178-4-22**]:
IMPRESSION: Normal lung scan.
.
LENI'S [**2178-4-22**]:
CONCLUSION: No evidence of DVT in right or left lower extremity.
.
TTE [**2178-4-23**]:
Conclusions
The left atrium is normal in size. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve is
not well seen. No aortic regurgitation is seen. The mitral valve
leaflets are not well seen. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Limited study. Preserved global left ventricular
systolic function.
Compared with the prior study (images reviewed) of [**2176-9-30**],
the current study is very limited secondary to poor echo
windows/patient body habitus and limited data acquisition in the
setting of a 'Code Blue' on the patient prior to study
termination; cannot compare.
.
CXR [**2178-4-25**]:
FINDINGS:
Frontal view of the chest compared to multiple prior
examinations. There is hazy opacification of both lungs, with
possible volume overload or congestive failure. Possible
pneumonia. Heart and mediastinum within normal limits. Mild
atelectasis at both lung bases.
.
CXR [**2178-4-25**]: LINE PLACEMENT
CLINICAL INFORMATION: New right IJ line.
Frontal view of the chest compared to multiple prior
examinations. Right IJ catheter at cavoatrial junction. Little
change since prior study, with
moderate congestive failure, interstitial prominence. Low lung
volumes.
Heart is enlarged.
.
CXR [**2178-4-28**]:
FRONTAL AND LATERAL VIEWS OF THE CHEST: Right IJ catheter ends
in the lower SVC, unchanged. Since the prior study, lung volumes
are slightly improved with improvement of bibasilar atelectasis.
There is no evidence of focal consolidation. There is no pleural
effusion or pneumothorax. Cardiomegaly remains unchanged.
.
TTE [**2178-5-1**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve is not
well seen. 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. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2178-4-23**], findings similar but technically suboptimal.
If clinically indicated, a transesophageal echocardiographic
examination is recommended.
IMPRESSION: no obvious vegetations seen on suboptimal imaging
.
MICROBIOLOGY:
BLOOD CX, X3 [**2178-4-24**]: NO GROWTH
BLOOD CX, X1 [**2178-4-25**]: NO GROWTH
BLOOD CX, X2 [**2178-4-26**]: NO GROWTH
BLOOD CX, X1 [**2178-4-27**]: NO GROWTH
BLOOD CX, X1 [**2178-4-27**]: [**2178-4-27**] 8:13 pm BLOOD CULTURE Source:
Line-tlc.
**FINAL REPORT [**2178-4-30**]**
Blood Culture, Routine (Final [**2178-4-30**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2178-4-28**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 21342**]) @ 2:39PM
[**2178-4-28**]
.
BLOOD CX, X 2, [**2178-4-28**]: PENDING
BLOOD CX, X 3, [**2178-4-29**]: PENDING
BLOOD CX, X 4, [**2178-4-30**]: PENDING
BLOOD CX, X 2, [**2178-5-1**]: PENDING
.
URINE CX [**2178-4-26**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
URINE CX [**2178-4-27**]:
URINE CULTURE (Final [**2178-4-29**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
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-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN----------- <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
URINE CULTURE (Final [**2178-4-30**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname **] is a 48yo female with extensive medical history
including multiple allergies, asthma/COPD, multiple
hypersensitivity skin reactions requiring previous burn unit
admission, who was admitted with chief complaint of body pain
and swelling. Patient's exam did not demonstrate overt swelling
on the medical floor although she was diffusely tender to
palpation. Initial concern for cardiac etiologies, PE, low
albumin states to explain anasarca. VQ and LENI's negative. CE's
negative and TTE demonstrated preserved systolic function. Pt
developed erythematous skin rash and dermatology was consulted.
IVIG was started; however, pt lost access, and was transferred
to the ICU for close monitoring and central line placement. Pt
transferred back to medical floors and completed course of IVIG
(4 doses total). Hospital course also complicated by fevers,
initially attributed to inflammation; however, pt grew MRSA from
1 blood culture and Klebsiella in urine. Klebsiella was thought
to be a colonization as pt with urostomy in placed and
asymptomatic. Pt was initially treated with Vancomycin for MRSA.
Central line was discontinued and pt was started on Linezolid.
Pt remained afebrile and and was continued on Linezolid per ID
recs until [**2178-5-14**].
Pt was able to perform all ADL's prior to discharge, and back to
baseline. Planned for [**Month/Day/Year 269**] services for skin care, but pt
refused.
.
ACTIVE ISSUES:
.
# Body pain, swelling: Concern for anasarca, though pt did not
appear particularly edematous on examination. Most likely
combination of hypoalbuminemia and possible prodrome of
hypersensitivity skin reaction (discussed below). Pt's albumin
quite low, likely [**3-4**] poor nutritional intake. UA without
protein and patient does not have a history of cirrhosis in
addition to normal LFT's. Other DDx included volume overload.
CE's were negative, and EKG was sinus rhythm with no ST
changes/TWI. Echo was a limited study, but demonstrated
preserved global left ventricular systolic function. Other
possibilites included venous insuffiency, or DVT/PE. LENIs and
V/Q scan were negative. Hypothyroidism considered, though pt had
normal TSH. Nutrition was consulted, and she was placed on high
protein/calorie diet with Ensure. Edema improved, though
progression to bullous skin rash as discussed below.
.
# Bullous Hypersensitivity skin reaction: Pt has a history of
drug induced hypersensitivity skin reaction requiring treatment
in burn unit and intubation on previous admissions. As above,
pt's developed erythematous and bullous skin reaction on upper
extremities, back, buttocks and thighs. Dermatology was
consulted, and thought this likely represented previous
reactions. Possible exacerbating drug was not identified. Pt was
treated with IVIG with improvement in skin condition. She was
monitored closely for mucosal involvement, but it did not
progress. Wound consult provided recs for skin care. She
completed a 4 day course of IVIG. She was scheduled for
follow-up in clinic with Dermatology on discharge. Skin exam on
discharge greatly improved with no more sloughing, and pt had
minimal to no pain.
Attempted to set up [**Month/Day (2) 269**] services for skin care; however, pt
adamantly refused services at time of discharge.
.
# Hypoxia: Unclear etiology as pt has fluctuating O2
requirement. Initially concerned for Asthma/COPD exacerbation
and completed 5 day course of Azithromycin. As above, also
considered pulmonary edema, though TTE was normal. Also concern
for related to skin reaction as above vs. IVIG treatment; though
O2 requirement did not increase on IVIG and she continued to
have oxygen requirement after skin improved. Other possibilities
include restrictive defect given body habitus and possible
component of OSA as desats seem to occur more often at night
when pt may be sleeping. Of note, [**Month/Day (2) 1570**]'s from [**2176**] demonstrating
restrictive defect, making body habitus likely contributing. We
were able to wean oxygen off and pt maintained O2 sats in mid-
to high-90s on room air. Pt had normal O2 sats and no complaints
of dyspnea on day of discharge.
.
# Fevers: Pt developed fevers during IVIG treatment. Initial
concern for relation to IVIG. However, pt continued to spike
fevers after completion of course. Also, likely contribution
from inflammatory relation to skin reaction. However, pt had
positive blood culture and urine culture as discussed below. On
discharge, she was hemodynamically stable and remained afebrile
for >72 hours.
.
# MRSA in BCx: Grew MRSA in 1 blood culture in addition to
fevers as above concerning for bacteremia. Serial blood cultures
were drawn, and Vancomycin was started empirically. Once culture
speciated to MRSA, ID was consulted. They recommended continuing
Vancomycin. TTE was negative for vegetations, but suboptimal.
Her central IJ was discontinued and she was switched to
Linezolid. She was to continue Linezolid through [**2178-5-14**] per ID
recs. Surveillance cultures were all pending at time of
discharge. She remained afebrile for >72hrs at time of
discharge.
.
# Klebsiella in urine: Initially thought to be UTI given
positive UA and foul smelling urine per report. Pt was initially
started on Gentamycin. However, given concern for toxicity and
unclear if UTI since now symptoms, discontinued per ID recs
since thought to be colonization. Repeat UCx demonstrated
contamination.
.
# Pain control: Pain secondary to skin reaction. Placed on
Oxycodone 5-10mg prn q4 hrs pain. On discharge, she was given a
limited dose of Oxycodone as her pain had improved.
.
# [**Month/Day/Year **], pseudoseizures: History of non-epileptic [**Month/Day/Year 54422**]
for which she has been seen by neurology. Concern for
psychiatric component as well. She had several witnessed events
which involved clenching bed rails, clicking mouth noises, eyes
rolling back in her head. However, she defeneded her face during
these events, suggestive of pseudoseizure. Electrolytes and
prolactin drawn immediately after the event were significant for
normal electrolytes and elevated prolactin (97). These events
resolved without need for medication. Depakote level was
subtherapeutic. Neurology was consulted, and recommended to
continue same dose of depakote for now as no clear evidence of
[**Month/Day/Year 54422**]. She was scheduled for follow-up with neurology.
.
# Hyponatremia: Na found to be low in setting of fevers,
insensible losses secondary to skin reaction. FeNa <1%, UNa 11.
Pt was treated with IVF's and hyponatremia resolved. She was
encouraged to take good po intake.
.
# Anemia: Normocytic anemia. No s/s bleeding. Thought to be in
part likely hemoconcentrated initially, and in part attributed
to dilution. Iron studies with no clear picture, suggested iron
deficiency anemia, though no symptoms of bleeding. Though
Ferritin was not elevated, still thought in part due to
inflammatory state. B12 and folate normal. Other etiologies
include hemolysis, though Tbili, LDH were normal with elevated
Haptoglobin. Hct remained stable and improved, and was 34.3 at
time of discharge. Possibly related to acute inflammatory state
as above.
.
# Constipation: Treated with senna, colace, lactulose prn. Pt
was haveing BM's at time of discharge.
.
# Abdominal pain: Pt initially presented with abdominal pain.
Unclear picture as pt's exam continued to fluctuate and pt was
diffusely tender to the touch associated with skin reaction. CT
abdomen demonstrated no acute change and no RP bleed. Pt's
abdominal pain resolved. LFT's were trended and were normal
except for mild elevation in AP, which downtrended. No abdominal
pain for several days prior to discharge.
.
INACTIVE ISSUES:
# GERD: Continued on home PPI, Omeprazole 20mg daily.
.
# HTN: Amlodipine initially held given swelling on presentation,
but restarted. BP well-controlled during this admission.
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP:
-PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Name (STitle) **]
-Dermatology
**Blood cultures pending at time of discharge.
3. MEDICAL MANAGEMENT:
-START Linezolid to continue through [**2178-5-4**]
-Medications for skin care
-STOPPED Trazodone as interaction with Linezolid and increased
risk of serotonin syndrome
4. BARRIERS TO RE-HOSPITALIZATION: pt with recurrent
hypersensitivity skin reaction, skin breadown, multiple
allergies, poor nutritional status, mild mental retardation
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE [VENTOLIN HFA] - (Prescribed by Other
Provider) - Dosage uncertain
AMLODIPINE - (Prescribed by Other Provider) - Dosage uncertain
CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
DIVALPROEX - (Prescribed by Other Provider) - 250 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth twice daily.
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - Dosage uncertain
MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day
QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth at bedtime
TRAZODONE - (Prescribed by Other Provider) - 100 mg Tablet - 0.5
(One half) Tablet(s) by mouth at bedtime as needed for
difficulty
sleeping.
.
Medications - OTC
ACETAMINOPHEN - (OTC) - 325 mg Tablet - [**2-1**] Tablet(s) by mouth
every six (6) hours as needed for pain
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 1,000 unit
Capsule - 1 Capsule(s) by mouth daily
SENNA - (OTC) (Not Taking as Prescribed: Not constipated, not
needed.) - 8.6 mg Capsule - 1 Capsule(s) by mouth once a day
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5 mg Inhalation every 6-8 hours as needed
for shortness of breath or wheezing.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
5. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Vaseline Gel Sig: as directed Topical three times a
day: Apply liberally to skin.
Disp:*1 tube* Refills:*2*
13. clobetasol 0.05 % Shampoo Sig: One (1) solution Topical
twice a day: Shampoo with bathing.
Disp:*1 tube* Refills:*2*
14. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for back.
Disp:*1 tube* Refills:*0*
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
Disp:*1 tube* Refills:*2*
17. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
18. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
19. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Disp:*60 Capsule(s)* Refills:*0*
20. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 11 days: Continue these antibiotics through
[**2178-5-14**].
Disp:*22 Tablet(s)* Refills:*0*
21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: [**Month (only) 116**] cause sedation, avoid while
driving or doing heavy activity.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Hypersensitivity skin reaction
2. Hypoxia
3. MRSA in blood culture
4. Anemia
Secondary Diagnoses:
1. Pseudoseizures
2. Depression
3. GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this
hospitalization.
You were admitted to [**Hospital1 **] for
body swelling and shortness of breath. You were treated with
your asthma medications and your symptoms improved. You had
ultrasounds of your legs and a ventilation-perfusion study which
were negative for clots. You had an echocardiogram to look at
your heart, which was normal. You developed a rash and you were
treated with intravenous immunoglobulins. You were found to be
growing an infection in your bloodstream. You were started on
antibiotics for this, and will need to continue these on
discharge.
The following changes were made to your medications:
-START Linezolid 600mg by mouth every 12 hours for 11 more days
(to complete the last dose on [**2178-5-14**])
-START Benadryl 25mg every 6hrs as needed for itching (**this
may cause dizziness, so please avoid if you plan on doing any
heavy activity)
-START Clobetasol shampoo when bathing as needed for itching
**Do not take this for more than 1 week
-START Sarna lotion applied to skin up to twice daily as needed
for itching
-START Miralax 17g by mouth daily for constipation
-START Vaseline and apply liberally to skin to keep moist
-START Oxycodone 5mg by mouth every 6 hours as needed for pain
**This medication can cause sedation, so please do not take it
when you are out of the house or doing heavy activity.
- STOP Trazodone at night as needed for insomnia.
**This medication can interact with the antibiotic you are
taking. Once you have completed the antibiotics, please discuss
with your primary care doctor when it might be safe to start
this.
Please continue the other medications you were on prior to this
admission.
Followup Instructions:
The following appointments have been made for you:
Name: [**Last Name (LF) 5240**],[**First Name3 (LF) 5241**]
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: Friday [**2178-5-8**] 10:20am
Department: NEUROLOGY
When: FRIDAY [**2178-5-8**] at 3:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 857**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital 2652**] Clinic
Date: [**2178-5-28**], 1:30pm
With: Dr. [**Last Name (STitle) **]
Phone: ([**Telephone/Fax (1) 8132**]
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
Completed by:[**2178-5-4**]
|
[
"V44.6",
"486",
"E879.8",
"518.0",
"693.0",
"317",
"401.9",
"569.3",
"786.05",
"278.00",
"741.90",
"311",
"276.1",
"344.1",
"599.0",
"694.8",
"041.12",
"041.3",
"790.7",
"996.62",
"780.39",
"E947.8",
"273.8",
"695.13",
"493.20",
"530.81",
"305.1",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
24050, 24056
|
11696, 11696
|
471, 478
|
24260, 24260
|
4598, 4598
|
26135, 27082
|
3089, 3220
|
21716, 24027
|
24077, 24176
|
20192, 21693
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11713, 13143
|
24372, 26112
|
5486, 11673
|
3235, 4579
|
24197, 24239
|
417, 433
|
13158, 19412
|
506, 2009
|
19429, 20166
|
4614, 5470
|
24275, 24348
|
2031, 2736
|
2752, 3073
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,873
| 135,912
|
5960
|
Discharge summary
|
report
|
Admission Date: [**2105-12-25**] Discharge Date: [**2106-1-29**]
Date of Birth: [**2026-4-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
PICC line placement [**1-14**], removed [**2106-1-29**]
History of Present Illness:
Mr. [**Known lastname 23503**] is a 79 M with a recent diagnosis of acquired
hemophilia who presents with back and left thigh pain. Patient
states that he was in his normal state of health until last
night at approx 11:30 pm when he noted upper back pain, the
character of which he is unable to describe. This pain was not
associated with any extremity weakness, numbess, bowel/bladder
incontinence. The pain has improved since it started last night.
Further, the patient has noticed pain in his left thigh which
started just as bruising but today became painful. Pt notes no
recent trauma or falls. No blood in stool. No Hematochezia. No
abdominal pain. Because of this pain the patient presented to
Heme/[**Hospital **] clinic and immediately was referred to [**Hospital1 18**] ED for
further evaluation with concern for epidural hematoma.
.
In the ED, initial vitals 97.1 76 139/58 16 100%. Exam normal
neurologic exam. MRI with epidural hematoma C6-7 through T1-2
and CT scan with left gluteal hematoma with active
extravasation. Three doses of Factor rVIIa given. Morphine 2mg
IV x one. HCT found to be 24.7, which is down 5 points over two
days. Though difficult to assess baseline. Repeat HCT was 20
prior to transfure. Patient became increasingly tachycardic
during ED course, however maintained a normal robust blood
pressure with systolics in the 130s.
.
In the ICU patient continues to be tachycardic, though blood
pressure stable. States in currently only notes pain in the left
hip which is improved.
Past Medical History:
1. Prostate cancer (dx. 3 years ago, low-volume, low grade
adeno, never treated, follows at [**Hospital1 3278**])
2. BPH
3. HTN
4. Hyperlipidemia
5. Acquired FVIII inhibitor - dx [**12-9**], also found to have
positive lupus anticoagulant
Social History:
Patient lives alone currently. Married; wife was [**Name2 (NI) **] in
[**Name (NI) 651**] living with her mother when pt was admitted
Tobacco: quit in [**2073**]
EtOH: 4 oz scotch most nights
Family History:
No family history of cancer.
Physical Exam:
Admission Exam:
VS: Temp:Afebrile BP:133/60 HR:109 RR: 13 O2sat: 100%
GEN: pleasant, comfortable, NAD, Madarin speaking (translator
used)
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: Large hematoma over the left thigh and gluteus maximus.
Margins marked. Pain with palpation. Warm extremities with
normal DP/PT pulses.
SKIN: Bruising upper/lower extremity.
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.
Discharge Exam:
VS: 97.9 116/89 16 99RA
EXT: 2+DP, PT pulses, bruise on left elbow and wrist, nonpainful
NEURO: AAO x3, CN II-XII intact, 5/5 strength throughout, no
sensory deficits
SKIN: improved bruising on left thigh and buttuck, nonpainful.
Bruises on left wrist and elbow, bilateral lower extremities
continue to retreat slowly. No new bleeding sites. He had an
elevated non-discolored 7 cm nodule over left shin that has been
stable for a week
Pertinent Results:
Admission Labs:
[**2105-12-25**] 01:05PM PT-12.7 PTT-55.2* INR(PT)-1.1
[**2105-12-25**] 01:05PM PLT COUNT-255
[**2105-12-25**] 01:05PM NEUTS-97.2* LYMPHS-1.6* MONOS-1.0* EOS-0.2
BASOS-0.1
[**2105-12-25**] 01:05PM WBC-12.5* RBC-2.51* HGB-8.4* HCT-24.7*
MCV-99* MCH-33.4* MCHC-33.9 RDW-20.8*
[**2105-12-25**] 01:05PM CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.3
[**2105-12-25**] 01:05PM GLUCOSE-208* UREA N-38* SODIUM-132*
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
[**2105-12-25**] 01:17PM LACTATE-3.6*
[**2105-12-25**] 01:17PM COMMENTS-GREEN TOP
[**2105-12-25**] 04:22PM estGFR-Using this
[**2105-12-25**] 04:22PM CREAT-0.8
[**2105-12-25**] 10:46PM HGB-6.7* calcHCT-20
Discharge Labs:
[**2106-1-29**] 05:21AM BLOOD WBC-3.1* RBC-2.91* Hgb-9.9* Hct-27.4*
MCV-94 MCH-34.2* MCHC-36.3* RDW-20.6* Plt Ct-198
[**2106-1-29**] 05:21AM BLOOD Glucose-94 UreaN-17 Creat-0.5 Na-136
K-3.2* Cl-100 HCO3-31 AnGap-8
Factor VIII Levels:
[**2106-1-29**] 05:21AM BLOOD FacVIII-2*
[**2106-1-25**] 05:29AM BLOOD FacVIII-3*
[**2106-1-18**] 05:34AM BLOOD FacVIII-2*
[**2106-1-12**] 06:45AM BLOOD FacVIII-2*
[**2106-1-6**] 10:27AM BLOOD FacVIII-4*
[**2106-1-6**] 09:15AM BLOOD FacVIII-4*
[**2105-12-29**] 04:29PM BLOOD FacVIII-LESS THAN
[**2105-12-28**] 03:55AM BLOOD FacVIII-2*
CT Ab pel [**2105-12-29**]:
IMPRESSION:
1. Stable left gluteal hematoma.
2. Interval development of some edema within the posterolateral
left chest wall without focal fluid, possibly due to chronic
positioning.
3. No abdominal or pelvic fluid or hemorrhage to explain this
patient's continuing transfusion requirement.
4. Some increased stranding and thickening of the subcutaneous
tissues and skin adjacent to this patient's left gluteal
hematoma.
MRI C SPINE [**2105-12-27**]
IMPRESSION: Compared to the study of the previous day, there has
been no significant change in the extent or mass effect of the
posterior spinal epidural hematoma, extending from the C4 to
the T3 level, with no evidence of new hemorrhage. COMMENT: In
the absence of significant change in clinical/neurologic status,
the utility of daily follow-up MR examinations in this setting
is unclear.
MRI C SPINE [**2105-12-26**]
IMPRESSION: Since the previous MRI. The epidural hematoma seen
in the lower cervical upper thoracic region has slightly
extended inferiorly to T2-T3 level with a small inferior extent
now visualized, minimally indenting the thecal sac. Overall, the
mass effect from the hematoma from C6-T2 level, which was
previously noted, has not significantly changed. Previously
noted degenerative changes are again identified.
CT AB PELVIS [**2105-12-25**]
IMPRESSION: Large left buttock hematoma, primarily intramuscular
involving the left gluteus maximus muscle with a focal area of
active extravasation just posterior to the left superior
posterior iliac spine. No evidence of retroperitoneal hematoma.
MRI T & C SPINE [**2105-12-25**]
IMPRESSION:
1. Severe multilevel cervical spine degenerative changes, worst
at C4-C5 with severe canal stenosis, cord compression,
myelomalacia, and bilateral severe neural foraminal narrowing.
2. Epidural hematoma involving C6-7 to T2-T3, as described
above.
Findings were entered in the ED Dashboard at 4:20 PM, after
initial
interpretation pending contrast enhanced studies. Additional
findings upon
availability of contrast enhanced study was entered at 5:27 PM.
CXR [**2106-1-11**]:
The lungs are well expanded and clear without focal
consolidation aside from minimal right basilar linear
atelectasis. There is no pleural effusion or pneumothorax. The
cardiac silhouette and hilar contours are normal. The aorta is
slightly tortuous, unchanged. IMPRESSION: Mild linear
atelectasis at the right base. No evidence of pneumonia.
ELBOW PLAIN FILM, LEFT [**2106-1-11**]:
No previous images. Three views show no evidence of acute bone
or joint space abnormality. There is, however, some elevation of
the anterior fat pad, suggesting some effusion that could
represent blood in the joint space.
Brief Hospital Course:
Mr. [**Known lastname 23503**] is a 79 M with a recent diagnosis of acquired
hemophilia A (factor VIII inhibitor) who presents with back and
left thigh pain who was found to have an epidural hematoma and
left gluteus maximus hematoma with active extravasation. He was
treated with recombinant factor VII infusions and
immunosuppression and was discharged after weaning factor
replacement.
1. C6-7 to T2-3 Epidural Hematoma: He presented with back pain
and was found to have an epidural hematoma related to his
acquired hemophilia. There was no evidence of neurologic
compromise on exam. This was his first significant bleed since
his diagnosis, and he was subsequently started on recombinant
factor VII infusions to prevent cord compression. His hematoma
remained stable on serial MRIs. His neurologic exam was
monitored daily throughout his hospitalization and remained
normal.
2. Left Gluteus Maximus Bleed: His CT scan showed evidence of
extravasation into left gluteus maximus muscle. Though the
patient developed extensive hematoma and edema over LLE, the pt
never developed compartment syndrome, and the hematoma
eventually largely absorbed by the time of discharge.
3. Acquired Hemophilia: He received a diagnosis of acquired
hemophilia A secondary to factor VIII inhibitor in [**Month (only) **] of
[**2105**]. This was his third hospitalization for this problem. [**Name (NI) 15110**]
to the seriousness of his epidural bleed, he was started on
recombinant factor VIIa infusions, initially on a q3hr schedule.
His factor infusions were incrementally spaced apart, however
intermittent findings of peripheral bruising delayed weaning at
several points during his month-long hospitalization. We were
eventually able to discontinue infusions on [**2106-1-27**] without
further bruising, or bleeding, and while maintaining a stable
HCT. With regards to factor suppression, he was continued on
high dose prednisone at 60mg daily, and cytoxan, initially 150mg
daily which was uptitrated to 200mg daily. He also completed 4
cycles of weekly rituximab in house. His inhibitor levels were
originally quite high, at 236.8. By the time of discharge, it
had dropped to 56. It will likely take many months to see a
full effect of immunosuppressive therapy. He was discharged
with close hematology-oncology follow up. The patient was
instructed at length about the concerning signs and symptoms of
bleeds for which he should call the on-call hematology/oncology
fellow.
4. Chronic steriod use: The patient was placed on Bactrim MWF
for PCP [**Name Initial (PRE) **]. Due to the development of leukopenia thought to be
secondary to bactrim, he began atovaquone 1500mg daily for PCP
prophylaxis prior to discharge. He was also started on daily
PPI as well as calcium/vit D supplementation. Due to persistent
hypokalemia requiring daily repletion, he was started on
supplementation on discharge. He was maintained on an insulin
sliding scale during his hospitalization, though this was
discontinued due to adequate control in the 100s.
5. Sinus Tachycardia: Likely related to significant anemia. EKG
with sinus tachycardia. No evidence of ischemia. Tachycardia
improved with hematocrit stability.
6. Leukopenia: He developed leukopenia to 2.5 which was thought
to be secondary to bactrim marrow suppression. He was started
on atovaquone instead for PCP prophylaxis instead, and his WBC
increased to 3.1 at the time of discharge.
7. Anemia: He presented with a HCT of 24 that dropped to 19 soon
after admission. The initial source of bleeding was felt to be
from his left gluteus maximus hematoma. He was transfused as
needed, and HCTs were initially trended TID, and were eventually
spaced out to [**Hospital1 **] then QD by the time of discharge. His HCT
remained stable at discharge.
8. Hypertension: he was started on lisinopril 5mg daily for
hypertension
INACTIVE ISSUES:
9. Prostate Cancer: this was diagnosed 3 years ago and is of
low volume and grade. It has not been treated, he follows at
[**Hospital1 3278**].
PENDING LABS: none
TRANSITIONAL CARE ISSUES
1. Will need close follow up with hematology oncology for
further management of his immunosuppression
2. Will need continued PCP [**Name9 (PRE) **], Ca/VitD supplementation, PPI
while on high-dose steroids.
Medications on Admission:
1. Folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.)
4. Cyclophosphamide 50 mg Tablet Sig: Three (3) Tablet PO for 2
weeks.
5. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet
Discharge Medications:
1. atovaquone 750 mg/5 mL Suspension Sig: 10 mL PO DAILY
(Daily).
Disp:*280 mL* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*5*
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*5*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*5*
9. cyclophosphamide 50 mg Tablet Sig: Four (4) Tablet PO once a
day.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Factor 8 Deficiency
2. Epidural Hematoma
3. Gluteus maximus hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 23503**],
You were admitted to the hospital with easy bruising and back
pain. You were found to have a low level of one of your
clotting factors (factor 8). This means your body was making an
inhibitor that would attack your normal factor 8. This problem
means that you cannot clot like a normal person and have a much
higher risk of bleeding. That is what caused the blood
collection around your spine.
The hematology team helped guide your care. You were treated
with blood transfusions, and were given a different clotting
factor through (factor 7) an IV to help prevent bleeding. We
tried to decrease your inhibitor by using steroids,
cyclophosphamide and rituximab while you were here.
The following changes were made to your medications:
1. continue cyclophosphamide 200mg daily
2. continue prednisone 60mg daily
3. START atovaquone 1500mg daily to prevent infections while on
prednisone
3. START POTASSIUM CHLORIDE 20mEq daily because your steroids
are likely causing low potassium
4. START VITAMIN D 1000units daily to protect your bones while
on prednisone
5. START CALCIUM CARBONATE 500mg three times daily to help
protect your bones while on prednisone
It was a pleasure taking care of you, Mr. [**Known lastname 23503**]
Followup Instructions:
You have the following appointments available with your PCP, [**Name10 (NameIs) **]
with a hematology expert.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital3 8233**]
Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 8236**]
When: [**Last Name (LF) 2974**], [**2-5**], 9:45AM
Name: [**Last Name (LF) 2805**], [**Name8 (MD) **] MD
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3062**]
*[**Doctor Last Name **] from Dr. [**Last Name (STitle) 23504**] office will call you to schedule an
appointment. If you dont hear from her by Monday, please call
the number above.
|
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icd9pcs
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315, 373
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1939, 2180
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2196, 2390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,809
| 137,594
|
18355
|
Discharge summary
|
report
|
Admission Date: [**2173-10-6**] Discharge Date: [**2173-10-11**]
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: Patient is an 87-year-old male
with history of peripheral vascular disease and coronary
artery disease, who presented to the Emergency Department
with the history of diarrhea for the past 1.5 weeks. The
patient had a stool test that was positive for Clostridium
difficile, and was started on metronidazole as an outpatient.
He continued to have diarrhea with bloody stools beginning
one day prior to admission. In addition, he had increased
weakness and decreased oral intake.
In the Emergency Department, he was found to be hypotensive
with a hematocrit of 18.2, INR of 6.7, and white blood cell
count of 31,800. The patient was given intravenous fluids,
levofloxacin, and Flagyl, as well as oral Vancomycin. He was
admitted to the CCU with the request of his outpatient
cardiologist, and due to his hemodynamic instability and
decreased hematocrit.
Of note, the patient had a recent SFA stent placed two weeks
prior to admission, and had been on intermittent antibiotics.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease with stent of the left SFA and
lower extremity ulcers bilaterally.
2. Coronary artery disease: Stress test from [**2173-9-22**]
showed a moderate inferior wall defect, which was partially
reversible.
3. CHF with ejection fraction of 33%.
4. Hypertension.
5. Hypercholesterolemia.
6. Chronic atrial fibrillation.
7. Chronic renal failure.
8. Cataract surgery.
9. Diabetes.
ALLERGIES:
1. Percocet.
2. Darvocet.
MEDICATIONS:
1. Lipitor 10 mg p.o. q.d.
2. Digoxin 0.125 mg 3x a week.
3. Niferex one q.d.
4. Nephrocaps one q.d.
5. Flomax 0.4 q.d.
6. Aspirin 325 q.d.
7. Plavix 75 mg q.d.
8. Lasix 40 mg 3x a week.
9. Coumadin.
10. Epogen 40,000 units q week.
11. Allopurinol 100 q.d.
12. Rocaltrol 0.25 q.d.
13. Diltiazem 120 mg q.d.
SOCIAL HISTORY: Patient lives with his daughter and is a
retired dentist.
PHYSICAL EXAMINATION: Was notable for vital signs as
follows: Afebrile, heart rate 22, blood pressure 81/36,
respiratory rate 16, oxygen saturation of 95% on room air.
Otherwise, examination was notable only for jugular venous
pulsation elevated at 10 cm and bilateral pitting edema in
the lower extremities to mid calves.
LABORATORIES: White blood cell count of 31,800 with 89
polymorphonuclear lymphocytes and 5 bands. Hematocrit of
18.2 down from 32.2, INR of 6.7, PTT of 51.7, and creatinine
of 2.1 up from 1.4, BUN of 73, up from 32. CK was 110, MB 7,
and troponin T was 0.17.
Chest x-ray showed cardiomegaly with prominent pulmonary
vasculature and upper zone redistribution.
EKG showed atrial fibrillation at a rate of 90 with right
bundle branch block.
HOSPITAL COURSE:
1. GI bleed: In the CCU, the patient was found to have
guaiac positive stools and an INR of 6.7 with persistent
melena. In light of these findings, the patient was
transfused to a goal hematocrit of 30 and anticoagulation was
held. Blood pressure responded to fluid replacement. The
patient received 5 units of packed red blood cells, 4 units
of FFP, and vitamin K.
An EGD was performed on [**10-7**], which showed ulcers in
the lower third of the esophagus just above the GE junction
and duodenitis. The patient was placed on IV Protonix. The
INR improved to 1.5. The patient's hematocrit remained
stable, though his stools remained guaiac positive. The
melena did resolve.
The patient was transferred to the Cardiology Service on
[**10-9**]. The patient will need colonoscopy as an
outpatient to further evaluate the cause of his bleed.
2. Peripheral vascular disease: Patient was thought not to
be a good candidate for revascularization surgery due to his
comorbidities. He received wound care with wet-to-dry
dressings b.i.d. Nutrition consult was obtained to recommend
supplements for wound healing. Per Dr. [**Last Name (STitle) **], debridement will
be addressed as needed on an outpatient basis.
3. Cardiovascular: Once the patient's hematocrit was stable,
his Plavix and aspirin were restarted. Patient was continued
on captopril and metoprolol. He was continued on digoxin for
rate control. Captopril should be switched to Zestril as an
outpatient for more convenient dosing.
4. Infectious disease: The patient's white blood cell count
decreased and he remained afebrile. His diarrhea decreased
on antibiotic treatment.
5. Renal: Creatinine was mildly increased during his
hospitalization, but was trending down at the time of this
dictation.
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg q.d.
2. Digoxin 125 mcg 3x a week.
3. Iron complex 150 mg q.d.
4. Folic acid/vitamin B 1 mg q.d.
5. Tamsulosin 0.4 mg q.h.s.
6. Epoetin 40,000 units injection once a week.
7. Captopril 12.5 mg half a tablet t.i.d.
8. Metoprolol 12.5 mg b.i.d.
9. Aspirin 81 mg q.d.
10. Clopidogrel 75 mg q.d.
11. Zinc sulfate 220 mg q.d.
12. Vitamin C 500 mg b.i.d.
13. Trazodone 25 mg q.h.s. for insomnia.
14. Protonix 40 mg b.i.d.
15. Miconazole nitrate 2% powder one application to sacrum
b.i.d.
16. Vancomycin 250 mg p.o. q.6h. for nine days.
17. Lasix 40 mg p.o. 3x a week.
18. Calcitriol 0.25 mcg p.o. q.d.
19. Allopurinol 100 mg p.o. q.d.
20. Coumadin 2.5 mg q.d. starting on [**2173-10-13**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: [**Hospital6 310**].
DISCHARGE DIAGNOSES:
1. Blood loss anemia.
2. Upper gastrointestinal bleed.
3. Peripheral vascular disease.
4. Hypotension.
5. Duodenitis.
6. Congestive heart failure.
7. Clostridium difficile colitis.
8. Diarrhea.
FOLLOWUP: The patient should follow up with podiatrist in
two weeks. He should follow up with Dr. [**Last Name (STitle) **] in one week. If
a repeat EGD or colonoscopy is desired, he should follow up
with Dr. [**First Name4 (NamePattern1) 12589**] [**Last Name (NamePattern1) 12590**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2173-10-12**] 17:20
T: [**2173-10-14**] 13:06
JOB#: [**Job Number 50558**]
|
[
"E935.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5304, 5354
|
5375, 6102
|
4575, 5282
|
2772, 4552
|
2008, 2755
|
142, 1123
|
1145, 1909
|
1926, 1985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,947
| 133,810
|
6473
|
Discharge summary
|
report
|
Admission Date: [**2105-9-2**] Discharge Date: [**2105-9-11**]
Date of Birth: [**2058-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Celexa / Effexor / Naprosyn / Desyrel
Attending:[**Known firstname 922**]
Chief Complaint:
NSTEMI and angina
Major Surgical or Invasive Procedure:
[**2105-9-4**] CABG X 4 (LIMA to LAD, SVG to DIAG, SVG to OM1, SVG to
PDA)
History of Present Illness:
46 yo male presented to [**Hospital3 **] ED with intermittent chest pain
for 3 days. NSTEMI with ongoing active sternal [**9-19**] CP & diaph.
EKG w/T wave changes in lateral leads; mild inferior ST
depressions. First Trop was 10.10 @ 1250 and CKMB of 229. He was
loaded with 325mg ASA, 600mg Plavix, started on intergrillin,
heparin, and nitro gtts and transfered to [**Hospital1 18**]. At [**Hospital1 18**], pt
taken to cath lab where 3VD was found. No intervention performed
and Dr. [**Last Name (STitle) 914**] in CT [**Doctor First Name **] preferring to wait until Tues for
proceedure to allow plavix washout. In holding area after cath
pt started having CP again and nitro was restarted and patient
was sent to the CCU for monitoring w/concern that he might need
a balloon pump.
.
Pt reports that his chest pain started on Monday. It was a
squeezing sensation that was mostly consitent with brief spells
of 3-5min where it would remit. There were no particular
aggrevating or alleviating factors. He reports radiation to his
R jaw and diaphoresis on an off during the pain. He denies
radiation to the arms or back, lightheadedness/dizziness,
nausea, vomiting, or SOB/DOE/Orthopnea since his pain started.
Before Monday, he had never had pain like this. 3-4 months agao
he does report episodes of "palpitations" where he felt as if
his heart was beating very fast without chest pain or SOB. He
saw his PCP about this and was given a heart monitor but the
monitor never picked up any abnormal rhythms and the sensation
of palpitations went away and has not returned. There were no
issues with SOB/DOE leading up to his current presentation
although he thinks he has decreased exercise capacity due to
being "fat and out of shape". He denies abdominal pain,
constipation, diarrhea, leg pain/weakness, headache, ear pain,
nasal discharge, cough, wheezing.
Past Medical History:
PAST MEDICAL HISTORY:
- Hypertension
- Dyslipidemia
- Diabetes
- GERD with breakthrough pain when not on prilosec.
- Testicular CA s/p chemo at age 24 ([**2083**]-[**2084**])
- Multiple abdominal surgeries in [**2083**]-[**2084**]
- Left finger fx
- Pain medication addition (Percocet) pt admits to in the past
during surgeries
Social History:
Lives Alone. Occupation: Mattress Salesman
Cigarettes: Smokes 1 pack every 3 days for last 4-5 years
ETOH: None currently. Drank heavily until 1-2 years ago when he
cut back. Cannot remember his last drink.
Illicit drug use - none currently. past marijuana. denies IVDU.
Contact: Mother [**Name (NI) **] Phone #[**Telephone/Fax (1) 24860**]
Family History:
Premature coronary artery disease - Brother's deceased in
40-50's from heart disease
Physical Exam:
Admission physical exam:
5'6" 220#
VS: T=98.5 BP=126/82 HR=82 RR=18 O2 sat= 98% on 2L NC
GENERAL: Obese male in NAD, Oriented x3, slightly anxious
HEENT: Sclera anicteric. PERRL, EOMI. NO cyanosis of lips
NECK: Supple with JVP difficult to assess due to neck thickness
but likely below clavicle
CARDIAC: soft S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: trace exp wheezing, bowel sounds heard near lung bases
ABDOMEN: Soft, distended [**2-11**] to habitus, bowel sounds
normoactive. No HSM or tenderness
EXTREMITIES: Warm, intact sensation, No c/c/e. No femoral
bruits, R wrist TR band with no swelling, erythema, or
induration
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+ Radial 2+
Left: DP 2+ PT 2+ Radial 2+
Pertinent Results:
Admission labs:
WBC 8.9 Hgb 13.2 Hct 37.6 Plts 300
PT 12.8 INR 1.1
Na136 K 3.5 Cl 104 CO2 22 BUN 21 Cr 1.1 Gluc 137
ALT 59 AST 200 CK 1405 Alk phos 67 Amylase 84
Trop-T 1.42
HgbA1c 6.3
EKG: NSR, normal axis, normal intervals, some inf/lat ST
depressions and T wave inversions, question of R bundeloid
pattern
.
CARDIAC CATH ([**2105-9-2**]):
Briefly: LMCA- normal, LAD 50% prox, 80-90% mid, 90% diagonal,
Left cx
60-70% ostial, 60% mid, RCA 60% prox, 60% mid, 60% distal
Echocardiogram-Conclusions:
PRE-BYPASS: The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is mild
regional left ventricular systolic dysfunction with severe
lateral, anterolateral, and inferolateral hypokinesis. Overall
left ventricular systolic function is mildly depressed (LVEF=
45%). 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. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results in the operating
room at the time of the study.
POST-BYPASS: Initially after separation from bypass, there was
normal right ventricular systolic function. The left ventricle
displayed the same focal and overall function noted in the
pre-bypass study. About 30 minutes after separation, both
ventricles developed moderate to severe global hypokinesis with
a left ventricular ejection fraction of 25%. Epinephrine and
milrinone infusions were started and function returned to
baseline. The mitral regurgitation was somewhat improved - now
mild to moderate. The tricuspid regurgitation was initially
worsened - up to moderate - but improved to mild after
ionotropes were started. The thoracic aorta was intact after
decannulation.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2105-9-4**] 15:11
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2105-9-9**] 6:02 PM
Wet Read: SJBj WED [**2105-9-9**] 7:06 PM
R PICC tip in R IJ. Tip extends cranially beyond field of view.
Stable left base opacification.
Final Report CHEST RADIOGRAPH
FINDINGS: As compared to the previous radiograph, the patient
has received a new right-sided PICC line. The line is
malpositioned in the right internal jugular vein, the tip is not
visualized on the image. Re-positioning of the line is required.
A wet read was delivered at the time of image acquisition.
No evidence of complications, notably no pneumothorax. Otherwise
unchanged
appearance of the lungs and the cardiac silhouette.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Mr. [**Known lastname 24861**] is a 46 year old man who presented with chest pain
and an NSTEMI from an outside hospital with three vessel disease
on cardiac catheterization but still was having intermittent
chest pain despite significant medical management. He was
referred for coronary artery bypass grafting and his
pre-operative work-up was completed. He underwent surgery with
Dr. [**Last Name (STitle) 914**] on [**9-4**]. He was transferred to the CVICU in stable
condition on milrinone, epinephrine, amiodarone and propofol
drips. His drips were weaned on POD #1 and he was extubated on
POD #2. He transferred to the floor on POD #4 to begin
increasing his activity level. The chronic pain service was
consulted to help manage his narcotic needs.
Once on the floor his hospital course was largely uneventful.
He was gently diuresed toward his preop weight, Beta blockade
was begun and titrated up as tolerated hemodynamically. A PICC
was placed the in midline position for access. Chest tubes and
pacing wires removed per cardiac surgery protocol. Oral
amiodarone was initiated and is continuing due to intraoperative
ventricular irritability.
He worked with physical therapy to increase his activity level
and endurance. His creatinine was elevated postoperatively but
remained stable at 1.8. His Potassium, BUN, and creatinine
should continue to be followed in rehab. His vein harvest site
was erythematous, which improved but did not resolve with
antibiotics. Although he was chronic systolic heart failure,
due to his creatinine elevation he was not placed on an ACE-I.
As his creatinine improves, an ACE-I should be considered. On
post-operative day seven he was transferred to [**Last Name (un) **] Nursing
and Rehab in [**Location (un) 701**] for continuing post-op recovery. All
follow-up appointments were advised.
Medications on Admission:
Prilosec 40 mg daily
Atenolol 50 daily
unknown purple anti-hypertension med
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
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. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 days: 200 mg [**Hospital1 **] through
[**9-11**]; then 200 mg daily ongoing.
8. hydromorphone 2 mg Tablet Sig: 1-4 Tablets PO Q4H (every 4
hours) as needed for pain: 2-8 mg prn q4h.
9. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*2*
11. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Outpatient Lab Work
Potassium/BUN/Cre [**9-12**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
coronary artery disease s/p cabg x4(LIMA-> LAD, SVG-> PDA, Diag,
OM)
PMH:
GERD
Left finger fx
Testicular CA s/p chemo at age 24
HTN
? pain med addiction
obesity
Past Surgical History:
Ex. lap for "retroperitoneal tumor" x 6
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Oxycodone and Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg - Left - healing well, no erythema or drainage.
Edema: 1+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] Phone:[**Telephone/Fax (1) 170**] Date/Time:
Tuesday [**2105-10-13**] 1:45 [**Hospital Ward Name **] 2A
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2105-9-17**] 10:15
[**Hospital Ward Name **] 2A
Cardiologist:Dr. [**Last Name (STitle) **] [**10-16**] @ 10:40 AM [**Hospital Ward Name 23**] 7
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 24862**] in [**4-14**] 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:[**2105-9-11**]
|
[
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"E947.8",
"305.53",
"272.4",
"414.01",
"V10.47",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"88.56",
"36.15",
"36.13",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10325, 10427
|
7206, 9047
|
334, 412
|
10695, 10940
|
3923, 3923
|
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|
3038, 3124
|
9173, 10302
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9073, 9150
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10632, 10674
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3164, 3904
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277, 296
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440, 2302
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3939, 7183
|
2346, 2654
|
2670, 3022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,911
| 115,440
|
21829
|
Discharge summary
|
report
|
Admission Date: [**2153-12-24**] Discharge Date: [**2154-1-1**]
Date of Birth: [**2093-7-11**] Sex: M
Service: NEUROLOGY
Allergies:
Glucocorticoids
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
Witnessed Seizure.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
60 yo man w/ hx of ESRD on HD, HTN, cocaine abuse p/w
seizure five hours ago. Pt reports that he had hemodialysis as
usual 2 days ago and stopped his anti-hypertensive meds 2 days
PTA. He felt fine until today when he stood up from a sitting
position to open the window, and as he was opening the window,
he
blacked out, but on his way down he thinks the clock said
4:37pm.
His last cocaine use was 5 days PTA. No other illicits.
In ED, was encephalopathic/aggitated, got lots of 8mg ativan,
sent to ICU for concern for airway protection. Noted to have
bites on his tongue, quite swollen, suscipicious for seizure.
Last seizure [**10-13**] resulting in a fall, he was found to have a
left parafalcine and tentorial subdural hematoma which was not
thought to require evacuation by neurosurgery. Due to agitation,
he received 5 mg Haldol and 4 mg ativan, after which he became
unresponsive and required an emergent tracheostomy after failed
intubation attempts (during last admission in [**10-13**]).
Past Medical History:
1. hepatitis C, last viral load [**10-13**] 1,120,000 but LFTs normal
2. subdural hematoma (small left parafalcine and tentorial)
3. ESRD on HD 3 days/wk from uncontrolled HTN (MWF)
4. substance abuse (cocaine, oxycontin)
5. prostate cancer unknown treatment, no PCP followup, PSA 7
[**10-13**]
6. diabetes
7. goiter
8. seizure two months ago
Social History:
Lives at home, non compliant with meds. Heavy cocaine and
oxycontin user per family history. They feel concerned that he
cannot take care of himself.
Contact[**Name (NI) **] Dr. [**Last Name (STitle) 31394**] (oncologist at [**Hospital3 328**]); his NP
states that the patient's prescription for Oxycontin 160mg po
bid was discontinued in [**2153-11-9**] owing to concerns of opiate
abuse on the patient's part. The patient was put on a taper, but
stopped coming for his weekly prescriptions once this became
conditional on urine sample testing.
Family History:
Non-contributory
Physical Exam:
GEN: Obese man appearing his stated age, sleeping, but
arousable,
lying in bed wearing hospital gowns breathing comfortably on
oxygen via NC, in NAD
SKIN: no rash
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm without murmurs
ABD: Normal bowel sounds in all 4 quadrants, obese, soft,
nontender, softly distended, no rebound or guarding, liver edge
3
cm below costal margin
EXT: Right wrist/hand in a brace, IV in right antecubital fossa
in place, no clubbing, cyanosis or edema, AV fistula in left
arm.
NEURO: Mental status: Patient is sleepy but awakens to voice and
can engage in conversation for several minutes before returning
to sleep. Oriented to person, place, time and president.
Language
is fluent with good comprehension, repitition, able to read, no
dysarthria. Unable write secondary to inattentiveness. Unable to
name MOYB. No apraxia, agnosias, no neglect. No left/right
mismatch.
Cranial Nerves: I: deferred II: Visual acuity: deferred
secondary
to patient unable to read card without his glasses. Visual
fields: full to left/right/upper/lower fields Pupils: 1mm,
consenual constriction to light. (pin point) III, IV, VI: EOMS
full, gaze conjugate. No nystagmus or ptosis. V: facial
sensation
intact over V1/2/3 to light touch and pin prick. VII: smile
slightly asymmetric secondary to swelling of tongue, brusises on
face, etc. VIII; hearing intact to finger rubs IX, X:
voice/swallowing normal. Symmetric elevation of palate. [**Doctor First Name 81**]: SCM
and trapezius [**6-13**] bilaterally XII: tongue midline without
fasciulations, but enlarged.
Sensory: Normal touch, proprioception, pinprick, sensation.
Motor: Normal bulk, tone. No fasciculations. Unable to assess
drift. No adventitious movements. There is mild asterixis of
the
left hand.
Strength: Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF
Toe
LEFT: limited by pain 5 5 5 5 4*
5 5
RIGHT: limited by pain 5 5 5 (unable to assess)5 4*
5 5
*holds legs up for 5 seconds, difficult to assess formal
strength. Proximal arm strength difficult to assess secondary
to
pain, could also have weakness
Reflexes: 2+ throughout. Toes downgoing bilaterally.
Coordination: mild dysmetria on finger-to-nose difficult to
asses
secondary to shoulder pain. Normal [**Doctor First Name **] bilaterally.
Gait: Not assessed.
Pertinent Results:
Cultures:
[**12-26**]: blood, urine, sputum pending
[**12-25**]: sputum oral flora
[**12-25**]: blood pending, urine negative
[**12-24**]: blood--coag negative staph in 1 bottle (likely
contaminant)
[**12-24**]: urine negative
[**12-27**] labs (on transfer to floor)
cbc: 14.7>30<253
lytes: Na 138, K 4.2, Cl 99, CO2 28, BUN 25, Cr 6.1, gluc 107,
Ca 8.7, Mg 1.8, Phos 5.2
[**2154-1-1**] 08:06AM 8.0 3.59* 10.8* 30.3* 84 30.0 35.6* 16.5*
380
call critical results to [**3-/8916**]
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2153-12-30**] 05:44AM 59.7 27.6 9.9 2.6 0.3
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2153-12-30**] 05:44AM 1+
BASIC COAGULATION PT PTT Plt Smr Plt Ct INR(PT)
[**2154-1-1**] 08:06AM 380
call critical results to [**3-/8916**]
HEMOLYTIC WORKUP Ret Aut
[**2153-12-27**] 10:03AM 2.8
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-1-1**] 08:06AM 128* 63* 7.8*# 131* 3.7 92* 21* 22*
call critical results to [**3-/8916**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2153-12-29**] 03:05AM 17 27 154 234*1 198* 0.4
ADD ON
1 NOTE UPDATED REFERENCE RANGES AS OF [**2152-8-8**]
OTHER ENZYMES & BILIRUBINS Lipase
[**2153-12-29**] 03:05AM 62*
ADD ON
CPK ISOENZYMES CK-MB cTropnT
[**2153-12-24**] 12:00PM 4 0.08*1
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2154-1-1**] 08:06AM 3.1* 9.1 3.4 2.1
call critical results to [**3-/8916**]
HEMATOLOGIC calTIBC Ferritn TRF
[**2153-12-27**] 10:03AM 178* 702* 137*
VANCO: @RANDOM
PITUITARY TSH
[**2153-12-23**] 09:11PM 0.951
1 NEW METHOD AS OF [**2152-5-1**]
HEPATITIS HBsAg HBsAb
[**2153-12-28**] 04:15PM NEGATIVE POSITIVE
ANTIBIOTICS Vanco
[**2153-12-27**] 10:03AM 9.3*
VANCO: @RANDOM
NEUROPSYCHIATRIC Phenyto Phenyfr %Phenyf
[**2153-12-29**] 03:05AM 11.0
ADD ON
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2153-12-23**] 05:45PM NEG1 NEG2 NEG NEG NEG NEG
ADDED SPECIMENS:STOX.
1 NEG
NEW UNITS IN USE AS OF [**2146-3-14**]
2 NEG
NEW UNITS IN USE AS OF [**2146-3-14**]: 80 (THESE UNITS) = 0.08 (% BY
WEIGHT)
LAB USE ONLY RedHold
[**2153-12-23**] 05:45PM HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP O2 O2 Flow pO2 pCO2
pH calHCO3 Base XS
[**2153-12-28**] 04:55AM ART 100 56* 7.30* 29 0
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate
[**2153-12-24**] 11:29AM 1.7
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat
[**2153-12-27**] 04:09AM 98
CALCIUM freeCa
[**2153-12-26**] 04:01AM 1.13
Brief Hospital Course:
ICU COURSE:
Neuro: Pt was loaded with dilantin, levels were followed and
were theraputic. An EEG was performed on [**12-25**] that showed
slowing c/w encephalopathy, but no seizure activity. Because of
hepatotoxicity in teh setting of hepatitis, on [**12-27**] a plan was
made to wean dilantin and start keppra. It is stil unclear why
he seized or had change in mental status, likely either HTN
encephalopathy, RPLE, or withdrawl. An MRI was scheduled but
pt's agitation made the study impossible to obtain.
Psych: Pt showing signs of withdrawal (from cocaine,
oxycontin?), namely HTN, tachycardia, hyperthermia, and extreme
agitation. He was initially treated with percedex (an alpha 2
agonist), and prior to transfer to the floor was switched to a
fentanyl patch, zyprexa, haldol prn, ativan prn (none), morphine
prn (none), oxycontin q12.
ID: He was intermittently febrile , tmax 102.4 ([**6-26**]), during
his hospital course. In the ER he refused an LP, and it was
deferred in teh ICU b/c he was clinically improving. Cultures
were no growth to date as of [**12-27**]. It was thought that, given
his clinical history and a concerning chest xray, that likely
that he had an aspiration pneumonia, and he was started on
levofloxacin on [**12-25**]. He also received one dose of ceftriaxone
and one dose of vancomycin empirically for fever in the ICU.
Resp: Pt was initially on bipap, primarily because of his
extremely swollen tongue. As the swelling improved and his
sedation improved, he was weaned to NC.
GI: He was NPO in the ICU, and on [**12-27**] with the improvement in
his tongue swelling he began to PO. He was started on
Multivitamin, B12, folate, thiamine.
Renal: Pt gets hemodialysis three times a week and was followed
by renal in the ICU. Prior ot transfer he was started on phoslo.
Heme: Pt was consistently anemic, likely due to renal disease,
but iron studies and retic count were sent on [**12-27**], will ask
renal about starting epo.
CV: Pt's blood pressure 200'/100's upon admission. He initially
was on nipride and nicardipine drip, then these were able to be
weaned and on transfer he was stable on clonidine patch,
hydralazine prn, and lopressor.
Ppx: SC heparin and proton pump inhibitor
General Neurology [**Hospital1 **] (Transferred on [**12-29**]):
While on the [**Hospital Ward Name 121**] 5 General Neurology Service, the patient's
mental status and strength gradually improved. He had no
seizures or new neurologal changes while on the unit. He was
alert and oriented x 3, with fluent speech and good
comprehension for the duration of his course on the neurology
unit. He was irritable at times, but had no episodes of
agitation and no hallucinations. The patient expressed his wish
to stop using cocaine and to seek psychiatric help for dealing
with depression about the loss of his wife 15 years ago. A
discussion was had with the patient in which the risks of
continuing to use cocaine were explained to him. An appointment
was made for the patient to follow up with an addiction recovery
doctor at the [**Location (un) 538**] [**Hospital **] Hospital.
Further, with the patient's permission, his oncologist (Dr.
[**Last Name (STitle) 31394**] at [**Hospital3 328**] was contact[**Name (NI) **]. Dr.[**Name8 (MD) 57285**] NP
explained that the patient does not have any history of bone
mets from his prostate cancer. He had been receiving Oxycontin
160mg po bid until [**Month (only) 359**]. At that time, Dr. [**Last Name (STitle) 31394**] became
suspicious that the patient was dealing his prescription. He
therefore made further prescriptions of Oxycontin contingent
upon urine screening and would only offer prescriptions for 1
weeks worth of Oxycontin. At that point, the patient stopped
coming to see Dr. [**Last Name (STitle) 31394**].
The patient's Hemodialysis team at the [**Location (un) 538**] VA was also
contact[**Name (NI) **]. [**Name2 (NI) 6**] appointment was made for the patient to follow up
there. See the follow up appointment list for details.
Lastly, the patient was given an appointment to see a PCP at the
[**Location (un) 538**] VA, with the plan to obtain a referral for a
psychiatric appointment.
The remainder of the [**Hospital 228**] hospital course was
uncomplicated. He was seen by physical therapy, who had him walk
with a cane (his baseline), and observed him walking stairs. The
physical therapy service recommended home physical therapy for a
home safety evaluation.
Lastly, prior to D/C, the patient received a final treatment of
hemodialysis.
Medications on Admission:
- nifedipine 30 qd
- ambien prn
- percocet prn
- thiamine
- flomax 0.4 qd
- calcitriol 0.25 qd
- oxycontin 160 [**Hospital1 **]
- metoprolol 50 [**Hospital1 **]
- ASA 81 qd
- Nephrocaps
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
4. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
Disp:*3 Patch Weekly(s)* Refills:*0*
5. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day:
Lorazepam 0.5mg po: dispense 45 tablets total. Patient should
take as follows: take 2 0.5mg tablets twice a day x 3 days, then
take 1 0.5mg tablets twice a day for 3 days, then 1 0.5 mg
tablet once a day for 3 days.
Disp:*21 Tablet(s)* Refills:*0*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Home physical therapy
Patient is to have home physical therapy for home safey
evaluation.
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-9**] Inhalation Q6
hours/prn.
Disp:*1 90mcg* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary Diagnosis: Generalized tonic-clonic seizure
Secondary Diagnoses: End Stage Renal Disease (on hemodialysis),
Type 2 diabetes, chronic back pain, prostate cancer,
hypertension, cocaine abuse, opiate dependence
Discharge Condition:
Stable, back to baseline.
Discharge Instructions:
Call your primary care doctor or go to the nearest emergency
department if you have any sudden onset of numbness/tingling,
weakness, change in speech, change in vision, or new seizures.
Followup Instructions:
1. Follow up at Dr.[**Name (NI) 11858**] [**Name (STitle) **] [**Hospital 878**] Clinic with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] in 2 months: call [**Telephone/Fax (1) 541**] to register for the
appointment
2. Follow up at the [**Location (un) 538**] VA for hemodialysis this
Friday [**2154-1-4**] at 11-11:30AM with Dr. [**Last Name (STitle) 4660**]/Dr.
[**Last Name (STitle) 19334**]
3. Follow up with your Primary Care intake apppointment to see
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Location (un) 538**] VA on [**1-15**]
at 3:30PM. You may call to confirm the appointment at
[**Telephone/Fax (1) 57286**]
4. You have an appointment for addiction recovery with Dr.
[**First Name4 (NamePattern1) 19948**] [**Last Name (NamePattern1) 57287**] at the [**Location (un) 538**] VA for Novemner 30th at
12pm. It's in [**Apartment Address(1) 57288**], [**Location (un) **], 4B.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
|
[
"185",
"780.39",
"403.91",
"304.01",
"507.0",
"285.21",
"250.00",
"305.60",
"070.70",
"292.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13971, 13990
|
7482, 12024
|
296, 304
|
14250, 14277
|
4771, 7459
|
14511, 15600
|
2283, 2301
|
12261, 13948
|
14011, 14011
|
12050, 12238
|
14301, 14488
|
2316, 2901
|
14084, 14229
|
238, 258
|
332, 1335
|
3305, 4752
|
14030, 14063
|
2916, 3289
|
1357, 1703
|
1719, 2267
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,721
| 141,387
|
48485
|
Discharge summary
|
report
|
Admission Date: [**2164-2-11**] Discharge Date: [**2164-3-6**]
Date of Birth: [**2096-6-9**] Sex: F
Service: MEDICINE
Allergies:
Latex / Oxaliplatin / Iodine; Iodine Containing / Fluconazole /
Ace Inhibitors
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
PICC placement
colonscopy
History of Present Illness:
Ms. [**Known lastname 69629**] is a 67 year old female with metastatic colon cancer
C32D12 5FU/Leucovocin (treatment days 1 and 8, 21 day cycle)
presenting to the ED with nausea, vomiting and decreased ostomy
output for 1 day. She was recently hospitalized from
[**Date range (1) 102072**] for tachycardia, abdominal pain and a report of
constant leakage from the ostomy site. She was manually
disimpacted in the ED by the surgery team, which improved her
ostomy output. She was hydrated and improved. She continued to
have exertional tachycardia. She received her C32D8
5-FU/Leucovorin and the RN notes indicate persistent leak from
the ostomy.
She presented to the ED today with a complaint of nausea,
bilious vomiting and decreased ostomy output. Admission ED
vitals were: 98.1 108 101/72 16 100% RA. KUB did not have an
obstruction. She was given ~3 liters of IVF and IV Zofran. She
remained mildly tachycardic with HR of 105 at transfer. Her labs
demonstrated an acute renal failure, hyponatremia and anion gap
metabolic acidosis. She was able to take po in the ED.
Upon arrival to floor, history was obtained with the help of the
Spanish Interpreter. Over the last day, the patient has felt
unwell. She has been dizzy and nauseated, she vomited twice. Her
ostomy output dramatically declined from the normal copious
output. She felt thirsty, but did not drink due to the nausea.
Since being hydrated in the ED, the dizziness is improved. She
is slightly nauseated, but better than arrival. She denies
headache, blurred vision, mouth sores, chest pain, shortness of
breath, constipation, abdominal pain, joint pains or rash. She
lives alone and has no sick contacts.
Past Medical History:
PAST MEDICAL HISTORY:
Pulmonary Embolism
Recurrent SBO
SVC syndrome
DM
PAST SURGICAL HISTORY:
s/p Small bowel resection, resection of mass, lysis of
adhesions [**5-20**]
s/p right cataract [**1-21**]
s/p port [**7-16**]
s/p repair of incarcerated incisional hernia w/mesh [**5-16**]
s/p ORIF right ankle distal fibular fracture with plate and
screws [**3-15**]
s/p right colectomy [**3-13**]
ONCOLOGIC HISTORY:
Prior chemotherapy and history:
[**2158-2-12**] Oxaliplatin/xeloda- discontinued after 1 dose because
of allergic reaction to oxaliplatin
[**2158-3-18**] Ankle fracture (admitted to hospital)
[**2158-3-15**]- [**2158-11-22**] Irinotecan/Xeloda for 9 cycles.
discontinued because of rising CEA
[**2158-12-27**] Erbitux/Irinotecan weekly started, baseline CEA 45
She received a total of 7 combined Erbitux/irinotecan
treatments. CEA fell to 7 ([**2159-3-14**])
[**2159-4-11**] Begin single [**Doctor Last Name 360**] Erbitux, baseline CEA [**2159-5-4**] Repair of surgical hernia
[**2159-6-6**]- [**2159-10-3**] Erbitux/irinotecan, discontinued
because of allergic reaction to Erbitux (see below)
[**2159-10-24**] Begin [**Month/Day/Year 49565**]/irinotecan, CEA rose to 43
[**2159-12-25**] Begin 5-FU/LCV/[**First Name9 (NamePattern2) 49565**]
[**2160-1-13**] Cyberknife treatment (radiation therapy)
[**2160-12-12**] Begin [**Year (4 digits) 102068**]
[**Date range (3) 102071**] Hospitalization for pneumococcal mastoiditis
and meningitis
[**2161-3-12**]- [**2161-5-12**] Begin 5-FU/Leucovorin/[**First Name9 (NamePattern2) 49565**]
[**2161-6-12**] Cyberknife (radiation treatment)
[**2161-9-12**] 5-FU/Leucovorin/[**Year (4 digits) 49565**]
[**5-20**]-present: 5FU/Leucovorin
Social History:
Husband died of cancer recently on [**2163-9-22**]. She immigrated from
[**Country 5976**] in [**2127**]. lives alone now. has 3 sons (1 in ME, 1 in UT, 1
in [**Location (un) 86**]). Currently on disability secondary to cancer;
formerly worked housekeeping for [**Hospital3 1810**].
EtOH: none
Tobacco: none
Family History:
Non contributory
Physical Exam:
Admission Exam:
VITALS:98,5 115/90 99 20 97% RA
GEN: chronically ill appearing, cachectic, no distress, able to
use phone for interpreter, but gives short answers
HEENT: MM dry, EOMI
LYMPH: no cervical, clavicular LAD
NECK: neck veins not dilated, JVP not seen
CAR: tachycardic, regular, no murmur
RESP: Clear to auscultation bilaterally
ABD: soft, nontender, not distended, ostomy with large volume
bilious fluid. Per patient--normal in appearance
EXT: no LE edema
SKIN: no rash
BACK: no midline, paraspinal or CVA tenderness
NEURO: CN II-XII intact, alert/oriented X 3, MAE normally
Pertinent Results:
Admission Labs
[**2164-2-11**] 04:57PM BLOOD WBC-11.6* RBC-4.68# Hgb-14.3# Hct-44.2
MCV-94 MCH-30.5 MCHC-32.3 RDW-16.2* Plt Ct-419
[**2164-2-11**] 04:57PM BLOOD Neuts-86.7* Lymphs-10.4* Monos-2.1
Eos-0.5 Baso-0.3
[**2164-2-11**] 04:57PM BLOOD Glucose-124* UreaN-67* Creat-4.3*#
Na-128* K-4.4 Cl-92* HCO3-15* AnGap-25*
[**2164-2-11**] 04:57PM BLOOD ALT-18 AST-37 LD(LDH)-270* AlkPhos-95
TotBili-1.2
[**2164-2-12**] 01:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2164-2-12**] 01:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2164-2-12**] 01:00AM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
[**2164-2-12**] 01:00AM URINE CastGr-16* CastHy-38*
[**2164-2-12**] 01:00AM URINE Mucous-RARE
[**2164-2-12**] 01:00AM URINE Eos-NEGATIVE
[**2164-2-12**] 01:00AM URINE Hours-RANDOM Creat-367 Na-LESS THAN
[**2164-2-12**] 01:00AM URINE Osmolal-470
Radiology
Barium enema [**2-17**]:
1. Probable narrowing and/or stricturing of the colon in the
region of the
ostomy. There is suggestion of spillage of small amount of
contrast from the colon into the ostomy device. There is no
definitive filling of more proximal loops of small bowel.
2. No evidence for formed feces within loops of opacified colon.
KUB [**2-11**] - IMPRESSION: No evidence of bowel obstruction or free
intraperitoneal air.
Renal u/s
[**2-11**]
RENAL ULTRASOUND: The right kidney measures 8.9 cm. The left
kidney measures 8.9 cm. The kidneys demonstrate normal
echotexture and corticomedullary differentiation. There is no
renal mass lesion, nephrolithiasis, or hydronephrosis
identified. There is symmetric renal parenchymal blood flow
bilaterally. The bladder was not well visualized as it is
decompressed by Foley catheter, and there is significant
overlying ostomy appliance/dressings precluding optimal
visualization window.
IMPRESSION: Normal renal ultrasound, with no nephrolithiasis,
renal mass
lesion, or hydronephrosis.
RUE U/S [**2-20**]
No evidence of right upper extremity DVT. This was discussed
with Dr. [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **] on the day of the examination.
CT abd/pelvis [**2-21**]
1. New large pleural effusions with associated atelectasis.
2. No contrast flows from the small bowel to the large bowel.
Adhesions from prior surgery and/or tethering involving the
peripancreatic mass might lead to some disruption in passage of
contrast; however, the pattern of distention is most suggestive
of occlusion and diversion at the site of fistula drainage to
the skin, in a location anterior to the previous iliocolic
anastamosis.
3. Residual contrast from the recent barium enema is seen within
the sigmoid, with a long segment of descending colon unfilled
and then in the upper descending colon and transverse colon
again with residual barium, where a probable tract is seen to
the body wall. Again, no contrast is seen in bowel just proximal
to the locale of this tract.
4. Possible herniation of fat into the fistula drainage/ostomy
sites
contributing to the obstruction.
5. Probable increased size of peripancreatic mass (limited
without contrast).
6. Ascites and pronounced anasarca.
Discharge labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2164-3-6**] 12:11AM
WBC5.4 RBC 2.69* Hgb 8.3* HCT 25.8* MCV 96 MCH 31.0 MCHC
32.3 RDW19.4* Plt 275
[**2164-3-6**] 12:11AM Gluc 182 BUN 21* Creat 0.8 Na 139 K+
4.4 Cl 106 CO2 26
[**2164-2-27**] 12:00AM AST 6 ALT 14 LDH 202 Alk Phos 39
T. Bili 1.3
Brief Hospital Course:
67 year old female with metastatic colon cancer C32D12
5-FU/Leucovorin presented with nausea, vomiting and acute renal
failure.
# Diarrhea/bleed: During admission ostomy output was
uncontrolled on imodium and TOP with lomotil and octreotide.
Cdiff and all viral and other cultures were negative. TSH and
T4 were normal. Per GI, got barium enema on [**2-17**] showing
stricture at small bowel/colon junction just distal to site of
the fistula without stool in the colon. Patient returned from
the enema with her ostomy bag full of blood. VSS, pressure was
applied and GI and surgery were consulted urgently. Hct was
stable from am (28) though started transfusing 1 U PRBC.
Bleeding subsided and was likely not intraluminal but from
necrotic skin around fistula [**2-14**] movement and bag friction
during enema. Patient soon developed fevers and rigors. She was
hypotensive and transfered to the ICU where she was given IVF
and a short course of pressors. She had been cultured,
subsequently grew e-coli sepsis and started on Cipro/Flagyl then
changed to Vanc/Zosyn, then Unasyn for 14 day course through
[**3-2**]. Surgery opting not to intervene at this time. Patient went
for colonscopy on [**2-29**] where a wire was placed up to ostomy
however could not insert into eneterocutaneous fistula.
Therefore, no stent was placed. Patient was maintained on TOP,
imodium, Lomotil, PPI TID, Rifaximin, Codeine standing and her
ostomy output did decrease. Patient also continued on TPN with
low residue/low lactose small quantity meals.
# elevated PTH: Odd in setting of nl corrrected calcium,
possibly primary hyperparathyroidism without hypercalcium due to
poor absorption. Likely will not have influence on overall care
or outcomes. Patient had pending vitamin D levels at discharge
and should consider seeing an endocrinologist.
# GNR bacteremia: Pt. cultures from port on [**2-17**] grew GNR on [**2-18**].
Her Cipro/Flagyll was changed to meropenem and peripheral and
port cultures were drawn at that time. A lactate was checked.
At the same time she became hypotensitve, initially unresponsive
to IVF. She had been trending down overnight and was SBP 79 in
the am. NS was started and as she was being transfered to the
ICU her SBP increased to 90. At baseline she has been 100-110.
Patient was transferred to the MICU for hypotension in the
setting of GNR septicemia. Her blood pressure was stabilized
with IVF resuscitation. She was on pressors transiently. She was
treated with broad-spectrum antibiotics and was stable and not
requiring pressor support for >24h before leaving the ICU. She
completed a course of Unasyn on [**2164-3-3**] and was afebrile after
this.
# Acute Renal Failure - Liekly pre-renal [**2-14**] hypovolemia in the
setting of vomiting and decreased PO intake. Renal function
improved within 48 hours with IV fluids. Additionally, urine Na
<10 consistent with pre-renal picture.
# Hyponatremia - Likely hypovolemia in nature as it rose with
IVF.
# Dizziness - Likely related to fluid depletion in the setting
of vomiting and decreased PO intake. Improved with IVF.
# Non Gap Metabolic Acidosis - Likely secondary to diarrhea.
# H/O PE/SVC Syndrome - Fondaparinux intially changed to Heparin
due to renal failure and changed back around [**2-15**]. Patient then
developed fistula site bleed so it was stopped on [**2-17**] and she
was given protamine and started on TEDs/SCDs. She was started
on SC Heparin daily for prophylaxis given the risk of bleeding
with Fondaparinux.
# RUE edema: On [**2-18**] it was noted that the pt. had RUE edema. An
u/s was done and was normal.
# DM - Not on meds at home. Patient was placed on an insulin
s/s but did not require insulin during this admission and not
discharged on insulin.
# CODE - Full (confirmed)
# Communication: Patient and son [**Name (NI) **] [**Telephone/Fax (1) 96530**]
# Dispo: At some point in the near future, code status and goals
of care should be reassessed with patient given her poor overall
prognosis.
Medications on Admission:
Dilatizem 240 mg daily
Fentanyl TD 100 mcg/72 hours
Flonase 100 mcg/daily
Ativan 0.5 mg prn
Topical metronidazole
Topical Nystatin
Omeprazole 20 mg daily
Compazine prn
Imodium 1 every 4 hours prn
MVI
Fondaparinux 5 mg daily
- pt was also recently on opium tincture but this was not
restarted during her previous hospitalization
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr [**Telephone/Fax (1) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) mL
Injection DAILY (Daily).
3. Fluticasone 50 mcg/Actuation Spray, Suspension [**Telephone/Fax (1) **]: Two (2)
Spray Nasal DAILY (Daily).
4. Lorazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
6. Rifaximin 200 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO TID (3 times a
day).
7. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical QID
(4 times a day) as needed for groin area.
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet [**Telephone/Fax (1) **]: One (1)
Tablet PO BID (2 times a day).
9. Codeine Sulfate 30 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID WITH
MEALS ().
10. Sodium Bicarbonate 650 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID
(3 times a day).
11. Ascorbic Acid 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2
times a day).
12. 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.
13. Compazine 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO every six (6)
hours as needed for nausea.
14. Lasix 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day.
15. Heparin Flush 10 unit/mL Kit [**Telephone/Fax (1) **]: One (1) flush Intravenous
once a month: please flush port-a-cath with heparin monthly.
16. Outpatient Lab Work
please have electrolytes and cbc checked weekly
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
Dehydration
Acute Renal Failure
Secondary
Metastatic Colon Cancer
Discharge Condition:
mentating well, ambulating with assistance.
Discharge Instructions:
You presented to the hospital with nausea, vomiting, dizziness,
and decreased kidney function. It appeared that your worsened
kidney function was likely due to dehydration. Therefore, you
were given IV fluids and your kidney function was monitored.
You also developed a blood infection and required a stay in the
intensive care unit. This infection was caused by the [**Hospital1 **] and
cancer in your abdomen. You were treated with antibiotics and
the infection improved. You continued to have increased output
from your ostomy and you were evaluated by the surgery and
gastrointestinal doctors. The surgeons decided that surgery was
not an option and the GI doctors tried to [**Name5 (PTitle) **] a stent however
this was not successful.
You should CONTINUE taking:
Fentanyl TD 100 mcg/72 hours
Flonase 100 mcg/daily
Ativan 0.5 mg prn
Compazine prn nausea
MVI
You should STOP taking:
Dilatizem 240 mg daily
Topical metronidazole
Topical Nystatin
Fondaparinux 5 mg daily
Omeprazole 20mg daily
You should also START taking:
Heparin 5000U SC once a day to prevent blood clots
Rifaximin 400mg TID
Pantoprazole 40mg TID
Ferrous gluconate 325mg [**Hospital1 **]
Codeine 30mg TID with meals
Miconazole Powder 2% TP QID prn groin rash
Sodium bicarbonate 650mg TID
Ascorbic Acid 500mg [**Hospital1 **]
Lasix 20mg qday
It was a pleasure taking part in your medical care.
Followup Instructions:
You should make an appointment to follow-up with your primary
care doctor, [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**], at [**Telephone/Fax (1) 21832**] within 1 week
after discharge.
You have the following appointments to follow-up:
Provider: [**Name Initial (NameIs) **]/OSTOMY NURSE Phone:[**Telephone/Fax (1) 13760**]
Date/Time:[**2164-3-16**] 11:30
Please call Dr.[**Name (NI) 10560**] office for a follow-up appointment.
His phone number is: [**Telephone/Fax (1) 68451**].
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59,452
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Discharge summary
|
report
|
Admission Date: [**2114-6-4**] Discharge Date: [**2114-6-15**]
Date of Birth: [**2050-4-4**] Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
64F had Right Nx 4 yr ago at OSH (Clear cell RCC), now 3.1cm
Left upper pole renal mass concerning for RCC. Baseline Cr
1.5-1.7.
Major Surgical or Invasive Procedure:
Left partial nephrectomy
History of Present Illness:
Mrs [**Known lastname **] is a 64 y/o F with history of renal cell carcinoma s/p
right nephrectomy in [**2108**], subsequent CKD (b/l creatinine 1.6),
hypertension and hyperlipidemia, with routine follow-up
demonstrating a new mass in upper pole of left kidney, admitted
on [**6-4**] for partial left nephrectomy, with post-operative course
complicated by significant hypoxia and bilateral pulmonary
emboli. She has had persistently high supplemental oxygen
requirements on the floor, and is being transferred to the ICU
for closer monitoring.
.
During her surgery on [**6-4**], she had an episode of
intra-operative SVT. She had a chest tube and nasogastric tube
placed, which have since been discontinued. She still has a JP
drain in place at her surgical site. Surgical EBL was 300 cc.
She was given 2700 cc of IVF during the surgery. Last evening,
she underwent CTA showing bilateral PE without evidence of right
heart strain, but with hypoperfused pulmonary parenchyma in her
left lower lobe, concerning for early parenchymal infarction vs
infectious infiltrate. She was started on a heparin gtt, which
has not yet reached a therapeutic level.
.
On the floor, she reports that she currently does not feel
particularly dyspneic at rest, but she feels significantly short
of breath with minimal movement, including reaching to her tray
to eat. She denies chest pain, palpitations, cough, fevers,
chills, abdominal pain, leg pain, numbness/tingling, or pain at
her surgical site. She has a good appetite, and denies nausea or
vomiting.
Past Medical History:
Clear cell renal carcinoma s/p right nephrectomy ([**2108**]), no
chemo
CKD with baseline creatinine 1.3-1.7 since original nephrectomy
Hypertension
Hyperlipidemia
COPD (reports she read this diagnosis in her medical record but
is not on treatment)
2x2mm right MCA aneurysm, monitored with yearly MRI
Gastritis/GERD
Depression
Anxiety
Osteopenia
H/o TAH-BSO for fibroids
H/o cholecystectomy and appendectomy
Lipomas
Arthritis/Gout
Thyroid nodules
H/o C-Section
Social History:
Originally from [**Location (un) 3156**], moved here more than 10 years ago.
Married and lives with husband. Sister is currently at bedside.
Has multiple children and grandchildren. Smokes 1ppd x 40 years,
denies alcohol or drug use.
.
Family History:
Family History: Mother died of pancreatitis. Father died of MI,
also had h/o CVA, varicose veins. Children are healthy.
Physical Exam:
WdWn woman in NAD, AVSS although maintained on nasal canula
oxygen support at 2-litres with saturations 90% ++.
Abdomen soft, supple, benign.
Incision line is c/d/i with well approximated wound edges and
surgical skin clips. No evidence of hematoma, dehisence or
infection. Chest tube site suture has been removed and drain
site dressing has been taken down.
Extremities w/out edema or pitting.
Pertinent Results:
[**2114-6-12**] 09:45AM BLOOD WBC-11.7* RBC-3.67* Hgb-10.5* Hct-31.6*
MCV-86 MCH-28.5 MCHC-33.1 RDW-14.2 Plt Ct-206
[**2114-6-11**] 06:12AM BLOOD WBC-13.0* RBC-3.67* Hgb-11.1* Hct-31.9*
MCV-87 MCH-30.4 MCHC-34.9 RDW-13.7 Plt Ct-229
[**2114-6-5**] 12:44PM BLOOD WBC-17.2* RBC-4.17* Hgb-12.6 Hct-37.3
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.4 Plt Ct-252
[**2114-6-15**] 06:30AM BLOOD PT-21.6* INR(PT)-2.0*
[**2114-6-14**] 09:35AM BLOOD PT-25.5* INR(PT)-2.4*
[**2114-6-13**] 04:10AM BLOOD PT-33.1* PTT-32.9 INR(PT)-3.3*
[**2114-6-15**] 06:30AM BLOOD Creat-1.8*
[**2114-6-13**] 04:10AM BLOOD Glucose-104* UreaN-12 Creat-1.7* Na-141
K-3.7 Cl-111* HCO3-24 AnGap-10
[**2114-6-12**] 09:45AM BLOOD Glucose-110* UreaN-11 Creat-1.7* Na-142
K-3.4 Cl-111* HCO3-20* AnGap-14
[**2114-6-12**] 09:45AM BLOOD Calcium-8.4 Mg-1.8
[**2114-6-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL, negative [**2114-6-9**] MRSA SCREEN MRSA
SCREEN-FINAL, negative
Brief Hospital Course:
ICU BHC: 64 y/o F with hx RCC s/p remote right nephrectomy, now
4 days post-op from left partial nephrectomy, with bilateral
pulmonary emboli and significant hypoxia.
# Hypoxia/Pulmonary embolism: CTA revealed clot burden in
majority of pulmonary vasculature. Hemodynamically stable but
has evidence of right heart strain on ECG; troponin negative.
Significant A-a gradient on ABG. Started on heparin drip. Per
primary surgery team, pt not a candidate for thrombolysis given
recent surgery. Lower extremity ultrasound to evaluate for DVT
was negative. Patient maintained O2 sats >90% on supplemental
oxygen. Plan to bridge to warfarin, preferred over enoxaparin
given possibly worsening renal function s/p surgery and IV
contrast.
# Renal cell carcinoma s/p resection: No major surgical
complications or blood loss. Creatinine stable post-operatively.
Pathology consistent with clear cell RCC. Maintained on pain
meds per urology service.
# Anemia: Low-normal MCV with significant hct drop 36 -> 31 in
setting of recently starting heparin gtt and surgery on highly
vascular organ. No ecchymoses at surgical site or significant
hematuria to suggest active bleeding, and blood pressure stable.
HCT was monitored every 6 hours and UAs were done to monitor for
hematuria. Throughout her ICU course, he had an active type and
screen and 2 units crossmatched.
# CKD: Post-operative creatinine remaining stable from
pre-operative level, although patient's renal functioning
currently operating on one-half of one kidney. Electrolytes
within normal limits and does not have significant acidosis on
ABG or chemistry panel. Making adequate urine. Did receive IV
contrast for chest imaging (CTA), at risk for CIN. Urine output
was monitored as well at BUN/creat/lytes. She received MIVFs in
setting of recent IV contrast load. THrough her ICU course,
ptient's sCr was stable.
# Hypertension: BP stable. No hemodynamic instability. Her
anti-HTN regmien was continued. AV nodal blocking agents were
avoided to avoid masking tachycardic response to worsening
hypoxia or bleed.
# Hyperlipidemia: Continued home statin.
# COPD: Not on home oxygen or inhaled therapy. Current hypoxia
felt most directly related to PE. Has respiratory alkalosis on
ABG, without prior pCO2 available for comparison. Continued with
nebs.
# Gastritis/GERD: Continued omeprazole
# Depression/Anxiety: Mood stable. Not on medication.
UROLOGY BHC: Ms. [**Known lastname **] was admitted to urology, Dr.[**Doctor Last Name **]
service after undergoing Left partial Nephrectomy. No adverse
intraoperative events were noted (except Anesthesia noted
paroxysmal SVT intra-op) but please refer to the detailed
operative note. Ms. [**Known lastname **] was taken to the PACU and then
transferred to the genral surgical floor where the first
two-three days were unremarkable. On POD1 her chest tube was
removed without difficulty and she was monitored for pain
control and her diet was restricted. Her post-operative course
was complicated by hypoxia due to bilateral pulmonary embolisms
for which she was initially started on a heparin drip and then
transitioned to coumadin. Her course was managed by the
intensive care unit and medicine service as described in OMR and
consult notes. Ultimately she was discharged in stable
condition, eating well, ambulating independently, voiding
without difficulty, and with pain control on oral analgesics. On
exam, incision was clean, dry, and intact, with no evidence of
hematoma collection or infection. The patient was given explicit
instructions to follow-up with Dr. [**Last Name (STitle) **], her PCP and Dr.
[**Last Name (STitle) 2805**].
Medications on Admission:
Home Medications:
Simvastatin 40mg po daily - not actually taking
Omeprazole 20mg po daily
Valsartan 160mg po daily
HCTZ 25mg po daily
ASA 81mg po daily
.
ICU transfer medications:
IV Heparin
Acetaminophen 1000mg po q6h standing
Albuterol nebs in q6h standing
Chloraseptic throat spray [**11-26**] sprays po q4h prn
Cepacol 1 loz po q2h prn sore throat
Docusate 100mg po bid
Hydralazine 10mg IV q6h (hold for SBP<135)
Hydromorphone PCA
Ondansetron 4mg IV q8h prn nausea
Oxycodone 5-10mg po q3h prn pain
Omeprazole 20mg po daily
Senna 1 tab po bid
Simvastatin 20mg po daily
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Outpatient Lab Work
It is important that you review your post-operative course,
medication changes and coumadin dosing/INR monitoring with PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4606**]
3. simvastatin 20 mg Tablet Sig: One (1) Tablet 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. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0*
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(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).
9. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. valsartan 160 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Nasal Moisturizing 0.65 % Aerosol, Spray Sig: [**11-26**] Nasal
four times a day.
13. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Take
at the same time daily. Follow up with PCP for
monitoring/dosing.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
International Health Solutions
Discharge Diagnosis:
1) Left renal mass suspicious for renal cell carcinoma.
2) Bilateral Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Home on oxygen support via nasal canula
Discharge Instructions:
-Please also refer to the educational handout on post-operative
instructions provided by Dr.[**Doctor Last Name **] office.
-You will be sent home with visiting nurse services and they
will assist you with setting up your home oxygen, wound care,
INR monitoring.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-If you had a drain removed from your abdomen, bandage strips
called ??????steristrips?????? have been applied to close the wound. Allow
these bandage strips to fall off on their own over time but
please remove the gauze dressing in 2 days. You may get the
steristrips wet.
-Your surgical skin clips (staples) be removed at your follow-up
appointment. Please wear loose fitting, breathable clothing that
won't snag or pull at your incision sites.
-Resume your pre-admission medications; EXCEPT there have been
some changes to your blood pressure control medications.
Prescriptions have been provided (Toprol XL,
Hydrochlorothiazide)
-You have also been started on a blood thinner called Warfarin
(coumadin) that requires routine monitoring and dosing
adjustments.
-DO NOT TAKE aspirin or other blood thinners. DO NOT take any
non-steroidal anti-inflammatories (NSAIDs) like advil, motrin,
ibuprofen, aleve, etc..)
-You will return to Dr.[**Doctor Last Name **] office for staple removal in
one week, the staples do not need to be covered however protect
staples from catching on clothing or bed sheets
-resume regular home diet and remember to drink plenty of fluids
to keep hydrated and to prevent constipation. Please continue
taking a daily multivitamin
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery.
Followup Instructions:
Please call today when you get home to confirm your appointment
with Dr. [**Last Name (STitle) 3357**] that has been scheduled for Monday, [**2114-6-18**].
It is important that you review your post-operative course,
medication changes and coumadin dosing/INR monitoring.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4606**]
Please call today when you get home to schedule/confirm an
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**]:
Job Title:Division Chief, Hemostasis and Thrombosis
Department:Medicine Division:Hematology/Oncology
Office Location:CLS 903 Office Phone:([**Telephone/Fax (1) 15734**]
This appointment was confirmed for [**2114-6-29**] at 10:00AM.
Call Dr[**Doctor Last Name **] office today to schedule/confirm your follow-up
appointment AND if you have any questions.
Your upcoming appointments are listed here:
Provider: [**Name10 (NameIs) 703**] [**Location 704**] [**Location 705**] / IOUS RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-6-20**] 1:00
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 164**]
Date/Time:[**2114-6-27**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2114-9-4**] 3:00
Completed by:[**2114-6-16**]
|
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icd9cm
|
[
[
[]
]
] |
[
"55.4"
] |
icd9pcs
|
[
[
[]
]
] |
10137, 10198
|
4295, 7936
|
430, 457
|
10330, 10330
|
3334, 4272
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|
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|
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|
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|
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|
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|
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|
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8143, 8537
|
485, 2025
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,652
| 109,518
|
13151
|
Discharge summary
|
report
|
Admission Date: [**2132-12-12**] Discharge Date: [**2132-12-18**]
Date of Birth: [**2051-9-27**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Ambien
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
81 y old male w/ extensive history CAD s/p AMI at age 37, CABG
in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in [**2121**] (occuded
LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2), DES to OM1 for
NSTEMI in '[**29**], CHF with EF of 20% s/p cardiac resynchronization
and biV ICD, and [**11-20**] admission for SOB and chest tightness in
which he had an echo w/ severe AS with an area of <8 cm2, and
therefore underwent apico-aortic valve conduit placement on
[**2132-12-2**]. Pre-op he had a cath demonstrating patent RIMA -->
LAD, and SVG --> OM2, but occluded SVG --> PDA, but had no
intervention and no bump in enzymes. Post operatively he was
initially on Amiodarone for ventricular ectopy which resolved
after a few days. He had persistent hypotension and it took
several days to wean him off inotropic support. Coumadin was
started for afib and continued. He was discharged post-operative
day seven. His discharge VSS were 96/50, 95%, and HR of 71. He
was d/c'd on [**12-9**] with coumadin and lasix with an eye toward
restarting an ACE inhibitor if his blood pressure improved.
Today pt presented to [**Hospital3 24768**] with shortness of
breath. His BNP was found to be 1152 and CXR showed CHF. He was
given lasix 40 IV x 2 with good urine output. However, his BP
decreased to 76/40 and then increased to 86/60 at time of
transfer to [**Hospital1 18**] for further eal and treatment.
.
Upon presentation to [**Hospital1 18**] hs vitals were BP 85/43, HR 77, RR
18, 96% on 2L, T 97.1. He reported shortness of breath that
improved with lasix. He reports that the shortness of breath
began this morning gradually. No chest pain. He is not walking
around much so he denies dyspnea on exertion. He denies PND, but
reports orthopnea. He does not know if his leg swelling is
increasing or decreasing. He does not know if he has had weight
gain or weight loss. He denied lightheadedness, cough, fevers,
chills.
Past Medical History:
# CAD
- s/p AMI at age 37
- s/p CABG in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in
[**2121**] (occuded LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2)
- s/p DES to OM1 for NSTEMI in '[**29**]
- [**11-24**] cath demonstrating patent RIMA --> LAD, and SVG --> OM2,
but occluded SVG --> PDA
# CHF with EF of 25% s/p cardiac resynchronization and biV ICD
# Severe AS with an area of <8 cm2 s/p apico-aortic valve
conduit placement on [**2132-12-2**]
- conduit gradient post-procedure: peak 5, mean 2.4 mm Hg
- native Aortic valve with a peak gradient 23 mm Hg
# Chronic Systolic Congestive Heart Failure with EF 20%
# Biventricular ICD and Cardiac Resynchronization
# Hypertension
# Hyperlipidemia
# History of Abscess Excision
# Cholecystectomy
# History of Remote MVA
Cardiac Risk Factors: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
Social History:
The patient lives alone in [**Location (un) 11790**]. Social history is
significant for the absence of current tobacco use though the
patient has a remote smoking history. He reports smoking 1PPD
for 20 years, but quit at age 37. There is no history of alcohol
abuse but he drinks alcohol occasionally. There is no family
history of premature coronary artery disease or sudden death.
Family History:
No premature coronary artery disease
Physical Exam:
VS - BP 81/42 , HR 66, RR 25, 96% on 2L, T 98.0
Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: arcus senilis. sclera anicteric. PERRL, EOMI.
Neck: JVP ~12
CV: Irregularly irregular. III/VI systolic murmur at apex. No
thrills, lifts. No S3 or S4.
Chest: tachypneic, speaking in complete sentences, crackles
bilaterally 1/3rd up
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace edema. stiches in L femoral groin, pulses intact
femoral area
Skin: warm
Pulses:
Right: Femoral 2+ DP 1+ PT 1+
Left:Femoral 2+ DP 1+ PT 1+
Pertinent Results:
[**2132-12-12**] 09:15PM PT-18.8* PTT-30.5 INR(PT)-1.8*
[**2132-12-12**] 09:15PM PLT COUNT-386#
[**2132-12-12**] 09:15PM WBC-9.7 RBC-3.26* HGB-9.6* HCT-30.5* MCV-93
MCH-29.5 MCHC-31.6 RDW-15.3
[**2132-12-12**] 09:15PM CALCIUM-8.1* PHOSPHATE-4.2 MAGNESIUM-2.3
[**2132-12-12**] 09:15PM CK-MB-NotDone cTropnT-0.35*
[**2132-12-12**] 09:15PM CK(CPK)-20*
[**2132-12-12**] 09:15PM GLUCOSE-145* UREA N-26* CREAT-1.1 SODIUM-133
POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-37* ANION GAP-10
Brief Hospital Course:
81 y old male w/ extensive history CAD s/p AMI at age 37, CABG
in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in [**2121**] (occuded
LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2), DES to OM1 for
NSTEMI in '[**29**], CHF with EF of 20% s/p cardiac resynchronization
and biV ICD, and severe AS s/p apico-aortic valve conduit
placement on [**2132-12-2**] now presenting with SOB. Patient was
admitted to the floor team who initiated diuresis. Patient was
then noted to be transiently hypotensive and was transferred to
the CCU for management.
.
#Hypotension: On arrival in CCU, patient noted to be hypotensive
in upper extremity b/l, but with elevated SBP in lower
extremity. Impression was for either b/l subclavian stenosis or
normal physiology with his apical-aortic conduit that was
preferentially directing flow to the lower extremity. Patient
was asymptomatic from the hypotension, and subsequent upper
extremity BP's were regularly in normal range.
.
#SOB: In CCU, patient was persistently tachypneic 20-30's at
baseline. Exam was consistent with volume overload with
elevated JVP, peripheral edema, and crackles on lung exam.
Diuresis resulted in mildly improved respiratory function.
Patient was optimized from a volume perspective, but continued
to be tachypneic with exertion. Patient was afebrile, without
WBC count elevation, and impression was for post-operative
deconditioning. He was transferred to the floor for management
where he was evaluated by PT and recommended for inpatient rehab
on discharge.
.
#Atrial Fibrillation: Patient was rate controlled with HR in
60's during much of his hospital stay. Coumadin was restarted
for anticoagulation. Please have your INR checked regularly on
discharge to ensure therapeutic level of your coumadin.
.
#Mental Status: Patient had episode of altered mental status on
AM of [**2132-12-16**]. Neuro exam was non-focal, CT head negative,
Neuro consult recommended A1c and lipid panel. Impression was
for benzo intoxication as patient had received an additional
dose of xanax on the AM of this episode. also w/ component of
sleep deprivation. Recommend that patient discontinue xanax on
discharge.
.
#PT: Physical therapy evaluated patient and recommended acute
[**Hospital 19586**] rehab on discharge.
.
#CAD: Patient was started/continued on ASA, zetia, low dose
beta-blocker, captopril, and statin therapy. Recommend
outpatient f/u with Cardiology.
.
Remainder of the [**Hospital 228**] hospital course was uncomplicated.
Medications on Admission:
On admit to CCU
Docusate [**Hospital1 **]
Ezeteimibe 10 q day
Aspirin 81 q day
Potassium chloride 20 [**Hospital1 **]
Toprol XL 25 q day
Pantoprazole 40 q day
Lasix 20 mg [**Hospital1 **]
Coumadin 1 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Ezetimibe 10 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Watch [**Doctor Last Name **] Manor
Discharge Diagnosis:
CHF Exacerbation
.
Apical-aortic conduit
Atrial Fibrillation
Coronary Artery Disease
Discharge Condition:
Stable, to acute rehab to address oxygenation.
Discharge Instructions:
you were admitted to the hospital for evaluation of shortness of
breath. Your symptoms are likely related to your congestive
heart failure. While in the hospital you were diuresed (fluid
was removed). Please continue to take all medications as
directed upon leaving the hospital. Some continued shortness of
breath is to be expected after your recent surgery and extended
hospital stay. Please continue to work with physial therapy in
this regard. Should you develop any worsening of your symptoms,
however, or if you feel that you have any new symptoms that are
concerning to you such as chest pain, productive cough, or any
other worrisome complaints please call your PCP or return to the
Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1-1.5 liters per day.
Followup Instructions:
Please call your PCP/Cardiologist Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 24717**]
([**Telephone/Fax (1) 24721**] for an appointment in the next 2-3 weeks. Family
assures they will call for a follow-up appointment.
You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], your
cardiologist, on [**12-24**] at 4:40pm. Please report to the [**Hospital Ward Name 23**]
Clinical Center at [**Location (un) **]., [**Location (un) 436**].
Please have your INR level checked regularly upon leaving the
hospital to ensure a therapeutic level of your coumadin (INR
[**3-15**]).
|
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
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|
4670, 6451
|
286, 293
|
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17,072
| 154,618
|
5601
|
Discharge summary
|
report
|
Admission Date: [**2141-11-2**] Discharge Date: [**2141-11-6**]
Date of Birth: [**2090-7-25**] Sex: M
Service: INTERNAL MEDICINE, [**Hospital3 22488**]
HISTORY OF PRESENT ILLNESS: This is a 51-year-old man with
diabetes mellitus, type 1, end-stage renal disease, status
post renal transplant times two, who reported several weeks
of watery stools, and several days of nausea with vomiting on
the day of admission. The patient admitted to having
a few weeks, which produced greenish sputum on the day of
admission. He denied any fevers, but he has had chills. He
also admitted that he has not taken his Insulin for two days
and has had decreased intake of food and liquids.
In the Emergency Department, the patient was found to have a
temperature of 100??????, blood pressure 140/82, heart rate 112,
He was started on an Insulin drip after a glucose of 588 was
discovered. He was also started on intravenous fluids, as
well as intravenous Ceftriaxone for questionable pneumonia.
PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes
mellitus. 2. Diabetes comorbidities: Nephropathy,
retinopathy, dysautonomia with orthostatic hypotension,
neuropathy, peripheral vascular disease. 3. End-stage renal
disease status post living-related kidney transplant in [**2128**]
and cadaveric kidney transplant in [**2136**]. 4. Chronic low
back pain. 5. Right index finger osteomyelitis. 6. Gout.
7. Transurethral resection of prostate. 8. Peripheral
vascular disease with several toe amputations.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Noncontributory. The patient lives in an
assisted-living facility. He denied alcohol, tobacco, and
intravenous drug use.
MEDICATIONS: Ultra Lente, regular Insulin sliding scale,
Aspirin 325 mg p.o. q.d., Allopurinol 500 mg p.o. q.d.,
Midodrine 2.5 mg p.o. q.d., Heparin 5000 U subcue b.i.d.,
Lopressor 12.5 mg p.o. b.i.d., Protonix 40 mg p.o. q.d.,
Colace 100 mg p.o. b.i.d., Celexa 20 mg p.o. q.d., Prograf 3
mg p.o. b.i.d., Depakote 500 mg p.o. q.h.s., Lasix 80 mg p.o.
b.i.d., Zaroxolyn 5 mg p.o. b.i.d., Prednisone 10 mg p.o.
q.d., K-Dur.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.9??????, heart
rate 110, blood pressure 119/76, oxygen saturation 99% on
room air. General: This was an ill-appearing man in
moderate distress. Skin: Wet and damp. HEENT: Right eye
shut. Oropharynx dry. No icterus. Neck: No jugular venous
distention. Supple. No lymphadenopathy. Cardiovascular:
Tachycardia. There was a 2 out of 6 systolic murmur. Lungs:
Decreased breath sounds. Abdomen: Bowel sounds positive.
Soft, nontender, nondistended. Back: No CVA tenderness. No
spinal tenderness. Extremities: No edema or finger
swelling. Neurological: Nonfocal.
LABORATORY DATA: The patient had a CBC drawn which revealed
a white count of 19.5 with 80% neutrophils, 16% lymphocytes,
and 3% monocytes. He also had a hematocrit of 44 and a
platelet count of 243. Chemistries revealed a sodium of 133,
potassium 3.6, bicarbonate 12, chloride 87, BUN 77,
creatinine 1.7, glucose 588, with an anion gap of 34. Serum
acetone was large. Urinalysis revealed greater than 1000
glucose, greater than ketones, no white blood cells, no red
blood cells.
Electrocardiogram revealed sinus tachycardia with normal
intervals and axis, poor R-wave progression, left and right
atrial enlargement, ST depressions in I, AVL, V5, and V6,
unchanged from previous.
Chest x-ray revealed no congestive heart failure or
pneumonia. Blood cultures, urine cultures, and sputum
cultures were taken and are pending.
ASSESSMENT: This is a 51-year-old male with diabetes
mellitus type 1 and end-stage renal disease status post renal
transplant who presented with DKA likely secondary to an
infectious process.
HOSPITAL COURSE: 1. Endocrine: The patient was started on
Insulin drip and aggressive intravenous hydration with normal
saline and D5 normal saline to close his anion gap. The
patient responded well to this treatment, as serial
fingersticks showed dramatic decreases in his blood glucose
to within normal levels. The patient was eventually switched
to a more normal regimen of Humalog sliding scale [**11-4**]. He
has, throughout his
hospitalization, exhibited good fingersticks and has been on
a diabetic diet.
2. Renal: The patient was continued on his steroids,
CellCept, and Prograf for his transplant. His fluid deficit
was repleted with intravenous fluids as mentioned above.
3. Cardiovascular: The patient was noted to have
electrocardiogram changes on a second EKG. Namely, he was
shown to have sinus rhythm of 82, left axis deviation with
possible left anterior fascicular block, a probably old
septal infarct, and lateral ST T-wave changes secondary to
ischemia that were more pronounced compared with the last
electrocardiogram. As a result, the patient was started on
Aspirin. The patient declined to be started on a
beta-blocker. The patient was scheduled for stress test on
the morning of [**11-6**] which was performed and revealed no
perfusion defects or ischemia. The patient had no reported
chest pain throughout his hospital stay.
4. Infectious disease: Given the patient's complaint of
cough and also gastrointestinal symptoms, the patient was
started on antibiotics. He was started on intravenous
Ceftriaxone and Azithromycin. Given his past history of
MRSA, the patient was given one dose of Vancomycin; however,
respiratory, urine, and blood cultures were negative to date,
and the patient was off antibiotics by [**11-4**]. The
patient has remained afebrile throughout his hospital course.
5. Fluids, electrolytes, and nutrition: The patient had
persistent hypokalemia at first, and he had hypomagnesemia
and hypophosphatemia; however, the patient had these
electrolytes replaced accordingly. He has had no
complications throughout his hospital stay with respect to
electrolyte balance.
CONDITION ON DISCHARGE: The patient is to be discharged
today back to his assisted-living facility.
DISCHARGE STATUS: The patient is in good condition.
DISCHARGE DIAGNOSIS: Diabetic ketoacidosis, resolved.
DISCHARGE MEDICATIONS: The patient is to continue his
outpatient medications.
FOLLOW-UP: The patient is to follow-up with the [**Last Name (un) **]
Diabetes Center within one month.
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**MD Number(1) 1335**]
Dictated By:[**Last Name (NamePattern1) 22489**]
MEDQUIST36
D: [**2141-11-6**] 14:00
T: [**2141-11-6**] 13:22
JOB#: [**Job Number **]
|
[
"250.11",
"794.31",
"250.41",
"008.8",
"V42.0",
"275.3",
"276.5",
"276.8",
"275.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1545, 1563
|
6161, 6598
|
6103, 6137
|
3804, 5925
|
2151, 3786
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201, 1006
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1029, 1528
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1580, 2128
|
5950, 6081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,408
| 173,881
|
5157
|
Discharge summary
|
report
|
Admission Date: [**2187-6-11**] Discharge Date: [**2187-7-13**]
Date of Birth: [**2111-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Anemia
Chronic Renal Insufficiency
Major Surgical or Invasive Procedure:
Tunneled cathether placement
Hemodialysis
CT Scan
MRI
History of Present Illness:
75 yoM w/ h/o CAD s/p CABG X 4, Type II DM, CRI presents from
[**Hospital1 **] with persistant anemia. Pt had prolonged admission
[**Date range (3) 21103**] following NSTEMI. Given 3 vessel disease on
cath, he underwent CABG X 4 [**2187-3-22**]. Post-op course c/b left
hemothorax, respiratory distress requiring re-intubation POD #9
followed by prolonged wean requiring trach/PEG [**2187-4-3**]. He was
diagnosed with VAP (Pseudomonas cepacia, MRSA), for which he was
treated with meropenem/vanco for 14 day course (completed [**5-14**]).
He was discharged to [**Hospital **] Rehab [**2187-5-11**]. He was weaned to a
trach mask by early [**5-29**]. On [**5-31**] a CXR (obtained due to
increased thick yellow secretions) showed moderate pulmonary
edema with bilateral pulmonary infiltrates. Sputum cx from [**5-31**]
grew Enterobacter cloacae, Paeruginsoa, and MRSA. He was covered
with Ceftaz/vanco starting [**6-4**] for presumed ventilator
associated pneumonia. On [**6-8**], RR was noted to be increased with
decreased O2 sats and he was placed back on vent (PS 15/5, FiO2
0.4, PEEP 5). His HCT decreased to 24 [**6-9**], for which he
received 2u PRBC with improvement of HCT to 31, followed by
decline to 29.6 today. Per NH records, he has had 3 transfusions
over the last 2-3 weeks (exact # unclear) and stools have been
brown gauiac positive. He was also noted to have increased tube
feed residuals, and vomited once today. He was transferred to
[**Hospital1 18**] today for further w/u of suspected GI bleed.
.
In the ED, T 97.5, p 58, bp 130/56, resp 18, 100% AC 550 x 16,
FiO2 0.5, PEEP 5. Lavage through PEG tube with BRB with mucus.
He received Protonix 40 mg IV X 1 and was transferred to MICU
for further management. Currently, the patient denies shortness
of breath, chest pain, nausea, abdominal pain. He has had
alternating constipation and diarrhea for the last several
weeks.
Past Medical History:
1. CAD: PTCA LAD ([**2180**]), NSTEMI ([**2-27**]), CATH ([**2187-3-19**])- LAD
90%, LCX 60%, RCA 100%, CABG X 4 ([**2187-3-22**]) LIMA -> LAD SVG ->
OM2 SVG -> PDA SVG -> Diag
- TTE 4/36/05 LVEF >55%, 1+ MR, impaired LV relaxation, apical
hypoK
2. CRI (CR 1.5-2.4)
3. DM II
4. CVA: Left sided weakness. Carotid US <40% stenosis bilateral
5. HTN
6. DEMENTIA (mild)
7. h/o VAP [**4-29**] with Pseudomonas cepacia, MRSA, s/p 14 days
vanco/meropenem.
8. s/p open trach/PEG [**2187-4-3**]
9. Right gluteal pressure sore
10. Anemia (baseline 26-31)
11. Arthritis
Social History:
Former judge in [**Country 532**]. Former EtOH (2 drinks/day), none for the
last 3 months. No tobacco or other drug use.
Family History:
N/C
Physical Exam:
PE: T 97.5, p 58, bp 130/56, resp 18 100%
AC 550 X 16, FiO2 0.5, PEEP 5
Gen: Elderly Russian male, alert, NAD
HEENT: PERRL, EOMI, anicteric, tracheostomy in place, neck
supple, no anterior cervical LAD, JVP ~10 cm
Cardiac: bradycardic, regular, II/VI SM at apex
Pulm: Coarse ronchi throughout. Decreased LS at bases
bilaterally with minimal crackles.
Abd: Distended, hypoactive BS, soft, NT
Ext: 1+ LE edema bilaterally, warm, 1+ DP bilaterally
Pertinent Results:
EKG: SB @ 56 bpm, 0.[**Street Address(2) 1755**] elevations V1, V2 (no sig change
from [**2187-4-13**])
RADIOLOGY Final Report
MRA BRAIN W/O CONTRAST [**2187-6-25**] 5:59 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: evaluate for bleed/CVA/acute process
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with vent-associated pneumonia, CRI on HD,
mental status changes
REASON FOR THIS EXAMINATION:
evaluate for bleed/CVA/acute process
INDICATION: 75-year old male with ventilation associate
pneumonia. Mental status change.
TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain.
MR angiography with time-of-flight technique also performed.
Comparison is made with a prior head CT dated [**2187-6-22**].
FINDINGS: Note is made of mild brain atrophy with mildly
enlarged ventricles. Note is made of multiple areas of T2 high
signal intensities within the deep white matter, representing
chronic small vessel ischemia and old infarction. No evidence of
acute or hyperacute infarction noted on diffusion-weighted
images. No evidence of intracranial mass lesion noted. No mass
effect is seen. No susceptibility abnormality is seen.
On MR angiography, note is made of hypoplastic right vertebral
artery with minimal flow, with probable PICA termination.
Otherwise, no significant stenosis is seen. No evidence of
aneurysm.
IMPRESSION:
MRI: Multiple old infarctions and chronic small vessel ischemia.
No evidence of acute infarction.
MRA: Small right vertebral artery with probable PICA
termination. No evidence of aneurysm or significant stenosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: TUE [**2187-6-26**] 2:15 PM
The recording began at 9:30 on the morning of [**7-4**]. It
showed a low voltage [**3-30**] Hz slow background in all areas with
occasional
bursts of generalized slowing. There was marginally more focal
slowing
in the right anterior quadrant. Occasional right frontal sharp
waves
appeared less frequent than on the previous day's recording. The
recording did not change significantly over the day.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This EEG monitored cerebral function at the bedside
from
[**9-4**]. It showed an encephalopathic background
throughout.
There were occasional right frontal or anterior quadrant blunted
sharp
waves and additional slowing but no signs of ongoing seizures.
The
encephalopathy was the dominant feature, and it did not change
significantly over the course of the recording.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] W.
([**3-/2091**]U)
Brief Hospital Course:
A/P: 75 yoM w/ CRI, CAD s/p CABG X 4, trach/PEG for prolonged
ventilator wean presented with VAP and persistant anemia with
guaiac positive stool. Hospital course complicated by
deteriorating mental status exacerbated by hypoglycemic episode
[**2187-6-28**] with probable associated seizure activity. Also
complicated by pneumonia on [**2187-7-10**].
1) Altered mental status: Decline in mental status
deteriorating to persistent vegetative state. Multifactorial
cause including uremic encephalopathy, hypoglycemic episode on
[**2187-6-28**], seizure activity, generalized atrophy noted on MRI,
likely reflective of chronic multi-infarct small vessel disease.
Throughout the pt's admission, he became increasingly obtunded.
As compared with his baseling on admission, he became
increasingly unable to interact or communicate with either
hospital staff or his family and became almost completely
unresponsive. Initially, several etiologic factors were
suspected, chiefly toxic metabolic disease secondary to his
worsening renal function. Also seizure activity secondary to
prior CVA may have contributed to this, suggested by
epileptogenic foci seen on EEG (although no active seizure was
seen). CT studies revealed no new mass or bleed, MRI revealed
no new ischemic or vascular disease but did reveal chronic
atrophic changes.
The patient's mental status showed mild improvement with
hemodialysis. By the fourth round of hemodialysis the patient
appeared to be aware of other people in the room. On [**6-28**], per his family, the patient was attempting to mouth words.
Unfortunately, his mental status acutely declined the following
night, becoming again almost completely unresponsive. His blood
glucose levels was noted to have fallen from 100-150 level to
almost nil within a few hours. He was given an ampule of D50
for profound hypoglycemia, 1 mg Ativan IV for possible seizure
activity and underwent CT scan which ruled out any acute bleed
or mass effect. After multiple treatments of dextrose his
blood glucose returned to 120-130 range, pt was temporarily on a
dextrose intavenous drip as well. His doses of Humalog were
stopped as was his insulin sliding scale. Neurology and
Endocrine services were consulted. Neurology recommended
starting patient on phenytion. Endocrine advised that, in the
setting of his renal function deteriorating to end stage, the
kinetics of insulins (which are renally cleared) would be
altered unpredictably. In addition renal gluconeogenesis is
impaired. The patient likely suffered increased impairment in
renal clearance of insulin, as well as in renal gluconeogenesis
that night that led to his acute hypoglycemia. With guidance of
the Endocrine service we changed his insulin from Humalog to the
shorter acting NPH and aiming for glucose ranges in the 150.
It should be noted that the patients kidney function had
been end stage for almost two weeks, that he had been on the
humalog/RISS as well as been on continuous tube-feedings
throughout that time. After his episode of hypoglycemia, we
aggressively monitored his glucose levels and, with the help of
the endocrine service, adjusted his doses of NPH accordingly.
Several EEG's were performed. No active seizure activity was
seen but there were foci with eptileptogenic potential noted in
R frontal lobe. Dilantin dosages were also adjusted until
therapeutic levels could be achieved. This patient will likely
require Dilantin for the remainder of his days. The patient
remained in eu- or hyperglycemic ranges following the
hypoglycemic episode on the [**6-28**]//05 but did not show significant
improvement in mental status over the next 10 days. Neurology
felt the prognosis for improvement of mental status to be very
poor. By the end of his stay, it was the opinion of both the
primary team and the neurology service that the patient was in a
persistent vegetative state.
2) Hypoxic respiratory failure
The patient was maintained on assist-control for the majority of
the hospital stay, demonstrating very good oxygen saturations.
On [**7-6**] patient was transitioned to pressure support ventilation
which was well tolerated. ABG notable for respiratory acidoses
but good oxygenation. On day before discharge patient weaned to
tracheostomy mask, again ABG showed good oxygenation with mild
respiratory acidosis with appropriate compensation.
3) End stage renal disease: The pt presented with acute on
chronic renal failure with Cr 3.3 from baseline of 2.4. During
his course, he developed progressive oliguria despite diuretic
therapy. The etiology of the pt's worsening renal function was
most likely pre-renal failure and ATN in setting of
intravascular volume loss [**12-27**] GI bleed.
Despite aggressive medical diuresis and hydration, the pt
continued to have worsening renal function by elevated
creatinines and volume overload. The pt also became increasingly
obtunded felt to be secondary to uremia. The pt was , therefore
started on HD and an HD tunnel catheter was placed on [**2187-6-26**].
Pt received hemodialysis on a Monday, Wednesday, Friday
schedule. His creatinine stabilized. He did appear to have
uremic platelet dysfunction on [**7-6**] which resolved (see
4) Anemia: Pt had anemia likely secondary to a number of causes
including possible GI bleed on admission, bleeding secondary to
thrombocytopenia/uremic platelet syndrome, anemia of End stage
renal disease, anemia of chronic disease.
The pt's admitting HCT was 29.6 (baseline HCT 26-31). He
required 2 Units PRBC during his admission on [**6-15**]. Following
that, his hct remained stable (28-30). An EGD on admission
revealed gastritis/gasrtic erosions and no significant active
bleeding. Colonoscopy likewise revealed no active bleeding,
though did reveal transverse and sigmoid colon polyps and
internal hemorrhoids. Iron studies, vit B12, folate were normal.
Retic count was normal as were LDH and haptoglobin. Given this
data, the pt's anemia did not appear to be secondary to
deficiency, destruction, or under-production.
The pt's anemia was felt to be likely secondary to a slow GI
bleed, possibly from gastric erosions. Stool specimens were
C.diff negative, Cx negative, campylobacter neg, and negative
for O and P. Therefore unlikely infectious etiology of GI bleed.
During his admission he received IV Protonix 40 mg [**Hospital1 **], this was
eventually changed to lansoprazole given though PEG.
On [**2187-6-27**] patient noted to have generalized bleeding in several
area including tracheostomy site, IV line insertion areas. He
was noted to have a decrease hematocrit and was transfused four
units of pRBC over the next two days, also received. Also
noted to have purpuric lesions and decreased platelets. HIT
sent, returned as negative. Rec'd 1 unit platelets. Platelets
normalized over next few days. His hematocrit stabilized and
pt required no further transfusions. The bleeding was felt to
be secondary to uremic platelet syndrome. Hematocrit was
generally stable as was the platelet count for rest of hospital
course.
Patient received epoetin treatment on hemodialysis days.
.
5) VAP: Pt had two occurrences of ventilator associated
pneumonia.
Upon admission, the pt had been on ceftaz/vanco since [**6-4**] given
increased secretions, infiltrates on CXR, though no documented
fever. A sputum on [**6-11**] grew out ceftaz sensitive Pseudomonas.
His vanc was d/c'd as he had been given a seven day course and
had no identifiable Gram positive organism grown out of cx. His
ceftazidime was continued on a 21 day course. Flagyl was added
on [**6-18**] for coverage of potential anaerobes, given a question of
aspiration.
The pt was followed clinically and radiographically throuigh
serial CXRs. As of [**6-21**] CXRs demonstrated resolution of the pt's
upper lobes opacities, though with worsening of the lower
lobes. Pt was afebrile however.
On [**2187-7-9**] pt noted to be in respiratory distress with fever,
increased respiratory rate and increased secretions. White
blood cell count elevated. Pt started on levofloxacin and
flagyl. Also on ampicillin given elevated LFTs that day for
possible acalculous cholecystitis (see below). Sputum culture
grew gram negative rods, chest x-ray show mildly increased
infiltrates but no effusion or consolidation.
Pt improved over next few days, defervescing with resolution of
respiratory distress. WBC returned to [**Location 213**]. Some resolution
of infiltrates on CXR. Less secretions noted. By discharge,
pneumonia had resolved. Pt discharged on antibiotic course of
levofloxacin and flagyl to complete on [**2187-7-23**].
Pt received alb/atr nebs and home fluticasone throughout
admission.
5) Transaminitis/biliary sludge. Pt noted to have markedly
elevated LFTs with some biliary sludge noted on RUQ ultrasound.
No gallstones seen. On [**7-9**] pt had fever and again had LFTs
elevated; this was concerning for acalculous cholangitis and pt
started on ampicillin. Repeat RUQ u/s showed no evidence of
this. Ampicillin was discontinued. Other than being briefly
intolerant to tube feeds, pt showed no signs on abdominal exam
consistent with biliary disease although his LFTs were generally
elevated throughout admission.
6) CAD: s/p CABG X 4 [**2-27**].
- hold ASA given suspected GI bleed
- unclear why patient is noTnT leak likely [**12-27**] decreased
clearance in the setting of acute on chronic renal failure. Will
monitor to ensure downward trend.
.
7) HTN: Proved difficult to control in setting of meds if
remains hemodynamically stable now adequate on labetalol,
amlodipine, hydralazine, and his dialysis.
.
11) Access: PIV, L PICC line (placed [**7-10**]), and tunneled cath
.
12) Code: Full code
.
13) Communication: HCP daughter [**Name (NI) 21105**] [**Name (NI) 21106**] (H:
[**Telephone/Fax (1) 21107**], C: [**Telephone/Fax (1) 21108**])
Medications on Admission:
1) Prevacid 30 mg PGT [**Hospital1 **]
2) Haldol 0.5 mg PGT [**Hospital1 **]
3) Ceftazidime 1 g IV q8h (started [**6-4**])
- vancomycin stopped [**6-9**] for elevated trough
4) Amlodipine 10 mg PGT daily
5) Ascorbic acid 500 mg PGT [**Hospital1 **]
6) Casec powder 2 tbsp PGT [**Hospital1 **]
7) Colace 100 mg PGT [**Hospital1 **]
8) Ferrous sulfate 300 mg PGT [**Hospital1 **]
9) Heparin 5000 u SC q12h
10) Hydralazine 50 mg PGT q6h
11) Ipratroprium INH QID and q4h prn
12) Labetolol 400 mg PGT q8h
13) Xopenex 0.63 mg neb TID and q4h prn
14) MV1 PGT daily
15) Senna 10 ml PGT [**Hospital1 **]
16) Dulcolax prn
17) Lactulose prn
18) Tylenol prn
19) NPH 20 u SC BID RISS
20) ECASA 325 mg PO daily
21) Fluticasone MDI 220 mcg INH q12h
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-26**]
Puffs Inhalation Q4H (every 4 hours).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-26**]
Drops Ophthalmic PRN (as needed).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) suspension PO DAILY (Daily).
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
7. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
9. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day) as needed.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
14. Phenytoin 100 mg/4 mL Suspension Sig: 6.4 mL PO TID (3 times
a day): Please give phenytoin 3 hours after tube feed.
15. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
17. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Fifty (50)
mL Intravenous Q24H (every 24 hours): End date [**2187-7-23**].
18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One Hundred (100) mL Intravenous Q8H (every 8 hours): End date
[**2187-7-23**].
19. Morphine 2 mg/mL Syringe Sig: 0.25 mL Injection Q4H (every 4
hours) as needed.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
units Subcutaneous twice a day: at 8 am and 8 pm. If dose to be
increased, please increase with caution.
22. Humalog 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous four times a day: Please give 3 units humalog 15
minutes before tube feedings. If need to increase dose, please
increase cautiously.
23. Tube feedings.
Please give tube feedings for times a day 6 am, 12 noon, 6 pm,
midnight. Full strength Nepro with promod. See page 1
referral.
24. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
25. Insulin
Goal blood sugar is 140-180. Titrate up humalog and NPH
ONE unit at a time to acheive this goal.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**]
Discharge Diagnosis:
Hypoxic respiratory failure.
Prolonged weaning from ventilatory requiring placement of
tracheostomy and PEG.
Persistent vegetative state.
Seizure disorder s/p stroke.
Hypoglycemic episode on [**2187-6-28**] with associated seizure
activity.
Ventilator Associated Pneumonia secondary to MRSA, Pseudomonas.
Ventilator Associated Pneumonia secondary to gram negative rods,
unspeciated.
Transaminitis.
Thrombocytopenia, now resolved.
Anemia of chronic disease.
Anemia secondary to suspected lower GI bleed.
End stage renal disease requiring hemodialyisis.
Anemia secondary to renal disease.
Renal hypertension.
Uremia with resulting encephalopathy and platelet dysfunction.
Coronary Artery Disease s/p cor a bypass graft surgery.
Discharge Condition:
Obtunded, suspected persistent vegetative state.
Medically, condition is fair. Breathing through tracheostomy
without ventilatory support, afebrile, hemodynamically stable
but hypertensive. Hematocrit stable. Tolerating hemodialysis,
no current signs of uremia.
Discharge Instructions:
Please continue hemodialysis on Monday, Wednesday, Friday
schedule.
Please continue dilantin therapy.
Please continue antibiotic therapy for total of two weeks, end
date [**2187-7-23**].
Please continue to use CONSERVATIVE blood glucose management
given episode of hypoglycemia. Goal blood glucose eventually
100-150, cautiously increase dose of humalog and/or NPH.
Followup Instructions:
Extended care in rehabilitation facility.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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"250.80",
"535.51",
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.95",
"45.12",
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icd9pcs
|
[
[
[]
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19716, 19823
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6380, 6745
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352, 407
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20593, 20860
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21275, 21446
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3072, 3077
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3864, 3945
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3092, 3538
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277, 314
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3974, 6357
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435, 2334
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6761, 16278
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2356, 2918
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2934, 3056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,069
| 168,287
|
27223
|
Discharge summary
|
report
|
Admission Date: [**2203-6-7**] Discharge Date: [**2203-7-8**]
Date of Birth: [**2133-5-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Ambien / Lopressor / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing DOE
Major Surgical or Invasive Procedure:
[**2203-6-13**] MVR (25/33 OnX valve)
History of Present Illness:
70 yo F presented to OSH with increasing DOE, BNP found to be
1100, R/o for MI. Admitted to CCU and given bumex with relief.
Cardiac cath showed 3+ MR, no CAD. Transferred for MVR.
Past Medical History:
PMH: COPD/asthma, HOCM, PAF s/p DCCV x 3, diverticulitis, GERD,
anxiety/depression/panic attacks, HTN, hypothyroid, hemorrhoids,
hiatal hernia, glaucoma, cysto adenocarcinoma of uterus s/p TAH
[**2159**], laser eye surgery x 2, PPM (St. [**Male First Name (un) 923**] dual chamber), lumbar
fusion, chole, hemorrhoids, s/p ventral hernia repair x 2
Social History:
SHx: patient lives in [**Hospital3 **], she's independent in her
IADLs, no alcohol, no drugs, smoked 25 years ago, 2 cigarrets a
day x 10 years.
.
Family History:
FHx: Mother - CAD 60s, depression. Sister - CVA [**59**]. Father - MI
in 80s. Sister - emphysema, HTN. Brother - neurofibromatosis.
Son with pulmonic stenosis.
Physical Exam:
NAD, no SOB at rest
Skin multiple ecchymosis
HEENT unremarkable, glassess
Lungs CTAB
Heart RRR
Abdomen scar tissue from hernia repair
Extrem warm, trace edema
Pertinent Results:
[**2203-7-8**] 06:01AM BLOOD WBC-13.1* RBC-3.77* Hgb-11.4* Hct-35.6*
MCV-95 MCH-30.2 MCHC-31.9 RDW-18.0* Plt Ct-309
[**2203-7-8**] 06:01AM BLOOD Plt Ct-309
[**2203-7-8**] 06:01AM BLOOD PT-37.6* PTT-42.2* INR(PT)-4.0*
[**2203-7-8**] 06:01AM BLOOD Glucose-90 UreaN-34* Creat-1.1 Na-143
K-3.5 Cl-109* HCO3-24 AnGap-14
FINDINGS: In comparison with study of [**7-7**], there is little
change. Again there is a moderate left pleural effusion that
obscures the left heart border. Probable underlying atelectatic
change involving the left lower lobe. The right lung is
essentially clear. Central catheter and pacemaker device remain
in place.
Brief Hospital Course:
She was cleared for surgery by dental. EGD done for anemia
showed no bleeding and three biopsies were done which have since
returned negative. She was taken to the operating room on [**2203-6-13**]
where she underwent a MVR, please see operative note for
details. She was transferred to the ICU in critical but stable
condition on epinephrine and propofol. She required significant
volume resuscitation. She was started on milrinone. She had
several episodes of hypertension with flash pulmonary edema, and
She was started on a lasix drip. She was started on a heparin
drip for her mechanical valve. She was started on anxiolytics
for agitation with attempts at vent weaning. TEE was negative
for perivalvular leak or other major pathology. Her milrinone
was weaned to off. Vanco was started empirically for GPC and GPR
in sputum. She remained intubated and not following commands.
Dobhoff tube was placed in IR on [**6-23**] and she was started on
tube feeds once the tube was post pyloric. Head CT done for
mental status showed no acute processes. Her white count rose
and she was started on flagyl and cipro along with vanco and she
was pancultured (remain negative). She awaited improved mental
status prior to extubation on [**6-27**]. She was started on coumadin
for her mechanical valve. Bedside swallow evaluation recommended
advancing diet to honey thick liquids and pureed solids. PICC
line was placed on [**6-29**]. She remained in the ICU for aggressive
pulmonary toilet. Her creatinine increased and her diuretic was
held, and she was given free water for hypernatremia. She was
seen by electrophysiology for persistent atrial fibrillation and
her medications were adjusted.
She was seen by ENT for continued hoarseness several days after
extubation. Exam showed mild vocal cord findings but no evidence
of nerve injury, and she was started on [**Hospital1 **] PPI. She was
transferred to the floor on POD #22. She has remained
hemodynamically stable, and is now ready to be transrferred to a
rehab facility.
Medications on Admission:
verapamil SR 360'', cozaar 100', flecainide 100'', singulair
10', combivent'', pulmicort'', prilosec 40'', zantac 300',
zoloft 200', synthroid 112', reglan 10'', bumex 0.5', albuterol
PRN, Ativan PRN, miralax PRN, klonopin 2', coumadin, premarin
0.625'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q6hours () as needed for prn dyspnea.
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
13. 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.
14. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day:
beginning on [**7-9**] if INR < 4.0. Target INR 3.0-3.5.
15. Bumex 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day: reduce to 20 mEq daily if K > 4.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
MR now s/p MVR
PMH: COPD/asthma, HOCM, PAF s/p DCCV x 3, diverticulitis, GERD,
anxiety/depression/panic attacks, HTN, hypothyroid, hemorrhoids,
hiatal hernia, glaucoma, cysto adenocarcinoma of uterus s/p TAH
[**2159**], laser eye surgery x 2, PPM (St. [**Male First Name (un) 923**] dual chamber), lumbar
fusion, chole, hemorrhoids, s/p ventral hernia repair x 2
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] [**Telephone/Fax (1) 14525**] 2 weeks
Dr. [**Last Name (STitle) **] after discharge from rehab
Completed by:[**2203-7-8**]
|
[
"425.1",
"518.5",
"V45.01",
"424.0",
"285.9",
"458.29",
"997.1",
"493.20",
"276.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"35.24",
"39.61",
"33.24",
"88.72",
"38.93",
"45.16",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5979, 6058
|
2150, 4174
|
330, 370
|
6465, 6475
|
1489, 2127
|
6801, 7001
|
1132, 1294
|
4478, 5956
|
6079, 6444
|
4200, 4454
|
6499, 6778
|
1309, 1470
|
276, 292
|
398, 580
|
602, 951
|
967, 1116
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,487
| 147,276
|
9316
|
Discharge summary
|
report
|
Admission Date: [**2192-6-8**] Discharge Date: [**2192-6-15**]
Date of Birth: [**2120-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x3 (Left internal mammary artery >
left anterior descending, saphenous vein graft > RAMUS,
saphenous vein graft > posterior descending artery)
History of Present Illness:
71 year old male with pertinent history of dyslipidemia and
hypertension who complains of a week and a half of substernal
pressure on exertion. He denies
associated symptoms.Pain relieved by rest. He was admitted to
[**Hospital6 **] and found to have three vessel coronary
artery disease. He transferred to [**Hospital1 18**] for evaluation for
coronary revascularization
Past Medical History:
Hypertension
Kidney Stone
Dyslipidemia
Colon cancer 22 years ago, s/p colon resection
s/p Lower back surgery
s/o colon resection
Social History:
Mr. [**Known lastname 31886**] lives with his wife. [**Name (NI) **] has three children and is a
retired newspaper publisher. He denies tobacco and alcohol.
Family History:
non-contributory
Physical Exam:
Pulse:70 Resp:18 O2 sat: 99%RA
B/P 170/96
Height: 5'5" Weight:200LBs
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
Abdomen: Soft [x non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
RLE
varicosity noted None []
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Carotid Bruit none appreciated, pulses Right:2+ Left:2+
Pertinent Results:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on no inotropes.
Preserved biventricular systolic fxn.
MR is trace.
No AI. Aorta intact.
EKG
Sinus rhythm. Baseline artifact. Non-specific inferolateral T
wave
flattening. No previous tracing available for comparison.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 142 98 422/437 45 -13 34
[**2192-6-15**] 06:10AM BLOOD WBC-8.4 RBC-3.11* Hgb-9.8* Hct-28.0*
MCV-90 MCH-31.7 MCHC-35.1* RDW-13.2 Plt Ct-275
[**2192-6-14**] 05:50AM BLOOD WBC-12.1* RBC-3.33* Hgb-10.8* Hct-30.0*
MCV-90 MCH-32.4* MCHC-35.9* RDW-12.9 Plt Ct-226
[**2192-6-15**] 06:10AM BLOOD UreaN-18 Creat-1.0 Na-138 K-4.2 Cl-100
HCO3-29 AnGap-13
[**2192-6-14**] 05:50AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-139
K-4.8 Cl-102 HCO3-30 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 31886**] was transferred in from outside hospital for
surgical evaluation. He underwent preoperative workup and on
[**6-11**] was taken to the operating room for a coronary artery
bypass graft. See the operative report for further details. He
received cefazolin and vancomycin for perioperative antibiotics
and was transferred to the intensive care unit for post
operative management. That evening he was weaned from sedation,
awoke neurologically intact and was extubated without
complications. On post operative day one his chest tubes were
removed and he was started on beta blocker and diuretics. Later
that day he was transferred to the floor. On post operative day
two physical therapy worked with him on strength and mobility.
His epicardial wires were removed. By post-operative day 4 he
was ready for discharge to home. All follow-up appointments
were advised.
Medications on Admission:
Lipitor 10mg Daily
Lisinopril 20mg Daily
Asprin 81mg Daily
MVI
Vitamin D and Vit E
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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
Wound Check at [**Hospital Unit Name 4081**], [**Telephone/Fax (1) 170**]
Date/Time:[**2192-6-20**] 10:00
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2192-7-5**] 1:15
Please call to schedule appointments with your
Cardiologist: Dr [**Last Name (STitle) 31887**] - please schedule an appointment to
be seen in 3 weeks
Primary Care Dr [**Last Name (STitle) 12816**] [**Telephone/Fax (1) 12817**] in [**4-3**] weeks [**Telephone/Fax (1) 12817**]
**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:[**2192-6-15**]
|
[
"414.01",
"V45.89",
"413.9",
"401.9",
"V10.05",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5813, 5896
|
4008, 4910
|
318, 492
|
5999, 6210
|
1913, 3985
|
7051, 7773
|
1239, 1257
|
5043, 5790
|
5917, 5978
|
4936, 5020
|
6234, 7028
|
1272, 1894
|
267, 280
|
520, 894
|
916, 1047
|
1063, 1223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,309
| 147,011
|
19624
|
Discharge summary
|
report
|
Admission Date: [**2182-6-20**] Discharge Date: [**2182-6-25**]
Date of Birth: [**2108-8-2**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Folic Acid / Diphenhydramine / Sulbactam
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Aphasia, CODE STROKE
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
73 yo RHF with history of possible prior stroke (details
unclear), NIDDM, diastolic dysfunction, s/p left total knee
replacement [**6-20**] at NEBH. After the procedure in the PACU she
was noted to develop sudden aphasia, right-sided arm and leg
weakness and left tongue deviation. She was last seen normal at
8:30pm and symptoms were noted at 8:45 PM. Her comprehension
remained intact as per the medical record and she denied any
headache, visual changes, or neck pain. She was transferred to
[**Hospital1 18**] and a code stroke was activated at 9:42 PM. On initial
neurologic examination by the ED physician, [**Name10 (NameIs) **] patient was
noted to have right face/arm/leg weakness, gaze preference to
the left, left tongue deviation, and severe aphasia; that
physician gave her [**Name9 (PRE) 18246**] score of 10. On initial neurologic
examination by the neurology stroke fellow, which took place 20
minutes after the examination by the ED physician, [**Name10 (NameIs) **] patient
had an isolated expressive aphasia, a questionable mild right
facial droop, and a mild dysarthria. Her comprehension was
entirely intact, and - through a series of yes/no questions and
answers, we were able to ascertain that the patient had no
nausea, headache, dizziness, palpitations, or pain.
NIHSS at 10:15pm = 6:
1a. Level of Consciousness: 0
1b. LOC questions: 2
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: Untestable (due to TKR today)
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 2
10. Dysarthria: 1
11. Extinction and inattention: 0
Total = 6
Past Medical History:
? of stroke in [**2178**] with somewhat unclear symptoms. Patient
states she was unable to speak at that time but does not recall
any focal weakness or other symptoms.
Asthma
NIDDM
Osteoarthritis
Glaucoma
Diastolic dysfunction
hypothyroidism
Celiac sprue
Sleep apnea
Esophageal hernia
CCY
Herniated discs
Social History:
She lives alone and has no social or medical help. Has 5 stairs
to step into her house, lives just on [**Location (un) 448**]. She is
retired and worked as a teacher. No children. She has never
smoked and denies any use of illicit drugs. Has 1 drink at
communion more than 1 a week.
Family History:
Father: died at 69 ?????? MI?
Mother: died at 82 ?????? heart and renal failure.
5 siblings who all suffered from heart disease and 4 of them
died because of an MI at the age of 45-55. One brother with DM.
No children.
Physical Exam:
Physical Examination;
VS; 97.3F 150/50, 75, 16, 99%RA
Gen: Lying in bed, NAD
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, +S1,S2, no murmurs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Extr: no edema. L-knee bandaged and drain in place
Neurologic examination:
Mental status: Awake and alert, cooperative with exam. Follows
all commands appropriately. Comprehension seems entirely
intact.
Stuttering and slow speech. Able to name common objects and
repeat a sentence. Able to identify the current president.
Able
to write and read. No L/R confusion. No neglect. No
extinction.
Cranial Nerves:
Pupils equally round and reactive to light, 2mm-->1.5mm
bilaterally. VFF, Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement somewhat
weak
B/L (air escapes when tries to puff out cheeks.) There is mild
flattening of the right nasolabial fold. Hearing grossly
intact.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 4+ 4+ 4+ 4+ 4+ 4+ 4+ 3+ 3+ 3+ 3+ 3+ 3+ 3+
L 4+ 4+ 4+ 4+ 4+ 4+ 4+ - - - - - - -
(Note: weakness is subtle in the UE B/L and seems to have a
giveway component with a give-and-go tone when pushing. Also RLE
appears to be effort-dependent and LLE was not testable due to
total knee replacement [**6-20**])
not testable)
Sensation: Intact to light touch and pinprick in all
extremities.
Reflexes:
0 throughout
Toes downgoing bilaterally
Coordination: finger-nose-finger with mild dysmetria, R worse
than L. RAMs slow bilaterally.
Pertinent Results:
WBC 10.5 HCT 27.7, Plts 309
Na 141 K 4.5, Cl 108 CO2 23 BUN 17 Cr 1.0 Gluc 168
ALT 60, AST 128, ALP 99, T bili 0.9
serum tox neg, u tox + opiates, benzos
UA; 10 wbc, 2 epis, neg nitrite, neg LE
CPK 209 --> 182
trop 0.01
lipids, HbA1c pending
TSH 1.5
PTT 22, INR 1.1
CTA head/neck; mild atrophy and white matter disease
MRI head;
1. No acute intracranial process.
2. Small vessel ischemic disease and age-related atrophy.
TTE;
IMPRESSION: Suboptimal image quality. Mild pulmonary artery
systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. No definite cardiac source of embolism
identified.
Image quality was suboptimal for saline contrast study for a
possible patent foramen ovale.
Compared with the prior report (images unavailable for review)
of [**2179-3-8**], the findings are similar.
Brief Hospital Course:
Ms. [**Known lastname 11925**] is a 73-year-old right-handed female with ? history
of stroke in [**2178**], NIDDM, diastolic dysunction, s/p L total knee
replacement [**6-20**] at NEBH with sudden development of aphasia and
right-sided weakness while in [**Hospital 53180**] transferred to
[**Hospital1 18**] as code stroke with NIHSS 6, and was administered IV TPA
given her the severity of her speech deficit. Neurological
examination on admission showed a mild right facial droop, mild
dysarthria, and nonfluent speech. Her motor exam appears more
consistent with giveway weakness and her deficits do not appear
unilateral. MRI head the following AM showed no evidence of
acute infarct. Given the lack of infarct by MRI and full
resolution of her deficits in the setting of tPA, the episode is
being diagnosed as a transient ischemic attack.
Neurology ICU course:
The patient was monitored in the intensive care unit s/p IV TPA
and had an uneventful course to date. Her home antihypertensive
medications were held and she was given normal saline boluses to
maintain systolic blood pressure above 110 mmHg. A lipid panel
revealed LDL of 79 and she was continued on her home
simvastatin. A TTE showed no evidence of a cardiac source
(however it was noted to be a suboptimal evaluation for PFO),
and there have not been any arrhythmias on telemetry.
Antiplatelet agents were intially held, resumed [**6-22**]. transfer to
floor [**6-22**].
Neurology Floor Course:
Pt had a normal neurologic examination with occasional slow
speech, but no deficits of language. She was continued on daily
aspirin therapy. She had a syncopal episode after standing from
the commode on the day of discharge. Her neurologic examination
was normal. She was notably orthostatic. Oral rehydration was
encouraged. Her diuretic dose was halved. She should follow up
in clinic with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**].
ID:
She had a mild leukocytosis with no clear source but has been
afebrile and the WBC is trending down. CXR, UA, culture, blood
cultures were all within normal limits.
Cardiovascular:
Budesonide was initially held, then restarted at 100mg daily.
Given poor PO intake it was decreased to 50mg daily. Clinical
signs for volume overload and titration of diuretics may occur
at rehab. Zestril was restarted, diovan was held and may be
restarted pending serial blood pressure monitoring and
resulution of her orthostatic symptoms.
Heme:
Her baseline HCT was 33.6 which slowly declined to 23 and was
stable for four days with serial hct checks. Stool was guaiac
negative. No evidence for hemarthrosis. Iron studies were sent
revealing: Iron 24, TIBC 204, Transferrin 157. She was started
on oral iron replacement. Serial hematocrit monitoring should
continue at rehab.
Orthopedic:
She is able to bear full weight on her left knee. The surgeon
performing the operation was at [**Hospital6 2910**]-
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 53181**], Office number [**Telephone/Fax (1) 29119**]. She should
continue with PROM exercises. Staples should be removed in 2.5
weeks. Enoxaparin should be discontinued per the discretion of
Dr. [**Last Name (STitle) 53181**] the indication is for post-orthopedic DVT
prophylaxis (not related to her neurologic event).
Endocrine:
She was continued on her synthroid for hypothyroidism. Metformin
was held following IV contrast for head CTA. It was restarted
the day of discharge. She should continue on an insulin sliding
scale for optimum blood sugar control.
Medications on Admission:
Glucophage 500 mg [**Hospital1 **]
Singulair 10 mg daily
Diovan 160 mg daily
Synthroid 200 mcg sunday, 300 mcg Monday-Saturday
Fluticasone 2 sprays in each nostril daily
Symbicort 1 puff daily
Zestril 2.5 mg daily
Zocor 40 mg daily
Celexa 20 mg daily
Demadex 100 mg daily
Potassium 20 meq daily
Zaroxolyn 2.5 mg daily
Vitamin D
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever >101.
7. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO 1X/WEEK
([**Doctor First Name **]).
8. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
13. Budesonide-Formoterol 160-4.5 mcg/Actuation HFA Aerosol
Inhaler Sig: Two (2) Inhalation [**Hospital1 **] () as needed for shortness
of breath or wheezing.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Torsemide 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
18. Zestril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
19. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
20. Humalog Sliding Scale
Breakfast, Lunch, Dinner, bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Transient Ischemic Attack- given IV tPA with full resolution of
deficits.
Discharge Condition:
awake, alert, comprehension intact. Occasional slowed speech,
but no deficit of speech production or comprehension. Strength
full. Slight generalized edema of upper and lower extremities
reducing rapid alternating movements bilaterally (improving
following diuresis at discharge). No dyspnea. Not on
supplemental oxygen.
Discharge Instructions:
Please follow up with your PCP as well as Dr. [**Last Name (STitle) **] (neurology)
as indicated below. Continue to take your medications as
prescribed. Return to the Emergency Department immediately for
any changes in your speech or comprehension, any visual changes,
weakness, or numbness.
Continue passive range of motion exercises with your left knee.
Weight bearing is allowed as much as you tolerate it. left knee
staples should be removed in 2.5 weeks.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 53181**] at [**Hospital6 **] for follow up
care of your knee replacement. [**Telephone/Fax (1) 29119**]. You will need the
staples removed in 2.5 weeks. You may discontinue lovenox at the
discretion of Dr. [**Last Name (STitle) 53181**].
You have an appointment to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD in the
neurology clinic at [**Hospital1 69**].
Date/Time:[**2182-7-31**] 1:30 Office Phone:[**Telephone/Fax (1) 44**]
Please see your primary care doctor for follow up within the
next 2-3 weeks.
|
[
"288.60",
"244.9",
"579.0",
"428.32",
"250.00",
"784.3",
"351.8",
"V45.89",
"780.57",
"365.9",
"342.90",
"285.1",
"553.3",
"458.0",
"435.9",
"493.90",
"715.90",
"V43.65",
"722.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
11347, 11430
|
5688, 9304
|
344, 353
|
11548, 11871
|
4778, 5665
|
12382, 12999
|
2705, 2928
|
9683, 11324
|
11451, 11527
|
9330, 9660
|
11895, 12359
|
2943, 3249
|
284, 306
|
381, 2058
|
3611, 4759
|
3288, 3595
|
3273, 3273
|
2080, 2388
|
2404, 2689
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,961
| 137,996
|
50981+59345
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-8-20**] Discharge Date: [**2162-8-27**]
Service:
CHIEF COMPLAINT: Chest pain and shortness of breath.
HISTORY OF THE PRESENT ILLNESS: This is an 88-year-old male
with a history of coronary artery disease status post CABG in
[**2157**] with a saphenous vein graft to PDA SVG to LAD and to the
RCA, CHF with ejection fraction of approximately 45% in [**2160**].
The patient presents from an outside hospital with chest pain
here for therapy. The patient was in the usual state of
health approximately two weeks ago. The patient has noted
progressive dyspnea on exertion, increasing orthopnea and
progressive paroxysmal nocturnal dyspnea. The patient has
had shortness of breath times three days, progressing to
hospital admission at [**Hospital6 2910**] on
[**2162-8-12**]. The shortness of breath resolved over the next
six days with aggressive diuresis. The patient was also in
new onset atrial fibrillation. The patient was started on
anticoagulation with Amiodarone.
The patient was discharged to rehabilitation on [**8-19**]. The patient developed severe chest pain and shortness of
breath. EKG taken at that time revealed left bundle branch
block with atrial fibrillation in the 150s. The patient was
given IV Lopressor, Lasix, and Cardizem drip. Enzymes
revealed CK of 263, MB 24, troponin 20.3. Echocardiogram
revealed inferior posterior and septal hypokinesis with
ejection fraction of 30%, 2+ to 3+ MR and 1+ AR and the
patient was transferred to [**Hospital1 188**] for wound cutting and brachytherapy.
Cardiac catheterization revealed hemodynamics in the right
atrium of 12, right ventricle 65/3, PA pressure of 62/31,
wedge of 35. Angiography revealed moderate disease, left
main 100% native LAD, left circumflex and moderate disease
100% proximal RCA, PDA restenosis in stent, 80% in stent
restenosis in the RPDA, unable to perform brachytherapy, but
had successful wound cutting. The patient was transferred to
the Coronary Care Unit for CHF and MI management.
PAST MEDICAL HISTORY:
1. CABG in [**2157**], status post stent, saphenous vein graft,
PDA saphenous vein graft to the LAD, saphenous vein graft to
the RCA.
3. Congestive heart failure.
4. Diabetes mellitus.
5. Hypertension.
6. Chronic renal insufficiency with baseline creatinine of
1.2 to 2.4.
7. Hypercholesterolemia.
8. Colitis.
9. Anemia.
10. Gout.
11. VRE positive stool.
MEDICATIONS ON TRANSFER:
1. Lopressor 50 mg PO b.i.d.
2. Nitroglycerin drip.
3. Cardizem drip.
4. Morphine.
5. Amiodarone 400 mg PO q.d.
6. Asacol 400 mg PO t.i.d.
7. Zestril 20 mg PO q.d.
8. Digoxin 0.125 mg PO q.d.
9. Epogen 3000 units subcutaneously q.Tuesday.
10. Protonix 40 mg PO q.d.
SOCIAL HISTORY: The patient lives in [**Location 583**] with his wife.
Wife has Parkinson disease. The patient is a current smoker.
The patient drinks alcohol occasionally and is able to walk
and ambulate on his own.
FAMILY HISTORY: History is significant for coronary artery
disease.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Temperature 97.0, heart rate 95 and irregular.
Blood pressure 137/84, respiratory rate 36, 96% on 10 liters
face mask. GENERAL: The patient appears tachypneic, but is
a pleasant male, alert and awake. HEENT: Normocephalic,
atraumatic. Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Mucous membranes dry.
Oropharynx clear. NECK: Jugulovenous distention at 8 cm at
30 degrees, supple with no carotid bruits. LUNGS: Crackles,
left greater than right approximately [**12-17**] of the way up in
the bases. CARDIOVASCULAR: S1 and S2 irregular rate, no S3,
S4, 3/6 systolic murmur loudest at the apex radiating to the
axilla. No rubs or gallops. Abdominal examination revealed
bowel sounds present. Umbilical hernia present, which is
reducible, soft, nontender, nondistended, no guarding,
tenderness, or rebound. EXTREMITIES: No clubbing, cyanosis
or edema, warm and Dopplerable dorsalis pedis pulses
bilaterally. GROIN: There was a small hematoma with minimal
oozing in the right groin.
LABORATORY DATA: Laboratory data revealed the following:
White count 6.7 hematocrit 26.1, platelet count 156,000,
sodium 141, potassium 5.0, chloride 103, CO2 23, BUN 70,
creatinine 3.6, glucose 175, Digoxin 1.1. CK from the
outside hospital revealed 263 with MB fraction at 24 and
troponin at 20. Upon arrival to the hospital the CK was 183,
with MB fraction of 14 and a troponin of 43.
EKG on admission revealed atrial fibrillation with normal QRS
axis, left bundle branch block, flipped T waves in V3 through
V6.
HOSPITAL COURSE:
#1. CARDIOVASCULAR: The patient was continued on aspirin
and started on Plavix and Integrilin for 18 hours post
catheterization. He was also started on Lipitor for the
coronary arteries. He continued on Amiodarone and Coumadin
for the atrial fibrillation. Regarding the cardiac pump, he
was aggressively diuresed with Lasix and Zaroxolyn, but
required doses of Lasix up to 200 mg with only a
mild-to-moderate response. In addition to Lasix and
Zaroxolyn therapy, .................... as added and the
patient diuresed well, meeting daily fluid balance goals.
The pulmonary examination markedly improved over the hospital
course requiring less supplemental oxygen and he was left on
a standing dose of Lasix 20 mg PO, which will be titrated as
needed to maintain the fluid balance.
Echocardiogram performed after the cardiac catheterization
revealed a mildly dilated left atrium, moderately dilated
right atrium, diametric left ventricular hypertrophy, basal
inferior and inferolateral akinesis with mild aortic
regurgitation and severe mitral regurgitation. The patient
will continue on his current medications. The patient will
follow up with Dr. [**Last Name (STitle) **].
#2. RENAL: The patient was initially admitted with a
creatinine elevated compared to the baseline creatinine. It
was initially thought that the rise in the creatinine was due
to acute tubular necrosis. Mucomyst 500 b.i.d. was given for
two doses after the cardiac catheterization. The creatinine
levels continued to rise to a peak of 4.2. The Renal Service
was consulted and agreed with the diagnosis of
contrast-induced nephropathy. A renal ultrasound was checked
to rule out hydronephrosis, which came back negative. Urine
sediment was examined, which revealed white blood cells, but
negative for eosinophils. The creatinine started to
downtrend from his peak. At the time of dictation, the
creatinine was 3.1. MRA of the kidneys was performed to rule
out baseline renal artery stenosis. The MRA showed moderate
left renal artery stenosis with an accessory renal artery on
the left side with high graft stenosis. The right renal
artery had low-grade stenosis, also concomitant findings
during the MRA revealed large cyst in the pancreas, also with
renal cortical thinning in the kidneys. The renal artery
stenosis will be further evaluated at the later date.
#3. ANEMIA: The patient was noted to have a hematocrit of
26.1 upon arrival to the Coronary Care Unit. The patient was
transfused one unit of packed red blood cells with minimal
response in the hematocrit. He was then given an additional
two units of packed red blood cells with an adequate bump in
the creatinine and required no further transfusion.
#4. ENDOCRINE: The patient continued to have elevated blood
sugars throughout the admission. The patient was started on
oral hypoglycemic, Glyburide 2.5 mg PO q.d. for better
optimal blood sugar control.
#5. CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to [**Hospital 46**]
Rehabilitation with appropriate follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
DISCHARGE MEDICATIONS:
1. Glyburide 2.5 mg PO q.d.
2. Furosemide 20 mg PO b.i.d.
3. Colace 100 mg PO b.i.d.
4. Metoprolol 25 mg PO b.i.d.
5. Warfarin 2 mg PO q.h.s.
6. Amiodarone 400 mg PO q.d.
7. ....................400 mg PO t.i.d.
8. Lipitor 10 mg PO q.d.
9. Digoxin 0.125 mg PO q.o.d.
10. Plavix 75 mg PO q.d. for 30 days.
11. Aspirin 325 mg PO q.d.
DIAGNOSIS:
1. Myocardial infarction.
2. Congestive heart failure exacerbation.
3. Anemia.
4. Diabetes mellitus.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2162-8-27**] 10:53
T: [**2162-8-27**] 10:58
JOB#: [**Job Number 78766**]
Name: [**Known lastname 77**], [**Known firstname 17398**] Unit No: [**Numeric Identifier 17399**]
Admission Date: [**2162-8-20**] Discharge Date: [**2162-8-27**]
Date of Birth: [**2074-6-1**] Sex: M
Service:
ADDENDUM: Glyburide was discontinued on the day of discharge
for blood sugars ranging in the 60s. The patient will be
managed without pharmacologic agents at this time for control
of his blood sugars.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 285**]
Dictated By:[**Name8 (MD) 1554**]
MEDQUIST36
D: [**2162-8-27**] 11:00
T: [**2162-8-27**] 11:31
JOB#: [**Job Number 17400**]
|
[
"440.1",
"584.5",
"428.0",
"427.31",
"414.00",
"396.3",
"V45.81",
"410.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2951, 3004
|
7840, 9206
|
4646, 7576
|
3027, 4628
|
102, 2027
|
2438, 2714
|
2049, 2413
|
2731, 2934
|
7601, 7817
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,876
| 163,404
|
40679
|
Discharge summary
|
report
|
Admission Date: [**2105-8-30**] Discharge Date: [**2105-10-6**]
Date of Birth: [**2079-11-21**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
spinal cord injury
Major Surgical or Invasive Procedure:
[**2105-8-31**]-EGD, ECMO cannulation
[**2105-9-7**]-ECMO decannulation
[**2105-9-16**]-IVC filter,trach, peg
History of Present Illness:
The patient is a 25-year-old male who was brought to [**Hospital1 18**] from
[**Hospital 8641**] Hospital in [**Location (un) 3844**] by helicopter for evaluation
and treatment of cervical spinal cord trauma. By report, he
fell off a bench, striking his head, and developing sensory loss
in his lower extremities and chest. He was evaluated at [**Hospital 8641**]
Hospital where he was found to have a severe spinal cord injury.
As such, he was transferred by [**Location (un) **] helicopter to [**Hospital1 18**]
for tertiary specialty spine evaluation and treatment. At [**Hospital1 **],
he was found to have congenital fusion C1-C4. MRI demonstrated
severe spinal cord compression with spinal cord edema consistent
with his fracture disruption, spinal instability,
and spinal cord contusion.
Past Medical History:
PMH: congenitally fused C1-4
PSH: Resection of subaortic membrane for subaortic stenosis,
[**2084**]
Social History:
NC
Family History:
NC
Physical Exam:
VS: 100.5 74 95/51 19 98TM .5 12L/min
Gen: NAD, A/Ox3
HEENT: trach midline, no surrounding erythema, fluctuance,
drainage
Resp: CTAB
CV: RRR
Abd: soft, NT/ND
GU: foley in place, clear urine
Ext: distal pulses intact, multipodus/[**Male First Name (un) **]/SCD in place
Skin: No break down noted, chronic pilonidal cyst post midline
lumbar
Pertinent Results:
CXR [**2105-10-5**]
INDICATION: ARDS, recurrent pneumothorax.
COMPARISON: [**2105-10-4**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Tracheostomy tube. Vertebral fixation devices. Status
post
sternotomy. Borderline size of the cardiac silhouette. Areas of
atelectasis at the right lung base. Currently there is no
evidence of pneumothorax. No pleural effusions. Borderline size
of the cardiac silhouette.
TTE [**2105-9-23**]
The left atrium is mildly dilated. The left atrium is elongated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF 65-70%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Moderate
to severe (3+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-8**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No valvular vegetations identified. Mild-moderate
aortic stenosis with moderate-severe aortic regurgitation.
Compared to the prior study dated [**2105-8-31**] (images reviewed),
degree of aortic regurgitation has worsened. The degree of
aortic stenosis is greater (now in the mild-moderate range).
While this change may be secondary to an increase of
transvalvular velocity due to worse aortic regurgitation, there
is also evidence of underestimation of the transaortic
velocity/gradients on the prior study.
CT [**Year (4 digits) 12784**] [**2105-8-30**]
INDICATION: Fall with paralysis
FINDINGS: There is no acute fracture or malalignment. Near
complete bony
fusion of C1 to C4 is noted. There is marked canal stenosis
particularly at C5-C6 levels with large central protrusion at
C4-C5 and left paracentral protrusion at C5-C6 causing severe
canal narrowing. Prevertebral soft tissues are unremarkable.
Soft tissues of neck and thyroid are normal. Imaged lung apices
demonstrate right upper lobe collapse.
IMPRESSION:
1. No fracture or malalignment with bony fusion of C1 to C4.
2. Marked spinal canal stenosis at C4-C5 and C5-C6 with disc
protrusions
causing severe stenosis.
3. Right upper lobe collapse.
MR [**Last Name (Titles) 12784**] [**2105-8-30**]
FINDINGS: The study is compared with the NECT obtained some 3
hours earlier. Better-demonstrated on the CT is the extensive
upper cervical congenital fusion anomaly with C1 through C4
"block vertebral body" and congenital spinal canal stenosis.
However, more evident on this examination is the severe
degeneration of the "C4/5," C5/6 and, to a lesser extent, C6/7
discs. At C4/5, a broad-based disc-endplate spondylotic complex,
superimposed on the abnormal canal geometry, with ligamentum
flavum thickening significantly and compresses and deforms the
spinal cord. At C5/6, a large, broad-based left
paracentral/proximal foraminal disc herniation, measuring 5 mm
(AP), markedly deforms the left anterolateral aspect of the
spinal cord at the exiting left C6 nerve root entry zone and in
its proximal foramen. At C6/7, a shallow left paracentral
protrusion only slightly effaces the ventral CSF, without
definite contact with the ventral cord or exiting nerve roots.
There is no significant neural foraminal narrowing at this
level.
The upper cervical spinal cord appears markedly abnormal with
somewhat
ill-defined ovoid T2-/STIR-hyperintense focus extending from the
mid-"C3"
through the C6 superior endplate level, over a roughly 4.1 cm
segment. While this may, in part, reflect pre-existent
myelomalacia, given the mechanism injury, the overall appearance
of the spinal canal (above), as well as at least one convincing
focus of slow diffusion (with corresponding hypointensity on the
ADC map) at the "C4/5" level and, possibly 1 or 2 additional
foci, slightly more caudally, this is highly suspicious for
acute contusion of the central cord. Of note, there is no
definitive focus of "blooming" susceptibility artifact at these
sites to specifically suggest a hemorrhagic component.
The limited included posterior fossa structures are grossly
unremarkable other than slightly low-lying cerebellar tonsils
with no evidence of Chiari I-type morphology. The surrounding
cervical soft tissues are grossly unremarkable, with no
significant prevertebral soft tissue edema or finding to
specifically suggest ligamentous or capsular injury on the STIR
sequence. Incidentally noted is a markedly abnormal appearance
to the lung apices, right significantly more than left, with
extensive airspace opacification suggestive of
consolidation/collapse.
IMPRESSION:
1. Markedly abnormal appearance to the upper cervical spinal
cord with
corresponding T2-signal and diffusion abnormality, highly
suggestive of acute contusion (in this clinical context).
2. The combination of possibly acute disc herniation (in the
setting of this traumatic mechanism), superimposed on markedly
abnormal spinal canal geometry, results in marked compression of
the upper and mid-cervical spinal cord, as above.
3. No definite evidence of associated ligamentous or capsular
injury.
4. Markedly abnormal appearance of the lung apices with
extensive
consolidation/collapse on the right (in this intubated patient);
correlate
with dedicated imaging of the chest.
CT Torso [**2105-8-30**]
CT OF THE CHEST WITH CONTRAST: Thyroid is normal in appearance
with symmetric enhancement. The aorta and major branches appear
patent with normal three-vessel arch. Mediastinum is
unremarkable with the exception of prominent mediastinal and
hilar lymph nodes with a 1.1 cm pretracheal node. The heart and
pericardium are unremarkable without effusion. There is no
pleural effusion. Partial collapse of the right lower lobe and
total collapse of the right upper lobe are noted with a focus of
pneumothorax layering between the heart and right upper lobe
(2:25). Partial opacification of the left lower lobe is also
seen, which could reflect atelectasis as well. Trachea and
central airways appear patent though evaluation of the segmental
airways and the collapsed lungs is limited.
CT OF THE ABDOMEN WITH CONTRAST: The liver demonstrates mild
periportal edema without focal lesion. The gallbladder is
normal. The pancreas, spleen, and bilateral adrenal glands are
unremarkable. Kidneys enhance and excrete contrast
symmetrically. Stomach, small and large bowel is unremarkable
with nasogastric tube in place. There is no free air or free
fluid in the abdomen. No mesenteric or retroperitoneal
pathologic lymphadenopathy. Aorta and major branches appear
patent.
CT OF THE PELVIS WITH CONTRAST: Bladder is decompressed by Foley
with gas
within, likely due to Foley placement. The prostate and rectum
are
unremarkable. There is no free pelvic fluid. There is no pelvic
or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bone lesion
concerning for osseous malignant process. Sternotomy wires are
noted.
IMPRESSION:
1. Total collapse of the right upper lobe with partial right
lower lobar
collapse and atelectasis of the left lung.
2. Focus of pneumothorax adjacent to the collapsed right upper
lobe.
3. Periportal edema.
4. No fractures or malalignment of the T- and L-spine.
Brief Hospital Course:
Mr. [**Known lastname 26929**] was admitted to the ACS service at [**Hospital1 18**]. MRI
C-spine showed marked canal narrowing with C4/5 and C5/6 disc
herniations resulting in cord compression without obvious
ligamentous disruption. He also had a CT C/A/P which showed
total RUL collapse with a small pneumothorax near the RUL lobe,
partial RLL collapse & left lung atelectasis. Hospital course,
by systems:
Neuro: Mr. [**Known lastname 26929**] was intubated and sedated on arrival to [**Hospital1 18**]
via [**Location (un) **]. He was noted to have preserved neurologic
function in his upper extremities, no movement of his lower
extremities and absent rectal tone at the OSH. He was taken
emergently to the OR by the ortho spine service for C4-C6
fusion/fixation upon arrival on [**2105-8-30**]. Please refer to the
operative note for additional details. He was then maintained
on a variety of sedatives, anxiolytics, paralytics, narcotics
during his course, including fentanyl/propofol which were
ultimately weaned to precedex and then off. He remained AAOx3
after being weaned from the ventilator. He was seen by the
psychiatry service for assessment of depression and anxiety. He
was maintained on a regimen of seroquel and ativan as needed for
treatment. For pain control, by time of discharge, he was on a
regimen of MS contin 50 mg PO BID with standing tylenol and PRN
dilaudidMS contin 60''; dilaudid po prn; tylenol standing;
ibuprofen prn; gabapentin
CV: Maintained on ECMO from [**8-31**] to [**2105-9-7**]. Please refer to
Respiratory section of this d/c summary for further details
leading up to his ECMO cannulation. Of note, he had a asystolic
arrest during initiation of ECMO with return of sinus rythym
with 20 seconds of chest compressions and ACLS protocol. HD
stable otherwise and did not require pressors or any cardiac
medications during the remainder of his hospitalization.
Respiratory: Initial CT C/A/P showed significant lung disease.
On HD1 he continued to show evidence of respiratory difficulty -
bronchoscopy at bedside showed evidence of mucous plugging with
SaO2 in the 70s/80s despite maximal ventilatory settings (100%
FiO2). Cardiology was consulted; a PICCO2 monitor was placed
and showed evidence of pulmonary edema. He was diuresed with
lasix. He continued with intermittent desaturations, especially
on turning and he had repeated bronchs showing minimal mucous
plugging; this in concordance with worsening CXR findings, he
was attributed to have severe ARDS. With continued worsening
respiratory status, he was evaluated by the cardiac surgery team
for ECMO. This was initiated on [**2105-8-31**]. There onwards, Mr.
[**Known lastname 26929**] had gradual improvement in his respiratory status with
continued antibiotic therapy (please refer to ID section) and
intermittent bronchoscopies removing mucous plugging. ECMO was
removed on [**2105-9-7**]. He continued to require mechanical
ventilation with improving xrays but continued high fevers.
He had a tracheostomy on [**2105-9-16**] and on [**2105-9-19**] was noted to
have a small pneumothorax on his CXR. He had a bedside chest
tube placed but still was noted to have an apical pneumothorax
and had an IR-guided chest tube placed in addition which
resolved the PTX. The chest tubes were monitored and the
basilar chest tube was dc'd on [**9-28**] with no pneumothorax on
post-pull CXR. The apical chest tube was subsequently dc'd
after without evidence of raccumulation. The post-pull film was
stable but the next day CXR showed a recurrent PTX, prompting
re-insertion of another chest tube. This was maintained for
three days, watersealed for 24 hours, showed no evidence of
leak, removed and post-pull films and 24 hours post were
negative for recurrent PTX. His respiratory status has been
stable since.
As noted, he was initially on a ventilator which was
periodically weaned. By [**10-3**] he had gone 24 hours without need
for intermittent ventilatory support via trach. He continued
with trach mask/PMV with Q6hour recruitment maneuvers to
improve/maintain pulmonary status.
GI: Mr. [**Known lastname 26929**] was initially NPO, then maintained on tube feeds
until he was extubated, stable on the trach and had PM valve
placed after which oral intake was resumed. He was supplemented
with marinol for appetite stimulation and did quite well,
tolerating a regular diet with a healthy appetite supplemented
with tube feeds at the end of his hospitalization.
GU: Maintained good urine output throughout his hospitalization.
Had a foley catheter in place which for the last week of
hospitalization was undergoing clamp trials (Q4 hour release)
for "bladder training" which he was tolerating well.
Heme: Heparin drip while on ECMO (Started on [**2105-8-31**] and dc'd on
[**2105-9-7**]). While on ECMO, Hct downtrending requiring intermittent
blood transfusions. This was thought to be secondary to some
bleeding around the ECMO catheters. He did not require
additional blood transfusions.
ID: Mr. [**Known lastname 26929**] was initially started on empiric broad spectrum
antibiotic coverage of vanc/cefepime. He was not febrile but
his respiratory status continued to decompensate, presumably due
to ARDS and was placed on ECMO. He was afebrile while on ECMO
but soon after its discontinuation persistently spike high
temperatures. Despite persistently being febrile, no definitive
source was identified. His cultures (blood and urine) continued
to be culture negative. He did grow yeast and commensal flora
in his BAL cultures and mixed bacteria in a pilonidal cyst that
was thought adequately drained and not likely to contribute as a
source of his fevers. He received a CT C/A/P on [**2105-9-9**] to
assess for a source of fevers; none was found. Antibiotic
course: Started on vanc/cefepime initially. Cipro was added on
[**9-4**]. Cefepime and cipro were replaced with meropenem and
tobramycin on [**9-10**]. Vanc was briefly discontinued for 2 days on
[**9-12**] before being restarted. He was continued on vanc/[**Last Name (un) 2830**]/tobra
until [**9-24**], spiked intermittently in between; on [**9-24**] all
antibiotics were discontinued in face of repeated negative
cultures from multiple sources. He was afebrile at the time and
remained afebrile after discontinuation of all antibiotics.
Heme: Had an IVC filter placed on [**2105-9-16**] and also was
maintained on SQH which was then transitioned to low-dose
coumadin.
By time of discharge, Mr. [**Known lastname 26929**] was AAOx3, tolerating a
regular diet, his neuro status was per his new baseline and
patient was discharged to a rehab facility.
Medications on Admission:
none
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation .
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
sob/wheeze.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q2H (every 2 hours) as needed for wheezing.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for hiccups.
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety, insomnia.
9. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety.
10. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for pain.
11. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours): not to exceed 4000mg/daily.
12. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
14. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
18. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours): hold for
oversedation, rr<12.
19. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain: hold for oversedation, rr<12.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] TCU - [**Location (un) 86**]
Discharge Diagnosis:
Isolated Cervical Spine Fracture
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:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Your risk for Deep Venous Thrombosis and Decubitus Ulcers is
increased. Please work actively with Physical Therapy, continue
DVT prophylaxis, and minimize periods of inactivity.
- Recommend q2 hour turning while in bed
- Recommend low dose coumadin administration
- Recommend continued physical therapy
Followup Instructions:
Please follow up in the Acute Care Surgery Clinic within 14 days
of discharge. Call ([**Telephone/Fax (1) 2537**] to schedule appt.
Completed by:[**2105-10-6**]
|
[
"309.28",
"518.1",
"518.5",
"511.9",
"305.00",
"780.61",
"839.05",
"756.15",
"263.9",
"276.1",
"V49.87",
"276.3",
"287.5",
"933.1",
"685.0",
"997.1",
"518.0",
"285.9",
"427.5",
"806.06",
"E884.9",
"746.81",
"512.1",
"E912",
"305.1",
"E879.9",
"726.0",
"958.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.65",
"84.52",
"03.09",
"33.29",
"96.6",
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"03.53",
"81.03",
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] |
icd9pcs
|
[
[
[]
]
] |
17848, 17922
|
9115, 15789
|
290, 402
|
17998, 17998
|
1772, 9092
|
20094, 20256
|
1393, 1397
|
15844, 17825
|
17943, 17977
|
15815, 15821
|
18173, 19154
|
1412, 1753
|
19186, 20071
|
232, 252
|
430, 1231
|
18013, 18149
|
1253, 1357
|
1373, 1377
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,761
| 101,405
|
26300
|
Discharge summary
|
report
|
Admission Date: [**2116-8-25**] Discharge Date: [**2116-9-9**]
Date of Birth: [**2033-2-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
S/P Fall with facial fractures and right sided subdural hematoma
Major Surgical or Invasive Procedure:
PEG Placement [**9-4**]
Upper Endscopy [**2116-9-6**]
History of Present Illness:
Ms. [**Known lastname 7931**] is an 83 year old woman with late stage Parkinson's
disease who fell at home today sustaining facial fractures and R
Subdural hematoma. Her husband reports he was at home with his
wife today and found it odd she did not hang the phone back onto
the receiever following a conversation with her daughter in the
living room. While placing the phone on the receiver he heard a
thud in the kitchen and found his wife on the floor. She was
conscious, able to speak and follow commands. Copious hemorrhage
from her face and nares. Was taken to [**Hospital3 **], found to
have SDH and facial fractures. Transferred to [**Hospital1 18**] for further
care.
The patient is unable to provide a reliable history of events.
She denies any headache. She denies any weakness numbness or
tingling. She does not provide a reliable ROS. Per husband and
daughter, no recent F/c or NS. no cough, no SOB,
no CP. no diarrhea. no N/V. She does have intermittent dysphagia
chronically. chronic urinary incontinence. no bowel
incontinence.
Past Medical History:
Parkinson's disease- cared for by Dr. [**Last Name (STitle) **] at [**Hospital1 18**].
Urinary incontinence
osteoporosis
compression spine fractures
eczema/psoriasis
Social History:
Former telephone operator who lives at home and uses a cane to
walk. Husband does cooking and cleaning. Pt requires some assist
with bathing and dressing. quit tobacco 30 years ago with 10
pack year history. no current ETOH use.
Family History:
Noncontributory
Physical Exam:
Vitals T 98.7, HR 78, BP 160/70, R 16, 100% 2LNC
Gen- on ED gurney with hard collar, facial trauma, attends only
briefly to examiner.
HEENT: Right facial hematoma, anicteric sclera.
Neck: in c collar, attempted to clear following review of CT
scan
and pt report mid-C-spine pain with head rotation. Hard collar
was replaced.
CV- RRR, no MRG
Pulm- CTA B
ABd- soft, NT, ND, BS+
Extrem- no CCE, warm, well perfused.
Neurologic Exam:
MS- she is unable to describe where she is. unable to choose
from
a list of places. Her speech is fluent, "I'm doing okay doctor,
I'm fine." She does not answer questions appropriately. +
Inattention. Follows few appendicular commands intermittently.
CN- PERRL 3-->2mm bilat, R eye edematous and difficult to
visualize. Gaze appears conjugate. lateral versions intact.
would
not cooperate with inferior or superior gaze. R facial
edema/hematoma resulting in asymmetry. She is able to smile with
reasonable symmetry. sensation is intact to LT. palate elevates
symmetrically.
Motor- no pronator drift. L > right cogwheel rigidity. + resting
tremor. Holds arms and legs antigravity to command.
Sensory- intact to light touch. difficult to reliably assess
given inattention.
Plantar response was extensor bilaterally
Reflexes: 2+ symmetric at [**Hospital1 **], tri, brachirad, patellars 3+,
abent
ankle jerks.
Gait: deferred
on discharge: AOx2,PERRL, Spontaneous movement in all
extremties, intermittant commands(pt [**Name (NI) **]
Pertinent Results:
Cardiology Report ECG Study Date of [**2116-8-25**] 4:59:18 PM
Sinus rhythm. Baseline artifact. No previous tracing available
for
comparison.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 178 90 366/401 63 -10 43
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-25**]
4:57 PM
[**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 4:57 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65112**]
Reason: eval for fx, bleed
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with fall ?Lefort fracture, SDH vs.
epidural
REASON FOR THIS EXAMINATION:
eval for fx, bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: GWp TUE [**2116-8-25**] 8:19 PM
R likely SDH No significant shift
Complex facial fractures
Final Report
INDICATION: 82-year-old woman with fall, query subdural hematoma
versus
epidural.
COMPARISON: [**2115-12-26**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is a 7-mm wide crescentic extra-axial hyperdense
collection layering over the right cerebral convexity,
compatible with an acute subdural hematoma. There is no
significant shift of midline structures. There is no mass effect
or edema. Ventricles, sulci, and cisterns are similar to prior.
Basal cisterns are preserved. Periventricular white matter
hypodensity is likely the sequela of chronic small vessel
ischemic disease.
There is a left frontal cephalohematoma with subcutaneous gas
seen (series 2, image 18). There are comminuted fractures of the
right lamina
papyracea and floor of the right orbit, with extensive
subcutaneous and
retroorbital gas, proptosis, and periorbital hematoma. A
depressed fracture fragement from the orbital floor fracture is
seen within the right maxillary sinus, but without entrapment of
the inferior rectus muscle. Comminuted fractures of both nasal
bones, as well as the anterior, medial, posterior, and lateral
walls of the right maxillary sinus are present. The frontal
process of the right zygoma also demonstrates comminuted
fractures.The left maxillary sinus also demonstrates comminuted
fractures of the lateral and medial walls. Minimally displaced
fractures of the medial and lateral plates of the pterygoid
processes bilaterally are fractured. Both orbits remain intact.
For further details, see the CT of the facial bones. High-
attenuation fluid is seen in both maxillary and ethmoid sinuses
consistent
with hemorrhage.
IMPRESSION:
1. Right subdural hematoma layering over the right cerebral
convexity without midline shift.
2. Extensive complex facial fractures. Refer to the CT facial
bones.
3. Right frontal subgaleal hematoma.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2116-8-25**]
7:03 PM
[**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 7:03 PM
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 65113**]
Reason: FALL, ? FX
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with fall
REASON FOR THIS EXAMINATION:
eval for fracture
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Fall.
COMPARISON: None available.
TECHNIQUE: MDCT axial images were obtained from the base of the
skull through T1 without intravenous contrast. Multiplanar
reformats were derived.
FINDINGS: There is no acute fracture of the cervical spine.
Exaggerated
lordosis of the cervical spine is present, without subluxation.
The
atlantodental and craniocervical junctions are normal. The
central canal is patent. There is prominence of the soft tissues
in the nasopharynx
posteriorly (series 200B, image 31). Otherwise, prevertebral
tissues are
unremarkable. The dens appears normal. Lateral masses of C1 well
seated on
C2. There is [**Hospital1 **]- apical scarring within the lungs. Calcification
of the
cervical carotid arteries bilaterally is present. Multiple
facial fractures are redemonstrated, better characterized on
concurrent facial bone CT.
IMPRESSION:
1. No acute fracture or subluxation of the cervical spine.
2. Prominence of posterior nasopharyngeal tissues. Recommend
direct
visualization.
3. [**Hospital1 **]-apical scarring.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2116-8-25**]
7:11 PM
[**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 7:11 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Clip # [**Clip Number (Radiology) 65114**]
Reason: FALL, ? INJURIES.
Field of view: 36 Contrast: OPTIRAY Amt: 130
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with fall
REASON FOR THIS EXAMINATION:
eval for chest trauma
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: GWp TUE [**2116-8-25**] 8:26 PM
Mult T L spine compression deformities
Distended bladder w/Foley balloon inflated in urethra / vagina
Final Report
INDICATION: Fall.
COMPARISON: None available.
TECHNIQUE: Multiple MDCT axial images were obtained from the
base of the neck through the proximal thighs after the
uneventful administration of 130 cc of Optiray intravenously.
Enteric contrast was not administered. Multiplanar reformats
were derived.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The thyroid enhances
homogenously. There is no axillary or mediastinal
lymphadenopathy. The pulmonary artery is normal in caliber. The
aorta is normal. The heart is normal in size. There is no
pericardial effusion. There are coronary artery calcifications.
There is a moderate-sized hiatal hernia.
Central airways are patent to the level of subsegmental bronchi.
There is no pulmonary mass, pleural effusion or pneumothorax.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver,
gallbladder, and
spleen appear normal. The pancreas is atrophic. The kidneys
symmetrically
take up and excrete contrast without hydronephrosis. A
subcentimeter renal
hypodensities are too small to characterize and likely represent
benign cysts. The adrenals are unremarkable. Abdominal loops of
bowel are unremarkable. There is no abdominal free air, free
fluid, or pathologic lymphadenopathy. The abdominal aorta is
normal in caliber and contour but demonstrates prolific
atherosclerotic calcifications.
CT OF THE PELVIS WITH CONTRAST: The bladder is distended. A
Foley is
malpositioned with the balloon abnormally inflated in the
urethra. The uterus and adnexa are unremarkable. There is no
pelvic free air or free fluid, or pathologic lymphadenopathy.
MUSCULOSKELETAL: There is no suspicious osteolytic or
osteoblastic lesion.
There is vertebra plana at T9 and mild compression deformities
at L1 and L4. There is mild anterolisthesis of L5 on S1.
IMPRESSION:
1. Malpositioned Foley balloon catheter in the urethra.
2. Multiple thoracolumbar compression deformities. Grade 1
anterolisthesis
of L5 on S1. These are age indeterminate. Correlate clinically.
3. Moderate sized hiatal hernia.
4. Coronary artery calcifications.
5. Bilateral renal hypodensities, possibly renal cysts.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report CT CHEST W/CONTRAST Study Date of [**2116-8-25**] 7:11
PM
[**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 7:11 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Clip # [**Clip Number (Radiology) 65114**]
Reason: FALL, ? INJURIES.
Field of view: 36 Contrast: OPTIRAY Amt: 130
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with fall
REASON FOR THIS EXAMINATION:
eval for chest trauma
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: GWp TUE [**2116-8-25**] 8:26 PM
Mult T L spine compression deformities
Distended bladder w/Foley balloon inflated in urethra / vagina
Final Report
INDICATION: Fall.
COMPARISON: None available.
TECHNIQUE: Multiple MDCT axial images were obtained from the
base of the neck through the proximal thighs after the
uneventful administration of 130 cc of Optiray intravenously.
Enteric contrast was not administered. Multiplanar reformats
were derived.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The thyroid enhances
homogenously. There is no axillary or mediastinal
lymphadenopathy. The pulmonary artery is normal in caliber. The
aorta is normal. The heart is normal in size. There is no
pericardial effusion. There are coronary artery calcifications.
There is a moderate-sized hiatal hernia.
Central airways are patent to the level of subsegmental bronchi.
There is no pulmonary mass, pleural effusion or pneumothorax.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver,
gallbladder, and
spleen appear normal. The pancreas is atrophic. The kidneys
symmetrically
take up and excrete contrast without hydronephrosis. A
subcentimeter renal
hypodensities are too small to characterize and likely represent
benign cysts. The adrenals are unremarkable. Abdominal loops of
bowel are unremarkable. There is no abdominal free air, free
fluid, or pathologic lymphadenopathy. The abdominal aorta is
normal in caliber and contour but demonstrates prolific
atherosclerotic calcifications.
CT OF THE PELVIS WITH CONTRAST: The bladder is distended. A
Foley is
malpositioned with the balloon abnormally inflated in the
urethra. The uterus and adnexa are unremarkable. There is no
pelvic free air or free fluid, or pathologic lymphadenopathy.
MUSCULOSKELETAL: There is no suspicious osteolytic or
osteoblastic lesion.
There is vertebra plana at T9 and mild compression deformities
at L1 and L4. There is mild anterolisthesis of L5 on S1.
IMPRESSION:
1. Malpositioned Foley balloon catheter in the urethra.
2. Multiple thoracolumbar compression deformities. Grade 1
anterolisthesis
of L5 on S1. These are age indeterminate. Correlate clinically.
3. Moderate sized hiatal hernia.
4. Coronary artery calcifications.
5. Bilateral renal hypodensities, possibly renal cysts.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-27**]
3:57 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG SICU-A [**2116-8-27**] 3:57 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65115**]
Reason: please eval for interval change. pls do at 0500 on [**8-27**]
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with 83 year old woman with sdh and facial
fx
REASON FOR THIS EXAMINATION:
please eval for interval change. pls do at 0500 on [**8-27**]
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 83-year-old woman with subdural hematoma and facial
fractures.
Please evaluate for interval change.
COMPARISON: Multiple head CTs, most recent of [**8-26**],
performed
approximately 11 hours prior.
TECHNIQUE: MDCT-acquired axial images were obtained of the head
without
contrast.
FINDINGS: No interval change when compared to study performed 11
hours prior. Again seen are bilateral acute on chronic subdural
hematomas, which remain stable. Acute subdural hematoma seen
over the right temporoparietal lobe measures 6 mm and is
unchanged. No areas of intracranial hemorrhage, large areas of
edema are seen. There is no new mass effect. High-density
material within the maxillary sinuses bilaterally, consistent
with blood, are unchanged.
IMPRESSION: No change in acute on chronic subdural hematomas. No
new areas
of intracranial hemorrhage.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report PORTABLE ABDOMEN Study Date of [**2116-8-27**] 12:59
PM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG SICU-A [**2116-8-27**] 12:59 PM
PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVIC Clip #
[**Clip Number (Radiology) 65116**]
Reason: NG tube placement
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with stroke. ng tube placement
REASON FOR THIS EXAMINATION:
NG tube placement
Provisional Findings Impression: [**Last Name (un) **] [**Doctor First Name **] [**2116-8-27**] 2:41 PM
In correct placement of NG tube.
Final Report
INDICATION: 83-year-old woman with stroke, status post NG tube
placement.
Evaluate for NG tube placement.
COMPARISON: CT chest, abdomen and pelvis with contrast
[**2116-8-25**].
TECHNIQUE: Portable abdominal radiograph.
FINDINGS: NG tube is noted, with sideport above the level of the
diaphragm
likely within the lumen of the stomach in this patient with
hiatal hernia
noted on previous CT. Compression fracture noted at vertebral
body T9. A mild compression deformity is also noted at L1-L4 as
previously noted on CT dated [**2116-8-25**]. Costochondral
calcifications are noted. Colon is noted to be filled with stool
and gas.
IMPRESSION: Side port of NG tube above the diaphragm, likely in
the lumen of
the stomach in patient with known hiatal hernia.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-30**]
11:23 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2116-8-30**] 11:23 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65117**]
Reason: 202
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with right sdh
REASON FOR THIS EXAMINATION:
less responsive? worseing bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: JXRl SUN [**2116-8-30**] 1:27 PM
Unchanged bilateral subdural collections, with high-density
material,
consistent with blood on the right. Small amount of
intraventricular blood is less prominent than on the study from
two days prior. No hydrocephalus.
Final Report
HISTORY: 83-year-old woman with right subdural hematoma and
decreased
responsiveness.
COMPARISON: Non-contrast head CT [**2116-8-28**].
TECHNIQUE: Non-contrast head CT was obtained.
FINDINGS: There is no significant change in the right subdural
collection,
with has a mixture of more acute hyperdense blood and chronic
hypodense
blood. The hypodense left subdural collection has slightly
decreased in
size. Hyperdense subdural blood along the posterior falx and
along the
tentorium is unchanged. A small amount of blood in the occipital
[**Doctor Last Name 534**] of
the left lateral ventricle is slightly decreased in density.
There is no shift of normally midline structures. Moderate
ventricular prominence is unchanged since [**2115-12-26**], likely
related to cerebral atrophy
High-density material within the maxillary sinuses bilaterally,
consistent
with blood is unchanged. Known maxillary sinus and nasal bone
fractures are partially visualized. There is a nasogastric tube.
IMPRESSION:
The hypodense left subdural collection has slightly decreased in
size. The
mixed-density right subdural collection is unchanged. Posterior
parafalcine subdural hematoma is unchanged. Expected evolution
of intraventricular hemorrhage.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report C-SPINE NON TRAUMA FLEX & EXT ONLY Study Date
of [**2116-9-2**] 9:53 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2116-9-2**] 9:53 AM
C-SPINE NON TRAUMA FLEX & EXT Clip # [**Clip Number (Radiology) 65118**]
Reason: 83 year old woman s/p fall with R SDH and facial bone
fx, pl
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman s/p fall with R SDH and facial bone fx,
please call [**Numeric Identifier 65119**], manual manipulation required for flexion and
extension, team member will need to be present.
REASON FOR THIS EXAMINATION:
83 year old woman s/p fall with R SDH and facial bone fx,
please call [**Numeric Identifier 65119**], manual manipulation required for flexion and
extension, team member will need to be present.
Final Report
HISTORY: 83-year-old female with fall, declining mental status.
C-SPINE, TWO VIEWS WITH FLEXION AND EXTENSION. Cervical spine is
visualized to the level of the C7-T1 disc. There is minimal
cervical motion observed between the flexion and extension
views. An NG tube is seen in the esophagus.
The vertebral bodies are normal in height and alignment. There
is diffuse
demineralization. There is a mild anterior vertebral spurring at
multiple
levels. There are no fractures or dislocations. The prevertebral
soft
tissues appear normal. The visualized portions of the lungs
appear normal.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**]
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2116-9-3**] 9:24 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2116-9-3**] 9:24 AM
VIDEO OROPHARYNGEAL SWALLOW Clip # [**Clip Number (Radiology) 65120**]
Reason: evaluate for aspiration
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with SDH
REASON FOR THIS EXAMINATION:
evaluate for aspiration
Final Report
INDICATION: 83-year-old woman with subdural hematoma, evaluate
for
aspiration.
TECHNIQUE: This study was performed in conjunction with speech
and swallow
pathologist. A limited oral and pharyngeal swallowing
videofluoroscopy was
performed. Nectar thick liquid, two tablespoon and pureed
consistency barium, one tablespoon were administered.
Following administration of nectar- thick liquid, there was
significant
prolongation of the oral transit time with immediate penetration
and
aspiration. Following this one tablespoon of pureed consistency
barium was
administered which also demonstrated immediate penetration and
aspiration. The patient was unable to clear the pharyngeal
residue. There was inability to consistently trigger a second
swallow or cough. At this point the study was aborted.
IMPRESSION: Penetration and aspiration with nectar-thick and
pureed
consistencies of barium. Please refer to the full speech and
swallow
pathologist's note for recommendations.
Brief Hospital Course:
Ms [**Known lastname 7931**] was admitted to the neurosurgery service for ICU close
neurological monitoring due to her subdural and facial
fractures. She had a trauma consult and was found to to have
multiple facial fractures including pterygoid processes, floor
of the right orbit, both maxillary sinuses, right lamina
papyracea, right zygoma, bilateral nasal bones, and [**Last Name (un) 2043**] nasal
septum. No muscular entrapment is seen within the right orbital
floor fracture. She also had extensive right periorbital
hematoma and subcutaneous gas, with extension of gas
retroorbitally. The right globe is proptotic, but remains
intact.
She was noted to have a triponin leak of 0.05 for which a beta
bloker was added. Plastic surgery recommended clindamycin for 5
days and a soft diet. Follow up head CTs were stable size of
subdural hematoma.
She was transferred to step down unit on [**8-26**]. Physical therapy
and occupational therapy felt she was appropriate for acute
rehab. Her mentation improved on a daily basis and she began to
speak and follow simple commands. She had a video swallow on
[**8-31**] which showed some aspiration. The patient had a
flex/extension x-ray of the cervical spine on [**9-2**] which was
negative for fracture or malalignment. Therefore her collar was
removed. She had a repeat video swallow evaluation on [**9-2**]
because she was able to have different positioning after the
collar was removed. The evaluation showed continued aspiration.
On [**9-4**] she had a PEG placed. Following the PEG placement she
had approx 200-250cc of melanotic stool. Gasteroenterology was
consulted to assess for etiology of bleeding and
recommendations. She was then scoped by GI and duodenal ulcers
x2 were noted and cauterized. She was maintained on a PPI, with
stable Hct.
On [**9-9**], she was discharged to an appropriate rehab
facility, and given instructions for follow up in 6 weeks with a
non-contrast Head CT.
Medications on Admission:
CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - Two tablets at 10 am
and 6 pm and 1 tablet at 2 pm and 10pm Tablet(s) by mouth As
above
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 1 Tablet(s) by mouth at
bedtime
GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 300 mg
Capsule - One Capsule(s) by mouth three times a day
OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg
Tablet - One Tablet(s) by mouth daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg IV Q12H
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q12H (every 12 hours).
4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day): AT 8AM AND 8PM PLEASE GIVE TWO TABS / AT 12
NOON AND 4 PM GIVE 1 TAB ONLY.
5. HydrALAzine 10 mg IV Q6H:PRN SPB >160
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right frontal Subdural Hematoma
GI Bleed
Acute blood loss anemia
Extensive facial fractures including involvement of both
pterygoid processes, floor of the right orbit, both maxillary
sinuses, right lamina papyracea, right zygoma, bilateral nasal
bones, and [**Last Name (un) 2043**] nasal septum. No muscular entrapment is seen
within the right orbital floor fracture.
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, or
Ibuprofen etc.
*you have been prescribed Keppra for seizure prophylaxsis. This
does not require blood work for monitoring. Please continue to
take this until you are seen in follow up in 6 weeks.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 6 weeks with a head CT, call
[**Telephone/Fax (1) 1669**] for an appointment.
Please call Dr. [**First Name (STitle) 2795**] in the [**Hospital **] CLINIC in 4 weeks at
[**Telephone/Fax (1) **]
If you have dark tarry bowel movements or bright red blood in
your bowel movements you should call the clinic immediately or
go to the nearest emergency room.
** PLEASE NOTE: YOUR H.PYLORI TEST WAS NEGATIVE (SEROLOGY STUDY)
Follow up as planned with Dr [**Last Name (STitle) **]. Your daughter is to email Dr
[**Name (NI) 17281**] in two weeks time
Completed by:[**2116-9-9**]
|
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icd9cm
|
[
[
[]
]
] |
[
"44.43",
"08.81",
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
25352, 25424
|
21968, 23922
|
339, 395
|
25837, 25861
|
3445, 4130
|
27013, 27634
|
1922, 1939
|
24393, 25329
|
20867, 20894
|
25445, 25816
|
23948, 24370
|
25885, 26990
|
1954, 2368
|
3328, 3425
|
235, 301
|
20926, 21945
|
423, 1470
|
2385, 3314
|
1492, 1660
|
1676, 1906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,202
| 114,654
|
21341
|
Discharge summary
|
report
|
Admission Date: [**2157-6-1**] Discharge Date: [**2157-6-3**]
Date of Birth: [**2081-5-20**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 76-year-old gentleman
with history of aortic valve replacement, mitral valve
replacement both bioprosthetic valve, status post 1 vessel
CABG for 3 vessel coronary artery disease back in [**2144**], who
presents to [**Hospital1 18**] [**Hospital6 3872**] for further
evaluation and treatment of his coronary artery disease,
severe mitral regurgitation. The patient recently presented
to his cardiologist, Dr. [**First Name (STitle) 1075**], with gradually worsening
shortness of breath with exertion over the last 12 months,
more significantly over the last 2 to 3 months. The patient
previously has been able to walk "three telephone poles "
distance before dyspnea. Now, the patient reports that he
gets dyspneic with less than one-half of that distance. The
patient also reports that he feels winded after 1 to 5
stairs. He denies history of chest pain, paroxysmal
nocturnal dyspnea, orthopnea, lower extremity edema,
palpitations, syncope or lightheadedness.
REVIEW OF SYSTEMS: On further review of systems, he denies
recent illness, injury, no recent fevers, chills, nausea,
vomiting, diarrhea, melena, hematochezia, dysuria, hematuria,
rash or headache. Cardiac catheterization at [**Hospital6 31672**] on [**2157-5-24**], showed three-vessel coronary
artery disease, distal LAD with tapered occlusion, (left
circumflex 90 percent, AV groove, occluded OM, OM-SVG, 85
percent at proximal RCA). In addition, a cardiac
catheterization showed left ventricular dysfunction at 25
percent with global hypokinesis and apical akinesis,
dysfunctional bioprosthetic mitral valve replacement with
moderate to severe regurgitation and moderate mitral
stenosis. The catheterization did reveal that the aortic
valve replacement was functional and there was trace aortic
insufficiency. The patient was referred to [**Hospital1 18**] for further
treatment. On the day of admission, [**2157-6-1**], the patient
had cardiac catheterization done here, which showed SVG to OM
totally occluded, RCA with severe disease, right atrial
pressure of 17, pulmonary catheter wedge pressure 36/65/37;
pulmonary artery pressure 85/32; cardiac index 2.54;
peripheral vascular distance at 346. A pulmonary artery
catheter was placed in the cardiac cath lab after the patient
had two stents deployed in his right coronary artery.
Postcatheterization on arrival to the coronary intensive care
unit, the patient was feeling well without complaints.
PAST MEDICAL HISTORY: Ischemic coronary artery disease.
Mitral stenosis, status post mitral valve replacement in
[**2149**]. Aortic stenosis, status post aortic valve replacement,
both bioprosthetic valves.
Paroxysmal atrial fibrillation.
Hypertension.
Pneumonia.
Status post right hip replacement.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is a
retired truck driver. He worked with Budweiser Horses. A
Korean War veteran. He was stationed in [**Country 2784**] during the
war. He never smoked. He has never drunken a beer in his
life, no other alcohol use. No history of illicit drug use.
His cardiologist is Dr. [**First Name (STitle) 1075**].
FAMILY HISTORY: No early coronary artery disease.
OUTPATIENT MEDICATIONS:
1. Aldactone 25 q.d.
2. Lasix 20 mg p.o. b.i.d.
3. Coumadin 3 mg q.d., except Wednesday, the patient takes 4
mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Atenolol 50 mg q.a.m., 25 mg q.p.m.
6. Zantac 150 mg b.i.d.
7. KCl 10 mEq q.d.
PHYSICAL EXAMINATION: On admission, temperature 97.4, heart
rate 62, blood pressure 116/47, respiratory rate 20, oxygen
saturation 98 percent on room air, weight 88.3 kg. In
general, he is in no apparent distress, calm. HEENT:
Sclerae anicteric. Pupils equal, round, and reactive to
light and accommodation. Extraocular muscles intact
bilaterally. Mucous membranes moist. Oropharynx: Clear.
Neck: Supple. JVD approximately 10 to 11 cm at 45 degree
angle. Cardiovascular: Regular rate and rhythm. Normal S1,
loud S2, 2/6 systolic ejection murmur, audible throughout,
loudest at apex. No rubs or gallops noted. Chest: Clear to
auscultation bilaterally, anteriorly good aeration. Abdomen:
Obese, soft, nontender, and nondistended. Normoactive bowel
sounds. No pulsatile masses or hepatosplenomegaly.
Extremities: Cool, dry, 1 plus pedal pulses bilaterally. No
clubbing, cyanosis or edema. Left groin site clean, dry, and
intact without hematoma, oozing or bruit.
LABORATORY DATA: Labs on admission, CBC, white count 9.3,
hematocrit 41, platelets 196,000. Chem-7, sodium 141,
potassium 5.2, hemolyzed chloride 105, BUN 26, bicarbonate
40, creatinine 1.6, calcium 10, INR 1.1. EKG on admission,
sinus bradycardiac 53 beats per minute, normal axis, PR
interval prolonged at 320 ms, QRS 166 ms, left bundle-branch
block. Old left atrial enlargement.
[**Last Name (STitle) 56412**]SPITAL COURSE: This 76-year-old man status post
bioprosthetic AVR and MVR now status post catheter since the
RCA, three-vessel disease, elevated pulmonary artery pressure
secondary to severe mitral regurgitation was admitted for
trial of vasodilators and diuresis, in hopes of optimization
of clinical status for consideration of mitral valve
replacement by Dr. [**Last Name (Prefixes) **].
Pu[**Last Name (STitle) **]y artery hypertension, mitral valve regurgitation:
The patient was started on a trial of Nipride, which the
patient tolerated well with significant reduction of his
pulmonary artery pressures. The initial upon readings for
pulmonary artery pressure 85/32 with a mean of 48, which
reduced to pulmonary artery pressure of 34/12 with a mean of
20 after nitroprusside. The patient's SVR also decreased
significantly from 1008 to 744 on the Nipride. His pulmonary
vascular resistance also decreased significantly from 346 to
160 on Nipride. His pulmonary capillary wedge pressure
decreased from 37 to 15 on Nipride. The patient tolerated
the trial of Nipride well. However, the patient's systolic
blood pressure did drop somewhat with the Nipride drip, which
was held secondary to hypotension after 12 hours of Nipride
therapy. After discussion with the patient, the decision was
made to transition the patient from Nipride to nesiritide for
conservative afterload reduction until mitral valve
replacement. The patient was diuresed significantly with
nesiritide and Lasix. The team felt that the patient was
diuresed to euvolemia given that his creatinine increased from
1.4 to 1.9 on the day of discharge. Discussion was held with
the patient and his wife as well as with Dr. [**Last Name (Prefixes) **]
regarding whether or not to keep the patient inpatient until
mitral valve replacement could be done or readmit the patient
to optimize his medical condition for possible surgery at a
later date. The
patient preferred to go home given that Dr. [**Last Name (Prefixes) **]
cannot do his mitral valve replacement until next week.
Therefore, the patient was discharged home on his
home medications with one change. The patient's atenolol was
felt to be too high of a dose for the patient. He was noted
to be hypotensive to a map of 55 to 60 and the heart rate in
the 50s on this atenolol dose of 50 mg q.a.m. and 25 q.h.s.
Therefore, the atenolol dose was decreased to 25 mg b.i.d.
The patient was advised that he felt dizzy or lightheaded
that he should discontinue his p.m. atenolol dose after
talking with his cardiologist, Dr. [**First Name (STitle) 1075**].
DISCHARGE DIAGNOSES: Congestive heart failure.
Severe mitral valve regurgitation.
Hypertension.
Paroxysmal atrial fibrillation.
Reversible pulmonary artery hypertension.
DISCHARGE CONDITION: Stable.
DI[**Last Name (STitle) 408**]E MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Spironolactone 25 mg p.o. q.d.
3. Aspirin buffered 325 mg p.o. q.d.
4. Lipitor 40 mg p.o. q.d.
5. Atenolol 25 mg p.o. b.i.d., hold if lightheaded.
6. Valsartan 320 mg p.o. q.h.s.
7. Zantac 150 p.o. b.i.d.
8. Coumadin 3 mg p.o. q.h.s. The patient's was told to
contact Dr. [**Last Name (Prefixes) **] regarding when to discontinue the
Coumadin prior to mitral valve replacement.
9. Lasix 20 mg p.o. b.i.d.
DI[**Last Name (STitle) 408**]E FOLLOW UP: The patient will be contact[**Name (NI) **] by Dr. [**Last Name (Prefixes) **] for mitral valve replacement surgery. He will be
called to schedule a follow up appointment likely next week.
He is advised if he has any chest pain, shortness of breath,
lightheadedness or dizziness, he should call his primary care
physician or his cardiologist, Dr. [**First Name (STitle) 1075**], for further advise.
He is advised that if he does not hear from Dr. [**Last Name (Prefixes) **]
next Tuesday that he should call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office to
inquire about an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Last Name (NamePattern1) 10641**]
MEDQUIST36
D: [**2157-6-3**] 14:13:21
T: [**2157-6-3**] 22:00:53
Job#: [**Job Number 47715**]
|
[
"416.8",
"398.91",
"427.31",
"414.01",
"401.9",
"394.2",
"V45.81",
"411.1",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.07",
"00.13",
"99.20",
"37.23",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
7823, 8352
|
3342, 3377
|
7651, 7801
|
8364, 9244
|
3401, 3636
|
3659, 7629
|
1161, 2605
|
163, 1141
|
2628, 2945
|
2962, 3325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,644
| 142,983
|
4399
|
Discharge summary
|
report
|
Admission Date: [**2200-12-17**] Discharge Date: [**2200-12-21**]
Date of Birth: [**2146-9-21**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 54-year-old woman with
a past medical history significant for 20 years of low back
pain managed with heavy-dose narcotics at home with several
recent admissions in the past year for hypercarbic
respiratory failure (reportedly, all these episodes have
occurred since she changed her opiate regimen last Spring).
She had a recent admission approximately 10 days ago at an
outside hospital for hypercarbic respiratory failure with
increased troponins at that time. On that admission, she was
extubated one day after admission and discharged to home. On
the day of admission she was found to be somnolent by
Emergency Medical Service with a respiratory rate of 8, and a
fingerstick in the 250s. She was brought to [**Hospital3 **]
where an arterial blood gas showed 7.19/73/32. She was
intubated with rapid improvement in her arterial blood gas,
but her systolic blood pressure subsequently dropped into the
50s and she was started on a dopamine drip. She was
transferred to [**Hospital1 69**] with her
dopamine drip partially weaned, and her systolic blood
pressure in the 120s.
She was seen in the Emergency Department at [**Hospital1 346**] by the Cardiology consultation
service secondary to her increase in troponin. Increased
troponins were thought to be secondary to hypotension causing
demand ischemia and a troponin lead. Her chest x-ray in the
Emergency Department showed bibasilar consolidations. A CT
angiogram showed bibasilar atelectasis/consolidation with air
bronchograms and numerous mediastinal lymph nodes. There was
no evidence of pulmonary embolus. Given the results of the
CT angiogram and the fact that the patient subsequently
spiked to a temperature of 103, she was started on
vancomycin, ceftriaxone, and metronidazole. Her troponin
came back at 26.2. She had no acute changes on her
electrocardiogram, but a heparin drip was started due to
concerns of a possible acute coronary syndrome. She
maintained her blood pressure, overnight on the night after
admission, as the dopamine drip was weaned off. The dopamine
drip was stopped entirely on the morning after admission.
She remained stable on a mechanical ventilator overnight, and
on the day after admission she was extubated without
difficulty. While in the Intensive Care Unit, she was seen
by the Pain consultation service who recommended stopping all
of her outpatient pain medications and staring a morphine
patient-controlled analgesia to evaluate her daily opiate
needs prior to starting a new pain control regimen.
REVIEW OF SYSTEMS: On review of systems in the Intensive
Care Unit she reported cough productive of scant sputum,
though she has always had a chronic cough secondary to
smoking. Per her report, she was feeling fine at home prior
to admission other than feeling a bit sleepy on the date of
admission. She went to sleep and was later found
unresponsive. At home she denied any fevers, chills,
shortness of breath, or chest pain. The patient and family
adamantly deny that the patient was overusing her narcotics
at home.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2195**], status post myocardial infarction. [**2200-3-25**] cardiac catheterization showed a patent left internal
mammary artery to left anterior descending artery, and
occluded saphenous vein graft to right coronary artery, a 40%
stenosis in the right internal mammary artery to right
coronary artery, and left ventricular ejection fraction
of 63%, left ventricular end-diastolic pressure of 26, and
occluded left main coronary artery, a proximally occluded
right coronary artery, 50% mid stenosis of the circumflex,
and a 100% stenosis of the mid left anterior descending
artery.
2. Hypertension.
3. Hypercholesterolemia.
4. Chronic low back pain, status post laminectomy times two
in the past. She is maintained on chronic narcotics at home.
5. Gastroesophageal reflux disease.
6. Question chronic obstructive pulmonary disease.
7. Question liver disease.
8. Depression.
MEDICATIONS ON ADMISSION: Medications at home included
Robaxin 750 mg 2 tablets q.4h., [**Doctor Last Name 18928**] 150 mg p.o. q.d.,
oxycodone 5 mg 6 to 8 tablets p.o. q.d., Neurontin 300 mg
p.o. t.i.d., Lipitor 80 mg p.o. q.d., aspirin, Prilosec 20 mg
p.o. q.d., Xanax 1.5 mg p.o. q.i.d., gemfibrozil 600 mg p.o.
q.d., Vioxx 25 mg p.o. q.d., atenolol 25 mg p.o. q.d.,
nitroglycerin p.r.n.
ALLERGIES: NITROGLYCERIN causes significant decreased blood
pressure. She has taken sublingual nitroglycerin in the past
without difficulty. She is also allergic to TAPE and BEE
STINGS.
SOCIAL HISTORY: She lives at home with her family. She has
been on disability for the last 20 years secondary to low
back pain. She smokes approximately one pack per day for
about a 50-pack-year history.
PHYSICAL EXAMINATION ON PRESENTATION: At the time of the
examination in the Intensive Care Unit she was afebrile. Her
blood pressure and heart rate were stable and within normal
limits, off cardiac medications except for the atenolol. She
was awake, alert, and pleasant, and cooperative. She was
interviewed with her daughter and husband in the room.
Pupils were equal, round, and reactive to light. Extraocular
movements were intact without nystagmus. Anicteric. The
oropharynx was benign. Neck was supple. Jugular venous
distention at 14 cm. Lungs had bibasilar crackles, dullness
to percussion at the bases. No wheezes, no rhonchi, no
accessory muscles for respiratory were used. Hear was
regular in rate and rhythm with normal first and second heart
sounds. There was a fourth heart sound present. No murmurs
were appreciated. The abdomen was soft. There was mild
diffuse tenderness which was not localized. There was trace
pitting and pretibial edema bilaterally. Neurologic
examination was nonfocal.
PERTINENT LABORATORY DATA ON PRESENTATION: On the day of
admission white blood cell count was 12.1 (with 79%
neutrophils and 16% lymphocytes), hematocrit of 34.9,
platelets of 196. Electrolytes were within normal limits.
PT and PTT were within normal limits. Urinalysis showed no
evidence of infection. Creatine kinases were 2108, 1708, and
1277. CK/MB were 49, 31, and 16. MB index was 2.3, 1.8, and
1.3. Troponin I was 26.2 and 21.7. On the day after
admission, white blood cell count was 9.5, hematocrit 30.3,
platelets 188. Electrolytes were within normal limits.
AST 117, ALT 40, alkaline phosphatase 149, total bilirubin
of 0.6, amylase 149, lipase 27, albumin 2.7. Calcium 7.7. A
post extubation arterial blood gas was 7.35/45/93. Sputum
culture from the date of admission had greater than 25
neutrophils, less than 10 epithelial cells, with 1+ multiple
organisms consistent with oropharyngeal flora. Blood
cultures times four and urine culture times one showed no
growth.
RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus
rhythm at 82 beats per minute. There was a normal axis and
normal intervals. There were Q waves in leads II, III, and
aVF. There were no ST depressions or elevations. There was
a T wave inversion in lead V1.
CT angiogram showed numerous mediastinal lymph nodes, the
largest 1.2 cm in diameter, bibasilar
consolidations/atelectasis, single bulla in the right lower
lobe, some air trapping in the right lower lobe, and
degenerative joint disease of the spine.
A Persantine MIBI in [**2198-12-25**] showed no reversible or
fixed ischemic defects with normal wall motion and an
ejection fraction of 70%.
HOSPITAL COURSE: Following transfer out of the Intensive
Care Unit, Ms. [**Known lastname 18929**] was admitted to the medical floor for
further management of her acute medical issues.
1. CARDIOVASCULAR: She was followed by the Cardiology
consul service while in the hospital. Their opinion was that
the increased troponins were due to demand ischemia and not
supply ischemia. They recommended increasing the beta
blocker as tolerated. She was maintained on her aspirin and
Lipitor. She had no further episodes of chest pain
throughout the remainder of her hospital course. Due to a
slight increase in peripheral edema during the course of her
hospital stay she received several liters of intravenous
fluids in the Intensive Care Unit, she was given several low
doses of intravenous diuretics.
2. INFECTIOUS DISEASE: She was started on levofloxacin in
the Intensive Care Unit for treatment of likely pneumonia.
Sputum cultures and blood cultures were all negative.
3. PAIN: She was seen by the Pain consultation service who
recommended starting her on a morphine patient-controlled
analgesia. After 24 hours on the morphine patient-controlled
analgesia they recommended switching her over to MS Contin
60 mg p.o. b.i.d. and MSIR 15 mg p.o. q.6h. p.r.n. She
maintained on her Neurontin for treatment of neuropathic
pain. Dr. [**First Name (STitle) **] at [**Hospital6 1708**] (her primary
pain specialist) was [**Hospital6 653**]. [**Name2 (NI) **] thought it was unlikely
that she had overdosed on the narcotics. He agreed to follow
up with her immediately after discharge.
4. PSYCHIATRY: She was seen by the Psychiatry consultation
service while in the hospital. They thought that she had
some mild delirium and would benefit from an outpatient
psychiatry followup. This was arranged prior to discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Hypercarbic/hypoxic respiratory failure; question
secondary to narcotic overdose.
2. Pneumonia.
3. Myocardial infarction.
4. Coronary artery disease.
5. Hypertension.
6. Hypercholesterolemia.
7. Chronic low back pain.
8. Gastroesophageal reflux disease.
9. Question chronic obstructive pulmonary disease.
10. Question liver disease.
11. Depression.
MEDICATIONS ON DISCHARGE:
1. MS Contin 60 mg p.o. b.i.d.
2. Neurontin 300 mg p.o. t.i.d.
3. Lipitor 80 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Prilosec 20 mg p.o. q.d.
6. Xanax 1.5 mg p.o. q.i.d.
7. Gemfibrozil 100 mg p.o. q.d.
8. Vioxx 25 mg p.o. q.d.
9. Atenolol 25 mg p.o. q.d.
10. Nitroglycerin p.r.n.
DISCHARGE FOLLOWUP: She was to follow up in the [**Hospital6 2399**] Clinic on [**12-25**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**]. She
was to follow up with her cardiologist, Dr. [**Last Name (STitle) **]. She was
to follow up with her pain specialist, Dr. [**First Name (STitle) **], at [**Hospital6 4193**] on [**12-23**]. An outpatient psychiatry
appointment was arranged for her on [**1-5**].
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 7787**]
MEDQUIST36
D: [**2200-12-22**] 11:22
T: [**2200-12-23**] 07:21
JOB#: [**Job Number 18930**]
|
[
"496",
"410.71",
"E854.3",
"486",
"414.01",
"970.1",
"293.0",
"518.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.44",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9599, 9971
|
9998, 10301
|
4237, 4793
|
7702, 9526
|
9541, 9577
|
2723, 3228
|
10323, 11010
|
177, 2702
|
3250, 4210
|
4810, 7684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,704
| 120,671
|
27442
|
Discharge summary
|
report
|
Admission Date: [**2147-3-14**] Discharge Date: [**2147-3-18**]
Date of Birth: [**2075-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atorvastatin / Zetia
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to
PDA) on [**2147-3-14**]
History of Present Illness:
72 y/o male with occassional dyspnea on exertion who stated he
was found to have an "irregular heart beat". Had a positve
stress test and then referred for cardiac cath. Cath showed
30-40% left main disease, 90% LAD, 85-90% RCA, 80% OM. PCI
attempted in RCA but was unsuccessful and was then referred for
surgical revascularization.
Past Medical History:
Hypertension
Hypercholesterolemia
Peripheral Vascular Disease (R Carotid Artery Stenosis 60-80%)
Social History:
Quit smoking 40 yrs ago
Drinks 2-3 whiskey pre day
Retired autobody worker
Family History:
Brother died of MI at age 46
Physical Exam:
VS: 78 18 134/70 140/72 5'4" 180#
General: 72 y/o male in NAD
Skin: Warm, Dry unremarkable
HEENT: NC/AT, EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD, -Carotid bruits
Chest: CTAB -w/r/r
Heart: RRR +S1S2 w/ 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: Grossly intact, MAE, non-focal, A&O x 3
Pertinent Results:
Echo [**3-14**]: Pre bypass: There is mild symmetric left ventricular
hypertrophy
with normal cavity size and systolic function (LVEF>55%). There
are focal calcificatioins of the sintubuar junction; remaining
root and ascending aorta poorly visualized. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
physiologic tricuspid regurgitation and no pulmonic
insufficiency. Post bypass: Perserved biventricular function
LVEF 60% with normal wall motion. Mitral regurg remains 1+.
Tricuspid regurg trace to mild. Aortic contours intact.
Remaining exam unchanged.
CXR [**3-15**]: There is no pneumothorax. Compared to the prior study
from [**2147-3-14**]. There is Stable left-sided pleural effusion and
atelectasis. There is stable appearance of a small right pleural
effusion. There are low lung volumes. The tip of the right IJ
line is in the proximal SVC.
[**2147-3-14**] 11:48AM BLOOD WBC-11.7* RBC-3.08*# Hgb-9.6*# Hct-27.9*#
MCV-91 MCH-31.3 MCHC-34.5 RDW-13.9 Plt Ct-21*#
[**2147-3-16**] 07:30AM BLOOD WBC-12.9* RBC-3.34* Hgb-10.5* Hct-29.8*
MCV-89 MCH-31.3 MCHC-35.1* RDW-13.9 Plt Ct-168
[**2147-3-17**] 08:02AM BLOOD Hct-31.5*
[**2147-3-14**] 07:06AM BLOOD PT-15.4* INR(PT)-1.4*
[**2147-3-15**] 02:43AM BLOOD PT-16.6* PTT-30.4 INR(PT)-1.5*
[**2147-3-15**] 02:43AM BLOOD Glucose-145* UreaN-13 Creat-1.1 Na-140
K-4.2 Cl-106 HCO3-23 AnGap-15
[**2147-3-16**] 07:30AM BLOOD Glucose-107* UreaN-23* Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-27 AnGap-14
[**2147-3-17**] 08:02AM BLOOD UreaN-22* Creat-1.0 K-3.8
[**2147-3-16**] 07:30AM BLOOD Mg-1.9
[**2147-3-15**] 03:51AM BLOOD freeCa-1.26
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 19356**] was a same day admit and on [**2147-3-14**] he was brought
directly to the operating room where he underwent a coronary
artery bypass graft x 3 by Dr. [**Last Name (Prefixes) **]. Please see op note
for surgical details. He tolerated the procedure well and was
transferred to the CSRU in stable condition on minimal Inotropic
support. Later on op day he was weaned from sedation and awoke
neurologically intact. He was then extubated. His chest tubes
were removed on post-op day two. All drips were weaned off and B
blockers and diuretics were started per protocol. He was gently
diuresed post-operatively towards his pre-op weight. He was
transferred later on post-op day one to the cardiac surgery step
down floor. Epicardial pacing wires were removed on post-op day
three. Physical therapy followed patient during entire post-op
course for strength and mobility. He was at level 5 per PT on
post-op day 4. He appeared to be recovering well with stable lab
results, vital signs, and physical exam. He was discharged home
on post-op day four with VNA services and the appropriate
follow-up appointments.
Medications on Admission:
1. Toprol XL 50mg qd
2. Hyzaar 50/12.5mg [**Hospital1 **]
3. Nifedipine 30mg qd
4. Aspirin 325mg qd
5. Plavix 75mg qd
6. NTG prn
7. Prevalite
8. Folic acid
9. Fish oil
10. Pravachol 40mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Packet(s)* Refills:*0*
8. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours.
Disp:*50 Tablet(s)* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Hypercholesterolemia
Peripheral Vascular Disease (R Carotid Artery Stenosis 60-80%)
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions with water and gently soap.
Gently pat dry. Do not take bath or swim. Do not apply lotions,
creams, ointments or powders to incisions.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
If you develop a fever more than 101.5 or notice drainage from
incisions, please contact office immediately.
[**Last Name (NamePattern4) 2138**]p Instructions:
Make an appointment with Dr. [**Last Name (Prefixes) **] for 4 weeks
Make an appointment with Dr. [**Last Name (STitle) **]/[**Doctor Last Name 20222**] in [**1-13**] weeks
Make an appointment with Dr. [**Last Name (STitle) 3265**] in [**12-12**] weeks
Completed by:[**2147-3-18**]
|
[
"272.0",
"433.10",
"413.9",
"424.0",
"401.9",
"780.57",
"414.01",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5799, 5848
|
306, 396
|
6049, 6055
|
1384, 3239
|
986, 1016
|
4667, 5776
|
5869, 6028
|
4453, 4644
|
6079, 6450
|
6501, 6785
|
1031, 1365
|
3290, 4427
|
247, 268
|
424, 758
|
780, 878
|
894, 970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,373
| 189,655
|
8701
|
Discharge summary
|
report
|
Admission Date: [**2204-5-11**] Discharge Date: [**2204-6-30**]
Date of Birth: [**2148-10-18**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
[**2204-5-11**]: GI Bleeding study
[**2204-5-12**]: Sigmoidoscopy
[**2204-5-18**]: GI Bleeding study
[**2204-5-20**]: Colonoscopy and EGD
[**2204-5-21**]: Angiogram, no intervention
[**2204-5-24**]: Exploratory laparotomy, intraoperative
endoscopy.
[**2204-6-12**]: Post pyloric feeding tube placement
History of Present Illness:
55 year-old male with hepatitis C cirrhosis s/p liver [**Month/Day/Year **]
with recurrent hepatitis C complicated by ascites/
encephalopathy/ varices (3 cords Grade I varices)/ portal
hypertensive gastropathy/chronic portal and splenic venous
thrombosis, recently discharged from [**Hospital1 18**] yesterday with upper
GI bleed, who presents with recurrent melena. He reports he
arrived home yesterday and ate a seafood salad with several dk
brown stools last night and some abd cramping. Pt this AM had
black loose stool with abdominal cramping.
The patient was hospitalized at [**Hospital1 18**] from [**Date range (1) 30469**] for
melanotic stools. He was admitted to the MICU for hemodynamic
monitoring. GI performed endoscopy on [**2204-5-7**] which showed
non-bleeding esophageal and gastric varices, portal hypertensive
gastropathy, and a bleeding polyp noted in proximal body of
stomach injected with epinephrine with hemostasis, as well as a
colonoscopy on [**2204-5-8**] and old blood. He received 3 U PRBCs, his
Hct remained stable at 27, and he was called out to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
on [**5-9**], where his stools were noted to clear prior to
discharged home.
In the ED, 97.9 77 95/47 18 100% on RA. Pt noted to be alert and
mentating well. NG lavage not performed. Laboratory data
significant for hematocrit 26 (baseline 31) and Cre of 1.4
(baseline 0.8). Patient was noted to become hypotensive to 68
SBP and was treated with 2 L NS given wide open-> response of
SBPs to 90s, and 1 U PRBCs with second unit written for. GI saw
the patient, recommended tagged RBC scan and plan for repeat
EGD. On transfer to MICU, VS were afebrile 63 12 86/40 100%
On the floor vitals were 109/54 HR70 RR18 99%RA, pt reports
feeling well. Reports nonproductive cough, longstanding.
Possible palpitations last night. Denies dizziness, weakness,
chest pain, shortness of breath. Reports occasional cramping in
lower abdomen. Denies nausea, vomiting, dysuria, hematuria,
weakness, numbness, muscle aches, bruising.
Past Medical History:
-Hepatitis C
-ESLD s/p liver Tx [**2198-5-20**], s/p revision [**12-27**]; complicated with
rejection and steroid use since [**2199-4-20**] to present; also
complicated with Hepatitis C recurrence and restarted peg
interferon [**2199-6-17**]. Hep C possibly contracted from tatoo [**2171**].
-Chronic pancreatitis
-Primary hypogonadism
-ITP
-SVT last episode approximately [**1-30**], medically managed at this
time (atenolol)
-Thoracic compression fractures: [**5-26**]
-Cognitive disorders: h/o post hypoxic encephalopathy [**2190**].
-Depression /anxiety
-Neutropenia and infections including c. diff x3, streptococcal
septicemia, anal fistula
-History of fistula in anus s/p Fistulectomy [**11/2198**]
-Chronic pain especially rectal pain
-Diabetes : steroid induced, managed at [**Hospital **] Clinic, recent
HBA1C 5.1 % (had received blood transfusions with splenectomy),
insulin requirements decreased
-S/p Appy
-S/p tonsillectomy
-Bilateral inguinal hernia
-S/p hernia repair which has failed
-S/p umbilical hernia repair and right inguinal hernia repair
[**11-22**]
-S/p ccy
-Left sided hydronephrosis due to obstruction from splenomegaly,
s/p left ureteral stent placement [**5-28**].
-Secondary hyperparathyroidism due to CKD managed by Dr. [**Last Name (STitle) 4090**]
at [**Last Name (un) **].
-Splenectomy, distal pancreatectomy, c/w fistula, s/p stent and
then removal [**2201**]
-History of peripancreatic abscess [**8-/2203**]
Social History:
Lives with mother in [**Name (NI) 583**] and they both help with ther
health issues. He has a sister that is also very involved in his
care. Patient sates he smoked in highschool socially (only in
parties), but quit since then. He denies any current or past
alcohol intake. He also denies at thit time any illegal
substance use, however, he also is denying any past illegal
substance use.
Family History:
Mother has DM2 and HTN. Uncle with cancer in his 80s (unknown
site). Denies any family history of MI, sudden cardiac death,
stroke and lung diseases has DM2
Physical Exam:
General: Alert, oriented, comfortable
HEENT: Sclera anicteric, dry mucous membranes
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI early
systolic murmur LUSB
Abdomen: Normoactive bowel sounds, prior incision scars noted,
soft, non-tender
GU: No foley
Rectal: Per ED, guaiac positive brown stool
Ext: Thin; warm, well perfused, 2+ pulses, no clubbing, cyanosis
or edema
Neuro: No asterixis
Pertinent Results:
ADMISSION LABS:
[**2204-5-10**] 04:15AM WBC-5.8 RBC-2.48* Hgb-8.5* Hct-26.1* MCV-106*
Plt Ct-136*
[**2204-5-10**] 04:15AM Glucose-77 UreaN-22 Cr-1.0 Na-135 K-4.8 Cl-110*
HCO3-20*
[**2204-5-10**] 04:15AM ALT-43* AST-92* AlkPhos-236* TotBili-1.4
[**2204-5-10**] 04:15AM tacroFK-8.5
MICRO:
[**5-11**] CMV VL: undetectable
STUDIES:
[**5-11**] RBC Scan:
Delayed imaging shows activity in the midline at the level of
the aortic bifurcation which is likely in small bowel. There was
no active bleeding during the time of imaging.
[**5-12**] KUB:
No evidence of a capsule is seen within the abdomen.
.
[**2204-5-17**]: CTA
1. Multiple variceal vessels are identified in the abdomen. No
active
extravasation of contrast is seen to indicate a site of active
hemorrhage.
2. Unchanged thrombosis of the portal vein, splenic vein, and
superior
mesenteric vein.
3. Fluid in the left abdominal flank is stable in size and
morphology.
.
[**2204-5-19**]:
GI bleeding study: No evidence of active GI bleeding at the time
of the study.
Discharge Labs: [**2204-6-27**]
WBC-8.9 RBC-2.76* Hgb-8.9* Hct-28.0* MCV-102* MCH-32.4*
MCHC-32.0 RDW-24.5* Plt Ct-213
PT-16.3* PTT-39.3* INR(PT)-1.4*
Glucose-106* UreaN-50* Creat-1.1 Na-138 K-5.2* Cl-106 HCO3-26
AnGap-11
ALT-14 AST-25 AlkPhos-270* TotBili-1.1
Calcium-9.9 Phos-3.2 Mg-2.1
tacroFK-8.8
Brief Hospital Course:
55M with hepatitis C cirrhosis s/p liver [**Month/Day/Year **] with
recurrent hepatitis C complicated by ascites, gastric and
esophageal varices, and encephalopathy admitted with recurrent
melena.
1. LGIB: Reported to have melena, although at different time
noted to have brown stool with bloody mucous. Immediate concern
was for UGIB, particularly variceal bleeding or portal
gastropathy in this patient with decompensated liver disease. Pt
with small intestine ulcers on recent capsule study. EGD on [**5-7**]
with non bleeding varices at the lower third of the esophagus
and gastroesophageal junction, portal hypertensive gastropathy,
polyp in proximal body of stomach, and 8 mm non bleeding polyp
adjacent to hepatico-jejunostomy. The patient had an RBC scan,
which showed no definite bleeding seen on 90 minute dynamic
imaging, but activity in the rectum on left lateral is
compatible with rectal bleeding. Pt had a sigmoidoscopy the next
morning on [**5-12**] that noted blood coating the colon, but no e/o
active bleeding. IR declined angiography at this time, as it
would be very low yield as no bleeding was noted on the RBC
scan. Over the pt's ICU course, he was transfused 5 units pRBCs.
The patient's HCT remained stable at 34 prior to call out to the
floor. On the floor the patient remained hemodynamically stable
however he continued to experience melanotic stools with a
downward trend in his hematocrit. He became transfusion
dependent, requiring about 2units/day. He subsequently had a
CT-A to looked for vascular abnormalities such as scarred
varices however this was unremarkable. A tagged red blood cell
study was repeated which showed no source of bleeding. The
patient continued to have melena, requiring [**12-24**] units of PRBCs
to maintain adequate hematocrit. The decision was made between
the patient and the team to proceed with an exploratory
laparotomy and a possible endoscopy in the OR. The patient was
taken to the OR on [**5-24**] with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. At the time of
surgery a small enterotomy
was made longitudinally and just in the Roux limb just beyond
the jejunojejunostomy. A colonoscope was advanced in from this
location distally toward the terminal ileum and then withdrawn.
No evidence of ulcerations or intramucosal or intraluminal
pathology was identified. A second enterotomy was made distally
in the mid to distal ileum, again transversely and then the
colonoscope was placed in this location and advance distally
into the terminal ileum and then eventually into the cecum. This
was withdrawn and again no identified lesions were noted. A
bleeding source was not identified during the surgery.
On POD 2 the patient had HR in the 130's and was found to be in
Afib, he was given Beta blocker and monitored.
Hematocrit was trended, in the ensuing days he received a total
of 4 units pRBCs.
He was also evaluated by nutrition services. After following
oral intakenit was determined to place a post pyloric feeding
tube and start tube feeds.
The wound was having ascitic fluid drainage, several clips were
removed and a VAC was placed. The patient had copius amounts of
fluid from the VAC, and the output was repleted with
intermittent albumin and IV fluids.
On POD 19 the patient was transferred to the SICU for increased
confusion. A head CT was obtained which showed no evidence of
acute intracranial abnormalities.
The patient remained in the SICU for 8 days. He was additionally
followed by neurology who atributed his confusion to
encephelopathy of metabolic of infectious etiology. An LP was
performed and infectious etiologies including cryptococcus were
ruled out. He had been started on acyclovir pending results of
LP, He received 6 days of this. In addition he received 6 days
of fluconazole for yeast in the urine. An EEG showed an abnormal
routine EEG in the waking state due to
a mildly slow and disorganized background with frequent theta
rhythms.
There were no focal, lateralized, or epileptiform abnormalities
noted.
He also had an unremarkable BAL. He was covered with Vanco and
meropenum, but never was febrile and all cultures were returned
as negative and the antibiotics were discontinued.
The patient eventually cleared and was able to be transferred
back to [**Hospital Ward Name 121**] 10. He continued to have large volume ascited from
the wound VAC and continued with albumin and fluid replacements,
the albumin replacement will continue upon discharge and extra
fluids are being instilled with tube feeds.
Two days prior to discharge, he spiked a fever and had increased
abdominal pain. His UA was concerning for a potential UTI, and
he was covered with ciprofloxacin. His urine cultures
eventually returned contaminated, and the ciprofloxacin was
dicontinued. Additionally, his PICC line was removed and sent
for culture, which showed no significant growth.
2. Acute on chronic renal failure: Creatinine 1.4 on admission,
likely due to decreased perfusion in the setting of bleed.
Improved to 1.0 but then elevated post op as high as 1.7.
Medications were adjusted accordingly. With adequate hydration
and use of albumin the patient once again returned to baseline
creatinine of 1.1 by day of discharge.
.
Medications on Admission:
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly take 30
minutes before other meds or food. Take w/ 8 oz water & remain
upright for 30 min. after dose.
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day
CLINDAMYCIN HCL - 300 mg Capsule - 2 Capsule(s) by mouth x 1 1
hour before dental work or cleanings.
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth weekly
LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - 1 Tablet(s) by mouth
once a day
LATANOPROST [XALATAN] - 0.005 % Drops - 1 Drops(s) in each eye
HS
(at bedtime) both eyes
LIPASE-PROTEASE-AMYLASE [PANCREASE] - 20,000 unit-[**Unit Number **],500
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by
mouth three times a day with meals
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by mouth twice a day
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg
Tablet
- 1 Tablet(s) by mouth three times a day
TACROLIMUS - 0.5 mg Capsule - 1 Capsule(s) by mouth twice a day
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet -
apply one packet per day daily (Patient should get 5 gram per
day) - No Substitution
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime)
as needed for insomnia
URSODIOL - 300 mg Capsule - 1 Capsule(s) by mouth twice a day
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 2 Tablet(s) by mouth
three times daily
CALCIUM CITRATE-VITAMIN D3 - 315 mg-200 unit Tablet - 1
Tablet(s)
by mouth twice a day
SIMETHICONE - 80 mg Tablet, Chewable - 40 mg by mouth three
times
a day
ZINC OXIDE [BOUDREAUXS BUTT PASTE] - 16 % Paste - Apply
topically
three times daily as needed
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Unit Number **]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Ursodiol 300 mg Capsule [**Unit Number **]: One (1) Capsule PO BID (2 times
a day).
3. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Unit Number **]: One (1)
Tablet PO TID (3 times a day): long term suppression for
pancreatic abscess.
4. Lamivudine 100 mg Tablet [**Unit Number **]: One (1) Tablet PO DAILY
(Daily).
5. Lipase-Protease-Amylase 16,000-48,000 -48,000 unit Capsule,
Delayed Release(E.C.) [**Unit Number **]: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Calcium Carbonate 500 mg Tablet, Chewable [**Unit Number **]: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
7. Ursodiol 300 mg Capsule [**Unit Number **]: One (1) Capsule PO BID (2 times
a day).
8. Albumin, Human 25 % 25 % Parenteral Solution [**Unit Number **]: 12.5 grams
Intravenous EVERY OTHER DAY (Every Other Day).
9. Tacrolimus 0.5 mg Capsule [**Unit Number **]: One (1) Capsule PO Q12H (every
12 hours).
10. Sertraline 50 mg Tablet [**Unit Number **]: 1.5 Tablets PO DAILY (Daily).
11. Epoetin Alfa 4,000 unit/mL Solution [**Unit Number **]: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Rifaximin 550 mg Tablet [**Unit Number **]: One (1) Tablet PO BID (2 times
a day).
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Unit Number **]:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
14. Nystatin 100,000 unit/mL Suspension [**Unit Number **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
15. Thiamine HCl 100 mg Tablet [**Unit Number **]: One (1) Tablet PO DAILY
(Daily).
16. Therapeutic Multivitamin Liquid [**Unit Number **]: One (1) Tablet PO
DAILY (Daily).
17. Folic Acid 1 mg Tablet [**Unit Number **]: One (1) Tablet PO DAILY (Daily).
18. Atenolol 25 mg Tablet [**Unit Number **]: One (1) Tablet PO DAILY (Daily).
19. Trazodone 50 mg Tablet [**Unit Number **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
20. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
21. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day): titrate to [**2-23**] BMs per day.
22. Fludrocortisone 0.1 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
23. Multivitamin Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
24. Hydromorphone 2 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO every four
(4) hours as needed for pain.
25. Docusate Sodium 100 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO BID
(2 times a day): [**Month (only) 116**] hold if stools loose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
GI bleed.
High output ascites
malnutrition
UTI
Acute on Chronic renal failure: resolved
.
Secondary:
s/p liver [**Hospital1 **] ([**2198-5-10**]).
Discharge Condition:
alert and oriented to person, place and time. Ambulatory with
supervision. Fall risk
Discharge Instructions:
Please call the [**Month/Day/Year 1326**] Office [**Telephone/Fax (1) 673**] if you experience
any of the warning signs listed below
You will be going to [**Hospital3 **]
Labs should be drawn twice weekly on Monday and Thursday
You will require IV albumin every other day
Tube feeds via post pyloric feeding tube
Wound VAC, primarily for ascites drainage
PICC line in place, care per facility protocol
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2204-7-6**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2204-8-3**]
10:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30470**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2204-8-31**] 1:40
[**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**] Date/Time:[**2205-3-20**]
10:00
|
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"584.9",
"456.21",
"456.8",
"211.1",
"E878.0",
"518.81",
"456.1",
"733.00",
"262",
"428.0",
"785.52",
"569.82",
"403.90",
"E849.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"45.23",
"96.72",
"45.24",
"38.93",
"96.04",
"93.59",
"45.21",
"99.15",
"96.08",
"54.11",
"45.13",
"33.24",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
16347, 16418
|
6604, 11853
|
294, 598
|
16609, 16696
|
5259, 5259
|
17146, 17735
|
4573, 4732
|
13609, 16324
|
16439, 16588
|
11879, 13586
|
16720, 17123
|
6295, 6581
|
4747, 5240
|
248, 256
|
626, 2678
|
5275, 6279
|
2700, 4150
|
4166, 4557
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,468
| 135,346
|
50922
|
Discharge summary
|
report
|
Admission Date: [**2104-11-13**] Discharge Date: [**2104-12-2**]
Service:
CHIEF COMPLAINT: Fatigue.
HISTORY OF PRESENT ILLNESS: This is an 88 year old woman
with past medical history of CLL, tuberculosis, status post
nine months of medical treatment; nephrolithiasis; recurrent
urinary tract infection; chronic renal insufficiency with
baseline creatinine between 1.5 and 2, who presented to the
Emergency Department for malaise. The patient reported that
she had been feeling great fatigue for a few weeks and had
decreased p.o. intake. She was having no abdominal pain,
nausea and vomiting or diarrhea. She did complain of some
chronic constipation. She was having no urinary symptoms
such as urgency, frequency or dysuria. She was initially
concerned that the fatigue might represent recurrence of her
anemia. She has required previous transfusions related to
decreased hematocrit from CLL.
PAST MEDICAL HISTORY: 1.) Tuberculosis; finishing a nine
month course of drugs. 2.) CLL. 3.) Hypothyroidism. 4.)
Nephrolithiasis. 5.) Recurrent urinary tract infection. 6.)
Chronic renal failure. 7.) Osteoporosis. 8.) Peripheral
vascular disease. 9.) IGM paraproteinemia.
HOME MEDICATIONS:
Chlorambucil.
Colace.
Fosamax.
Isoniazid.
Lasix.
Levothyroxine.
Metamucil.
Protonic.
B-6.
Potassium.
Urecholine.
Quinine.
Rifampin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in a building for the
elderly. Her niece, who is her closest living relative,
visits two to three times per week. She receives some help
from her niece with her activities of daily living but
appears to be fairly self sufficient.
PHYSICAL EXAMINATION: Upon arrival, vital signs reveal a
temperature of 99.3; heart rate of 90; blood pressure 122/55;
respiratory rate of 25; 100% saturation on room air. This is
a cachectic, elderly woman, noted to be tachypneic. Pupils
were equal, round and reactive to light with full extraocular
motions. She had anicteric sclera. Her neck was supple,
with mild anterior tenderness over the area of the thyroid,
which the patient reports is not new. Regular rate and
rhythm; normal S1 and S2; coarse breath sounds were noted,
but no rhonchi, rales or wheezes. Her abdomen was flat with
poor muscle tone. There were positive bowel sounds and
diffuse mild tenderness to deep palpation. Pitting edema was
noted to the knee; left greater than right. Cranial nerves
were intact and the patient had normal strength and sensation
to light touch.
LABORATORY DATA: CBC showed a white count of 18.4. The
patient's baseline white count is around 20, secondary to her
CLL. Hemoglobin was 8.6; hematocrit was 27.7; platelet count
of 55. Platelets were noted to be in the 40's to 50's since
[**Month (only) 116**]. Chemistry 7 showed a sodium of 140; potassium of 4.8;
chloride of 112; C02 of 10; BUN of 104; creatinine of 4.9 and
glucose of 113. Her calcium was 9.5; magnesium was 2.2;
phosphorus of 7.5. Urinalysis was cloudy, with moderate LE
and positive nitrites, large blood; 30 protein; 21 to 50
white blood cells; 3 to 5 red blood cells; rare bacteria; 0
to 2 epis. Urine culture was sent. Urine electrolytes and
osmolarity was sent, as well as urine eosinophils given the
drugs that she was taking. Liver function tests and TSH were
also sent at that time.
Arterial blood gases on the Emergency Department was 7.26,
20, 104, 9, negative 15, with a lactate of 0.7. She had a
chest x-ray done in the Emergency Department showing
bilateral patchy opacities that may be secondary to
atelectasis or low lung volume.
A renal ultrasound was ordered at that time but was still
pending. The patient was admitted to the floor for acute on
chronic renal failure with noticeable elevated anion gap,
metabolic acidosis.
HOSPITAL COURSE: The [**Doctor First Name **] was well above one, arguing
against a prerenal cause of her acute renal failure. The
positive urinary tract infection was treated with
Ciprofloxacin. The renal ultrasound acquired on the night of
admission showed severe right hydronephrosis with a 16 mm
stone in the lower pole of the right kidney. An atrophic
cortex was noted in that kidney. The left kidney was not well
visualized but in previous imaging done in [**2104-11-3**]
had severe hydronephrosis. CT non contrast of the abdomen was
taken as well, which showed a very atrophic left kidney as
well as right hydro. Given the presence of obstructive
uropathy, as well as evidence of infection in the urinalysis,
a urology consult was called the night of admission. Urology
evaluated the patient and recommended watching the cultures
and fever curve and continuing antibiotics and intravenous
hydration. A formal renal consult was called the following
morning, in order to fully evaluate her acute renal failure.
Her tuberculosis medications were discontinued, secondary to
concerns for INH exacerbating her acidosis as well as concern
that multiple medications have been previously implicated as
a cause of acute interstitial nephritis. The Ciprofloxacin
was dosed for her estimated creatinine clearance for her
urinary tract infection. She received intravenous fluids
with b1 to attempt to compensate for her acidosis and her
chemistries and arterial blood gases were monitored. Renal
felt there were multiple possible causes for the acute
episode of renal failure, including infection, dehydration,
medications and chronic obstruction.
The patient's creatinine started to decline by hospital day
number two to three, into the lower 4's. She continued to
have good urine output and was never oliguric. Her urine was
noted to be cloudy yellow and have some particulate matter in
it. Urinalysis clearly showed pyuria but cultures remained
negative during the hospital stay. This prompted a search
later in the stay for urinary tuberculosis, which ultimately
was negative. The patient continued to receive intravenous
fluids with bicarbonate as well as Ciprofloxacin for presumed
urinary tract infection and her creatinine continued to
improve. There was an ongoing discussion between the renal
service, urology service and medicine service, with regards
to help as to handle this episode of renal failure. Her
creatinine had clearly been climbing slowly over the last two
years, in the setting of a chronic obstructive uropathy.
Urology was not included during this visit to engage in any
lithotripsy or attempt to break up or remove the stone
sitting in the right kidney. They were concerned about her
comorbidities as well as her low platelet count from CLL.
There was discussion of a possibility of a percutaneous
nephrostomy for the right kidney, in order to attempt to
relieve the obstruction and hence preserve some kidney
function and stave off the need for ultimate dialysis. This
option was presented to the patient and a discussion of the
risks and benefits of that procedure was discussed.
Ultimately, the patient decided that she did not wish to
pursue a PCN.
Over the week-end of the [**11-16**], the patient
developed persistent wheezing that was not particularly
responsive to Albuterol and Atrovent nebs. She had no known
history of asthma or chronic obstructive pulmonary disease.
Since her bicarbonate had normalized, intravenous fluids with
bicarbonate were held. Repeated chest x-ray showed evidence
of mild failure. Given the absence of history of lung
disease, the wheezing was preliminarily presumed to be a
cardiac wheeze, as a result of hydration for the renal
failure. By this point, her creatinine had continued to fall
and was now under 3.0 so the decision was made to add some
Lasix diuresis prn in order to improve her congestive heart
failure. The patient responded beautifully to small doses of
intravenous Lasix in the range of 20 mg and was easily
diuresed about negative half a liter per day for several
days. Despite successful diuresis, her wheezes continued and
she continued to have shortness of breath. An arterial blood
gases was performed on the 16th showing a pH of 7.35, PC02 of
50; P02 of 60; bicarbonate of 29 and base excess of 0. She
was maintained on oxygen at all times, including during
ambulation, given her low P02. The cause of the respiratory
abnormalities were unclear to the care team. The leading
theory was still that intravenous fluids with bicarbonate as
well as the transfusion she had required early in her stay
for anemia had caused a fluid overload and the heart failure
was the cause of her respiratory difficulty.
On the evening of [**11-20**], the cross cover house officer
was called to the patient's side for shortness of breath and
wheezing. Repeat arterial blood gases showed a pH of 7.06
and P02 of 120. Anesthesia was called to the bedside for a
stat evaluation and the patient was intubated. She was
transferred to the Medical Intensive Care Unit that evening
for her respiratory distress and maintained on ventilatory
support. A right internal jugular line was placed and she was
briefly put on pressors for low blood pressure.
The patient was started on Meropenem while in the unit, in
order to cover for possible pathogens. The patient improved
and was weaned off pressors and was extubated on [**11-23**].
She did very well on nasal cannula oxygen following
extubation and was transferred back to the floor on [**11-24**]. A pulmonary consult had been called just prior to her
Medical Intensive Care Unit transfer and was continued after
she was back on the floor. The patient had a CT of the chest
ordered which showed multiple, ill-defined nodules in the
right upper lobe, with peribronchial wall thickening,
possibly due to progressive infection, such as granulomatous
disease versus tracheobronchitis, via neoplastic
infiltration. A bronchoscopy was considered. There was also
apparent tracheobronchial malacia noted when the patient
breathed during the examination. There was chronic middle
lobe collapse with a probable broncholithiasis. There was a
small pericardial effusion that appeared improved from
previous examination and interval resolution of the left
pleural effusion.
She had also had a VQ scan that was done just prior to unit
transfer that was low probability. An echo done on the 19th
showed an ejection fraction of over 55% with mild left
ventricular hypertrophy, 1+ aortic regurgitation, trace
mitral regurgitation and no evidence of tamponade. The
pulmonary team remained unclear on the source of her CT
abnormalities as well as her continued breathing
difficulties. She was maintained on her nebs, continued on
Lasix diuresis, and given chest physical therapy. The
patient's code status had been changed and a family meeting
that was held on [**11-25**]. The pulmonary team felt that
bronchoscopy to take samples would be inappropriate given the
code status and the potential for decompensation during the
test. Therefore, it was decided not to proceed with
bronchoscopy.
The patient was placed on intravenous Ceftazidime and thought
that perhaps this represented a pneumonia and that she might
improve with antibiotics. During the last days of her stay,
her respiratory status did improve and she had decreased
rhonchi, elimination of wheezing and improved shortness of
breath. The patient had the onset of some abdominal pain
that she first noticed in the unit that increased over her
first few days back on the floor. She also noted episodes of
diarrhea that created some incontinence and were very
distressing to her. She was tested for Clostridium difficile
times three on the 21st through the [**11-25**] and was
negative on each test. Nevertheless, empiric trial of Flagyl
was tried in an attempt to improve her symptoms. Over
several days, her diarrhea disappeared on Flagyl.
During her hospital stay, the patient did develop a rash on
her buttocks that appeared consistent with zoster. She
received a one week course of Valtrex p.o.
The patient continued to improve and by the 28th was much
more animated, feeling better and getting up and ambulating.
The care team felt that a short stay in pulmonary
rehabilitation would be beneficial to her and she agreed.
The acute renal failure appeared to have completely resolved
and her creatinine had fallen to 1.6. She was diarrhea and
abdominal pain free and feeling much better.
CODE STATUS: DNR/DNI.
DISCAHRGE STATUS: To pulmonary rehabilitation.
DIAGNOSES:
1. Acute on chronic renal failure.
2. Respiratory failure, status post intubation.
3. Possible misocomial pneumonia.
4. CLL.
5. Nephrolithiasis with chronic obstructive uropathy.
6. Hypothyroidism.
MEDICATIONS:
1. Furosemide 60 mg p.o. q. day.
2. Isosorbide dinitrate 10 mg p.o. three times a day.
3. Zolpidem 5 to 10 mg p.o. h.s. prn.
4. Albuterol and Ipratropium nebs.
5. Ceftazidime one gram intravenous q. 24 hours, to be
completed to a 14 day course.
6. Metronidazole 500 mg p.o. three times a day, to complete
a 14 day course.
7. Milk of Magnesia prn.
8. Pantoprazole 40 mg p.o. q. 24 hours.
9. Subcutaneous heparin shots until ambulatory.
10. Advair discus, one puff twice a day.
11. Epo 5000 units subcutaneous three times a week.
12. Ferrous sulfate 325 mg p.o. q. day.
13. Psyllium prn.
14. Levothyroxine 125 mcg p.o. q. day.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 10454**]
MEDQUIST36
D: [**2104-12-1**] 08:29
T: [**2104-12-1**] 20:33
JOB#: [**Job Number 105835**]
|
[
"585",
"276.2",
"518.81",
"428.0",
"204.10",
"584.9",
"599.0",
"287.5",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"99.04",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3801, 13474
|
1214, 1385
|
1675, 3783
|
103, 113
|
142, 914
|
937, 1196
|
1402, 1652
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,260
| 104,305
|
24138
|
Discharge summary
|
report
|
Admission Date: [**2152-4-28**] Discharge Date: [**2152-5-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
Hypoxia and decreased mental status.
Major Surgical or Invasive Procedure:
Right central line placed. Removed on [**2152-4-30**].
History of Present Illness:
Patinet is an 86 year old woman with COPD on 2L at baseline,
congestive heart failure, and a resident at [**Hospital1 10151**] facility who was transferred due to concern for
decreased mental status and hypoxia. On day of admission, she
developed hypoxia, requiring a 100% NRB to maintain good
saturation. Vitals on transfer were BP 100/60, T 102, and she
was given morphine 8 mg SL. EMS was called and per verbal
report, during transfer SBP dropped to 60s but this responded to
2L NS. According to personnel at rehab center, patient has had
increased difficulty breathing over past week. Treatment was
started with Lasix, albuterol, levofloxacin, and prednisone
taper.
.
In the ED, patient was obtunded and febrile to 101.3 F axillary.
RR was in the 30s, HR was 161, and blood pressure was in the
70-90s. On presentation, a central line was placed under
standard sterile conditions. ED staff noted patient has had
significant diarrhea while there, also witnessed an aspiration
event. She was treated with solumedrol for possible COPD flare,
blood gas obtained which showed ph 7.32, co2 72. Labs in ED
otherwise notable for leukocytosis, bicarbonate 41, creatinine
1.5, and sodium 152.
ED staff discussed with pt's son, her HCP. Confirmed that she is
DNR but would want intubation. She was treated with vancomycin,
ceftriaxone, and metronidazole. 1.4 mg Narcan was given with
some response.
Past Medical History:
-[**Hospital1 5595**] has a [**Location (un) 27292**] epidemic-symptom free for 10 days
-Influenza vaccine [**2151-12-7**]
-COPD/emphysema with CO2 retention: admitted in [**2152-2-14**] to
NEBH with fever, hypoxia and respiratory distress with
improvement with bipap, nebulizers, levoquin and steroids. ABG
on admission in [**2-20**] was 7.38/64/70-per d/c summary report. In
[**2152-2-14**], found to have bilateral lower lobe PNA and
presented with hypotension with BP 83/50 requiring ICU
admission.
-Schizophrenia
-Cataracts, status post iridectomy ROS
-Congestive heart failure: EF 55% and mild pulmonary
hypertension ([**2152-4-13**])
-Vitamin B12 deficiency, with macrocytic anemia
-Dementia
-Bladder spasm
-Urinary incontinece
-Partial lung collapse in [**2149**]
-Diabetes Type II, with creatinine in [**2152-2-14**] of 0.8
Social History:
At baseline, she is able to hold a superficial conversation. Her
memory is quite poor. Dependent for all ADL. She could feed
herself after the tray was set up. Spoke to [**First Name8 (NamePattern2) 47532**] [**Last Name (NamePattern1) 4894**] at
[**Hospital 100**] Rehab who notes that patient is dependent in all ADLS
except feeding. Total care. Been at [**Hospital1 5595**] for 2 weeks.
Family History:
Noncontributory.
Physical Exam:
(on admission to MICU):
Vitals: Tm = 97.0 on the floor and 103.8 in the ED, Tc = 95.5,
83/31, CVP= 10, HR 71-82,
AC 30%, PEEP = 10, VT = 400s, 7.28/64/48
GEN: Elderly female who appears younger than her stated age
NECK: No LAD
HEENT: PEERLA
CARD: nml S1, S2, distant heart sounds.
CHEST: Coarse breaths sounds with upper airway sounds
ABD:nabs, soft nt.
EXT: no edema.
NEURO: obeys simple commands
SKIN: No obvious wounds or rashes.
Pertinent Results:
Images:
-Chest Xray ([**2152-4-28**]): Evidence of congestive heart failure.
There may be superimposed pneumonia versus atelectasis of the
right middle lobe.
.
-Cardiac ECHO ([**2152-4-29**]): EF >55%. Right atrial pressure
11-15mmHg. Dilated RV cavity with RVH suggestive of chronic
pulmonary
hypertension. Normal RV systolic function suggests no acute (on
chronic) RV strain.
.
-Head CT ([**2152-4-28**]): 1. No hemorrhage or mass effect. 2.
Chronic microvascular infarction.
.
EKG ([**2152-4-28**]): SVT at 161 bpm.
.
.
MICRO:
Blood culture ([**4-28**], [**4-30**]): Negative to date.
.
Urine ([**2152-4-28**] and [**2152-4-30**]): Negative.
.
Stool ([**2152-4-28**]): NO CAMPYLOBACTER FOUND. NO E.COLI 0157:H7
FOUND. FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
.
LABS:
[**2152-5-2**] 07:00AM BLOOD WBC-11.5* RBC-3.01* Hgb-10.0* Hct-29.8*
MCV-99* MCH-33.1* MCHC-33.4 RDW-16.0* Plt Ct-289
[**2152-5-1**] 10:01AM BLOOD WBC-11.1* RBC-2.83* Hgb-9.4* Hct-28.0*
MCV-99* MCH-33.3* MCHC-33.6 RDW-16.1* Plt Ct-268
[**2152-4-28**] 10:30AM BLOOD WBC-14.1* RBC-3.20* Hgb-10.4* Hct-33.5*
MCV-105* MCH-32.6* MCHC-31.1 RDW-15.9* Plt Ct-317
[**2152-4-29**] 02:51AM BLOOD Neuts-88.6* Lymphs-9.8* Monos-1.5*
Eos-0.1 Baso-0
[**2152-4-28**] 10:30AM BLOOD Neuts-76.7* Lymphs-17.2* Monos-5.5
Eos-0.5 Baso-0.2
[**2152-5-2**] 07:00AM BLOOD Plt Ct-289
[**2152-5-2**] 07:00AM BLOOD PT-12.2 PTT-38.0* INR(PT)-1.0
[**2152-4-28**] 10:30AM BLOOD PT-12.4 PTT-25.8 INR(PT)-1.1
[**2152-5-2**] 07:00AM BLOOD Glucose-154* UreaN-18 Creat-0.7 Na-147*
K-4.4 Cl-108 HCO3-31 AnGap-12
[**2152-4-28**] 10:30AM BLOOD Glucose-87 UreaN-60* Creat-1.4* Na-154*
K-4.4 Cl-108 HCO3-37* AnGap-13
[**2152-4-28**] 05:20PM BLOOD ALT-22 AST-36 LD(LDH)-250 CK(CPK)-158*
AlkPhos-44 TotBili-0.2
[**2152-4-28**] 05:20PM BLOOD CK-MB-8 cTropnT-<0.01 proBNP-5066*
[**2152-4-28**] 10:30AM BLOOD CK-MB-4 cTropnT-0.05*
[**2152-5-2**] 07:00AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.3
[**2152-4-28**] 10:30AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.7*
[**2152-5-1**] 04:24PM BLOOD Type-ART pO2-71* pCO2-53* pH-7.47*
calTCO2-40* Base XS-12
[**2152-4-28**] 10:41AM BLOOD Type-ART pO2-167* pCO2-73* pH-7.34*
calTCO2-41* Base XS-10
[**2152-5-1**] 10:15AM BLOOD Type-ART pO2-67* pCO2-58* pH-7.46*
calTCO2-42* Base XS-14 Intubat-NOT INTUBA
[**2152-4-30**] 08:23AM BLOOD Type-ART Temp-37.6 pO2-80* pCO2-58*
pH-7.42 calTCO2-39* Base XS-10 Intubat-NOT INTUBA
[**2152-4-30**] 04:15AM BLOOD Type-MIX pO2-33* pCO2-56* pH-7.39
calTCO2-35* Base XS-6
[**2152-4-28**] 02:16PM BLOOD Type-ART pO2-96 pCO2-71* pH-7.31*
calTCO2-37* Base XS-5
[**2152-5-1**] 04:24PM BLOOD Glucose-152* Lactate-1.72 Na-141 K-4.1
Cl-99* calHCO3-38*
[**2152-5-1**] 04:24PM BLOOD freeCa-1.19
[**2152-5-1**] 10:15AM BLOOD freeCa-1.21
Brief Hospital Course:
Hospital Course/Assessment/Plan:
Patient is an 86 year old woman with COPD, CHF, who was
transferred for an acute respiratory hypercarbic hypoxemic
failure thought to be due to COPD exacerbation. Patient with
pronounced diarrhea, with cultures negative. Hypernatremic and
resolving renal failure. Cultures to date negative.
.
.
1)Infectious Process:
On admission to the MICU, patient thought to have sepsis and
severe hypovolemia in the setting of diarrhea. Concern for
aspiration pneumonia or infectious diarrhea. Reccurent episodes
of pneumonia and COPD exacerbation concerning for potential
aspiration.
-In MICU, required IV fluids and neosynephrine. CVP 10-14.
Received solumedrol in ED. Initially, started broad spectrum
vancomycin, ceftriaxone, and flagyl. Urine, blood, and stool
cultures negative. Patient came from nursing home where large
outbreak of [**Location (un) **] virus.
-Speech and swallow performed video swallowing study, as concern
for aspiration pneumonia. Patient will need to continue on
pureed solids and thick liquids to prevent aspiration.
-Will be discharged on levofloxacin for four more days for COPD
exacerbation.
.
2)Respiratory Distress:
Hypercarbic and hypoxemic repsiratory failure most likely
secondary to COPD flare. Previous ABGs revealed carbon dioxide
retention. Cardiac ECHO on [**4-29**] revealed elevated right atrial
pressure and dilated right ventricle, consistent with pulmonary
hypertension. Placed on bi-pap initially, but on discharge
tolerating 2L nasal canula. At baseline, patient requires
supplemental oxygen.
-Patient to continue on levofloxacin and prednisone, as
respiratory distress most consistent with COPD exacerbation.
Will continue prednisone for four more days. 40mg for the next
two days and then 20mg for the following two days. Patient will
also complete four more days of levofloxacin.
-Patient will be discharged on lasix 40mg daily, PRN for
pulmonary congestion.
.
3)Hypernatremia:
On admission, appeared hypovolemic, in setting of diarrhea.
Patient with dementia, so difficult to maintain adequate
hydration. Initially, calculated free water deficit of 3.9
liters. Continued to gently hydrate with IV fluids and follow
serum sodium levels. By discharge, sodium corrected at 147.
Continue to encourage PO liquid supplementation.
.
4)Diarrhea:
Patient from nursing home where previous norovirus outbreak.
Sent stool cultures for C. dificile and cultures. Initially
started metronidazole for empiric coverage.
-Patient's diarrhea resolved on discharge. Stool cultures
negative to date.
.
5) Altered Mental Status:
Underlying schizophrenia and dementia. Improved mental status
with improved ventilation. Head CT negative for intracranial
hemorrhage. Vitamin B12 864. Depakote level 16. Initially
held all psychotropic medications for schizophrenia, but
restarted on [**4-29**].
.
6) Acute renal insufficiency:
On presentation, creatinine 1.4, with baseline creatinin
0.8-1.0. With IV fluids, creatinine improved to 0.7.
.
7) Anemia:
Patient with history of macrocytic anemia on B12
supplementation. Iron studies on [**2152-4-4**] demonstrated ferritin
127, TIBC 246, iron 53.
.
8) Diabetes:
Placed on insulin sliding scale. Switched to glargine 10 and
humalong sliding scale.
-On discharge, will need to continue to monitor blood sugars, as
patient receiving prednisone.
.
9) Prophylaxis:
Placed on PPI and heparin subcutaneously. Previously colonized
with MRSA, so placed on precautions.
.
10) Code:
HCP: [**Name (NI) 25812**] [**Name (NI) **] [**Telephone/Fax (1) 61335**].
DNR, but can intubate for short periods of time.
Medications on Admission:
-albuterol
-Vitamin C
-Aricept
-Lasix 40 mg po qd
-Levofloxacin ([**2152-4-26**]->[**2152-5-3**])
-Morphine oral q4
-Magnexium oxide
-Ditropan
-Prednisone 40 mg as part of taper started at prednisone 60 mg
po qd on [**2152-4-26**]
-Risperdal 1 mg [**Hospital1 **]
-Depakote 500 qam
-Depakote 250 q pm
-Trazadone 50 mg po qhs
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
3. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)).
4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
q6hr PRN as needed for shortness of breath or wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
q6hr PRN as needed for shortness of breath or wheezing.
9. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
10. Ditropan 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for shortness of breath or wheezing.
13. MEDICATION
Continue on insulin sliding scale (see attached)
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: Give 40 mg on [**5-3**] and [**5-4**].
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Give 20mg on [**5-5**] and [**2152-5-6**]. No
further prednisone after [**5-6**] required.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
-COPD exacerbation
.
Secondary:
-Schizophrenia
-Cataracts, status post iridectomy
-Congestive heart failure: EF 55% and mild pulmonary
hypertension ([**2152-4-13**])
-Vitamin B12 deficiency, with macrocytic anemia
-Dementia
-Bladder spasm
-Urinary incontinece
-Partial lung collapse in [**2149**]
-Diabetes Type II
-Influenza vaccine [**2151-12-7**]
Discharge Condition:
Stable.
Discharge Instructions:
-You were admitted for hypoxia and decreased mental status. You
were started on a bi-pap machine. Most likely, you had an
exacerbation of your underlying COPD. Antibiotics were started
and you will continue on levofloxacin for four more days.
Prednisone will be continued for four more days (40mg per day on
[**5-3**] and [**5-4**], followed by 20mg per day on [**5-5**] and [**5-6**]).
-Continue on all medications prescribed on discharge. Lasix can
be used for increased edema or pulmonary congestion.
-You should continue to be followed by an attending physician at
your facility.
-If you experience any chest pain, shortness of breath, or any
other concerning symptoms, call your PCP or come to the ED
immediately.
Followup Instructions:
-You should continue to be followed by an attending physician at
your facility.
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
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12243, 12253
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,650
| 197,229
|
30443
|
Discharge summary
|
report
|
Admission Date: [**2122-5-1**] Discharge Date: [**2122-5-15**]
Date of Birth: [**2048-12-10**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Zantac / Ciprofloxacin
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
1. Right-sided frontal craniotomy for resection.
2. Intraoperative image guidance.
3. Microscopic dissections.
4. Duraplasty.
5. Transbronchial and endobronchial biopsy
History of Present Illness:
This is a 73 year-old man with a history of hypertension, atrial
fibrillation, prostate cancer treated with surgical resection
and radiation in [**2120**], bladder diverticuli with resection,
benign parotid tumor resected in [**2115**] who presents with two
weeks of altered cognition. Patient and his wife report for the
past two weeks the patient has had episodes of staring into
space, forgetfulness, confusion and disorientation. Yesterday
the patient was at a funeral and forgot where his car was
located. With increasing concern, the patient's family decided
to bring it to medical attention at [**Hospital3 68**]. There the
patient was noted to have 17mm right frontal mass and right
perihilar mass on CT head and chest. Loaded with dilantin,
decadron started. Patient transferred here for further work-up.
.
In ER here, seen by neurosurgery who recommended dilantin,
decadron, CT torso and bone scan for staging. MRI here confirmed
mass.
.
Patient denies [**Hospital3 5162**], weight change, other complaints.
Past Medical History:
Atrial fibrillation
Hypertension
Prostate cancer in [**2120**] treated with resection and radiation
Benign parotid tumor resected in [**2115**]
Bladder diverticula requiring resection
Aspirin allergy, nasal polyps--?Samter's triad.
Inguinal hernia
Social History:
Heavy smoking until quit in [**2097**], occasional alcohol, no drug
use. Good family support-wife. [**Name (NI) **] children.
Family History:
Both parents with lung cancer, father with brain tumor as well.
Physical Exam:
general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd, no carotid bruits, no thyromegaly or thyroid nodules
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, harsh 3/6 systolic murmur
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no edema
skin/nails: no rashes
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. Please see detailed
neuro exam done by neurosurgery in OMR earlier this morning
Pertinent Results:
Admission labs:
[**2122-4-30**] 11:10PM GLUCOSE-261* UREA N-25* CREAT-1.1 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-29 ANION GAP-12
.
[**2122-4-30**] 11:10PM WBC-9.0 RBC-4.93 HGB-14.7 HCT-41.6 MCV-84
MCH-29.9 MCHC-35.5* RDW-14.3
.
[**2122-4-30**] 11:10PM NEUTS-90.5* BANDS-0 LYMPHS-8.3* MONOS-0.6*
EOS-0.4 BASOS-0.2
[**2122-5-1**] 07:33AM DIGOXIN-0.9
[**2122-5-1**] 07:33AM PHENYTOIN-10.1
[**2122-5-1**] 07:33AM PT-14.0* PTT-24.6 INR(PT)-1.2*
.
[**2122-5-1**] Portable AP
Right lower lobe/parahilar mass or consolidation with satellite
nodules, is better evaluated on concurrent CT. No pneumothorax,
post-biopsy.
.
CT PELVIS W/CONTRAST [**2122-5-1**] 11:02 AM
1. Right hilar opacity demonstrating calcification and adjacent
bronchiectasis and satellite nodules, most suggestive of an
infectious process, of which tuberculosis is of concern.
2. Left adrenal adenoma.
3. Hypodensity within the left kidney, too small to
characterize.
.
BONE SCAN [**2122-5-1**]
No evidence of osseous metastases.
.
MR HEAD W & W/O CONTRAST [**2122-5-1**] 12:14 AM
Large, partially cystic and solid right frontal lobe mass. In a
patient of this age, either a primary brain tumor, likely a
glioma or a solitary metastatic deposit, the latter a much less
likely diagnostic consideration, could be present. Clearly,
definitive diagnosis will be achieved via biopsy.
.
Pathology Examination
TRANSBRONCHIAL AND ENDOBRONCHIAL BXS (2).
73 y/o with remote prostate cancer and new right lung mass.
Gross: The specimen is received in two formalin containers
labeled with the patient's name, "[**Known lastname 72364**], [**Known firstname 122**]" and the
medical record number.
Part 1 is additionally labeled "right lower lobe medial basal
transbronchial biopsy" and consists of multiple fragments of
tan-brown tissue aggregating 0.4 x 0.3 x 0.2 cm, entirely
submitted in cassette A.
Part 2 is additionally labeled "endo biopsy" and consists of
multiple fragments of tan-brown soft tissue aggregating 0.2 x
less than 0.1 x less than 0.1 cm, entirely submitted in cassette
B.
.
[**2122-5-4**] ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (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 mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
CT HEAD W/O CONTRAST [**2122-5-6**] 8:07 PM
Post right frontal mass resection and frontal craniotomy, with
postoperative changes and small amount of hemorrhage, persistent
vasogenic edema and shift of normally midline structures.
.
MR HEAD W/ CONTRAST [**2122-5-6**] 5:53 AM
This study was performed for operative planning and has limited
diagnostic utility. Again seen is a 4-cm cystic and solid mass
centered within the right frontal parasagittal region, with
marked compression of the corpus callosum and contiguous lateral
ventricles. There is promiennt surrounding edema. There is 9-mm
leftward shift of the midline structures. There is a sickle
shaped area of fluid attenuation within the left sublenticular
region, which is unchanged and may represent a chronic small
vessel infarction or unusually configured sublenticular cyst.
There is mucosal thickening of the frontal and ethmoid sinuses
and slight mucosal thickening within the maxillary sinuses,
inflamamtory in origin.
1. Limited study for preoperative planning.
2. Large cystic and solid right frontal mass with prominent
surrounding edema and compression of the genu of the corpus
callosum and adjacent lateral ventricles.
.
[**5-6**] brain biopsy:
#1, RIGHT FRONTAL TUMOR BIOPSY (including intraoperative smear):
METASTATIC MODERATELY DIFFERENTIATED ADENOCARCINOMA, consistent
with metastasis from lung primary.
#2, RIGHT FRONTAL TUMOR RESECTION:
METASTATIC MODERATELY DIFFERENTIATED ADENOCARCINOMA, consistent
with metastasis from lung primary.
.
[**5-8**] cxr:
IMPRESSION: Increasing size of right perihilar mass and
associated right lower lobe consolidation. The rapid interval
progression suggests an underlying infectious etiology. There is
also a new left pleural effusion.
.
[**5-13**] LE veins:
IMPRESSION:
1) Occlusive thrombus from the popliteal vein to the mid
superficial femoral vein on the left.
2) No DVT on the right.
.
[**5-14**] ct head:
NON-CONTRAST HEAD CT SCAN: Post-surgical changes are again noted
as such. There has been a right frontal craniotomy.
Pneumocephalus is slightly decreased from [**5-8**]. Extra-axial
fluid appears similar in degree. There is no new large
intracranial hemorrhage. Small amounts of blood layering
posteriorly within the occipital horns of lateral ventricles
appears similar to slightly decreased compared to [**5-8**].
There is slightly leftward shift of the normally midline
structures anteriorly, possibly in part related to slightly
decreased pneumocephalus. The third ventricle is slightly more
prominent, though the lateral ventricles appear quite similar in
configuration. A large area of vasogenic edema involving the
right frontal lobe appears similar as well. There is partial
opacification of the ethmoid sinuses, and a rounded hyperdense
structure containing air within the left side of the frontal
sinus appears similar. There is slightly more air within this
structure today.
IMPRESSION: Post-surgical changes as described. No new large
intracranial hemorrhage. Small amounts of intraventricular blood
are similar to slightly decreased compared to [**5-8**].
Brief Hospital Course:
73yo male with R frontal brain mass and R perihilar mass.
.
#Brain mass - 17 mm right frontal mass with surrounding
vasogenic edema and midline shift. On admission, with the help
of input from neuro-oncology the patient was started on Decadron
TID, dilantin and subsequent addition of Keppra. Dr [**Last Name (STitle) **] from
neuro [**Doctor First Name **] performed craniotomy on Wednesday [**5-6**], without major
complications. Pt had been having short episodes of confusion
lasting minutes with resolution, likely related to small
seizures, pt started on kepra 500 mg [**Hospital1 **] day two of admission.
Postoperatively he began to taper off the dexamethasone, with a
plan to continue it at 2 mg PO BID until he is seen for followup
in the brain tumor clinic after discharge. He was kept on Keppra
500 mg [**Hospital1 **] for sz ppx. The patient began to improve and have
less confusion and weakness, and did well with the continuation
of keppra for seizure prophylaxis and steroids for decreasing
edema. The brain biopsy pathology revealed metastatic
adenocarcinoma, presumptively from the lung (+adenoCa on
bronchial washings as well), and he has follow-up with
neuro-oncology and will at that time decide on a definitive
treatment plan. He was discharged on keppra and dexamethasone
and he will have his staples removed at his neuro-oncology
follow-up appointment. At discharge his mental status was
improved and he will have close follow-up at home with physical
therapy and occupational therapy.
.
#Right perihilar mass - Initial differential diagnoses included
metastasis vs infection vs primary cancer. Given smoking
history, lung cancer was a concern. He had a bronchoscopy and
initial bronchial washings showed 0 PMNS and 0 microorganisms.
Initial biopsies were negative for any malignancies. AFB smear
x1 negative, and his PPD negative. His bronchial brushings
returned positive for malignant cells consistent with
adenocarcinoma. As above, he has follow-up with neuro-oncology
as an outpatient, and given the primary tumor is pulmonary his
outpatient primary doctor [**First Name (Titles) **] [**Last Name (Titles) **]-oncology will decide on an
outpatient plan for treatment.
.
# Pneumonia: During the patient's course he developed RLL
crackles on exam, cough and a CXR with interval increase in RLL
opacity. He was initially started on clindamycin and
ceftazadime for pneumonia, but prior to discharge was
transitioned to cefpodoxime and flagyl. He was afebrile at
discharge and will complete his course of antibiotics.
.
# Left foot swelling/DVT: The patient was noted to have
asymmetric swelling of his left foot and on US was noted to have
and occlusive thrombus from the popliteal vein to the mid
superficial femoral vein on the left. Dr. [**Last Name (STitle) **] from
neurosurgery and Dr. [**Last Name (STitle) 4253**] from oncology advised starting
heparin without a bolus and having a low PTT goal. Once the
patient was at goal he had a head CT, and bleed was ruled out.
Prior to discharge, Dr. [**Last Name (STitle) **] said the patient could be safely
discharged on lovenox as a bridge to therapeutic coumadin with a
goal inr 2-2.5. The patient will have close follow-up by his
primary care physician and local coumadin clinic.
.
# Atrial fibrillation. The patient has a history of afib
controlled prior to admission with digoxin and verapamil. Prior
to surgery, his verapamil was switched to metoprolol. During
his course he developed a rapid ventricular rate, he responded
to IV metoprolol x 3. His beta-blocker was uptitrated and he
was rate controlled prior to discharge. He should continue
digoxin and metoprolol as an outpatient and be closely followed
for this condition. Decisions regarding long term
anticoagulation for PAF should be addressed after treatment of
DVT is complete based on risk/benefit ratio at that point, as
well as chronicity of Afib.
.
# Hypertension. The patient was on HCTZ and verapamil as
outpatient, but as stated prior verapamil was replaced with
metoprolol perioperatively. His beta-blocker was uptitrated for
heart rate and blood pressure control and he was well controlled
with the beta-blocker and HCTZ.
.
# Hyperglycemia. Has borderline DM, was started on glyburide day
prior to admission. Thus his current hyperglycemia likely
reflects the effect of steroids on top of his baseline insulin
resistance. Given the patient was to continue steroids as an
outpatient he was instructed on how to test and administer
insulin at home, and will have VNA help. He will need close
outpatient follow-up for this and may not need insulin once his
steroids are stopped.
.
# BPH: The patient has a history of BPH and was continued on
doxazosin.
.
# Left adrenal adenomatous mass on abd CT: On abdominal CT the
patient was noted to have a 2x2 cm mass, benign in appearance.
This should be followed in [**4-21**] months with repeat imaging.
.
# diarrhea: The patient likely developed diarrhea from his
antibiotics. C. difficile was ruled out and he improved with
immodium.
Medications on Admission:
HCTZ 25mg daily
verapimil 240 daily
cardura 8mg daily
digoxin .250
colace
glyburide 2.5 mg daily started recently
Discharge Medications:
1. glucometer
One touch ultra glucometer
Disp# one
2. Lancets & Blood Glucose Strips Combo Pack Sig: One (1)
pack Miscellaneous four times a day: one touch ultra lancets and
test strips.
Disp:*1 pack* Refills:*2*
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*30 qs* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
5. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
cardura.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. 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*
10. Insulin Syringes (Disposable) Syringe Sig: qs
Miscellaneous four times a day.
Disp:*120 qs* Refills:*2*
11. Insulin Glargine 100 unit/mL Cartridge Sig: 12 units qhs
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
12. Humalog 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous four times a day.
Disp:*qs qs* Refills:*2*
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*0*
14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
Please have PT/PTT/INR checked [**2122-5-17**] with goal 2-2.5
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
1. Right frontal brain mass possible adenocarcinoma
2. Perihilar lung mass possible adenocarcinoma
3. Pneumonia
4. Left lower extremity DVT
5. Atrial fibrillation
6. Steroid induced hyperglycemia
7. Left adrenal mass
8. Seizures
Discharge Condition:
stable, tolerating medications
Discharge Instructions:
1. You have a lung and brain mass that will be further
investigated and explained at the brain tumor clinic. You will
be taking a lot of new medications and should follow the new
list you are given. You will take all of your old medications
except glyburide and verapamil.
.
2. Please attend all follow-up appointments
.
3. Please get frequent monitoring of your Inr as you are on
coumadin. You are at increased risk for bleeding and should
notify your doctor of falls or new bleeding.
.
4. Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**], chills, vomiting, headache,
worsened mental status, bleeding, falls, weakness, shortness of
breath, chest pain and any worrisome signs.
Followup Instructions:
1) You have an appointment with [**Doctor First Name 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
(Neuro-Oncology). Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-5-18**] 3:00.
They will take out your staples then
.
2) Please have your PT/PTT/INR drawn at [**Hospital1 29405**], telephone # [**Telephone/Fax (1) 72365**]. They have a walk in lab and
the results should be faxed to [**Telephone/Fax (1) 54537**] (Dr. [**Last Name (STitle) **]).
Your first draw should be sunday [**2122-5-17**]. You have a standing
order in place.
.
3) Please follow-up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] at [**Telephone/Fax (1) 40067**], in
2 weeks. He is aware you will need an upcoming appointment
.
|
[
"227.0",
"198.3",
"486",
"401.9",
"162.5",
"600.00",
"584.9",
"427.31",
"250.02",
"453.41",
"780.39",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"33.27",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
15624, 15686
|
8473, 13526
|
303, 479
|
15959, 15992
|
2676, 2676
|
16745, 17494
|
1960, 2026
|
13690, 15601
|
15707, 15938
|
13552, 13667
|
16016, 16722
|
2041, 2657
|
254, 265
|
507, 1527
|
7278, 8450
|
2692, 7269
|
1549, 1799
|
1815, 1944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,085
| 129,478
|
7392
|
Discharge summary
|
report
|
Admission Date: [**2177-12-9**] Discharge Date: [**2177-12-17**]
Date of Birth: [**2108-8-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
mediastinal mass
Major Surgical or Invasive Procedure:
radical resection mediastinal mass with left phrenic and
recurrent laryngeal removal, left innominate vein removal [**12-9**]
History of Present Illness:
69yW who in [**2177-8-4**] underwent a CXR for evaluation of
posterior neck and chest discomfort. A soft tissue mass was
noted in the mediastinum at that time, and a subsequent PET CT
demonstrated abnormal uptake in this area. The patient then
underwent a bronch/mediastinoscopy with biopsy which returned as
poorly differentiated carcinoma, suggestive of squamous
carcinoma. She then developed a new pericardial effusion which
necessitating emergent pericardiocentesis in [**2177-10-4**].
Subsequent Echocardiograms have demonstrated slight
reaccumulation of the pericardial fluid but no evidence of
tamponade. She has undergone induction chemotherapy using
cisplatin and etoposide with a partial response. The patient
presents for elective resection of her mediastinal mass. She
otherwise has been feeling well.
Past Medical History:
h/o mediastinal mass s/p chemo
Social History:
40 pack year history, continues to smoke a few cigarettes per
day
Family History:
NC
Physical Exam:
Gen: thin, pleasant, NAD
HEENT: EOMI, nares patent, oropharynx without erythema/exudate
Neck: no masses
CV: RRR, no m/r/g
Lungs: occasional expiratory wheezes bilaterally
Abd: soft, NTND, +BS
Ext: no edema
Neuro: aao x 4
Pertinent Results:
[**2177-12-14**] 03:00AM BLOOD WBC-7.8 RBC-3.89* Hgb-11.8* Hct-35.4*
MCV-91 MCH-30.5 MCHC-33.5 RDW-15.3 Plt Ct-152
[**2177-12-14**] 03:00AM BLOOD PT-12.1 PTT-20.4* INR(PT)-1.0
[**2177-12-15**] 03:12PM BLOOD Glucose-104 UreaN-29* Creat-0.9 Na-142
K-3.8 Cl-96 HCO3-34* AnGap-16
[**2177-12-15**] 03:12PM BLOOD Calcium-7.9* Phos-4.1 Mg-1.4*
[**2177-12-14**] 12:51PM BLOOD K-4.5
Brief Hospital Course:
Patient was admitted and underwent an uncomplicated resection of
her left mediastinal mass with removal of both her left phrenic
and recurrent laryngeal nerves secondary to involvement with
tumor. Her left innominate vein was also removed during the
surgery. Postoperatively she was transferred stable and
intubated to the CSRU for further monitoring. She was sedated
with a precedex/fentanyl drip. She was transfused PRBC's for a
Hct of 26.3. Intraoperatively, four drains were placed, two in
the mediastinum and two in the left chest. She was bolused
overnight in order to maintain adequate blood pressure. On POD
#1, she was extubated without complication and had adequate
oxygen saturations on 4L NC. She was transferred to the floor on
POD #5.
1. Pulmonary
Patient's initial postoperative CXR demonstated L opacification.
An chest ultrasound was performed which did not reveal and
pleural effusion. She underwent flexible bronchoscopy on POD #2
with mild improvement of her left sided atelectasis. Her
respiratory status immediately postoperatively was stable
although she received albuterol nebulizer treatments throughout
the day. She received another bronchoscopy on POD #3 with
increased improvement in her respiratory status. Subsequent
CXR's continued to improve and she did not require additional
bronchoscopy. Her mediastinal and chest drains were removed
postoperatively without complication. She continued to improve
from a respiratory standpoint and was able to maintain adequate
oxygen saturations on room air prior to discharge.
2. Cardiovascular
Postoperatively patient initially tachycardic in the 110-120's,
metoprolol was increased up to 75mg qid with adequate control of
her heartrate to normal. Prior to discharge, she was started on
Toprol XL 300mg with good control of her heart rate. Her blood
pressure remained stable after initial fluid resuscitation
postoperatively.
Left lower extrem swelling was noted on day of discharge -LE
non-invasives were done and were neg for DVT.
3. Neuro
Initially maintained on a fentanyl drip with adequate control of
pain. She was transitioned on POD #4 to subcutaneous dilaudid
with good control. Prior to discharge, she was transitioned to
po dilaudid and had adequate pain control.
4. GI
Initially NPO, patient underwent both a bedside and video
swallow evaluation which demonstrated no impairment or
aspiration during swallowing. She was cleared for a regular
solid diet with thin liquids and was tolerating po's prior to
discharge. Patient was seen by otolaryngology who noted a
paralyzed left vocal cord. Recommended outpatient follow up for
potential vocal cord medialization.
5. GU
Initially diuresed successfully using iv using furosemide.
Adequate urine output, foley d/c'ed on POD #5.
6. HCT
Required PRBC's initially with an intraoperative blood loss of
1000cc's, however, her Hct stabilized prior to being transferred
to the floor.
7. ID
Patient remained afebrile throughout her hospital course, and
after initial postoperative treatment with Cefazolin,
antibiotics were discontinued.
8. Dispo
To home, to follow up with Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] in [**10-17**] days
following discharge.
Medications on Admission:
lipitor, MVI
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-9**]
hours as needed.
Disp:*100 Tablet(s)* Refills:*0*
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
Disp:*qs * Refills:*0*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*qs * Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Mediastinal mass
Discharge Condition:
good
Discharge Instructions:
Call Thoracic Surgery office at [**Telephone/Fax (1) 170**] for: fever,
shortness of breath, chest pain, excessive nausea or vomitting,
bleeding from incision sites. Your incision site may have a
small amount of drainage. You may shower ; pat your incision dry
after showering. No tub bathing or swimming for 2 weeks.
Do not drive while taking pain medications.
Followup Instructions:
Appointment with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] in [**10-17**] days- call
[**Telephone/Fax (1) 170**].
Call for ENT appointment in [**2-6**] weeks after discharge w/
Dr.[**Telephone/Fax (1) 27178**].
Completed by:[**2177-12-17**]
|
[
"164.0",
"198.89",
"197.0",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.22",
"32.29",
"40.11",
"34.4",
"33.22",
"07.82",
"37.31",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
6008, 6014
|
2086, 5286
|
303, 431
|
6075, 6082
|
1688, 2063
|
6492, 6749
|
1428, 1432
|
5349, 5985
|
6035, 6054
|
5312, 5326
|
6106, 6469
|
1447, 1669
|
247, 265
|
459, 1274
|
1296, 1328
|
1344, 1412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,874
| 145,326
|
53842
|
Discharge summary
|
report
|
Admission Date: [**2177-5-1**] Discharge Date: [**2177-5-5**]
Date of Birth: [**2135-12-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
CT scan dye
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2177-5-1**] - Coronary artery bypass graft x4, with bilateral
internal mammary arteries, left internal mammary artery to left
anterior descending artery and right internal mammary artery to
distal right coronary artery, and saphenous vein grafts to
diagonal 1 and diagonal 3
History of Present Illness:
41 year old male with relatively new-onset angina with a
markedly abnormal stress echocardiogram. He reports chest
tightness and throat discomfort on exertion on treadmill and
while walking at a fast pace which occurs
frequently, but not every time. Also reports fatigue which he
attributes to atenolol. He was referred for cardiac
catheterization. He was found to have coronary artery disease
upon cardiac catheterization and is now being referred to
cardiac surgery for recascularization.
Past Medical History:
Coronary Artery Disease
Hypercholesterolemia
History of tachycardia
Hemorrhoids
Sciatica
Rhinitis
Carpal Tunnel
Social History:
Lives with:wife and children, ages 8 and 5, and his parents
Contact: [**Name (NI) **] [**Name (NI) **] (wife) Phone# [**Telephone/Fax (1) 110481**]
Occupation:computer programmer
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-4**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Pulse:75 Resp:16 O2 sat:100/RA
B/P Right:120/70 Left:138/70
Height:5'7" Weight:167 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] _no edema____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left:2
DP Right: 2 Left:2
PT [**Name (NI) 167**]: 2 Left:2
Radial Right: 2 Left:2
Carotid Bruit none Right: Left:
Pertinent Results:
[**2177-5-1**]-ECHO
PRE-BYPASS: The left atrium is normal in size. No mass/thrombus
is seen in the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolci function
2. No change in valve structure or function.
3. Intact aorta
.
[**2177-5-5**] 04:35AM BLOOD WBC-5.0 RBC-2.52* Hgb-7.9* Hct-24.1*
MCV-95 MCH-31.2 MCHC-32.7 RDW-12.3 Plt Ct-193
[**2177-5-4**] 09:30AM BLOOD WBC-6.4 RBC-2.64* Hgb-8.2* Hct-25.2*
MCV-95 MCH-31.2 MCHC-32.7 RDW-12.2 Plt Ct-151
[**2177-5-5**] 04:35AM BLOOD Glucose-117* UreaN-14 Creat-0.6 Na-135
K-4.2 Cl-102 HCO3-24 AnGap-13
[**2177-5-4**] 09:30AM BLOOD Glucose-130* UreaN-16 Creat-0.6 Na-134
K-4.2 Cl-101 HCO3-24 AnGap-13
[**2177-5-5**] 10:30AM BLOOD Hct-28.0*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2177-5-1**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
As a free right internal mammary artery graft was used, he was
placed on nitroglycerin which was transitioned to imdur to
prevent vasospasm. Post operatively he was taken to the
intensive care unit for monitoring. Over the next several hours,
he awoke neurologically intact and was extubated. He began auto
diuresing his first night and required volume and Neo for
hypotension. After fluid administration the Neo was weaned off.
He remained hemodynamically stable. Low dose Lopressor was
initiated. He transferred to the floor on POD#1. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. He continued to progress
well and on POD 4 he was deemed safe for discharge to home with
VNA services.
Medications on Admission:
ATENOLOL 50 mg Daily
FENOFIBRATE MICRONIZED 200 mg Daily
FLUTICASONE 50 mcg Spray, Suspension [**12-30**] sprays each nostril
once
a day in am
PRAVASTATIN 40 mg Daily
ASPIRIN 81 mg DAily
CETIRIZINE 10 mg Daily
NAPHAZOLINE-PHENIRAMINE [EYE ALLERGY RELIEF]0.[**Numeric Identifier **] %-0.315 %
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
10. Outpatient Lab Work
CBC on [**2177-5-7**]
results to Dr. [**First Name (STitle) **] fax: [**Telephone/Fax (1) 5793**]
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease
Hypercholesterolemia
History of tachycardia
Hemorrhoids
Sciatica
Rhinitis
Carpal Tunnel
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2177-5-13**] 10:00
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**], [**2177-6-3**] 1:00
Cardiologist Dr. [**Last Name (STitle) 42388**] (office will call you with appt)
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 29117**] in [**4-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2177-5-5**]
|
[
"413.9",
"414.01",
"272.0",
"458.29",
"472.0",
"285.9",
"512.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.16"
] |
icd9pcs
|
[
[
[]
]
] |
6239, 6273
|
3749, 4775
|
287, 566
|
6428, 6599
|
2284, 3131
|
7387, 8081
|
1587, 1606
|
5118, 6216
|
6294, 6407
|
4801, 5095
|
6623, 7364
|
1621, 2265
|
237, 249
|
594, 1087
|
1109, 1223
|
1239, 1571
|
3142, 3726
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,361
| 194,740
|
33307
|
Discharge summary
|
report
|
Admission Date: [**2196-4-1**] Discharge Date: [**2196-4-30**]
Date of Birth: [**2121-7-2**] Sex: M
Service: MEDICINE
Allergies:
Succinylcholine / Inhaled Anesthetics (Halogen Based)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal intubation
Right Heart Catheterization
Placement and removal of central line
Placement and removal of arterial line
Placement and removal of swan catheter
Myocardial Biopsy
Thoracentesis
History of Present Illness:
Mr. [**Known lastname 77315**] is a 74yo male with PMH significant for CAD s/p
CABG, atrial fibrillation on anticoagulation, CRI, and CHF who
is being transferred from the CCU for management of respiratory
failure. He was initially admitted on [**4-1**] to the [**Hospital1 1516**] service
with increasing dyspnea on exertion at home. He had been
complaining of exertional dyspnea and increased weight despite
increasing doses of Lasix. Of note, he was diagnosed with atrial
fibrillation in [**Month (only) 404**].
During his time on the [**Hospital1 1516**] service he was given boluses of
Lasix IV
with little improvement. He was then transitioned to a nitro and
Lasix gtt. He also underwent a thoracocentesis and 1.5L of fluid
was removed. The patient continued to become more dyspneic,
tachypneic, and hypoxic despite thoracocentesis and diuresis.
Further diuresis was limited by lower blood pressures. He was
then transferred to the CCU for further management.
In the CCU the patient became more short of breath and hypoxic.
He was intubated and then diuresed. His acute respiratory
failure was
thought to be related to his heart failure. After significant
diuresis and improvement in his oxygen requirements, he was
weaned from the ventilator. On the day of extubation, the
patient remained sedated. Due to hypercarbic respiratory
failure, the patient was re-intubated the same day. His altered
mental status was further worked up since it was thought that it
contributed to difficulty weaning from the ventilator. Despite
this, he was not able to be extubated. He also completed a 10
day course of vanc/zosyn during this time for VAP. Given
difficulty with weaning off the ventilator, the pt underwent
tracheostomy. Given difficulty with diuresis with diuretics, the
patient was started on CVVH. In addition, he was started on
Meropenem for sputum culture grew Enterobacter. He also
underwent a bronchoscopy today which revealed blood and
increased secretions. He is now being transferred to the MICU
for management of his respiratory failure.
Past Medical History:
1)CAD: s/p CABG in [**2172**]
2)s/p pacemaker implantation for ? sick sinus
3)Hypercholesterolemia
4)Atrial fibrillation on coumadin at home
5)Diastolic Congestive heart failure EF>55%
6)Chronic renal insufficiency (on OMR 2.2 in [**2196-2-23**], as high
as 3.[**3-26**])
7)Difficult intubation [**12-26**] spinal fusion
Social History:
NC
Family History:
NC
Physical Exam:
vitals T 96.3 BP 109/45 AR 70 RR 32 O2 sat 100%
Vent settings: PCV/0.5/20/10
Gen: Patient sedated, not responsive to commands
HEENT: Tracheostomy in place, PERRLA
Heart: RRR, no m,r,g
Lungs: CTAB
Abdomen: +Anasarca, soft, NT/ND, +BS
Extremities: Mild LE edema, well perfused
Pertinent Results:
[**2196-4-1**] 11:52AM BLOOD WBC-9.3 RBC-3.98* Hgb-13.4* Hct-40.2
MCV-101* MCH-33.8* MCHC-33.5 RDW-16.3* Plt Ct-204#
[**2196-4-1**] 11:52AM BLOOD Neuts-79.7* Lymphs-12.8* Monos-6.9
Eos-0.3 Baso-0.3
[**2196-4-1**] 11:52AM BLOOD PT-22.0* PTT-33.9 INR(PT)-2.1*
[**2196-4-13**] 01:40PM BLOOD Fibrino-549*
[**2196-4-13**] 03:48AM BLOOD Ret Man-2.3*
[**2196-4-1**] 11:52AM BLOOD Glucose-114* UreaN-50* Creat-3.1* Na-138
K-4.2 Cl-97 HCO3-28 AnGap-17
[**2196-4-7**] 06:15AM BLOOD ALT-41* AST-67* LD(LDH)-448* AlkPhos-73
TotBili-2.1*
[**2196-4-27**] 03:43PM BLOOD proBNP-9360*
[**2196-4-2**] 06:15AM BLOOD TotProt-6.6 Calcium-9.1 Phos-5.0* Mg-2.1
[**2196-4-13**] 03:48AM BLOOD Hapto-235*
[**2196-4-14**] 06:25AM BLOOD calTIBC-226* VitB12-809 Folate-8.6
Ferritn-890* TRF-174*
[**2196-4-26**] 05:46PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2196-4-28**] 03:03AM BLOOD ANCA-NEGATIVE B
[**2196-4-26**] 05:16PM BLOOD C3-121 C4-21
Relevant Imaging:
1)CT chest ([**4-25**]): Moderate bilateral pleural effusions, right
more than left. Large parts of the lung parenchyma are involved
in an ongoing fibrotic process that may be triggered by other
infection or overhydration. No mass lesions, no relevant
lymphadenopathy.
2)CT head ([**4-25**]): In comparison with the prior study, no
significant change is noted, persistent mild prominence of the
sulci and ventricles, likely age related and involutional in
nature. There is no evidence of intracranial hemorrhage or
infarct.
3)ECHO ([**4-15**]): Small pericardial effusion without
echocardiographic signs of tamponade. Grossly preserved
biventricular systolic function.
Brief Hospital Course:
74yo male with complicated medical history who initially
presented for CHF exacerbation and then transferred to the CCU,
then MICU for respiratory failure.
1) Resp failure - The patient was admitted to the CCU and
rapidly became more short of breath and hypoxic. He was
intubated and initially required high settings to maintain
oxygenation. He was diuresed and his respiratory failure was
thought to be related to his heart failure. After significant
diuresis and improvement in his oxygen requirement, the patient
was weaned from the ventilator. On the day of extubation, the
patient was still somewhat sedated, but it was thought he was
awake enough to maintain ventilation. Due to hypercarbic
respiratory failure, the patient was re-intubated the same day.
It was thought his mental status was not alert enough at the
time for successful extubation. His sedating medicines were
held and he was worked up for other causes of altered mental
status including uremia or hepatic encephalopathy. Neither of
these were felt to be contributing to his difficulty with
extubation. Metabolic abnormalities including increased bicarb
and low sodium were also corrected. However, the ventilator was
not able to be weaned successfully. Once on pressure support,
the patient respiratory rate increased and he was agitated.
Pulmonary was consulted but also could not fully explain why he
could not come off the ventilator. He also completed a 10 day
course of vanc/zosyn for VAP. A working hypothesis is that his
failure is related to his profound diastolic heart failure and
some underlying restrictive pulmonary defect that is not well
understood. A tracheostomy was placed. Bronchoscopy was also
done which revealed increased secretions and presence of blood.
The patient was then transferred to the MICU for management of
his respiratory failure. His respiratory status continued to
decline and he became increasingly difficult to oxygenate and
his pH on ABG became more acidotic. After a family meeting the
decision was made to change code status to comfort status only.
Patient expired quickly after the tracheostomy was disconnected
from the ventilator.
2)Hypotension - Patient was hypotensive upon admission to the
CCU. He was noted to be febrile and broad spectrum antibiotics
were started with vancomycin and zosyn. He was treated with a
10 day course for hospital associated pnuemonia. A swan was
placed for better management of his hypotension and shock. It
is likely that he had a mixed picture of some septic and
cardiogentic shock. Initially he was quickly weaned from the
levophed and he maintained his pressures. Later in his ICU
course, he was sent to the cath lab for replacement of a swan
and a new IJ line. During this procedure he again became
hypotensive and it was thought that some quantity of bacteria
was liberated during removal of his old line. He was restarted
on levophed and again started on vancomycin. Cultures remained
negative. It seems likely that the cause of this new
hypotension was propofol. The propofol gtt was stopped and he
was taken off pressors. During his stay in the MICU the patient
became hypotensive and required 2 pressors to maintain his blood
pressure. The pressors were stopped after the decision was made
to withdraw care and change code status to CMO.
3)CHF - Per the patient's history, it seems that he has
worsening heart failure of the past 5-6 months. He was
initially treated on the floor for a CHF exacerbation. However
this did not improve with diuresis and he was transfered to the
CCU and intubated as noted above. Multiple Echocardiograms were
performed in house and they were consistent with diastolic heart
failure. This was also confirmed with a right heart
catheterization. These numbers were more consistent with a
restrictive cardiomyopathy. He also underwent a mycardial
biopsy which was unrevealing. Given poor response with diuretics
and worsening renal function, he was started on CVVH as a
temporazing messure. Further diuresis became increasingly more
difficult since his blood pressures started to drop.
4)Acute on chronic renal failure - Patient was admitted with
acute renal failure. Renal was consulted during the
hospitalization and they believe that both his acute and chronic
failure are related to poor forward flow of blood to his
kidneys. Patient was started on CVVH as a temporizing measure to
help with fluid removal. Once code status was changed to CMO,
CVVH was stopped.
5)Afib/flutter - Patient was initially admitted with a rapid
heart rate. EKGs confirmed that his pacer was pacing his
ventricle 1:1 from his atria. The atrial sensing was turned off
and his ventricular rate set to 70. Cardioversion was attempted
in house but was unsuccessful. He was continued on amiodarone
while in house.
Medications on Admission:
Amiodarone 200mg daily
Atorvastatin 10mg, [**11-25**] tablet
Diltiazen 120mg daily
Lasix 20mg daily
Toprol XL 50mg daily
Omeprazole 20mg daily
Coumadin 2.5 daily
Aspirin 81mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired at 6/7.
Discharge Condition:
Patient expired at 6/7.
Discharge Instructions:
Patient expired at 6/7.
Followup Instructions:
Patient expired at 6/7.
|
[
"276.2",
"V45.4",
"V58.61",
"V45.01",
"518.84",
"V45.81",
"348.30",
"785.52",
"584.5",
"427.31",
"427.32",
"428.33",
"511.9",
"416.8",
"425.4",
"482.83",
"995.92",
"585.9",
"038.9",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"37.21",
"96.04",
"37.25",
"97.23",
"33.24",
"39.95",
"96.72",
"31.1",
"96.6",
"34.91",
"38.93",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
10025, 10034
|
4945, 9765
|
334, 535
|
10102, 10128
|
3312, 4232
|
10200, 10227
|
2998, 3002
|
9996, 10002
|
10055, 10081
|
9791, 9973
|
10152, 10177
|
3017, 3293
|
273, 296
|
4250, 4922
|
563, 2618
|
2640, 2962
|
2978, 2982
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,784
| 193,418
|
5633
|
Discharge summary
|
report
|
Admission Date: [**2137-4-28**] Discharge Date: [**2137-5-7**]
Date of Birth: [**2059-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Left chest tube placement
History of Present Illness:
77 yo M s/p AVR/CABG and d/c to rehab, transferred from OSH
after presenting with SOB and having chest xray which showed
left sided white out.
Past Medical History:
--Severe aortic valve stenosis (area <0.8cm2).
--COPD
--Hyperlipidemia -> TC 159, LDL 95, HDL 48, TG 78.
--AAA s/p endovascular repair with stent [**2133**]
--Ulcerative colitis
--H/O bladder cancer (presumably in remission)
--Gastric mass with 4/07 biopsy which showed intestinal
metaplasia and Paneth cell metaplasia, the [**Doctor Last Name 6311**] stain is
focally positive for organisms consistent with H. pylori.
Social History:
Social history is significant for the absence of current tobacco
use. 100 pack year history (quit 2 years ago). There is no
history of alcohol abuse. He drinks ETOH 1 beer/day.
Family History:
Father MI in 40s and fatal MI at 75, sister lung cancer
Physical Exam:
Admission
SOB
HR 71 BP 121/44 RR 23
Lungs Clear on right, left with no breath sounds.
Heart RRR
ABdomen benign
Extrem 2+ edema
Discharge
VS T 97.6 HR 67 SR BP 105/84 RR 22 O2sat 94%/2lnp
Gen NAD
Pulm CTA somewhat diminished in left base
CV RRR, NO murmur. Sternum stable incision CDI
Abdm soft, NT/+BS
Ext warm, 1+ edema bilat
Pertinent Results:
[**2137-5-6**] 05:35AM BLOOD WBC-3.9* RBC-3.26* Hgb-9.4* Hct-28.9*
MCV-89 MCH-28.7 MCHC-32.4 RDW-15.6* Plt Ct-80*
[**2137-4-28**] 05:00PM BLOOD WBC-6.4 RBC-3.44* Hgb-9.9* Hct-30.4*
MCV-88 MCH-28.7 MCHC-32.5 RDW-15.5 Plt Ct-82*#
[**2137-5-6**] 05:35AM BLOOD PT-13.1 PTT-30.1 INR(PT)-1.1
[**2137-4-28**] 05:00PM BLOOD PT-31.3* PTT-34.2 INR(PT)-3.2*
[**2137-5-6**] 05:35AM BLOOD Glucose-84 UreaN-16 Creat-0.7 Na-134
K-4.3 Cl-96 HCO3-33* AnGap-9
[**2137-4-28**] 05:00PM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-134
K-5.0 Cl-98 HCO3-30 AnGap-11
[**2137-5-5**] 06:45AM BLOOD Vanco-21.6*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2137-5-5**] 1:40 PM
CHEST (PA & LAT)
Reason: increase in pleural effussion / progression of pnuemonia
/ p
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with
REASON FOR THIS EXAMINATION:
increase in pleural effussion / progression of pnuemonia / pt
requiring 4 l oxygen
REASON FOR EXAMINATION: Followup of pleural effusion.
PA and lateral upright chest radiograph was compared to [**2137-5-4**].
The patient is after median sternotomy and CABG. The appearance
of the heart and the mediastinum is unchanged during the short
time interval. There is also no significant change in the
moderate left pleural effusion and small right pleural effusion.
There is no evidence of failure. The lungs are hyperinflated
most likely due to underlying emphysema.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: SUN [**2137-5-5**] 11:16 PM
RADIOLOGY Final Report
VIDEO OROPHARYNGEAL SWALLOW [**2137-5-1**] 2:46 PM
VIDEO OROPHARYNGEAL SWALLOW
Reason: ?aspiration
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with s/p CABG x4
REASON FOR THIS EXAMINATION:
?aspiration
VIDEO OROPHARYNGEAL SWALLOW:
INDICATION: 77-year-old man with four-vessel CABG, concern for
aspiration.
COMPARISON: Reports from [**4-18**] and [**2137-4-22**].
FINDINGS: Video oropharyngeal swallow was performed with various
consistencies of barium administered to the patient under video
fluoroscopic imaging in conjunction with the speech pathologist.
There is normal bolus formation, AP tongue movement, and oral
transit time. There was mild impairment of bolus control as well
as some oral cavity residue. There is mild impairment of swallow
initiation and laryngeal valve closure. The velar and laryngeal
elevation was normal.
Pharyngeal transit time was normal without any residue. There
was penetration with thin liquids and a tiny amount of trace
aspiration without spontaneous cough. This improved with the
chin tuck for thin liquids.
IMPRESSION: Mild impairments of oral and pharyngeal phases with
some penetration and tiny trace aspiration. Per report, this is
improved from priors.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: [**Doctor First Name **] [**2137-5-2**] 11:2905/25/08 8:52 pm SPUTUM Site:
EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final [**2137-5-6**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
[**2137-5-2**] 1:21 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2137-5-4**]**
GRAM STAIN (Final [**2137-5-2**]):
[**10-5**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2137-5-4**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
MOLD. 1 COLONY ON 1 PLATE.
Brief Hospital Course:
He was admitted to the cardiac surgery ICU, and a left chest
tube was initially for 1 liter of seroanguinous fluid. He was
diuresed. He was transferred to the floor on HD #3. He was
reevaluated by speech and swallow and his diet remained as
nectar thick liquids and pureed solids. HD#4 CT was discontinued
with minimal drainage,pulmonary hygiene, diuresis continued.
Vanco started prophylactically while sputum culture resulted.The
culture revealed normal oral flora, 1 colony of mold. ID felt
that the mold was contaminant. Vanco was dc'd. On HD #10 Mr
[**Known lastname **] was doing well and it was felt he would benefit from
transferring to rehab for further strength and endurance
training.
Medications on Admission:
Prevalite 4gm packet [**Hospital1 **], Aspirin 81', Omeprazole 20',
Terazosin 5', Asacol 800'''
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Terazosin 5 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
5. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
9. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) Inhalation Q4H (every 4 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours) as needed.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
15. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed.
18. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML
Miscellaneous Q2H (every 2 hours) as needed.
19. Furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
20. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
21. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]
Discharge Diagnosis:
Left pleural effusion
Severe Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Post-op Atrial Fibrillation
Emphysema
Thyroid Nodule
PMH: Hyperlipidemia, Gastroesophageal reflux, GI Bleed,
Ulcerative colitis, Benign Prostatic Hypertrophy, Bladder
cancer, Endovascular AAA repair
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] after discharge from rehab
Already scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-5-21**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2137-5-13**] 1:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2137-8-19**]
1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2137-5-7**]
|
[
"492.8",
"556.9",
"V45.81",
"414.00",
"530.81",
"511.9",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8756, 8830
|
5552, 6249
|
323, 351
|
9208, 9216
|
1602, 2333
|
9542, 10166
|
1178, 1235
|
6396, 8733
|
3262, 3295
|
8851, 9187
|
6275, 6373
|
9240, 9519
|
1250, 1583
|
5060, 5529
|
4965, 5029
|
280, 285
|
3324, 4927
|
379, 523
|
545, 965
|
981, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,973
| 144,659
|
944
|
Discharge summary
|
report
|
Admission Date: [**2181-10-10**] Discharge Date: [**2181-10-17**]
Date of Birth: [**2098-1-31**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yoF w/ a h/o CAD and CHF (EF 50%) presented with epigastric
pain, intermittent x 3 days. She states that the pain is
intermittent, not related to PO intake, no nausea or vomiting.
She has also felt some headache and some photophobia which has
improved. She has had no blood in her stool or melena, she has
been constipated lately. She also complains of dysuria x 1
month. She denies any blurred vision, lightheadedness, syncope
or presyncope. She states she has chest pain but when she
describes it futher it seems she is referring to her epigastric
pain.
.
She currently has no other symptoms.
.
2 units PRBC, 2 units FFP, vitamin K. She was given cipro for +
u/a. NG lavage was clear.
.
In the ED, initial vs were: T 99.1 P 60 BP 129/40 R 20 O2 sat
98% RA
Past Medical History:
CAD s/p anterior apical MI and s/p stent in past
Chronic systolic and diastolic CHF, EF 50%
afib
s/p PPM and ICD
DMII- diet controlledHypertension
Hyperlipidemia
Asthma
Left Trochanteric Bursitis
Cataract left eye- s/p extraction [**2178-6-11**]
Chronic renal insufficency, baseline creatinine 1.7 - 2.0
Venous stasis
Recurrent LE cellulitis
Social History:
The patient is Polish and does not speak English. She lives
alone, but is very close with her son and daughter-in-law
[**Doctor First Name 6303**] is a [**Hospital1 18**] employee at [**Hospital3 **]. No
alcohol, drugs, or smoking. No pets at home.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 97.2 BP: 125/72 P: 60 R: 15 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, conjunctiva pale
Neck: supple, JVP elevated to the earlobe at 90 degrees, no LAD
Lungs: diffuse wheezes bilaterally
CV: Regular rate and rhythm, normal S1 + S2, [**4-6**] HSM at the LLSB
Abdomen: soft, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
trace pedal edema with evidence of chronic venous stasis
changes.
Pertinent Results:
[**2181-10-10**] 07:25PM BLOOD WBC-7.5 RBC-2.04*# Hgb-6.0*# Hct-19.5*#
MCV-96 MCH-29.6 MCHC-31.0 RDW-17.1* Plt Ct-201
[**2181-10-11**] 08:38AM BLOOD WBC-7.1 RBC-2.88*# Hgb-8.8*# Hct-26.2*#
MCV-91 MCH-30.4 MCHC-33.4 RDW-16.8* Plt Ct-193
[**2181-10-10**] 07:25PM BLOOD PT-40.6* PTT-34.4 INR(PT)-4.3*
[**2181-10-11**] 08:38AM BLOOD PT-15.6* PTT-27.5 INR(PT)-1.4*
[**2181-10-10**] 07:25PM BLOOD Glucose-198* UreaN-88* Creat-2.2* Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2181-10-10**] 07:25PM BLOOD CK(CPK)-75
[**2181-10-10**] 07:25PM BLOOD CK-MB-NotDone proBNP-4839*
[**2181-10-10**] 07:25PM BLOOD cTropnT-0.04*
[**2181-10-12**] 07:30AM BLOOD WBC-12.1*# RBC-3.17* Hgb-9.5* Hct-29.2*
MCV-92 MCH-30.1 MCHC-32.7 RDW-17.0* Plt Ct-257
[**2181-10-13**] 07:55AM BLOOD WBC-7.4 RBC-2.58* Hgb-8.0* Hct-24.2*
MCV-94 MCH-31.0 MCHC-33.1 RDW-17.1* Plt Ct-207
[**2181-10-13**] 09:30PM BLOOD Hgb-9.7* Hct-29.3*
[**2181-10-14**] 01:30PM BLOOD Hct-25.7*
[**2181-10-15**] 07:20AM BLOOD WBC-6.9 RBC-2.94* Hgb-9.1* Hct-27.3*
MCV-93 MCH-30.9 MCHC-33.2 RDW-16.9* Plt Ct-208
[**2181-10-11**] 08:38AM BLOOD calTIBC-269 VitB12-253 Folate-GREATER TH
Ferritn-35 TRF-207
[**2181-10-10**] CHEST (PA & LAT): A dual-lead pacer device is again noted
with lead tips in the expected location of the right atrium and
right ventricle. The lungs appear essentially clear bilaterally,
aside from mild bibasilar plate-like atelectasis. There is no
pleural effusion or pneumothorax. Cardiomediastinal silhouette
is stable. Bones are diffusely osteopenic. Atherosclerotic
calcification along the thoracic aorta is noted. Old right lower
posterolateral rib fractures are again seen.
[**2181-10-11**] EGD: Normal mucosa in the stomach (biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
[**2181-10-11**] Gastric mucosal biopsy:
A. Gastric body: Antral/corpus type mucosa with chronic
inactive inflammation.
B. Antrum: Chronic focally active gastritis.
Note: [**Doctor Last Name 6311**] stain for H. pylori will be reported in an
addendum.
[**2181-10-15**] Colonoscopy: Normal mucosa in the whole colon
Polyp at a distance between 80 cm and 65 cm in the colon
Polyp at 20cm in the sigmoid colon (polypectomy)
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
Assessment and Plan: 83 yoF w/ a h/o CAD and CHF (EF 50%)
presents with epigastric pain, hct drop and supratherapeutic
INR.
# upper GIB / Anemia: baseline hct 30- [**2181-9-26**], dropped to 19.
INR was supratherapeutic, and aspirin and coumadin were held.
Following transfusions with 2 units prbcs, hct responded to
26.2. Acute hct drop likely related to GI bleed in the setting
of an elevated INR and guiac positive stools. Hemodynamically
stable. No other history for bleeding. NG lavage and EGD were
negative. Colonoscopy did not show any clear source of
bleeding. A video capsule study was performed to evaluate the
small bowel for a source of bleeding -- resutls were pending at
discharge. Folate and B12 levels were wnl. She will need to
have hct checks 2-3 times / week with results followed by her
primary doctor, Dr. [**Last Name (STitle) 4844**]. She will need to follow up
restarting her aspiring for coronary artery disease with the
discharge clinic. She will need to follow up her lower GI bleed
with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] GI. She will need to follow up her
anticoagulation with Dr. [**Last Name (STitle) 4844**]. At discharge her hematocrit
was stable and she was restarted on aspirin
# a-fib: Currently a paced. Coumadin and carvedilol were
initially held then restarted. Home amiodarone was continued.
LFTs were within normal limits. She has a Chad2 score of 6
indicative of a high stroke risk. Plan to discharge on aspirin
only. After HCT remains stable restarting coumadin should be
considered.
# CAD: the patient has a h/o CAD, s/p MI and s/p LCx mid and
prox stending and mid LAD stenting in [**2172**]. Cath w/o
intervention in [**2176**]. Asa was held and should be restarted at
outpatient discharge clinic appointment if hct is stable.
Cardiac enzymes were cycled and remained normal to rule out
cardiac source of pain.
# + u/a: the patient has had 1 month of dysuria. urinalysis was
consistent with infection. she was treated for three day course
with ciprofloxacin. EKG was monitored and showed no signs of QT
prolongation.
# ARF: baseline Cr 1.7 - 2.0. admitted with Cr of 2.2 w/ high
BUN of 80. Received 1L IVF in ER, FFP, and 2units of PRBC.
Given 40mg PO lasix x 1 dose between blood transfusions. High
BUN may be secondary to GI bleed as well. Her Cr normalized to
1.5.
# DM: Placed on insulin sliding scale in hospital.
# Asthma: The patient was wheezing on exam at admission. She
was given duonebs with good response. She appeared comfortable,
sating well on room air and expiratory phase is not prolonged.
Stable at discharge.
Code: Full
Medications on Admission:
Amiodarone 100 mg daily
Lipitor 10 mg daily
calcitrol 0.25 mcg three days a week
carvedilol 25 mg twice a day
Aranesp as directed by renal
vitamin D once a week
Pepcid 40 mg daily
furosemide 40 mg daily
warfarin
aspirin 81 mg daily
iron daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime.
9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
11. Aranesp (Polysorbate) Injection
12. Iron-B Cplx-B12-Liver Extract Intramuscular
13. Outpatient Lab Work
Blood draw for HCT 2 times a week, starting [**2181-10-15**]. Diagnosis
Anemia.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Anemia, Lower GI Bleed
Secondary Diagnoses: Chronic systolic and diastolic dysfunction
with LVEF of 50%; long-standing hypertension; atrial
fibrillation currently controlled on low-dose amiodarone with
cardioversion in the past; CAD with PCI/stenting; DM; stage IV
chronic kidney disease secondary to hypertension (baseline Cr
1.7-2.0); sick sinus syndrome with symptomatic bradycardia s/p
post dual chamber pacemaker in [**2173**]; bronchitis; s/p
cholecystectomy; anemia (baseline hct 30)
Discharge Condition:
Good.
Discharge Instructions:
You were admitted to the hospital for fatigue and abdominal
pain. On admission, your blood levels were low. You were
transfused 2 units of red blood cells and given fluids. A
nasogastric lavage was performed and did not show any signs of
blood in your stomach. Likewise an EGD did not show any source
of bleeding in your upper GI tract. Colonoscopy was performed
and did not show any bleeding source from your colon. Finally a
video capsule study showed was performed to look for a source of
bleeding in your small bowel. The results from the capsule
study were pending at discharge and you should follow up with
the GI doctors.
At the time of admission your blood thinner (coumadin) was
stopped since you were bleeding. You will need to follow-up
with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4844**], regarding
restarting your coumadin. You will have a visting nurse come to
do blood checks 2 or 3 times per week. You will need to follow
up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 767**] GI regarding your lower GI bleed. You were
also noted to have a urinary tract infection and were treated
with three days of antibiotics. Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
The following changes were made to your medications:
Your coumadin was stopped.
If you experience any of the following symptoms you should call
your doctor or go to the emergency room: blood in your stool,
diarrhea, vomiting (especially blood in the vomit),
light-headedness or dizziness, abdominal pain, chest pain,
shortness of breath, fevers or chills.
Followup Instructions:
You will need to follow-up with the following appointments:
A visiting nurse will come to draw your blood.
Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2181-10-19**] 10:30 a.m.. Before this appointment you
should go to the lab and have your blood drawn for a hematocrit
level.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2181-10-26**] 10:30 a.m..
You should discuss restarting your coumadin with Dr. [**Last Name (STitle) 4844**]
Provider: [**Name10 (NameIs) 81**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2181-10-24**] 2:00
pm. in the [**Hospital Unit Name **], [**Location (un) 453**].
|
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icd9pcs
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82,769
| 182,947
|
34730
|
Discharge summary
|
report
|
Admission Date: [**2182-8-22**] Discharge Date: [**2182-8-27**]
Date of Birth: [**2102-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Left shoulder pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 y/o M h/o CAD s/p CABG, CVA, HTN, COPD who presented to
[**Hospital 1474**] Hospital ED with c/o [**10-23**] constant left shoulder and
neck pain radiating across his chest and down his arms, worse
with inspiration and cough. Had increasing cough x 1-2 days
productive of yellow, blood-tinged sputum and generalized aches
x 3 days. There was some associated shortness of breath, most
prominent when lying on his left side, but relieved when lying
on his right. He has never had this pain before, and is
confident that this is different than pain from a past MI. He
tried bengay and an OTC analgesic without relief. He denies
diaphoresis, N/V, abdominal pain, LE edema.
In OSH ED, afebrile, HR 70s RR 16-18 O2sat 94-98% on 2L, BP
initially 80/50, 100/50 when repeated. WBC 16.3, K 5.9, BUN 112,
Cr 3.2. Notably, OSH records state that last recorded serum Cr
was 1.2 on [**2182-7-10**]. He was given 1 L of IVF, as well as doses of
ceftaz and vanco for presumed PNA based on left perihilar
infiltrate on CXR. He was treated with bicarb, D50/insulin,
kayexelate for hyperkalemia. He was also given hydrocortisone
100 mg IV x 1. CK 166 CK MB 3.6 Trop <0.01. He was transferred
to [**Hospital1 18**] for further management of renal failure and PNA at the
family's request.
In the ED, T 96.2 HR 86 BP 110/52 RR 20 O2sat 93% on 4L NC. SBP
then drifted down to 70-80's systolic. A right IJ was placed,
during which the patient had nonsustained VT. An EKG was
reportedly unchanged from prior. CVP was initially 4 mmHg.
Received another 5 L IVF. He had watery stools, reportedly
guaiac positive but was noted to have excoriations on his
buttocks. The patient vomited with an attempt at NG lavage, but
the wash was reportedly nonbloody. CXR showed a left perihilar
infiltrate and he was given zosyn 4.5 g IV x 1.
Past Medical History:
CAD s/p CABG
CVA w/ residual R hemiparesis
COPD
HTN
hyperlipidemia
parkinson's
hiatal hernia
chronic back pain
Social History:
Lives in [**Hospital1 1474**], MA with wife, nephew, granddaughter. Wife
with multiple medical problems as well. Drank 4-5 beers/day, a
"case" of beers on the weekends, prior to quitting before CABG
(unclear how long ago). Smoked 1 ppd x 60+ years, quit around
the time of CABG.
Family History:
Brother died of cancer, unknown site; Father died of a stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
V/S- T95.8 HR 79 BP 98/45 RR 19 O2sat 96% 4L NC CVP 8
GEN- Awake, cachectic, dysarthric; NAD
HEENT- PERRL; sclera anicteric; right-sided lower facial droop
NECK- R IJ in place [**Location (un) 1131**] CVP 8, leftsided JVD not appreciated
CV- RRR nl S1S2 no m/r/g
PULM- diffuse rhonchi on left, no wheeze, rales
ABD- soft, NTND, +BS; tender hepatomegaly, no appreciable
ascites
EXT- warm, dry; +PP, 1+ pitting edema, L > R
SKIN - no rash, spiders
NEURO- A+Ox3; complete right-sided hemiparesis of arm/leg;
hyperreflexic at right patella, hyporeflexic at left patella
Pertinent Results:
LABS: 138 111 92 AGap=12
-----------------< 176
4.0 15 3.0
CK: 172 MB: 6
Ca: 7.6 Mg: 2.6 P: 3.9
ALT: 49 AP: 907 Tbili: 3.0 Alb: 2.7
AST: 309 [**Doctor First Name **]: 174 Lip: 434
WBC 15.2 N:90.1 L:5.2 M:4.5 E:0.1 Bas:0.1
Hct 33.4 Hgb 11.2 Plt 268
Lactate 3.0 --> 1.8 -->1.6
ABG 7.37/24/84/14 O2sat 95% on 4L NC
EKG: SR 79 nl axis, intervals, TWI II,III,F; no ST depr/elev
IMAGING:
CXR - Left perihilar and retrocardiac opacity; left-sided volume
loss; large hiatal hernia
RUQ U/S - Numerous hypoechoic foci in the liver c/f diffuse
metastatic disease. Poor visualization of gallbladder and CBD
due to gross distortion of liver architecture, but gallbladder
does not appear distended.
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname 8840**] is an 80 y/o M h/o CAD s/p CABG, CVA, HTN,
COPD p/w atypical chest pain, sepsis, and hypotension in the
setting of likely pneumonia and a new diagnosis of CA metastatic
to the liver. On admission he was septic and hypotensive
requiring aggressive fluid resuscitation to support his blood
pressure, volume status, and maintain his urine output. He
required aggressive volume resuscitation for several days. He
was placed on empiric antibiotic therapy to cover for a possible
pneumonia. No organisms were ever identified in his blood or
urine. During hospital day [**3-17**] of admission, the patient had
episodes of unstable angina with EKG changes and was treated
with Heparin gtt, oxygen, morphine, nitroglycerine and
beta-blockers. His cardiac enzymes were cycled and they did not
indicate that the patient was having a myocardial infarction.
The patient was noted to have abnormal liver function tests on
admission. A RUQ U/S revealed hypoechoic lesions in the liver
that were consistent with metastatic cancer to the liver. The
patient did not have a known primary cancer at that time. Due
to his acute renal failure further CT imaging was initially
deferred to allow his kidney function to return to baseline.
However, the patient suffered worsening respiratory distress
throughout his admission which was thought to be related to a
pneumonia. To further evaluate his respiratory status a
non-contrast CT of the chest/abdomen/pelvis was obtained. It
showed bilateral pleural effusions and areas of lung
consolidation with a large 6 cm mediastinal mass and bulky
lymphadenopathy. The liver lesions could not be well-visualized
due to the lack of contrast. The patient's respiratory status
continued to deteriorate. The ICU team had multiple discussions
with the patient's family regarding prognosis and goals of care
occurred. Eventually, the decision was made to make the patient
DNR/DNI and place him on comfort measures only. He passed away
peacefully on [**2182-8-27**].
Medications on Admission:
Combivent 2 puffs QID
Flovent 2 puffs [**Hospital1 **]
Prednisone 40 mg on the 3rd day
Metoprolol SR 50 mg daily
Crestor 10 mg daily
Plavix 75 mg daily
Omeprazole 20 mg [**Hospital1 **]
Nifedipine ER 30 mg daily
Carbidopa/levodopa 25/100 [**Hospital1 **]
Lisinopril 10 mg daily
Naproxen [**Hospital1 **] PRN
ASA 81 mg daily
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2182-8-27**]
|
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icd9pcs
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334, 340
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,293
| 150,170
|
6632
|
Discharge summary
|
report
|
Admission Date: [**2145-2-11**] Discharge Date: [**2145-2-14**]
Date of Birth: [**2112-7-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
DKA (patients Insulin pump malfunctioned at home)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
32 year old female with type 1 DM on insulin pump presenting
with nausea, vomiting and DKA. Two days prior to admission, the
patient passed out at home after eating breakfast. She was down
X 5-6 minutes but reports she did not hit her head. BG after
incident 92. She went to work but reports feeling "fuzzy,"
therefore she came home and napped X 4 hr (unusual for her). BG
wnl for her. The next day she continued to feel off at
work--cognitive slowing, feeling as if in a fog, slowed memory.
She subsequently vomited. She reports approximately 1 month of
memory delay, feeling intermittently dizzy and nauseated. The
patient started her menstrual period 2 days ago. She was seen in
the ED for evaluation of these symptoms. Labs at that time were
remarkable for a BG at the time was 343 and AG was 10, UA with
15 ketone and 1000 Glucose and CT head was negative. She was
encouraged to follow up at urgent care neurology. That night,
her qhs BG was 140.
.
On the day of admission, the patient awoke feeling "off," with
continued dizziness and nausea and generalized not feeling well.
Her am BG was 400 and she bolused herself 7 units on her insulin
pump and had coffee only for breakfast. She came to the
neurology urgent care clinic for evaluation. At the clinic she
had acute worsening of her menstrual cramps in her lower back
and pelvix. She also vomited several times--her coffee and
lunch, no blood. She had 1 liquid BM with the vomiting mixed
with some blood from her period. She was given 2 tylenol for a
HA then vomited again. Prior to these GI events, she reports
feeling slightly sob and sweaty. Otherwise, denies fever,
chills, chest pain, headache, sore throat, cough, abd pain,
dysuria or any other symptom. Of note, the patient had
discontinued all meds except the insulin pump X 1 week prior to
admission as she thought they may be contributing to her
neurologic symptoms.
.
FS ag ED arrival was 400. Initial vitals were 97.7, 90, 111/72,
18, 100% on 3L NC. She was given 5 L NS and started on D5NS with
20 mEQ prior to floor transfer. She was also given Zofran 4 mg
IV X 2, Morphine 2 mg for abd cramping/pain. The ED team
discussed with [**Last Name (un) **] who recommended turning off the pump and
using SQ insulin. Insulin gtt started at 1 mg /hr. Initial AG
35, down to 17 at transfer to MICU. BG [**Month (only) **] to 213 at transfer
and patient changed to D5NS with 20 mEq KCl. Symptomatically she
was much improved prior to transfer.
.
Past Medical History:
IDDM
Elevated cholesterol
s/p ccy
Social History:
no tob, no etoh, no drugs, administrator at Montessori school
Family History:
Crohn's disease, HTN
Physical Exam:
98.7, 117/56, 89, 15, 99% RA 74 Kg
Gen: well appearing, nad
HEENT: OP clear, MMM, PERRL
Neck: no JVD, no LAD
Car: RRR No MRG
Resp: CTAB No RRW
Abd: s/nt/nd/nabs
Ext: no LE edema
Pertinent Results:
[**2145-2-11**] 09:05AM WBC-14.8*# RBC-4.33 HGB-13.7 HCT-41.1 MCV-95
MCH-31.7 MCHC-33.3 RDW-12.0
[**2145-2-11**] 09:05AM NEUTS-90.0* BANDS-0 LYMPHS-7.5* MONOS-1.9*
EOS-0.3 BASOS-0.4
[**2145-2-11**] 09:05AM PLT SMR-NORMAL PLT COUNT-348
[**2145-2-11**] 09:05AM GLUCOSE-428* UREA N-17 CREAT-1.0 SODIUM-134
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-13* ANION GAP-27*
[**2145-2-11**] 09:05AM CK(CPK)-98
[**2145-2-11**] 09:05AM CK-MB-NotDone cTropnT-<0.01
[**2145-2-11**] 09:05AM CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-1.9
.
Brief Hospital Course:
32-year-old female with type I DM presenting with n/v/d and DKA,
from unclear precipitant.
.
1. DKA: From insulin pump failure. Was admitted to the MICU and
started on insulin drip, which was then weaned off as her DKA
resolved with her AG closing and FS in the low 100s. She was
started on SC insulin and transferred to the floor. She was
discharged with instructions to follow up with [**Last Name (un) **].
.
2. Neurologic symptoms: constellation of global neurologic
symptoms and one episode of syncope. Symptoms are subacute,
lasting about 1 month with questionable worsening over last
several days. Neurologic exam nonfocal. Unclear relationship to
current DKA presentation. ? worsening related to self d/c'ing of
SSRI and benzo. By discharge she had no neurologic symptoms.
.
3. Hyperlipidemia: continued on outpatient simvastatin.
.
4. Anxiety: paroxetine was initially held but restarted by
discharge.
.
5. Code: full
Medications on Admission:
Ativan 1 mg prn
Paxil 10 mg daily
Lipitor 20 mg daily
Insulin/Novolog pump
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
unit Subcutaneous at bedtime.
Disp:*QS 1 month supply* Refills:*2*
2. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous QACHS: Per sliding scale.
Disp:*QS 1 month supply* Refills:*2*
3. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Paxil 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for anxiety.
6. Syringe (Disposable) 1 mL Syringe Sig: One (1) syringe
Miscellaneous four times a day.
Disp:*qs 1 month supply * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: diabetic ketoacidosis, type 1 diabetes
mellitus
Secondary diagoses: hypercholesterolemia, anxiety
Discharge Condition:
Stable. On sub-cutaneous insulin, eating, fs well controlled.
Discharge Instructions:
You were admitted for DKA (very high sugars and metabolic
dysregulation). It was from your pump failure (no other
inciting factors found.
Please take your medications, including insulin, as instructed
below. Please make sure you make the recommended outpatient
appoitnments instructed below.
If you develop fevers, chills, syncope, headache, fatigue, or
any other concerning symptoms, please go to the nearest
Emergency Room or call your physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please call the following numbers to make the recommended
outpatient tests:
* Evaluation of autonomic neuropathy: ([**Telephone/Fax (1) 19252**]
* Sleep study: ([**Telephone/Fax (1) 9525**]
* Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]: [**Telephone/Fax (1) 25350**]
* [**Hospital **] clinic: ([**Telephone/Fax (1) 4847**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
|
[
"V58.67",
"250.13",
"300.00",
"272.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5470, 5476
|
3800, 4729
|
365, 371
|
5638, 5703
|
3250, 3777
|
6233, 6726
|
3014, 3036
|
4855, 5447
|
5497, 5497
|
4755, 4832
|
5727, 6210
|
3051, 3231
|
276, 327
|
399, 2861
|
5516, 5617
|
2883, 2919
|
2935, 2998
|
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