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49,555
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42486
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Discharge summary
|
report
|
Admission Date: [**2167-12-29**] Discharge Date: [**2168-3-25**]
Date of Birth: [**2092-9-1**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Iodine / cefepime
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
HCAP and Vocal Cord Dysfunction
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy
History of Present Illness:
Mrs. [**Last Name (STitle) 65107**] is a 75 year-old woman with COPD, mild
bronchiectasis and suspected vocal cord dysfunction admitted
[**12-25**] from [**Hospital3 **] to [**Hospital 8**] Hospital with PNA/Septic
Shock. Patient met SIRS criteria on admission and received EGDT
with 4L NS, 2 units PRBC and was transiently on norepinephrine.
She was also started on Vanc,Zosyn,Aztreonam on [**12-25**]. Sputum
culture grew ESBL E.Coli and MRSA and she was narrowed to
Vanc/Ertapenem. Patient required intubation on resentation and
was extubated on [**12-28**]. Following extubation she required
non-invasive ventillation intermittently throughout the day. The
patient's daughter subsequently requested transfer to [**Hospital1 18**] for
further care.
.
On arrival to the MICU, the patient is somnolent but eaily
awakes to touch and has expiratory stridor.
Past Medical History:
dCHF EF 60%
DMII (A1c 6.8 [**11/2167**])
Mild Bronchiectasis
Anxiety
Microcytic Anemia
?Thalassemia Trait
Hypertension
GERD
Hiatal Hernia on EGD [**2161**]
s/p Cholecystectomy
Social History:
Originally from [**Country 47535**], moved here from [**Country 47535**] [**2166-10-24**].
Has 2 daughters (both physcians) one here and one in [**Country 47535**].
Her son also lives in US. She is a widow. Per family no tobacco,
EtOH or drug use.
Family History:
Her father had COPD and asthma, no other respiratory or cardiac
history.
Physical Exam:
Admission:
VS: T: 98.4, P: 88, BP: 132/78, RR: 21, 97% on CPAP
HEENT: cracked lips, no erythema
Neck: supple, JVP not elevated, no LAD
Lungs: Audible expiratory stridor, No inspiratroy wheezing
CV: distant heart sounds, regular rhythm
Abdomen: soft, non-tender, non-distended, bowel sounds present
Neuro: Somnolent, awakes to touch, tracks with eyes, pupils
3->2mm BL
.
Discharge:
VS: Tmax around 99, HR=100s-110s, BP=130s-160s/60s-90s, RR=20s,
99% on PSV 5/3 with FiO2=40%
General: pleasant but at times confused and agitated,
intermittently pulling on tracheostomy
HEENT: Anicteric sclera, EOMI, PERRL
Neck: Supple, trach in place
CV: tachycardic but regular rhythm, distant heart sounds
Lungs: diminished lung sounds bilaterally with crackles and
rhonchi intermittently noted in left lung; trach suctioning
significant for tan, thick sputum
Abdomen: soft, NT/ND, normoactive bowel sounds, PEG tube in
place
Neuro: Mostly alert and interactive, at times somnolent. Able
to walk about 50 feet with physical therapy on the vent. Able
to tolerate PMV to speak for a short period of time. Speaks
Bengali only.
Pertinent Results:
[**2167-12-29**] 10:59PM PT-11.4 PTT-22.0* INR(PT)-1.1
[**2167-12-29**] 10:59PM PLT SMR-NORMAL PLT COUNT-308
[**2167-12-29**] 10:59PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2167-12-29**] 10:59PM NEUTS-76* BANDS-7* LYMPHS-6* MONOS-6 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-3*
[**2167-12-29**] 10:59PM WBC-11.9* RBC-4.03* HGB-10.7* HCT-34.2*
MCV-85 MCH-26.5* MCHC-31.3 RDW-17.2*
[**2167-12-29**] 10:59PM CALCIUM-9.2 PHOSPHATE-3.9 MAGNESIUM-2.3
[**2167-12-29**] 10:59PM ALT(SGPT)-61* AST(SGOT)-27 TOT BILI-0.4
[**2167-12-29**] 10:59PM estGFR-Using this
[**2167-12-29**] 10:59PM GLUCOSE-102* UREA N-35* CREAT-0.8 SODIUM-143
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-34* ANION GAP-13
[**2167-12-29**] 11:57PM TYPE-ART O2-35 PO2-84* PCO2-69* PH-7.35 TOTAL
CO2-40* BASE XS-8 INTUBATED-NOT INTUBA
ECHO [**2167-12-31**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. 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. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a prominent fat pad.
CT Chest [**2168-3-10**]
IMPRESSION:
1. Multicystic abnormality in the left lung apex, likely
pneumatoceles, not significantly changed since [**2168-2-22**].
2. Small left pneumothorax.
3. New left lower lobe pneumonia and accompanying nonhemorrhagic
pleural
effusion.
4. Diffuse bilateral bronchial wall thickening, mucoid
impaction, and
bronchiectasis, likely reflect chronic recurrent aspiration.
Brief Hospital Course:
This is a 75 year old woman with PMH of COPD,
tracheobronchomalacia, bronchiectasis, diastolic CHF,
Mycobacterium avium complex pulmonary colonization, recent MRSA
and ESBL E.coli cavitary pneumonia, and DM2 who was transferred
from [**Hospital 8**] Hospital for further management of HCAP/sepsis,
ultimately requiring tracheostomy and PEG placement with course
complicated by multiple pneumothoraces requiring several chest
tube placements.
.
#. Respiratory Failure: Patient was intubated on admission to
[**Hospital 8**] Hospital and was extubated there on [**2168-12-28**] before
being transferred to [**Hospital1 18**]. She has a diagnosis of COPD and is
likely hypercarbic at baseline. She had audible expiratory
stridor on admission exam and required non-invasive ventilation
after admission to the MICU. She then developed increased work
of breathing and was re-intubated at [**Hospital1 18**]. Bronchoscopy was
done and showed severe distal tracheal malacia and severe
bilateral main bronchi malacia. A tracheostomy was performed
[**1-6**]. She was given a prednisone taper, saline and albuterol
nebs, and her HCAP was treated as below. She requires
intermittent PSV ventilation, but has been tolerating trach
collar for prolonged periods of time recently.
.
#. Multiple left sided pneumothoraces: She developed a left
sided pneumothorax on [**1-7**] and chest tube was placed. She
developed multiple left sided pneumothoraces throughout her
hospital course requiring several chest tubes. She was
pleurodesed by the thoracic surgeons on [**2168-3-15**] and the chest
tube removed, but she developed a repeat pneumothorax requiring
a pig tail chest tube placed. Thoracics initially recommended a
repeat pleurodesis, but the daughter declined given that her
mother experienced a lot of pain after her first one. Her last
chest tube was removed [**2168-3-24**]. She should be monitored closely
for any further pneumothoraces.
.
#. HCAP/Sepsis: Patient presented to [**Hospital 8**] Hospital in
severe sepsis requiring aggressive care. Sputum culture grew
ESBL E.Coli and MRSA. She was continued on a course of
vancomycin and meropenem. BAL grew aspergillus and she was
given a course of voriconazole. She developed several
ventilator associated pneumonias throughout her course requiring
multiple extended courses of meropenem for continued ESBL E.
Coli in her sputum samples, but no MRSA or aspergillus. Her
most recent 21 day course of meropenem ended [**2168-3-25**] and she is
currently on inhaled colistin to suppress any future infections.
.
#. Positive sputum AFB/Mycobacterium avium complex: A sputum
sample from [**2167-12-29**] was AFB positive. She was placed on
tuberculosis precautions for two months while the sample was
sent to the state lab for speciation. Her quantiferon gold was
negative. Speciation revealed atypical mycobacteria,
respiratory precautions were discontinued, and no further
treatment was pursued.
.
#. Diastolic CHF: Patient has known CHF on Lasix and [**First Name8 (NamePattern2) **] [**Last Name (un) **] as
an outpatient. Her [**Last Name (un) **] has been held and her Lasix is currently
dosed at 20mg IV BID with a goal of keeping her ins/outs even as
she currently appears euvolemic.
.
#. Diabetes Mellitus: Her blood sugars were checked four times
daily and she was maintained on Lantus and insulin sliding
scale.
.
#. Anemia: Patient has baseline anemia of chronic inflammation
and her hematocrit remained close to baseline in the mid 20s
throughout her hospitalization. Her type and screen is positive
for [**Doctor Last Name **] antibody and her transfusion threshold is Hct<21.
.
#. Anxiety/depression/acute delirium: Patient has significant
baseline anxiety and depression. Her citalopram was initially
increased at 40 mg from 20 mg po daily at home. Her clonazepam
was initially increased from 0.5 mg po BID to 1 mg po BID. She
was also given prn lorazepam throughout her hospitalization.
Unfortunately, she developed significant delirium related to her
length of stay in the ICU and all benzodiazepines, SSRIs, and
opiates were discontinued for the last couple weeks of her
course with improvement in her mental status. She was instead
transitioned initially to Seroquel 25mg twice daily which was
then titrated down to 25mg at bedtime to decrease daytime
somnolence.
.
#. Pain control: On Tylenol only at this point. Opiates are
being held given delirium.
.
#. Seizures Prophylaxis: She developed new seizures as of
[**2168-1-28**] thought to be secondary to cephalosporins and toxic
metabolic contributions. She was started on Keppra for seizure
prophylaxis and has been clinically stable since its initiation.
Cephalosporins should be avoided if possible.
.
#. T5 compression fracture: She has no pain and has remained
clinically stable in this regard.
.
#. Nutrition: PEG was placed without incident and she tolerated
tube feeds well. She is currently on Two Cal HN with 21
grams/day Beneprotein at a rate of 50 ml/hr. These tube feeds
are cycled from 8AM to 8PM. Residuals are checked every 4 hours
and were being held for residuals > 200 ml. She is being
flushed with 100 ml of water every 4 hours.
.
#. IV access: She had a right sided PICC line with some
erythema around the site which was pulled on [**2168-3-20**] and a new
PICC was placed in her left arm on [**2168-3-22**]. There was no growth
from the PICC tip culture.
.
#. Communication: Patient's daughter, [**Name (NI) **] [**Name8 (MD) 61683**] MD is a
nephrologist in [**Location (un) 2725**], MA and can be reached at [**Telephone/Fax (1) 91954**]
or [**Telephone/Fax (1) 91955**]
.
#. Code Status: DNR, patient already with tracheostomy, OK to
continue vent support
Medications on Admission:
Home medications:
Citalopram 20mg daily
Clonazepam 0.5mg [**Hospital1 **] PRN Anxiety
Ferrous Gluconate 240 daily
Fluticasone Nasal daily
Advair 500/50 [**Hospital1 **]
Lasix 20mg daily
Hydrocortisone 2.5% rectally
Combivent QID PRN
Lidocaine 5% ointment
Losartan 50mg daily
Montelukast 10mg HS
Omeprazole 20mg [**Hospital1 **]
Simethicone 80mg Q6H
Tiotropium 18mcg daily
Vit B-12 1000mcg daily
Vit D3 1000 unit daily
Discharge Medications:
1. fluticasone 110 mcg/actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]:
6-8 Puffs Inhalation Q2H (every 2 hours) as needed for
SOB/wheezing.
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
SOB/wheezing.
4. bacitracin-polymyxin B Ointment [**Hospital1 **]: One (1) Appl Topical
Q6H (every 6 hours) as needed for redden site.
5. colistin (colistimethate Na) 150 mg Recon Soln [**Hospital1 **]: One
[**Age over 90 1230**]y (150) mg Injection [**Hospital1 **] (2 times a day): Inhaled
colistin. Please administer albuterol prior to colistin
administration.
6. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
7. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: 325-650 mg PO Q6H
(every 6 hours) as needed for fever/pain.
8. thiamine HCl 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
9. niacin 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
10. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for yeast infection.
11. B-complex with vitamin C Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
12. ranitidine HCl 15 mg/mL Syrup [**Hospital1 **]: One [**Age over 90 1230**]y (150)
mg PO DAILY (Daily).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. camphor-menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: 1000 (1000) mg PO BID
(2 times a day).
16. sodium chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-25**] Sprays Nasal
QID (4 times a day) as needed for dry nasal.
17. insulin regular human 100 unit/mL Solution [**Month/Day (2) **]: as directed
Injection four times a day: per sliding scale.
18. quetiapine 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at
bedtime).
19. Furosemide 20 mg IV BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
-Tracheobronchomalacia
-COPD
-VAP
-Respiratory failure s/p tracheostomy and PEG requiring pressure
support ventilation intermittently
-Mycobacterium avium complex lung colonization
-Multiple pneumothoraces requiring chest tube placements
-Bronchiectasis
-Delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transferred from [**Hospital 8**] Hospital to [**Hospital1 771**] for further treatment of pneumonia and
septic shock. Unfortunately, your hospitalization was prolonged
with several complications. You had signifcant respiratory
distress on arrival requiring intubation. Unfortunately, you
were not able to be taken off of the ventilator and ultimately
required tracheostomy with intermittent ventilator support to
maintain proper oxygenation given your severe
tracheobronchomalacia, bronchiectasis, and COPD. You also
developed several pneumothoraces requiring multiple chest tubes.
There was also initial concern for tuberculosis given some
findings from your sputum, but thankfully your sputum grew out
an atypical mycobacterium which is not concerning.
Followup Instructions:
Please follow-up with the physicians at [**Hospital 100**] Rehab MACU.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
]
] |
13337, 13403
|
4849, 10582
|
328, 353
|
13711, 13711
|
2943, 4826
|
14692, 14858
|
1722, 1797
|
11050, 13314
|
13424, 13690
|
10608, 10608
|
13898, 14669
|
1812, 2924
|
10626, 11027
|
256, 290
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381, 1240
|
13726, 13874
|
1262, 1440
|
1456, 1706
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,775
| 108,010
|
8286+8287+55931
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2125-4-16**] Discharge Date: [**2125-4-24**]
Date of Birth: [**2048-6-6**] Sex: M
Service: VASCULAR SURGERY
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2125-4-23**] 14:56
T: [**2125-4-23**] 16:24
JOB#: [**Job Number 29387**]
Admission Date: [**2125-4-16**] Discharge Date: [**2125-4-24**]
Date of Birth: [**2048-6-6**] Sex: M
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Acutely ischemic left leg.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
non-diabetic white male with coronary artery disease, status
post coronary artery bypass graft, congestive heart failure,
with hypertension, end-stage renal disease on peritoneal
dialysis, peripheral vascular disease, status post bilateral
bypass grafts with multiple revisions on the left. He was
seen by Dr. [**Last Name (STitle) **] in the office on [**2125-4-12**] for
complaints of severe left calf claudication. The patient
denied rest pain or ulceration.
An outpatient arteriogram was scheduled on [**2125-4-16**], with
Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY:
1. Coronary artery disease; coronary artery bypass graft in
[**2120**].
2. Congestive heart failure.
3. Hypertension.
4. Bilateral pneumonia.
5. Tremor, hands, right greater than left, treated with
Primidone times two years with improvement.
6. End-stage renal disease on peritoneal dialysis.
7. Peripheral vascular disease; status post bilateral lower
extremity bypass graft with multiple revisions on the left.
PAST SURGICAL HISTORY:
1. Left capped fem-[**Doctor Last Name **] bypass graft with Dacron in [**2096**],
thrombectomy times two.
2. Right SFA to popliteal bypass graft in [**2096**].
3. PTA of right bypass graft in [**2101**].
4. Left CFA to AT with Dacron in [**2109**]; revision four months
later.
5. Jump graft from existing left fem-tib bypass graft to the
dorsalis pedis using nonreversed right basilic vein in [**2116-3-25**].
6. Repair of vein graft stenosis times two in [**2120-3-25**] by Dr. [**Last Name (STitle) **] after TPA thrombolysis.
7. Coronary artery bypass graft times three with right upper
arm vein and right lower saphenous vein [**2120**].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] quit
smoking cigarettes about six years ago. He does not drink
alcohol.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Digoxin 0.25 mg p.o. q. day.
2. Atenolol 75 mg p.o. q. h.s.
3. Losartan 50 mg p.o. q. day.
4. Zocor 40 mg p.o. q. day.
5. K-Dur 20 mEq p.o. q. day.
6. Nephrocaps one p.o. q. day.
7. Rabeprazole 20 mg p.o. q. day.
8. Aspirin 81 mg p.o. q. day.
9. Mysoline 50 mg p.o. q. h.s.
10. Metamucil two teaspoons p.o. three times a day.
PHYSICAL EXAMINATION: Vital signs with temperature of 97.0
F.; pulse is 58; respiratory rate 18; blood pressure 186/55;
O2 saturation equals 98% on two liters nasal cannula. In
general, alert, cooperative white male in no acute distress.
HEENT: Pupils equally and round. Extraocular muscles are
intact. Neck: Range of motion within normal limits.
Carotids palpable; no bruits. Chest: Heart is regular rate
and rhythm without murmur. Lungs clear bilaterally. Abdomen
soft, nontender. Extremities with right sheath in place in
right groin. Feet warm. Sensation and motor function intact
bilaterally. Pulse examination: Femoral pulses palpable
bilaterally. Popliteal pulses nonpalpable bilaterally.
Right dorsalis pedis has a Doppler signal. Right posterior
tibial and left pedal pulses have no Doppler signals.
ADMISSION LABORATORY: White blood cell count 13.1,
hematocrit 39.7, platelets 201,000. Creatinine 3.8, PT 12.8,
INR 1.1.
HOSPITAL COURSE: The patient was admitted to the hospital
following an arteriogram done by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The
left internal iliac artery and the left femoral to dorsalis
pedis bypass graft were occluded. Thrombolysis with TPA was
started.
Post procedure, the patient's popliteal artery and bypass
graft became palpable. There was a monophasic Doppler signal
of the left dorsalis pedis and posterior tibial pulses.
About 24 hours later, the patient left his pedal Doppler
signals on the left. He was maintained on heparin at 5000
units per hour as well as the TPA. The patient denied any
rest pain.
The following day, [**2125-4-18**], the arteriogram was repeated
to assess the distal embolization. A #4 French sheath was
placed in the bypass graft on the left and lysis of the
dorsalis pedis artery with a 1 mg bolus of TPA was initiated.
Post procedure, the patient's left foot was warmer with
increased capillary refill but the patient still had some
foot pain.
Vein mapping of arms and legs was done. Right cephalic vein
was measured. Left saphenous and basilic veins had been
harvested. Lesser saphenous veins were not visualized.
The patient was transfused one unit of packed red blood cells
for a hematocrit of 27.0. Hematocrit at time of dictation is
29.0.
Anti-coagulation with Coumadin was started. The patient was
maintained on Lovenox until the patient became therapeutic.
At the time of dictation, the patient's INR was 4.0 after
several days of 5 mg of Coumadin. His dose of Coumadin will
be adjusted to maintain an INR of approximately 2.5.
On [**2125-4-22**], petechiae were seen on the patient's left
foot. Physical Therapy assessed the patient and felt that in
another day he would be safe to be discharged home. The
patient was able to walk the hospital corridor fairly
comfortably with some pain but much less than on admission.
The Renal Service followed the patient and managed his
peritoneal dialysis.
At the time of dictation, the patient has a palpable left
graft pulse and a Doppler signal at the left dorsalis pedis.
He will be instructed when to follow-up with Dr. [**Last Name (STitle) **] in
the office at the time of discharge. He will have INR
checked twice per week with results called in to Dr.[**Name (NI) **] office and Coumadin dose adjusted accordingly.
DISCHARGE MEDICATIONS:
1. Coumadin, dose to be determined at discharge.
2. Digoxin 0.0625 mg p.o. q. day.
3. Losartan 50 mg p.o. q. day; hold for systolic blood
pressure less than 100.
4. Atenolol 50 mg p.o. q. h.s.; hold for systolic blood
pressure less than 100; heart rate less than 55.
5. Simvastatin 40 mg p.o. q. day.
6. Calcium carbonate 1500 mg p.o. three times a day with
meals.
7. Primidone 50 mg p.o. q. h.s.
8. Psyllium one packet p.o. three times a day p.r.n.
9. Nephrocaps, one p.o. q. day.
10. Protonix 40 mg p.o. q. 24 hours.
11. Colace 100 mg p.o. twice a day.
12. Tylenol 325 to 650 mg p.o. every four to six hours p.r.n.
13. Hydromorphone 3 to 4 mg p.o. q. three to four hours
p.r.n. pain.
14. Dulcolax 10 mg p.o. / p.r. q. day p.r.n.
15. Epogen [**2121**] units subcutaneously q. Wednesday.
CONDITION AT DISCHARGE: Satisfactory.
DISPOSITION: Home.
PRIMARY DIAGNOSES:
1. Thrombosis of left femoral to dorsalis pedis bypass
graft.
2. TPA thrombolysis of bypass graft on [**2125-4-16**] by Dr.
[**Last Name (STitle) **].
3. Distal embolization with repeat TPA of left bypass graft
and left dorsalis pedis on [**2125-4-18**] by Dr. [**Last Name (STitle) **].
SECONDARY DIAGNOSES:
1. Blood loss anemia, transfused.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
5. End-stage renal disease on peritoneal dialysis.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2125-4-23**] 14:56
T: [**2125-4-23**] 16:24
JOB#: [**Job Number 29387**]
Name: [**Known lastname 5139**], [**Known firstname **] W Unit No: [**Numeric Identifier 5140**]
Admission Date: [**2125-4-16**] Discharge Date: [**2125-4-25**]
Date of Birth: [**2048-6-6**] Sex: M
Service: VASCULAR SURGERY
ADDENDUM: This is an addendum to the discharge summary
dictated on [**2125-4-23**]. The patient complained of difficulty
urinating due to his BPH. His Flomax and Proscar were
resumed and within 24 hours, the patient was able to void
more comfortably.
Anticoagulation with Coumadin for his bypass graft was
started with 5 mg of Coumadin q.d. His goal INR is 2.5 to
3.0. On the day of discharge, his INR was 2.7. Initially,
the patient will need to have his INR checked twice per week.
His PCP was [**Name (NI) 178**] regarding monitoring the patient's INR
and adjusting the Coumadin dose. The PCP was agreeable and
requested that the patient come to the [**Hospital **] Medical office
for blood draws.
The patient stated that he was a very difficult blood draw
stick and would only agree to having his blood drawn at the
[**Hospital1 2314**] [**Location (un) 1144**] Dialysis Center by his nurse there, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
who draws his blood weekly. She was agreeable to drawing his
blood twice weekly until his INR was stabilized. The patient
was satisfied with this arrangement. The patient's INR
results will be called into Dr.[**Name (NI) **] office for a
Coumadin dose adjustment. When he is stabilized then his PCP
or his nephrologist will check his INR routinely.
The patient is discharged home on 2.5 mg of Coumadin p.o.
q.d.
The patient will follow-up with Dr. [**Last Name (STitle) 4107**] in the office in
two weeks and will have an ultrasound graft surveillance in
the office on the same day prior to the scheduled
appointment. At the time of discharge, the patient had a
palpable graft pulse.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4108**], M.D. [**MD Number(1) 4109**]
Dictated By:[**Last Name (NamePattern1) 4409**]
MEDQUIST36
D: [**2125-4-27**] 05:04
T: [**2125-4-28**] 07:19
JOB#: [**Job Number 5154**]
|
[
"V45.81",
"428.0",
"996.74",
"285.1",
"E878.2",
"600.01",
"403.91",
"447.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"54.98",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
2382, 2400
|
6289, 7097
|
3911, 6266
|
2604, 2943
|
1714, 2365
|
7482, 10133
|
2966, 3893
|
7113, 7461
|
600, 628
|
657, 1248
|
1270, 1691
|
2417, 2581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,293
| 136,994
|
40169
|
Discharge summary
|
report
|
Admission Date: [**2168-12-14**] Discharge Date: [**2169-1-2**]
Date of Birth: [**2083-6-26**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
confusion, found to have right Frontal and Left parietal brain
lesions
Major Surgical or Invasive Procedure:
Stereotactic Brain Biopsy
History of Present Illness:
85 yo right handed M who was in his usual good state of health
until 2 weeks ago when family began to notice change in mental
status - he lost his way when driving to familiar place and has
not been as engaged in daily activities. He denies headache,
seizures, visual changes.
.
Patient presented electively on [**12-14**] for stereotactic brain
biopsy of his right frontal lesion. He tolerated the procedure
well and was extubated in the OR then transferred to the PACU
for recovery. After a short period of time in the PACU he was
trasnferred to the floor where he remained stable overnight. On
the morning of POD#1 he was seen by physical therapy who
recommended that he would need to be sent to a rehab facility.
Rehab screen was started on [**12-15**]. On the evening on [**12-15**] he
grew increasingly confused and agitated, and was likely
sundowning. He was given zyprexa SL x 1 and placed in a posey.
He remained agitated overnight, and in the morning was more
calm. A geriatric consult was obtained, and they recommended
that seroquel be given for agitation, and for his dexamethasone
to be tapered to 2mg [**Hospital1 **]. A UA and CXR were obtained on [**12-16**],
which were both negative for an infectious process. He became
increasingly difficult to arouse on [**12-16**] in the evening, and a
head CT was obtained which demosntrated no acute change.
.
Over the weekend on [**12-17**] and [**12-18**], his mental status remained
confused and agitated. His morning temp was found to be 101.1
axillary, so blood and urine cultures were obtained. A chest
XRay was repeated, and given his WBC count to 19, coarse lung
sounds, and fever, it was thought that the patient likely had a
pneumonia. His was started on Vanc/Zosyn for coverage. In the
afternoon he developed increasing respiratory distress and
tachnypnea. He was transferred to the stepdown unit and diuresed
with lasix. Blood gas remained stable and and EKG as well as
CE's were ordered. Overnight he developed hypotension therefore
he was tranferred to the MICU.
Past Medical History:
Afib, silent MI 2yr ago, R total hip, bilat cataract repair,
emphasema, umbilical hernia, OA
Social History:
lives with wife, quit smoking 20 yr ago, no EtOH. Daughter very
involved in their care
Family History:
non-contributory
Physical Exam:
Admission Exam:
Alert + Oriented to self, month, hospital. Confused at times
PERRL, EOMI
face symmetric, tongue midline
no pronator drift
MAE's symmetrically
ambulates with cane at times
Pertinent Results:
ADMISSION LABS:
[**2168-12-18**] 07:50AM BLOOD WBC-19.9* RBC-4.48* Hgb-13.2* Hct-39.9*
MCV-89 MCH-29.5 MCHC-33.1 RDW-13.3 Plt Ct-326
[**2168-12-18**] 07:50AM BLOOD PT-14.2* PTT-25.3 INR(PT)-1.2*
[**2168-12-18**] 07:50AM BLOOD Glucose-125* UreaN-46* Creat-1.4* Na-142
K-4.4 Cl-101 HCO3-29 AnGap-16
CT HEAD STEREOTACTIC [**12-14**]
1. Redemonstration of right frontal and left parietal enhancing
lesions with resultant surrounding edema, most likely
representing metastatic disease however also could represent
lymphoma.
2. No evidence of midline shift or hydrocephalus.
.
CT HEAD POST-OP [**12-14**]
1. Mild pneumocephalus in the region around the biopsy of the
right frontal lobe mass. No evidence of hemorrhage.
CXR [**12-16**]:
No acute process
CXR [**12-17**]:
Lungs are clear.
LENIS:
No evidence of DVT.
CXR [**12-29**]:
As compared to the previous radiograph, there is a slight
increase in extent of the pre-existing left pleural effusion. As
a consequence, the left retrocardiac atelectasis, resulting in
lung parenchymal consolidation, has also slightly increased.
Otherwise, there is no relevant parenchymal change. Unchanged
position of the right PICC line.
Brief Hospital Course:
Neurosurgical Course as above in HPI
====================================
MICU Course [**Date range (1) 88219**]
# Hypotension: Patient was thought to be hypovolemic from
pneumonia as well as diuresis in the step down unit. He was
given IVF with good result. BPs came up to the 120s systolic and
lactate trended down to 1.0 (from 3.4).
# Brain Lesions: Pathology result of brain biopsy revealed B
cell lymphoma. Oncology was consulted and recommended workup
including: SPEP, UPEP, LDH, HIV test, B2 microglobulin. They
also recommended consulting neuro-oncology (Dr. [**Last Name (STitle) 6570**] for
further treatment options which will likely include MTX and XRT.
Patient was initially deferred for MTX because of pleural
effusion noted on CXR.
# PNA: given leukocytosis, fever, and increased work of
breathing with LLL infiltrate on CXR consistent with PNA.
Possibly aspiration given poor MS on other services. Continued
vanc/zosyn for planned 8day course (to end [**2168-12-24**]). Leukocytosis
trended down and tachypnea resolved.
# AMS: Patient was noted to be delirious on admission to MICU.
This was thought [**1-18**] infection, hypotension, and underlying
brain lesions. His MS improved with IVF and resolution of his
hypotension although he still remained somewhat disoriented,
worsening at night. Geriatrics followed the patient while
admitted and continues to follow.
=======================================
OMED Course: 85 yo M with hx of Emphysema, A Fib presenting with
confusion, found to have diffuse large B cell lymphoma of the
brain. Hospital stay complicated by delirium, LLL PNA,
hypotension and respiratory distress requiring transfer to MICU.
Transferred to OMED for continued management, and initiation of
MTX.
.
# DLBC CNS Lymphoma: Patient underwent stereotactic biopsy of
right frontal lesion on [**12-14**] showing DIFFUSE LARGE B-CELL
LYMPHOMA. CSF flow cytometry showed non-specific T cell dominant
lymphoid profile. He was transferred to Medicine-Oncology
service for initiation of methotrexate therapy, which he
received [**2168-12-27**] and tolerated well except for mild mucositis.
For this he is on Gelclair TID. He had an EEG, which showed
encephalopathy. MRI spine was obtained on [**1-1**], read pending. He
is on Keppra 500 [**Hospital1 **], Decadron 2 mg daily, and prophylactic
daily Omeprazole. He will need a double lumen port placed and
eye exam done prior to his next admission for chemotherapy. He
will need to continue leucovorin and Na bicarbonate for one day
after discharge. He will need to take Na bicarbonate and collect
all of his urine for 24 hours prior to his next admission
(roughly two weeks from his first day of chemotherapy [**2168-12-27**]).
.
# Delirium/Encephalopathy: Likely multifactorial in etiology
infection, brain lesions, hospital environment. Improved during
his hospital course; however, patient remains confused, oriented
to self and general location. We provided frequent re-directing
and reassuring, was placed in a chair for his meals, and started
on Seroquel 37.5 mg nightly to restore his sleep-wake cycle.
.
# L Pleural Effusion: Likely transudative in setting of
receiving IV hydration with MTX protocol. Patient remained
afebrile, without leukocytosis. Received IV Lasix 10mg X2 with
subsequent good urine output and improvement in oxygenation. He
has only needed supplemental oxygen at night for the last two
days.
.
# Anemia: Normocytic. Hematocrit has been trending down. No
signs of bleeding. Stools were guaiac negative. Likely a
component of hemodilution secondary to IVFs. Also likely marrow
suppression from recent illness as retic count was 1.0. Was
transfused one unit of packed red blood cells on [**12-30**] with
appropriate response. This will need to be monitored in the
future.
.
# Transaminitis: Likely secondary to methotrexate therapy.
Patient had no right upper quadrant pain. His bilirubin was
within normal limits. There was no new medications coinciding
with the transaminase elevation. This will need to be monitored
in the future.
.
# Acute Kidney Injury: Resolved. Baseline creatinine is 1.1.
Patient's creatinine bumped to 1.4 on [**12-28**]. His FeNa was >1%.
Renal ultrasound was negative for obstruction; however, a
post-void residual showed that showed he was retaining urine. A
foley was placed, then discontinued two days later after
finasteride was re-started. His IVFs were increased to 125 cc/hr
and his creatinine trended down. This will need to be monitored
in the future.
.
# A fib: Paroxysmal. Remained in sinus rhythm. Metoprolol 12.5
TID was continued for rate control. Coumadin was discontinued
secondary to bleeding risk after brain biopsy. The patient was
started on a daily aspirin.
.
# LLL PNA: Received 9 days of Vancomycin and Zosyn for
aspiration/healthcare-associated pneumonia. Ended [**2168-12-25**]. Blood
cultures were final no growth.
.
# Diarrhea: Resolved. C difficile stool toxin assay was negative
X 3. Occurred likely secondary to antibiotics, and improved once
they were discontinued.
.
# Emphysema: Continued Fluticasone-Salmeterol Diskus (250/50)
[**Hospital1 **], and provided albuterol and ipratropium nebulizers as
needed.
.
# BPH: Started on Finasteride 5 daily two days prior to
discharge. Discharged on home Avodart.
.
# Code status: Full code
.
# To do: Please check CBC, Chem 7, LFTs in one week.
Medications on Admission:
fluticasone, Toprol XL, Valsartan, HCTZ, Advair, Avodart,
Spiriva, Dilantin, Lovastatin, Dexamethasone, Famotidine
Discharge Medications:
1. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for discomfort/fever.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for wheezing.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. oral wound care products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day) as needed for mouth pain.
8. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for wheezing.
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal rash.
13. quetiapine 25 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
14. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
15. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
16. leucovorin calcium 25 mg Tablet Sig: One (1) Tablet PO every
six (6) hours for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
17. sodium bicarbonate 650 mg Tablet Sig: Five (5) Tablet PO
every six (6) hours for 2 days: Take for one day after
discharge, and one day prior to next admission.
Discharge Disposition:
Extended Care
Facility:
Country Rehabilitation and Nursing Center - [**Location (un) 5028**]
Discharge Diagnosis:
diffuse large B-cell CNS lymphoma
acute toxic/metabolic encephalopathy
pneumonia
pleural effusion
acute kidney injury
anemia
transaminitis
diarrhea
.
atrial fibrillation
emphysema
benign prostatic hyperplasia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 86647**],
It was a pleasure taking care of you during this
hospitalization. You were admitted for evaluation of increasing
confusion, underwent a brain biopsy that showed lymphoma (a type
of cancer), and received methotrexate chemotherapy. During your
admission you were treated for a pneumonia, as well as a kidney
injury. You are being discharged to a rehabilitative facility
for continued strength building.
.
We are making some changes to your outpatient medication regimen
based on what you needed in the hospital.
.
Also, it is important that you continue to take sodium
bicarbonate (3250 mg every six hours) and leucovorin (25 mg
every six hours) for one day after discharge.
.
24 hours before your next admission you will need to start
taking sodium bicarbonate (3250 mg every six hours). You will
also need to save all of your urine 24 hours prior to your next
admission.
Followup Instructions:
You have no schedueled follow up appointments at this time. You
will be contact[**Name (NI) **] regarding your next admission (roughly two
weeks from your first day of chemotherapy on [**2168-12-27**]). You also
may be contact[**Name (NI) **] regarding the need to have a port placed and
eye exam done.
|
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"276.52",
"285.9",
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
"03.31",
"01.13",
"99.25",
"93.59",
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icd9pcs
|
[
[
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] |
11474, 11569
|
4156, 9509
|
377, 405
|
11822, 11869
|
2959, 2959
|
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|
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|
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|
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|
2613, 2702
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,676
| 190,103
|
9719
|
Discharge summary
|
report
|
Admission Date: [**2151-6-4**] Discharge Date: [**2151-6-8**]
Date of Birth: [**2070-5-18**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Metoclopramide / Cephalosporins / Penicillins
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Nephrostomy tube fell out.
Major Surgical or Invasive Procedure:
Replacement of bilateral nephrostomy tubes [**6-4**]
Central line placement [**6-4**]
History of Present Illness:
81 year old female with remote history of cervical cancer status
post XRT with resultant vesicovaginal/rectovesical/rectovaginal
fistulae and bilateral nephrostomy tubes who was sent to [**Hospital1 18**]
from [**Hospital3 2558**] after her nephrostomy tube fell out.
Of note, she has had 2 recent [**Hospital1 18**] hospitalizations, both for
urinary tract infections with ESBL Klebsiella. During her last
hospitalization from [**2151-4-25**] through [**2151-5-11**], she was treated
with a 2 week course of meropenem, as well as flagyl for concern
for C. Difficile given persistent fevers. She had a CT abd that
demonstrated the aforementioned fistulas, a sacral decub, and
thickening of the right iliopsoas muscle that may represent
early inflammatory changes secondary to an infectious process
ascending from the pelvis. During this hospitalization the
patient refused many interventions/diagnostic studies, including
replacement of her nephrostomy tubes, and repeat CT scan to
further assess the concern for psoas abscess. She was evaluated
by the Gyn Onc as well as colorectal surgery services for
possible diverting colostomy, but was felt to be a poor surgical
candidate by both services. After completion of her antibiotic
courses ([**5-7**]) she was discharged to [**Hospital3 2558**] with plans
to follow up with ID, however she missed her appointment. She
was restarted on imipenem at [**Hospital3 **] from [**Date range (1) 32810**]
presumably for a repeat urine culture with Klebsiella, although
that data is not available.
Per her NH notes, she was sent to [**Hospital1 18**] yesterday because her
nephrostomy tube fell out. Of note, a urine culture at [**Hospital 7137**] on [**5-31**] again grew out ESBL Klebsiella; she was started on
imipenem there on [**6-3**] when the culture results became
available. Of note, she has also had a PICC line in place, of
unclear duration.
In our ED, the pt was febrile to 101.2, with initial HR 100, BP
136/80. She was given Imipenem 500 mg IV x 1 and vancomycin 1 g
IV x 1. She received Ativan 0.5 mg IV at around 1 a.m., and
again at 4 a.m. Shortly thereafter her BP dropped to 88/43.
She subsequently received 4L IVF with minimal blood pressure
response. At around 10 a.m. she was started on a dopamine drip.
She had a L SC central line placed. Dopamine was subsequently
changed to levophed.
Past Medical History:
1. Cervical Cancer 30 yrs ago, treated with XRT. Known
vesicovaginal fistula, with recently discovered rectovaginal
fistula, and rectovesical fistula. Per d/c summary, she is a
poor surgical candidate for repair of this, but could consider a
diverting colostomy done endoscopically, however patient did not
want any further invasive procedures. Status post bilateral
nephrostomy tubes which per notes were last placed [**2151-4-8**].
2. Type 2 DM
3. Hypothyroidism
4. History of VRE, MRSA UTIs
5. Bipolar d/o
6. Anemia of chronic disease, baseline around 28.
7. delirium
Social History:
Living at [**Hospital3 2558**] currently. Daughter [**Name (NI) **] is HCP.
Family History:
Non-contributory
Physical Exam:
97.0, 135/75, 96 and irreg, 96% on 2L NC.
I/O: 4000/1600
Gen: Elderly female, resting comfortably in bed, conversant,
responding appropriately to all questions.
HEENT: Dry MM. Pupils equal.
Neck: Jugular veins collapse with inspiration.
Lungs: CTA anteriorly.
Cor: Regularly irregular rhythm, [**2-22**] harsh systolic murmur
heard best at apex. No extension to carotids.
Abd: Normoactive bowel sounds, soft, NT/ND. Nephrostomy tubes in
place bilaterally, covered with dressings.
Ext: Warm, no edema.
Pertinent Results:
[**2151-6-4**] 08:00PM GLUCOSE-120* UREA N-17 CREAT-0.6 SODIUM-143
POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-21* ANION GAP-11
[**2151-6-4**] 08:00PM CK(CPK)-18*
[**2151-6-4**] 08:00PM CK-MB-NotDone cTropnT-0.03*
[**2151-6-4**] 08:00PM CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2151-6-4**] 10:30AM GLUCOSE-133* UREA N-20 CREAT-0.6 SODIUM-138
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-20* ANION GAP-13
[**2151-6-4**] 10:30AM TSH-0.47
[**2151-6-4**] 10:30AM WBC-11.0 RBC-3.48* HGB-10.1* HCT-31.4* MCV-90
MCH-28.9 MCHC-32.0 RDW-15.8*
[**2151-6-4**] 10:30AM NEUTS-76.9* LYMPHS-17.5* MONOS-5.0 EOS-0.5
BASOS-0.2
[**2151-6-4**] 10:30AM PLT COUNT-375
[**2151-6-4**] 07:16AM TYPE-ART PO2-76* PCO2-39 PH-7.39 TOTAL CO2-24
BASE XS-0 INTUBATED-NOT INTUBA
[**2151-6-4**] 07:16AM LACTATE-1.3
[**2151-6-4**] 05:50AM GLUCOSE-159* UREA N-22* CREAT-0.7 SODIUM-135
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13
[**2151-6-4**] 05:50AM CK(CPK)-8*
[**2151-6-4**] 05:50AM cTropnT-<0.01
[**2151-6-4**] 05:50AM CK-MB-NotDone
[**2151-6-4**] 05:50AM WBC-12.5* RBC-3.51* HGB-10.2* HCT-31.1*
MCV-89 MCH-28.9 MCHC-32.7 RDW-16.4*
[**2151-6-4**] 05:50AM NEUTS-81.1* LYMPHS-14.5* MONOS-3.7 EOS-0.2
BASOS-0.4
[**2151-6-4**] 05:50AM ANISOCYT-1+ MICROCYT-1+
[**2151-6-4**] 05:50AM PLT COUNT-347
[**2151-6-4**] 05:50AM PT-13.5* PTT-31.7 INR(PT)-1.2*
[**2151-6-4**] 01:21AM LACTATE-1.8
[**2151-6-4**] 01:20AM GLUCOSE-176* UREA N-23* CREAT-0.7 SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
[**2151-6-4**] 01:20AM CK(CPK)-12*
[**2151-6-4**] 01:20AM CK-MB-NotDone cTropnT-<0.01
[**2151-6-4**] 01:20AM WBC-14.9*# RBC-4.05*# HGB-12.0# HCT-36.4#
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.9*
[**2151-6-4**] 01:20AM NEUTS-77* BANDS-1 LYMPHS-8* MONOS-4 EOS-1
BASOS-0 ATYPS-9* METAS-0 MYELOS-0
[**2151-6-4**] 01:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
[**2151-6-4**] 01:20AM PLT SMR-HIGH PLT COUNT-483*
[**2151-6-4**] 01:20AM PT-13.0 PTT-30.7 INR(PT)-1.1
_
_
_
_
_
_
_
_
_
________________________________________________________________
Time Taken Not Noted Log-In Date/Time: [**2151-6-4**] 12:36 am
BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
[**2151-6-5**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32811**] AT 4:40 AM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
ANAEROBIC BOTTLE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
_
_
_
_
_
_
_
_
_
________________________________________________________________
[**2151-6-4**] 10:52 pm STOOL CONSISTENCY: LOOSE
**FINAL REPORT [**2151-6-6**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2151-6-6**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2151-6-6**] AT 0740.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2151-6-5**] 6:50 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Please re-evaluate psoas area for abscess, or other
intra-ab
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with bilat nephrostomies,
rectovaginal/rectovesicle/vaginovesicle fistulae, with recurrent
Klebsiella UTIs, fever while on meropenem, prev CT w/ ?psoas
collection, now s/p course of meropenem.
REASON FOR THIS EXAMINATION:
Please re-evaluate psoas area for abscess, or other
intra-abdominal abscess.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 80-year-old female with bilateral nephrostomy tubes
due to rectovaginal/rectovesical/vaginovesical fistulae. A prior
CT mentioned possible right psoas fluid collection. Reevaluate.
COMPARISON: CT abdomen and pelvis with contrast dated [**2151-3-27**].
TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed
following the administration of 130 cc of intravenous Optiray.
Nonionic contrast was administered per protocol. Coronal and
sagittal reformatted images were obtained.
CT ABDOMEN WITH ORAL, WITH INTRAVENOUS CONTRAST: Dependent
changes are seen within bilateral lung bases. The liver enhances
normally without focal nodules or masses. The gallbladder is
collapsed. Stable gallstones within the distal CBD are again
noted. The pancreas, spleen, and bilateral adrenals glands are
unremarkable.
Nephrostomy tubes are seen in the kidneys bilaterally,
terminating within the proximal ureters. The kidneys enhance
symmetrically without evidence of hydronephrosis. There has been
interval placement of a gastrostomy tube. The abdominal loops of
large and small bowel are normal in caliber and contour. There
is no retroperitoneal or mesenteric lymphadenopathy. There is no
free air and no free fluid.
CT PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: A large amount
of stool is present within the urinary bladder. Stool is again
seen within the vagina. There is marked thickening of the
urinary bladder. Abnormal soft tissue stranding in the presacral
space consistent with inflammatory change is unchanged since the
prior study. The right iliopsoas muscle is somewhat
asymmetrically larger than the left, but stable since prior
exam. No fluid collection is identified. Stable subcutaneous
inflammatory changes posterior to the sacrum are again noted,
possibly relating to a decubitus ulcer in this location. There
is no adjacent bony erosion.
BONE WINDOWS: A fixation screw is seen within the right proximal
femur. A generalized mottled appearance of the bones is again
noted, appearing unchanged since the prior exam.
Coronal and sagittal reformatted images confirm the axial
findings. MPR value grade 2.
IMPRESSION:
1. Unchanged interval appearance of asymmetrically enlarged
right iliopsoas muscle, without definite fluid collection or
significant surrounding inflammatory change.
2. Stable interval appearance of stool within the urinary
bladder and vagina consistent with patient's known rectovesical
and likely rectovaginal fistulae. The appearance and small
surrounding fluid are unchanged since prior exam.
3. Unchanged appearance of the subcutaneous tissues posterior to
the sacrum without adjacent bony erosions. These may be related
to a sacral decubitus ulcer.
4. Choledocholithiasis without biliary dilatation.
_
_
_
_
_
_
_
_
_
________________________________________________________________
Brief Hospital Course:
81 year old female with recurrent ESBL Klebsiella UTIs, most
recently with UCx from [**5-31**] with same organism, presenting after
nephrostomy tube dislodgement, with hypotension in ED following
Ativan, which resolved within an hour of arriving in the MICU.
MICU COURSE:
#) Hypotension: The patient was not hypotensive on arrival,
and the hypotension was temporally related to the ativan doses
given in ED. Nevertheless, she also was febrile, with
leukocytosis and tachycardia, meeting criteria for sepsis with a
suspected source given her recently positive urine culture for
ESBL Klebsiella. The patient was started on meropenem, and
levophed was quickly weaned off within an hour of arriving to
the unit. CVP was persistently [**7-26**], with MAPs around 60 and
SBP around 100, however the patient was making large amounts of
urine and mentating well. On review of the record, it seems
that her SBP normally runs around 100. On the morning after
admission to the ICU, [**1-20**] blood culture bottles grew out gram
positive cocci in pairs and chainsthat turned out to be coag neg
staph. She was therefore also started on vancomycin for a total
course of 10d. Her PICC line had been removed on arrival to the
ICU the evening prior shortly after her central line had been
placed. Central line was removed and PICC placed after stable,
afebrile, with negative survelence cultures.
#) Urinary tract infection: Her urine culture from [**Location (un) **] on
[**5-31**] grew recurrent ESBL Klebsiella. Given that patient has a
rectovesical fistula, she will likely never clear this organism.
She was restarted on meropenem. She also may have a psoas
abscess as indicated on prior CT scan (pt. had previously
refused repeat CT scan), therefore a CT of her abdomen was
repeated during this admission which demonstrated no abscess.
She will be continued on meropenum for a 2 wk course.
#) Nephrostomy tube dislodgement: Her L nephrostomy tube was
replaced by IR shortly after arrival in the MICU. She also had
her R nephrostomy tube changed as it was due. Her urine output
was clear and light yellow subsequently.
#) Tachycardia: She was tachycardic initially secondary to her
fever and hypotension. Subsequently her pulse consistently
ranged from 90-110. On tele she had very frequent PACs as the
etiology. A TSH was normal. Resolved prior to discharge.
#) ST depressions on EKG: She had ST depressions in V3-V5 while
her rate was 120 in the setting of hypotension which
subsequently resolved on repeat EKG after hydration. She likely
had some rate related demand ischemia. 3 sets of cardiac
enzymes were flat.
.
#) C-diff positive - ON meropenum. toxin assay positive. Started
on flagyl. WIll complete a three week course (1 wk longer than
meropenum).
.
#) Sacral decubitus: Her sacral decubitus ulcer appeared to
have a purulent base and plastic surgery was consulted for
repeat evaluation. The recommended woulnd care, increased
nutritional support, and accuzyme to area.
#) Type 2 DM: Checked finger sticks QID. Diet controlled so
finger sticks stopped.
#) Hypothyroidism: Continued outpatient levothyroxine. TSH
normal.
#) Bipolar disorder: Continued zyprexa QHS.
#) FEN: She ate a regular diet while in house, without
consistency modification.
#) Code: Status was confirmed as DNR/DNI with daughter,
although she is OK with central line and pressors.
Medications on Admission:
1. Levothyroxine 100 mcg PO DAILY
2. Prilosec 20 mg daily
3. Ascorbic Acid 500 mg PO BID
4. Gabapentin 300 mg PO BID
5. Olanzapine 7.5 mg PO HS
6. Heparin 5,000 unit/mL SQ TID
7. Multivitamin Capsule PO DAILY
8. Oxycodone 5 mg PO Q4-6H PRN
9. Acetaminophen 325 - 625 mg PO Q4-6H PRN
10. Albuterol Sulfate neb Q6H PRN
11. Remeron 15 (recently d/c'ed)
12. Imipenem 500 IV q8h today day 2 (finished course on [**5-28**]
prior to this, restarted on [**6-3**])
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day): to sacral decub.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 18 days.
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: PICC care.
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 12 days.
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Hypotention secondary to ativan
.
UTI.
.
Bacteremia.
.
C.Diff colitis
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2151-6-11**]
11:00
.
Please call Dr.[**Last Name (STitle) 5351**] to be seen in the next 10 days
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
Completed by:[**2151-6-7**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
16182, 16252
|
10960, 14352
|
350, 437
|
16366, 16373
|
4100, 7704
|
16460, 16800
|
3538, 3556
|
14859, 16159
|
7741, 7952
|
16273, 16345
|
14378, 14836
|
16397, 16437
|
3571, 4081
|
284, 312
|
7981, 10937
|
465, 2832
|
2854, 3427
|
3443, 3522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,176
| 178,691
|
49712
|
Discharge summary
|
report
|
Admission Date: [**2121-3-31**] Discharge Date: [**2121-4-10**]
Date of Birth: [**2072-1-21**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain and distention
Major Surgical or Invasive Procedure:
[**2121-4-3**] Exploratory laparotomy with left salpingo-oophorectomy,
[**Last Name (un) **] gastrostomy tube placement, and placement of a vacuum
dressing.
[**2121-4-7**] Re-exploration with washout and placement of large
vacuum-assisted closure dressing.
[**2121-4-10**] Re-exploration with washout, GJ tube placement,
tracheostomy, [**State 19827**] patch placement
History of Present Illness:
This is a 49 year-old female with a history of EtOH dependence
who presents with abdominal pain and distention. Unfortunately,
she is not able to clearly recall the sequence of her symptoms.
She reports 3 days of increasing abdominal distention, abdominal
discomfort, loose non-bloody, non-melenic stools, and occasional
nausea/vomitting. She denies any increase in the amount she
drinks (fifth of vodka daily). Denies any urinary symptoms.
Denies any fevers, chills, sick contacts, or recently consuming
potential food triggers of gastrointestinal illness.
Past Medical History:
EtOH abuse
Social History:
+ History of EtOH. Denies any tobacco, IVDU, illicit drug use,
ethylene glycol or mouthwash consumption. Lives with mother.
Family History:
non-contributory
Physical Exam:
Vitals: T:97.5 BP:125/75 HR:110 RR:23 O2Sat:100% on RA
GEN: Thin female, NAD
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, trachea midline
COR: Tachycardic, III/VI systolic murmur, normal S1 S2, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, Distended, +BS, TTP diffusely, no rebound or
guarding, tympanitic throughout, no shifting dullness.
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to [**Hospital1 18**], name, and month but not year.
CN II ?????? XII grossly intact. Moves all 4 extremities. Struggling
to pull NG tube but in restaraints.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
ADMISSION LABS
[**2121-3-31**] 04:15PM BLOOD WBC-2.0* RBC-2.18* Hgb-7.4* Hct-22.2*
MCV-102* MCH-34.0* MCHC-33.4 RDW-16.1* Plt Ct-95*
[**2121-4-1**] 03:55AM BLOOD Neuts-75.3* Bands-0 Lymphs-18.4 Monos-5.6
Eos-0.6 Baso-0.2
[**2121-4-1**] 03:55AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Burr-1+ Stipple-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2121-3-31**] 04:15PM BLOOD PT-15.8* PTT-28.9 INR(PT)-1.4*
[**2121-3-31**] 04:15PM BLOOD Gran Ct-1300*
[**2121-3-31**] 04:15PM BLOOD Glucose-172* UreaN-52* Creat-1.1 Na-138
K-3.1* Cl-103 HCO3-22 AnGap-16
[**2121-3-31**] 04:15PM BLOOD ALT-12 AST-39 LD(LDH)-371* AlkPhos-110
TotBili-1.4 DirBili-0.7* IndBili-0.7
[**2121-3-31**] 04:15PM BLOOD Calcium-9.0 Phos-1.9* Mg-2.5 Iron-16*
[**2121-3-31**] 04:15PM BLOOD calTIBC-338 VitB12-1550* Folate-14.3
Ferritn-143 TRF-260
[**2121-3-31**] 04:15PM BLOOD Osmolal-306
[**2121-3-31**] 05:52PM BLOOD Ammonia-34
[**2121-4-1**] 03:55AM BLOOD TSH-1.9
[**2121-3-31**] 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-3-31**] 10:46PM BLOOD Lactate-2.2*
RESULTS
[**3-31**]-head CT w/o contrast-negative
[**3-31**]-CT abdomen-1. Diffuse small bowel dilatation with no
evidence of obstruction. The presence of air-fluid levels raises
the possibility of enteritis. Clinical correlation is advised.
Ascites.
2. Leiomyomatous uterus.
3. Small hepatic hypodensity too small to adequately
characterize.
4. Left renal cyst.
5. Extensive pancreatic calcification and atrophy compatible
with chronic pancreatitis.
6. Cholelithiasis.
7. Sclerotic focus in the right iliac bone abutting the SI joint
of uncertain clinical significance. Recommend clinical
correlation. Bone scan may be obtained for further evaluation as
clinically warranted.
[**3-31**]-KUB-1. Dilated small bowel, which is concerning for
small-bowel obstruction.
2. Pancreatic calcifications suggesting chronic pancreatitis.
Recommend clinical correlation.
[**4-1**]-cXR-No previous images. The cardiac silhouette is within
normal limits and there is no vascular congestion or pleural
effusion. Specifically, no convincing evidence of acute
pneumonia.
Nasogastric tube extends to the lower body of the stomach, then
coils back on itself to lie in the upper body of the stomach.
Brief Hospital Course:
In the ED, patient underwent bedside ultrasound that did not
demonstrate any ascites amenable to bedside paracentesis. Abd
CT showed diffuse small bowel dilatation with no evidence of
obstruction or free air. She was also noted to be pancytopenic
with a hematocrit of 22, baseline unknown. She was given 1 unit
PRBC while in the ED. For bordeline hypotension of systolic of
95, patient was given 2 litres normal saline. Incidentally, she
was also noted to have progressive delerium and was given
diazepam 5mg IV, and started on thiamine/folate intravenously.
Head CT was performed given mental status changes and was
unremarkable. She was admitted to MICU for further monitoring of
mental status, and borderline hypotension. At this point, the
etiology was still unclear given the workup.
In the MICU, NGT was placed for decompression. The patient was
kept NPO. On the following morning, the patient had a clear
mental status and was able to answer questions appropriately.
She was kept on CIWA scalenad required diazepam x 2. She was
aggressively hydrated with a total of 3L of IVF and continued to
be tachycardic, likely either to dehydration or to withdrawal
from alcohol. She reported resolution of her nausea and pulled
her own NGT. It was not replaced since she was no longer
nauseated. She was called out to the floor for further
management.
On arrival to the medical floor she was tachycardic at 110,
other vitals stable and similar to those on arrival to the ED.
She had [**7-20**] RUQ pain, and her abdomen was found to be
distended. She had a RUQ ultrasound that did not show
cirrhosis, or cholecystitis. She remained afbrile, and did not
have leukocytosis, or jaundice, or a cholestatic picture in her
LFTs thus cholangitis was not felt to be likely. She was given
IV fluids for her volume depletion. On the first day she had
four bowel movements that were guaiac positive and watery.
Stool cultures were collected to evaluate for c.diff. She
remained stable until [**4-2**], when her abdomen became increasingly
distended. An NGT was placed, which did not provide the patient
relief, drained a total of 600cc of yellow fluid. Her abdomen
became increasingly distended, and she had a new O2 requirement
and her tachycardia increased from 110 to 140's, sinus. An ABG
was done that was unremarkable, a CXR showed hazyness at the
right base. Surgery was consulted and they recommended a CTA
chest and CT abdomen. Her chest CTA showed a large right sided
pleural effusion, no PE and her CT abdomen was unchanged. She
was given 20mg IV lasix for her pleural effusion. She continued
to be uncomfortable, with increasingly distended bowel that was
rigid and there was an abscence of bowel sounds. In addition
she became slightly confused, but was still oriented times
three. A repeat ABG showed an increased lactate to 2.2.
Surgery raised concern for ischemic bowel and she was
transferred to the ICU for closer monitoring as well as possible
intubation as she required volume resuscitation.
Given her worsening condition and concerning abdominal exam, the
patient was taken to the operating [**2121-4-3**] for an
exploratory laparotomy and found to have diffuse peritonitis and
fibrinous coating of the bowel with clearly purulent ascites,
ileus, and ruptured left tubo-ovarian abscess. She had a left
salpingo-oophorectomy, [**Last Name (un) **] gastrostomy tube placement, and
placement of a vacuum dressing since her abdomen was unable to
be closed. [**Name (NI) **], pt was transferred to the SICU for
further management. She did develop sepsis and was started on
pressors and broad spectrum antibiotics. Since she was a
Jehovah's witness, she only received crystalloid and hespan for
volume resuscitation. She remained intubated and sedated.
On post-op day 4, she was taken back to the OR for
re-exploration with washout and
placement of large vacuum-assisted closure dressing. She was
started on TPN for nutrition and was able to be weaned off
pressors on post-op day 6. She continued to require volume
resuscitation. She returned to the OR the following day for a
re-exploration with washout, GJ tube placement, and
tracheostomy. During the surgery, pt became hemodynamically
unstable, had increased pressor requirement for hypotension, and
had diffuse intra-abdominal oozing of blood. No specific
bleeder could be identified and the bleeding could not be
stopped. Pt transferred back to the SICU for further
management. Contact was made with the pt's mother regarding the
dire situation and she reiterated that no blood products be
given. She also expressed that she did not want further
escalation of care or cardiopulmonary resuscitation. The pt
expired shortly thereafter.
Medications on Admission:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Ruptured tubo-ovarian abscess
Discharge Condition:
Expired
|
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58,264
| 156,248
|
44596
|
Discharge summary
|
report
|
Admission Date: [**2128-4-16**] Discharge Date: [**2128-5-1**]
Date of Birth: [**2086-5-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
HD line placement and dialysis initiation
History of Present Illness:
41 y/o M with hx of HIV, stage 4 CKD secondary to MPGN, severe
HTN, with recent admission for ruptured [**Hospital Ward Name 4675**] cyst / LE edema,
presents with worsening bilateral LE edema since prior
discharge, shortness of breath for the past 4 days, [**10-31**]
non-radiating constant sharp substernal/epigastric pain,
non-productive cough x1 day, nausea, 2 episodes of non-bilious
vomiting with small specks of blood, subjective fevers and
chills x 1 day.
.
In the ED, the patient was noted to have BP of 199/99. CXR was
conistent with pulmonary edema. The patient was given Morphine,
Nitro paste, 40mg IV Lasix, Hydralazine. CT scan of chest was
performed which revealed bilateral pleural effusions and likely
atelectasis, but possible PNA at right lower lobe. The patient
was started on Vancomycin and Cefepime for empiric treatment of
HAP. After SBP returned to 170s, the patient received clonidine
and morphine and a second dose of [**1-24**] inch nitro paste. Vital
signs of transfer included BP in 150s and HR in 70s.
.
He was admitted to the floor and treated for HAP with vanco and
cefepime. Had been diuresed with a total of 40 mg IV lasix x2
and his I/Os were about negative 300 cc. The night of admission,
he had several small episodes of coffee ground emesis. NG lavage
on the floor was negative. Hct remained stable. In the early
morning prior to transfer to MICU, he was hypertensive with SBPs
to the 200s. He was complaining of headache. EKG was without
changes. He was treated with his home BP meds and 60 mg IV
hydral in several boluses.
.
Patient's blood pressure did not improve so he was transfered to
MICU. On transfer, vitals T 99.8, Tm 100.6, BP 199/108
(152/82-231/115), P 94 (73-98), R 18, 96% on RA. He looked
uncomfortable, was sitting up in bed and looked worse when lying
down.
.
In the MICU, he was poorly controlled on a nitro drip but his
BPs improved with a labetolol drip and his headache resolved.
His Hct went down to 19.7 and he got 1unit PRBCs with a rise to
22.0. He had a head CT that showed a new hypodensity along the
left periventricular white matter. However, the findings could
represent an old insult such as old infarct. Because he was
completely intact neurologically and his headache had resolved,
an LP was not pursued. Eventually the patient was put back on
his home BP regimen and transferred back to the floor.
Past Medical History:
1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections.
2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**].
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction [**2126-7-23**].
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit 20-24.
10. Hypertriglyceridemia - TG 282 in [**3-/2126**]
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
[**1-30**]
13. Influenza B, [**2126-2-22**].
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in [**2123**].
17. Left ankle ORIF in [**2122**].
18. Appendectomy in [**2101**].
Social History:
History of incarceration for 4 yrs. Is self-employed, unmarried.
He
has three children. Denies alcohol. Reports marijuana use daily,
denies tobacco or cocaine.
Family History:
Mother and father have hypertension; has 3 bros, 3 sis: all
healthy, none with HTN. There is also a family history of type 2
diabetes mellitus. No family history of sudden death and
premature atherosclerotic cardiovascular disease.
Physical Exam:
Vitals: T: 99.0 BP: 164/89 P: 81 R: 22 O2: 95% RA
I: 1.7L, O: 1L, balance +700ccs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 10cm, no LAD
Lungs: clear to ausculation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
loudest at apex, no rubs, gallops
Abdomen: soft, ttp in epigastric region, small well-healed scar
above umbilicus with diasthasis, mildly distended, bowel sounds
present, no rebound tenderness or guarding.
GU: no foley
Ext: warm, well perfused. 2+ L>R pitting edema bilaterally, no
clubbing or cyanosis.
Pertinent Results:
Admission labs: [**2128-4-16**]
WBC-9.1# RBC-2.44* Hgb-7.0* Hct-21.8* MCV-89 RDW-13.3 Plt Ct-350
Neuts-85.5* Lymphs-7.3* Monos-5.7 Eos-1.3 Baso-0.2
PT-16.3* PTT-32.9 INR(PT)-1.4*
Glucose-102* UreaN-43* Creat-4.8*# Na-142 K-4.7 Cl-110* HCO3-20*
AnGap-17
ALT-11 AST-15 CK(CPK)-62 AlkPhos-170* TotBili-0.1
proBNP-[**Numeric Identifier 42739**]*
Lipase-20
Albumin-3.4* Calcium-8.6 Phos-4.7* Mg-3.0*
Lactate-0.8 K-4.6
.
Discharge labs: [**2128-5-1**]
Hct-20.3*
Glucose-136* UreaN-40* Creat-4.0* Na-140 K-4.1 Cl-101 HCO3-28
AnGap-15
LD(LDH)-775*
.
Other pertinent labs:
[**2128-4-19**] 12:40PM Fibrino-762*
[**2128-4-21**] 11:10AM Thrombn-10.7
[**2128-4-22**] 06:25AM [**Doctor Last Name 17012**]-NEGATIVE
[**2128-4-21**] 05:50AM Ret Aut-1.4
[**2128-4-21**] 11:10AM Inh Scr-NEG
[**2128-4-20**] 06:10AM ALT-9 AST-18 LD(LDH)-420* AlkPhos-122
TotBili-0.3
[**2128-4-20**] 06:10AM Lipase-21
[**2128-4-22**] 06:25AM TotProt-6.8 Iron-19*
[**2128-4-22**] 06:25AM calTIBC-191* VitB12-436 Folate-7.8
Ferritn-1168* TRF-147*
[**2128-4-19**] 12:40PM Hapto-<5*
[**2128-4-22**] 06:25AM PEP-NO SPECIFI
[**2128-4-22**] Cdiff negative
[**2128-4-21**] Urine culture: yeast
[**2128-4-16**] Blood culture negative x 2 (final)
.
[**2128-4-26**] 5:02 pm URINE Source: CVS.
**FINAL REPORT [**2128-4-28**]**
URINE CULTURE (Final [**2128-4-28**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
[**2128-4-21**] LENI: No DVT in the left lower extremity.
[**2128-4-21**] CXR: As compared to the previous radiograph, there is no
relevant
change. An enlarged upper and lower lobe arteries with signs of
blood flow
redistribution and cardiomegaly. Minimal left pleural effusion.
No newly
appeared focal parenchymal opacities suggesting pneumonia. No
lung nodules or masses.
[**2128-4-19**] MRI w/o: Encephalomalacia within the left corona radiata
with associated hemosiderin staining, new since [**2126**], without
any acute infarct component. The findings likely represent a
chronic infarction with hemorrhagic transformation or sequela of
a previous hypertensive hemorrhage. While evaluation for
intracranial infection is limited in the absence of intravenous
contrast, there are no findings to suggest an infection.
[**2128-4-19**] Abd u/s: 1. Patent hepatic vasculature. No thrombosis
identified.
2. No liver lesions identified. 3. Small amount of gallbladder
sludge. Thickened gallbladder wall is likely due to underlying
disease. 4. Small bilateral pleural effusions.
[**2128-4-17**] CT head w/o: 1. Tiny rounded hypodensity in the right
caudate head is unchanged, previously thought to represent
subacute or chronic infarct (MRI [**2126-1-30**]). 2. Since [**2126-11-14**],
there is new hypodensity along the left periventricular white
matter. Given what appears to be ex vacuo dilatation along the
frontal [**Doctor Last Name 534**] of the left lateral ventricle, findings may
represent old insult such as old infarct. However, given the
history of HIV, headache and fever, active process would be
difficult to exclude. MRI is recommended for more sensitive
evaluation for subtle process.
3. No acute intracranial hemorrhage seen
[**2128-4-17**] Echo: The left atrium is moderately dilated. The right
atrium is moderately dilated. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
There is mild to moderate global left ventricular hypokinesis
(LVEF = 40 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The aortic root is
mildly dilated at the sinus level. 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. Mild to moderate ([**1-24**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a small pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. No right atrial or right ventricular
diastolic collapse is seen. Compared with the findings of the
prior study (images reviewed) of [**2128-3-22**], the findings are
similar.
[**2128-4-16**] CT abd/pelvis: 1. Small bilateral pleural effusions,
right greater than left, with probable adjacent dependent
atelectasis. More consolidative appearing opacity within the
right lower lobe, however, could represent pneumonia. Findings
discussed with Dr. [**First Name (STitle) **] at 1pm, [**2128-4-16**]. 2. Moderate-sized
pericardial effusion. 3. Small amount of ascites with anasarca
and pericholecystic fluid indicating
volume overload with third spacing. 4. No evidence of bowel
obstruction, hernia, or focal fluid collection. 5. Probable
anemia.
Brief Hospital Course:
41 y/o M with hx of HIV, CKD, HTN and CHF who presents to the ED
with worsening pedal edema, SOB and possible PNA. The second day
of admission was transferred to the ICU with hypertensive
urgency with worsening symptoms of heart failure and headache.
.
# Hypertension: Patient was initially managed in ICU but
eventually resumed most of his home regimen. His nifedipine and
minoxidil were stopped because he had adequate blood pressure
control and these were thought to be contributing to his lower
extremity edema.
.
# Headache: Resolved with blood pressure control. No acute
pathology seen on imaging.
.
# Acute on chronic kidney disease: Patient did not improve with
lasix and dialysis was initiated. Will have a Tu, Th, Sat
dialysis schedule with follow up with Dr. [**Last Name (STitle) 1366**].
.
# Coffee Ground Emesis: Patient had coffee ground emesis in
MICU. NG lavage was negative. He was continued on his ranitidine
with no further episodes.
.
# Nausea/abdominal pain: Initially on narcotics for symptomatic
control. Imaging and labs did not reveal clear etiology. Thought
most likely [**2-24**] gut edema and uremia. Improved after dialysis
and patient was not discharged on narcotics.
.
# Anemia: Heme was consulted and they thought most like etiology
was from cryoglobulins. Blood bank was also following and
patient has E antibodies. After not appropriately bumping to
several tranfusions, patient finally had appropriate response
after being given warmed blood. Patient has heme follow up. HCT
was at baseline prior to discharge.
.
# Pericardial Effusion: Small pericardial effusion on echo.
Unclear etiology. Likely uremic, and expected to improve with
dialysis.
.
# Elevated INR: Patient's INR was elevated but this improved
with vitamin K suggesting nutrtional deficiency.
.
# Pseudomonas UTI: Patient was pseudomona UTI that is resistant
to Cipro. Started on Cefepime and switched to Ceftaz. Will get
Ceftaz at HD to complete 1 week course. If patient UTI not
clearing should consider switching back to Cefepime or drug with
higher sensitivity than Ceftaz. For sensitivities see results
section.
.
# HIV: stable, continue current HARRT
.
# Hep C: stable
Medications on Admission:
1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
----9. Nifedipine 60 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO DAILY (Daily).
10. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: Three
[**Age over 90 **]y Five (325) mg PO DAILY (Daily).
14. Terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
15. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-27**]
hours as needed for pain.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
19. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
20. Aranesp (Polysorbate) Injection
21. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
22. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Medications:
1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO once a day.
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
14. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
Disp:*270 Tablet(s)* Refills:*2*
15. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
16. 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*
17. Ceftazidime 2 gram Recon Soln Sig: Two (2) gram Intravenous
asdir for 2 doses: at dialysis on [**3-6**] and [**3-8**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypertension
Anemia
Acute on chronic renal failure
.
Secondary Diagnosis:
HIV
Hep C
h/o polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with hypertension and
worsening renal failure. You were temporarily monitored in the
ICU because your blood pressure was difficult to control. You
developed leg edema because of your worsening kidney function.
We treated you with a medication called lasix to decrease the
fluid in your legs and improve the function of your kidneys, but
eventually you needed to initiate hemodialysis. You will
continue dialysis on Tuesday, Thursday, and Saturdays. You will
also follow up with Dr. [**Last Name (STitle) 1366**].
.
You also have a urinary tract infection. We are treating you
with an antibiotic called Ceftazidime. You will get this
antibiotic at dialysis for the next two sessions.
.
Your blood count (hematocrit) was low during this hospital
admission. We gave you several blood transfusions. Your blood
count was stable at time of discharge but you should follow up
with a hematologist at the appointment listed below.
.
We have made the following changes to your medications:
1. Restart Hydralazine 75mg by mouth three times a day.
2. Start Calcium Acetate 667mg by mouth three times a day
3. Stop sodium bicarbonate
4. Stop minoxidil
5. Stop Nifedipine
6. Increase Ferrous sulfate to 325mg by mouth three times a day
7. Ceftazidime 2g IV at dialysis for the next two sessions
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2128-5-4**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2128-6-3**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2128-5-11**] at 9:00 AM
With: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], 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: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2128-5-11**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], 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: [**Hospital3 249**]
When: WEDNESDAY [**2128-5-12**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: TUESDAY [**2128-5-18**] at 3:30 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
Completed by:[**2128-5-1**]
|
[
"425.4",
"V08",
"V45.11",
"585.6",
"530.81",
"428.23",
"403.01",
"305.00",
"041.7",
"584.9",
"070.54",
"285.9",
"423.9",
"305.60",
"599.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
15466, 15472
|
10139, 12316
|
326, 369
|
15643, 15643
|
4828, 4828
|
17225, 19282
|
3942, 4176
|
14022, 15443
|
15493, 15493
|
12342, 13999
|
15794, 16780
|
5259, 5370
|
4191, 4809
|
16809, 17202
|
274, 288
|
397, 2772
|
15586, 15622
|
4844, 5243
|
15512, 15565
|
5392, 10116
|
15658, 15770
|
2794, 3748
|
3764, 3926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,780
| 163,864
|
20599
|
Discharge summary
|
report
|
Admission Date: [**2139-6-21**] Discharge Date: [**2139-7-1**]
Date of Birth: [**2057-9-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
left lower extremity ischemia, failing vein graft
Major Surgical or Invasive Procedure:
[**6-22**]: L fem endarterectomy and patch angioplasty, L fem-[**Name (NI) 55075**]
PTFE jump graft
[**6-23**]: L [**Name (NI) 55076**] PTFE graft, removal of fem-veingraft PTFE graft,
ligation of fem-AT vein graft
History of Present Illness:
81 year olf f s/p LT CFA-AT with reversed vein, found to have
high grade stenosis of bypass on duplex and angio. Presents for
revision of left leg bypass.
Past Medical History:
Diabetes Mellitus
Hypercholesterolemia
Coronary artery disease
Hypertension
S/P CABG
S/P right Common Femoral Artery to the Popliteal Artery, below
the knee
[**2139-6-10**] LLE angio: high grade stenosis on L CFA, focal High grade
graft stenosis
Social History:
Cantonese speaking
Family History:
Noncontributory
Physical Exam:
VSS:98.8, 140/64 60 18 95%RA FS 77-134
GEN: NAD
CARD: RRR
Lungs: CTA
ABD: soft, NT
Wound/Incision: C/D/I
Pulses: B/L dop DP/Pt
Pertinent Results:
[**2139-7-1**] 06:00AM BLOOD WBC-15.3* RBC-3.78* Hgb-11.3* Hct-34.3*
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.0 Plt Ct-468*
[**2139-7-1**] 06:00AM BLOOD Plt Ct-468*
[**2139-6-30**] 05:55AM BLOOD Glucose-59* UreaN-15 Creat-0.9 Na-137
K-3.9 Cl-102 HCO3-27 AnGap-12
[**2139-6-30**] 05:55AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.4
Brief Hospital Course:
[**2139-6-21**]: admitted for revision of LLE bypass from home.
[**2139-6-22**]: Underwent left common femoral and profunda femoral
endarterectomies with Dacron patch angioplasty and left PTFE
jump graft from common femoral artery to pre-existing fem-AT
bypass. Extubated and transferred to PACU. Postoperatively, her
graft went down and her foot started becoming more painful. She
was brought back to the operating room for exploration and
revascularization. She underwent thrombectomy of left profunda
femoral artery and common femoral artery and bypass graft to the
anterior tibial artery, transposition of proximal PTFE graft off
of the common femoral artery over to the profunda femoral artery
on the left side, removal of distal PTFE graft, ligation of vein
graft to the left anterior tibial artery.
Left foot warmer, doppler pulses. Placed on Heparin gtt.
[**Date range (1) 3643**] Doing well, no events. On Heparin gtt. OOB with
assist. IVF discontinued, diet advanced. Pneumonia on chest
x-ray- started Levo and Flagyl.
[**2139-6-25**]- Developed chest pain and ECG changes. Relieved with
nitro. Enzymes cycled. Betablocker, statin, ASA, plavix and Hep
gtt continued. may require cardiac cath.
[**2139-6-26**]- Tmax 102.5. ABX continued. Cdiff and BC pending. BP
stable. No chest pain. Heparin gtt adjusted to maintain ptt
60-80. WBC elevated.
[**Date range (1) 51037**] No events. working with physical therapy. patient and
daughter do not want rehab. Plan is home with services.
Monitoring WBC.
[**6-29**] VSS, Tmax 99.8, WBC 21,000. Patient pan cultured. ABX
continued. Cdiff negative X2
[**2139-6-30**]: No overnight events. Pulses dopplerable. Physical
therapy recommending rehab. Daughter and patient refusing rehab,
will take home with services. Foley discontinued.
[**2139-7-1**]: VSS. WBC 15. Heparin gtt discontinued at discharge.
Daughter will arrange services, refusing VNA or PT. patient will
follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] in 2 weeks. Will continue
ABX X 2 weeks.
Medications on Admission:
Lopressor 50", Lipitor 10', ASA81', Diovan 320- on hold, Colace,
HumalogSS, NPH 38am/22hs
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): obtain refills from Primary: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 8236**].
.
Disp:*30 Tablet(s)* Refills:*0*
2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5455**](cardiology) with any chest pain .
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
12. Humalog Sliding Scale
Humalog
Glucose Insulin Dose
0-60 mg/dL 4 oz. Juice
61-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
> 350 mg/dL 8 units and [**Name6 (MD) 138**] Primary MD
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 38
units with breakfast, 22 units at [**Name6 (MD) 21013**] Subcutaneous twice a
day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower leg ischemia, s/p bypass
PMH: DM, CAD-CABG, CRI, Hyperchol, HTN, RLE Bypass
Discharge Condition:
Good
Cr 0.9
WBC 15.3
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
You have a visit with Dr.[**Name (NI) 1720**] office on [**7-21**] at 1015am.
Call [**Telephone/Fax (1) 1241**] with any questions.
Call Dr.[**Name (NI) 5452**] office at ([**Telephone/Fax (1) 5455**] to schedule follow up to
be seen in [**3-14**] weeks. This is very important as you require
close follow up with your cardiologist.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2139-8-24**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2139-9-17**] 10:00
Completed by:[**2139-7-1**]
|
[
"997.3",
"V45.81",
"E878.2",
"414.01",
"403.90",
"996.1",
"411.1",
"440.21",
"585.9",
"272.0",
"486",
"996.74",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.08",
"39.49",
"00.41",
"38.18",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
5695, 5701
|
1603, 3640
|
363, 580
|
5832, 5855
|
1265, 1580
|
8699, 9362
|
1086, 1103
|
3780, 5672
|
5722, 5811
|
3666, 3757
|
5879, 8266
|
8292, 8676
|
1118, 1246
|
274, 325
|
608, 764
|
786, 1033
|
1049, 1070
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,695
| 117,752
|
54945
|
Discharge summary
|
report
|
Admission Date: [**2192-6-25**] Discharge Date: [**2192-7-3**]
Date of Birth: [**2140-6-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Acute liver failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 15674**] is a 52 year old male with a pmh of DMII, EtOH abuse,
and Crohn's disease who presented to an OSH after a night of
partying with friends where they had wine and raw oysters. He
went home and slept until he awoke with acute N/V/D and fevers.
At the OSH he was found to be in ALF with AST of >5000, ALT >
3000 INR of 3.2 and platelets of 62. Given his history of EtOH
abuse he was given a dose of steroids, covered for vibrio with
doxycycline and ceftriaxone, and started on NAC drip (Tylenol
level <15). Per report, U/S was negative at the OSH ED. After
acute worsening of his liver failure and development of
encephalopathy/withdrawal, he was transferred to [**Hospital1 18**] for
ongoing care.
Prior to transfer he had received a total of 16mg Ativan, 2mg
Haldol for agitation and withdrawal. QTc on arrival is 410.
On arrival to the MICU, he is extremely agitated. Thrashing in
the bed trying to break free of restraints kicking the bed.
Easily redirectable for short periods of times. Initially vitals
were with HR in 120s, BP 110s/60s, RR 16 and temp of 102.3.
However, he became acutely agitated and BP elevated to 210/120s,
HR in 150s. Given 2mg IV ativan, 5mg IV haldol. Fan and cooling
blanket being used to help cool patient.
Review of systems:
(+) Per HPI - Unable to obtain.
Past Medical History:
DMII complicated by neuropathy
Narcotic Agreement
Asthma
HL
HTN
GERD
Alcohol Abuse
Crohn's Disease
Barrett's Esophagus
Social History:
- Tobacco: Never
- Alcohol: Yes documented as abuse and "heavy" but not
quantified.
- Illicits: Denies
Family History:
Unable to obtain.
Physical Exam:
Vitals: T:102.3 BP:113/55 P:121 R:22 O2: 97% on RA
General: Agitated, thrashing in bed.
HEENT: Sclera icteric, dry MM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-tender, non-compliant from exam
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Very warm. Erythema over chest and face
Neuro: Unable to cooperate
Pertinent Results:
ADMISSION
[**2192-6-25**] 08:59AM URINE MUCOUS-RARE
[**2192-6-25**] 08:59AM URINE GRANULAR-6*
[**2192-6-25**] 08:59AM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2192-6-25**] 08:59AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-300 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2192-6-25**] 10:54AM FIBRINOGE-196
[**2192-6-25**] 10:54AM PT-38.7* PTT-29.1 INR(PT)-3.8*
[**2192-6-25**] 10:54AM PLT SMR-VERY LOW PLT COUNT-58*
[**2192-6-25**] 10:54AM NEUTS-90.0* LYMPHS-7.0* MONOS-2.7 EOS-0
BASOS-0.1
[**2192-6-25**] 10:54AM WBC-5.2 RBC-3.89* HGB-11.9* HCT-37.5* MCV-96
MCH-30.6 MCHC-31.7 RDW-12.5
[**2192-6-25**] 10:54AM HCV Ab-NEGATIVE
[**2192-6-25**] 10:54AM IgG-620* IgA-248 IgM-114
[**2192-6-25**] 10:54AM AMA-NEGATIVE Smooth-NEGATIVE
[**2192-6-25**] 10:54AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-POSITIVE
[**2192-6-25**] 10:54AM IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2192-6-25**] 10:54AM calTIBC-265 HAPTOGLOB-108 FERRITIN-[**Numeric Identifier 112216**]*
TRF-204
[**2192-6-25**] 10:54AM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-1.7*
MAGNESIUM-1.6
[**2192-6-25**] 10:54AM IRON-214*
[**2192-6-25**] 10:54AM ALT(SGPT)-5735* AST(SGOT)-[**Numeric Identifier 20965**]*
LD(LDH)-[**Numeric Identifier 112217**]* ALK PHOS-132* TOT BILI-3.4*
[**2192-6-25**] 10:54AM GLUCOSE-211* UREA N-21* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-22*
[**2192-6-25**] 11:04AM LACTATE-7.8*
.
DISCHARGE
[**2192-7-3**] 04:47AM BLOOD WBC-6.3 RBC-3.48* Hgb-10.7* Hct-34.3*
MCV-99* MCH-30.7 MCHC-31.0 RDW-13.9 Plt Ct-90*
[**2192-7-3**] 04:47AM BLOOD PT-14.9* PTT-32.3 INR(PT)-1.4*
[**2192-7-3**] 04:47AM BLOOD Glucose-105* UreaN-20 Creat-1.5* Na-136
K-4.1 Cl-102 HCO3-25 AnGap-13
[**2192-7-3**] 04:47AM BLOOD ALT-279* AST-101* AlkPhos-359*
TotBili-7.4*
[**2192-7-3**] 04:47AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.8 Mg-1.5*
.
MICRO
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2192-6-28**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2192-6-28**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2192-6-28**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
[**2192-6-27**] 5:45 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2192-6-29**]**
C. difficile DNA amplification assay (Final [**2192-6-28**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2192-6-29**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2192-6-29**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2192-6-28**]):
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 [**2192-6-29**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2192-6-29**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2192-6-28**]):
NO E.COLI 0157:H7 FOUND.
CMV, HCV VL negative
Urine cx [**7-2**] no growth
Blood cx [**6-25**], [**7-2**] no growth to date
OSH blood cx no growth
.
[**2192-6-25**] Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta and aortic arch are mildly dilated. 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. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild pulmonary artery hypertension. Mildly dilated
thoracic aorta.
CLINICAL IMPLICATIONS:
Based on [**2187**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2192-6-25**] LIVER/GALLBLADDER ULTRASOUND:
IMPRESSION:
Increased liver echogenicity, compatible with fatty deposition.
However, more advanced types of liver disease,
fibrosis/cirrhosis cannot be excluded. No discrete hepatic
lesion. Hepatic vasculature is patent.
.
[**2192-6-25**] CXR:
NG tube tip is in the stomach. Heart size is top normal. There
is prominence of the right pulmonary artery, most likely
asymmetric due to patient rotation. Mild vascular edema is
present, but no overt consolidations to suggest infectious
process are seen.
.
[**2192-6-25**] CT ABDOMEN and PELVIS with CONTRAST:
IMPRESSION:
1. Fatty liver.
2. No evidence of colitis or intra-abdominal abscesses.
3. Small left lower lobe consolidation, might represent
subsegmental
atelectasis, still, infection cannot be ruled out.
.
[**2192-6-26**] RENAL ULTRASOUND:
FINDINGS: The right kidney measures 12.3 cm and the left kidney
measures 11.2 cm. There is no hydronephrosis. No cyst or stone
or solid mass is seen in either kidney. No perinephric fluid
collection is identified. The bladder is collapsed on a Foley
catheter.
IMPRESSION: No hydronephrosis.
.
[**7-2**] Liver U/S
1. Gallbladder wall edema is likely related to underlying
fulminant hepatitis and low albumin levels. No son[**Name (NI) 493**]
evidence of acute cholecystitis, as the gallbladder is
nondistended. The above findings are new since [**2192-6-25**] exams.
2. Echogenic liver, compatible with fatty deposition.
3. Splenomegaly.
Brief Hospital Course:
52 year old male with a pmh of DMII, EtOH abuse with past
hospitalizations for withdrawal, on chronic pain medications who
is transferred from an OSH for worsening hepatic function.
# Liver Failure: DDx includes acute EtOH hepatitis, acute viral
hepatitis, autoimmune hepatitis, obstruction, toxin (statin or
tylenol), and vascular compromise of the liver with portal
thrombosis. The patient was acutely agitated and delirious at
admission with significant synthetic dysfunction with an INR of
5.5, AST >[**Numeric Identifier 3301**] and ALT >5000. He was initially treated with 18
mg of Ativan and 7 mg of Haldol for acute agitation and presumed
alcohol withdrawal. The patient also apparently ingested 20
Percocet prior to the acute onset of his nausea/vomiting. Given
his ingestion, toxic consumption with delayed presentation is
most likely (chronology of patient's history is likely not
reliable) though alcoholic hepatitis could also have been
contributing. Given the patient's clinical story, Vibrio was
also a possibility so he was started on doxycycline until
cultures returned negative. Hepatitis, HSV, CMV, and EBV
serologies were negative as were [**Doctor First Name **], [**Last Name (un) 15412**], AMA, Alpha-1, and
iron studies. Per Infectious Disease, he was covered with
ceftazidime empirically until blood cultures from OSH returned
negative. The patient was also evaluated by Hepatology who
recommended treating the patient per NAC protocol for presumed
acetaminophen ingestion and acute liver injury. The patient's
LFTs and coag labs downtrended continuously during this
hospitalization and his mental status improved so that he was
oriented and appropriate by discharge. His statin was held at
discharge and patient was advised to stay away from tylenol and
alcohol.
.
# Fevers: Given history of raw oyster consumption, he was
presumptively started on doxycycline and ceftaz empirically for
vibrio and enteric coverage which was discontinued once cultures
returned negative. Given his negative abdominal imaging (RUQ U/S
and CT abdomen), fever is most likely in response to
inflammation associated with the patient's liver disease.
.
#Renal failure: Patient's Creatinine peaked at at 3 on [**6-27**].
Given the patient's history of Percocet ingestion and his last
urinalysis showing urine casts, ATN secondary to toxic ingestion
was the most likely etiology. Patient had also received some IV
contrast during his admission likely contributing to his renal
decline. However, the patient was treated with IV fluids and
maintained adequate urine output during his hospitalization with
improvement of his Cre to 1.5 at discharge.
.
#Thrombocytopenia: The patient was thrombocytopenic at
admission with platelets of 58. The patient remained
thrombocytopenic throughout his hospitalization. This finding
was likely associated with alcohol abuse. DIC was less likely
given his normal FDP and normal PTT.
.
# Delirium/Hallucinations: The patient's mental status seemed a
combination of EtOH withdrawal and hepatic encephalopathy
secodnary to acute liver failure. The patient at admission was
combative and agitated. However, he was kept on CIWA with
Ativan and his mental status improved. His mental status
continued to improve during his hospital course so that he was
appropriate at discharge.
.
#Narcotic withdrawal: The patient normally takes 6 Percocet/day
with increased ingestion over the weekend immediately prior to
onsest of acute nausea and vomiting. The patient initially
experienced abdominal pain and hypertension but this resolved
over the course of his stay. Given his likely withdrawal, he
was started on oxycodone PRN for pain.
.
#Hypertension: The patient has a history of hypertension, but
his systolic BPs ran in the 180s. His BP initally may have been
more elevated given his abdominal pain as well as withdrawal
symptoms. His pain was controlled with Dilaudid and then
switched to oxycodone PRN. Given [**Last Name (un) **], his home lisinopril was
held and he was started on labetalol. This was uptitrated during
his stay to achieve BPs in the 150s at discharge. His ACE was
held but can likely be restarted once his creatinine fully
normalizes.
.
# Diabetes: Insulin SS while in house. His blood sugars remained
elevated in the 200s with an A1c of 8.4. He was discharged on
glipizide. His metformin was held but this can likely be
restarted once his creatinine normalizes.
.
# Neuropathic pain: Patient complained of neuropathic pain in
his feet. Had been on percocet at home but this was switched to
oxycodone. His gabapentin was decreased as well so that it was
renally dosed.
TRANSITION ISSUES:
1. Recheck ferritin, TIBC after resolution of acute liver injury
to screen for hematochromatosis and if elevated would send
genetic testing
2. Hold statin until liver function tests normalize; hold
metformin and ACE until renal function normalizes
3. Continue to advocate for abstinence from alcohol
Medications on Admission:
Oxycodone-Acetaminophen 7.5-325 PO Q4H prn pain
Gabapentin 300mg tabs; 2 tabs PO TID
Glipizide 5mg; 1 tab PO daily
Metformin 500mg; 2 tabs PO daily
Lorazepam 1mg; 1 tab PO daily
Omeprazole 20mg caps; 1 cap PO daily
Simvastatin 40mg tabs; 1 tab QHS
Lisinopril 10mg tabs; 1 tab PO daily
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Lorazepam 1 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg daily Disp #*30 Tablet Refills:*2
5. Labetalol 200 mg PO BID
hold for SBP<100 or HR<55 and inform H.O.
RX *labetalol 200 mg twice a day Disp #*60 Tablet Refills:*2
6. Lactulose 30 mL PO QID
hold for BM > 4
RX *lactulose 20 gram/30 mL four times a day Disp #*3600
Milliliter Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *Daily Multi-Vitamin daily Disp #*30 Tablet Refills:*2
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg daily Disp #*30 Tablet Refills:*2
9. OxycoDONE (Immediate Release) 7.5 mg PO Q6H:PRN pain
RX *Oxecta 7.5 mg every six hours Disp #*12 Tablet Refills:*0
10. GlipiZIDE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute liver failure
tylenol overdose
opioid abuse
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 15674**]. You
were admitted with nausea and vomiting. You were found to have
acute liver failure likely due to tylenol overdose from taking
too many percocets. You need to stop abusing prescription
medications and you cannot drink any alcohol as this can
severely damage your liver.
Continue your home medications with the following changes:
1. STOP percocet and START oxycodone instead
2. STOP lisinopril until your kidney function can be rechecked
3. STOP metformin until your kidney function can be rechecked
4. STOP simvastatin until your liver function returns to normal
Followup Instructions:
When: THURSDAY, [**7-5**] at 11:00AM
Name: [**First Name4 (NamePattern1) 4134**] [**Last Name (NamePattern1) **] (nurse practictioner of [**Last Name (LF) **],[**First Name3 (LF) 177**] M)
Location: [**Hospital 20086**] MEDICAL GROUP
Address: [**Street Address(2) 20087**], STE 3C, [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 7164**]
Department: LIVER CENTER
When: FRIDAY [**2192-7-13**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"530.81",
"584.5",
"E850.4",
"357.2",
"305.51",
"250.60",
"965.4",
"555.9",
"292.0",
"570",
"305.00",
"293.0",
"272.4",
"287.5",
"304.91",
"493.90",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14650, 14656
|
8589, 13548
|
330, 337
|
14770, 14770
|
2455, 6806
|
15591, 16439
|
1970, 1990
|
13883, 14627
|
14677, 14749
|
13574, 13860
|
14921, 15568
|
2005, 2436
|
6829, 8566
|
1654, 1690
|
271, 292
|
365, 1635
|
14785, 14897
|
1712, 1833
|
1849, 1954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,358
| 105,688
|
24241
|
Discharge summary
|
report
|
Admission Date: [**2142-5-7**] Discharge Date: [**2142-7-14**]
Date of Birth: [**2084-9-20**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Wound Dehiscence
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Repair with Mesh
VAC dressing
STSG
History of Present Illness:
This is a 57-year-old male with renal cell carcinoma metastatic
to the thoracic
spine. He also had several pulmonary nodules which are of
unclear significance. He previously had undergone left
nephrectomy and placement of metallic hardware in the back for
stabilization. The patient was maintained on a tyrosine kinase
inhibitor with potent antiangiogenic properties. I had first
encountered the patient in [**2141-10-26**] when he presented with
perforated diverticulitis. At that time, after a failed attempt
at conservative management, I had performed
a sigmoid colectomy with end-sigmoid colostomy. The patient
failed to heal either the stoma tunnel or his midline wound
completely. Presumably, this was due to his study drug which was
reinstituted after the surgery. Over a few months, I had
observed the gradual development of a small ventral hernia.
However, on the day of surgery, the patient presented to the
medical oncology clinic with acute enlargement of the hernia. I
evaluated him and felt that he was at risk for evisceration and
transferred him emergently to the [**Hospital3 **] [**Hospital Ward Name 517**]. After
arriving there, he ruptured the peritoneal investment overlying
the hernia and small bowel was observed to be present outside of
the abdomen. Therefore, he was taken to the operating room for
closure and exploration.
Past Medical History:
exlap, end colostomy c Hartmann's for perf'd sigmoid colon [**10-30**]
renal cell CA s/p L nephrectomy [**2139**]
h/o herpes zoster
T5 vertebrectomy secondary metastases
h/o nasal polyps
sp resect of benign R knee mass
Social History:
lives in [**Location (un) 538**] with wife
quit tobacco 1 yr ago, no EtOH
Family History:
NK
Physical Exam:
Gen: Obese male, apparent pain and discomfort, agitated.
CV: RRR, no M/R/G
Lungs: Rhonchi diffusely
Abd: obese with wound dihiscence, bowel protruding from wound.
Ext: mild pedal edema, + 2 pulses
Pertinent Results:
Cardiology Report ECG Study Date of [**2142-5-7**] 9:36:00 PM
Sinus tachycardia. Baseline artifact precludes adequate
interpretation. Left
anterior fascicular block. Right bundle-branch block. Compared
to the previous
tracing of [**2142-5-8**] the rate is increased. Otherwise, no
diagnostic interim
change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
104 164 160 382/442.57 80 -78 55
CHEST (PORTABLE AP) [**2142-5-9**] 8:26 AM
CHEST (PORTABLE AP)
Reason: Please eval for cardiopulmonary process, compare to
prior CX
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration
transferred to ICU with respiratory distress.
REASON FOR THIS EXAMINATION:
Please eval for cardiopulmonary process, compare to prior CXR
[**5-8**]
INDICATION: Postop day two for repair of bowel evisceration,
respiratory distress.
COMPARISON: [**2142-5-8**].
UPRIGHT AP VIEW OF THE CHEST: Patient is status post posterior
thoracic spinal fusion with vertebral body cage device again
noted. Marked cardiomegaly is unchanged. The aorta is tortuous.
Pulmonary edema has nearly completely resolved. No focal
consolidation, pleural effusions, or pneumothorax is present.
Resection of several left-sided ribs is again demonstrated. New
right internal jugular central venous catheter tip is positioned
within the distal SVC.
IMPRESSION: Unchanged marked cardiomegaly with near complete
resolution of pulmonary edema.
CHEST (PORTABLE AP) [**2142-5-14**] 8:56 AM
CHEST (PORTABLE AP)
Reason: Eval for PNA
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration c
fever
REASON FOR THIS EXAMINATION:
Eval for PNA
HISTORY: Status post bowel repair with fever.
COMPARISON: [**2142-5-9**].
CHEST: AP semi-upright view. The right internal jugular central
venous catheter tip is in the superior vena cava. There is no
pneumothorax. Cardiac and mediastinal contours are unchanged.
There is no pulmonary edema. The lungs are clear. Spinal fusion
hardware and evidence of left upper rib resection is again
noted.
IMPRESSION: No evidence of pneumonia.
SCROTAL U.S. [**2142-5-17**] 5:36 PM
SCROTAL U.S.
Reason: Hydrocele? Prostatitis?
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with tender scrotal edema and +UTI
REASON FOR THIS EXAMINATION:
Hydrocele? Prostatitis?
INDICATION: 57 year male with scrotal tenderness.
There are no prior studies for comparison.
SCROTAL ULTRASOUND: The right testicle measures 2.9 x 3.4 x 3.7
cm. The left testicle measures 3.4 x 2.9 x 3.7 cm. The
echogenicity of the testicles is normal. Increased vascularity
is seen in a heterogeneous right epididymis. There is a
moderate-sized complex right hydrocele and pyocele cannot be
excluded. There is a small-to-moderate sized left hydrocele.
There is a small left epididymal head cyst.
IMPRESSION: Right-sided epididymitis with complex hydrocele. A
pyocele cannot be excluded.
CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST
Reason: History of renal cancer, now post-op with shortness of
breat
Field of view: 50 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with
REASON FOR THIS EXAMINATION:
History of renal cancer, now post-op with shortness of breath,
chest pain, and desaturation; is there a PE?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of renal cancer now postop shortness of
breath, question PE.
COMPARISON: [**2142-3-15**].
TECHNIQUE: MDCT non-contrast and contrast-enhanced axial CT
imaging of the chest with multiplanar reformats was performed.
In addition, contrast- enhanced CT axial imaging of the abdomen
and pelvis with multiplanar reformats was also performed.
CT CHEST WITH CONTRAST: Evaluation for pulmonary embolus is
limited secondary to respiratory motion. However, the main and
proximal pulmonary arteries enhance without filling defects. The
heart and other great vessels of the mediastinum are
unremarkable. Within the mediastinum are multiple new
pathologically enlarged lymph nodes, not present in [**2142-2-24**].
The largest is a precarinal node measuring 22 x15 mm. A 12-mm
subcarinal and multiple greater than 12-mm subcarinal nodes are
present as well as a 14-mm precarinal node. These are all new or
increased in size since priro scan. No pathologic axillary
adenopathy is identified. Bilateral enlarged hilar adenopathy is
also present and markedly increased from the interval. The
largest node is a left hilar node measuring 22 x 12 mm. There
has also been interval enlargement of a large spinal mass
encompassing multiple thoracic vertebrae. A vertebral fixation
hardware and a spinal canal stent is in place. Small bilateral
pleural effusions are unchanged. Lung windows demonstrate
several pulmonary nodules, increased in size, including a 7- mm
right lower lobe nodule, previously 3 mm. Note that the target
lesions do not reflect the progression of tumor as the left
upper lobe nodule (target 1) today measures 14 x 8 mm,
unchanged. Target lesion 2, a upper lobe nodule measures 12 x 12
mm, unchanged. Increased interstitial markings and engorged
pulmonary vessels.
CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously. A
hypodense 15- mm cyst in the left lobe is unchanged. No
suspicious lesions are identified. A 15-mm soft tissue nodule in
the gallbladder is not apparent on the previous study. This is
of unclear etiology, possibly a metastasis. The pancreas,
spleen, stomach, and small bowel loops are within normal limits.
Target lesion #3, a left adrenal nodule, measures 34 x 30 mm,
increased since prior study here it measured 27 x 24 mm.
Multiple small retroperitoneal lymph nodes have also enlarged in
the interval. The patient is status post left nephrectomy. The
right kidney is normal. No free air or free fluid is present in
the abdomen.
CT PELVIS WITH CONTRAST: Contrast is present within the Hartmann
pouch. The bladder, seminal vesicles and prostate are normal. No
pathologic adenopathy is identified. No free fluid or free air
is present. Note is made of bilateral fat-containing inguinal
hernias.
BONE WINDOWS: Besides the large mass involving multiple
mid-to-upper thoracic vertebrae as described above, no new
suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
1. Limited study, but no evidence for pulmonary embolus.
2. Disease progression with multiple new enlarged mediastinal,
hilar nodes and and pulmonary nodules. Interval enlargement of
the thoracic spine mass and enlargement of the left adrenal
nodule and retroperitoneal nodes. The target lesions are
unchanged and do not reflect progression.
3. ? Mild CHF.
4. Unchanged small bilateral pleural effusions and associated
atelectasis.
A preliminary report was provided overnight to the resident
taking care of the study. "Limited study due to motion. No
saddle or main artery PE. Evaluation of segmental branch is
limited. Bilateral pleural effusions and atelectasis. M.
[**Doctor Last Name 24949**]."
MR HEAD W & W/O CONTRAST [**2142-6-13**] 10:15 AM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Altered mental status; non-specific head CT.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with
REASON FOR THIS EXAMINATION:
Altered mental status; non-specific head CT.
MR HEAD
HISTORY: 57-year-old male with altered mental status,
nonspecific head CT.
TECHNIQUE: Multiplanar multisequence images of the brain were
obtained using the standard departmental protocol with
administration of gadolinium.
FINDINGS: Comparison is made to a head CT dated [**2142-6-12**].
There are no masses or mass effect. There are no areas of
abnormal enhancement.
There are scattered cerebral periventricular white matter T2
hyperintensities, which likely represent microangiopathic
changes.
There is enlargement of the ventricles, sulci, basal cisterns,
consistent with atrophy.
The cervicomedullary junction is normal. The major flow voids
are normal.
Minimal mucosal thickening of the ethmoid and sphenoid sinuses
are seen.
The visualized orbits are normal.
No focal bony abnormalities are seen.
CHEST (PORTABLE AP) [**2142-6-14**] 1:41 AM
CHEST (PORTABLE AP)
Reason: eval pna, effusion, edema
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration c
hypoxia
REASON FOR THIS EXAMINATION:
eval pna, effusion, edema
REASON FOR EXAMINATION: Followup of patient with pneumonia and
effusion after abdominal operation.
AP supine chest radiograph compared to the previous film from
[**2142-6-13**].
IMPRESSION:The moderate cardiomegaly and widened mediastinum are
stable. The enlargement of the pulmonary vessels is slightly
more pronounced than it was on the previous film representing
worsening of the pulmonary edema which is of mild degree. There
is new left lower lobe atelectasis involving most of the left
lower lobe. There is no pneumothorax or sizable pleural
effusion. The spinal fusion hardware is in unchanged position.
Cardiology Report ECHO Study Date of [**2142-6-14**]
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Left ventricular function.
Height: (in) 72
Weight (lb): 255
BSA (m2): 2.36 m2
Status: Inpatient
Date/Time: [**2142-6-14**] at 13:31
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W026-1:26
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: *4.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
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: 250 msec
TR Gradient (+ RA = PASP): *27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal
LV wall motion abnormality cannot be fully excluded. Overall
normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - body habitus.
Conclusions:
1. 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%).
2. The aortic valve leaflets are mildly thickened.
3. The mitral valve leaflets are mildly thickened.
CHEST (PORTABLE AP) [**2142-6-17**] 5:50 AM
CHEST (PORTABLE AP)
Reason: eval edema
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration
s/p bronchoscopy [**6-14**] for mucus pluggin
REASON FOR THIS EXAMINATION:
eval edema
CLINICAL HISTORY: Status post laparotomy, postoperative day two.
CHEST: The heart remains enlarged and widening of the aorta is
again seen. Some upper zone redistribution is present suggesting
some mild failure, but it is not significantly changed since the
prior chest x-ray of [**6-16**]. The right effusion has resolved.
IMPRESSION: Mild failure is still present. Resolution of right
effusion.
CHEST (PORTABLE AP) [**2142-6-21**] 8:10 PM
CHEST (PORTABLE AP)
Reason: acute process
[**Hospital 93**] MEDICAL CONDITION:
57 yo male c ?CHF
REASON FOR THIS EXAMINATION:
acute process
57-year-old male with concern for CHF.
COMPARISON: [**2142-6-17**].
AP PORTABLE CHEST: The spinal fixation construct is unchanged.
There is stable mild cardiomegaly and mediastinal widening.
There are probable small bilateral pleural effusions. Patchy
bilateral airspace opacities are noted, which are slightly more
prominent compared to [**2142-6-17**].
IMPRESSION: Small bilateral pleural effusions. Patchy bilateral
airspace opacity likely represents mild congestive failure;
however, pneumonia cannot be entirely excluded.
RENAL U.S. [**2142-6-22**] 9:18 AM
RENAL U.S.
Reason: 57 year old man met renal cell CA now in acute renal
failure
[**Hospital 93**] MEDICAL CONDITION:
57 year old man met renal cell CA now in acute renal failure.
REASON FOR THIS EXAMINATION:
57 year old man met renal cell CA now in acute renal failure.
INDICATION: Patient with metastatic renal cell carcinoma now on
acute renal failure. History of left nephrectomy.
COMPARISON: CT of the abdomen and pelvis of [**2142-6-13**].
RENAL ULTRASOUND: The right kidney measures 12.7 cm. There is no
hydronephrosis, stone, or mass of the right kidney. The left
kidney is absent. The known left adrenal nodule could not be
visualized on this ultrasound examination. The bladder was
empty.
IMPRESSION: Unremarkable ultrasound appearance of the right
kidney.
CT ABDOMEN W/O CONTRAST [**2142-6-29**] 5:25 PM
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
Reason: Please assess aggregate tumor burden.
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with metastatis renal cell carcinoma.
REASON FOR THIS EXAMINATION:
Please assess aggregate tumor burden.
CONTRAINDICATIONS for IV CONTRAST: Recent ATN
INDICATION: Renal cell carcinoma, please assess aggregate tumor
burden.
COMPARISON: [**2142-6-13**].
TECHNIQUE: Non-contrast axial CT imaging of the chest, abdomen
and pelvis with coronal and sagittal reformats was reviewed.
CT CHEST WITHOUT CONTRAST: There is a new patchy opacity in the
right upper lobe. Interstitial lines and engorged pulmonary
vessels indicate degree of pulmonary edema. Evaluation of the
lung windows is limited secondary to marked respiratory motion.
Moderate right pleural effusion has enlarged in the interval.
There is moderate associated right lower lobe atelectasis. There
is a small left pleural effusion. A peripheral fluid attenuation
nodularity of the left apex may represent a small amount of
loculated pleural fluid. This is incompletely evaluated, and
pleural-based tumor may need to be considered. This is
unchanged. Pathologic mediastinal and hilar adenopathy is
unchanged from [**2142-6-13**]. The pleural nodules previously
identified are less well characterized on today's study given
respiratory motion, effusions, and pulmonary edema. There is a
very small pericardial effusion.
There has been no interval change in the large spinal mass with
vertebral fusion rods and vertebral body metallic cage.
Evaluation of this mass is limited secondary to the hardware.
CT ABDOMEN WITHOUT CONTRAST: Hypodense lesion in the left lobe
of the liver is unchanged, possibly a cyst, but not fully
characterized on today's study. No suspicious lesions
identified. The gallbladder, pancreas, spleen, stomach, small
bowel loops are unchanged. Right kidney is unchanged with a
small amount of perinephric stranding. Adjacent to the lower
pole of the right kidney is a 1.6-cm fluid density nodule,
unchanged. There is no hydronephrosis. The right adrenal gland
is normal. Left adrenal mass is unchanged, measuring 3.4 x 3.0
cm. Multiple small but suspicious retroperitoneal adjacent nodes
are present, not markedly changed in the interval. There is no
free air or free fluid.
CT PELVIS WITH CONTRAST: Note is made of anterior wall defect
and stoma in the left lower quadrant. The Hartmann pouch
contains contrast. The bladder is decompressed about a Foley.
There are bilateral fat-containing inguinal hernias. No
pathologic adenopathy, free air, or free fluid is present in the
pelvis.
BONE WINDOWS: Besides the previously mentioned thoracic spinal
mass, no suspicious lesions are identified.
IMPRESSION:
1. Enlarging right moderate pleural effusion with associated
atelectasis. Small left pleural effusion, possibly loculated
with associated atelectasis.
2. New right upper lobe patchy opacity that represents atypical
edema versus pneumonia in the proper clinical setting. Engorged
pulmonary vessels and septal lines indicate mild pulmonary
edema.
3. No significant change in metastatic disease in the chest or
abdomen including pathologic mediastinal nodes, large thoracic
spinal mass, and left adrenal mass with adjacent adenopathy.
Brief Hospital Course:
The patient went to the OR emergently on [**2142-5-7**]. He had Vicryl
mesh in place and a wound VAC covering his abdomen. His stoma
was pink and functioning. He was instructed to remain on bed
rest for 7 days post-op.
He was hypertensive and tachycardic in the PACU. Acute Pain
Service was called and he was started on a Dilaudid PCA, with
good effect. He was ordered for Cefazolin and Flagyl.
#Respiratory
On POD 1, he had respiratory distress with a respiratory rate of
24 and brief apnea episodes. He appeared to have sleep apnea,
although there is nothing documented in his history for sleep
apnea. His fluids were decreased, nebulizers were ordered, an
ABG was 7.43/37/85/25/0. Labs were checked and CXR done. The
patient was transferred to the ICU for continued care of his
respiratory distress. He was stable in the ICU and the
respiratory issues was likely related to sleep apnea. He
returned to the floor on POD 2.
On POD 37 ([**2142-6-13**]) he was transferred to the ICU secondary to
respiratory distress. His pO2 was 56. He was intubated soon
after arriving to the ICU and had metabolic alkalosis. He
received 2 Units of PRBCs. A CT showed no evidence of a PE, a
CXR showed some CHF, and a MRI of his brain showed no acute
changes. He received Lasix with a good response. A bronchoscopy
was performed that showed increased secretions in the left
mainstem. He remained intubated for 3 days (extubated [**2142-6-17**]),
and was tolerating extubation. He continued to receive nebulizer
treatments and chest PT as tolerated. His respiratory status
continued to be tenuous. He received Lasix, with good response,
for increased SOB on [**2142-6-23**]. He received aggressive pulmonary
toilet for suspected pneumonia. Chest PT was difficult due to
the back pain.
#Code Status
DR. [**Last Name (STitle) 519**] met with the family on [**2142-6-14**] and [**2142-6-16**] to discuss
further care for this patient. He was made DNR at this time. A
family meeting with Dr. [**Name (NI) 519**], wife and son on [**2142-6-30**] resulted in
absolute DNR/DNI status and he was made "comfort measures only".
#Renal Consult
After several days of diuresis with Lasix, his creatinine was
rising (up to 4.2 on [**2142-6-23**]) and he was noted to have ARF. His
Vanco level was 26.1 on [**2142-6-19**]. His antibiotics and diuretics
were held. We monitored his fluid status closely and he received
several fluid boluses to increase his urine output.
A renal ultrasound was negative. He was thought likely to have
ATN as the etiology. He may intravascularly depleted secondary
to a low albumin.
His labs gradually improved and the creatinine slowly came down
and the Vanco level was 9.3 on [**2142-6-25**]. His urine output began
to improve. On [**2142-7-7**] his BUN was 27, and Cr was 1.4.
#Nutrition Consult
The patient was instructed on a Renal Diet and menu choices. He
and his wife were instructed to choose high protein, low sodium,
low potassium and low phosphate foods.
#Physical Therapy
Physical Therapy worked with him on a consistent basis. He
continued to be very deconditioned and functionally dependent
due to the prolonged bed rest and hospitalization. He was
Hoyered out of bed daily, received chest PT, and range of motion
exercises. Due to the abdominal wound, activity was limited to
ensure proper wound healing and decrease the risk of dehiscence.
The patient was intermittently confused at the beginning of his
hospitalization. His narcotics were D/C'd and the patient began
to clear. He was not complaining of pain.
His abdomen remained soft, with decreased bowel sounds. He was
on a regular diet. His ostomy was in place and the stoma pink.
He continue on bedrest until POD 7. He was then assisted to the
chair using the [**Doctor Last Name 2598**] lift and he was allowed to sit in a
wheelchair.
A air mattress was in place to help maintain skin integrity and
he wore pneumoboots for DVT prophylaxis.
[**2142-5-11**], POD 4, his VAC dressing was changed, some scant
granulation tissue was noted. The VAC dressing was again changed
on [**2142-5-14**] and [**2142-5-19**], with granulation tissue noted.
Subsequent VAC changes occurred on [**8-4**], [**6-1**] and every [**1-27**]
days thereafter.
On [**2142-6-21**] (POD 45) he went to the OR for a Skin graft split
thickness to the abdominal wound from the right thigh. The
abdominal wound had a VAC dressing in place; the thigh wound was
dressed.
On [**2142-6-29**] the VAC dressing was removed. The skin graft appeared
to be in excellent condition with nice, pink tissue forming.
Xeroform dressing and dry gauze was. His mental status continued
to wax and wane with periods of confusion as his hospitalization
continued.
#Pain Consult
He was complaining of increased pain ([**2142-6-19**]), especially to
his back. The Chronic Pain service recommended medication
adjustments and his pain was in much better control. He was
requiring more Morphine on HD 53 for increased pain. The Pain
service recommended increased fentanyl patch from to 200mcg/hr,
increased oxycontin to 40mg [**Hospital1 **].
# Urology
A urine culture on [**2142-5-14**] showed P. Aeruginosa and Gram
negative rods. He was started on Cipro. Urology was consulted
for scrotal swelling. An ultrasound revealed a right-sided
epididymitis with complex hydrocele. A repeat urine culture
showed E.coli resistant to Cipro. He was kept on Cipro for the
epididymitis and added Ampicillin for UTI. A post-void residual
was 15 cc. A urine culture on [**2142-5-26**] revealed Klebsiella
Pneumoniae, pan resistant. A urine culture on [**2142-5-29**], again
showed Klebsiella Pneumoniae. The Ampicillin was D/C'd.
#Heme
His platelet count went from 192 to a low of 66 and gradually
climbed up to the low 100's. His labs were watched closely and
his heparin products were held.
#Tachycardia
The patient was tachycardic in the low 100's with a BP of
130/80. One unit of PRBC was given for a HCT of 28.5. His HR
settled in the 80's.
#PALLIATIVE CARE
A plan was develped with the palliative care physician and his
oncologist Dr. [**Last Name (STitle) **]. It was thought that due to his poor
performance status and overall condition that resumed chemo
would have little benefits greater than burdens.
Medications on Admission:
Decadron 2', Darvocet, Fentanyl patch, sunitinib (=Sutent),
roxicet prn, ranitidine50", Zofran prn.
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
8. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
9. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed.
10. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR
Transdermal Q48H (every 48 hours).
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Wound Dehiscence
Ventral Hernia Repair
Discharge Condition:
Poor
Code status: Do not resuscitate (DNR/DNI)
Comments: Family meeting with Dr. [**Name (NI) 519**], wife and son on [**2142-6-30**]
resulted in absolute DNR/DNI status
Corroborated with: [**Last Name (LF) **],[**First Name3 (LF) **] E. on [**2142-6-30**] at 1130
Discussed with: health care proxy
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
Wound Care
Ostomy Care
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] as needed for wound issues. Call
([**Telephone/Fax (1) 5323**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2142-7-13**]
|
[
"518.81",
"198.5",
"V58.69",
"V45.3",
"599.0",
"198.89",
"293.0",
"569.69",
"998.31",
"344.1",
"276.52",
"780.57",
"511.9",
"604.90",
"287.5",
"486",
"552.21",
"584.5",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"53.61",
"86.69",
"93.59",
"99.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
26321, 26362
|
18996, 25230
|
290, 349
|
26445, 26746
|
2315, 2946
|
26979, 27284
|
2079, 2083
|
25380, 26298
|
15833, 15887
|
26383, 26424
|
25256, 25357
|
26770, 26956
|
11460, 13541
|
2098, 2296
|
234, 252
|
15916, 18973
|
377, 1729
|
1751, 1971
|
1987, 2063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,550
| 170,703
|
2056
|
Discharge summary
|
report
|
Admission Date: [**2154-5-12**] Discharge Date: [**2154-5-23**]
Service: CTU
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
male who was in his usual state of health until the day of
admission when he developed sudden onset of shortness of
breath while gardening. The patient took two sublingual
nitroglycerin which provided him no relief and he called EMS.
In the field, the patient was found to be tachypneic with
saturations in the mid 80s and a blood pressure initially of
250/palpation. The patient was intubated in the field for
respiratory distress. He received Lasix 80, aspirin and
nitroglycerin in the field. On arrival to the Emergency
Department, he received fentanyl, Versed and patient's blood
pressure dropped to 53/27. He was started on peripheral
dopamine. Following that, his blood pressure then bounced up
to 170s/60s and the dopamine was discontinued. The patient
also received 80 more of intravenous Lasix in the Emergency
Department. He put out about 500 cc with a total of 160 mg
of intravenous Lasix. Per report, the patient denied any
chest pain, palpitations, fevers or chills prior to the
development of shortness of breath.
PAST MEDICAL HISTORY:
1. Coronary artery disease. Last echocardiogram in [**2154-1-8**] showing an ejection fraction of 30% to 35% and
moderately dilated left atrium, moderately dilated LV,
inferolateral akinesis, basal inferior septal akinesis,
inferior akinesis and hypokinesis of the lateral wall, 1 to
2+ mitral regurgitation. The patient's last catheterization
was in [**Month (only) 116**] of '[**50**], which showed multi vessel disease with a
30% distal left main, proximal 30% LAD, 60% ostial RCA with a
90% proximal stenosis, a wedge of 27, an LVEDP of 20.
2. The patient is status post AICD and pacer placement in
'[**49**] for bradycardia.
3. Chronic obstructive pulmonary disease with mild
restrictive disease.
4. Chronic renal insufficiency with a baseline creatinine of
1.6 to 2.5.
ADMISSION MEDICATIONS:
1. Aspirin
2. Lopressor 12.5 qd
3. Lisinopril 10 qd
4. Lipitor 20 qd
5. Lasix 40 qd
6. Amiodarone 200 qd
7. Nitroglycerin prn
SOCIAL HISTORY: The patient speaks Italian and some English,
lives with his wife, is a 130 pack year smoker, quit six
years ago, no alcohol or intravenous drug use.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 144/51, heart rate 95, O2
saturation 99% on 100% FIO2. The patient is on ventilator
set at AC, tidal volume of 700, rate of 12, 100% FIO2 and
PEEP of 10.
GENERAL: The patient was intubate and sedated.
HEAD, EARS, EYES, NOSE AND THROAT: ETT tube in place, moist
mucous membranes.
NECK: The patient is obese with jugular venous distention
unappreciable.
LUNGS: Bibasilar crackles.
CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2 at
2/6 heart systolic murmur heard throughout at the left upper
sternal border, right upper sternal border and the apex.
ABDOMEN: Obese, nontender, nondistended, no bowel sounds.
EXTREMITIES: The patient has 1+ pitting peripheral edema in
his lower extremities. Extremities were warm with 2+ pulses.
NEUROLOGIC: Patient sedated and intubated.
STUDIES: Electrocardiogram was normal sinus rhythm at a rate
of 90 with a left bundle branch block, V-paced with ST
elevations in V2 through V5. Chest x-ray showed congestive
heart failure, cardiomegaly and a possible right middle lobe
infiltrate.
ADMISSION LABS: White count 13, hematocrit 44.8, platelets
668, 64% neutrophils, 27 lymphocytes, 4 monocytes. PT 13.9,
INR 1.3, sodium 140, potassium 4.5, chloride 102, bicarbonate
23, BUN 34 and creatinine 2.6. Glucose 215, anion gap of 15.
ALT 15, AST 13, alkaline phosphatase 122, magnesium 2.3,
phosphate 6.5, CK 110, MB 2 and troponin less than 0.3.
HOSPITAL COURSE: The patient is an 82-year-old male with a
history of multivessel coronary artery disease, congestive
heart failure, chronic renal insufficiency and chronic
obstructive pulmonary disease who was admitted with pulmonary
edema requiring intubation in the field, initially on
pressors secondary to sedating medications, but pressors were
discontinued by the time the patient arrived to the CCU.
1. CARDIOVASCULAR:
A. ISCHEMIA: Patient with known multivessel disease,
without intervention in '[**50**]. The patient denied any
proceeding chest pain as a precipitant for his congestive
heart failure. Electrocardiogram shows a left bundle branch
block, so difficult to evaluate for ischemia. The patient
had his cardiac enzymes cycled and his CKs peaked at 287 on
the 7th and the patient had a CK of 0.6 on the 6th. His
electrocardiogram showed no evidence of ischemic changes.
The patient was continued on his aspirin, statin, beta
blocker and ACE were held due to his acute renal failure and
acute congestive heart failure. The patient did have a
cardiac echocardiogram on the 6th which showed evidence of
progression of coronary artery disease. The echocardiogram
showed multiple regional wall motion abnormalities, including
basal anterior septal akinesis, mid anterior septal akinesis,
basal inferior septal akinesis, mid inferior septal akinesis,
basal inferior akinesis, mid inferior akinesis, basal
inferior lateral akinesis, septal apex akinesis, inferior
apex akinesis and apical akinesis. The patient's
echocardiogram also showed evidence of a worsened ejection
fraction from echocardiogram previous in [**Month (only) 404**] of this
year. Ejection fraction on the echocardiogram done on [**2154-5-13**]
estimated ejection fraction was 15% to 20% down from previous
of 30. Management of the patient's coronary artery disease
was discussed with the team and it was decided that at the
acute setting, a cardiac catheterization would not be
pursued. This may be considered as an outpatient by the
patient's cardiologist and consider evaluation for coronary
artery bypass graft as per patient's cardiologist. Prior to
discharge, the patient was able to presume Lopressor at 12.5
[**Hospital1 **]. ACE inhibitor had still not been resumed due to the
renal failure and should be resumed at the discretion of the
patient's cardiologist.
B. PUMP: The patient was intubated for flash pulmonary
edema. Unclear precipitant of patient's congestive heart
failure. No evidence of acute ischemia, however suggests
worsening coronary artery disease. Echocardiogram on [**2154-5-13**],
showed a depressed ejection fraction of 15% to 20% and new
wall motion abnormalities as noted above. The patient was
aggressively diuresed with Lasix. His urine output and
oxygenation were followed. The patient was extubated on
[**2154-5-16**]. He was placed on hydralazine and Isordil for
afterload reduction. Lopressor was resumed when his acute
congestive heart failure resolved. The patient was also
restarted on his outpatient Lasix dose of 40 po qd. Weight
and urine output was monitored closely and the patient showed
no signs of congestive heart failure at the time of
discharge.
C. RHYTHM: The patient has a history of VT, bradycardia
with a pacemaker and AICD unplaced. EP saw the patient and
evaluated his device. He should follow up with his
cardiologist regarding maintenance of the device. He was
continued on amiodarone for his hospital stay.
2. PULMONARY: The patient was intubated for acute
respiratory distress secondary from flash pulmonary edema.
Unclear precipitant of congestive heart failure. The patient
was also noted to have a right middle lobe infiltrate on
chest x-ray and he completed a 10 day course of levofloxacin
and Flagyl for presumed aspiration pneumonia in the field.
He was treated with nebulizer treatments prn and his
respiratory status improved and he was extubated on the 9th.
He had no dyspnea following that.
3. INFECTIOUS DISEASE: The patient was admitted with a
borderline elevated white count which persisted throughout
his hospital stay. He was treated for 10 days for an
aspiration pneumonia with levofloxacin and Flagyl. He was
cultured on multiple days and all of his cultures were
negative, including blood, urine and sputum. The patient had
some low grade temperatures and no source other than the
aspiration pneumonia was localized.
4. RENAL: The patient has baseline chronic renal
insufficiency with a creatinine of 1.6 to 2.5. His
creatinine did become elevated during his hospital stay to a
peak of 3.6 on the 8th with his aggressive diuresis. By time
of discharge, his creatinine was more in his baseline range.
On day prior to discharge, his creatinine was 2.5. His ACE
inhibitor has not been restarted at this point and should be
restarted by his primary care physician or cardiologist. The
patient will need his creatinine evaluated closely as well as
his urine output.
5. NEUROLOGIC: The patient was difficult to sedate on the
ventilator. He required an Ativan drip and after extubation,
the patient had a very prolonged period of delta MS. [**Name13 (STitle) **]
gradually awoke and it was thought that this prolonged
duration of sedation was secondary to the large amounts of
Ativan while intubated. By time of discharge, he was at his
baseline mental status.
DISCHARGE DIAGNOSES:
1. Congestive heart failure
2. Coronary artery disease
3. Acute on chronic renal failure
4. Chronic obstructive pulmonary disease
5. AICD and pacer in place.
6. Resolving pneumonia
DISCHARGE MEDICATIONS:
1. Aspirin 325 po qd
2. Lopressor 12.5 po bid
3. Lasix 40 po qd
4. Hydralazine 30 po qid
5. Isordil 10 po tid
6. Amiodarone 200 po qd
7. Lipitor 20 po qd
8. Flagyl 500 po q8 until [**2154-5-26**]
9. Protonix 40 po qd
10. Colace 100 po bid
The patient will be discharged to rehabilitation prior to
discharge home. He will need to follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6680**], as well as his
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2154-5-23**] 07:53
T: [**2154-5-23**] 08:24
JOB#: [**Job Number 11200**]
cc:[**Last Name (un) 11201**]
|
[
"425.4",
"458.2",
"507.0",
"428.0",
"V45.02",
"496",
"584.9",
"424.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9204, 9392
|
9415, 10287
|
3827, 9183
|
2053, 2187
|
2379, 3450
|
107, 128
|
157, 1225
|
3467, 3809
|
1247, 2030
|
2204, 2364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,561
| 178,941
|
10014+10015
|
Discharge summary
|
report+report
|
Admission Date: [**2184-2-7**] Discharge Date: [**2184-2-13**]
Date of Birth: [**2135-4-10**] Sex: M
Service: MEDICINE
Allergies:
Remicade / Lipitor
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
dyspnea, fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 year old man here with complaint of decreased po intake and
inability to get out of bed for 5 days. Pt was in his usual
state of health until 5 days earlier when he [**Last Name (un) 4996**] to have
generalized fatigue. The next day he began to experience a
decrease in appetite, nausea, decreased PO intake, subjective
fevers, chills and diarrhea: Pt normally has [**5-9**] BMs per day
from Crohns disease, however on this day his stools became more
watery and frequent. Pt frequently has blood streaked stools,
but has not noticed an increase in bloody stools, and denies
black tarry stools. Meanwhile his generalized fatigue was
worsening to the point that it was difficult for him to make it
out of bed and into the bathroom. By the day of admission pt had
continued low PO intake, and has notices decreased urine output.
The diarrhea had begun to resolve, and on the day of admission
pt had not had any bowel movements.
Pt reports that his wife was recently sick with the flu, however
her symptoms consisted mostly of nausea and vomitting.
In ED: Tmax 101.7, SBP in the 60s. MM dry, guiac trace positive.
Hct was 28.1 so a T/C obtained. CXR with question of LML, LLL
PNA, so a ct chest/abd obtained and showed LLL PNA and
nonspecific stranding around the kidneys. UA with trace Leuk,
Neg Nitrite, (WBC, RBC, and Bact Pending). Sepsis protocol
initiated. Pt given vanco, levo, flagyl. R SCL placed and 4 L
NS given, with pressures increasing to the 80s, so levophed
given for persistent hypotension and systolic pressures rose to
100s. Cortisol level ordered, and still pending. Utox
+opiates, but pt takes Vicodin.
Past Medical History:
- Crohn's disease
- obesity
- HTN
- inflammatory arthritis
- s/p cholecystectomy
PSYCHIATRIC HISTORY: Several prior inpatient hospitalizations
for depression at [**Hospital1 18**] and Bay Ridge, he says he has been at [**Hospital1 **]
3-4 times. Said he experienced visual and auditory
hallucinations ("not of this world") in [**2170**] for which he
received hospitalization here, but he never experienced them
again. His current psychiatrist is Dr. [**Last Name (STitle) **] whom he sees once
every 2 months, prior psychiatrist was Dr. [**Last Name (STitle) 1452**]. Has had 2
prior overdoses (he denies trying to kill self,) once in [**5-6**]
with valium, and once in [**9-6**] with klonopin. He denies other
suicide attempts, he denies any h/o homicidal or violent
behavior.
Social History:
Lives with family. No illicit drug use. Smoker.
Family History:
Non contributory.
Physical Exam:
VS: Temp:98.2 BP: 129/73 HR:96 RR:20 O2sat 98% 4L NC
GEN: obese gentleman, comfortable, NAD, slightly slurred speech
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: End exp wheeze throughout, rhonchorous BS at L Base
CV: Distant, RR, S1 and S2 wnl, no m/r/g
ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3 nonfocal
RECTAL: guaiac positive (per ED)
Pertinent Results:
[**2184-2-12**] 05:02AM BLOOD WBC-5.7 RBC-2.75* Hgb-9.1* Hct-28.4*
MCV-103* MCH-33.2* MCHC-32.2 RDW-13.3 Plt Ct-467*
[**2184-2-7**] 02:20PM BLOOD WBC-19.6*# RBC-3.18* Hgb-11.1*#
Hct-32.0*# MCV-101* MCH-35.0* MCHC-34.8 RDW-13.4 Plt Ct-370#
[**2184-2-10**] 05:48AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Target-OCCASIONAL
[**2184-2-13**] 06:01AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-137
K-4.1 Cl-105 HCO3-26 AnGap-10
[**2184-2-7**] 02:20PM BLOOD Glucose-143* UreaN-87* Creat-6.3*#
Na-120* K-4.0 Cl-86* HCO3-19* AnGap-19
[**2184-2-13**] 06:01AM BLOOD ALT-26 AST-23 AlkPhos-82 Amylase-381*
TotBili-0.4
[**2184-2-10**] 05:48AM BLOOD ALT-52* AST-87* LD(LDH)-204 AlkPhos-135*
Amylase-342* TotBili-0.6
[**2184-2-7**] 02:20PM BLOOD ALT-30 AST-69* CK(CPK)-218* AlkPhos-105
Amylase-50
[**2184-2-13**] 06:01AM BLOOD Lipase-577*
[**2184-2-12**] 05:02AM BLOOD Lipase-657*
[**2184-2-11**] 05:34AM BLOOD Lipase-640*
[**2184-2-10**] 05:48AM BLOOD Lipase-598*
[**2184-2-7**] 02:20PM BLOOD Lipase-45
[**2184-2-13**] 06:01AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8
[**2184-2-7**] 02:20PM BLOOD TotProt-6.6 Albumin-2.8* Globuln-3.8
Calcium-8.3* Phos-4.7* Mg-2.0
[**2184-2-8**] 05:34AM BLOOD calTIBC-131* VitB12-1503* Folate-12.6
Ferritn-GREATER TH TRF-101*
[**2184-2-7**] 02:20PM BLOOD Cortsol-54.8*
[**2184-2-8**] 05:34AM BLOOD Vanco-7.5*
[**2184-2-7**] 05:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2184-2-7**] 11:50PM BLOOD Type-MIX Temp-37.2 Rates-/28 O2 Flow-4
pO2-42* pCO2-40 pH-7.31* calTCO2-21 Base XS--5 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**]
[**2184-2-7**] 05:00PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2184-2-7**] 05:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-0.2 pH-6.5 Leuks-TR
[**2184-2-7**] 05:00PM URINE RBC-0-2 WBC-[**4-7**] Bacteri-FEW Yeast-NONE
Epi-0-2 TransE-0-2
[**2184-2-7**] 07:15PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2184-2-8**] 09:52AM URINE Streptococcus pneumoniae Antigen
Detection-Test
Blood culture - negative
C diff negative x3
Sputum culture - normal flora
US liver: IMPRESSION: Limited evaluation of the pancreas and
distal common bile duct due to overlying bowel gas. Normal
son[**Name (NI) 493**] appearance of the liver.
CT OF THE ABDOMEN: Extensive airspace opacity within the left
lower lobe has improved moderately since the prior exam. There
is no pleural effusion. The heart size is normal. The contrast
bolus is suboptimal, which may relate to the patient's body
habitus. There is evidence of prior ventral hernia repair with a
mesh. The liver, spleen, and adrenal glands are normal. The
gallbladder is surgically absent. Multiple subcentimeter
periportal lymph nodes are again noted. There is mild stranding
of the peripancreatic fat in the region of the celiac axis,
consistent with the patient's clinical picture of pancreatitis.
The pancreas enhances homogeneously. There is no evidence of
complication. No free fluid or abscess formation. The kidneys
enhance and excrete contrast symmetrically with mild stable
perinephric stranding. The intra-abdominal small and large bowel
loops are normal.
CT OF THE PELVIS: Air is seen within the bladder, likely related
to recent Foley catheterization. The sigmoid colon and rectum
are normal. No free fluid or pelvic lymphadenopathy.
No suspicious lytic or sclerotic lesions. Degenerative changes
are noted at L5-S1.
IMPRESSION:
1. Mild uncomplicated pancreatitis.
2. Improving left lower lobe pneumonia.
3. Unchanged subcentimeter periportal lymphadenopathy.
CXR: IMPRESSION:
1. Left-mid and lower lung opacity concerning for pneumonia.
Lateral view may be performed to further evaluate.
CT on admission (Torso)
IMPRESSION:
1. Multilobar left-sided consolidation consistent with
pneumonia. Follow up imaging after treatment and resolution of
symptoms recommended.
2. Several periportal lymph nodes which are not enlarged by CT
criteria, although more numerous than typically are seen.
3. Nonspecific stranding surrounding the kidneys. Please
correlate with urinalysis/culture.
Brief Hospital Course:
The patient was diagnosed with pneumoni and required O2 and
pressors for hypotension. After clinical stabilization in ICU,
he was transferred to floor. After initial broad spectrum
antibitics, he was tapered to levofloxacin. In terms of the
diarrhea, at discharge the patient reported his diarrhea was at
baseline. He was continued on flagyl at home dose and C diff was
negative. ARF resolved completely with fluids and thought to be
from hypovolemia. Similarly, hyponatremia resolved. Guiac
positive stool are likely from Crohns disease. A recent
colonoscopy was done that revealed colitis. He has a follow up
with Dr [**Last Name (STitle) 1940**] next week.
In the hospital, he was noted to have elevated lipase, US and CT
abd negative for gall stone or tumor. GI consulted and did not
recommend further testing, but to follow up with Dr [**Last Name (STitle) 1940**] for
further assessment. Interestingly, he had no abdominal pain,
nausea or vomiting and was eating a regular diet at the time of
pancreatitis.
Sugars were mildly high. Given h/o obesity he may have impaired
glucose tolerance. Also noted to be tachycardic on ambulation,
but asymptomatic. Further PCP follow up is recommended.
Medications on Admission:
CYMBALTA 60 mg--1 capsule(s) by mouth once a day
GABAPENTIN and tizanidine - patient stopped them as they made
him very drowsy.
HUMIRA 40 mg/0.8 mL--sq every other week
RISPERDAL 1MG--One by mouth at bedtime
VICODIN ES 7.5 mg-750 mg--1 tablet(s) by mouth four times a day
as needed for pain
ZESTRIL 40 mg--1 tablet(s) by mouth 1 po qd
HCTZ - patientstopped taking shortly after being prescribed by
PCP as he though thathis admitting symptoms were from HCTZ.
Metronidazole 250 mg QID - but patient takes [**Hospital1 **].
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*0*
3. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Metronidazole
(flagyl) - continue to take as recommended by Dr [**Last Name (STitle) 1940**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Community acquired pneumonia/ respiratory failure
Acute pancreatitis
Delirium - resolved
Rectal bleeding / diarrhea likely from history of crohns disease
Acute renal failure - resolved
Possible impaired glucose tolerance
Tachycardia on ambulation
Discharge Condition:
stable
Discharge Instructions:
Your are being treated for a pneumonia with antibiotic:
levofloxacin for pneumonia. Take medicines as prescribed.
Keep your appointments as scheduled.
Return to the hospital if you have worsening diarrhea, abdominal
pain or any other symptoms of concern to you.
You should see Dr [**Last Name (STitle) 1940**] for further work up of the
pancreatitis and also about the further plan for humira.
your sugars were mildly high in the hospital. discuss with Dr
[**Last Name (STitle) **] about further monitoring to see if you have diabetes.
your heart rate was higher when you walked on the [**Hospital1 **]. Discuss
with Dr [**Last Name (STitle) **] about further heart testing before your surgery.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1144**]. Appointment on [**2184-2-17**] at 1415
hours.
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2184-2-16**] 11:30
Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**]
Date/Time:[**2184-3-2**] 11:20
Provider: [**Name10 (NameIs) **] RM 3 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2184-3-4**]
10:30
(Double entry) Refer to the discharge summary in OMR.
|
[
"038.9",
"584.9",
"518.81",
"458.9",
"577.0",
"995.92",
"278.00",
"486",
"276.52",
"401.9",
"785.0",
"311",
"555.9",
"305.1",
"276.1",
"276.8",
"285.9",
"792.1",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10111, 10169
|
7712, 8911
|
296, 303
|
10460, 10469
|
3487, 7689
|
11216, 11850
|
2860, 2880
|
9482, 10088
|
10190, 10439
|
8937, 9459
|
10493, 11193
|
2895, 3468
|
239, 258
|
331, 1971
|
1993, 2778
|
2794, 2844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,444
| 101,630
|
38255
|
Discharge summary
|
report
|
Admission Date: [**2141-7-23**] Discharge Date: [**2141-8-2**]
Date of Birth: [**2060-10-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
nausea, vomiting, unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 RHM chinese speaking only, with PMH significant for HTN, a.
fib (on Coumadin), presented to ED for evaluation of nausea and
vomiting. History provided by son in law, who speaks English.
Per him and patient, he went out at around 11 am today to have
breakfast and tea with the family. After having the
refreshments , he was returning from subway to home. he felt a
little lightheaded while travelling back but was able to walk
and come back home. After coming home, around 3 pm, as he tried
standing up, he felt sudden onset dizziness. He means
lightheadness by :"dizzy". He could not stand and was going
towards right when tried to stand and felt like a drunk man. He
felt "imbalance". Shortly, he had an episode of vomiting and 3
more after that in next hour. He started having dull bifrontal
diffuse headache with no radiation. It was [**5-29**], non throbbing,
no photophobia but nausea. Due to this , the family called 911
who brought him to [**Hospital1 18**] ED.
Per ED team, his blood pressure was 177 systolic when he
presented. ED team got CT head which revealed 3.2 cm right
cerebellar bleed, hence neurology and
neurosurg were consulted.
ROS
Neuro- No visual symptoms, diplopia, No sensory symptoms, no
weakness, no bladder/ bowel issues.
Gen-
Negative than mentioned
Past Medical History:
HTN
dyslipidemia
a. fib (on Coumadin)
Social History:
No smoking
No alcohol
retired restaurant worker
Family History:
Neg for stroke, DM
Physical Exam:
General: Awake, NAD
HEENT: NC/AT, , MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: rapid, regular
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic: done with help of son in law as chinese interpreter
Mental Status: Awake and alert, cooperative with exam, normal
affect
Oriented to person, place, month
Language: Fluent with good comprehension and repetition.
There is no dysarthria, no paraphasic errors and naming is
intact
Fund of knowledge normal
No apraxia, No neglect
Cranial Nerves:
pupils [**3-21**] equally round and reactive to light
bilaterally.Visual
fields are full to confrontation
Extraocular movements intact. He has nystagmus on right as well
as upgaze. Facial sensation intact to pain and touch . facial
movement are normal and face is symmetric. Hearing intact to
finger rub bilaterally. Tongue midline, no fasciculations.
Sternocleidomastoid and trapezius normal bilaterally.
Motor:
Normal bulk and tone bilaterally.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
No pronator drift
Sensation was intact to light touch, pin prick, temperature
(cold), vibration, and proprioception all over.
Reflexes: B T Br Pa A
Right 2 2 2 1 -
Left 2 2 2 1 -
Toes were upgoing bilaterally.
Coordination -
Has dysmetria on FNF on right side, RAMS clumpsy on right side,
has difficulty with alternate hand tapping on right, knee shin
test clumsy on right side, repetitive foot tapping was clumspy
and incoordiated on the right side.
Gait / Rhomberg - deferred.
Pertinent Results:
[**2141-7-23**] 06:45PM WBC-16.2* RBC-4.67 HGB-13.6* HCT-39.5* MCV-85
MCH-29.1 MCHC-34.3 RDW-13.9
[**2141-7-23**] 06:45PM NEUTS-87.8* LYMPHS-8.6* MONOS-2.8 EOS-0.6
BASOS-0.2
[**2141-7-23**] 06:45PM PLT COUNT-267
[**2141-7-23**] 06:45PM GLUCOSE-190* UREA N-23* CREAT-1.2 SODIUM-142
POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-28 ANION GAP-16
[**2141-7-23**] 06:45PM ALT(SGPT)-11 AST(SGOT)-28 ALK PHOS-75
AMYLASE-55 TOT BILI-0.4
[**2141-7-23**] 08:18PM LACTATE-2.5*
[**2141-7-23**] 06:45PM MAGNESIUM-1.8
[**2141-7-23**] 06:45PM cTropnT-<0.01
[**2141-7-23**] 09:59PM PT-29.5* PTT-27.3 INR(PT)-2.9*
[**2141-7-23**] 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2141-7-23**] 06:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
Imaging:
EKG: sinus rhythm
CXR: Low lung volumes which may accentuate the hila, but small
right hilar opacity cannot be excluded, which may reflect
developing pneumonia.
CT head: 3.2 cm right intraparenchymal cerebellar hemorrhage. no
herniation.
MRI head: Right cerebellar hemorrhage unchanged compared to
recent CTs. Little to no mass effect. Multiple additional foci
of prior parenchymal hemorrhage noted in the basal ganglia,
thalamus, pons, subcortical white matter and left cerebellum.
Overall, this pattern is most compatible with amyloid
angiopathy.
ECHO: There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**1-21**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Brief Hospital Course:
1) Neuro: Patient presented with symptoms of nausea, vomiting,
unsteadiness. CT scan of the head was performed, which showed a
3.2 cm right cerebellar hemorrhage. Neurology and Neurosurgery
were subsequently consulted and the patient was admitted to the
ICU for close monitoring. No neurosurgical intervention was
required. Antiseizure prophylaxis was not indicated given the
region of the hemorrhage. The patient was managed medically. A
repeat CT scan was performed the morning after admission, which
showed a stable hemorrhage. An MRI was subsequently performed to
evaluate for possible etiologies of the bleed and this showed
multiple additional foci of prior parenchymal hemorrhage in the
basal ganglia, thalamus, pons, subcortical white matter and left
cerebellum. These multiple microhemorrhages noted is most
consistent with a diagnosis of amyloid angiopathy. The
hemorrhage secondary to the amyloid angiopathy was then likely
exacerbated by the patient being coagulopathic secondary to the
Coumadin the patient was on for a. fib (initial INR was 2.9).
The INR was corrected with FFP and Vitamin K. INR should be less
than 1.6 to avoid extension of hemorrhage. The patient continued
to note vertiginous symptoms and was started on Meclizine for
symptomatic relief. The patient was started on baby aspirin (to
avoid further bleeding risks) for anti-platelet activity. A
lipid panel was performed as part of the stroke work-up and this
noted dyslipidemia, so the patient was started on Simvastatin.
Patient's condition gradually improved and he was stable for
transfer to floor. While on floor, patient eventually passed
speech and swallow and was started on regular diet. Patient was
seen by PT/OT who determined that patient would benefit from
rehab placement.
2. Cardiology: Patient initially hypertensive, with goal <160
given hemorrhage. Patient received prn doses IV Hydralazine to
help control blood pressure. For continued elevated BP, patient
was on Metoprolol 50 mg [**Hospital1 **] and Lisinopril 5 mg daily. The
patient continued to require IV doses Hydralazine despite the
standing anti-HTN meds; however, one night after receiving a
dose of IV Hydrlazine for a BP of 170s systolic, the patient
developed an episode of epigastric pain and chest pain without
radiation that was associated with lightheadedness. Patient
became hypotensive at this time with SBP into 80s. An EKG was
performed which showed ST changes concerning for ischemia. A
cardiology consult was obtained and the patient was transfered
back to the ICU for closer monitoring. The ST depression on EKG
were transient and have since resolved. Cariology noted this was
most likely demand-perfusion ischemia. An outpatient stress test
is reccomended to further work-up this event. In a separate
event, patient developed a. fib episode with RVR; heart rate
into 160s. The patient received IV Metoprolol and PO Metroprolol
was increased to 50 mg tid. Patient has remained rate controlled
on this higher dose. Will avoid anticoagulation with Coumadin
for the a. fib at this time given the hemorrhage.
3. Renal: After the hypotensive episode, patient had Creatinine
level rise to 1.4 from 1.2. Determined to be pre-renal and was
likely secondary to hypotension. The [**Last Name (un) **] imrpoved with IVF; it
is currently 1.1. Another possibility for the elevated
creatinine is the addition of Lisinopril for blood pressure
control. The Lisinopril has been stopped. Will need to monitor
BUN and creatinine as an outpatient.
4. Heme: Hematocrit trended down after hypotensive episode with
concurrent drop in Hemoglobin from 13.5 to 11.5. Iron panel was
ordered, there was no evidence of acute blood loss or iron
deficiency anemia.
5. HTN: Patient initially required IV Hydralazine prn for BP
control. Metoprolol now at 50 tid for rate as well as blood
pressure control. Patient initially started on lisinopril for BP
control but given elevated Creatinine, this was swtiched to
Amlodipine 5 mg daily, with possible need to increase to 10 mg
daily in future if BP remains elevated.
Medications on Admission:
Terazosin 10 mg po qhs
Metoprolol (dose unknown)
Discharge Medications:
1. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for vertigo.
2. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain fever. Tablet(s)
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for c.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
R cerebellar hemorrhage secondary to amyloid angiopathy
atrial fibrillation
Acute kidney injury
Demand Ischemia
HTN
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital with sudden onset nausea, vomiting, and
unsteadiness. A CT scan of your brain showed that there was a
bleed in a part of your brain called the cerebellum, resulting
in the above symptoms. This bleed was due to something called
amyloid angiopathy. The bleed was likely made worse because of
Coumadin, the medication you were on for your heart arrythmia,
atrial fibrillation. Because of the bleeding, your Coumadin was
stopped. You were started on a baby ASA for the stroke. You were
also started on a medication called Simvastatin for a high
cholesterol.
While you were in the hospital, you had an episode of low blood
pressure, which caused some EKG changes that have since returned
to normal. The cardiologists would like you to get a stress test
as an outpatient to be followed by your PCP. [**Name10 (NameIs) **] also had an
episode of a fast heart rate, so your Metoprolol was increased
to 50 mg three times a day.
Also, on Friday [**2141-8-4**], would like you to have your kindey
function checked with labwork (BUN, Creatinine) as the time you
were hypotensive seemed to affect your kidneys, though function
has improved with the IV fluids you received.
Followup Instructions:
Please follow with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2141-9-1**] 1:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-8-31**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2141-8-31**] 2:00 ([**Hospital **] Medical Building [**Hospital Unit Name 12193**])
Completed by:[**2141-8-2**]
|
[
"790.92",
"458.29",
"600.00",
"414.8",
"277.39",
"401.9",
"431",
"427.31",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10671, 10741
|
5748, 9812
|
355, 362
|
10916, 10916
|
3754, 4743
|
12309, 12939
|
1819, 1839
|
9911, 10648
|
10762, 10895
|
9838, 9888
|
11100, 12286
|
1854, 2310
|
285, 317
|
390, 1676
|
2601, 3735
|
4752, 5725
|
10931, 11076
|
1698, 1737
|
1753, 1803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,873
| 164,147
|
2307
|
Discharge summary
|
report
|
Admission Date: [**2175-3-24**] Discharge Date: [**2175-3-30**]
Date of Birth: [**2108-5-17**] Sex: F
Service: MEDICINE
Allergies:
Dyazide / Prozac / Nsaids / Inderal / Cefazolin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever at HD
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
Femoral line placement and removal
History of Present Illness:
66 yo woman with h/o ESRD on HD, s/p failued renal transplant on
immunosuppression, DM, diastolic CHF, CAD, presents with fever
at HD. Per discussion with patient and daughter, she had had
some stomach upset earlier this morning and cold symptoms prior
to HD. No fever, chills, LH, dizziness, chest pain, SOB,
abdominal pain, diarrhea, vomiting, constipation, urinary
symptoms. At HD, she had a fever to 102.8, malaise, respiratory
distress. Also had an episode of emesis at HD. Unclear whether
she finished her HD treatment today. Blood cultures were drawn
at HD, she was given 1g vanco, tylenol, and transferred to the
ED.
In the ED, initial vitals were T 102.8, BP 142/64, HR 87, RR 16,
SaO2 95% on 2L. While in the ED, she spiked to a Tmax of 104.
Remained HD stable. She was given 2L NS, tylenol for fever,
zosyn for broad antibiotic coverage. Given that she is on
chronic steroids, the ED gave her 100mg IV hydrocortisone. There
was also concern for PE, given her history of PE as well as her
tachypnea and hypoxia. Pt also developed severe R flank pain and
was given morphine 2mg IV x 2. She was started on a heparin drip
with the plan to get a VQ scan on the floor. Admitted to the
MICU for closer monitoring.
On arrival to the MICU, the patient complains of feeling very
tired and having severe [**6-2**] pain at her R back/flank. She has
never had pain like this before. She also complains of
lightheadedness, SOB, nausea.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough. 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:
-ESRD - HD MWF
-s/p cadaveric renal transplant in [**2168**]
-DM II with retinopathy, neuropathy
-h/o PE (dx [**1-30**])
-SVC syndrome
-Hyperlipidemia
-HTN
-s/p mult CVA's (recently [**2173-8-23**])
-CHF [**12-26**] diastolic function
-CAD
-Pulmonary artery hypertension
-hyperparathyroidism
-L2 compression fracture
-depression
-anemia
Past Surgical History:
1. L AV graft [**2171**] Dr. [**Last Name (STitle) 816**] Multiple thrombectomies done by Dr.
[**Doctor Last Name 816**] Dr. [**First Name (STitle) **] and Dr.[**Last Name (STitle) **] and Dr. [**First Name (STitle) 2491**] (IR).
2. cadaveric renal transplant
3. s/p cataract extraction
Social History:
Lives with daughter. Retired nurses aid. No tobacco or EtOH use.
Walks with cane for balance. Born in [**Country **]. HD at [**Location (un) **]
[**Location (un) **] M/W/F.
Family History:
Father w/ DM and kidney disease and mother w/ HTN.
Physical Exam:
Vitals: T 97.3 BP 160/57 P 81 RR 21 O2: 98% RA
General: Ax+Ox2 (name, [**Hospital1 18**]), fatigued, writhing in discomfort
from her back pain, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest: L SC HD line without surrounding erythema or fluctuance,
lungs clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur loudest at RUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2175-3-24**] 04:30PM GLUCOSE-110* UREA N-12 CREAT-3.7*# SODIUM-139
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2175-3-24**] 04:30PM ALT(SGPT)-13 AST(SGOT)-32 CK(CPK)-130 ALK
PHOS-92 TOT BILI-0.3
[**2175-3-24**] 04:30PM LIPASE-18
[**2175-3-24**] 04:30PM CK-MB-3 cTropnT-0.08*
[**2175-3-24**] 04:30PM TOT PROT-7.5 CALCIUM-9.2 PHOSPHATE-2.0*#
MAGNESIUM-1.5*
[**2175-3-24**] 04:30PM WBC-14.2*# RBC-4.30# HGB-12.6 HCT-38.9 MCV-91
MCH-29.3 MCHC-32.3 RDW-15.5
[**2175-3-24**] 04:30PM NEUTS-81* BANDS-2 LYMPHS-11* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2175-3-24**] 04:30PM PLT SMR-NORMAL PLT COUNT-271 LPLT-2+
[**2175-3-24**] 04:30PM PT-16.6* PTT-33.9 INR(PT)-1.5*
[**2175-3-24**] 10:36PM URINE RBC-[**5-3**]* WBC-[**1-26**] BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2175-3-24**] 10:36PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2175-3-24**] 07:11PM LACTATE-2.6* K+-4.2
EKG: NSR at 84, nl axis, incomplete RBBB, no ST or TW changes,
no significant change from prior
MICROBIOLOGY:
[**3-24**] BCx x 4 Coag-negative Staph
[**3-24**] UCx - no growth
[**3-24**] DFA negative
[**3-25**] UCx - no growth
[**3-26**] BCx x 2 - no growth
[**3-27**] BCx x 2 - NGTD
[**3-27**] BCx x 1 - (after multiple days) grew out Coag-netiave Staph
(thought to be a contaminant)
[**3-28**] BCx x 2 - NGTD
[**3-29**] BCx - NGTD
STUDIES:
CXR ([**3-24**]): IMPRESSION: No acute intra-thoracic process.
CT abd/pelvis ([**3-25**]): IMPRESSION:
1. Limited non-contrast evaluation. No definite evidence of
large fluid collection.
2. Distended gallbladder with gallstones, unchanged.
Renal US ([**3-25**]):
[**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] images were obtained
that demonstrate the native kidneys to be echogenic and small
(right 6.2 cm, left 8.5 cm). An anechoic avascular approximately
1 cm structure is
identified in the left kidney laterally, likely a cyst. The
transplant kidney measures 10 cm and is located in the right
pelvis. There is no hydronephrosis or renal mass. No perinephric
fluid is identified. Hyperechogenic foci likely represent sinus
fat.
IMPRESSION: No son[**Name (NI) 493**] evidence for perinephric abscess.
TTE ([**3-27**]):
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). 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
are moderately thickened. No masses or vegetations are seen on
the aortic valve. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**11-25**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Tricuspid regurgitation is present but cannot
be quantified. The pulmonary artery systolic pressure could not
be determined. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
US of the left upper extremity AV fistula ([**3-27**]):
1. Thrombosed arteriovenous graft on the left upper arm and
forearm.
2. Patent left brachial and radial arteries.
3. No fluid collections on the left arm.
Brief Hospital Course:
66 yo female with pmh of ESRD s/p failed transplant on
immunosuppressants and HD, CAD, dCHF, DMII, htn, recent PE
admitted to the MICU after developing a fever and respiratory
distress at HD found to have a Coag-negative Staph bacteremia.
# Fevers/Coag-negative Staph bacteremia: The day after
admission her blood cultures from the ED began growing out gram
positive cocci which speciated to coag-negative staph. A line
infection was thought to be the cause of her fevers. She was
started on vancomycin at HD on Friday and Zosyn was added on
admission for broader coverage (before the cultures had
returned). She was continued on vancomycin, dosed by levels and
the zosyn was stopped. Her leukocytosis trended down and her
fevers resolved. Her last temperature spike was the morning of
[**3-26**]. Blood cultures were sent for surveillance and have
remained negative, except for one culture from [**3-27**] which grew
out coag-negative staph after multiple days which was thought to
be a contaminant as she was clinically improving and all other
cultures remained negative. Transplant surgery was consulted as
they placed her tunneled HD line and she also has a non-working
left upper extremity AV graft. After discussion with renal and
transplant surgery, it was agreed that we would treat through
the line and only pull it if she continued to spike, or if
surveillance cultures returned positive. She [**Month/Day (4) 1834**] a TTE
which showed no evidence of endocarditis. An ultrasound of her
LUE AV graft showed no fluid collections. She was discharged to
complete a 3 week course of vancomycin given at HD.
# Hx of PE/SVC syndrome: She was found to have a PE and SVC in
[**1-30**] and was discharged on coumadin, however on admission her
INR was subtherapeutic at 1.5. She was started on a heparin gtt
in the ED which was continued until her INR was therapeutic.
She was discharged on 5 mg of coumadin daily.
# Respiratory distress: The patient initially had respiratory
distress in the ED and had a recurrent episode during her fever
spike on the morning of [**3-26**]. A CXR showed no evidence of
infiltrate and she was able to be quickly weaned off the oxygen
she was requiring. She was ruled out for influenza and had been
on a heparin gtt, making recurrent PE unlikely. It was thought
that her respiratory distress was secondary to her fevers as she
improved very quickly after her fever was controlled with
Tylenol. She was breathing comfortably on RA at time of
discharge.
# Flank pain: The patient had a CT abd/pelvis for evaluation of
her pain which was unremarkable. Two urine cultures returned no
growth. A renal US showed no evidence of a perinephric abscess.
Throughout her hospital course her pain improved and eventually
resolved. She is known to have chronic back pain, so this may
have been musculoskeletal in origin.
# ESRD s/p failed transplant on HD: The patient has [**Month (only) 2286**]
MWF at [**Location (un) **] in [**Location (un) **]. She had [**Location (un) 1834**] her full [**Location (un) 2286**]
session the Friday of admission. Prior to admission she was on
tacrolimus and prednisone for immunosuppression for her failed
renal transplant. Per renal tacrolimus was stopped as she is
many years out from her failed transplant and had bacteremia.
She was continued on her home prednisone of 5 mg po daily. She
[**Location (un) 1834**] HD on Monday. She was continued on nephrocaps,
cinacalcet, and epogen.
# DMII: She was continued on her home regimen of NPH with qid
fingersticks and SSI coverage.
# Chronic diastolic heart failure/Hypertension: She appeared
euvolemic during this hospitalization. Initially her metoprolol
and lisinopril were held due to her bacteremia and widely
varying SBPs. As she was stable her metoprolol, then lisinopril
were restarted prior to discharge.
# Anemia of chronic renal disease: Likely due to anemia of
chronic renal disease. Her Hct decreased from 38.9 to 35.1
after getting IVF, likely dilutional. Her baseline is in the
30's. She had no clinical evidence of bleeding while
hospitalized. Her Hct remanied within the 30's. Epo was given
per renal at HD.
# Hx of CAD: She remained asymptomatic during her
hospitalization. She had a slightly elevated trop on admission
at 0.8, however she is on HD and her trops usually are within
this range. She was continued on [**Location (un) **] and atorvastatin.
Metoprolol was originally held due to her bacteremia, but
restarted as above.
# ACCESS: The patient had a femoral central venous line placed
due to lack of ability to obtain peripheral lines while she
needed IV antibiotics and the heparin drip. Her tunneled HD
line was present and is discussed above.
# CODE: Full code
[**Location (un) **] on Admission:
[**Location (un) **] (per last D/C summary):
Aspirin 81mg PO daily
Atorvastatin 40mg Po qHS
Docusate 100mg PO BID
Lisinopril 10mg PO daily
Metoprolol 25mg PO BID
B Complex-Vitamin C-Folic Acid 1 mg 1 tab PO daily
Gabapentin 100mg PO q24
Paroxetine 10mg PO daily
Prednisone 5mg PO daily
Tacrolimus 1mg PO qAM, 0.5mg PO qPM
Protonix 40mg PO daily
Cinacalcet 30mg PO daily
Senna 8.6mg PO BID
NPH 25 units qAM, 5 units qPM
Lispro sliding scale
Epogen
Coumadin
Trazodone 25mg PO qHS
Discharge [**Location (un) **]:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous every morning.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous every evening.
13. Insulin Lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous three times a day: sliding scale.
14. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO once a day.
15. Vancomycin 1000 mg IV HD PROTOCOL
16. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day: Adjust
dose per your coumadin clinic recommendations. Have INR checked
at your next [**Location (un) 2286**].
[**Location (un) **]:*75 Tablet(s)* Refills:*0*
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Epogen Injection
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary -
Coag-negative Staph bacteremia, presumed secondary to HD
catheter
End-stage renal disease on hemodialysis
Failed renal transplant
History of recent pulmonary embolus
History of superior vena cava syndrome
Secondary -
Diabetes Type II
Hypertension
Chronic diastolic heart failure
History of coronary artery disease
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital due to fevers at [**Location (un) 2286**].
You were found to have an infection in your blood and were
treated with IV antibiotics. You will need to complete a total
of 3 weeks of antibiotics. This will be given to you while at
[**Location (un) 2286**].
Medication changes:
1. Vancomycin 1000 mg IV every [**Location (un) 2286**] (dosed by levels) until
[**4-17**] (three weeks total).
2. Your tacrolimus was stopped. You should not take this
medication any more.
3. Your coumadin was increased to 5 mg daily. You will need to
have your INR checked at your next [**Month/Year (2) 2286**] appointment.
Otherwise continue your outpatient [**Month/Year (2) 4982**] as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, blood in your stool, dark black
stool, chest pain, or shortness of breath.
Followup Instructions:
You will need to follow up with your primary doctor. Please
call [**Telephone/Fax (1) 12071**] to scheduled an appointment within the next
week.
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2175-3-31**]
7:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2175-4-1**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,358
| 176,083
|
10625
|
Discharge summary
|
report
|
Admission Date: [**2168-3-17**] Discharge Date: [**2168-4-2**]
Date of Birth: [**2114-1-25**] Sex: F
Service: EMERGENCY
Allergies:
doxycycline / Tetracycline
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Elevated creatinine
Major Surgical or Invasive Procedure:
Central line placement
Hemodialysis line placement
History of Present Illness:
54F with history of recently diagnosed EtOH abuse and alcohol
induced cirrhosis during long admission at [**Hospital1 18**] ([**2167-12-29**] -
[**2168-2-18**]) during which she received 30 days of steroids, now
presenting from Spualding with increased confusion, report of
elevated creatinine, and concern for decompensation. Of note,
has been receiving large volume [**Doctor First Name **] since discharge to control
her ascites, last was [**2168-3-14**] with removal of 7.5L.
She was sent in from [**Hospital1 **] because report of increased
ammonia levels, increased confusion, and Cr elevation to 2.2. Pt
herself says that yesterday evening she was confused and very
anxious. She describes a panic attack type episode last night,
similar to an episode she had during her recent [**Hospital1 **] admission.
She says her confusion has resolved and she feels at baseline
mental status now and no longer anxious. No fevers, chills, N/V,
diarrhea, menala, BEBPR, anorexia, or abdominal pain. She has
felt slightly off the last couple days, "blah" is the word she
identifies with to describe how she feels. She also endorses
constipation with no bowel movement since yesterday, still
passing gas. Having intermittent crampy gas pains that come
every few minutes. No acute rash, no recent trauma, no
headaches, no cough, no SOB. She says the main reason they sent
her in from [**Hospital1 **] was concern that her kidneys were
worsening.
During recent hospitalization, she was diagnosed with alcoholic
hepatitis with cirrhosis. Her viral hepatitis panel and
autoimmune panel were neg. Ultimately the patient could not
maintain adequate nutrition on her own, and an dobhoff tube was
placed and tube feeds were started. Her MELD labs continued to
trend up despite prednisone and ursodiol was started. Eventually
her labs stabilized and her prednisone and ursodiol were stopped
after 30 days steroids. She was initally treated with diuretics
but this was complicated by [**Last Name (un) **] so these were stopped. She also
had hepatic ecephalopathy despite lactulose so rifaxamin was
started which succesfully controlled her encephalopathy. She
undewent endoscopy which showed grade I varices at the
gastroesophageal junction. She did not undergo colonoscopy. She
was discharged to [**Hospital3 **] with plan for scheduled large
volume paracentesis to control her ascites.
In the ED, initial VS: 98.4 74 86/37 16 100%. Pt was given 1L NS
due to elevated lactate, 2 PIV placed. Diagnostic para done
showing 385 WBC (PMNs pending). All labs stable from recent
discharge and Cr here was normal at 0.4 (not elevated at 2.2 as
reported from [**Hospital1 **]). Given lactulose in ED and admitted to
CC7 for encephalopathy work-up. VS at transfer were 97.9 74 14
107/46 18 100%RA.
Currently, pt with no complaints except for her gas pains. Also
feels thirsty.
Past Medical History:
Alcoholic Hepatitis complicated by cirrhosis
Bleeding peptic ulcer several years ago
S/p L hip replacement [**2164**]
Social History:
Drank 1 L of wine/daily until [**12-17**]. Denies any tobacco, drug
use, sick contacts. Lives with boyfriend, but ex-husband is HCP.
[**Name (NI) 4084**] any IVDU, no travel. Has had blood transfusion before,
about 5 years ago.
Family History:
No family history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.2F, BP 109/60, HR 80, R 20, O2-sat 100% RA, 66.8kg
GENERAL - Alert, interactive, sickly appearing
HEENT - PERRLA, EOMI, sclerae very icteric, dry MM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, blowing systolic
ejection murmur loudest over arotic band
LUNGS - decreased breath sounds at the left base, otherwise
clear
ABDOMEN - distended, +shifting dullness, nontender, + caput
medusa
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - multiple excoriated lesions over chest obliterating most
of her spiders, grossly jaundiced
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, able to say days of week backwards,
+asterixis
.
PHYSICAL EXAM PRIOR TO MICU TRANSFER:
VS - 96.8 (98.5) 71/28 (76-88/30-64)
59 (50s-60s) 18 100%RA (94-100%RA)
I/O: 1160/150+ BMx3
GENERAL - Alert and interactive, jaundiced, slow speaking
HEENT - sclerae icteric, OP clear
HEART - RRR with holosystolic murmur over LLSB and apical area
LUNGS - Rales [**1-4**]-way up lung fields bilaterally.
ABDOMEN - soft, less distension, no shifting dullness,
tenderness to deep palpation in the RLQ, caput medusa, dressing
of paracentesis site clean/dry/intac
EXTREMITIES - WWP, no peripheral edema, 2+ peripheral pulses
SKIN - erythema and multiple excoriated lesions over upper
chest/shoulders, few excoriations over abdomen with bleeding on
LUE, skin jaundiced throughout
NEURO: AAOx3, no asterixis
Pertinent Results:
ADMISSION LABS:
[**2168-3-17**] 06:20PM BLOOD WBC-12.1* RBC-2.60* Hgb-9.3* Hct-24.8*
MCV-95# MCH-35.8* MCHC-37.5* RDW-16.9* Plt Ct-114*
[**2168-3-17**] 06:20PM BLOOD Neuts-86.1* Lymphs-8.9* Monos-3.0 Eos-1.6
Baso-0.4
[**2168-3-18**] 05:45AM BLOOD PT-26.7* PTT-48.7* INR(PT)-2.6*
[**2168-3-17**] 06:20PM BLOOD Glucose-170* UreaN-36* Creat-0.4 Na-127*
K-4.1 Cl-91* HCO3-21* AnGap-19
[**2168-3-17**] 06:20PM BLOOD ALT-57* AST-135* AlkPhos-122*
TotBili-36.9*
[**2168-3-17**] 06:20PM BLOOD Albumin-3.5 Calcium-9.8 Phos-4.4 Mg-2.6
OTHER PERTINENT LABS:
[**2168-3-28**] 06:35AM BLOOD WBC-7.7 RBC-2.23* Hgb-7.5* Hct-22.8*
MCV-102* MCH-33.6* MCHC-32.8 RDW-16.2* Plt Ct-62*
[**2168-3-29**] 06:30PM BLOOD PT-34.3* PTT-72.9* INR(PT)-3.3*
[**2168-3-29**] 06:35AM BLOOD Glucose-83 UreaN-92* Creat-8.4*# Na-123*
K-4.0 Cl-88* HCO3-12* AnGap-27*
[**2168-3-29**] 06:30PM BLOOD ALT-22 AST-59* AlkPhos-58 Amylase-152*
TotBili-38.5* DirBili-25.2* IndBili-13.3
[**2168-3-30**] 02:36AM BLOOD TotProt-6.3* Albumin-5.4* Globuln-0.9*
Calcium-9.6 Phos-8.4* Mg-3.0*
[**2168-3-30**] 02:36AM BLOOD Cortsol-14.0
[**2168-3-17**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-3-29**] 09:48AM BLOOD Type-[**Last Name (un) **] pO2-157* pCO2-33* pH-7.22*
calTCO2-14* Base XS--13
STUDIES:
[**2168-3-17**] ECG: Sinus rhythm. Poor R wave progression. Left axis
deviation Left anterior fascicular block.
[**2168-3-17**] CXR: Overall improvement of the bilateral opacities
identified on
prior. However, there has been progression of disease at the
left lung base suggesting possible new pneumonia and small
effusion. Two-view chest x-ray may help further characterize.
[**2168-3-18**] CXR: As compared to the previous radiograph, the patient
shows no
interval development of pneumonia. A small left-sided pleural
effusion,
better seen on the lateral than on the frontal view, is
unchanged. Equally
unchanged are signs of mild fluid overload. Borderline size of
the cardiac
silhouette. No lung nodules or masses.
[**2168-3-17**] RUQ Ultrasound: 1. In comparison to [**2168-2-6**] exam, there
is no significant change in hepatic vasculature which is widely
patent. Hepatopetal flow in the left portal vein. The right
portal and main portal veins demonstrate hepatofugal flow. 2.
Heterogeneous echotexture and lobulated contour of the liver,
compatible with underlying cirrhosis. 3. Gallbladder wall edema,
likely related to underlying liver disease.
4. Moderate ascites. 5. Splenomegaly.
TTE [**2168-3-18**]: Mild-moderate mitral regurgitation with mildly
thickened leaflets, but without discrete vegetation. Mild
pulmonary artery systolic hypertension. Compared with the prior
study (images reviewed) of [**2168-1-1**], the severity of mtiral
regurgitation and the estimated PA systolic pressure are both
higher. If the clinical suspicion for endocarditis is moderate
or high, a TEE is suggested to better define the mitral valve.
TEE [**2168-3-22**]: No vegetations or masses seen. Normal biventricular
function. Moderate mitral regurgitation. Trivial tricuspid
regurgitation with eccentric regurigation jet (may underestimate
degree of regurgitation).
CXR [**2168-3-31**]:
FINDINGS: As compared to the previous radiograph, there is an
increased loss
of transparency of the left and right lung parenchyma, likely
caused by mildly
increasing fluid overload.
The left lower lobe atelectasis that preexisted is unchanged.
Unchanged
aspect of the cardiac silhouette. Unchanged left and right
central venous
access lines.
Brief Hospital Course:
54 year old female with h/o alcoholic cirrhosis and recent
prolonged admission for alcoholic hepatitis who presented with
acute renal failure and confusion (please see below for detailed
floor course).
MICU course: Patient was admitted with hypotension, worsening
renal failure and coagulopathy in setting of worsening liver
failure, worsening encephalopathy and acedemia. She had an HD
line placed [**3-30**]. With CVVH, no singificant improvement was
found in mental status despite some improvement in acidema.
Broa spectrum antibiotcs were started for possible sepsis.
Unfortunately, due to profound coagulopathy, patient continued
to have blood loss from both, her L IJ triple lume as well as HD
line. She required multiple transfusions of RBC, Platelets, FFP
and Cryo. Given no significant improvement in her hypotension,
renal failure, liver failure and encephalopathy and per
discussion with her health care proxy, goals of care were geared
towards comfort. Patient was made CMO on [**2168-3-31**] and died
[**2168-4-2**] of suspected cardiac arrest in setting profound bleeding
and coagulopathy. She appaered comfortable at time of death.
Floor course:
#. Acute renal failure: She had a rise in creatinine prior to
admission from 1.0 to 2.0 at rehab. She was therefore
readmitted, although her creatinine on presentation was similar
to her recent baseline (around 1.3). She had been previously
treated with midodrine/octreotide for hepatorenal syndrome on a
prior admission, and was continued on midodrine on admission
(octreotide had been stopped at discharge several weeks prior).
Her renal function initially stayed stable with albumin and
midodrine, but eventually her creatinine started to increase and
urine output dropped. Diuretics were held on admission given
likely HRS. This was felt to be related to hepatorenal syndrome
and was unresponsive to albumin. Her midodrine was stopped and
she was enrolled in the terlipressin placebo-controlled trial.
Terlipressin vs placebo was started [**3-28**] with no improvement in
her creatinine and she was transferred to the MICU [**3-29**] due to
persistent acidemia, declining mental status, and hypotension.
#. Hypotension: She was admitted with low blood pressures in the
80-90's and her BP remained in this range for first week of
hospitalization. As her renal failure worsened, her midodrine
was held in order to enroll her in the terlipressin trial, and
her blood pressure became 70-80's/40's. She was eventually
transferred to the MICU for persistent hypotension to 70/40
despite albumin administration. She was initiated on pressors
overnight on [**3-30**] and treated for potential sepsis with broad
spectrum antibiotics.
#. Hepatic Encephalopathy: She was admitted with confusion and
slowing of her speech, which improved with lactulose and
rifaximin after admission. Her mental status remained clear for
the first several weeks of her admission, although she was still
had slowed speech and forgetfulness. The trigger for worsening
encephalopathy was not entirely clear as an infectious workup on
admission was negative. She was empirically treated for
endocarditis initially, but this was stopped and her mental
status remained stable until her renal failure worsened. She
did get more confused on [**3-9**], potentially related to uremia in
the setting of her renal failure. She was then transferred to
the MICU.
#. Alcoholic hepatitis and cirrhosis: She was admitted with
persistently elevated bilirubin and cholestasis due to alcoholic
hepatitis. Her poor prognosis was discussed with her multiple
times given her multiple ongoing medical issues. Her MELD on
admission was 32 and increased in the setting of worsening renal
function. Her bilirubin continued to show no signs of
improvement since her initial admission in 12/[**2167**]. She was
continued on lactulose, rifaximin, and cipro prophylaxis for
SBP.
#. Heart murmur: She had a systolic apical heart murmur on
admission that was louder than previously documented. Blood
cultures were drawn and TTE revealed worsening MR without clear
vegetation. She was treated empirically with 48 hours of
vancomycin due to concern for endocarditis. TEE was performed
which was negative for endocarditis and vancomycin was stopped.
#. Anemia: She had persistent anemia during this admission and
guaiac positive stools, although no frank bleeding noted from
her GI tract. She was transfused several units of blood
intermittently for anemia and her hematocrit responded minimally
but remained stable. Given her persistent hypotension and other
ongoing issues, EGD/colonoscopy was not performed.
#. Rash: She had a rash felt to be secondary to hepatic and
renal failure over her chest and extremities. She was seen by
dermatology who recommended triamcinolone and other topical
treatments, as well as treating her underlying disease.
#. Stage III Pressure Ulcer: Noted on her coccyx on admission.
Medications on Admission:
Ciprofloxacin HCl 250 mg PO/NG Q24H Start: In am
Furosemide 40 mg PO/NG [**Hospital1 **]
Spironolactone 100 mg PO/NG DAILY
Lactulose 30 mL PO/NG [**Name (NI) **] (pt says only taking [**Hospital1 **])
Rifaximin 550 mg PO/NG [**Hospital1 **]
Multivitamins 1 TAB PO/NG DAILY
Thiamine 100 mg PO/NG DAILY
FoLIC Acid 1 mg PO/NG DAILY Start: In am
Pantoprazole 40 mg PO Q24H Start: In am
Simethicone 40-80 mg PO/NG [**Hospital1 **]:PRN gas pains
Sodium Bicarbonate 1300 mg PO/NG [**Hospital1 **]
Sarna Lotion 1 Appl TP [**Hospital1 **]:PRN itching skin
Ursodiol 300 mg PO BID
TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
traZODONE 75 mg PO/NG HS:PRN insomnia
Midodrine 10mg [**Hospital1 **]
Albuterol Inh or NEB Q6hrs PRN SOB/wheezing
Cepacol Lozenges TID PRN
Guaifenesin 200mg Q6hrs PRN
Ondansetron 4mg Q8hrs PRN
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver failure
Discharge Condition:
patient died
Discharge Instructions:
patient died.
Followup Instructions:
none
Completed by:[**2168-4-2**]
|
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"54.91",
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icd9pcs
|
[
[
[]
]
] |
14514, 14523
|
8710, 13661
|
307, 359
|
14580, 14594
|
5152, 5152
|
14656, 14690
|
3644, 3680
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14544, 14559
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13687, 14491
|
14618, 14633
|
3720, 5133
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248, 269
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387, 3242
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5168, 5678
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5700, 8687
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3264, 3383
|
3399, 3628
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,822
| 177,917
|
24416
|
Discharge summary
|
report
|
Admission Date: [**2163-4-14**] Discharge Date: [**2163-5-11**]
Date of Birth: [**2118-9-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
44y male transferred from [**Hospital 1474**] Hospital, where he was
admitted [**2163-4-12**] with severe abdominal pain, likely due to
alcoholic pancreatitis. He was transferred to [**Hospital1 18**] at 7pm [**4-14**]
after he became unstable with increasing respiratory distress.
At the time of admission, he reported his abdominal pain was
improved from his initial presentation. However, he was
becoming more tachycardic, and his respiratory rate was
increasing. He was diaphoretic. He was admitted to the medical
ICU, but a surgical consult was called upon his arrival.
Past Medical History:
Alcohol abuse
bronchitis
chronic back pain with transient left arm paresthesias
Social History:
Married. +EtOH. 1 pack per day tobacco. Works at night.
Takes care of his 3 children during the day.
Family History:
Noncontributory
Physical Exam:
T 100.4, HR 154, BP 148/100, RR 37, 96% on face mask
In general, the patient is diaphoretic and agitated
HEENT: PERRLA, EOMI, no JVD
CV: tachycardic, sinus rythym
Resp: wheezing bilaterally
Abdomen: distended, appropriately tender, no guarding or rebound
Ext: no clubbing, cyanosis or edema. DP and PT 1+ bilat.
Neuro: alert and oriented x3.
Pertinent Results:
[**2163-4-14**] 08:08PM WBC-24.8* RBC-4.73 HGB-14.4 HCT-42.6 MCV-90
MCH-30.5 MCHC-33.9 RDW-12.7
[**2163-4-14**] 08:08PM PLT COUNT-181
[**2163-4-14**] 08:08PM PT-14.1* PTT-27.8 INR(PT)-1.3
[**2163-4-14**] 08:08PM GLUCOSE-165* UREA N-32* CREAT-2.3* SODIUM-142
POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-18* ANION GAP-18
[**2163-4-14**] 08:08PM ALT(SGPT)-13 AST(SGOT)-33 LD(LDH)-446* ALK
PHOS-56 AMYLASE-658* TOT BILI-0.8
[**2163-4-14**] 08:08PM LIPASE-1346*
[**2163-4-14**] 08:08PM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-2.2*
MAGNESIUM-2.2 CHOLEST-101
[**2163-4-14**] 08:08PM TRIGLYCER-169* HDL CHOL-18 CHOL/HDL-5.6
LDL(CALC)-49
[**2163-5-11**] 06:50AM BLOOD WBC-12.6* RBC-3.56* Hgb-10.4* Hct-31.6*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.6 Plt Ct-504*
[**2163-5-11**] 06:50AM BLOOD Plt Ct-504*
[**2163-5-11**] 06:50AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-137 K-3.7
Cl-100 HCO3-22 AnGap-19
[**2163-5-11**] 06:50AM BLOOD ALT-74* AST-43* AlkPhos-101 Amylase-44
TotBili-0.4
[**2163-5-11**] 06:50AM BLOOD Lipase-38
[**2163-5-11**] 06:50AM BLOOD Albumin-3.4 Calcium-9.0 Phos-4.2 Mg-1.8
[**4-20**]: CT abdomen/pelvis:
IMPRESSION:
1) Extensive peripancreatic inflammation, with inflammatory
changes in the pararenal spaces bilaterally.
2) Heterogeneous enhancement of the pancreatic body and tail,
which raises the question of possible early necrosis. Close
short-term followup is recommended.
3) Bibasilar atelectasis and effusions.
4) Patchy bilateral parenchymal opacities in the lungs, which
are nonspecific.
5) Occlusion of the splenic vein.
6) No evidence of abscess or fluid collection.
[**2163-4-27**]: CT abdomen/pelvis:
IMPRESSION:
1) Stable appearance of extensive peripancreatic inflammation
and stable extent of nonenhancing regions within the pancreas
(although these regions are better seen on today's exam due to
differences in phase of contrast). The splenic vein is again not
seen. There is no evidence of splenic artery aneurysm.
2) Persistent but decreased bilateral pleural effusions. Slight
interval increase in atelectasis at the left lung base.
Brief Hospital Course:
The patient was admitted to the medical ICU for pancreatitis,
and a surgery consult was obtained. On hospital day one, he
required intubation for respiratory decompensation. He was
followed closely by the medical and surgical teams. He was
aggressively fluid resuscitated. He was started on imipenem and
fluconazole. An insulin drip was necessary for glucose control
His respiratory decompensation was suggestive of an ARDS-like
picture. Due to his pancreatitis and intubated status, he was
started on TPN. On hospital day 2, the patient was transferred
to the hepatobiliary surgery service. On hospital day 3, he was
transferred to the SICU. He had several episodes of temperature
spikes throughout his early hospital course. He was
pan-cultured. The only positive suggestion of infection was
yeast in his sputum. On [**4-21**], an esophageal balloon was placed
as part of an ARDS protocol for ventilation. Lopressor was
added for persistent tachycardia. He was started on trophic
tube feeds. He was maintained on ativan for DT prophylaxis,
given his history of alcohol abuse. On [**4-23**], his tube feeds
were held for gastric distention. He received 2units of blood
for blood loss anemia. Imipenem and fluconazole were
discontinued, as all cultures had been negative. However, he
continued to be febrile, and on [**4-24**] and [**4-25**], blood cultures
were positive for gram positive cocci, which later speciated to
coagulase negative staph. He was started on vancomycin. On
[**4-25**], his tube feeds were restarted. He was started empirically
on flagyl for diarrhea concerning for c diff. On [**4-27**], his tube
feeds were held for increased diarrhea. He was transfused with
one unit of blood for anemia. His antibiotics were changed to
linezolid, and the flagyl was discontinued because cultures were
negative for c diff. An infectious disease consult was
obtained. His lines were all resited. On [**4-30**], the patient was
extubated. He was very agitated, hypertensive and tachycardic,
and required hydralazine, labetolol, clonidine, metoprolol,
haldol, and ativan. On [**5-1**], zosyn was added for continued
temperature spikes, with no clear site of infection. On [**5-3**],
his trophic tube feeds were again restarted. He was very
confused, and so his ativan was tapered slowly. On [**5-5**], he was
stable enough to be transferred to the floor; his linezolid was
discontinued. His tube feeds were at goal. On [**5-6**], he was
evaluated by the speech and swallow nurse, and was cleared for
sips of water only, until his mental status was improved. On
[**5-7**], his haldol was discontinued. His mental status improved
dramatically and his agitation has resolved. On [**5-9**], his diet
was advanced to full liquids. His zosyn was stopped and he was
started on levofloxacin. On [**5-10**], he was started on a regular
diet. He had been followed by physical therapy throughout his
hospital course, and they cleared him to be safe to go home,
with home physical therapy. On [**5-11**], he was discharged to home
in good condition. He was advised to refrain from alcohol.
Medications on Admission:
nicotine patch, Tums, tylenol, motrin
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*7 Patch Weekly(s)* Refills:*2*
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
Disp:*5 mcg* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q 6hr prn
pain as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*10 Patch 24HR(s)* Refills:*2*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Necrotizing pancreatitis
HTN
GERD
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon or return to the emergency room if you
experience fever >101.5, nausea, vomiting, increasing abdominal
pain, chest pain, shortness of breath or any significant change
in your medical condition. Please refrain from alcoholic
bevarages of any kind as this could lead to recurrent
pancreatitis.
Followup Instructions:
Please follow up with Dr.[**Last Name (STitle) **] in 3 weeks. Upon discharge from
the hospital please call Dr[**Doctor Last Name **] office in order to
schedule a follow up appointment. ([**Telephone/Fax (1) 2363**]
|
[
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icd9cm
|
[
[
[]
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] |
[
"96.04",
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icd9pcs
|
[
[
[]
]
] |
7773, 7844
|
3673, 6801
|
327, 339
|
7922, 7930
|
1583, 3650
|
8295, 8515
|
1188, 1205
|
6889, 7750
|
7865, 7901
|
6827, 6866
|
7954, 8272
|
1220, 1564
|
273, 289
|
367, 947
|
969, 1051
|
1067, 1172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,496
| 137,506
|
30395
|
Discharge summary
|
report
|
Admission Date: [**2134-5-10**] Discharge Date: [**2134-5-19**]
Date of Birth: [**2083-4-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status, rectal bleeding
Major Surgical or Invasive Procedure:
Endotracheal intubation, paracentesis, central venous lines
History of Present Illness:
51 yo w h/p cirrhosis [**1-8**] ETOH, ascites, hemorrhoids, and anemia
p/w rectal bleeding for 4-5 days and MS changes per family to
[**Hospital1 **] MC on [**2134-5-1**]. Pt received 4U? of blood. She underwent
paracentesis without evidence of SBP on [**2134-5-2**]. A CT abdomen
was negative for hepatoma. Pt also presented with ARF on
admission with creatinine 2.2, improved with fluids initially.
However, subsequently her renal function was worsening to a
creatinine of 3.1. A component of HRS was suspected and
midodrine and octreotide was started. Albumin was given as well.
She was treated with Levofloxacin and initially also with FLagyl
presumptively for SBP, then FLagyl was discontinued and
Levofloxacin was continued for SBP prophylaxis and ? treatment
of UTI.
Currently the pt c/o intermittent pain in her lower abdomen that
has started with placement of foley catheter. The pain has been
stable for the last few days and she has received po and iv
narcotics for it. It is a crampy pain that last several seconds
and then resolves by itself. The pt also reports pain in her R
arm however she has trouble to describe it any furhter. Over the
last days she had several BM a day. She denies N, V. She reports
being confused and her husband confirms this. However the
husband reports that the MS improved initially and has been
stable for the last few days. She denies any furhterHer weakness
has improved initially at rehab but has worsened over her
hospitalization predominantly on her R.
In terms of her ETOH abuse the pt reports being sober for the
last 12months, per records from OSH 6months.
.
ROS: negative for CP, SOB, diarrhea, constipation, f/c/ns,
weight loss.
Past Medical History:
Recent admission at [**Hospital1 **] for myopathy thought to be due to
viral infection in [**2134-3-7**]
Recent admission for hypotension thought to be due to blood loss
anemia from rectal bleeding in [**2134-4-6**]
ESLD, [**1-8**] ETOH with cirrhosis > previous workup for transplant
at [**Hospital1 2025**], not listed due to ongoing ETOH abuse, also the pt wanted
less aggressive measures
Portal hypertension with ascites, no evidence of SBP
Per intern admission note negative endoscopy and colonscopy
during recent admission
Rectal bleeding from medium size hemorrhoids, s/p banding [**2134-4-13**]
Pt and husband denies heart, lung disease
Social History:
ETOH: heavy in the past, several glasses of red wine a day, no
hard drinks, last 12months ago
Tobacco: none
Living situation: married, from [**Country 532**], immigrated 20yrs ago
Family History:
No liver disease
Physical Exam:
VS T 98.2 BP 102/60 HR 94 RR 18 O2Sat 96RA FS 123
Gen: NAD, AAOx1
HEENT: NC/AT, PERRLA, mmm, sclerae icteric
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breathsounds in the bases, otherwise CTA b/l, no
wheezing or rhonchi
ABD: + bowel sounds, soft, tympanic, tense distension, no pain
on palpation
Skin: warm extremities, anasarca R>L, ecchymosis, spider
angiomata, erythema in R armpit, tender to palpation, ROMI
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: 4/5 strength in R arm, due to pain?, handgrip [**4-10**] b/l,
4/5 strength in hip/knee flexor and hip/knee extensor, [**4-10**] in
foot extensor and flexor, following commands, PERRLA, reflexes
2+ b/l, positive asterixis, recall immediate intact, delayed [**12-9**]
Pertinent Results:
.
Labs on [**2134-5-10**] from OSH:
......10.2
9.7>-----< 52
......29.5
75N, 10L, 14M
.
INR: 2.4, aPTT: 49.6
.
134/105/49
----------<109
4.4/19/3.1
.
Calc 9.1, Phos: 5.5, Mg 1.9
.
Bilirubin 6.9 on [**2134-5-8**], Alb 2.4, AST 68, ALT 25
.
UA [**5-9**]: 1.017, 150prot, small bili, large blood, negative
nitrate
Used [**5-9**]: >100WBC, > 100 RBC, may bact
UCx: MRSA 10-50,000 organisms
.
EKG: [**2134-5-1**] from OSH: SR, HR 70, NA,QT mild prolonged at 455,
early RW progression, no ST or TW changes
.
CT abdomen [**2134-5-3**]
Large ascites, thickened irregular appearing colon, more
pronounced in ascending colon, cholelithiasis, nodular contour
of the liver, mild splenomegaly
.
Brief Hospital Course:
51 yo with end-stage ETOH cirrhosis who presented from an
outside hospital with rectal bleeding, MS changes, and renal
failure. The pt was transferred for further treatment and
evaluation for possible liver transplant. She was treated
aggressively for medical issues (as outlined below); however, as
she developed progressive multi-organ failure including probable
pneumonia the family decided to make her comfort measures only.
She died shortly thereafter.
.
# End-stage liver disease: Pt developed liver disease due to
years of ETOH abuse. She was abstinent for 12 months prior to
admission. Her disease had been progressing rapidly with MELD
score was around 34. She was cared for by the liver service as
well as the transplant team during her stay. She was unable to
be listed for transplant due to probable pneumonia and overall
deteriorating condition. She was transferred to the MICU, where
she was intubated electively for further MRI, however,
eventually developed respiratory failure due to volume overload
and pneumonia.
.
# Abdominal pain: due to tense ascites. She had multiple
therapeutic paracentesis and was treated symptomatically wtih
pain medication.
.
# Anemia: Pt has history of esophageal varices which have bled
in the past. She is s/p rectal banding in early [**2134-4-6**].
.
# ARF: baseline crt 0.5. However, over a period of months her
renal function declined. Prior to admission crt was
approximately 2. Etiology thought to be hepatorenal syndrome.
During her hospital stay, her renal function continued to
decline (crt 3.4).
.
# Encephalopathy: due to ESLD. Treated symptomatically.
.
# Congestive heart failure: pt developed volume overload while
being resuscitated for episodes of hypotension. Diuresis with
lasix drip was given with incomplete response.
.
# Pneumonia: pt with hypoxia & CXR findings suspicious for PNA,
thus she was treated with antibiotics for hospital acquired
infection.
Medications on Admission:
Octreotide and midodrine since [**5-8**]
Levofloxacin 500 QD
Ferrous sulfate
KCL
Lasix
Protonix
Prozac
Nadolol
Lidoderm patch
Lactulose
Aldactone
K-phos
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
End-stage liver disease from alcholic cirrhosis
Renal failure
Respiratory failure
Congestive heart failure
Encephalopathy
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
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"571.2",
"V11.3",
"285.9",
"588.89",
"682.3"
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icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"38.93",
"54.91",
"99.05",
"96.04",
"96.72",
"89.64",
"33.24",
"45.24",
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] |
icd9pcs
|
[
[
[]
]
] |
6715, 6724
|
4546, 6483
|
353, 414
|
6899, 6909
|
3840, 4523
|
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|
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|
6686, 6692
|
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|
6509, 6663
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|
3041, 3821
|
275, 315
|
442, 2125
|
2147, 2795
|
2811, 2992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,900
| 151,550
|
46599
|
Discharge summary
|
report
|
Admission Date: [**2187-4-23**] Discharge Date: [**2187-5-2**]
Date of Birth: [**2130-11-6**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Levofloxacin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Acute on Chronic Diastolic congestive heart failure
Major Surgical or Invasive Procedure:
Left knee arthrocentesis
right heart catheterization
History of Present Illness:
Mr. [**Known lastname 98957**] is a 56 year old gentleman with signficant PMH of
CAD s/p MI in [**2175**] with DES to RCA and DES to LCx, systolic CHF
with last LVEF 25-30% and multiple admissions for sCHF
exacerbations who presents as direct admission for refractory
volume overload due to sCHF.
Patient is followed closely for his sCHF by Dr. [**First Name (STitle) 437**] and is
frequently seen in the CHF outpatient infusion clinic. His last
visit was on [**4-19**] where his weight was 265 (baseline 250) and he
received 80mg IV lasix and 5mg po metolazone. He says that he
has had progressive weight gain and DOE over the last several
months, but notes no acute changes within the last several
weeks. His legs are progressively becoming more edematous and he
describes them currently as 'hefty'. He has consistent 2 pillow
orthopnea and denies PND. He can walk approximately 1 block
before becoming shortness of breath. He denies any anginal or
claudication pain. He does report eating a fair amount of
'processed' foods. Notably, he was admitted [**Date range (1) 51038**] for CRF
and hyperglycemia. During this admission, he reportedly made
trips off the floor to the cafeteria, and his dietary compliance
was questionable.
On arrival to the floor, patient is ambulatory and out of bed
upon entering the room. He has no complaints except for chronic
back and knee pain and is asking for dilaudid.
.
REVIEW OF SYSTEMS
As above, otherwise 10 point review of systems is unremarkable.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- Systolic CHF (last EF 20 % on [**1-28**])
- CAD s/p MI [**2175**], DES to RCA and LCx
3. OTHER PAST MEDICAL HISTORY:
- Diabetes
- CKD
- Hypertension
- Hyperlipidemia
- Untreated Hepatitis C
- Low back pain
- Substance abuse (cocaine, heroin, tobacco and alcohol)
- History of angioedema
- Hiatal hernia
- Generalized osteoarthritis
Social History:
Patient is currently living at [**Hospital 16662**] Nursing Home [**Location (un) 8608**]. He denies employment history and was incarcerated for
several years.
-Tobacco history: 0.5 ppdx30 years, currently smoking
-ETOH: Denies recent use
-Illicit drugs: History of cocaine and heroin. + IVDA. Reports
quitting approximately 5 years ago.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Mother with hypertension, father with HTN
and cirrhosis, brother with HIV
Physical Exam:
ON ADMISSION
VS: T=98.4 BP= 145/82 HR= 73 RR=15 O2 sat=96%RA
GENERAL: Ambulatory at baseline. Obese man in NAD. WDWN.
Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. MMM.
NECK: Thick, unable to appreciate JVD due to habitus.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Nonlabored at rest. Clear to ausculation
ABDOMEN: Obese, distended, nontender. No HSM or tenderness.
EXTREMITIES: [**1-21**]+ pitting edema to knees.
SKIN: No rashes or lesions.
ON DISCHARGE:
VS:
Temp 97.7, HR 71-82, RR 20, BP 100-168/80-102, O2 sat 100% RA
Weight 255 pounds
General: alert and oriented, annoyed with staff
CV: RRR, no M/R/G, unable to assess JVD
Chest: Clear, no crackles
ABD: soft, obese, NT, pos BS
Extremeties: 2+ pitting edema to knees, has ACE bandages for
compression
Neuro: A/O, NAD, memory intact, can be demanding of staff.
Pertinent Results:
ADMISSION LABS:
[**2187-4-23**] 12:37PM BLOOD WBC-9.4 RBC-4.88 Hgb-14.0 Hct-43.7 MCV-90
MCH-28.6 MCHC-32.0 RDW-15.2 Plt Ct-235
[**2187-4-23**] 12:37PM BLOOD Glucose-184* UreaN-35* Creat-1.3* Na-136
K-4.1 Cl-100 HCO3-24 AnGap-16
[**2187-4-23**] 12:37PM BLOOD ALT-44* AST-41* LD(LDH)-433* AlkPhos-73
TotBili-0.4
[**2187-4-23**] 12:37PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.1 Mg-1.9
RADIOLOGY:
[**2187-4-23**] Radiology CHEST PORT. LINE PLACEM
Portable upright frontal chest radiograph demonstrates interval
placement of a left upper extremity PICC, the tip of which
projects over the upper SVC. Multiple blebs are again noted in
the peripheral right upper lung, better seen on CT from [**2186-6-23**]. The cardiac silhouette is top normal in size, accentuated
by portable technique. The pulmonary vasculature appears mildly
engorged. There is no pleural effusion or pneumothorax. The
mediastinal contours are normal.
IMPRESSION:
1. Interval placement of left upper extremity PICC, the tip of
which is in the upper SVC.
2. Interval decrease in heart size from [**2186-11-19**]; the
pulmonary
vasculature is minimally engorged.
ECHO TTE [**2187-4-24**] ON MILRINONE;
Conclusions
Poor image quality. The left atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated. There
is mild to moderate regional left ventricular systolic
dysfunction with infero-septal, inferior and infero-lateral
hypokinesis suggested. There is no ventricular septal defect. RV
systolic function is difficult to assess but appear borderline
in some views. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2187-2-22**],
LVEF has improved and LV systolic dysfunction now appears more
regional than
RIGHT HEART CATH [**2187-4-25**]:
FINAL DIAGNOSIS:
1. Moderate elevation of the wedge pressure consistent with
moderate
left ventricular diastolic heart failure.
2. Severe pulmonary hypertension with marked resipiratory
variation.
3. Moderately elevated pulmonary vascular resistance.
4. Normal cardiac output and index on milrinone.
PORTABLE ABD XRAY [**2187-4-27**]:
FINDINGS: Study is limited due to the patient's extreme
obesity. However, no signs of obstruction or ileus are noted.
The lungs show pulmonary edema and cardiomegaly. PICC line
terminates in appropriate posistion. No obvious pleural
effusions are noted. No free air or obstructive pattern. Bony
structures are unremarkable.
IMPRESSION:
1. Pulmonary edema and cardiomegaly.
2. No evidence of obstruction or ileus.
.
Labs on Discharge:
[**2187-5-2**] 05:34AM BLOOD WBC-10.8 RBC-4.89 Hgb-13.9* Hct-43.5
MCV-89 MCH-28.3 MCHC-31.9 RDW-14.1 Plt Ct-314
[**2187-5-2**] 05:34AM BLOOD Glucose-377* UreaN-83* Creat-1.6* Na-132*
K-3.8 Cl-89* HCO3-35* AnGap-12
[**2187-5-2**] 05:34AM BLOOD Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 98957**] is a 56 year old gentleman with diabetes mellitus
(DM), coronary artery disease (CAD), and stage III systolic
heart failure (sCHF) who presented as a direct admission for
milrinone and lasix drip for refractory edema.
ACTIVE PROBLEMS:
# Refractory edema: Likely due to worsening chronic sCHF. Liver
synthetic function was intact making HCV associated cirrhosis
unlikely. Diuresis was achieved with lasix gtt augmented with
milrinone gtt as below. Weight on admission was 119.75 kgs.
# Acute on chronic systolic function: Patient with sCHF and LVEF
25-30 % in [**2187-2-18**]. Primarily has right sided symptoms at
this time given his gross peripheral edema and clear lungs on
admission. Home regimen includes torsemide 100mg daily,
spironolactone 25mg daily, carvedilol 25mg twice daily and
valsartan 40mg daily. We initially continued his carvedilol and
valsartan, but held valsartan following a bump in his Cr early
in his stay. Torsemide and spironolactone held while on lasix
gtt. He was loaded with midodrine 0.5mcg/kg over 15 minutes
before beginning maintenance infusion of 0.375 mcg/kg/min, which
was increased to 0.5mcg/kg/min for 2 days. After achieving a net
diuresis of > 15 L during the admission, his milrinone was
discontinued. He was restarted on torsemide 100 mg daily and
metolazone was added at 2.5 mg 3 times per week. Also continued
on valsartan 40 mg daily, carvedilol 25 mg [**Hospital1 **], aspirin 325 mg
daily, simvastatin 20 mg daily, and spironolactone 25 mg daily
for heart failure. Weight on discharge was 255 pounds.
# Atrial fibrillation (afib): After several days of diuresis,
he developed afib acutely. The inpatient team felt that his
afib was precipitated by milrinone and aggressive diuresis. He
was asymptomatic although he did develop heart rates to the
140s. He did not achieve rate control with metoprolol IV and so
he was given diltiazem 10 mg IV and then diltiazem 30 mg QID for
2 doses. Because we did not want to continue Calcium channel
blocker in a heart failure patient, the diltiazem was
discontinued in favor of digoxin. He was loaded with 0.75 total
dose of digoxin, divided over 18 hours and he converted to sinus
rhythm. He refused a heparin gtt to bridge to warfarin.
Ideally, he would need to continue anticoagulation with warfarin
for at least 1 month, however he stated that he would not be
compliant with INR checks so he was discharged without
anticoagulation.
# Chronic pain: Patient with history of chronic low back pain,
gout, and generalized OA. Also likely has some element of
neuropathy from diabetes and is also being treated for carpal
tunnel syndrome with wrist splints. He is on extensive
outpatient regimen of amitryptiline, gabapentin, percocet,
tizanidine, and cyclobenzaprine. He was demanding dilaudid on
admission. We had no record of him receiving dialudid in OMR,
and after calling his nursing home, there was no report of
dilaudid use there. He was provided increased oxycodone dosing
of 10mg po q4 hours with standing tylenol and transitioned to
oxycontin 20mg every 12 hours. We continued his additional pain
medications including gabapentin, amitryptiline, tizandine and
cyclobenzaprine. Lidocaine patch was also offerred.
# Gout: Patient developed acute left knee pain on [**4-27**].
Aspiration of left knee was consistent with gout flare. He was
started on a prednisone taper and continued chronic pain regimen
as above. Prednisone dose on discharge was 15 mg and should be
decreased by 5 mg every 2 days.
CHRONIC PROBLEMS
# Chronic kidney disease: Recent baseline Cr of 1.4-1.7. Cr was
1.3 on admission but increased to 2.6 on [**4-24**]. We held his
valsartan and decreased his gabapentin dose. Cr returned to
baseline with further diuresis. Gabapentin was returned to home
dose and valsartan was restarted on discharge. Cr on discharge
was 1.6.
# CAD: History of MI in [**2175**] with DES to RCA and DES to LCx.
Last catheterization in [**2181**] showed no significant flow
obstructing lesions. Home regimen includes carvedilol 25mg [**Hospital1 **]
and ASA 325. No current anginal symptoms. We continued ASA,
valsartan, carvedilol, and simvastatin.
# Diabetes: Poorly controlled with last A1c 9.6 on [**8-15**]. Home
regimen includes Novolin 60 [**Hospital1 **] with lispro SS. We increased NPH
to 75 units [**Hospital1 **] because of hyperglycemia from prednisone. This
should be tapered down slowly as prednisone is transitioned off
and blood sugars decrease. Enhanced sliding scale is attached.
# Hypertension: We continued his home carvedilol as above with
diuresis. Valsartan was restarted at discharge.
# HLD: Last LDL 59 and HDL 62 in [**2184**]. We continued home
simvastatin 20mg daily.
# HCV: Last viral load 31,400,000 in 4/[**2185**]. No history of
treatment. Patient to follow up with his PCP as an outpatient.
# Hiatal hernia: Stable. Continued omeprazole 20mg daily
# Polysubstance abuse: Reports no recent alcohol or illicit drug
use. Continues to smoke, and we encouraged smoking cessation
TRANSITIONAL ISSUES:
- Please monitor for recurrent afib. If he has further afib, he
should be investigated for other causes.
- Please address ongoing anticoagulation: As he has been
non-compliant in the past and as the AF lasted less than 24
hours, he will not be started on warfarin at this time but
strong consideration should be given to this if he develops AF
again.
- Please assess fluid balance with weights and exam, adjust the
doses of diuretics as tolerated by his kidneys and potassium.
Medications on Admission:
- Allopurinol 100mg daily
- Amytryptiline 10mg qhs
- Carvedilol 25mg [**Hospital1 **]
- Cyclobenzaprine 5mg [**Hospital1 **] prn neck pain
- Gabapentin 600mg q8 hours
- NPH 60 units [**Hospital1 **]
- Humalog SS
- Lidocaine patch prn to knees or back
- Omeprazole 20mg daily
- Percocet 5-325 1-2 tabs q6 hours prn pain
- Miralax daily as needed
- KCl 20meq daily
- Sildenafil 100mg prn
- Tizanidine 4mg qhs
- Torsemide 100mg qam
- Valsartan 40mg daily
- ASA 325 daily
- Bisacodyl 5mg prn
- Camphor-Menthol lotion [**Hospital1 **] prn itching
- Docusate 100mg [**Hospital1 **]
- Senna 8.6 2 tabs qhs prn constipation
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
4. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day) as needed for Neck pain.
5. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. NPH insulin human recomb 100 unit/mL Suspension Sig: Seventy
Five (75) Subcutaneous twice a day: Use this increased dose
while you are taking the prednisone.
7. insulin lispro 100 unit/mL Solution Sig: As per sliding scale
doses Subcutaneous as per sliding scale.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for knee pain.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO once a day as needed for constipation.
11. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
12. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day
as needed for ED.
13. tizanidine 4 mg Capsule Sig: One (1) Capsule PO at bedtime.
14. torsemide 100 mg Tablet Sig: One (1) Tablet PO every
morning.
15. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours):
discussed with outpt PCP.
19. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO
Monday/Wednesday/Friday: Pt is refusing dose this am, please
give [**5-3**] as well.
20. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**2-23**]
hours as needed for pain.
21. prednisone 5 mg Tablet Sig: Three (3) Tablet PO QDAY () for
2 days: [**5-3**] and [**5-4**].
22. prednisone 10 mg Tablet Sig: One (1) Tablet PO QDAY () for 2
days: [**5-5**] and [**5-6**].
23. prednisone 5 mg Tablet Sig: One (1) Tablet PO QDAY () for 2
days: [**5-7**] and [**5-8**]. then d/c.
24. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
chronic systolic heart failure--ejection fraction 25-30%
chronic kidney disease
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 98957**],
You were admitted to the hospital because you were retaining a
lot of extra fluid. This is due to your heart failure which
causes the heart to pump only about 25% of the fluid with each
beat. The rest of the fluid leaks out of your blood vessels
into the area under your skin and causes swelling. You were
treated with medications to increase the squeezing power of your
heart and to force more fluid out in your urine. You responded
well and we were successful in getting 15-20 pounds of fluid
off.
You also developed worsening knee pain, and we had our joint
doctors (rheumatologists) examine the fluid in your knee. We
found you developed a gout attack and gave you steroids both in
your knee and by mouth to help with the pain. We also started
new pain medications for you.
Please note the following changes to your medications:
Start Oxycontin 20mg tab twice daily
Start Prednisone 5mg tabs as directed to slowly decrease the
dose
Increase NPH insullin and sliding scale insulin to control your
blood sugars
Start metolazone to decrease your swelling.
No other changes were made to your medications. In the future,
you will need to keep a very close eye on your medications,
diet, and weight. Weigh yourself every morning, and call your
doctor if weight goes up more than 3 lbs in 1 day or 5 pounds
in 3 days. Also, you need to keep a strict low salt diet which
will help reduce the amount of fluid your body retains.
Make sure that you keep all of the follow-up appointments listed
below. Bring your medications to each appointment so your
doctors [**Name5 (PTitle) **] update their records and adjust doses as needed.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Name: Dr. [**First Name8 (NamePattern2) 17765**] [**Last Name (NamePattern1) 17385**]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: CARDIAC SERVICES
When: MONDAY [**2187-5-7**] at 1:30 PM
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
Department: RHEUMATOLOGY
When: TUESDAY [**2187-5-15**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2187-5-9**] at 1:15 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2187-5-9**] at 1:35 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.9",
"427.31",
"428.0",
"414.01",
"715.00",
"357.2",
"272.4",
"416.8",
"403.90",
"274.01",
"553.3",
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"V58.67",
"412",
"724.2",
"070.70",
"250.62",
"305.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"89.64",
"81.92",
"81.91",
"99.23"
] |
icd9pcs
|
[
[
[]
]
] |
15758, 15857
|
7282, 12333
|
349, 403
|
16017, 16017
|
3954, 3954
|
17921, 19553
|
2875, 3036
|
13499, 15735
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16168, 17015
|
3051, 3561
|
2165, 2254
|
3575, 3935
|
12354, 12833
|
17044, 17898
|
258, 311
|
7008, 7259
|
431, 2054
|
3970, 6230
|
16032, 16144
|
2285, 2502
|
2076, 2145
|
2518, 2859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,774
| 146,298
|
8551
|
Discharge summary
|
report
|
Admission Date: [**2140-9-7**] Discharge Date: [**2140-9-12**]
Date of Birth: [**2068-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
melana, chest pain
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
72 year old male with CAD s/p CABG, atrial fib on coumadin, s/p
VT/VF arrest with BiV pacer; CHF with EF 15% admitted to the
MICU ([**9-7**]) after presenting with CP, SOB, abdominal pain,
melena, INR of 3, and Hct drop from 40 to 37. He was admitted to
the MICU where he was given FFP and 1u PRBCs and ruled out for
ACS. He was seen by GI, Surgery, and Cardiology. GI c/s resulted
in plan for EGD. Surgery c/s resulted in INR reversal and serial
exams and hcts. Cardiology felt the patient's CP was not [**2-13**] a
cardiac etiology. He was ruled out for MI regardless. His Hct
was 31 at its lowest but remained stable and, as he was stable
overall, he was felt appropriate for transfer to the floor for
further work up of his melena.
.
Of note, last [**Month (only) 547**], the patient had a similar presentation and
EGD, c-scope, and capsule endoscopy demonstrated gastritis,
Barrett's, diverticulosis and grade 1 hemorrhoids were found,
without any active bleeding.
At time of transfer, the patient endorsed mild abdominal pain
and diaphoresis. He denied chest pain. He had not had a BM in 2
days.
Past Medical History:
--CAD status post CABG with simultaneous aortic aneurysm repair
in [**2133**], history of stenting of the left circumflex artery [**2135**]
--s/p VT/VF arrest, s/p ICD placement in [**2135**]
--Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**]
--Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer
pocket infection
--PAF
--CKD with baseline Cr. 1.6-2
--Hyperlipidemia
--Asthma
--Anxiety
--Alzheimer's dementia
--Hypothyroidism
--GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis,
Barrett's esophagus, and duodenitis. No ulcers.
--Diverticulosis
--GERD
--S/P Cholecystectomy
Social History:
Patient originally from [**Country 4754**] and moved to the United States
in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he
continues to live with his wife. Father of five children.
Retired 6 years ago, and since his recent heart problems, says
he rarely leaves the house. Most of his time is spent in front
of the television with his wife handling their affairs at home.
No history of smoking, past or present. Patient was a heavy
drinker until 20 years ago, when he stopped completely after
attending AA and encountering marital difficulties. No history
of illicit drug use.
Family History:
Non-contributory.
Physical Exam:
Afebrile, 115/69, 75, 18, 99%2L
General Appearance: Pleasant, obese male, mildly diaphoretic
lying in bed in no acute distress.
Eyes / Conjunctiva: PERRL, EOMI, no icterus
Head, Ears, Nose, Throat: NCAT, MMMI, JVD 10cm
Cardiovascular: paced, [**3-17**] looud blowing systolic murmur loudest
at LUSB with radiation along the left sternal border throughout,
large, prolonged and displaced PMI
Respiratory / Chest: CTA b/l
Abdominal: Soft, mild guarding, +BS, subumbilical tenderness
with mild tenderness in bl lower quadrents, no guarding
Extremities: pneumoboots in place, dps 1+ bl
Neurologic: Attentive, Follows simple commands, a and o times 3,
movement and sensation intact in all extremities
Pertinent Results:
[**2140-9-7**] 03:20PM PT-29.2* PTT-31.4 INR(PT)-3.0*
[**2140-9-7**] 03:20PM PLT COUNT-168
[**2140-9-7**] 03:20PM NEUTS-75.5* LYMPHS-13.8* MONOS-7.0 EOS-3.4
BASOS-0.4
[**2140-9-7**] 03:20PM WBC-8.6 RBC-4.30* HGB-12.4* HCT-37.0* MCV-86
MCH-28.8 MCHC-33.5 RDW-14.6
[**2140-9-7**] 03:20PM DIGOXIN-0.9
[**2140-9-7**] 03:20PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.3
[**2140-9-7**] 03:20PM CK-MB-4
[**2140-9-7**] 03:20PM cTropnT-0.01
[**2140-9-7**] 03:20PM LIPASE-44
[**2140-9-7**] 03:20PM ALT(SGPT)-20 AST(SGOT)-28 CK(CPK)-112 ALK
PHOS-89 TOT BILI-0.2
[**2140-9-7**] 03:20PM estGFR-Using this
[**2140-9-7**] 03:20PM GLUCOSE-72 UREA N-23* CREAT-1.7* SODIUM-138
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-32 ANION GAP-10
[**2140-9-7**] 03:32PM K+-4.6
[**2140-9-7**] 03:32PM COMMENTS-GREEN TOP
[**2140-9-7**] 06:02PM HCT-35.6*
[**2140-9-7**] 06:12PM LACTATE-0.9
[**2140-9-7**] 11:30PM HCT-31.1*
[**2140-9-7**] 11:30PM URINE HOURS-RANDOM UREA N-377 CREAT-52
SODIUM-50
[**2140-9-7**] 11:30PM DIGOXIN-0.8*
[**2140-9-7**] 11:30PM MAGNESIUM-2.0
[**2140-9-7**] 11:30PM CK-MB-4 cTropnT-0.01
[**2140-9-7**] 11:30PM CK(CPK)-110
[**2140-9-7**] 11:30PM GLUCOSE-89 UREA N-20 CREAT-1.6* SODIUM-141
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11
EKG - [**9-7**]: Ventricular paced rhythm
Atrial mechanism uncertain - may be paced ot possible ectopic
atrial rhythm
Since previous tracing of [**2140-4-19**], ventricular ectopy absent and
P wave
morphology appears changed
CXR - [**9-7**]: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The
cardiomediastinal contour is
unchanged, with moderate cardiomegaly. There is no pleural
effusion or
evidence of focal consolidation. The dual-lead pacing device is
unchanged in appearance. Osseous structures are unremarkable.
IMPRESSION: No significant change since [**2140-4-12**]. No evidence
of pneumonia or congestive heart failure.
KUB - [**9-9**]: FINDINGS: There is non-specific bowel gas in the
abdomen. There are no distended loops of bowel, or concerning
air-fluid levels. There is air in the rectum. There is a large
amount of feces in the descending colon, suggesting
constipation. Of note, there is a right hip hemiarthroplasty
hardware, without apparent hardware complication. There is a
mild lumbar levoscoliosis. There are surgical clips at the right
upper quadrant, from prior cholecystectomy. There are wires
projected on to the heart, likely pacer wires.
IMPRESSION: No evidence of bowel obstruction. Likely
constipation.
EGD - [**9-9**]: Barrett's Exophagitis, Gastritis, Duodenitis
Brief Hospital Course:
72 year old male with CAD s/p CABG, atrial fib on coumadin, s/p
VT/VF arrest now with BiV pacer; CHF with EF 15% who presented
with what appears to be non-cardiac chest pain, abdominal pain
and melena.
.
# Melena/Abdominal pain: HCT decreased to 31 from BL of 33 on
arrival to MICU. INR was reversed. Serial hematocrits were
checked and remained stable despite the patient remaining guiac
positive. Aspirin and Coumadin were held until after EGD at
which time they were restarted. IV PPI was given until EGD.
Patient was converted to PO PPI [**Hospital1 **] and instructed to continue
as such for six weeks. GI follow up [**Hospital1 1988**]. Patient had
similar episode in [**4-19**] and had an extensive GI workup which was
negative.
.
# Chest Pain: Pain resolved by the time the patient arrived to
the floor. Cardiology felt the pain was unlikely to be cardiac
in nature as cardiac enzymes were negative on arrival to the ED
after 5 hours of constant chest pain. Pain could be esophageal
as patient has history of Esophagitis and Barretts esophagus.
Last possibility is aortic chest pain as patient has history of
thoracic aortic aneurysm repair, small concern for dissection
although unlikely as patient remained stable throughout his
hopitalization and his CP resolved.
.
# CAD: Patient is s/p CABG. Chest pain unlikely to be cardiac.
MI ruled out. ASA, BB and statin were initially held in setting
of possible GIB but were restarted prior to discharge.
.
# CHF: Patient with history of ischemic CMP with EF 15%. Home
Lasix, Aldactone, and Toprol were intially held but reintroduced
prior to discharge. Home digoxin was continued.
.
# PAF: Patient s/p BiV pacer placement on Coumadin. INR was
reversed intially but coumadin was restarted prior to discharge.
Digoxin was continued.
.
# VF/VT arrest: Patient is s/p BiV pacer/ICD placement. Home
Sotalol, Mexiletine were continued.
.
# Asthma: Albuterol MDI at home. Albuterol Nebs were given PRN.
.
# Hypothyroidism: Home levoxyl was continued.
.
# CKD: Patient with Cr of 1.7 on admission with Baseline Cr
1.5-2. Remained stable.
.
# Alzheimer??????s: Held home Donepezil, Celexa initially. Restarted
prior to discharge.
Medications on Admission:
Sotalol 80mg [**Hospital1 **]
Lipitor 20mg daily
Donepezil 5mg daily
Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS
Celexa 60mg daily
Protonix 40mg daily
ASA 81mg daily
Clonazepam 0.5mg TID PRN
Lisinopril 5mg daily
Digoxin 125mcg, [**1-13**] tab daily
K-Dur daily
Spironolactone 25mg daily
Levothyroxin3e 112mcg daily
Trazodone 25mg qHS
Mexiletine 150mg TID
Albuterol MDI 2puf q6hPRN
Fluticasone 110mcg 2puff [**Hospital1 **]
Toprol SL 50mg daily
Lasix 40mg TID
Coumadin
Discharge Medications:
1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Digoxin 125 mcg Tablet Sig: [**1-13**] Tablet PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
Take twice per day for a total of 6 weeks. Can then resume once
per day.
Disp:*45 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Warfarin 1 mg Tablet Sig: 2-3 Tablets PO once a day: 2 to 3
tablets by mouth once per day or as directed.
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
10. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Celexa 40 mg Tablet Sig: 1.5 Tablets PO once a day.
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
17. Miralax 100 % Powder Sig: One (1) packet PO once a day.
18. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
19. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO qam.
20. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO qnoon.
21. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO at bedtime.
22. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
23. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
24. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
25. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Upper GastroIntestinal Bleed
Barrett's Esophagitis
Gastritis
Duodenitis
Discharge Condition:
Fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
You were admitted to the hospital because you had blood in your
stool along with a decrease in your blood count/hematocrit
concerning for ongoing bleeding. Because you also had chest pain
upon presentation, you were also admitted to rule out the
possibility that you were experiencing a heart attack.
You had an EGD performed which showed irritation and
inflammation of your esophagus, stomach, and duodenum. This
irritation could be the cause of your bloody stool and decrease
in blood count. You were given blood replacement products along
with high doses of protonix and your blood count remained
stable. You should continue to take you protonix twice per day
for the next 6 weeks. You have follow up with the GI doctors
[**Name5 (PTitle) 1988**].
You should call your doctor and/or return to the emergency room
if you have dark tarry stools or bright red blood in your stool,
Chest Pain, Shortness of Breath, or any other corncerning
symptoms.
Followup Instructions:
[**9-14**] at 9:30am DEVICE CLINIC (Phone:[**Telephone/Fax (1) 59**])
[**9-14**] at 10:00am [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP (Phone:[**Telephone/Fax (1) 62**])
[**9-30**] at 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD (Phone:[**Telephone/Fax (1) 463**])
|
[
"578.9",
"272.4",
"530.85",
"535.60",
"427.1",
"331.0",
"V45.81",
"786.59",
"V58.61",
"428.22",
"493.90",
"294.10",
"535.50",
"427.31",
"414.8",
"530.81",
"428.0",
"V45.02",
"244.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11002, 11060
|
6133, 8323
|
334, 363
|
11175, 11182
|
3543, 6110
|
12307, 12649
|
2790, 2809
|
8866, 10979
|
11081, 11154
|
8349, 8843
|
11206, 12284
|
2824, 3524
|
276, 296
|
391, 1495
|
1517, 2142
|
2158, 2774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,318
| 113,694
|
52959
|
Discharge summary
|
report
|
Admission Date: [**2112-7-25**] Discharge Date: [**2112-8-13**]
Date of Birth: [**2057-6-4**] Sex: F
Service: Surgery
CHIEF COMPLAINT: Recurrent sigmoid diverticulitis,
postoperative anastomotic leak.
MAJOR SURGICAL PROCEDURES: Sigmoid colon resection on [**2112-7-25**], exploratory laparotomy, and diverting ileostomy on
[**2112-8-2**], and removal of retained drain on [**2112-8-11**].
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
woman with a history of recurrent diverticulitis. Since [**2110**],
she had at least 3 documented episodes of acute
diverticulitis. Patient was now admitted for elective sigmoid
resection.
Patient underwent a sigmoid colon resection on [**2112-7-25**].
Patient had a postoperative complication with an anastomotic
leak which necessitated exploratory laparotomy and diverting
ileostomy. Subsequently, 1 of the drains that was placed at
the 2nd operation was retained and could not be removed at
bedside. Therefore, patient required an additional procedure
in the operating room with extraction of the drain.
After that procedure, the patient was doing well, and she
could be discharged home on [**2112-8-13**].
DISCHARGE STATUS: On discharge, the patient was in good
general condition. She was afebrile. Her ileostomy was
working well.
DISCHARGE FOLLOWUP: Patient will follow up in Dr.[**Name (NI) 109160**] office in approximately 10 days.
[**Name6 (MD) 5183**] [**Last Name (NamePattern4) 5184**], [**MD Number(1) 5185**]
Dictated By:[**Last Name (NamePattern4) 95468**]
MEDQUIST36
D: [**2112-11-10**] 11:18:39
T: [**2112-11-11**] 09:55:24
Job#: [**Job Number 109161**]
|
[
"562.11",
"401.9",
"305.1",
"997.4",
"458.29",
"998.2",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"54.25",
"38.93",
"99.15",
"46.01",
"97.53"
] |
icd9pcs
|
[
[
[]
]
] |
156, 413
|
1333, 1680
|
442, 1312
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,775
| 129,923
|
26628
|
Discharge summary
|
report
|
Admission Date: [**2115-11-4**] Discharge Date: [**2115-11-12**]
Date of Birth: [**2043-6-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
elective admission for left crani after history of clumsiness to
right side
Major Surgical or Invasive Procedure:
Left craniotomy [**2115-11-4**]
PICC LINE [**2115-11-7**]
History of Present Illness:
72 yo F with h/o temporal arteritis, PMR and colon CA s/p
partial colectomy in [**2106**] with clear margins c/o few week h/o
gait instability and transient confusion and right arm weakness
this afternoon lasting approximately 4 hours. She denied speech
difficulty or leg weakness. She has chronic HA, c/o HA today
similar to her typical temporal arteritis HA. She denies
numbness, no nausea/vomiting, no visual disturbances, no
seizures.
Past Medical History:
colon CA s/p partial colectomy [**2106**], temporal arteritis,
hyperlipidemia, hypertension, polymyalgia rheumatica
Social History:
denies smoking/EtOH, lives alone fully independent
Family History:
unkown
Physical Exam:
O: T: 98.9 BP: 155/78 HR: 72 R 16 O2Sats 98% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2mm bilat EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-6**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-10**] throughout with trace weakness
of right deltoid and bicep. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge
Pt awake alert oriented with slightest of prompting / exam
intact except for right hemipariesis [**3-11**] with right drift / no
obvious facial / slight preseveration at times
Pertinent Results:
PATH REPORT pending*************
CT HEAD W/O CONTRAST Study Date of [**2115-11-4**] 3:43 PM
Final Report
FINDINGS: The patient is status post left parietovertex
craniotomy and
resection of left parietal mass, with related pneumocephalus. A
small
hyperdense focus is noted at the left superolateral margin of
the air-filled surgical cavity with a subarachnoid component
(2:23-25), representing post-operative hemorrhage. Residual
regional vasogenic edema is noted, similar in extent to the
previous study. There is no shift of
normally-midline structures.
Cortical atrophy is again noted, likely related to the patient's
age.
Vascular calcification of the carotid siphons is also seen. The
paranasal
sinuses and mastoid air cells are well aerated. The soft tissues
of the
orbits are symmetric and grossly unremarkable. No bone
destruction is seen.
IMPRESSION: Small hemorrhagic focus at the margin of the new
surgical cavity, with blood in the immediately suprajacent
subarachnoid space, consistent with small amount of
post-operative bleeding. Attention should be paid to this
finding on subsequent f/u studies.
CT HEAD W/O CONTRAST Study Date of [**2115-11-5**] 1:02 PM
FINDINGS: There is a left parietal craniotomy. In the left
parietal surgical bed, there is a 4.7 cm hyperdensity consistent
with acute hemorrhage, markedly increased in size since the
prior study. There is tenting of the falx to the right, which is
new compared to prior. There is compression of the body of the
left lateral ventricle, which is also new compared to prior.
Left frontal and parietal white matter hypodensity with mass
effect is grossly stable in extent, related to the resected
tumor.
There is a mucous retention cyst in the right posterior ethmoid
air cells.
IMPRESSION: Markedly increased hematoma in the left parietal
surgical site.
[**Known lastname **],[**Known firstname 95**] [**Medical Record Number 65683**] F 72 [**2043-6-5**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2115-11-7**]
6:30 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG PACU [**2115-11-7**] 6:30 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65684**]
Reason: 72 year old woman s/p crani for mass resection - now
with di
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman s/p crani for mass resection - now with
difficult to arouse.
Eval for interval change
REASON FOR THIS EXAMINATION:
72 year old woman s/p crani for mass resection - now with
difficult to arouse.
Eval for interval change
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: [**First Name9 (NamePattern2) **] [**Doctor First Name **] [**2115-11-7**] 11:31 AM
Overall similar compared to most recent prior 24 hours earlier.
PFI AUDIT # 1 [**First Name9 (NamePattern2) **] [**Doctor First Name **] [**2115-11-7**] 9:45 AM
Study limited by motion artifact and therefore it is difficult
to assess in detail minor changes in the degree of mass effect
secondary to this
hemorrhage. Overall, it appears similar compared to most recent
prior 24
hours earlier. However, if clinical concern persists, MR is
recommended.
Final Report
CLINICAL INDICATION: 72-year-old female with postoperative
intracranial
hemorrhage, now difficult to arouse. Evaluate for interval
change.
COMPARISON: [**2115-11-6**] at approximately 6 a.m.
TECHNIQUE: Axial CT images of the head were acquired without
intravenous
contrast. Coronal and sagittal reformatted images were reviewed.
FINDINGS: This study is slightly limited by motion artifact.
There has been slight reduction in the amount of pneumocephalus.
Again seen is the left parietal hemorrhage at the operative
site. The patient is status post
parietal craniotomy and post-surgical bony changes are
visualized. The
hyperdense focus of hemorrhage continues to measure 4.7 cm,
similar to most recent prior. There is slightly increased
hypodensity within the posterior portion of the hemorrhage,
consistent with evolving hematoma. The surrounding edema appears
similar in amount and distribution. Mild tenting of the falx to
the right is again seen. There is persistent compression of the
body of the left lateral ventricle.
Left frontoparietal white matter hypodensity with mass effect is
similar in distribution.
Mucosal thickening in the right posterior ethmoid air cell is
again seen.
IMPRESSION: Left parietal hemorrhage, similar in size and
appearance compared to prior, with stable appearing mass effect.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname 95**] [**Medical Record Number 65683**] F 72 [**2043-6-5**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2115-11-7**] 8:51
PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG TSICU [**2115-11-7**] 8:51 PM
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN [**Name Initial (PRE) 7417**] #
[**Clip Number (Radiology) 65685**]
Reason: NGT placement
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with s/p crani/mass resect
REASON FOR THIS EXAMINATION:
NGT placement
Final Report
HISTORY: NG tube placement.
FINDINGS: In comparison with the earlier study of this date,
there has been placement of a nasogastric tube that extends to
the body of the stomach. The limited evaluation of the lungs is
essentially within normal limits.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: FRI [**2115-11-8**] 9:28 AM
Imaging Lab
Brief Hospital Course:
The pt was admitted throught the SDA department for the proposed
procedure. She underwent the Left Craniotomy and awoke from
anesthesia without complication. Her postoperative exam and CT
scan were stable. Post op day # 1 the pt had slight difficulty
with word finding. This evolved into a new right prontator
drift. A CT scan of the brain was obtained stat. It
demonstrated new hemorrhage into the postoperative bed. Her sub
q heparin was discontiued, a bolus of 10 mg dexamethasone was
given and her BP parameters were tightened to strict <140. Her
exam remained stable otherwise.
On postop day 2 her mental status had declined a little further.
She was now more lethargic with minimal command following. She
was not oriented at all and is preseverative. At this time a
repeat CT was deemed stable. Her Na was 128 this am which may
explain her mental status. A 3% Na drip was started at 20cc hr.
Her na level stabilized and the 3% saline was discontinued. She
was seen by speech and swallow and limited to dysphagia diet
with thin liquids.
Rad onc and neuro oncology saw the pt and left recommendations.
Her activity was advanced with PT and foley and IVF were
discontinued. Staples to scalp were removed and her incision is
clean and dry.
She agree with plan for discharge.
Medications on Admission:
1. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*30 Tablet(s)* Refills:*0*
2. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day.
Disp:*21 Capsule(s)* Refills:*0*
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain headache.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for Insomnia.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
14. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO q6h () for 7
days.
15. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6h () for
100 days.
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. HydrALAzine 10 mg IV Q6H:PRN sys >160
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Left parietal brain tumor
Post-operative Intracerebral hemorrhage
Complicated Urinary tract infection
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:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam)for seizure
prophylaxis, you will not require blood work monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2115-11-18**]
11:30 - The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] 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.
The following appointment was in our system and is listed below
to serve as a reminder to you.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2115-12-16**] 10:00
Completed by:[**2115-11-12**]
|
[
"198.3",
"733.00",
"599.0",
"348.5",
"V15.82",
"997.02",
"446.5",
"431",
"276.1",
"725",
"401.9",
"E849.7",
"272.4",
"V10.05",
"E878.8",
"342.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"01.59",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11826, 11971
|
8279, 9577
|
358, 418
|
12117, 12117
|
2735, 4974
|
14261, 14985
|
1115, 1123
|
10415, 11803
|
7730, 7775
|
11992, 12096
|
9603, 10392
|
12300, 14238
|
1138, 1396
|
243, 320
|
7807, 8256
|
446, 890
|
1688, 2716
|
12132, 12276
|
912, 1030
|
1046, 1099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,497
| 163,334
|
49542
|
Discharge summary
|
report
|
Admission Date: [**2141-11-20**] Discharge Date: [**2141-12-12**]
Date of Birth: [**2060-12-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
cardiac catheterization
[**11-24**] CABG x4 (LIMA>LAD, SVG>RAMUS SVG>OM SVG>PDA), MV repair
History of Present Illness:
This is an 80 yo M with history of HTN, DM, anemia, who presents
with dyspnea. He was recently hospitalized from [**Date range (1) 55797**] for
pre-syncope in the setting of a junctional bradycardia. He was
discharged to a [**Hospital 599**] Nursing Home in [**Location (un) 55**], where he
was experiencing worsening DOE in the last 2-3 days. He also
complains of band-like chest discomfort while working with PT.
He denies nausea or vomiting with these episodes. He also
denies lightheadedness/dizziness with these episodes as well.
.
During the patient's last admission, he was managed for
bradycardia likely due to hyperkalemia. Given his history of
claudication, his ASA was stopped and he was started on
clopidogrel. He was medically managed for presumed CAD despite a
pMIBI which did not show evidence of ischemia. He was
discharged home on a clopidogrel, statin, and ACE-I. He was not
started on a b-blocker due to his bradycardia at admission.
Also, the patient had cardiac enzymes on admission with a
trop<0.01 and CK 48. His ECG was negative for ST segment
changes during that admission.
.
In the ED, his EKG showed new ST depressions in V5-V6. CXR
showed new b/t pleural effusions. His Hct was noted to be 24.6,
down from his baseline of 30. He had an ABG on room air that
showed 7.51/26/59. He was placed on a non-rebreather mask and
was unable to be weaned (86% RA). He was placed on a heparin
gtt, given 1 unit pRBCS (guaiac negative), metoprolol 12.5, ASA
325 mg, and lasix 20 IV (put out approx 1000 cc).
.
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.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain and dyspnea
on exertion (as described above), but he denies paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope, or
presyncope.
.
Patient does admit to exertional leg pain which he feels has
gotten worse. He endorses occasional ankle edema.
Past Medical History:
Diabetes - A1c 7.3 in [**2141-9-2**]. alb/Cr ratio 800 in [**2141-10-2**].
Hypertension
PVD - sx of claudication, seen on MRA
Iron-deficiency anemia - Hct around 30, no colonscopy
spinal stenosis
Social History:
Social history is significant for quitting tobacco over 35 years
ago. There is no current alcohol abuse. Worked in a cemetery;
never married; never had kids.
Family History:
Father died of influenza, mother died of old age. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
VS - T 98.1, BP 131/60, HR 88, RR 22, 96% on NRB
Gen: thin elderly male in mild respiratory distress. Oriented
x3. Mood, affect appropriate. Tangential historian.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with 12 cm JVD. right carotid bruits.
CV: RR, normal S1. [**2-7**] holosystolic murmur loudest at apex. No
r/g. No S3 or S4.
Chest: Resp were mild labored with some accessory muscle use.
Bibasilar crackles present [**Date range (1) 61126**] posterior lung fields. No
wheezes or rhonchi.
Abd: mild voluntary guarding on exam; nontender. nondistended.
No HSM.
Ext: No cyanosis or clubbing. 1+ edema BLE to knees.
Skin: Dry flaky skin on shins and feet.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT
absent
Left: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT absent
Pertinent Results:
[**2141-12-12**] 06:30AM BLOOD WBC-17.4* RBC-2.93* Hgb-9.2* Hct-28.1*
MCV-96 MCH-31.2 MCHC-32.6 RDW-15.6* Plt Ct-732*
[**2141-12-11**] 06:50AM BLOOD WBC-18.1* RBC-3.01* Hgb-9.4* Hct-29.1*
MCV-97 MCH-31.2 MCHC-32.3 RDW-15.2 Plt Ct-714*
[**2141-12-12**] 06:30AM BLOOD Plt Ct-732*
[**2141-12-11**] 06:50AM BLOOD PT-16.7* INR(PT)-1.5*
[**2141-12-10**] 06:07AM BLOOD PT-17.6* PTT-37.9* INR(PT)-1.6*
[**2141-12-9**] 05:36AM BLOOD PT-18.6* INR(PT)-1.7*
[**2141-12-12**] 06:30AM BLOOD Glucose-46* UreaN-44* Creat-1.6* Na-149*
K-3.5 Cl-119* HCO3-21* AnGap-13
[**2141-12-11**] 06:50AM BLOOD Glucose-64* UreaN-45* Creat-1.7* Na-147*
K-3.7 Cl-119* HCO3-18* AnGap-14
[**2141-12-10**] 06:07AM BLOOD Glucose-248* UreaN-50* Creat-2.0* Na-151*
K-3.9 Cl-123* HCO3-20* AnGap-12
[**2141-11-20**] 07:40PM BLOOD Glucose-135* UreaN-38* Creat-1.2 Na-136
K-4.6 Cl-102 HCO3-20* AnGap-19
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 103627**], [**Known firstname 900**] [**Hospital1 18**] [**Numeric Identifier 103628**] (Complete)
Done [**2141-11-24**] at 11:00:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2060-12-20**]
Age (years): 80 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Congestive heart failure. Left
ventricular function. Mitral valve disease. Myocardial
infarction. Valvular heart disease.
ICD-9 Codes: 428.0, 440.0, V43.3, 396.9
Test Information
Date/Time: [**2141-11-24**] at 11:00 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary
veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mildly dilated LV cavity. Mildly
depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular calcification. Moderate thickening of mitral
valve chordae. Moderate to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
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. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45 %). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is moderate
thickening of the mitral valve chordae. Moderate to severe (3+)
mitral regurgitation is seen.
IABP in good position.
POST CPB:
Improved LV systolic function EF =55%. With back groung epi
infusion.
Annuloplasty ring in mitral position. Mechanically stable and
well seated. Good leaflet excursion , with no MR.
[**Name14 (STitle) 8751**] by PHT = 1.7 cm2/Mean Gradient = 7. 0 mm HG. (Cardiac Output
= 8.0 L/min)
No other change.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-11-28**] 13:30
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 103627**], [**Known firstname 900**] [**Hospital1 18**] [**Numeric Identifier 103628**] (Complete)
Done [**2141-11-28**] at 11:27:29 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2060-12-20**]
Age (years): 80 M Hgt (in): 70
BP (mm Hg): 125/43 Wgt (lb): 143
HR (bpm): 78 BSA (m2): 1.81 m2
Indication: Atrial flutter.
ICD-9 Codes: 427.32
Test Information
Date/Time: [**2141-11-28**] at 11:27 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2007W0-0:0 Machine: Vivid i-4
Sedation: Patient was monitored by a nurse throughout the
procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.
AORTA: Complex (mobile) atheroma in the aortic arch. Complex
(>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Trivial MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was sedated for the TEE. Medications
and dosages are listed above (see Test Information section). No
TEE related complications.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is grossly preserved (not fully visualized). There are
complex (mobile) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear mildly thickened. The aortic valve
leaflets are mildly thickened. A mitral valve annuloplasty ring
is present. Trivial mitral regurgitation is seen.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-11-28**] 17:40
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] V on WED [**2141-11-29**]
5:40 PM
Name: [**Known lastname 103627**], [**Known firstname 900**]
Unit No: [**Numeric Identifier **]
Service:
Date: [**2141-11-24**]
Date of Birth: [**2060-12-20**]
Sex: M
Surgeon: [**Name6 (MD) 59497**] [**Name8 (MD) **], [**MD Number(1) 79029**]
OPERATION: Coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery and
saphenous vein grafts to the ramus, obtuse marginal and
posterior descending arteries and mitral valve repair with a
size 28 [**Doctor Last Name **] physio-ring.
ASSISTANT: [**Name6 (MD) 59498**] [**Name8 (MD) 59499**], MD
PREOPERATIVE DIAGNOSIS: This 80-year-old patient presented
with shortness of breath and lightheadedness and was found to
be in congestive heart failure. He was investigated and was
found to have severe triple-vessel disease with 80% left main
stem lesion, with severe mitral regurgitation and pulmonary
edema. He was electively intubated preoperatively and had a
balloon pump placed after angiogram. He was taken to the
operating room for coronary artery bypass grafting and mitral
valve repair or replacement. An intraoperative
transesophageal echocardiogram confirmed severe mitral
regurgitation with ejection fraction of about 45%.
POSTOPERATIVE DIAGNOSIS: This 80-year-old patient presented
with shortness of breath and lightheadedness and was found to
be in congestive heart failure. He was investigated and was
found to have severe triple-vessel disease with 80% left main
stem lesion, with severe mitral regurgitation and pulmonary
edema. He was electively intubated preoperatively and had a
balloon pump placed after angiogram. He was taken to the
operating room for coronary artery bypass grafting and mitral
valve repair or replacement. An intraoperative
transesophageal echocardiogram confirmed severe mitral
regurgitation with ejection fraction of about 45%.
INCISION: Routine median sternotomy.
FINDINGS: The left internal mammary artery was of excellent
quality. The long saphenous vein from the leg was of moderate
quality, somewhat small in size. The ascending aorta was
normal size with some palpable disease in the innominate
artery. The left anterior descending artery was a good 2.5 mm
diseased vessel as was the ramus artery. The obtuse marginal
artery was a 1.5 mm vessel. The posterior descending artery
was a 2 mm vessel. The mitral pathology was mainly annular
dilatation and central regurgitation with no leaflet prolapse
as was seen in the transesophageal echocardiogram. This was
amenable for repair with complete ring. The left atrium was
moderately dilated with no clots.
PROCEDURE: After informed consent, the patient was
transferred from the intensive care unit intubated and with a
balloon pump to the operating room. The patient remained
hemodynamically stable. He was prepped and draped in routine
fashion. Median sternotomy incision was made. Simultaneous
harvesting of the pedicle of the left internal mammary artery
and endoscopic harvesting of the long saphenous vein from the
leg were done. The mammary artery was of good quality. The
vein was small in some sections, otherwise usable. The best
pieces were used for the grafting. Next the pericardium was
opened. The patient was fully heparinized. Cardiopulmonary
bypass was instituted using ascending aortic arterial cannula
and a 3-stage venous cannula in the right atrium and IVC,
antegrade as well as retrograde coronary sinus catheters were
inserted. The patient was cooled down to 32 dB Centigrade.
The aorta was crossclamped. Myocardial protection obtained by
infusion of antegrade as well as retrograde coronary sinus
infusion of cold multidose blood cardioplegia along with
topical iced saline. After arresting the heart, bypass
grafting was commenced. First the ramus artery which was a
2.5 mm vessel was opened. A piece of reversed saphenous vein
graft was anastomosed to this using 7-0 Prolene sutures. Next
the posterior descending artery which was opened quite
proximally, a 2 mm vessel and another piece of vein was
anastomosed to this. Next the obtuse marginal artery was
exposed very proximally. Distally it was quite small. Very
proximally, it was about a 2 mm vessel and another piece of
vein was anastomosed to this. Next the mitral valve was
approached through a left atriotomy. A size 28 Physio
complete ring was chosen. This was inserted using 2-0
Ethibond interrupted sutures. The ring was tied down
satisfactorily with no residual mitral regurgitation. The
left atriotomy was closed in layers of Prolene. Next during
the process of rewarming, the left internal mammary artery
was anastomosed to the left anterior descending artery which
was a 2.5 mm good vessel. Using a single aortic crossclamp
technique, the 3 proximal ends of the vein graft were
anastomosed to the ascending aorta. The crossclamp was
removed. Heart started beating spontaneously in a slow
rhythm. Atrial and ventricular pacing wires were inserted.
Thorough de-airing of the heart was done through the aortic
root cannula and was confirmed by echo. After full rewarming
to 37 dB Centigrade, cardiopulmonary bypass was discontinued
uneventfully with no inotropic support. Good biventricular
function and excellent repair of the mitral valve with no
residual regurgitation was confirmed by echo. Routine
decannulation and reversal of heparin with protamine was
done. Good hemostasis was obtained. He had significant
bilateral large pleural effusions. Both pleura were opened
wide and 2 pleural chest tubes along with 2 mediastinal chest
tubes were placed. Sternum was closed with 6 sternal wires.
The wound was closed in layers. The patient was transferred
back to the intensive care unit in stable condition with
minimal inotropic support, minimal chest tube drainage. The
swabs, needles, instrument counts were reported correct at
the end of the procedure.
[**Name6 (MD) 59497**] [**Name8 (MD) **], MD
[**MD Number(2) 69417**]
Dictated By:[**Name8 (MD) 79030**]
MEDQUIST36
D: [**2141-11-24**] 12:40:41
T: [**2141-11-24**] 20:40:02
Job#: [**Job Number 103629**]
OPERATIVE REPORT
[**Last Name (LF) 1533**],[**First Name3 (LF) 1532**] P.
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname 103627**], [**Known firstname 900**]
Unit No: [**Numeric Identifier **]
Service:
Date: [**2141-12-1**]
Date of Birth: [**2060-12-20**]
Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 67965**]
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Respiratory failure.
PROCEDURE: An 8-0 Portex tracheostomy tube and flexible
bronchoscopy, 20 French Ponsky PEG tube placement.
ASSISTANT: [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **], RES and [**Name6 (MD) **] [**Name8 (MD) 41455**], MD
ANESTHESIA: General endotracheal.
IV FLUIDS: 500
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE: Mr. [**Known lastname **] is an 80-year-old
gentleman who underwent a cardiac procedure several days ago
and has had persistent ventilator dependence.
PROCEDURE IN DETAIL: The patient was positioned supine and
had his neck extended and he was prepped and draped in the
usual sterile fashion.
We created a 4 cm incision 1 finger breadth above the sternal
notch and used electrocautery to divide the subcutaneous
tissue and platysma and then split the median raphe between
the strap muscles in a vertical direction. We then suture
ligated the [**Known lastname **] isthmus with 2-0 silk. We absolutely
identified the second tracheal ring and incised the space
between the second and third tracheal rings. We then used an
adenoid punch to resect a portion of the second and third
tracheal rings. We then used electrocautery to achieve
hemostasis of the mucosal surface.
We then withdrew the endotracheal tube past the tracheotomy
and then placed an 8-0 Portex tube into the lumen of the
trachea without undue resistance. We confirmed placement of
the chest rise and end tidal CO2. We then inspected for
hemostasis and were happy. We anchored the tube to the skin
using zero Prolene.
Next, we redraped the abdomen in sterile fashion. We
performed upper endoscopy to the first portion of the
duodenum and found no anatomic abnormalities or mucosal
abnormalities. We insufflated the stomach and then palpated
the left subcostal region and saw good indentation of the
gastric antrum. We saw good transillumination as well.
We placed an angiocatheter percutaneously into the gastric
antrum. Through this, we placed a wire which was grasped with
a snare through the gastroscope and then withdrawn retrograde
through the patient's mouth. We anchored this to the Ponsky
tube and pulled this so that the mushroom cap lay comfortably
on the antral mucosa. This was at 2 cm at the skin level.
We then inspected once more with the scope for any injury and
there was none. All sponge and needle counts were correct x2.
I was present and scrubbed for the entire procedure. At the
completion, we did also do a bronchoscopy and aspirated some
mucopurulent secretions from the right lower lobe.
[**Name6 (MD) **] [**Name8 (MD) **], MD
CHEST (PORTABLE AP) [**2141-12-11**] 7:48 AM
CHEST (PORTABLE AP)
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
INDICATION: Status post CABG. Assess for effusion.
COMPARISON: [**2141-12-7**].
UPRIGHT AP CHEST: The tracheostomy tube is 7.9 cm above the
carina. Sternal wires and valve replacement are unchanged. The
central venous catheter has been removed since [**12-7**]. No
pneumothorax is seen. Moderate pulmonary edema is worsened,
particularly on the right. Bilateral pleural effusions, left
greater than right, persists. No pneumothorax. A gastrostomy is
seen in the left upper quadrant.
IMPRESSION: Worsened congestive heart failure.
Brief Hospital Course:
80 yo M with HTN, DM, anemia, ataxia likely due to spinal
stenosis, and symptoms of peripheral arterial disease presenting
with dyspnea, chest pain, and ECG changes/cardiac enzyme
elevations consistent with NSTEMI.
EKG on admission consistent with lateral NSTEMI with V5-V6
depressions and troponin peak of 1.33, CK peak of 191. ACS
protocol was initiated with ASA, plavix, heparin gtt, high-dose
statin, metoprolol, and ACE-I. He was also transfused 2 units
pRBC to keep his Hct > 30. A TTE was significant for new onset
focal inferior hypokinesis and moderate to severe MR. The
patient was electively intubated for a cardiac catheterization
the following morning after discussion with the patient as he
was unable to lie flat to tolerate a cath secondary to shortness
of breath in spite of diuresis. The cath was significant for
severe 3 vessel disease and an IABP was placed. He was evaluated
by cardiac surgery and he was taken to the operating room on
[**11-24**] where he underwent a CABG x 4/MV Repair. He was
transferred to the ICU in critical but stable condition on
epinephrine, neosynephrine and propofol, and IABP. He received
perioperative Vancomycin because he was inpatient prior to his
surgery. His IABP was dc'd and his epinephrine was weaned to off
on POD #1. He had atrial fibrillation for which he was given
amiodarone, and he subsequently became asystolic. He was paced,
and returned to atrial fibrillation. He was started on heparin.
He was found to have right sided weakness and had a CT of the
head which was negative for acute infarct. He underwent TEE
which showed no thrombus, and he was cardioverted with return to
NSR. He remained ventilator dependent, sedation was held, and
tube feeds were started. A right thoracentesis was attempted for
large right effusion, no fluid was withdrawn, CXR showed large
pneumothorax and a right chest tube was placed. He was extubated
on [**11-30**] and reintubated approximately 1 hour later for
respiratory distress. He was seen by thoracic surgery and
underwent tracheostomy and PEG tube placement on [**12-1**]. He was
started on nafcillin and zosyn for GPC in blood and sputum.
Coumadin was started for afib. He was weaned to trach collar on
[**12-4**] and TF were advanced via peg. On [**12-5**] a CT of the chest
and abdomen was done for increased WBC and revealed a large left
lower lobe effusion which was drain via thoracentesis for 1100ml
of serous fluid. on [**12-6**] he was started empirically on Flagyl
for diarrhea pending results fo cdiff B toxin, cdiff a has been
negative. On [**12-6**], he passed his PMV evaluation but failed his
swallow evaluation. On [**12-7**] he was stable and transferred to
the floor for further management of his post-operative care. He
continued to improved neurologically and on POD #18 he was ready
for discharge to rehab.
Medications on Admission:
Amlodipine 10 mg daily
Simvastatin 20 mg daily
Omeprazole 20mg daily
Hydrochlorothiazide 12.5 daily
Lisinopril 20mg daily
Plavix 75 mg daily
Terazosin 4 mg QHS
Lantus 14 u QHS with humalog SSI
Vitamin D3 400 IU daily
Calcium 500 mg daily
Iron 65mg by mouth daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
8. Insulin Lispro 100 unit/mL Solution Sig: sliding scalew
Subcutaneous every six (6) hours.
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
check inr [**12-13**] and dose accordingly.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-3**]
Puffs Inhalation Q6H (every 6 hours) as needed.
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: through [**12-18**].
13. Nafcillin 2 gm IV Q6H Duration: 3 Weeks
completes [**12-31**]
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 3 days: through [**12-14**].
15. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
CAD, MR now s/p CABG/MV Repair
PMH:
DM, HTN, PVD, anemia, spinal stenosis
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 or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 2450**] after discharge from rehab
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-12-27**] 1:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2142-9-10**] 12:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-12-21**]
2:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2141-12-12**]
|
[
"410.71",
"293.0",
"427.31",
"414.01",
"519.19",
"427.5",
"428.31",
"424.0",
"401.9",
"250.00",
"427.32",
"428.0",
"997.1",
"482.41",
"512.1",
"280.9",
"591",
"790.7",
"E942.1",
"440.21",
"999.9",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"37.23",
"37.61",
"36.15",
"89.60",
"96.56",
"88.72",
"34.04",
"99.04",
"88.56",
"97.44",
"33.23",
"31.1",
"36.13",
"34.91",
"43.11",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
26913, 26978
|
22391, 25227
|
296, 390
|
27096, 27106
|
4020, 7811
|
27405, 28117
|
2980, 3113
|
25540, 26890
|
21763, 21793
|
26999, 27075
|
25253, 25517
|
27130, 27382
|
7860, 8733
|
3128, 4001
|
249, 258
|
21822, 22368
|
418, 2567
|
2589, 2787
|
2803, 2964
|
8743, 21726
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,674
| 185,485
|
34131
|
Discharge summary
|
report
|
Admission Date: [**2155-4-20**] Discharge Date: [**2155-4-25**]
Date of Birth: [**2076-12-21**] Sex: F
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 y/o female with dementia s/p fall from chair, then off porch
1 step above ground. No reported LOC. She was transported to
[**Hospital1 18**] for further care.
Past Medical History:
DM, HTN, Dementia, CAD s/p CABG, h/o chronic anemia, DJD s/p
Right THA
Family History:
Noncontributory
Physical Exam:
Upon admission:
T:98 BP: 143/53 HR:74 RR:22 O2Sats 99% 4L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: lethargic, minimally cooperative with exam,
Orientation: UNABLE TO BE TESTED
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R UNABLE TO BE TESTED
L UNABLE TO BE TESTED
Sensation: UNABLE TO BE TESTED
Reflexes: B T Br Pa Ac
Right 2+-------------
Left 2+------------
Propioception intact:Unable to test
Toes downgoing bilaterally
Pertinent Results:
[**2155-4-20**] 06:40PM WBC-10.6 RBC-3.86* HGB-11.6* HCT-33.2* MCV-86
MCH-30.1 MCHC-35.0 RDW-14.1
[**2155-4-20**] 06:40PM PT-13.3 PTT-24.7 INR(PT)-1.1
[**2155-4-20**] 06:40PM PLT COUNT-179
[**2155-4-20**] 06:40PM CK(CPK)-224*
[**2155-4-20**] 06:40PM cTropnT-<0.01
[**2155-4-20**] 06:40PM GLUCOSE-310* UREA N-34* CREAT-1.3* SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-23 ANION GAP-19
[**2155-4-20**] 09:42PM URINE RBC-0-2 WBC-[**4-29**]* BACTERIA-MANY
YEAST-NONE EPI-0-2
CT HEAD W/O CONTRAST [**2155-4-21**] 5:23 AM
CT HEAD: A high-density extra-axial collection is again noted
along the left temporal and parietal convexity which currently
measures up to 8 mm in thickness, again likely representing a
subdural hematoma. Again noted is mild mass effect on the
adjacent sulci. There is no evidence of new hemorrhage, edema,
shift of normally midline structures, hydrocephalus, or acute
large vascular territory infarction. Encephalomalacic changes in
the right frontal region are unchanged.
Extensive vascular calcifications are again noted in the
cavernous carotid arteries and to a lesser extent the vertebral
arteries. No fracture or bony destruction is seen. There is
under- pneumatization of the mastoid air cells. A small amount
of fluid is seen layering in the right sphenoid sinus. Mucosal
thickening involving the ethmoid air cells and maxillary sinuses
is unchanged. The patient is status post bilateral lens
replacement.
IMPRESSION: Study again limited by patient motion. There appears
to be some interval redistribution of left subdural hematoma. No
new focus of hemorrhage and midline shift seen.
CT ABDOMEN W/CONTRAST [**2155-4-21**] 11:11 AM
FINDINGS:
CT ABDOMEN: The visualized lung bases are clear. There is no
pericardial or pleural effusion. Minimal bibasilar atelectasis
is noted. The liver, gallbladder, adrenal glands, and kidneys
are unremarkable. There is fatty atrophy of the pancreas. Within
the spleen, there is a 1.3-cm hypodense lesion. Extensive
calcification of the aorta and its branches including the
splenic artery, celiac artery, and iliac arteries are noted.
Celiac artery stenosis with post-stenotic dilatation is also
identified (2, 28). There are two right renal veins which drain
into the IVC. The left renal vein is retroaortic and originates
just superior to the confluence. There is no mesenteric or
retroperitoneal lymphadenopathy. There is no free fluid or free
air. Bowel loops are normal in caliber and without focal wall
thickening.
CT OF THE PELVIS: A Foley catheter is within the bladder, which
is collapsed. The rectum, sigmoid colon are unremarkable. There
is no pelvic or inguinal lymphadenopathy. Extensive streak
artifact from the right hip prosthesis limits full evaluation of
this area. There is no free fluid or free air.
BONE WINDOWS: A fracture through the proximal left femur with
dislocation of the distal fracture fragment is noted. There are
no suspicious lytic or sclerotic lesions identified. Extensive
degenerative changes of the spine are noted.
IMPRESSION:
1. Left retroaortic renal vein which arises just above the
confluence of the iliac veins. Duplicated right renal veins.
2. 1.3 cm splenic hypodensity, incompletely characterized on
this study. This likely represents a hemangioma or simple cyst.
3. Extensive aortic artery calcifications and calcifications of
its branches with likely celiac artery stenosis.
4. Left proximal femur fracture with dislocation of the distal
fracture fragment.
HAND (AP & LAT) SOFT TISSUE PO
Reason: eval for fracture of right thumb (1st MC)
FINDINGS: There is a comminuted fracture of the base of the
first metacarpal. No definite intra-articular extension is seen,
although evaluation is suboptimal. There is osteopenia.
Degenerative changes are noted at the DIP joints. Soft tissues
are otherwise unremarkable.
IMPRESSION:
1. Comminuted fracture at the base of the right first
metacarpal. Dedicated views are advised in order to evaluate for
intra-articular extension.
2. Osteopenia.
Brief Hospital Course:
She was admitted to the Trauma Service. She was noted to have a
positive U/A suggestive for a UTI and was treated with a course
of Cipro. Neurosurgery was consulted given her head injuries;
they were non operative. She was loaded with Dilantin, serial
head CT scan was followed and remained stable. She was continued
on the Dilantin for a total of 7 days from time of admission.
Follow up a an outpatient in 4 weeks for repeat head imaging
with Dr. [**Last Name (STitle) **], Neurosurgery.
Orthopedics was consulted for her left femur fracture which was
managed conservatively. She will need to follow up with
Orthopedics in clinic in 2 weeks. She may be WBAT on that
extremity.
Geriatric Medicine was also consulted because of her age,
mechanism of injury, and for delirium which she developed
postoperatively. There were several medication recommendations
made. She was started on standing doses of Haldol initially and
this was later stopped and switched to Zyprexa 5 mg [**Hospital1 **] wit ha
prn dose for increased agitation.
Plastics/Hand Surgery was consulted for her right first
metatarsal fracture. She was fitted for a splint which will need
to remain in place. Follow up in Hand Clinic in the next week.
Her appetite has been only fair, because of her dementia she
does need assistance with feeding. Discussion took place with
the daughter on whether or not to place a feeding tube; the
daughter declined this intervention at this time.
She was evaluated by Physical and Occupational therapy and they
have recommended rehab after her acute hospital stay.
Medications on Admission:
Zocor 80 4x/wk, MVI 1', vit B12, Epogen, Darvocet, Cozaar 50',
Atenolol 50', Glipizide ER 10', Triamterene, HCTZ, Celexa 40',
Namenda 10'
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO at bedtime.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ML
Injection TID (3 times a day).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime).
5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
7. Memantine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO daily ().
8. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule
PO TID (3 times a day) for 1 days.
9. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr [**Last Name (STitle) **]: Two (2)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule [**Last Name (STitle) **]: One
(1) Cap PO M,W,F,S ().
11. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
12. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours).
13. Citalopram 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Cyanocobalamin 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Losartan 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
16. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day).
17. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Rehab & Nursing Home
Discharge Diagnosis:
s/p Fall
Left temporoparietal subdural hematoma
Left subtrochanteric fracture
Right 1st metacarpal fracture at base
Urinary tract infection
Discharge Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 65817**] Neurosurgery in clinic in 4 weeks,
call [**Telephone/Fax (1) 1669**] for an appointment.
Follow up in 2 weeks in [**Hospital 5498**] clinic, call [**Telephone/Fax (1) 1228**]
for an appointment.
Follow up in Plastics/Hand Clinic in the next 1-2 weeks, call
[**Telephone/Fax (1) 3009**] for an appointment.
Completed by:[**2155-4-25**]
|
[
"852.20",
"815.02",
"V45.81",
"331.0",
"293.0",
"599.0",
"820.22",
"250.00",
"294.10",
"272.0",
"V43.64",
"E884.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
8867, 8934
|
5322, 6895
|
278, 285
|
9118, 9125
|
1268, 1803
|
9148, 9537
|
588, 605
|
7085, 8844
|
8955, 9097
|
6921, 7062
|
620, 622
|
230, 240
|
313, 477
|
1812, 5299
|
636, 856
|
871, 1249
|
499, 572
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,507
| 119,553
|
8015
|
Discharge summary
|
report
|
Admission Date: [**2176-11-19**] Discharge Date: [**2176-11-23**]
Date of Birth: [**2110-2-1**] Sex: F
Service: [**Hospital1 **]
CHIEF COMPLAINT: Black diarrhea.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 66-year-old
woman with a past medical history significant for end-stage
renal disease (on hemodialysis), type 2 diabetes, and a
history of endocarditis; who, on the evening of [**11-18**],
developed nausea, abdominal cramping, and vomiting at
approximately 10 p.m.
She noted some vomitus of dark fluid which her daughter
reported as appearing like coffee-grounds. She vomited three
times on the night prior to admission, and the crampy pain
was relieved status post vomiting. She also notes weakness,
being lightheaded, and transient dizziness on the morning of
admission while standing. She also noticed diarrhea on
[**11-13**] and has been constipated since then, until the
time of admission. Her last bowel movement was the night
prior to admission. It was hard, and she has not noticed any
bright red blood per rectum. She has had some black stools
for about one week. She denies any fevers, chills, short of
breath, chest pain, dysuria, and lower extremity edema. She
has noticed some mild dyspnea on exertion for the last two to
three days. No paroxysmal nocturnal dyspnea. No orthopnea.
Her exercise tolerance consists of two to three flights of
steps; after which she has to stop to rest. She has no
history of every having a gastrointestinal bleed.
In the Emergency Department, her initial vital signs were a
heart rate of 92, blood pressure was 82/palpation, and oxygen
saturation was 71% on room air. Her blood pressure was
remeasured at 123/80 with a heart rate of 82 without any
intervention. She received several volumes of normal saline
in the Emergency Department, and her blood pressure remained
low at 106/42.
An nasogastric lavage in the Emergency Department revealed
coffee-grounds emesis but cleared. She was guaiac-positive
in the Emergency Department. She received 2 units of packed
red blood cells in the Emergency Department as well as
desmopressin acetate. Ms. [**Known lastname **] also has a left ring
finger ulcer for which she has been taking a significant
amount of Naprosyn for over the last several weeks. This
ulcer was thought secondary to a shunt for dialysis and a
steel phenomena.
PAST MEDICAL HISTORY:
1. Native mitral valve endocarditis; for which she was
ampicillin-sensitive. She was treated with eight weeks of
antibiotics in [**2175-5-21**].
2. End-stage renal disease (on hemodialysis since [**2174-9-21**]).
3. Anemia.
4. Hypertension.
5. Obesity.
6. Gastroparesis.
7. Cataracts.
8. Type 2 diabetes (times three years).
9. Left finger ulcer.
10. Hypercholesterolemia.
11. History of superior vena cava clot (with Perm-A-Cath).
12. Vestibular toxicity (secondary to gentamicin).
13. Second-degree heart block in a Wenckebach pattern.
14. Echocardiogram in [**2175-10-21**] showed mild mitral
regurgitation, moderate tricuspid regurgitation, and a normal
ejection fraction of greater than 55%.
15. Cardiac catheterization in [**2175-7-22**] revealed
50% stenosis of the left circumflex.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Lipitor 10 mg p.o. q.d.
2. Ativan.
3. Phos-Lo 2 mg p.o. t.i.d.
4. Tylenol.
5. Oxycodone.
6. Insulin 70/30.
7. Naprosyn (times three weeks).
8. Prilosec.
9. Aspirin.
10. Nephrocaps.
11. Zestril 10 mg p.o. q.d.
12. Imdur 30 mg p.o. q.d.
13. Subcutaneous heparin.
14. Calcitriol.
15. Timolol eyedrops.
ALLERGIES: CODEINE and PERCOCET (cause nausea and vomiting).
SOCIAL HISTORY: She denies any drug use, alcohol use, or
tobacco use. She lives with her son at home.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 97.9, heart rate was
72, blood pressure was 97/42, respiratory rate was 26, oxygen
saturation was 99% on 4 liters. In general, alert and
oriented times three. In no acute distress. Pupils were
status post cataract surgery. Extraocular movements were
intact. Conjunctivae were pale. Neck examination revealed
no jugular venous distention. Heart had a regular rate and
rhythm. Normal first heart sound and second heart sound. A
2/6 systolic ejection murmur. The lungs were clear to
auscultation bilaterally. The abdomen was soft, obese,
nontender to deep palpation. Rectal examination revealed
normal tone. No masses. Heme-positive. Lower extremity
without any clubbing, cyanosis, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 13.6,
hematocrit was 22.3 (last hematocrit was on [**2176-10-10**]
and was 30; in [**2175-9-21**] her hematocrit was 39), and
platelets were 337. Sodium was 140, potassium was 4.4,
chloride was 96, bicarbonate was 23, blood urea nitrogen was
73, creatinine was 7.8, and blood glucose was 199. INR was
1.4 and PTT was 35. Hematocrit on discharge was 35.1.
HOSPITAL COURSE:
1. ANEMIA AND GASTROINTESTINAL BLEED: Given Ms. [**Known lastname 28683**]
significant hematocrit drop and history of coffee-grounds
emesis (also verified on a nasogastric lavage) and
guaiac-positivity, it was felt that she had a significant
upper gastrointestinal bleed; most likely secondary to recent
nonsteroidal antiinflammatory therapy for her finger ulcer.
She was admitted to the Medical Intensive Care Unit for
careful observation, and they proceeded with an upper
endoscopy on [**2176-11-20**]. The findings on endoscopy
showed a medium-sized hiatal hernia. The mucosa in the
stomach had localized continuous friability with erythema and
congestion of the mucosa with contact bleeding noted in the
antrum. These findings were compatible with gastritis.
There was some patchy erythema, friability, and erosion of
the mucosa with no bleeding noted in the stomach body or
fundus. There were two acute stellate crated nonbleeding
ulcers ranging in size from 5 mm to 15 mm found in the
fundus. The ulcers were white-based with no visible vessel
and no stigmata of bleeding or suggesting of bleeding. The
duodenum had diffuse discontinuous erythema and friability of
the mucosa with contact bleeding compatible with duodenitis.
Following the upper endoscopy, Ms. [**Known lastname **] was transferred
to the floor, and her hematocrits were followed serially.
Her hematocrit stayed stable. She was transfused 2 units of
blood in dialysis on [**2176-11-21**], and her hematocrit on
discharge was 35.1 (up from 22 on the day of admission,
status post a blood transfusion of 4 units).
At the time of discharge, it was felt that her upper
gastrointestinal bleed had been stopped. She was initially
maintained on intravenous Protonix q.12h. She was then
switched to oral Protonix q.12h.
After endoscopy, she was maintained on ice chips and was
eventually advanced to a regular diabetic diet.
2. FINGER ULCER: The finger ulcer was thought secondary to
a steel phenomena related to her dialysis shunt in her left
arm.
On [**2176-11-21**], the Transplant Service took Ms. [**Known lastname **]
to the operating room and ligated the shunt. She was to
follow up with the Plastic Surgery/Hand Clinic on [**2176-12-3**] at 9 a.m. to re-evaluate further treatment for the
ulcerated finger.
3. RENAL SYSTEM: Given the loss of dialysis access from the
shunt, Ms. [**Known lastname **] also received a right internal jugular
Perm-A-Cath which was changed over while in the operating
room by the Transplant Surgery team at the time of ligation
of her dialysis shunt.
Ms. [**Known lastname **] received dialysis on [**2176-11-21**] and on
[**2176-11-23**] prior to discharge; as regularly scheduled.
4. HYPERTENSION: Ms. [**Known lastname **] has had her blood pressure
medications held during her acute gastrointestinal bleed and
were restarted at the time of discharge.
5. PAIN: Given a history of nonsteroidal antiinflammatory
drugs use leading to a gastrointestinal bleed, Ms. [**Known lastname **]
was continued on oxycodone and Tylenol to help her with pain
control, and she was instructed to avoid nonsteroidal
antiinflammatory drugs if at all possible.
6. ENDOCRINE SYSTEM: Ms. [**Known lastname **] was maintained on a
sliding-scale of insulin, and her fingersticks were well
controlled during her hospital stay.
DISCHARGE DISPOSITION: Ms. [**Known lastname **] was to be discharged
back to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient to follow up with Dr. [**First Name (STitle) 805**] as previously
scheduled in the next one to two weeks.
2. Ms. [**Known lastname **] had an appointment with the Plastic
Surgery/Hand Clinic on [**2176-12-3**] at 9 a.m. in the
[**Last Name (un) 469**] Building of [**Hospital1 69**]
([**Hospital Ward Name **]) to evaluate her finger ulcer.
MEDICATIONS ON DISCHARGE: The patient was to continue all
medications previously taken except for Naprosyn. Avoid any
nonsteroidal antiinflammatory drugs (including Naprosyn,
Advil, ibuprofen, and Motrin).
1. Oxycodone 5 mg to 10 mg p.o. every four to six hours as
needed (for pain).
2. Protonix 40 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Ativan.
5. Phos-Lo 2 mg p.o. t.i.d.
6. Tylenol.
7. Insulin 70/30.
8. Aspirin.
9. Nephrocaps.
10. Zestril 10 mg p.o. q.d.
11. Imdur 30 mg p.o. q.d.
12. Subcutaneous heparin.
13. Calcitriol.
14. Timolol eyedrops.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 9126**]
MEDQUIST36
D: [**2176-11-22**] 17:47
T: [**2176-11-25**] 10:59
JOB#: [**Job Number 28684**]
|
[
"996.73",
"E935.9",
"403.91",
"785.4",
"250.00",
"278.00",
"285.9",
"E849.0",
"535.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"39.95",
"45.13",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
8425, 8487
|
8906, 9468
|
3246, 3667
|
5060, 8401
|
8520, 8879
|
9483, 9834
|
164, 181
|
210, 2381
|
2404, 3219
|
3684, 5042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,279
| 122,953
|
32064
|
Discharge summary
|
report
|
Admission Date: [**2149-11-4**] Discharge Date: [**2149-11-12**]
Date of Birth: [**2073-1-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3
History of Present Illness:
76 yo F with known CAD She underwent BMS x 2->OM & BMS x 1 to
LCx on [**9-22**] for NSTEMI and was dc'd home the next day. She again
presented on [**9-27**] with chest pain, +NSTEMI. Cath on [**10-10**] with
totally occluded OM stents, PTCA done. Referred for surgery.
Past Medical History:
CAD (see below)
DM type II
HTN
cryptogenic cirrhosis
Gastric varices s/p GIB in past
bilat carotid stenosis, s/p R CEA
Anxiety
Osteoarthritis (chronic LBP, R hip pain)
s/p cholecystectomy
.
Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
.
Cardiac History:
Percutaneous coronary intervention, in [**2149-9-22**] anatomy as
follows: BMS x 2 to OM1 c/b dissection in LCx requiring
placement of BMS
Social History:
significant for the absence of current tobacco use. There is no
history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Pertinent Results:
[**2149-11-12**] 10:40AM BLOOD WBC-11.9* RBC-2.97* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.7 MCHC-32.4 RDW-17.2* Plt Ct-240
[**2149-11-11**] 11:20AM BLOOD WBC-13.2*# RBC-2.90* Hgb-8.9* Hct-27.8*
MCV-96# MCH-30.8 MCHC-32.1 RDW-16.7* Plt Ct-244#
[**2149-11-12**] 10:40AM BLOOD Plt Ct-240
[**2149-11-11**] 11:20AM BLOOD PT-12.9 PTT-28.4 INR(PT)-1.1
[**2149-11-11**] 11:20AM BLOOD Glucose-174* UreaN-8 Creat-0.6 Na-137
K-4.8 Cl-104 HCO3-27 AnGap-11
BILAT HIPS (AP,LAT & AP PELVIS) [**2149-11-11**] 2:15 PM
BILAT HIPS (AP,LAT & AP PELVIS
Reason: rt hip and rt side pain
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with s/p CABG
REASON FOR THIS EXAMINATION:
rt hip and rt side pain
HISTORY: Right-sided pain.
Four radiographs of the pelvis and bilateral hips demonstrate
acute fracture. The bilateral femoral head contours are smooth.
Sacroiliac joint spaces are not narrowed. Atherosclerotic
calcifications are evident. The pubic symphysis is unremarkable.
No previous studies are available for comparison.
IMPRESSION:
No fracture.
LUMBO-SACRAL SPINE (AP & LAT) [**2149-11-11**] 2:15 PM
LUMBO-SACRAL SPINE (AP & LAT)
Reason: rt hip and rt side pain
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with s/p CABG
REASON FOR THIS EXAMINATION:
rt hip and rt side pain
HISTORY: Pain.
Two radiographs of the lumbar spine demonstrate multilevel
degenerative endplate change and intervertebral body disc space
narrowing. No spondylolisthesis or fracture is evident.
Atherosclerotic calcifications are evident. Surgical staples are
seen in the right upper quadrant. Assessment is limited by
overlying radiopaque wires. Visualized portions of the hip and
sacroiliac joint spaces are unremarkable. Curvilinear calcific
density projecting over the left lower quadrant is not readily
identified on subsequent pelvic and hip radiographs and is of
uncertain clinical significance.
IMPRESSION:
Lumbar spondylosis without spondylolisthesis or fracture.
CHEST (PA & LAT) [**2149-11-11**] 2:16 PM
CHEST (PA & LAT)
Reason: lead position
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with CHB
REASON FOR THIS EXAMINATION:
lead position
HISTORY: Post-cardiac surgery to evaluate for change.
FINDINGS: In comparison with the study of [**11-7**], there is still
substantial opacification at the left base consistent with
atelectasis and pleural effusion. Pleural fluid at the right
base is also seen in this patient status post CABG with dual
pacer leads in place. No evidence of acute pneumonia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 4617**] [**Hospital1 18**] [**Numeric Identifier 75074**]TTE (Complete)
Done [**2149-11-11**] at 9:53:17 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: [**2073-1-23**]
Age (years): 76 F Hgt (in): 61
BP (mm Hg): 120/70 Wgt (lb): 102
HR (bpm): 98 BSA (m2): 1.42 m2
Indication: Coronary artery disease. Left ventricular function.
ICD-9 Codes: 424.0, 786.05, 427.89, 414.8
Test Information
Date/Time: [**2149-11-11**] at 09:53 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2007W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 214 ms 140-250 ms
TR Gradient (+ RA = PASP): *25 to 39 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2149-9-30**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Mild-moderate regional LV systolic dysfunction. Mildly depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Cannot assess regional
RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe inferolateral wall hypokinesis and mild inferior wall
hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %). Right ventricular chamber size
is normal. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2149-9-30**],
the left ventricular regional dysfunction is more evident and
the left ventricular systolic function is worse. The estimated
pulmonary artery systolic pressure has also increased.
Brief Hospital Course:
She was admitted and taken to the operating room on [**11-4**] where
she underwent a CABG x 3. SHe was transferred to the ICU in
stable condition. She was extubated later that same day. She was
found to be in complete heart block with an escape of 40. She
remained in the ICU and was seen by EP. SHe was transferred to
the floor on POD #4. She had a permenant pacemaker ([**Company 1543**])
placed on [**11-10**], and her epicardial wires were pulled. She was
seen by ortho for a fall while in the ICU, and plain films of
her hips and L-spine were taken, there was no evidence of
fracture. She was ready for discharge to rehab on POD #8.
Medications on Admission:
ASA 325', colace 100", Corgard 20', Evista 60', Omeprazole 20',
Enalapril 5', lipitor 80', lasix 40', glargine 20', plavix 75'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day.
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Vasotec 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
9. Humalog 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD now s/p CABG
Postop Complete heart block now s/p PPM
Cryptogenic Cirrhosis
Astric Varices 9s/p GI bleed)[**2147**]
Bilateal Carotid Disease s/p Right endartectomy
Diabetes Mellitus Type 2
Hyperlipidemia
Cholecystectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact surgeon at ([**Telephone/Fax (1) 4044**] with any wound issues.
2) Report any fever greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks from the date
of surgery.
5) No driving for 1 month or while taking narcotics.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 60745**] 2 weeks
DEVICE CLINIC, [**Hospital Ward Name 23**] 7 Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2149-11-19**]
9:00
Completed by:[**2149-11-12**]
|
[
"426.0",
"401.9",
"721.3",
"250.00",
"571.5",
"E878.2",
"414.01",
"997.1",
"410.72",
"715.35"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.83",
"36.12",
"36.15",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
9273, 9303
|
7703, 8343
|
329, 364
|
9570, 9577
|
1327, 1890
|
10041, 10302
|
1225, 1308
|
8520, 9250
|
3408, 3435
|
9324, 9549
|
8369, 8497
|
9601, 10018
|
283, 291
|
3464, 7680
|
392, 662
|
684, 1101
|
1117, 1209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,216
| 188,522
|
17790
|
Discharge summary
|
report
|
Admission Date: [**2196-1-12**] Discharge Date: [**2196-1-23**]
Date of Birth: [**2119-7-18**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 76-year-old male who
presented to [**Hospital6 33**] on [**12-31**] after
experiencing substernal chest pain at rest on the day prior
to admission. Sublingual nitroglycerin had provided mild
relief, but the pain had recurred overnight. The patient had
ST depressions on electrocardiogram, but he subsequently
ruled out for a myocardial infarction; although, he mildly
elevated troponins.
The patient continued to have episodes of chest pain while in
the hospital not associated with electrocardiogram changes.
The patient was transferred to [**Hospital1 188**] to undergo a cardiac catheterization.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Coronary artery disease; status post myocardial
infarction in [**2195-3-18**].
2. End-stage renal disease (on hemodialysis on Monday,
Wednesday, and Friday).
3. Peripheral vascular disease; status post aortobifemoral
bypass in [**2181**].
4. Hypertension.
5. Chronic obstructive pulmonary disease.
6. Hypercholesterolemia.
7. Status post left carotid endarterectomy.
8. Congestive heart failure (with an ejection fraction of
35% to 40%).
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Aspirin 325 mg p.o. q.d.
2. Metoprolol 100 mg p.o. b.i.d.
3. Norvasc 10 mg p.o. q.d.
4. Imdur 120 mg p.o. q.d.
5. Zocor 60 mg p.o. q.d.
6. Lasix 40 mg p.o. b.i.d.
7. Iron sulfate 325 mg p.o. b.i.d.
8. Calcium carbonate 1250 mg p.o. t.i.d.
9. Nephrocaps one tablet p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: The patient presented
to the hospital, and on admission he was afebrile, and vital
signs were stable. Oxygen saturation was 94% on 3 liters
nasal cannula. Lung examination revealed the patient was
clear to auscultation. Heart examination had a regular rate
and rhythm.
HOSPITAL COURSE: The patient underwent cardiac
catheterization which showed moderate diffuse disease with a
95% lesion of first diagonal.
Cardiac Surgery was consulted on hospital day two and planned
for a coronary artery bypass graft by Dr. [**Last Name (STitle) 70**]. The
patient underwent this procedure on [**1-15**]; coronary
artery bypass graft times one for unstable angina.
The patient was extubated on postoperative day one. He had
hemodialysis as well on postoperative day one.
The patient underwent cardiac catheterization again on
postoperative day three which showed the left internal
mammary artery to left anterior descending artery from the
coronary artery bypass graft to be patent. The left anterior
descending artery had a 95% lesion at the bifurcation with
first diagonal as noted in the prior catheterization.
The patient underwent percutaneous transluminal coronary
angioplasty and stent of the left anterior descending artery,
first diagonal, with rescue left anterior descending artery.
The patient had an uncomplicated hospital course except
postoperative day six in the afternoon when the patient had a
6-beat ventricular tachycardia noted on the monitor. The
patient was seen and examined. He was in no acute distress,
and he was asymptomatic with no complaints of chest pain or
shortness of breath and was resting comfortably. The patient
was afebrile with stable vital signs. The patient was given
2 g of magnesium; of which only 1 g was infused before the
intravenous line was lost. The patient was then subsequently
given 400 mg p.o. of magnesium oxide.
An electrocardiogram was checked, which showed no changes
when compared to the previous. Electrolytes were checked in
order to make sure that any discrepancies were corrected.
Cardiology was consulted with regard to any further
intervention regarding the episode, and it was felt that he
did not merit an electrophysiology study.
DISCHARGE DISPOSITION: On postoperative day seven, the
patient was afebrile, vital signs were stable, tolerating a
regular diet, ambulating well, and with good oral pain
control and was felt to be ready for discharge to a
rehabilitation facility and was awaiting placement. The
patient to be discharged to a rehabilitation facility.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 70**] in six weeks.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg p.o. q.d.
2. Calcium carbonate 1250 mg p.o. q.8h.
3. Nephrocaps one tablet p.o. q.d.
4. Simvastatin 60 mg p.o. q.d.
5. Milk of Magnesia 30 mL p.o. q.h.s. as needed (for
constipation).
6. Ibuprofen 400 mg p.o. q.4-6h. as needed.
7. Percocet one to two tablets p.o. q.4h. as needed.
8. Tylenol 650 mg p.o. q.4h. as needed.
9. Enteric-coated aspirin 325 mg p.o. q.d.
10. Colace 100 mg p.o. b.i.d.
11. Lopressor 75 mg p.o. b.i.d.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to a rehabilitation
facility (to be named at a later date).
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times one.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2196-1-23**] 15:20
T: [**2196-1-23**] 02:45
JOB#: [**Job Number 49403**]
|
[
"585",
"428.0",
"416.8",
"272.0",
"414.01",
"997.1",
"411.1",
"401.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"88.55",
"36.06",
"36.05",
"37.23",
"36.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3971, 4283
|
5069, 5400
|
4425, 4897
|
1383, 2013
|
2031, 3947
|
4317, 4398
|
4912, 5047
|
184, 797
|
820, 1356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,179
| 104,640
|
41765
|
Discharge summary
|
report
|
Admission Date: [**2163-10-4**] Discharge Date: [**2163-10-12**]
Date of Birth: [**2087-11-14**] Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / Prochlorperazine / amiodarone
Attending:[**Last Name (un) 11974**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
ventricular tachycardia ablation
History of Present Illness:
Ms. [**Known lastname 90719**] is a 75yo female who initially presented to an OSH
with palpitations. Her AICD fired and she was noted to be in
recurrent v-tach at the OSH ED. She denies CP and SOB.
OSH Course:
She was transferred to the CCU at the OSH and had recurrent
episodes of v-tach with AICD pacing her. Subsequently, her
v-tach resolved spontaneously. In the CCU at the OSH, her vitals
at presentation were 130/90 HR 70-130 (tachycardia was
ventricular tachycardia) T98 RR 20 and satting 96% on RA.
Reportedly, device interrogation demonstrated recurrent runs of
ventricular tachycardia, some of which were pace-terminated but
one of them required of electrical cardioversion on [**2163-10-1**]. CXR
showed cardiomegaly but no lung pathology and EKG with
ventricular tachycardiat at 129 beats per minute, left bundle
branch with superior axis with atypical right bundle branch in
leads V1 and V2. The patient had WBC of 7 and hct of 34 with a
negative troponin and CPK times two, and K 3.4 and Mg 2.0. The
ICD was adjusted, enabling adaptive and pacing thresholds as
well as lowering the detection rate of slow ventricular
tachycardia zone from 140-120 beats per minute. The patient was
started on quinidine 324mg [**Hospital1 **] and her home dose of metoprolol
from 150mg [**Hospital1 **] to 100mg [**Hospital1 **].
.
Vitals on transfer were T 97 HR 70 BP 123/72 RR 18 O2 Sat: 97%
RA
.
On arrival to the floor, patient reported that she is tired, but
is asymptomatic. She denies CP, SOB. She reports ongoing
intermittent palpitations but has never had LOC. She says that
she feels well and is looking forward to her ablation so she can
"stop feeling this way." She does endorse dyspnea on exertion,
which she says is unchanged from her.
Past Medical History:
1. CARDIAC RISK FACTORS: NO Diabetes, NO Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CHF EF 35-45% with posterobasal aneurysm, atrial fibrillation,
bradycardia, 70% obtuse marginal branch stenosis and an occluded
RCA which are medically managed and LAD stent.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: LAD stent. Multiple
percutaneous interventions and ventricular tachycardia ablation
at [**Hospital6 **].
-PACING/ICD: AICD
3. OTHER PAST MEDICAL HISTORY:
1. c. diff colitis- [**2163-6-29**]
2. PVD s/p PTCA of bilateral lower extremities [**2160**]
3. Renal artery stenosis
4. carotid artery stenosis
5. vertebral artery stenosis
6. s/p thyroidectomy; hypothyroidism.
7. s/p appendectomy
8. COPD
Social History:
-Tobacco history: 1 ppd x 60 years ex-smoker, quit 4 years ago.
-ETOH: has not had alcohol for years. She used to drink
occassionally.
-Illicit drugs: denies
Family History:
No family history of CAD. Negative for early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97 BP 123/72 HR 70 RR 18 O2 sat 97% RA
GENERAL: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CN II-XII intact.
NECK: Supple with JVP at clavicles. No carotid bruits.
CARDIAC: RR, normal S1, S2. III/VI systolic murmer. No thrills,
lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi. Diminished breath
sounds at bases bilaterally. Resp were unlabored, no accessory
muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: no pronator drift.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
.
DISCHARGE PHYSICAL EXAM:
BP 86-123/58-79 HR 64-75 >94% RA
no LE edema, JVP at clavicles when patient is at 25 degree
elevation of head of the bed. She is alert and oriented but does
feel "weakness" in LE when ambulating.
Pertinent Results:
ADMISSION LABS
[**2163-10-4**] 01:15PM BLOOD WBC-11.1* RBC-4.05* Hgb-12.6 Hct-36.0
MCV-89 MCH-31.1 MCHC-35.1* RDW-16.4* Plt Ct-210
[**2163-10-6**] 03:28AM BLOOD Neuts-83.2* Lymphs-9.8* Monos-5.2 Eos-0.9
Baso-0.8
[**2163-10-4**] 01:15PM BLOOD Plt Ct-210
[**2163-10-4**] 01:15PM BLOOD Glucose-76 UreaN-21* Creat-1.2* Na-129*
K-4.6 Cl-91* HCO3-27 AnGap-16
[**2163-10-4**] 01:15PM BLOOD Calcium-8.7 Phos-4.2 Mg-2.2 Cholest-141
PERTINENT LABS AND STUDIES
[**2163-10-4**] 01:15PM BLOOD Triglyc-60 HDL-45 CHOL/HD-3.1 LDLcalc-84
[**2163-10-4**] 01:15PM BLOOD TSH-6.4*
DISCHARGE LABS AND STUDIES
[**2163-10-12**] 05:35AM BLOOD WBC-7.2 RBC-3.26* Hgb-10.0* Hct-29.2*
MCV-89 MCH-30.7 MCHC-34.3 RDW-16.2* Plt Ct-228
[**2163-10-12**] 05:35AM BLOOD Plt Ct-228
[**2163-10-6**] 03:28AM BLOOD PT-12.4 PTT-27.7 INR(PT)-1.0
[**2163-10-12**] 05:35AM BLOOD Glucose-86 UreaN-18 Creat-1.4* Na-129*
K-4.3 Cl-95* HCO3-26 AnGap-12
[**2163-10-12**] 05:35AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
Brief Hospital Course:
71yo female with significant past cardiac history presenting s/p
ablation for ventricular tachycardia, now with ongoing
hypotension and malaise.
.
ACUTE CARE
# RHYTHM: Initially presented with paroxysmal ventricular
tachycardia, for which she would receive ICD firings. She is s/p
ablation but did have VT on the table so it may not have been
successful. Patient is refusing amiodarone due to history of QT
prolongation. She has had [**4-2**] nonsustained beats of vtach, which
the patient reports some fluttering at the time of these
findings. Mexiletine was started [**10-11**], with improvement in blood
pressures (previously had been symptomatically hypotensive to
the systolic 80s with feelings of "dizziness and weakness" and
some orthostatic hypotension).
.
# CORONARIES: known CAD. Medically managed and s/p PCI.
Continued [**Last Name (LF) **], [**First Name3 (LF) **], BB, statin. Stopped Imdur as the patient
is not having anginal chest pain. She presented on Metoprolol
tartrate 150mg [**Hospital1 **] but was not tolerating this dose after her
ablation and is on a lower dose of metoprolol tartrate now, 25mg
[**Hospital1 **]. She had not previously been on an [**Last Name (LF) **], [**First Name3 (LF) **] Lisinopril 5mg
was started. Lipids not at goal with LDL of 141 in setting of hx
of CAD, continue statin therapy, consider uptitration of statin.
.
# UTI: Bactrim started [**10-8**], completed a 5 day course. Culture
did show e. coli which was sensitive to bactrim. Patient was asx
and it was an incidental finding.
.
# PUMP: CHF with EF of 35%. Currently optimized and not
fluid-overloaded, not symptomatic. Continued Aldactone. The
patient did have hypokalemia prior to starting her Aldactone but
this was resolved after introduction of the aldactone. She could
not tolerate Lasix, as her hypotension was limiting. She is
being discharged without this medication, but it could be
restarted in the outpatient setting.
.
# HYPOTHYROIDISM: currently asx, on home regimen of
levothyroxine, the patient is s/p thyroidectomy. TSH elevated at
6.6, will allow for outpatient f/u because we will do not
increase synthroid in the inpatient setting.
.
CHRONIC CARE
# GERD: continued Ranitidine. Not symptomatic during
hospitalization.
.
#COPD: continued Spiriva
.
# PSYCH: insomnia and anxiety-continued home ambien 5mg qhs. She
did have significant anxiety in the setting of her ICD firing
and the procedure and benefited from her home dose of Lorazepam
0.5mg prn 6h anxiety in setting of procedure.
.
ISSUES OF TRANSITIONS IN CARE:
CODE STATUS: DNR DNI
CONTACT: [**Name (NI) 13291**] [**Name (NI) 90719**] (son) [**Telephone/Fax (1) 90720**]
[**First Name8 (NamePattern2) **] [**Known lastname 90719**] Harding (daughter) [**Telephone/Fax (1) 90721**]
PENDING STUDIES: NONE
FOLLOW UP ISSUES OF CARE:
-Finding of elevated TSH (6.6) during hospitalization.
-Finding of elevated LDL (141).
-Note: discontinued Lasix (due to hypotension during the
hospitalization) and started Lisinopril, (because she has known
coronary artery disease and CHF).
Medications on Admission:
1. [**Telephone/Fax (1) **] 325mg daily
2. Lasix 40mg [**Hospital1 **]
3. Spiriva 18mcg daily
4. Levothyroxine 25mcg daily
5. Ambien 5mg qhs
6. Zocor 40mg
7. [**Hospital1 **] 75mg qday
9. Nitroglycerin .4mg prn chest pain
10. Calcium carbonate 1000mg [**Hospital1 **]
11. Ativan .5mg [**Hospital1 **] prn anxiety
12. Imdur 30mg daily
13. Metoprolol tartrate 150mg [**Hospital1 **]
14. Zantac 150mg [**Hospital1 **]
15. Aldactone 25mg daily
17. Lactobacillus gg 1 cap daily
OSH Medications: as above as well as:
- Lasix 40mg [**Hospital1 **]
- Quinidine 324mg [**Hospital1 **]
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day) as needed
for dyspepsia.
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual up to 3 times prn as needed for chest pain.
15. Outpatient Lab Work
please obtain CBC and chemistry on Friday [**10-14**]. Please send
results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone is ([**Telephone/Fax (1) 90722**]
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**]
Discharge Diagnosis:
primary diagnosis: ventricular tachcardia
secondary diagnoses: peripheral vascular disease, peripheral
arterial disease, hypothyroidism, Chronic Obstructive Pulmonary
Disease, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 90719**],
It was a pleasure taking care of you. You were admitted to the
hospital for ventricular tachycardia and you were transferred to
[**Hospital1 69**] for ablation for this
condition. You underwent the ablation with the following result:
improvement in your symptoms.
.
Please note the following changes to your medications:
- STOP Imdur
- STOP Lactobacillus
- STOP Lasix
- DECREASE Metoprolol
- START Lisinopril
- START Mexilitine.
Please keep your follow up appointments with your physicians.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please make an appointment to see your cardiologist within [**4-1**]
weeks.
.
Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
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75,086
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44812
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Discharge summary
|
report
|
Admission Date: [**2140-1-13**] Discharge Date: [**2140-1-15**]
Service: MEDICINE
Allergies:
Diovan
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
abdominal pain
.
Major Surgical or Invasive Procedure:
IJ Central line placement
History of Present Illness:
Patient is a [**Age over 90 **] F with PMH of dementia, a. fib with tachy-brady
syndrome who was brought in from [**Hospital **] rehab with 1 week of
abdominal pain, nausea, vomiting, poor po intake on liquid diet.
She had an ultrasound at [**Hospital 100**] Rehab which showed a gallstone
or porcelain gallbladder. She was treated with oxycodone for
pain and zofran for nausea. She developed acute renal failure
with increase in her creatinine to 3.13 on [**1-11**]. She was given
IVF and her torsemide dose was increased. She initially had a Do
Not Hospitalize order but after discussion with the daugher and
HCP, this was reversed.
.
In the ED, initial VS were: T 96.3 P 45 (30-70) 150/98 16 89% on
RA. Her BP dropped to 56-64 systolic, on recheck was 90/doppler
in L arm, 70/doppler in R arm. BP remained 87/60 after 4L NS and
she was started on levophed drip. Exam showed RUQ abdominal
pain. Her EKG showed afib rvr @ 116, no ischemic change. Stools
were guaiac positive. She was given ceftriaxone and flagyl. CXR
was neg for pna. Pelvic films showed no fx. She was seen by
surgery who recommended zosyn and ERCP eval as HCP does not want
surgery. VS prior to transfer were T 95, P: 107, BP: 117/99, RR:
23, 95% on RA
.
On arrival to the MICU, patient was comfortable. She was
complaining of mild nausea but no abdominal pain at rest.
Past Medical History:
- Hypertension
- Atrial fibrillation
- Dementia
- GERD
- h/o frequent falls, ? association w/syncope
- depression and anxiety
- DM II
- cholelithiasis
Social History:
Russian-speaking only, lives at [**Hospital 100**] Rehab nursing home. Has
daughter. [**Name (NI) **] tobacco, EtOH or drugs
Family History:
Noncontributory.
Physical Exam:
Admission Physical
General: elderly female, smiling, oriented to person, hospital
but not time
HEENT: Sclera anicteric, MMM, oropharynx clear,
Neck: supple, JVP not elevated, R IJ in place
CV: Irregular rate and rhythm (tachy-brady), normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, TTP in RUQ, hypoactive bowel
sounds present, no organomegaly
GU: foley in place
Ext: cool, well perfused, 2+ pulses, 2+ pedal edema
Neuro: CNII-XII grossly intact, moving all extremities, no focal
deficits
.
Discharge Physical
P-109, 100% RA , 130/80
General: elderly female, smiling, oriented to person, hospital
but not time
HEENT: Sclera anicteric, MMM, oropharynx clear,
Neck: supple, JVP not elevated, R IJ in place
CV: Irregular rate and rhythm (tachy-brady), normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, TTP in lUQ,No RUQ tenderness,
hypoactive bowel sounds present, no organomegaly
GU: foley in place
Ext: cool, well perfused, 2+ pulses, 2+ pedal edema
Neuro: CNII-XII grossly intact, moving all extremities, no focal
deficits
.
Pertinent Results:
Admission Labs
[**2140-1-13**] 09:07PM CK(CPK)-65
[**2140-1-13**] 09:07PM CK-MB-6 cTropnT-0.07*
[**2140-1-13**] 09:07PM WBC-6.0 RBC-2.43* HGB-8.5* HCT-26.5* MCV-109*
MCH-34.9* MCHC-32.0 RDW-14.6
[**2140-1-13**] 09:07PM PLT COUNT-234
[**2140-1-13**] 12:30PM URINE OSMOLAL-324
[**2140-1-13**] 12:30PM URINE OSMOLAL-324
[**2140-1-13**] 12:30PM URINE HOURS-RANDOM UREA N-483 CREAT-51
SODIUM-13 POTASSIUM-55 CHLORIDE-25
[**2140-1-13**] 12:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2140-1-13**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-SM
[**2140-1-13**] 12:30PM URINE RBC-0 WBC-7* BACTERIA-MOD YEAST-NONE
EPI-0
[**2140-1-13**] 12:30PM URINE HYALINE-1*
[**2140-1-13**] 12:28PM COMMENTS-GREEN TOP
[**2140-1-13**] 12:28PM GLUCOSE-93 LACTATE-1.3 NA+-134 K+-4.3 CL--95*
TCO2-26
[**2140-1-13**] 12:20PM GLUCOSE-101* UREA N-69* CREAT-2.6*#
SODIUM-133 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-26 ANION GAP-15
[**2140-1-13**] 12:20PM ALT(SGPT)-29 AST(SGOT)-19 ALK PHOS-128* TOT
BILI-0.9
[**2140-1-13**] 12:20PM ALT(SGPT)-29 AST(SGOT)-19 ALK PHOS-128* TOT
BILI-0.9
[**2140-1-13**] 12:20PM cTropnT-0.09*
[**2140-1-13**] 12:20PM LIPASE-23
[**2140-1-13**] 12:20PM WBC-6.5 RBC-2.67* HGB-9.4* HCT-28.8* MCV-108*
MCH-35.1* MCHC-32.6 RDW-14.6
[**2140-1-13**] 12:20PM PLT COUNT-272
[**2140-1-13**] 12:20PM NEUTS-67.2 LYMPHS-27.3 MONOS-2.8 EOS-2.5
BASOS-0.2
[**2140-1-13**] 12:20PM PT-12.6* PTT-28.2 INR(PT)-1.2*
.
Discharge Labs
[**2140-1-15**] 02:20AM BLOOD WBC-4.9 RBC-2.39* Hgb-8.7* Hct-26.2*
MCV-110* MCH-36.4* MCHC-33.2 RDW-14.8 Plt Ct-238
[**2140-1-14**] 03:54AM BLOOD WBC-5.3 RBC-2.32* Hgb-8.1* Hct-25.4*
MCV-110* MCH-35.1* MCHC-32.0 RDW-14.8 Plt Ct-223
[**2140-1-13**] 12:20PM BLOOD Neuts-67.2 Lymphs-27.3 Monos-2.8 Eos-2.5
Baso-0.2
[**2140-1-15**] 02:20AM BLOOD Plt Ct-238
[**2140-1-14**] 03:54AM BLOOD Plt Ct-223
[**2140-1-15**] 02:20AM BLOOD Glucose-80 UreaN-47* Creat-2.0* Na-138
K-3.8 Cl-106 HCO3-19* AnGap-17
[**2140-1-14**] 03:54AM BLOOD Ret Aut-2.1
[**2140-1-14**] 03:54AM BLOOD Glucose-78 UreaN-55* Creat-2.0* Na-140
K-3.7 Cl-108 HCO3-23 AnGap-13
[**2140-1-15**] 02:20AM BLOOD ALT-25 AST-23 LD(LDH)-324* AlkPhos-105
TotBili-0.8
[**2140-1-14**] 03:54AM BLOOD ALT-22 AST-17 LD(LDH)-234 CK(CPK)-74
AlkPhos-100 TotBili-0.6
[**2140-1-14**] 03:54AM BLOOD CK-MB-6 cTropnT-0.07*
[**2140-1-13**] 09:07PM BLOOD CK-MB-6 cTropnT-0.07*
[**2140-1-13**] 12:20PM BLOOD cTropnT-0.09*
[**2140-1-15**] 02:20AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7
[**2140-1-14**] 03:54AM BLOOD calTIBC-199* VitB12-1727* Folate-16.8
Ferritn-161* TRF-153*
[**2140-1-13**] 12:28PM BLOOD Glucose-93 Lactate-1.3 Na-134 K-4.3
Cl-95* calHCO3-26
.
Micro- Blood cx pending, negative to date
Brief Hospital Course:
Patient is a [**Age over 90 **] F with PMH of dementia, a. fib with tachy-brady
syndrome with 1 week of abdominal pain, nausea, vomiting, was
found to have RUQ pain, gallstones with possible
choledocholithiasis.
.
#Hypotension: Now resolved. Patient presented with RUQ pain,
findings of choledocholithiasis, hypotension and hypothermia.
Patient was volume resuscitated in the ED with 4 L NS. Her
hypotension was likely worsened by her tachy-brady syndrome and
her history of baseline relative hypotension/dehydration.
Suspicion for sepsis was low given the resolved hypotension in
less than 12 hours, no fevers, no leukocytosis or infection
localized. Could also be related to hypovolemia and tachycardia
causing hypotension. Zosyn for choledocholithiasis has been
discontinued
given very low clinical suspicion for cholangitis.BCx, UCx ??????
pending and negative to date.
.
# Abdominal pain: likely secondary to chololithiasis given RUQ
US that showed porcelain gallbladder, intra and extrahepatic
biliary dilation, with CBD measuring up to 17 mm along with RUQ
pain and positive [**Doctor Last Name 515**] sign. These changes however were felt
to be more chronic in nature than acute given normal LFT's.
Would expect her LFTs to be more elevated if gallbladder was
etiology of septic shock and WBC also remains normal. Family is
against any surgical intervention at this time but open to ERCP.
Could be more of a chronic biliary process given porcelain
gallbladder and normal labs, such as a pancreatic or biliary
malignancy. No acute indication for ERCP
.
# Acute on chronic renal failure: Patient's creatinine peaked at
3.13 on [**1-11**], now sl improved at 2.0 with IVF. ARF likely
secondary to poor po intake in the setting of sepsis and
infection. Resolved with fluids to a creatinine of 2.0.
.
#Elevated troponin: also associated with TWI which are resolved
and CE trending down. Patient denies CP currently.Per patient
has had chest pain intermittently for over 20 years. Likely
related to demand ischemia in the setting of hypotension and
tachycardia when the patient was off beta blockade at the
beginning of the admission.
Repeat ECG [**1-15**] revealed no new ischemic changes trop
downtrending from 0.09 to 0.07 and negative CK-MB. Continued
home aspirin 325 mg po daily. Restarted Metoprolol after
hypotension resolved and patient's heart rate stabilized around
100-110.
.
# Macrocytic Anemia: HCT 28.8 sl lower than prior of 34 in [**2138**]
though unclear recent baseline. HCT 26.5-> 25.4 after 4 L NS
likely from hemodilution.Hct stabilized around 26. Continue PPI
for now, will discontinue on discharge to rehab given low
suspicion for gastric ulcer or bleed.Vitamin B12 and Folate
were normal and not iron deficient.
.
#Dementia: Patient has dementia at baseline and is not oriented
to time. She continues to have agitation and is trying to get
out of bed but can reorient. Reoriented frequently. Haldol prn
agitation
# Communication: Daughter
# Code: DNR/DNI confirmed with Ludmila Dymina [**Telephone/Fax (1) 95876**]
# Disposition: back to rehab.
.------------------
Transitional issues
-f/u CBC and creatinine in 1 week time
-Up titrate beta blockade as tolerated to control atrial
fibrillation
- Ensure patient is hydrated
Medications on Admission:
protonix 40mg [**Hospital1 **]
ranitidine 300mg qhs
fludrocortisone .1mg [**Hospital1 **]
topamax 100mg [**Hospital1 **]
naproxen 375mg [**Hospital1 **]
klonopin 1mg qhs, .5mg qAM
symbicort 80mcg 2 puff [**Hospital1 **]
Alb inh and nebs prn
singulair 10mg qhs
fioricet prn
nortriptyline 50mg qhs
asacol 2400mg daily
nimodipine 60mg [**Hospital1 **]
.
Allergies:
amoxicillin
reglan
compazine
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
6. hyoscyamine sulfate 0.125 mg Tablet Sig: Two (2) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary Diagnosis
Hypotension
Dehydration
Chronic Biliary Obstruction
.
Secondary Diagnosis
Atrial Fibrilliation
Coronary artery disease
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of low blood pressures
and high heart rate which we felt was due to dehydration and a
underlying arrythmia which you have. Your low blood pressure
resolved with fluids and your high heart rate improved with the
medication named Metoprolol. [**Name2 (NI) **] signs of infection was found in
your urine or blood. An ultrasound of your liver showed dilated
gall bladder which most likely represents a chronic process of
unknown etiology.
.
There was no changes made to your home medication list.
.
Please follow up with your care at [**Hospital 100**] Rehab.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
[**Hospital 100**] Rehab
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10214, 10299
|
6021, 9279
|
232, 259
|
10489, 10489
|
3225, 5998
|
11388, 11416
|
1964, 1983
|
9721, 10191
|
10320, 10468
|
9305, 9698
|
10625, 11365
|
1998, 3206
|
175, 194
|
287, 1629
|
10504, 10601
|
1651, 1804
|
1820, 1948
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,111
| 134,243
|
4707
|
Discharge summary
|
report
|
Admission Date: [**2130-7-21**] Discharge Date: [**2130-8-3**]
Date of Birth: [**2061-9-19**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
female, admitted to the cardiology service after a recent
accident and presented with signs and symptoms of [**Last Name (un) **]-Tsubo
cardiomyopathy and myocardial infarction related to this.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia,
diabetes mellitus, paroxysmal atrial fibrillation,
hypertension and iron deficiency anemia.
ALLERGIES: She denied any known drug allergies.
MEDICATIONS:
1. Toprol
2. Lipitor
3. Univasc
4. Warfarin
5. Flecainide
6. Metformin
7. Glyburide
SOCIAL HISTORY: She does not smoke or drink.
PHYSICAL EXAMINATION: She appeared comfortable in no
apparent distress. There were bilateral rales on chest
examination with a 9 cm jugular venous distension. The heart
was of a regular rate and rhythm. The abdomen was soft and
nontender.
LABORATORY DATA: Significant for an EKG showing atrial
fibrillation at 93 beats per minute and early repolarization
in V1 to V3 with T wave inversions in V3 through V6 and 1, 2
and F.
Her hemoglobin level was 11.6 and white count 13.7. The INR
was 2.7.
ASSESSMENT: This is a 68-year-old female, admitted to the
cardiology service with [**Last Name (un) **]-Tsubo cardiomyopathy and
myocardial infarction.
HOSPITAL COURSE: She underwent cardiac catheterization. She
was noted to have a depressed ejection fraction. On [**2130-7-22**], she was noted to develop diffuse then focal right lower
quadrant tenderness with nausea. Workup revealed leukocytosis
and a CT scan of the abdomen revealed mesenteric vessel air
near the cecum. Repeat CT scan on [**2130-7-23**], revealed
pneumatosis of the cecum and proximal right colon. She was
also in atrial fibrillation and flutter, which had been
treated with amiodarone and heparin drip.
The patient was seen in consultation by general surgery and
was felt to have right colon and cecal ischemia, possibly a
necrosis, and was taken urgently for exploratory laparotomy.
There were findings of ischemic cecum and scattered areas of
ischemia throughout the transverse colon. She underwent
ileocecectomy with stapling of the ends as she was
hemodynamically unstable with an arrhythmia in the operating
room. Therefore, the abdomen was left open and closed with a
[**Location (un) 5701**] bag and she was taken to the intensive care unit for
further stabilization.
She was stabilized and then brought back to the operating
room on [**2130-7-24**], where the remainder of the colon at
this time appeared pristine and we were able to perform an
ileocolostomy. Please see the operative note for further
details of these procedures.
Postoperatively, she recovered well. She was eventually
weaned and extubated. She remained on anticoagulation for the
atrial fibrillation and flutter, as well as the amiodarone
and Lopressor. She continued to do well. She was diuresed.
She was begun on her diet and advanced well with that. She
was noted to be C-diff positive and was treated with Flagyl
for this. She was well enough on [**2130-8-3**], to be
discharged to home.
DISCHARGE DIAGNOSES:
1. [**Last Name (un) **]-Tsabu syndrome with myocardial infarction and
cardiomyopathy.
2. Ischemic colon requiring ileocolectomy.
3. Atrial fibrillation and flutter.
4. C-difficile diarrhea.
5. Comorbidities of diabetes mellitus, paroxysmal atrial
fibrillation, high blood pressure.
DISCHARGE CONDITION: Improved.
DISCHARGE INSTRUCTIONS: The patient was asked to followup
with Dr. [**Last Name (STitle) **] in 1 week. She was also to followup with her
primary care physician [**Last Name (NamePattern4) **] 1 week. She was to followup with
cardiology, who would monitor her heparin and Coumadin. She
was to continue taking Flagyl for the C-difficile colitis.
She was to supplement her diet with Boost or Ensure
supplement as she advanced further on her diet.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 14981**]
Dictated By:[**Last Name (NamePattern1) 19834**]
MEDQUIST36
D: [**2130-9-27**] 18:52:30
T: [**2130-9-27**] 19:31:13
Job#: [**Job Number 19835**]
|
[
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"578.0",
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"567.2",
"693.0",
"785.51",
"280.9",
"V58.61",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.93",
"99.04",
"99.07",
"00.17",
"88.53",
"45.73",
"37.22",
"96.71",
"88.56",
"47.19"
] |
icd9pcs
|
[
[
[]
]
] |
3548, 3559
|
3229, 3526
|
1431, 3208
|
3584, 4273
|
785, 1413
|
182, 406
|
429, 715
|
732, 762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,130
| 186,411
|
34029
|
Discharge summary
|
report
|
Admission Date: [**2151-7-15**] Discharge Date: [**2151-7-20**]
Date of Birth: [**2077-4-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Biaxin
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Pulmonary Edema, question of acute coronary syndrome.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74yoF with COPD (4L home o2), DM, HTN, CEA, anemia hx of unknown
etiology presents from Lakes [**Hospital 12018**] Hospital with pulmonary
edema, troponin elevation/lateral ST depressions, ?ACS.
Pt had colonoscopy ~[**7-8**] for work-up of chronic anemia, after
prep she developed cough, SOB, and weakness, and was started on
Z-pak by outpt pulmonologist. Pt presented OSH ED [**7-13**] for
continued "cough, SOB, and weakness." At presentation, was
found to be afebrile, HR 107, BP 126/63, RR 28, 93% on 2L. Had
hct 20, wbc 11.4 (3% bands), CXR - L costophrenic angle
blunting, bnp 514, with trop 0.47. She was admitted for cardiac
ischemia in the setting of anemia and given transfusion (3uPRBCs
received, pre-treated with Benadryl), then treated with
cipro/clindamycin for presumed CAP, sputum showed no bacteria.
An EKG showed "possible" ST-depressions in v4-v6. Post
transfusion became acutely SOB, ABG showed desaturation
(7.12/94/62/30), lactate 1.7, 78% sat, and she was intubated.
After intubation, she had SBP in 70s-80s, anuric. An EKG showed
septal q waves, improvement in lat-ST changes. Cardiology
consult was called and suggested possible cardiac cath. Pt
treated with lasix bolus(s) (with 4 250cc NS bolus for unknown
reason), solumedrol (for ?copd component), abx, heparin gtt for
ACS concern, 3uPRBCs on [**7-13**], and propofol.
On arrival to [**Hospital1 18**] CCU ([**7-15**], 16:50), pt alert, on
heparin gtt, low dose profol but awake, bagged ventilation,
switched to mechanical ventilation, 95% Fio2 30%, HR 120,
164/84, afebrile.
.
On ROS (pt's written response), patient appears to have had
approximately 4 courses of treatment with antibiotics for
presumed PNA in last year. Has been on home O2 for 7 years.
.
Cardiac review of systems is notable for absence of CP currently
(although per report had CP at OSH), DOE, PND, orthopnea, ankle
edema, palpitations, syncope or presyncope.
Past Medical History:
1. COPD - 40+ pack yr hx
2. CHF - EF 15-20%, mod mitral insufficiency
3. PVD
4. Carotid endarterectomy
5. Diabetes Mellitus TII - on PO glyburide
6. Anemia - transfusion requiring (at unknown intervals).
Notes report pt refusal of bone marrow biopsies in past, unsure
of indication for BM biopsy.
7. Hyperlipidemia - no statin on med list
8. Cataracts
9. Hypothyroidism - synthroid 200 qd
10. HTN
11. Osteopenia
Social History:
Patient reports rare alcohol use. She has raised 5 children. She
is a former tobacco user, 1 ppd x 30 yrs, quit 20yrs ago.
Family History:
Father died 42 MI. Mother died of colon cancer age 54. On home
O2 x 7 years
Physical Exam:
VS: T 98.8, BP 164/80, HR 115, RR 28, 98% fi02 40%, ps 10, peep
5
Gen - elderly female, communicating with pen, awake, moderately
alert, could not assess orientation, referring to dyspnea on
vent.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVD (+) R, with left carotid bruit. +spider
angiomatas on anterior chest.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, + accessory muscle use, retractions. + crakcles,
R>L. Rhonchi and wheezes diffusely.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Ecchymoses. No stasis dermatitis, 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:
OSH - anterior q waves, twi lateral leads, nl axis/intervals.
[**7-15**] - Nl axis, nl intervals, mild st-lat flattening, ant q
waves, no acute ST changes.
OSH labs:
[**7-13**] - wbc 20.8, d-dimer 2990, trop 1.82, hct 20 (--> 29.9 -->
33 reported 3 uPRBCs), sputum no bacteria (cx -). cr 1.23, tp
6.6, alb 2.8, alk p 142, ast 40, alt 44, tb 2.8.
.
[**7-14**] - wbc 15.4 (15 bands), bnp 1280, hct 35, plat 249. trop
1.5. hdl 31, trig 80, ldl 87. sputum gs (-), sputum cx (-).
.
[**7-15**] - wbc 15.7, 20% bands, hct 26, plat 330, cr 1.5, alt 32,
ast 23, alk p 94, tb 0.6, bnp 1170, trop 1.37. na 135, k 3.7,
cl 98, hco3 20, bun 37, cr 1.54, gluc 145, mg 1.9. bnp 1170.
abg = 7.57, 33, 78 (fio2 30%). ESR 98. INR 1.03.
.
[**2151-7-19**] 06:33AM BLOOD WBC-11.5* RBC-3.52* Hgb-10.6* Hct-31.7*
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.2 Plt Ct-372
[**2151-7-17**] 03:30AM BLOOD WBC-14.1* RBC-3.35* Hgb-10.0* Hct-30.2*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.3 Plt Ct-370
[**2151-7-15**] 05:18PM BLOOD WBC-24.9* RBC-3.53* Hgb-10.7* Hct-32.2*
MCV-91 MCH-30.3 MCHC-33.2 RDW-14.4 Plt Ct-526*
[**2151-7-17**] 03:30AM BLOOD Neuts-89.4* Lymphs-7.4* Monos-2.9 Eos-0.1
Baso-0.1
[**2151-7-15**] 05:18PM BLOOD Neuts-94.2* Bands-0 Lymphs-3.8*
Monos-1.7* Eos-0.1 Baso-0.2
[**2151-7-15**] 05:18PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL
[**2151-7-19**] 06:33AM BLOOD Plt Ct-372
[**2151-7-19**] 06:33AM BLOOD PT-14.4* PTT-38.0* INR(PT)-1.3*
[**2151-7-15**] 05:18PM BLOOD PT-13.3 PTT-36.5* INR(PT)-1.1
[**2151-7-15**] 05:18PM BLOOD Plt Smr-HIGH Plt Ct-526*
[**2151-7-16**] 05:45AM BLOOD Ret Aut-1.6
[**2151-7-19**] 06:33AM BLOOD Glucose-123* UreaN-28* Creat-1.3* Na-143
K-4.0 Cl-98 HCO3-32 AnGap-17
[**2151-7-16**] 05:45AM BLOOD Glucose-192* UreaN-42* Creat-1.3* Na-139
K-4.7 Cl-97 HCO3-26 AnGap-21*
[**2151-7-15**] 05:18PM BLOOD ALT-48* AST-35 LD(LDH)-297* CK(CPK)-69
AlkPhos-123* Amylase-43 TotBili-0.3
[**2151-7-16**] 05:45AM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2151-7-15**] 05:18PM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2151-7-15**] 05:18PM BLOOD TotProt-6.2* Albumin-3.5 Globuln-2.7
Calcium-9.1 Phos-3.5 Mg-2.3
[**2151-7-16**] 05:45AM BLOOD calTIBC-229* TRF-176*
[**2151-7-15**] 05:18PM BLOOD Ferritn-[**2103**]*
[**2151-7-15**] 05:18PM BLOOD IgG-569* IgA-204 IgM-133
[**2151-7-16**] 02:44PM BLOOD Type-ART pO2-110* pCO2-46* pH-7.48*
calTCO2-35* Base XS-9
[**2151-7-15**] 08:51PM BLOOD Type-ART pO2-78* pCO2-49* pH-7.40
calTCO2-31* Base XS-3
[**2151-7-16**] 02:44PM BLOOD Glucose-182* Lactate-0.8 Na-134* K-3.7
Cl-90* calHCO3-33*
[**2151-7-15**] 08:51PM BLOOD Glucose-246* Lactate-1.5 Na-133* K-4.8
Cl-94*
[**2151-7-15**] 08:51PM BLOOD freeCa-1.11*
.
Sputum - GRAM STAIN (Final [**2151-7-16**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
Urine cx (-)
Urinary legionella antigen (-)
.
CXR [**7-15**] - Hyperinflation is consistent with COPD. Bilateral
pleural effusions are small. Pulmonary vascular congestion and
bronchial cuffing suggest cardiac decompensation. Opacification
at the base of the left lung could be either atelectasis,
asymmetric edema or recent aspiration, warranted followup.
[**7-19**] PMIBI - INTERPRETATION:
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a moderate fixed
perfusion defect of the
mid and distal anteroseptal wall and a mild fixed defect of the
inferior wall. Gated images reveal global hypokinesis most
prominently involving the anteriorand inferior walls. The
calculated left ventricular ejection fraction is 33%.
IMPRESSION: 1. Moderate fixed mid and distal anteroseptal and
mild inferior
fixed inferior wall perfusion defects. 2. Global hypokinesis
(LVEF 33%).
Brief Hospital Course:
.
# CAD/Ischemia -Patient denied history of known coronary artery
disease. However, EKGs obtained from outside cardiologist and
EKGs from [**2147**] and [**2148**] demonstrate pathologic Q waves in
anterior leads, suggesting prior infarct in that territory. On
presentation to the outside hospital, she had an elevated
troponin to 1.8 in setting of severe anemia. CKs not elevated.
This was felt to likely be secondary to demand ischemia, as
there were no ST elevations, TWI, or regional pattern. She was
treated with an aspirin, high dose statin and started on
metoprolol. An ACEI was also added this hospital stay. In
addition, a PMIBI was done which and showed Moderate fixed mid
and distal anteroseptal and mild inferior fixed inferior wall
perfusion defects, and Global hypokinesis (LVEF 33%). A
catheterization was deferred after this study (given the
increased risk and absence of evidence of active ischemia) and
follow up with Dr. [**Last Name (STitle) **] (at the request of the patient and
her family)was scheduled as an outpatient.
# Systolic Heart Failure - Initially there were no prior reports
to document cardiac function but outpatient PCP was [**Name (NI) 653**].
She did have a stress test in [**2147**]/[**2148**] that calculated her
ejection fraction as 45%. ECHO [**2151-7-17**] on admission showed EF of
30% with severe hypo/akinesis as noted. She was started on
Lisinpril 5mg daily as well as diuresed when intubated for
respiratory distress. She was ultimately placed on 20mg lasix
daily for chronic management of her CHF. Beta blocker is also
part of her new regimen. Her calcium channel was stopped.
.
# HTN - On admission pt was on verapamil, HCTZ and a beta
blocker at home. These medications were changed and her BP was
ultimately managed with Metoprolol and lisinopril.
.
# Respiratory failure - This was felt to most likely
multifactorial with COPD requiring O2 at baseline, complicated
by CHF with suspected volume overload secondary to bowel prep,
and a pneumonia as she had an elevation in WBC. She was
intubated at the OSH for respiratory failure. She was treated
with Lasix, steroids, and antibiotics. She was subsequently
extubated. She continued a course of antibiotics with
Vancomycin and Levofloxacin. Vanco was stopped because it was
unlikely her pneumonia was MRSA. Initially flagyl was given but
discontinued given sputum showed GPC in clusters. Her steroids
was subsequently tapered from IV to PO. She continued her home
inhalers. She was discharged with two more days of levofloxacin
and no steroids. She is also on home O2 and nebs per her
baseline prior to admission.
.
# ID - no cx data available from OSH, had leukocytosis with
bandemia at OSH, and then on admission to [**Hospital1 78544**] her WBC was 25K,
no bands. Was on cipro/clindamycin at OSH, DC'ed on AM of
transfer, unclear as to thought process behind these agents.
Afebrile during hospitalization. Levo/flagyl was started and
vancomycin was added for sputum which grew GPC in
pairs/clusters. Flagy was subsequnetly discontinued as C.diff
negative x2. She was continued on the abx for 7 day course.
.
# Anemia - normocytic, severe with HCT to 20 when admitted to
the OSH and received transfusion with 3 U pRBCs. BMB had been
rec'd but patient deferred.
Other heme abnormalities on admission included a thrombocytosis,
WBC 28K without fever. Concern for hematological malignancy or
bone marrow infiltration. Globulin gap nl. Appointment with
hematology was made for her as an outpatient. She will see Dr.
[**Last Name (STitle) **] at [**Hospital1 18**].
.
# DM - Type II for unknown duration. Her home oral agents were
held and she was put on a sliding scale. She will be discharged
on her oral regimen that she was one prior to admission..
# Conditioning - PT evaluated patient and recommended PT at
home. Pt left with walker and will be evaluated in the upcoming
days.
Medications on Admission:
HOME MEDS:
Glyburide 1.25 mg qday
Synthroid 200 mcg qday
Verapamil SR 240 mg Qday
Avapro 300 mg qday
HCTZ 12.5 mg qday
MVI
Glucagon 400-500 mg qday
Fosamax 70 mg qwk
Pravastatin 40 mg qday
ASA 81 mg qday
Flovent 110 mcg QID
Albuterol PRN
Metformin 500 mg qday
.
CURRENT MEDICATIONS (on transfer):
insulin sliding scale
multivitamin
synthroid 200mcg qd
protonix 40iv
clindamycin 300 iv q6, DC'ed [**7-15**]
glucophage 500 [**Hospital1 **], DC'ed [**7-15**]
asa 325 qd
lasix 20mg iv q12, DC'ed [**7-14**]
epo 10K MWF
glyburide 1.25 [**Hospital1 **]
Discharge Medications:
1. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-27**] Inhalation Q6H (every 6 hours) as needed.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other
day for 2 days: You have 2 more days of your 7 day antibiotic
course, to end on [**7-23**]. Take on [**7-21**] and [**7-23**].
Disp:*2 Tablet(s)* Refills:*0*
10. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Glucagon (Human Recombinant) 1 mg Kit Sig: 400-500
Injection once a week: Resuming at-home regimen. Address with
PCP.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community Health and Hospice
Discharge Diagnosis:
Primary:
1. Respiratory failure [**2-27**] COPD and pulmonary edema
2. Pneumonia
.
Secondary:
1. COPD - 40+ pack yr hx
2. CHF - EF 15-20%, mod mitral insufficiency
3. PVD
4. Carotid endarterectomy
5. Diabetes Mellitus TII - on PO glyburide
6. Anemia - transfusion requiring (at unknown intervals). Notes
report pt refusal of bone marrow biopsies in past, unsure of
indication for BM biopsy.
7. Hyperlipidemia - no statin on med list
8. Cataracts
9. Hypothyroidism - synthroid 200 qd
10. HTN
11. osteopenia
Discharge Condition:
Stable, vital signs stable, afebrile, speaking on her own,
ambulating with walker, tolerating POs.
Discharge Instructions:
You were admitted to the hospital with respiratory failure and
likely too much fluid in your lungs. You were intubated briefly.
You were treated for a possible infection in your lungs with
antibiotics. In addition, you were given steroids to treat your
COPD.
.
You also were found to have some evidence of coronary artery
disease based on your EKGs. You also have some depression
pumping function of your heart. New medications were started to
help improve your overall cardiac function including Lisinpril
and Metoprolol. You also will take Lasix daily. We are
stopping your verapamil, avapro and hydrochlorothiazide (HCTZ).
.
You had a pMIBI which showed you have had a heart attack in the
past, but the problems with your heart muscle are unlikely to be
fixed at this time with a catheterization. The report also
noted you have an ejection fraction of 33%. You will follow up
with Dr. [**Last Name (STitle) **] in regards to your cardiac care.
.
You should follow up with your PCP [**Name Initial (PRE) 78545**].
You should also see a cardiologist. You have an appointment
with Dr. [**Last Name (STitle) **] on Wed [**2151-7-28**] at 2:20pm in [**Hospital Ward Name 23**]
Building floor 7.
You have anemia and should be seen by a hematologist. You have
an appointment with Dr. [**Last Name (STitle) **] on [**2151-8-13**] at 4 pm.
Please call [**Doctor Last Name 636**] at [**0-0-**] for registration prior to this
appointment.
.
If you have any chest pain, shortness of breath, palpitations,
or other concerning symptoms, please go to the emergency room,
call 911, or call your PCP.
Followup Instructions:
Please make sure to contact Dr.[**Name (NI) 56119**] your primary care doctor
about transferring your records to the clinics at [**Hospital1 18**] prior to
your appointments. Especially important is your colonoscopy
report for your hematology appointment.
PCPProvider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 4023**]
Date/Time:[**2151-7-28**] 2:20 - cardiology
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2151-8-13**] 4:00
Provider: [**Name10 (NameIs) **] HEMATOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2151-8-13**] 4:00
Completed by:[**2151-7-20**]
|
[
"401.9",
"518.81",
"424.0",
"486",
"733.90",
"496",
"250.00",
"V45.89",
"443.9",
"428.21",
"428.0",
"366.9",
"285.9",
"244.9",
"412",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13900, 13959
|
7853, 11766
|
343, 350
|
14509, 14610
|
4007, 7830
|
16254, 16966
|
2910, 2989
|
12364, 13877
|
13980, 14488
|
11792, 12341
|
14634, 16231
|
3004, 3988
|
250, 305
|
378, 2309
|
2331, 2754
|
2770, 2894
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,481
| 162,685
|
29731
|
Discharge summary
|
report
|
Admission Date: [**2109-3-1**] Discharge Date: [**2109-3-21**]
Date of Birth: [**2041-10-30**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
pedestrian struck
Major Surgical or Invasive Procedure:
Right hemicraniectomy
History of Present Illness:
HPI:60 year old male s/p MVA at 5-10 MPH presents with diffuse
SAH, SDH, and multiple skull fractures. He was assessed by the
trauma team upon arrival and thought to have only head injuries.
The patient was admitted to the Trauma service and a bolt was
placed in the ICU. He had elevated ICP so the decision was made
to take him to the operating room.
Past Medical History:
PMHx:unknown
All:NKDA
Social History:
All:NKDA
Medications prior to admission:unknown
Social Hx:unknown
Family Hx:unknown
ROS:unknown
PHYSICAL EXAM:
T:95.9 BP:193/63 HR:46 RR: 20 O2Sats:100% ventilated
Gen: intubated, not moving
HEENT: Pupils:PERRL EOMs-not tested
Neck: in cervical collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: no eye opening, not responding to commands
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally.
III-XII: not tested
Motor: Not moving any extremity spontaneously. Withdraws to deep
painful stimuli in extremities.
Toes mute
CT head:
1) large comminuted calvarial fracture with apparent depression
in parietal region. large assoc. subgaleal hematoma.
2) subarachnoid and subdural hematoma, with leftwards shift of
~8mm. mass effect on right lateral ventricle. suprasellar
cistern appears irregular, concerning for impending
uncal/transtentorial herniation
3) hemorrhage along lateral left globe
Assessment/Plan:
60 year old male w/SAH, SDH with mass effect and concern for
impending herniation. He also has a large comminuted skull
fracture.
- Patient will go to the OR emergently
- SBP < 140
- Will monitor in ICU post-operatively w/Q 1 hour neuro checks
Family History:
not obtained
Physical Exam:
T:95.9 BP:193/63 HR:46 RR: 20 O2Sats:100% ventilated
Gen: intubated, not moving
HEENT: Pupils:PERRL EOMs-not tested
Neck: in cervical collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: no eye opening, not responding to commands
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally.
III-XII: not tested
Motor: Not moving any extremity spontaneously. Withdraws to deep
painful stimuli in extremities.
Toes mute
Pertinent Results:
CT head:
1) large comminuted calvarial fracture with apparent depression
in parietal region. large assoc. subgaleal hematoma.
2) subarachnoid and subdural hematoma, with leftwards shift of
~8mm. mass effect on right lateral ventricle. suprasellar
cistern appears irregular, concerning for impending
uncal/transtentorial herniation
3) hemorrhage along lateral left globe
[**2109-3-1**] 06:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2109-3-1**] 06:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2109-3-1**] 06:25PM URINE RBC-[**7-7**]* WBC-[**7-7**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2109-3-1**] 06:25PM URINE MUCOUS-OCC
[**2109-3-1**] 06:26PM PT-12.2 PTT-23.0 INR(PT)-1.0
[**2109-3-1**] 06:26PM WBC-10.7 RBC-4.82 HGB-14.8 HCT-43.9 MCV-91
MCH-30.7 MCHC-33.7 RDW-14.3
[**2109-3-1**] 06:26PM PLT COUNT-229
[**2109-3-1**] 10:56PM GLUCOSE-174* LACTATE-4.3* NA+-132* K+-3.3*
CL--104
Brief Hospital Course:
Prior to transfer to medicine service:
.
67 year old man who is s/p MVA with resulting traumatic brain
injury, including: depressed right skull fracture, subarachnoid,
subdural, and epidural hemorrhage,
and sagittal sinus laceration. He underwent right-sided
hemicraniectomy, evacuation of hematoma, and dural repair of the
superior sagittal sinus.
.
His hospital course was complicated by what was thought to be a
superior saggital
thrombosis, and interval development of fevers without a clear
microbiological source. He has had a single positive blood
culture with coag positive staph growing - his CVL was removed
and has no growth to date. He has had three sputum samples, two
with MSSA and one with E. Coli, all in the abscence of
radiographic evidence of pneumonia. A single stool sample is
negative for c. difficile.
.
He was given empiric perioperative vancomycin and gentamicin x 3
doses starting on [**3-2**]/7, and then started on vancomycin and
zosyn from [**Date range (1) 8301**], and nafcillin from [**Date range (1) 71203**], for empiric
coverage of fevers. He was also on dilantin from [**Date range (1) 71204**] and
then changed to keppra.
.
His LFT's and pancreatitic enzymes were noted to be elevated on
[**3-6**] with his ALT peaking at 258, alk phos at 623, and lipase at
623, they are all now trending down. He has also had a
progressive leukocytosis with a peak at 22.6, his differential
is left-shifted, but there is no eosinophilia. He also had a
morbiliform rash on his trunk.
After transfer to medicine service:
.
# Fevers. The patient was felt unlikely to have an infectious
source of his fevers and these were thought more likely to
represent drug reaction or central fevers. The patient had
repeat pan-culture (blood, urine and sputum) revealing negative
blood and urine cultures and sputum growing Staph and E. Coli as
known prior to transfer. The patient had no signs of infiltrate
on repeat CXR and therefore his sputum growth was not treated as
a pathogen. Further antibiotics were held and the patient was
maintained off of dilantin (as this may represent a component of
dilantin hypersensitivity syndrome). His fever curve trended
downward. The patient was afebrile for >48 hours prior to
discharge.
.
# Transaminitis. The patient was transferred to the medicine
service with a transaminitis, benign abdominal exam and no signs
on abdominal imaging (abdominal plain film and ultrasound) of an
acute process. This was also felt consistent with a drug
reaction (again possibly dilantin hypersensitivity syndrome).
Hypotensive shock liver was considered, though the patient did
not have a prolonged hypotensive episode. The patient was
maintained off of antibiotics and dilantin. His liver enzymes
continue to trend toward normal.
.
# Pancreatitis. Likely chemical pancreatitis secondary to
numerous acute issues and/or drug reaction. The patient had a
benign abdominal exam and benign abdominal imaging as described
above. The patient was maintained off of possible inciting drugs
and his pancreatic enzymes are trending toward normal.
.
# Traumatic brain injury with bleeding complications. Patient
with a question of mental status changes on the day of transfer.
Head CT revealed no interval change. The patient's earlier
diagnosis of saggital sinus thrombosis was called into question
as the saggital sinus was found to opacify with dye with
extrinic compression causing luminal irregularity. The patient's
IV heparin was discontinued. He received intensive tracheostomy
care. He was continued in a helmet for when out of bed. The
patient was continued on valproic acid for seizure prophylaxis
and underwent an EEG which showed encephalopathy but no active
seizure activity. His mental status and neuro exam was monitored
and unchanged throughout his remaining hospital course, with the
exception of occasional eye opening to voice. The patient was
continued on metoprolol for bp control (target is SBP<120) and
sliding scale insulin for tight glycemic control. The patient's
metoprolol may be titrated up at his extended care facility as
tolerated to 50mg three times daily. The patient underwent PEG
tube placement and IVC filter placement on [**2109-3-19**]. He
tolerated tube feedings for > 4 hours prior to discharge. The
patient should continue on DVT prophylaxis (subq heparin)
despite IVC filter. This can be stopped if overt bleeding
occurs.
.
# Question of saggital sinus thrombosis, though now not to be
the case. See above.
.
# Normocytic anemia. Etiology unclear. On admission, Hct was 43,
24 on the time of discharge. He has been persistently anemic
since his surgery. The patient was trace guaiac positive in the
setting IV heparin when thought to have sagittal sinus
thrombosis. After several units of PRBCs, the patient Hct
stabilized. Iron studies were inconsistent with iron deficiency
and hemolysis labs were not consistent with hemolysis.
.
# Anasarca/edema. Patient with lower extremity edema and left
upper extremity anasarca. Likely secondary to low albumin.
Ultrasounds negative for lower extremity or upper extremity DVT.
.
# Code Status. This was discussed with the patient's daughter
who stated that the patient would have wanted to be fully
rescuscitated unless there is long term evidence that he will
not improve neurologically. He remains full code. This should be
readdressed as the clinical condition is reassessed over time.
Medications on Admission:
unknown
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Last Name (STitle) **]: One (1)
Appl Ophthalmic PRN (as needed).
3. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
4. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
6. Outpatient Lab Work
Blood draw: ALT, AST, AP, LDH, Amylase, Lipase, CBC. To be drawn
within 5 days of discharge. Transfuse for Hct<21.
7. Valproic Acid 250 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO QPM
(once a day (in the evening)).
8. Valproic Acid 250 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO QAM,
QNOON ().
9. Morphine 15 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
10. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): Hold for sbp<100, HR<60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1) MVA resulting in traumatic head injury with subarachnoid
hemorrhage, subdural hemorrhage, epidural hemorrhage, lacerated
superior sagittal sinus from depressed right-sided high
parietal/high frontal skull fracture crossing midline.
--s/p Right-sided hemicraniectomy, evacuation of
hematoma, repair of sinus
2) Fevers - query drug hypersensitivity
3) Chemical pancreatitis (perhaps secondary to #2)
4) Transaminitis/hepatitis (perhaps secondary to #2)
5) Thrombocytosis - query secondary to #2
6) Moderate malnutrition
7) Anemia of inflammation, no evidence for hemolysis, with some
mild blood loss - occult blood positive stools
8) Hypertension
9) Elevation of alpha-1-antitrypsin - query significance - would
repeat when acute inflammatory state subsides
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Discharge instructions for medical service:
.
Your hospital course was complicated by fevers, rash and
elevations in your liver and pancreatic enzymes. This likely was
due to a drug reaction. The most likely culprit drugs are
dilantin and possibly nafcilling. Avoid these medications. Avoid
new antibiotics unless there is a clear source of infection to
be treated. Have your liver and pancreatic enzymes monitored on
blood work within 5 days of discharge to ensure normalization of
these values.
.
You also must have your blood drawn to monitor your hematocrit.
You should receive blood transfusions for Hct <21.
.
Take all medications as prescribed.
.
Wear your helmet when out of bed and with all transfers.
.
Follow-up with Dr. [**Last Name (STitle) **] for further care.
.
Call your doctor for any new fevers, change in mental status or
rising liver or pancreatic enzymes.
Followup Instructions:
Have your blood drawn within 5 days of discharge to ensure
resolution of your liver and pancreatic enzyme abnormalities.
You also should have your hematocrit checked at this time.
Receive a blood transfusion for any Hct<21.
.
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) [**2109-4-16**]. Arrive at 9:00AM for
9:15AM CT scan of your head to be completed in the [**Last Name (un) 469**]
building [**Location (un) **]. Do not eat for 3 hours prior to this study.
Immediately travel from the CT scan to Dr.[**Name (NI) 9034**] office for a
10:00AM appointment at [**Hospital Unit Name 71205**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"577.0",
"401.9",
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"573.3",
"285.1",
"800.15",
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icd9cm
|
[
[
[]
]
] |
[
"02.92",
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"96.6",
"43.11",
"99.04",
"99.05",
"02.02",
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] |
icd9pcs
|
[
[
[]
]
] |
10351, 10421
|
3727, 9128
|
298, 322
|
11241, 11265
|
2702, 2702
|
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|
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|
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807, 867
|
241, 260
|
350, 704
|
2467, 2683
|
2711, 3704
|
2407, 2451
|
726, 750
|
766, 776
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,955
| 138,599
|
27630
|
Discharge summary
|
report
|
Admission Date: [**2145-8-22**] Discharge Date: [**2145-8-29**]
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female, who was visiting her daughter from [**Name (NI) 3908**]. She is
chronically on warfarin therapy for a mechanical aortic valve
replacement. Fall some time prior to admission hitting her
head on a bedside table. Immediately she had epistaxis and as
well she complained of head pain. She was taken to [**Hospital **]
Hospital where a CT scan of the head revealed a 7 mm subdural
hematoma with no midline shift and an INR of 3.9. At the
outside hospital, she was given 2 units of fresh frozen
plasma and 10 mg of subcutaneous vitamin K. She was then
intubated for airway protection and transferred to the [**Hospital1 1444**]. Her repeat head CT at our
institution showed a small subdural hematoma along the falx.
PAST MEDICAL HISTORY: Significant for congestive heart
failure, hypertension, and hypothyroidism.
PAST SURGICAL HISTORY: Significant for mechanical aortic
valve replacement for which she was on warfarin therapy.
MEDICATIONS: Her other medications included potassium,
furosemide and metoprolol.
ALLERGIES: She is not allergic to anything.
SOCIAL HISTORY: As was noted before, she lived in [**State 3908**]
but was visiting her daughter in the area at which time her
accident happened.
PHYSICAL EXAMINATION: Her vital signs at the time of
admission were as follows: A temperature of 97.9, heart rate
89 and normal sinus, blood pressure 148/58, respiratory rate
of 16, and she was 100% on mechanical ventilator, the
settings of which were AC, FiO2 of 1.0, tidal volume of 500,
rate of 16, and a PEEP of 5. On exam, she was noted to be
intubated and sedated. There was an epistaxis balloon that
was placed in the right naris to prevent her nosebleed. She
was also noted to have a large neck goiter. Her oropharynx
was noted to be clear. On heart exam, she was noted to have a
regular rate and rhythm and mechanical S2. On lung exam, she
was noted to be clear to auscultation bilaterally. Her
abdomen was soft and nondistended. She was noted to have
guaiac positive rectal exam. Her feet were warm and well
perfused.
In addition to her CT scan of the head which she received on
admission, she also received a CT of the cervical spine which
revealed no fracture. She had plain x-ray films of her
thoracic, lumbosacral spine as well as of her left femur and
right hip, and these all proved negative for fracture and
dislocation.
HOSPITAL COURSE: She was admitted to the trauma intensive
care unit. Her white count on admission was 8.6 and
hematocrit on admission was 34.2. Her INR had been reversed
from 3.8 to 2.3 with the use of fresh frozen plasma and
vitamin K. Her UA was negative as well. On hospital day 2,
the patient was evaluated off sedation for mental status. She
was noted to be unresponsive to commands which appeared to be
different from prior neurologic exams, and she was taken for
a stat head CT which revealed no acute changes from the prior
CT. She was noted to have a bradycardic episode at the time
and her rhythm at that time was irregularly irregular. The
neurosurgery team who had been following the patient since
admission also evaluated the patient for this alteration in
mental status and recommended that a CT scan be repeated in
the morning. She was cleared for extubation as soon as she
was able to tolerate weaning mode on ventilation. Her
systolic blood pressures were kept below 140 and her INR was
kept below 1.5 in order to minimize the effects of her head
bleed. On postoperative day 3, the patient was extubated and
was somewhat responsive to commands although her mental
status seemed to wax and wane. On exam, she was found to have
bilateral coarse wet crackles and was administered furosemide
with good effect. Cardiac enzymes were also drawn and tested
to rule out a cardiac event and these proved negative.
Despite furosemide therapy, her respiratory status continued
to decline and she was reintubated by the anesthesia team in
the trauma ICU. On hospital day 4, a chest x-ray revealed
worsened pulmonary edema despite furosemide therapy. The plan
was to continue to diurese her until her respiratory status
improved. She was weaned to pressure support ventilation with
good effect. On hospital day 5, the patient was found to be
awake and intermittently following commands. She was noted to
move her head from side to side but had no other spontaneous
movements of extremities. She had been weaned to face tent
but was noted to have respiratory acidosis despite 100% FiO2.
Acetazolamide was started for her respiratory acidosis and
metabolic alkalosis and she was tolerating extubation
relatively well. An EKG revealed left anterior fascicular
block as well as right bundle branch block although her
cardiac enzymes had proved negative. The cardiology consult
was obtained to evaluate the patient for new onset atrial
fibrillation as well as to help manage her congestive heart
failure. They recommended that her beta blocker be restarted.
On hospital day 6, the patient continued to have tolerated
extubation but her mental status never quite improved past
intermittently following commands and responding to voice. A
chest x-ray showed again persistent pulmonary edema that
seemed to be somewhat intractable to Lasix therapy. Later
that day on [**2145-8-29**], the patient's respiratory status
was noted to steadily worsened. The thought was to reintubate
her. As the patient failed extubation twice before and as her
congestive heart failure did not seem to be improving at all,
the patient's family was contact[**Name (NI) **] with regard to their
wishes and the patient's wishes for intubation and
resuscitation. After lengthy conversation with the family and
after the family had arrived at the bedside of the patient,
the patient was made first DNR/DNI and then was made comfort
measures only. She expired at 12:00 p.m. on [**2145-8-29**], in
the presence of her family. The medical examiner was called
and notified about the death. The family declined postmortem
and the medical examiner declined postmortem as well.
DISCHARGE DIAGNOSES:
1. Status post fall.
2. Anticoagulated due to mechanical valve replacement.
3. Congestive heart failure.
4. Hypothyroidism.
5. Respiratory distress.
6. Altered mental status.
DISCHARGE STATUS: Expired.
CONDITION ON DISCHARGE: Expired.
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Doctor Last Name 9032**]
MEDQUIST36
D: [**2145-10-18**] 13:40:22
T: [**2145-10-18**] 14:45:17
Job#: [**Job Number 67503**]
|
[
"852.21",
"401.9",
"V58.61",
"V43.3",
"E884.4",
"428.0",
"241.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6166, 6377
|
2520, 6145
|
991, 1213
|
1384, 2502
|
118, 867
|
890, 967
|
1230, 1361
|
6402, 6712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,979
| 146,051
|
4800
|
Discharge summary
|
report
|
Admission Date: [**2141-12-15**] Discharge Date: [**2141-12-20**]
Date of Birth: [**2066-2-8**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Kefzol / Ciprofloxacin / Levaquin / Augmentin /
Clindamycin / Amiodarone
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypoxic arrest
Major Surgical or Invasive Procedure:
Right femoral TLC placement
Left IJ TLC placement
Right radial arterial line placement
History of Present Illness:
75yp F with multiple medical problems including CAD, CHF, a-fib,
DM, & CRI who presents with increasing BLE edema extending to
upper thighs, 25 lb wt gain over last 3 weeks despite diuretics
(lasix & zaroxolyn). Pt also with increasing erythema/redness to
BLE, greatest R foot where there is also a healing wound -
reports cat landing on foot ~ 2 weeks ago with break in skin. No
drainage. No fevers, but subjective chills (? cold intolerance).
Pt is primarily non-ambulatory, gets around in motorized chair
but increasing difficulty with minimal standing due to pain from
swelling.
Patient admitted to floor, started on vanc and lasix/zaroxlyn.
At 9pm, code blue called. Patient found hypoxic, NSR in 70's
with weak pulse, intubated, PEA, recieved epi x2, chest
compressions, vfib, recieved shock 200J, regained pulse, Afib
w/RVR, BP 98/50. Transferred to the MICU.
Past Medical History:
-CAD S/P CABG in [**2132**]
-CHF EF 40%
-Type 2 Diabetes Mellitus
-Chronic renal insufficiency
-paroxysmal atrial fibrillation, DDD pacer
-ASD
-S/P CEA in [**2135**]
-hyperlipidemia
-recurrent LLE cellulitis
-Iron deficiency anemia
-h/o nephrolithiasis
-diverticulosis
-depression
Social History:
Pt. is widowed having just lost her husband in the last 6 months
Family History:
Non-contributory.
Physical Exam:
on transfer to the MICU
GEN: obese female, intubated
HEENT: NCAT, pupils unequal R>L and minimally reactive, no gag,
ETT and OG tubes in place
PULM: course rhonchi bilaterally with decreased BS at bases
CV: RRR, no murmurs
ABD: grossly obese, hypoactive bowel sounds, mildly distended
GU: foley in place
EXT: [**2-14**]+ pitting edema from feet to groin with erythema, warmth
of RLE
NEURO: intubated, not responding to pain
Pertinent Results:
CT HEAD W/O CONTRAST [**2141-12-15**] 11:15 PM
Examination is limited due to difficulties with patient
positioning. Allowing for this, there is no acute intracranial
hemorrhage, mass effect, or shift of normally midline
structures. Ventricles and sulci are prominent but symmetric,
compatible with involutional change. The [**Doctor Last Name 352**]- white matter
differentiation is grossly preserved. Focal hypodensity in the
periventricular white matter adjacent to the left frontal [**Doctor Last Name 534**]
likely represents a chronic area of ischemia. Osseous structures
are unremarkable. There is mucosal thickening of the ethmoid air
cells.
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
IMPRESSION:
1. Small bilateral pleural effusions and moderate amount of
ascites.
2. No evidence of retroperitoneal hematoma.
3. Gallstones.
EEG Study Date of [**2141-12-17**]
IMPRESSION: This is an abnormal EEG due to the presence of a
slow
background suggesting a moderate encephalopathy of toxic,
metabolic, or
anoxic etiology. No evidence for ongoing seizures was seen.
ECHO Study Date of [**2141-12-17**]
Conclusions:
1. The left atrium appears elongated and slightly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
mildly
depressed. Resting regional wall motion abnormalities include
apical and
septal akinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function appears depressed. Unforutnately, views are limited.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
6. Moderate to severe [3+] tricuspid regurgitation is seen.
There is moderate
pulmonary artery systolic hypertension.
7.There is an echolucent region around th heart which appears to
be
pericardial fat but cannot rule out pericardial clot. No right
sided
ventricular collapse to suggest tamponade. No doppler studies
across the
mitral and tricuspid valve to evaluate for tamponade.
Brief Hospital Course:
[**2141-12-15**] to [**2141-12-20**]
The patient was discovered on the hospital floor in her room
during a routine vital check hypoxic, unresponsive, and apneic
at 9PM on [**12-15**]. Code blue was called, the patient was
resuscitated as described in the HPI and transferred to the ICU.
Etiology of the arrest was thought to be related to likely
aspiration in the setting of CHF. A Head CT was performed that
evening post-arrest with suspicion of bleed [**2-13**] unequal pupils
and poor neuro status. CT was negative for acute bleed. Patient
was seen by neuro on [**2141-12-16**] who found her to have intact
brainstem reflexes but was in a comatose state with a poor
prognosis. EEG was performed and did not show any seizure
activity. A MRI was not done given the patient has pacemaker.
The patient remained intubated until [**2141-12-17**] when she was
extubated. Post extubation she remained in a dissociative state,
awake but unaware of her surroundings, did not follow commands,
non-verbal. She also had intermitent fevers, remained treated
with ABx. A family meeting was held on [**12-20**] and the patient was
made CMO DNR/DNI with all family members in agreement. The
patient expired shortly after being made CMO.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
hypoxic PEA arrest
Discharge Condition:
expired
|
[
"V45.01",
"995.92",
"250.00",
"428.0",
"593.9",
"518.81",
"584.9",
"038.9",
"682.6",
"276.8",
"507.0",
"424.0",
"272.4",
"427.31",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"38.93",
"38.91",
"99.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5641, 5650
|
4363, 5589
|
359, 447
|
5712, 5722
|
2226, 4340
|
1746, 1765
|
5612, 5618
|
5671, 5691
|
1780, 2207
|
305, 321
|
475, 1344
|
1366, 1648
|
1664, 1730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
145
| 138,459
|
23673
|
Discharge summary
|
report
|
Admission Date: [**2145-2-15**] Discharge Date: [**2145-2-22**]
Date of Birth: [**2089-3-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Left subclavian central line - removed [**2145-2-19**]
PICC line - placed [**2145-2-19**]
History of Present Illness:
55 y/o F w/ complicated PMHx w/ known type II aortic dissection
c/b sma occlusion s/p bowel resections c/b short gut syndrome
(now on chronic TPN), s/p recent ARF, s/p recent open chole,
recent MRSA bacteremia on a long course of vancomycin, chronic
stage 4 sacral decub, now is transferred from OSH ED with fevers
to 103 at home. The pt was recently hospitalized [**Date range (1) 60533**] for
ARF felt to be due to ATN, and she was treated with Vanc/Zosyn
for fever and a Stage IV decub. Since she was discharged from
[**Hospital1 18**] off of therapy for her stage IV decubitus ulcer, she did
well until [**1-22**] when she developed fever to 101.9. She was
restarted on Zosyn and vancomycin that day. Blood cultures were
drawn at that time. 2/4 bottles from [**1-22**] grew MRSA. Of note,
her PICC line through which she receives TPN was changed on
[**1-21**], so it was felt less likely that this was the source. She
was complaining of low back and hip pain, and Dr. [**Last Name (STitle) 2716**]
recommended MRI of the pelvis to reassess the SI joint and
sacral decubitus ulcer and possibly an echocardiogram. Pt
states she thinks this was done and did not reveal a source. OMR
notes indicate that repeat blood cultures were drawn on [**1-25**] x1
and [**1-26**] x2 and as of [**2145-1-27**] these were negative. She recently
returned home with VNA from rehab facility on [**2145-2-8**] and has
been doing well until the day PTA when she developed the fevers.
In the ED at OSH, pts blood cx are growing GNR in [**2-6**] bottles.
The pt denies SOB, abdominal pain, dysuria, diarrhea, headache.
She admits to a chronic cough nonproductive of sputum and 3
minutes of L sided sharp chest pain on arrival to [**Hospital Unit Name 153**], not
associated with SOB, nausea, or radiation. She currently feels
chills.
.
In the ED, the pts BP was initially 145/77. However, the pts
SBP was noted to drop to 77/41 with pulse 99, requiring a 3 NS
and then levophed gtt. She was also noted to be febrile to 103
with WBC 11.9, lactate up to 2.4 (resolving to 1.2 s/p fluids),
and CXR was negative for acute process. In ED she was seen by
both vascular and transplant surgery who felt abd was stable and
were concerned fevers were likely [**2-4**] line infection and
recommmended removing PICC line vs. following blood cultures
before removing. The pt was seen by ID wo recommended obtaining
records of pts recent MRI, starting meropenem/levoflox,
obtaining ab imaging to eval for intrab collection, and d/c of
PICC line. She received Vancomycin 1 gm IV, Zosyn, and
Levofloxacin 500 mg IVx1.
Past Medical History:
1. Descending Aortic Dissection [**3-7**], s/p repair, c/b bowel
ischemia and resection. Briefly:
.
-[**2144-3-30**]: fenestration and SMA stent
- [**2064-4-9**]-- Pt underwent stenting of both renal arteries as the
aortic dissection had spread and had stenosed both renal
arteries.
- [**2144-4-16**]-- Abdominal aorta and bilateral pelvic runoff, aortic
dissection and fenestration, removal and replacement of right
renal stent.
- [**2144-4-22**]-- Pts. bowel ischemia worsened, went to the OR for
exploratory laparotomy, ascending aorta to superior mesenteric
artery bypass, Resection of distal ileum, right colon, and
transverse colon, Ileostomy, and subtotal colectomy and small
bowel resection.
Over the next week the pt underwent several
laparotomies/washouts and revisions of her ileostomy. Finally, a
GJ tube was placed for enteral feeding.
- [**2144-6-29**]-- Pt underwent a CT angiogram which demonstrated a
widely patent sma graft, and a stable aortic dissection.
2. Open cholecystectomy [**9-7**].
3. Stage IV sacral Decub (MRSA/VRE)
4. Short gut syndrome, on TPN
5. Bilateral Pneumothorax
6. h/o of G/J tube now removed
7. Anxiety
8. Depression
9. HTN
10. h/o hepatitis
11. h/o Pancreatitis
12. Klebsiella Bacteremia/pneumonia [**9-7**]--complicating pts
cholecystitis
13. MRCP [**1-8**]: 1. Status post cholecystectomy. Normal biliary
system. No evidence for retained stones. No explanation for
abnormal liver enzymes by MRI examination.
14. Recent Hospitalization [**Date range (1) 60534**] for sacral decub:
"dedicated hip and sacrum MRI, which showed the sacral ulcer,
infectious changes tracking up into the SI joint and fluid
around the sciatic notch. In addition, it noted AVN of the left
femoral head. No abscess was seen. The patient was continued on
Vancomycin and started on Zosyn per ID service recommendations.
Per ID recs, the patient will remain on Vanc and Zosyn
indefinitely, and will be followed in [**Hospital **] clinic."--per d/c
summary. MRI [**12-8**]: 1. Edema or minimal fluid within the left
sacroiliac joint, and edema within the adjacent soft tissues,
extending through the sciatic notch. Findings concerning for
underlying infectious etiology. No abcess is identified.
Minimal marrow edema within the left sacrum may be reactive;
while, osteomyelitis cannot be entirely excluded, it is thought
less likely.
15. h/o HIT ab
16. admssion [**Date range (1) 60535**]/05 for MRSA line infection
Social History:
40 pack year history but quit [**3-7**], occ etoh, no illicit drug
use, on disability
Family History:
mother: cad
Physical Exam:
Vs: T 97.7 BP 141/78 P 127, R29 Sat 98%RA CVP 11, SVO2 80
Gen - overweight female, having rigors
HEENT - OP clear, MM very dry, poor dentition
Neck - supple, no LAD, no JVD, no bruits
Cor - RRR, [**2-8**] HSM at LUSB
Chest - CTAB, sternal scar well healed
Abd - midline abdominal scar well healed. Illeostomy
bag with liquid output. +ttp in middle of abdomen to upper left
of colostomy bag, NABS
Ext- warm, well-perfused, no c/c/e
Back - sacral decub (stage IV) with slight erythema surrounding,
ttp. No prurulence or fluctuance.
Neuro: A&Ox3.
Pertinent Results:
[**2145-2-15**] 11:54PM GLUCOSE-102 UREA N-29* CREAT-1.4* SODIUM-139
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
[**2145-2-15**] 11:54PM CALCIUM-8.1* PHOSPHATE-2.2* MAGNESIUM-1.8
[**2145-2-15**] 11:54PM CORTISOL-43.0*
[**2145-2-15**] 11:54PM WBC-12.2* RBC-3.54* HGB-10.5* HCT-30.6*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.8
[**2145-2-15**] 11:54PM NEUTS-90.7* LYMPHS-5.6* MONOS-3.4 EOS-0.1
BASOS-0.2
[**2145-2-15**] 11:54PM PLT COUNT-211
[**2145-2-15**] 11:53PM URINE OSMOLAL-263
[**2145-2-15**] 11:21PM CORTISOL-23.1*
[**2145-2-15**] 10:14PM TYPE-MIX
[**2145-2-15**] 10:14PM HGB-11.2* calcHCT-34 O2 SAT-95
[**2145-2-15**] 06:21PM LACTATE-1.2
[**2145-2-15**] 05:15PM GLUCOSE-92 UREA N-38* CREAT-1.6* SODIUM-132*
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16
[**2145-2-15**] 05:15PM LIPASE-16
[**2145-2-15**] 05:15PM TOT PROT-6.0* CALCIUM-9.4 PHOSPHATE-2.4*
MAGNESIUM-2.1
[**2145-2-15**] 05:15PM CORTISOL-43.4*
[**2145-2-15**] 05:15PM CRP-103.8*
[**2145-2-15**] 05:15PM WBC-11.9* RBC-3.86* HGB-11.6* HCT-33.2*
MCV-86 MCH-30.1 MCHC-34.9 RDW-15.3
[**2145-2-15**] 05:15PM NEUTS-64 BANDS-27* LYMPHS-0 MONOS-6 EOS-1
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2145-2-15**] 05:15PM PLT COUNT-232
[**2145-2-15**] 03:17PM LACTATE-2.4*.
.
CXR: no acute cardiopulm process
EKG: NSR, no ST changes, nl axis
[**2145-2-15**] 06:43AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2145-2-15**] 06:43AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2145-2-15**] 12:50AM GLUCOSE-81 UREA N-46* CREAT-1.5*# SODIUM-135
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
[**2145-2-15**] 12:50AM ALT(SGPT)-67* AST(SGOT)-57* LD(LDH)-116 ALK
PHOS-309* AMYLASE-45 TOT BILI-1.1
[**2145-2-15**] 12:50AM ALBUMIN-3.7 CALCIUM-9.3 PHOSPHATE-3.5
MAGNESIUM-1.5*
[**2145-2-15**] 12:50AM NEUTS-84.9* BANDS-0 LYMPHS-7.6* MONOS-4.5
EOS-2.5 BASOS-0.6
[**2145-2-15**] 12:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2145-2-15**] 12:50AM PLT COUNT-283
[**2145-2-15**] 12:50AM PT-13.4* PTT-31.3 INR(PT)-1.2*
[**2145-2-15**] 12:49AM COMMENTS-GREEN TOP
[**2145-2-15**] 12:49AM LACTATE-1.3
Brief Hospital Course:
Briefly, this is a 55 yo F with MMP including stage IV sacral
decub, PICC for chronic TPN, avascular necrosis with fluid in L
sacroiliac joint, recent MRSA bacteremia, and GNR in blood from
OSH, admitted with sepsis. Pt was found to have positive blood
cx for Klebsiella, now afebrile on vanc and levoflox.
.
# Sepsis/ID: Likely Klebsiella line infection. Pt was
hypotensive and febrile on admission to SBP 70s, requiring
pressors in the ICU. Her WBC was 11.9 with 27% bands on
admission. The pt has a h/o MRSA bacteremia from [**1-22**] and now
GNR in blood (now +for Klebsiella) from [**Hospital3 26615**] ED on [**2-15**].
CXR was negative for acute cardiopulm process and UA was
somewhat dirty but not grossly positive. The pt responded
appropriately to [**Last Name (un) 104**] stim test. Given it was the most likely
source of infection, the pts PICC line was pulled on admission.
Repeat RUQ US [**2-16**] was wnl. TTE on [**2-16**] was negative for
vegetations. Levophed was weaned off [**2-16**] and pts BP has been
holding. Meropenem was d/c'd [**2-16**] after blood cx from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] showed Klebsiella S to levoflox. ID was [**Last Name (NamePattern1) 4221**]
and has been following the pt. the patient was transferred to
the medical floor once stable. It was decided to continue the
levoflox for treatment of the Klebsiella line infection and
Vancomycin for h/o MRSA until she saw ID in clinic for further
f/u.
.
# Sacral Decub: Stage IV. Wound vac was discontinued PTA due to
pain. Per one of pts prior hospitalizations, plastic surgery was
considering a flap. Plastic surgery was [**Last Name (NamePattern1) 4221**] and states
decub appears to be healing well. Wound care was [**Last Name (NamePattern1) 4221**]
regarding decub care. The pt has been receiving pain meds with
oxycodone and dilaudid prn.
.
#Hyponatremia: Na 132 on admission, with baseline 136-140.
Likely hypovolemic in etiology. Na improved after fluids.
.
#URI sxs:
--r/o with influenza DFA; droplet precautions
.
# Elevated LFTs: AST, ALT and alk phos are all down compared to
discharge. These elevations have been present since [**5-7**] prior
to dissection. She had an open cholecystectomy in [**2144-9-3**]
for cholecystitis. Previous workup has included: negative
hepatitis B and C serologies x 2, nml HIDA scan [**9-7**], MRCP
showed s/p cholecystectomy: normal biliary system, no evidence
for retained stones, MRI with no explanation for abnormal liver
enzymes, negative AMA, negative HIV. Abd pain is currently at
baseline. Repeat RUQ US on [**2-16**] was negative
.
# Short gut syndrome: The pt is on chronic TPN. Abd exam seems
stable. Per PCP pt has been on TPN since [**Month (only) 216**] and is followed
by surgery. It is unclear if the pt still needs TPN, so a trial
without TPN had been initiated. However, per nutrition, the
patient needs TPN due to poor absorption given her short gut
syndrome. TPM was re-initiated and the patient had another PICC
line placed for both TPN and her antibiotics.
.
# Anemia: Hct was 32 on admission, was previously 30 on
discharge. The pt has been on epo as outpt started during last
hospitalization for ARF, but unclear if pt still needs it. Her
Epo has been discontinued this admission.
.
# h/o ARF: on last admission was felt [**2-4**] ATN in setting of
hypotension. Cr now 1.5, down from 2.6 on last discharge.
.
# Avascular necrosis with fluid within the L sacroiliac joint:
- repeat MRI here showed persistent fluid in left sacroiliac
joint. On vancomycin. To f/u with ID re: duration of vancomycin.
.
# HTN: The pts hydral and metoprolol were held in the setting of
sepsis. Her BP was normotensive without the medications, so she
was not discharged on either hydral or metoprolol.
.
# FEN: replete prn
.
# PPX: pneumoboots given h/o HIT, no bowel regimen given short
gut syndrome, PPI
.
# Full Code
,
#Communication: HCP [**Name (NI) **] [**Name (NI) 60531**] [**Telephone/Fax (1) 60536**]
.
Medications on Admission:
-zoloft 50mg po qd
-metoprolol 25mg po bid
-hydralazine 150mg po tid
-multivitamin po qd
-vitamin D 800 units po qam
-epogen 10,000 units Inj qMon
-metoclopramide 5mg po qid
-protonix 40mg po qd
-prochlorperzine 10mg po tid prn
-clonazepam 1mg po bid prn
-benefiber qam
-vancomycin 1g IV q72
-hydromorphone 2mg po tid to q4 hours prn
-oxycodone 5mg po q6hours prn
-acetominophen 650mg prn
-trazodone 50mg po qhs prn
-ambien 5mg po qhs prn
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 and HR<55.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*1 bottle* Refills:*0*
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed.
12. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
dose Intravenous Q24H (every 24 hours): Continue until you see
Dr. [**Last Name (STitle) 2716**] on [**2145-3-22**].
Disp:*35 doses* Refills:*0*
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
dose Intravenous Q 24H (Every 24 Hours).
Disp:*35 doses* Refills:*0*
14. IV care
Infusion pump and tubing
15. PICC line
PICC line care per protocol
16. Outpatient Lab Work
Needs weekly CBC, Chem 10, LFTs, Vancomycin trough starting
[**2145-2-23**] drawn - results to be faxed to Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 2716**] at
[**Telephone/Fax (1) 11959**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary - klebsiella bacteremia, sacro-iliac joint enhancement
Secondary - mesenteric ischemia s/p aortic dissection; on TPN;
stage IV sacral decub, depression, HTN, h/o hepatitis, h/o MRSA
line infection
Discharge Condition:
Stable, tolerating TPN, afebrile, walking with PT
Discharge Instructions:
-continue with medications as prescribed
-please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-4**] weeks
-continue with vancomycin and levofloxacin until you see Dr.
[**Last Name (STitle) 2716**] on [**2145-3-22**]
-please see Dr. [**Last Name (STitle) 2716**] on [**2145-3-22**] as scheduled below - it is
very important!
-please come back to the ED if you have any fevers,
dizziness/lightheadedness, shortness of breath, nausea/vomiting,
or any other concerning symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2145-3-4**]
2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2145-3-22**] 10:00 ([**Last Name (NamePattern1) 439**])
Please see your PCP [**Last Name (NamePattern4) **] [**1-4**] weeks for follow-up - call
[**Telephone/Fax (1) 29115**] to make an appointment
Completed by:[**2145-3-25**]
|
[
"579.3",
"995.91",
"585.9",
"276.1",
"707.03",
"996.62",
"401.9",
"V44.2",
"720.2",
"038.49",
"733.42",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14750, 14799
|
8496, 12528
|
294, 387
|
15049, 15101
|
6179, 8473
|
15638, 16112
|
5586, 5599
|
13018, 14727
|
14820, 15028
|
12554, 12995
|
15125, 15615
|
5614, 6160
|
249, 256
|
415, 3003
|
3025, 5466
|
5482, 5570
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,009
| 192,836
|
45103
|
Discharge summary
|
report
|
Admission Date: [**2191-4-2**] Discharge Date: [**2191-4-6**]
Date of Birth: [**2112-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hematuria, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo M h/o HTN, ESRD [**2-18**] to HTN nephropathy, dementia, BPH, LBP
p/w hematuria, chills. Pt was recently admitted [**Date range (1) 96389**]
for penile discharge. [**Date range (1) 159**] was consulted and placed a foley
which revealed purulent discharge. Pt was placed on daily
irrigation with abx, though this was discontinued at the time of
d/c with plans for out-pt f/u with [**Date range (1) **]. Also during that
admission, multiple [**Date range (1) **] cxs grew out E coli. Pt was discharged
with plans for tx with [**Date range (1) **] with HD X 4 weeks. Initially the
pt felt well after discharge and had no complaints. However,
yesterday pt noted mild "chills and sweats." This AM pt noted
large amount of hematuria, but he and his wife decided to go to
HD. Pt with worse chills and sweats at HD. Given persistent
symptoms and worsening hematuria, pt's wife brought him to [**Hospital1 18**]
[**Name (NI) **].
.
In ED, vitals: 96.1, hr 70, 110/50, rr 18, 96% RA. Lactate 1.8.
BUN 23, cr 5.6. Hct 35, baseline 41. CXR with patchy
retrocardiac opacity, likely atelectasis. EKG: nsr@78 bpm, LAD,
RBBB, TWF v2-3 (new). [**Name (NI) 159**] consulted and foley was palced.
Renal called for HD and elected to hold on dialysis today. LIJ
placed for access (white port not flushing). Pt given vanc 1
gram, gent 80 mg for ? endocarditis, flagyl 500 mg given for
prior h/o b frag bacteremia (on admission [**12-22**]), [**Month/Year (2) **] given
for prior e coli bacteremia, tylenol 325 mg. Home BP meds held.
Pt started on labetalol gtt for elevated sbps to 270s, which
were controlled. However, pt's sbps dropped to 70s. Drip turned
off and pt bolused with sbp to 120s. Pt transferred to MICU for
further management.
.
ROS: Denies chest pain, abdominal pain, nausea, vomiting, or
shortness of breath
Past Medical History:
-ESRD related to HTN nephropathy s/p av graft in both arms, R
arm was functional until the past 24h
-HTN x >20 yrs
-Multivascular dementia
-BPH
-Chronic LBP with DJD, spinal stenosis
-Macrocytic anemia, unclear etiology
-Bacteremia - [**12-22**]- Ecoli and B. Fragilis; [**3-23**] - Ecoli
-Prostatitis - [**3-23**] - CT of prostate with hypodense area and
Ecoli in penile discharge swab and [**Month/Year (2) **]. Daily bladder
irrigation through the Foley with fluid containing
Neomycin-Polymyxin was done. Pt discharged on 4 weeks of [**Month/Year (2) **]
as endocarditis not ruled out on TEE.
Social History:
Lives w/ wife in [**Location (un) 686**]. Retired plumber; no tob, etoh or
drugs;
No recent sexual activity.
Family History:
NC
Physical Exam:
Vitals- 98.4, 158/p, 78, 20, 100% RA
Gen - Alert, no acute distress, but appears confused.
HEENT - PERRL, extraocular motions intact, anicteric, MMM
Neck - no JVD, no cervical lymphadenopathy, central line left
neck without erythema
Chest - Clear to auscultation bilaterally
CV - irregularly irregular, nml s1,s2. No murmurs noted.
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - 2+ DP, PT pulses bilaterally, no edema or cyanosis, warm
and well perfused.
Skin - No rashes or petechiae noted.
foley catheter in place. draining bright red [**Location (un) **].
Pertinent Results:
[**2191-4-2**] 02:10PM PLT COUNT-255
[**2191-4-2**] 02:10PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+
[**2191-4-2**] 02:10PM NEUTS-75.6* LYMPHS-16.1* MONOS-3.9 EOS-2.9
BASOS-1.6
[**2191-4-2**] 02:10PM WBC-6.6# RBC-3.49* HGB-11.4* HCT-35.8*
MCV-103* MCH-32.7* MCHC-31.9 RDW-17.2*
[**2191-4-2**] 02:10PM CALCIUM-9.2 PHOSPHATE-3.8# MAGNESIUM-2.0
[**2191-4-2**] 02:10PM CK-MB-NotDone cTropnT-0.28*
[**2191-4-2**] 02:10PM CK(CPK)-94
[**2191-4-2**] 02:10PM estGFR-Using this
[**2191-4-2**] 02:10PM GLUCOSE-136* UREA N-23* CREAT-5.6*#
SODIUM-142 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-36* ANION GAP-16
[**2191-4-2**] 02:27PM LACTATE-1.8
[**2191-4-2**] 02:27PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2191-4-3**] 12:00AM HCT-28.9*
.
CHEST (PORTABLE AP) [**2191-4-2**] 2:33 PM
UPRIGHT AP CHEST: Heart size is normal, though there is a left
ventricular configuration. Mediastinal and hilar contours are
unchanged. There is minimal patchy opacity in the retrocardiac
area which likely reflects atelectasis. There is no definite
consolidation. No evidence of failure. No pleural effusion or
pneumothorax. Flecks of dense material are seen within the
bowel, likely reflecting bits of retained barium from recent CT.
-Minimal patchy opacity in the retrocardiac region likely
reflects atelectasis. To better evaluate this area, a lateral
view could be obtained.
.
EKG [**2191-4-2**]
Baseline artifact. Sinus rhythm. Atrial ectopy. Left axis
deviation with left anterior fascicular block. Right
bundle-branch block. Compared to the previous tracing of [**2191-3-29**]
no significant diagnostic change.
.
[**2191-4-4**]- TTE
The left atrium is dilated. The right atrium is moderately
dilated. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2191-3-26**],
there is
sginificant change. No vegetation is seen on either study.
Brief Hospital Course:
79 yo M h/o HTN, ESRD [**2-18**] to HTN nephropathy, dementia, BPH, LBP
p/w hematuria, chills.
.
In MICU continued [**Month/Day (2) 21347**], flagyl and vanc dosed by levels. Foley
with numerous clots, periodically flushed. Dialysis planned for
Tuesday as per renal, with [**Month/Day (2) **] 2 grams IV to be given during
hemodialysis. Stabilized BP on home meds. Question of vegetation
on TTE [**3-26**] admission.
.
#Fever/chills: Question of endocarditis (especially given
previous ECHO) vs. prostatic infection, abscess. Vanc and flagyl
DC'd shortly after initiation. Continued [**Month/Year (2) 21347**] 2 gm per
dialysis. TTE with no evidence of vegetation. Wife would not
like TEE at this time. E-coli bacteremia noted. Frequent bouts
of prostatis, but family not interested in TURP at this time. ~6
week course of [**Month/Year (2) **].
.
#hematuria: ddx includes prostatitis v abscess v prior trauma
from foley placement.
foley in place by [**Month/Year (2) **]. Monitored crit which were stable.
[**Month/Year (2) 159**] had replaced the 16F Coude catheter placed in ED,
numerous clots irrigated from the bladder. As patient did not
produce much urine, it was difficult to tell whether foley was
clotted vs. his baseline anuria. Irrigated the foley regularly
to clear out any residual clots. Clear urine at the time of
discharge. Patient denied any pain. No white count or fever,
hemodynamically stable. Transfused PRBC's last 2 units on
[**2191-4-5**]. [**Date Range 159**] follow up.
.
ESRD: on HD as an out-pt. Dialysis as per renal during
admission. Electrolytes stable. Continued sevelamer, nephrocaps,
CaCo3, cinacalcet.
.
#HTN urgency: transient HTN, resolved with gtt and now stable on
no meds. Transient hypotension, likely related to Labetolol
drip. No evidence of sepsis. Continue amlodipine and metoprolol
[**Hospital1 **]. Stable [**Hospital1 **] pressure on the floor up to discharge.
.
#elevated tpn: in setting of renal failure. Minimal non-specific
EKG changes. Pt asymptomatic. Pt was ruled out.
.
#FEN: renal/HH diet, IVF as above
#ppx: pneumo boots, po diet
#Full Code
Medications on Admission:
Amlodipine 7.5 mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Levothyroxine 25 mcg daily
Cinacalcet 30 mg daily
nephrocaps
Ceftazidime 2 gm QHD X 4 weeks ([**Date range (3) 96388**]).
Sevelamer 800 mg tid
Calcium Carbonate 500 mg tid
.
MEDS on transfer to the floor:
Levothyroxine Sodium 25 mcg PO DAILY
Amlodipine 7.5 mg PO DAILY
Metoprolol 25 mg PO BID
Calcium Carbonate 500 mg PO TID W/MEALS
Nephrocaps 1 CAP PO DAILY
CeftazIDIME 2 gm IV QHD
Senna 1 TAB PO BID:PRN
Cinacalcet HCl 30 mg PO DAILY
Sevelamer 1600 mg PO TID
Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day). Tablet(s)
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. CeftazIDIME 2 gm IV QHD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
E-coli bacteremia
Prostatitis
Hematuria
Hypertension
ESRD secondary to hypertensive nephropathy
.
Secondary:
s/p av graft in both arms, R arm is functional
Multivascular dementia
BPH
Chronic LBP with DJD, spinal stenosis
Macrocytic anemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with fever, chills, bleeding from urethra with
clots. Your [**Date range (3) **] pressure was also very elevated, and then
dropped after being placed on a Labetolol drip. You were given
dialysis, foley catheter placed and flushed. You were continued
on [**Last Name (LF) 21347**], [**First Name3 (LF) **] antibiotic given to you at dialysis. A repeat TTE
demonstrated no vegetation concerning for endocarditis, and your
wife would not like a TEE at this time.
-Please continue [**First Name3 (LF) 21347**] 2 grams every dialysis until ID follow
up on [**2191-4-25**]. A decision will be made at that time to continue
with [**Date Range 21347**] or to have course of cipro or bactrim.
-You will have a 6 week course of [**Date Range **] for your e-coli
bacteremia, prostatis.
-You will need your LFT's and CBC checked weekly at dialysis.
-Please maintain all appointments, with your [**Date Range 3390**], [**Name10 (NameIs) **] and kidney
doctors.
-Please return to the hospital if you are feverish, have
bleeding through your urethra, altered mental status, severely
elevated [**Name10 (NameIs) **] pressure, or any other symptoms concerning to you
or your wife.
.
Changes to your medications:
-Your Metoprolol was increased to 50 mg twice daily
-Sevelamer was increased to 1600 three times a day
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD. Phone [**Telephone/Fax (1) 133**]: Date/Time
[**2191-4-15**] 3:00 PM
-Will follow up on pending [**Month/Day/Year **] culture results.
.
Please follow up with Dr. [**Last Name (STitle) **] tomorrow at Dialysis in
[**Location (un) **]. Discussed with Mrs. [**Known lastname 24110**], and she will see Dr.
.
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2191-4-13**]
10:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2191-4-25**] 9:30
|
[
"290.40",
"041.4",
"458.9",
"599.7",
"585.6",
"601.1",
"403.91",
"790.7",
"281.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9478, 9484
|
6093, 8196
|
331, 338
|
9777, 9786
|
3566, 6070
|
11150, 11820
|
2940, 2944
|
8805, 9455
|
9505, 9756
|
8222, 8782
|
9810, 10994
|
2959, 3547
|
11023, 11127
|
273, 293
|
366, 2177
|
2199, 2797
|
2813, 2924
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,807
| 197,561
|
18598+56972
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-6-19**] Discharge Date: [**2119-6-27**]
Date of Birth: [**2069-8-4**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Angiography with coiling of Right MCA
History of Present Illness:
Ms. [**Known lastname 51078**] is a 49 y/o woman known to the Neurosurgery service
from a prior admission in [**2119-4-23**] after a SAH from two
right MCA aneurysms, presents from drug rehab. She woke up
early on the morning of presentation with a severe
headache, nausea and vomiting and was seen ambulating in the
halls dragging her left side.
Past Medical History:
HIV,diagnosed 22 years ago, no HAART, last CD4 659, VL 21k [**8-31**]
Hepatitis C
Emphysema
Sarcoid
HTN
Abnormal pap smears
Social History:
Lives in [**Location 669**], works as medical tech at Community Health
Center
- Tobacco: 30 years x 1ppd, "in process of quitting"
- EtOH: social
- Illicits: denies current, + in past
Family History:
Her father had a history of lung cancer, and her mother had a
history of throat cancer.
Physical Exam:
On Discharge:
nonfocal
Pertinent Results:
Angiogram [**2119-6-19**]- successful coiling of R MCA aneurysm
CT head [**2119-6-19**]-Stable subarachnoid hemorrhage, without evidence
of new
hemorrhage, infarction, or mass effect
Brief Hospital Course:
Ms. [**Known lastname 51078**] was admitted to the Neurosurgery service on [**2119-6-19**]
and taken for angiography for treatment of the subarachnoid
hemorrhage. She was treated with 5 endovascular coils to the
Right MCA. Following the procedure, she was taken to the SICU
for further observation and management. She was also started on
Nimodipine as well as a Prednisone taper for her headache.
Non-contrast Head CT performed on the evening of admission and
angiography demonstrated stable SAH. Her groin sheath was
pulled later that day.
On the morning of post-procedure day #1, the patient reported a
persistent headache. Her exam was non-focal. Transcranial
Dopplers were ordered to assess for vasospasm which were normal.
On [**6-21**], patient remains stable in ICU for close monitoring. Her
activity was advanced to OOB.
On [**6-22**], TCDs were ordered and because patient nonfocal on exam,
she was transferred to SDU. Her a-line was removed.
On [**6-23**]-3, The patient's exam was neurologically intact. She was
oriented to person, place, time. Strength was full/sensation
intact. The femoral groin site was clean/dry/intact. There was
no hematoma and the pedal pulses were palpable. The patient was
able to independently ambulate. Intravenous fluid continued at
75 cc/hr.
On [**6-26**], The patient complained of urinary freqency and a urine
analysis was sent which was negative. Transcranial dopplers
were done and negative. The intravenous fluid was discontinued.
She was deemed fit for discharge with plans for going home
without services on [**6-27**].
On [**6-27**] she was discharged to home without services and was given
instructions for follow-up and prescriptions for required
medications. She was also given 2 days dosages of Nimodipine as
her pharmacy had to order the pills for her.
Medications on Admission:
The patient denies taking any medications at home.
Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 13 days.
Disp:*156 Capsule(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. 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*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
.
?????? 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.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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:
??????You will require a repeat Cerebral Angiogram in 14 days. You
will be contact[**Name (NI) **] by Dr [**Last Name (STitle) **] office regarding the date and
time for this. If you do not hear a time by [**2119-6-30**] please
call ([**Telephone/Fax (1) 2102**] to schedule this
Completed by:[**2119-6-27**] Name: [**Known lastname 9512**],[**Known firstname **] Unit No: [**Numeric Identifier 9513**]
Admission Date: [**2119-6-19**] Discharge Date: [**2119-6-27**]
Date of Birth: [**2069-8-4**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 40**]
Addendum:
Please disregard instructions above that state to take Aspirin.
You are not required to take it.
Discharge Disposition:
Home
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Take Nimodipine 60mg every 4 hours until your
prescription runs out
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
.
?????? 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.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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.
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2119-6-27**]
|
[
"305.51",
"784.3",
"784.59",
"430",
"042",
"300.4",
"305.1",
"781.2",
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"796.9",
"V58.65",
"784.0",
"V58.83",
"401.9",
"070.54",
"496",
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
"88.41",
"39.75"
] |
icd9pcs
|
[
[
[]
]
] |
7879, 7885
|
1454, 3283
|
314, 354
|
4153, 4153
|
1245, 1431
|
7074, 7856
|
1098, 1187
|
3384, 4056
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4106, 4132
|
3309, 3361
|
7909, 9006
|
9032, 10817
|
1202, 1202
|
1216, 1226
|
266, 276
|
382, 732
|
4168, 4280
|
754, 880
|
896, 1082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,786
| 178,679
|
11419
|
Discharge summary
|
report
|
Admission Date: [**2153-7-20**] Discharge Date: [**2153-7-22**]
Date of Birth: [**2094-4-5**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Left Carotid Stenosis
Major Surgical or Invasive Procedure:
Left Carotid Angiogram and Stent
History of Present Illness:
Pt. is a 59 yo male with history of PVD, HTN,
hypercholesterolemia, and CAD who presented for a left carotid
stent placement secondary to severe left carotid stenosis. Pt.
has long standing CAD. Cardiac cath. from [**10-26**] showed 60-70%
stenosis of left main coronary artery. Pt. subsequently
underwent 3-vessel CABG (LIMA-LAD, SVG-OM1, SVG-RPDA). Recent
cardiac cath. ([**2153-7-11**]) showed patent LIMA-LAD, SVG-RPDA and
occluded SVG-OM1. Pt. had carotid ultrasound on [**2153-6-7**]
demonstrating 80-99% stenosis of bilateral ICA's. Pt. denies
any recent dizziness, syncope, chest pain, slurred speach prior
to admission.
Past Medical History:
CAD
PVD
HTN
Hypercholesterolemia
Social History:
Pt. is a current smoker with a hisory of smoking 1/2-1 ppd for
>50 years. Questionable history of ETOH abuse. Patient
currently denies any abuse. States last drink was over 1 week
ago. Currenly lives at home and able to perform ADL's
Family History:
Brother died in 40's from CAD
Physical Exam:
Vitals: BP: 129/37 HR: 73 RR: 15 O2sat: 97% RA
HT: 5'[**60**]" WT: 168 lbs.
Gen.: Awake, alert, NAD
HEENT: wnl
Heart: Irregular rhythm, +S1/S2, no murmurs/rubs/gallops
Vasculature: no bruits, 1+ DP in rt foot
Lungs: CTA bilaterally, good aeration
Abd: NT, no masses, +BS, no HSM
Skin: wnl
Neuro: no deficits noted
Ext: no edema/cyanosis, Lt BKA
Pertinent Results:
[**2153-7-20**] 12:00PM WBC-7.6 RBC-4.17* HGB-13.0* HCT-37.9* MCV-91
MCH-31.1 MCHC-34.2 RDW-12.7
[**2153-7-20**] 12:00PM PLT COUNT-220#
[**2153-7-20**] 12:00PM CALCIUM-8.9 MAGNESIUM-1.9
[**2153-7-20**] 12:00PM CK(CPK)-141
[**2153-7-20**] 12:00PM GLUCOSE-84 POTASSIUM-4.3
[**2153-7-20**] 09:28PM HCT-33.6*
[**2153-7-20**] 09:28PM POTASSIUM-3.8
[**2153-7-20**] 09:28PM UREA N-11 CREAT-0.7 POTASSIUM-3.9
Brief Hospital Course:
Pt. was referred to the cardiac cath. lab for a left carotid
stent placement by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. A AccuNet 6.5 mm was
placed in the left carotid without difficulty. The patient
tolerated the procedure well and was admitted to the CCU for
post procedural monitoring. The patients SBP was maintained
between 140-160 with Neo-synephrine and three bolusses of 250
NS. Pt. had serial neurological checks with no notable changes.
After 24 hours the Neo was slowly weaned off and the pt
maintained a SBP>120. Pt. was without complaints on the floor
and was stable for discharge on [**2153-7-22**].
Medications on Admission:
Lipitor 10mg Qday
Lopressor 50mg [**Hospital1 **]
Plavix 75mg Qday
Aspirin 325mg Qday
Discharge Medications:
Lipitor 10mg Qday
Plavix 75mg [**Hospital1 **] x 30 days, then switch to one tablet once a day
Aspirin 325mg Qday
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Internal Carotid Stenosis
Discharge Condition:
Pt. was stable and in good condition on discharge.
Discharge Instructions:
Pt. is to resume all previous medications except for his blood
pressure medication, metoprolol (Lopressor). If the patient
experiences any weakness, numbness, slurred speech, or chest
pain he is to go to the emergency room.
Followup Instructions:
Pt. has an appointment for next Tuesday with Dr. [**Last Name (STitle) 11493**]. At that
time his blood pressure will be taken and meds adjusted
accordingly. He is to follow up with the [**Hospital **] clinic in one
month. Dr. [**First Name (STitle) **] will call to set up the time. At this visit,
the patient will be scheduled for his right carotid stent.
|
[
"V45.81",
"272.0",
"443.9",
"401.9",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"88.41",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
3163, 3169
|
2234, 2889
|
356, 390
|
3248, 3300
|
1793, 2211
|
3573, 3934
|
1381, 1412
|
3025, 3140
|
3190, 3227
|
2915, 3002
|
3324, 3550
|
1427, 1774
|
295, 318
|
418, 1054
|
1076, 1110
|
1126, 1365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,320
| 126,103
|
51762
|
Discharge summary
|
report
|
Admission Date: [**2142-8-4**] Discharge Date: [**2142-9-22**]
Date of Birth: [**2086-4-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet / Codeine / Ativan
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
54F s/p completion VATS LLLobectomy for staple line recurrence,
readmitted w/ resp distress.
Major Surgical or Invasive Procedure:
s/p tracheostomy, open Jejunostomy tube [**2142-8-16**],
Hemodialysis tunnel catheter [**2142-9-19**]
History of Present Illness:
56 year old female admitted [**2142-8-4**]
s/p completed VATS for left lower lobe lobectomy c/b a. fib,
collapsed left lung, and CHF. Pt was discharged on [**2142-8-2**] and
readmitted on [**2142-8-4**] due to changes in MS, SOB, and fever. Pt
was intubated on admission. Bronch revealed significant [**Date Range **]
in bilateral bronchi, worse in RUL. Pt was extubated on
[**2142-8-5**].
Pt has had increased O2 demand and is currently on 5L NC and 70%
O2 via shovel mask, sating at 100%. We were consulted to
evaluate pt's swallowing due to concern for aspiration as [**Name8 (MD) **] MD
[**First Name (Titles) **] [**Last Name (Titles) 50508**] have not grown out any flora.
Past Medical History:
Cardiomyopathy, CHF
Hodgkin's, diagnosed [**2122**], s/p BMT
Hep C [**1-11**] transfusion
s/p chole
endometriosis
hypothyroidism
s/p splenectomy
carpal tunnel
adenocarcinoma of LLL, s/p wedge resection [**2139**], recent
lobectomy
[**2142-7-23**] after development of additional nodule
Social History:
Lives with son.
Smoked from [**2095**] to [**2121**].
Occasionally ETOH.
Family History:
Mother had breast cancer.
Physical Exam:
From [**2142-9-21**]
VS- T 98.0, HR 74, BP 93/42, RR 13, O2 98% on TM 50% FiO2
Gen- NAD, comfortable
Cards- RRR, S1S2
Lungs- coarse b/l
Abdomen- soft, NT/ND, BS +
Extremities- 2+ pitting edema b/l
Neuro- AxOx3
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2142-8-22**] 02:12AM 10.9 3.51* 10.8* 33.0* 94 30.9 32.9 21.4*
61*
Source: Line-a-line
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos NRBC
[**2142-8-17**] 11:34AM 72* 0 14* 12* 0 0 0 0 2* 1*
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2142-8-17**] 11:34AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2142-8-22**] 02:12AM VERY LOW 61*
Source: Line-a-line
[**2142-8-22**] 02:12AM 28.3* 56.8* 2.9*
Source: Line-a-line
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2142-8-16**] 07:57AM 507*
HEMOLYTIC WORKUP Ret Aut
[**2142-8-10**] 03:24AM 4.7*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2142-8-22**] 02:12AM 64* 1.5* 140 111* 23
Source: Line-a-line
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2142-8-19**] 03:08AM 32 101* 149* 1.9*
OTHER ENZYMES & BILIRUBINS Lipase
[**2142-8-17**] 11:34AM 16
CPK ISOENZYMES CK-MB cTropnT
[**2142-8-17**] 05:33PM NotDone1 0.08*2
Vancomycin @ trough @19:00
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2142-8-17**] 11:34AM NotDone1 0.08*2
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2142-8-17**] 05:56AM NotDone1 0.07*2
TNT ADDED [**8-17**] @ 11:26
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2142-8-22**] 02:12AM 7.7* 3.6 2.4
Source: Line-a-line
HEMATOLOGIC calTIBC VitB12 Folate Hapto Ferritn TRF
[**2142-8-20**] 02:19AM 129* 341* 99*
GREEN TOP TUBE
LIPID/CHOLESTEROL Cholest Triglyc
[**2142-8-12**] 03:10AM 921
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
PITUITARY TSH
[**2142-8-14**] 04:18AM 4.7*
Micro data
[**8-4**] Cx: OPF from BAL
[**8-8**] Blood: no growth
[**8-10**] [**Month/Day (4) **]: rare OPF
[**8-11**] BAL: oropharyngeal
[**8-11**] HCV viral load: VL>700,000
[**8-12**] BAL: no growth
[**8-13**] [**Month/Day (4) **]: neg. pneumocystis
[**8-14**] SCx: GS-GPC, Cx: OPF
[**8-14**] RPR: neg.
[**8-15**] B/UCx , BAL:GS(-), no microrganisms, OPF, CathTip: no growth
[**8-15**] urine: no growth
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2142-8-20**] 8:06 AM
Reason: asses pneumonia/effusion
[**Hospital 93**] MEDICAL CONDITION:
56 year old woman s/p left lower lobectomy with PNA, s/p
intubation for resp failure, ?aspiration
REASON FOR THIS EXAMINATION:
asses pneumonia/effusion
AP CHEST, 8:47 A.M. [**8-20**].
HISTORY: Left lower lobectomy. Intubated. Respiratory failure.
IMPRESSION: AP chest compared to [**8-15**] through 10:
Lung volumes are smaller today than yesterday, accounting for
increase in the radiodensity of predominantly dependent
pulmonary edema but shifted to the left. Tracheostomy tube and
right internal jugular line are in standard placements. No
pneumothorax.
CArdiac Echo- [**2142-8-11**]
Conclusions:
1. 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 mildly depressed.
2. The right ventricular cavity is moderately dilated. There is
moderate
global right ventricular free wall hypokinesis.
3. The aortic valve leaflets are moderately thickened. Moderate
(2+) aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.
6. There is a trivial/physiologic pericardial effusion.
7. Compared with the prior study (images reviewed) of [**2142-5-28**],
RV and LV function has decreased.
RADIOLOGY Final Report
BILAT LOWER EXT VEINS PORT [**2142-8-11**] 10:59 AM
Reason: w/u for DVT s/p acute desat. and resp. arrest
[**Hospital 93**] MEDICAL CONDITION:
56 year old woman with acute desat ? DVTs
REASON FOR THIS EXAMINATION:
w/u for DVT s/p acute desat. and resp. arrest
INDICATION: 56-year-old female with acute desaturation.
COMPARISONS: None.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **] scale and
Doppler son[**Name (NI) 1417**] of the bilateral common femoral, superficial
femoral, popliteal, and calf veins performed. In the proximal
right common femoral vein, a small focus of echogenic material
is seen along the posterior venous wall, consistent with a small
nonocclusive thrombus. Normal compressibility, augmentation,
flow, and waveforms were demonstrated throughout. No echogenic
thrombus is seen within the remaining vascular structures.
IMPRESSION:
1. Echogenic material along the posterior wall of the right
common femoral vein consistent with nonocclusive thrombus,
likely not acute.
2. No evidence of deep venous thrombosis within the left lower
extremity.
Misc- Radiology results:
CT Head w/o contrast: acute sinusitis
CTA CHEST: neg. PE, b/l effusions, R. breast mass (need f/u
[**Last Name (un) 3907**]), stenotic SVC
Liver/GB u/s: fatty liver
B/L LENI: Echogenic material posterior wall R. common
femoral
vein - nonocclusive thrombus.
Echo: LVEF mildly depressed, mod. R. wall hypokinesis, 2+
aortic
regurg., trivial mitral regurg
Brief Hospital Course:
54F s/p completion VATS LLLobectomy for staple line recurrence
[**2142-7-23**], course complicated by: occassional desat r/t
secretions/ activity intolerance, bronchoscopy x1 for secretion
clearance, Afib- treated w/ Amiodarone, HIT -neg, and
transfusion of 2u PRBC post-op. Patient d/c'd to rehab [**2142-8-2**].
Patient readmitted [**8-4**] w/ pneumonia, resp distress, +/- ms
changes.
Patient presented to ED with SOB and increase in O2 requirement,
then intubated. Bronchoscopy done w/ BAL: gram + cocci in pairs
and clusters, started on antibiotics. Patient extubated on [**8-5**]
and transferred to floor [**8-6**].
REsp- On floor patient required aggressive pulmoonary toilet and
CPT as tolerated w/ fair outcome. [**8-9**] transferred back to ICU
for worsening resp status/ aggressive pulmonary toilet,
ultimately requiring re-intubation [**2142-8-11**] for respiratory
failure, resp arrest/coded, and intubated. Patient required
mechanical ventilation until weaned and extubated [**8-13**].
Events of [**2142-8-11**]-
[**8-11**] Respiratory failure, coded, intubated
CT Head w/o contrast: acute sinusitis
CTA CHEST: neg. PE, b/l effusions, R. breast mass (need f/u
[**Last Name (un) 3907**]), stenotic SVC
Liver/GB u/s: fatty liver
B/L LENI: Echogenic material posterior wall R. common
femoral
vein - nonocclusive thrombus.
Echo: LVEF mildly depressed, mod. R. wall hypokinesis, 2+
aortic
regurg., trivial mitral regurg
[**8-11**] started on TPN (day 1), argatroban started for DVT
9/6-7 Episode hematemesis followed by incr resp distress.
Intubated and bronched w/diffuse blood in airways. OG placed w/
blood..lavaged for clots. Intermittent blood in aspirate
overnight. Transfused 1U PRBC. Trach and open jejunostomy tube
planned.
[**8-16**] trach, open gastrojejunostomy tube placed. EGD (severe
gastritis, no active bleeding).Mechanical ventilation resumed
p-op- assist control mode and transitioned to CPAP w/ PS mode
16/8. [**8-20**]- w/ stable secretions, afebrile, WBC normal and
antibiotic course completion active aggressive CPAP wean started
and tolerated well. Pt to trach mask [**8-21**] during day tolerated
well, CPAP overnight on [**9-2**].9/14 overnight pt tolerated
trach mask alone.
Cardiac- Afib- [**2142-8-6**] on amiodarone w/ [**3-15**] second pauses
[**2142-8-21**]. EP consulted and Amiod/ and propofinone-150 TID started
w/ low dose atenolol (BB indicated w/ use of propofinone). Long
term course.
Anticoag- anticoag for afib and thrombus:
Heme- concern for HIT w/ plt decreasing on Heparin IV for tx
afib and thrombus. HIT negative x2 but low plt <50-60 persisted.
Pt anticoag w/ argatroban started for DVT [**2142-8-11**], and
transitioned to fundaparinox w/ coumadin(start [**8-12**]) until INR
therapeutic [**8-19**]. Coumadin continues daily per INR. [**Date range (1) 59633**]-
INR 3.7 and 3.6 respectively and therefore coumadin held.
ID Course-all [**Date range (1) 50508**] [**Date range (1) 86900**] negative for organisms.
Antibiotic course of Vancomycin, levofloxacin, flagyl completed
[**2142-8-20**]. Pt has remained afebrile, w/ WBC wnl since [**8-20**]. Vanco
d/c [**8-7**]. Culture data in pertinent results.
GI-9/6-7 Episode hematemesis followed by incr resp distress.
Intubated and bronched w/diffuse blood in airways. OG placed w/
blood..lavaged for clots. Intermittent blood in aspirate
overnight. Transfused 1U PRBC. Open gastrojejunostomy tube
placed [**8-16**]. G-tube remains to gravity w/ daily outputs of
300-500. All meds should be give via J- tube w/ tubefeedings.
REflux work-up when patient when more stable and recovered from
surgery and current hospital/post-surgical course
CT Head w/o contrast: acute sinusitis
CTA CHEST: neg. PE, b/l effusions, R. breast mass (need f/u
[**Last Name (un) 3907**]), stenotic SVC
Liver/GB u/s: fatty liver
B/L LENI: Echogenic material posterior wall R. common
femoral
vein - nonocclusive thrombus.
Echo: LVEF mildly depressed, mod. R. wall hypokinesis, 2+
aortic
regurg., trivial mitral regurg
Hospital course since [**2142-8-25**]: She was doing well, tolerating
her PMV, and her voice was improving. That night, she had to be
placed back on the ventillator for respiratory acidosis. She
was weaned off of the ventillator, but on On [**9-6**], she had to be
put back on the vent for a pH of 7.19. She resonded on CPAP
[**4-18**] and her gas improved (pH 7.34). Her BP was maintained on
low dose Neosynepherine. Her UOP was very low, at 252 over the
course of the previous day. Her createnine was gradually
increasing (it had reached 3.1). The renal department
implemented CVVHD on [**9-7**] (UOP was 139 the previous day). She
was tolerating tube feeds at goal (Nepro 3/4 strength at
50cc/h). Her vent was weaned off and she was maintained on
trach mask at 50% FiO2. She was on Ceftriaxone for an E.Coli
pneumonia (14 day total course). She had a renal ultrasound,
which was normal. She recieved 1 unit of RBC for blood loss
anemia. On [**9-9**], she was started on a heparin drip for a goal
PTT of 50. CVVHD had taken off over 4 liters the day before.
They took off another 4+ liters the follwing day. Her total
body edema was decreasing noticably. Her BP tolerated it,
although she was maintained on low dose neosynepherine. By
[**9-10**], she had lost 8 kg due to her CVVHD. Her PTT was difficult
to control as she tolerated only 200-300 units/hr of heparin.
On [**9-12**], we stopped CVVHD in an effort to transition to HD. She
was off of pressors. She was dialyzed later that day. On [**9-13**],
her heparin drip was held due to elevated PTTs. She only made
20cc of urine on her own. On [**9-14**], she received another unit of
RBCs for blood loss anemia. She was dialyzed on [**9-14**]. She was
off of antibiotics and had a low grade temperature of 100.4, and
her WBC was elevated to 18. We removed her Quentin HD catheter
and her A-line empirically, and subsequent [**Month/Day (4) 50508**] were
negative. on [**9-15**], she spiked to 101.1. Reglan was held for a
prolonged QTc. On [**9-16**], Linezolid was started for VRE in the
urine. Off of HD, she was essentially anuirc and her createnine
rose to 5.2 on [**9-17**]. Later that day, Levophed was started for a
goal MAP 60-65. Zosyn and Levaquin was started for Pseudomonas
in the [**Month/Day (4) **]. On [**9-18**], she had to be put back on the
ventillator (SIMV 50%, 450X16, [**4-20**]). She was on low dose
Levophed and a heparin drip at 200. On [**9-19**], a tunned HD line
was placed by IR and she was dialyzed (1 L taken off). She was
taken off all antibiotics and started on Meropenem for
Pseudomonas in the [**Month/Year (2) **] (14 day course). On [**9-20**], she had a
swallow evaluation during which she had signs of aspiration
after thin liquid. She was to repeat a video-swallow prior to
discharge. Levophed had to be restarted. Coumadin was started
at 0.5. On [**9-21**], she was dialyzed and had her video swallow.
She failed her video swallow so nothing by mouth and she will
continue her current tube feeds. Her heparin drip was at 50.
She is doing well and is stable for rehab with trach care and
ventilation. She will also need to continue dialysis.
Medications on Admission:
Miscalcin, Synthroid 125', Toprol XL 50', Combivent prn, ECASA
81', Protonix 40', Prempro 0.045', Zoloft 25 prn, Calcium 500'
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) cc PO DAILY
(Daily).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
(3 times a day).
11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)): DO NOT STOP-has had
high gastric residuals w/ emesis/aspiration.
12. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO DAILY (Daily).
16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 14 days: started
[**2142-9-19**].
17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
18. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO DAILY
(Daily).
19. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
20. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal QID PRN ().
21. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
22. Warfarin Oral
23. Outpatient Lab Work
We have been giving her Coumadin 0.5 mg every night which was
just restarted. Please give 0.5mg tonight and then check an INR
tomorrow and adjust her coumadin accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
VATS LLLobectomy for staple line recurrence: re-presented with
pneumonia, resp distress, and mental status changes. S/p
trach/open J-T [**8-16**], acute tubular necrosis requiring HD, Afib,
Left lower extrem DVT on coumadin, urinary tract infections,
multiple nosocomial pneumonias.
PMH: HD s/p chemo/rads/BMT; HEP C; CHF; chole; splenectomy;
kidney stones; endometriosis; carpal tunnel; cervical LN bx;
hypothyroid
Discharge Condition:
Stable.
Discharge Instructions:
CAll Dr.[**Doctor Last Name **]/ Thoracic Surgery office for any [**Hospital **]
hospital issuesat [**Telephone/Fax (1) 170**]. Please call for any fevers,
nausea, vomiting, blood pressure lability, respiratory distress,
or any other concerning issues that may arise. Please see
detailed instructions on the Page 1 form, system by system.
Followup Instructions:
CAll Dr.[**Doctor Last Name **]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for
appointment in 3 weeks.
Provider: [**Name Initial (NameIs) 2169**]: PFTLAB-CC2 PULMONARY LAB-CC2
Date/Time:[**2142-12-14**] 10:30
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2142-12-14**] 10:30
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2142-12-14**] 11:00
Completed by:[**2142-9-22**]
|
[
"V58.61",
"244.9",
"403.91",
"070.70",
"427.31",
"V10.72",
"584.5",
"599.0",
"518.81",
"162.5",
"585.6",
"V42.81",
"287.5",
"461.9",
"428.0",
"453.8",
"482.1",
"425.4",
"482.82",
"300.00",
"V13.01",
"578.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.03",
"31.1",
"99.15",
"38.95",
"96.71",
"39.95",
"99.04",
"96.04",
"99.07",
"33.24",
"96.6",
"38.93",
"46.39",
"00.17",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
17014, 17093
|
7385, 14659
|
394, 498
|
17554, 17564
|
1901, 4458
|
17952, 18536
|
1629, 1656
|
14835, 16991
|
5997, 6039
|
17114, 17533
|
14685, 14812
|
17588, 17929
|
1671, 1882
|
262, 356
|
6068, 7362
|
526, 1212
|
1234, 1522
|
1538, 1613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
695
| 177,128
|
10673+10674
|
Discharge summary
|
report+report
|
Admission Date: [**2178-8-5**] Discharge Date: [**2178-8-12**]
Service: MICU-ORANG
HISTORY OF PRESENT ILLNESS: An 85-year-old female with a
history of
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 14605**]
MEDQUIST36
D: [**2178-8-12**] 16:06
T: [**2178-8-12**] 17:44
JOB#: [**Job Number 34998**]
Admission Date: [**2178-8-5**] Discharge Date: [**2178-8-13**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 85 year old female
with a history of chronic pancreatitis secondary to ethanol
use and peptic ulcer disease, status post distal diskectomy,
admitted to Surgical Intensive Care Unit [**2178-8-5**]
from [**Hospital **] Hospital where she presented with nausea,
vomiting, diarrhea and epigastric pain. The patient
presented to [**Hospital1 **] at 9:45 PM, [**2178-8-4**] with a
history of weakness, nausea, vomiting and creamy diarrhea
times one to two weeks with poor p.o. intake. The patient
reports a one month history of diarrhea. No fever or chills.
The patient reports epigastric pain, 6 out of 10, no
radiation.
PAST MEDICAL HISTORY: 1. Chronic pancreatitis diagnosed in
[**2175**] with pancreatic pseudocyst drained [**2176-6-2**]; 2.
Peptic ulcer disease, status post partial distal diskectomy;
3. Atrial fibrillation; 4. Gout; 5. Hyperlipidemia; 6.
Ethanol abuse.
MEDICATIONS ON ADMISSION: Medications at home include -
1. Lasix; 2. Diovan; 3. Propranolol.
SOCIAL HISTORY: Positive tobacco history, none currently.
Positive heavy ethanol use in the past, unclear use now. The
patient is married and lives with her husband.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: On admission temperature was 96.3,
pulse 86, blood pressure 126/54, respirations 18, sating 100%
on 100% face mask. The patient was on Dopamine 7.5 mcg/min.
General: Frail elderly female in mild distress secondary to
abdominal pain. Head, eyes, ears, nose and throat: Positive
icterus, oral mucosa slightly dry. Oropharynx clear. Neck:
Supple, jugulovenous distension to jaw line at 45 degrees.
No lymphadenopathy. Cardiac: Regular rhythm, no murmurs,
rubs or gallops. Lungs: Decreased breathsounds with mild
rhonchi. Abdomen: Old scar noted. Normoactive bowel
sounds. Soft, moderate tenderness in the epigastrium,
positive guarding. Distention of abdomen, but soft without
evidence of peritoneal signs or rebound. Extremities, warm
with no edema. Rectal, poor tone, guaiac negative.
LABORATORY DATA: Laboratory studies on admission revealed
white blood cell count 10.6, hematocrit 25.3, platelets 310,
INR 1.1, PTT 25.5, sodium 138, potassium 4.1, chloride 115,
bicarbonate 12, BUN 51, creatinine 1.6, glucose 151. ALT 43,
AST 72, alkaline phosphatase 140, total bilirubin 1.2,
amylase 27, lipase 52, calcium 7.6, magnesium 1.3, phosphorus
3.5. Arterial blood gases, 7.29, 28, 68, lactate 1.3.
Computerized tomography scan: Small amount of fluid in
retroperitoneum. Mildly thickened small bowel loop,
bilateral pleural effusions, positive pleural plaques.
Ultrasound: No dilated common bile duct, cholelithiasis but
no evidence of cholecystitis.
HOSPITAL COURSE: 1. Abdominal pain - The patient's
abdominal pain with nausea, vomiting and diarrhea was felt to
be consistent with chronic pancreatitis flare versus
gastroenteritis. There was no evidence of cholecystitis or
common bile duct dilatation on right upper quadrant
ultrasound and aside from a few loops of thickened bowel on
abdominal computerized tomography scan, abdominal findings
were unremarkable. The patient's initial acidosis were felt
secondary to fluid losses from diarrhea and improved with
volume resuscitation. The patient's abdominal examination
steadily improved and her liver function tests remained
unremarkable throughout the hospital stay. At the time of
discharge the patient was without nausea, vomiting or
diarrhea.
2. Cardiology - The patient's cardiac enzymes were cycled
with a troponin peak of 0.14. Cardiology was consulted who
recommended a transthoracic echocardiogram and Persantine
MIBI with gentle diuresis for elevated jugulovenous pressure
and initiation of Lopressor. The patient's transesophageal
echocardiogram on [**2178-8-6**] showed an ejection
fraction of 60% with 1+ mitral regurgitation, 2+ tricuspid
regurgitation, severe pulmonary artery and systolic
hypertension. The patient's troponin leak is likely
secondary to strain and further workup not pursued at this
time. The patient will require a Persantine MIBI scheduled
as an outpatient through her primary care physician.
3. Respiratory - The patient developed a cough with
increased respiratory rate into the 30s on [**2178-8-8**].
A chest x-ray at that time showed left upper lobe and lower
lobe opacities consistent with congestive heart failure
versus pneumonia as well as a bilateral pleural effusion.
The patient was diuresed with Lasix over 2.3 liters over the
next 36 hours with no improvement in respiratory symptoms.
Follow up chest x-ray showed an increase in the size of the
left pleural effusion and multifocal bilateral pulmonary
infiltrates. The patient was begun empirically on
Levofloxacin and Flagyl and was transferred to the Medicine
Intensive Care Unit for further management of suspected
nosocomial pneumonia. The patient had sputum culture taken
on [**2178-8-6**] and [**2178-8-8**] which grew
Methicillin-resistant Staphylococcus aureus and Vancomycin
was added upon transfer on [**2178-8-9**] to the Medicine
Intensive Care Unit. The patient will continue
Ciprofloxacin, Flagyl and Vancomycin for a total of 14 day
course for nosocomial pneumonia. The patient underwent a
thoracentesis on [**2178-8-10**] which gram stain showed no
polymorphonucleocytes and no microorganism. Total protein
1.3, albumin less than 1, glucose 138, LDH 81, preliminary
probe fluid culture was negative. Based on these results
pleural effusion was felt to be a transudate likely secondary
to congestive heart failure and the patient was gently
diuresed during the course of the hospital stay. The patient
was noted to have copious secretions throughout length of
stay in the Medicine Intensive Care Unit requiring frequent
suctioning. She had a weak cough and was unable to bring up
secretions on her own without chest physical therapy.
3. Fluids, electrolytes and nutrition - The patient was
noted to be hypernatremic with sodium 149 at time of transfer
to the Medicine Intensive Care Unit. Free water deficit was
1.6 liters. The patient was repleted with 1/2 normal saline.
The sodium had stabilized at the time of discharge. Sodium
was 139. Metabolic acidosis was noted on admission to
Surgery Intensive Care Unit, resolved with closing anion gap
and normalization of PH. The patient had speech and swallow
evaluation on [**2178-8-11**] given concern of possible
aspiration as a contributor to her current pneumonia.
Bedside swallowing evaluation showed that the patient
appeared to aspirate water but refused to take more than one
bite or one sip. Her lack of cooperation, lack of desire to
eat and drink and her waxing and [**Doctor Last Name 688**] level of alertness
placed her at significant nutritional risk, even if she could
swallow safely. Therefore, the patient's Dobbhoff tube was
placed and tube feeds started. The patient will require
further evaluation once strength increases to evaluate
whether she is able to take p.o. once she is over her acute
illness.
5. Anemia - The patient was noted to have decreased
hematocrit on transfer to the Medicine Intensive Care Unit,
although this was within her baseline ranges of 25 to 35.
The patient was guaiac negative. Iron studies suggestive of
anemia of chronic disease. We continued to monitor her
hematocrit through her hospital course. It remained stable
and at the time of discharge was 28.2. The patient will
require further monitoring of her hematocrit as an outpatient
to ensure that it remains stable.
6. Delirium - The patient was noted to have waxing and
[**Doctor Last Name 688**] mental status throughout the course of her hospital
stay although it gradually improved as we avoided sedatives.
The delirium was felt likely secondary to acute infection
overlying the existing underlying dementia, possibly from
prior heavy ethanol use. The patient's mental status
stabilized. No further workup was performed at this time.
7. Renal failure - The patient's elevated creatinine noted
on admission to Surgery Intensive Care Unit gradually
returned towards normal with a creatinine of 1.0 at the time
of discharge. Given the patient's creatinine clearance, less
than 35, all medications were dosed renally. The patient
will require further follow up of creatinine to ensure that
it remains within normal limits. The patient's elevated
creatinine on admission was likely secondary to prerenal
although there may have been an acute tubular necrosis
component.
CONDITION ON DISCHARGE: Fair
DISCHARGE STATUS: To be discharged to acute rehabilitation
facility.
DISCHARGE DIAGNOSIS:
1. Chronic pancreatitis
2. Nosocomial pneumonia
3. Atrial fibrillation
4. Gout
5. Peptic ulcer disease
6. Hyperlipidemia
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Metronidazole 500 mg intravenously q. 8 hours
3. Regular insulin sliding scale
4. Pantoprazole 40 mg p.o. q. 24 hours
5. Ciprofloxacin 400 mg intravenously q. 24 hours
6. Vancomycin 500 mg intravenously q. 24 hours
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 6008**]
MEDQUIST36
D: [**2178-8-12**] 17:58
T: [**2178-8-12**] 19:37
JOB#: [**Job Number 34999**]
|
[
"427.31",
"482.41",
"397.0",
"424.0",
"511.9",
"276.2",
"577.1",
"428.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.91",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
1728, 1747
|
9303, 9829
|
9152, 9280
|
1471, 1542
|
3262, 9029
|
1770, 3244
|
552, 1183
|
1206, 1444
|
1559, 1711
|
9054, 9131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,696
| 105,292
|
45875+58858
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-7-18**] Discharge Date: [**2120-7-30**]
Date of Birth: [**2049-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Right Medial Tibial Plateau Fracture
Major Surgical or Invasive Procedure:
Hemodialysis x2
History of Present Illness:
Patient is a 71 year old female with PMHx significant for IDDM,
ESRD, CAD, and HTN p/w with knee swelling, pain and limited ROM.
Patient reports that her pain developed over the course of 7
weeks and progressively got worse over time. She cannot recall
any particular event that could have caused trauma however she
does mention that when she uses an elevator at home that she
occasionally develops bruises on her knee from the apparatus.
She used to ambulate with a walker and but has recently been
unable to use it due to the pain. She was recently discharged
from [**Hospital1 18**] on [**2120-6-20**] after being admitted for lower extremity
cellulitis (MSSA, psuedomonas, sensitive to zosyn, clinda,
oxacillin, erythro, gent, bactrim. resistant to PCN). At this
point she was treated with a course of vancomycin and unasyn
however was transitioned to ciprofloxacin and dicoxacillin. She
had her R knee tapped during the hospitalization and only 444
WBC, but many thousand RBC (?traumatic). Xray of the knee at the
time showed tibial osteopenia and an U/S neg for DVT. Soon after
she developed nausea/vomiting following taking the dicloxacillin
and returned to the health center to be given injections of
vancomycin to finish her course. Since then the patient reports
that her redness on the leg has diminished greatly but the pain
has never subsided requiring a total of 6 percocet per day and
intermittent motrin.
.
Patient presents on this admission with persistent right knee
pain, swelling, warmth, and limited range of motion, which has
progressively gotten worse since [**Month (only) 205**] especially after her taps.
She was seen by her rheumatologist earlier today and was sent to
the ER for further work-up to r/o infection, internal
derrangement, and better pain control. She states that she has
been wheelchair bound since [**Month (only) 205**] and is unable to use her walker
since she is not able to bear weight on her right knee.
.
Patient complains of dyspnea/SOB on admission but denies any
fevers, chills, chest pain, SOB, abdominal pain, or N/V/D.
Remaining review of systems was unremarkable.
.
In the ED, the patient was seen by the Ortho consult team and
her right leg was placed in a brace for tibial plateau fracture.
Past Medical History:
1. ESRD/CRI - Patient receives HD @ "[**Last Name (un) 96929**]" center in [**University/College **]
- M/W/F.
2. IDDM - Course has been complicated by polyneuropathy,
nephropathy, retinopathy, and Charcot foot bilaterally
- patient does not check her FS at home, she received 70 u in am
and 30 u in pm of 70/30. Followed by Dr. [**First Name (STitle) 1313**] ? in [**Last Name (un) **].
3. Peripheral vascular disease
4. AF - Pt is s/p pacemaker placement. She is not anticoagulated
due to multiple falls.
5. Anemia
6. Hyperlipidemia
7. Cirrhosis secondary to cholestasis
8. Hypertension
9. Coronary artery disease- Pt had three vessel disease on
cardiac cath from [**2111**]. She is s/p NSTEMI in [**2110**].
Stress test '[**12**]. Moderate, fixed perfusion defect in the
inferior wall. Mild global hypokinesis.
10. Dilated ischemic cardiomyopathy- Pt's most recent echo was
[**2119-6-26**]. EF 40%; mod LA/RA dilation; mild LVH/mild global HK
(most prominent in the septum); 1+ MR. Mod pulmonary HTN
11. Adrenal adenoma
12. S/P TAH for leiomyoma
13. Right facial droop in [**7-/2119**] for which she declined workup
or treatment.
14. Depression
15. s/p mechanical fall, L elbow/olecranon Fx on [**2120-1-6**] -
conservative management
Social History:
Pt lives in her own home in [**Location (un) 1110**]. She has 24 hour help at this
time, although recently helper can't come in over the weekend,
the son has been speding more time with her. The patient rare
walks with a walker and mostly gets about in a wheelchair. She
is very close with her daughter, [**Name (NI) 2808**], who visits often and
her son, [**Name (NI) 96930**], who is her healthcare proxy. His phone number
is [**Telephone/Fax (1) 96931**]. DNR/DNI. Pt used tobacco in the past - quit 24
years ago. Denies ETOH or drug use.
Family History:
Fa - DM, CAD; Ma - Breast Ca;
Physical Exam:
vital signs: T 98.4 BP 120/70 HR 84 RR 20 O2Sat 96% on 2L
General: obese, sleepy, NAD, brace on her right knee
HEENT: PERRLA, dry mucous membranes
Neck: No lymphadenopathy/thyromegaly
Lungs: minimal crackels and wheesing, poor inspiratory effort
dialysis catheter site on right chest wall-intact, no
erythema/tenderness
Heart: RRR, nl s1 and S2, no s3/s4, no m,r,g
Abdomen: Obese, soft, non-tender/non-distender, +BS. No
hepatosplenomegaly.
Extremities: Right leg in brace, knee not examined; DP/PT pulses
not palpable, poor sensory exam, diabetic foot ulcers
Brief Hospital Course:
- R tibial plateua fracture: followed by Orhto and deemed
inoperable. Worked with PT/OT and was unable to pivot on one
foot and will required acute rehab with HD services.
- ESRD: recieved hemodialysis x2
- IDDM: intermittent hypoglyxemia so regular 70/30 doses of 70U
am 30U pm were hjalved to 35U am 15U pm with good results
- Pain: manage with standing morphine 30U SR PO Q12 hr and PRN
oxycodone for breakthrough pain
- UTI: asymptomatic UTI with UCx treated with Bactrim x5d
Medications on Admission:
1. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*15 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*0*
11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
Disp:*80 Tablet(s)* Refills:*0*
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48 ().
Disp:*30 Capsule(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*1 1* Refills:*0*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
20. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous [**Hospital1 **]: give 35U am and 15U pm.
Disp:*30 1* Refills:*0*
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*15 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*0*
11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
Disp:*80 Tablet(s)* Refills:*0*
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48 ().
Disp:*30 Capsule(s)* Refills:*0*
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*1 1* Refills:*0*
16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*1*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
20. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous [**Hospital1 **]: give 35U am and 15U pm.
Disp:*30 1* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary: Right Medial Tibial Plateau fracture
Secondary: Insulin dependent diabetes mellitus, End stage renal
disease requiring hemodialysis, coronary artery disease,
hypertension, diabetic foot ulcers, anemia
Discharge Condition:
The patient was admitted with a right medial tibial plateau
fracture that was deemed inoperable by the orthopedics service.
She was stabilized medically and begun on her regular home
medication regimen. She is currently s/p two hemodialysis
treatments and her course has only been complicated by
intermittent episodes of hypoglycemia in the 70-80's which
required reducing her insulin regimen from 70am/30pm to
35am/15pm, treated UTI with Bactrim, and constipation treated
with colace, senna, enema.
Discharge Instructions:
Please have your nurse administer all medications as noted. You
will be transfered to a facility where your rehabilitation will
be monitored and you will be able to have your hemodialysis as
normally scheduled M/W/F and please hold BP meds those mornings.
Please adhere to a diet that is low in sodiuma, fats, and
sugars. Please speak to you healthcare provider in the extended
care facility if you develop fevers, chills, night sweats,
nausea, vomiting, diarrhea, or change in your mentation.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 1-[**Telephone/Fax (1) 250**] when you
are finished with your rehabilitation. Also, please call to make
an appointment with the orthopedics department following your
evaluation at the extended care facility.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2120-7-23**] Name: [**Known lastname **],[**Known firstname **] G Unit No: [**Numeric Identifier 15580**]
Admission Date: [**2120-7-18**] Discharge Date: [**2120-7-30**]
Date of Birth: [**2049-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 758**]
Addendum:
[**2120-7-30**]: R1 addendum to d/c summary
Patient is a 71 yo female w/IDDM, HD dependent ESRD, CAD s/p PPM
and NSTEMI, ischemic cardiomyopathy (EF 40%), PVD, Afib without
anticoagulation, old Right facial droop who was planned for
discharge on [**2120-7-23**], but found to be unresponsive likely [**1-11**] to
accumulation of opiates [**1-11**] renal failure and redistribution in
fat; now improved s/p weaning off Narcan gtt.
.
MICU course by problem:
.
1. Hypercarbic resp failure: Given patient's abrupt response to
Narcan, it was thought likely that the patient experienced
central apnea secondary to narcotic effect. Although the doses
she received were not large, given her ESRD, it is likely the
cumalitive doses of these meds and their metabolites was
increased. Conversation with pharmacy additionally revealed that
even though patient was being dialyzed, effect could be
prolonged secondary to accumulation in soft tissues. The patient
was admitted to the MICU and started on a Narcan gtt given
recurrence of somnolence and apnea one hour after inital Narcan
dose. The patient demonstrated excellent response with improved
mental status and ventilatory effort. All sedating medications
were held during her MICU course. The patient refused A-line or
repeat ABG the night of admission, however, her resp rate was
improved and O2 sats stable. Repeat ABG the following day
revealed near resolution of hypercarbia and acidosis. After
approximately 24 hours, narcan gtt was discontinued and the
patient observed for 12 hours without recurrence of symptoms.
.
2. Leukocytosis - The day after admission, the patient was noted
to develop a leukocytosis to 25.8 from 12.2 the day prior.
Although the patient vomited multiple times with Narcan
treatment, all episodes were observed without gross aspiration,
although microaspiration events cannot be excluded. However,
lung exams remained clear and chest films do not demonstrate
evidence of PNA. Review of OMR notes revealed the patient had
previously been treated for cellulitis. Examination of the
previously affected leg revealed no recurrece of skin infection.
The patient was pan-cultured. Given patient's report of
abdominal pain throughout this admission, C. Diff infection is
possible given previous abx. Patient's abdominal pain has
however greatly improved after large BM with enema and manual
disimpaction. Differential likely C. Diff vs. aspiration
pneumonitis. C. Diff pending.
.
3. ESRD - The patient received dialysis on [**2120-7-24**] and [**2120-7-26**]
in the ICU.
.
4. CAD - Metoprolol and Isordil held on day of admission given
hypotension. Metoprolol reintroduced [**2120-7-25**], will need to be
uptitrated with reintroduction of isordil. Patient was noted to
have troponin leak which is trending down. Given normal CK and
CK-MB, this is not likely to represent a primary cardiac event.
The patient received ASA 325mg x 1 and was restarted on
outpatient regimen of ASA 81mg daily. Heparin gtt was not
initiated as this did not appear to represent plaque
rupture/thrombus mediated ischemia.
.
5. IDDM - The patient was continued on most recent 70/30 regimen
of 35qam 8 qpm with 1/2 dose while NPO.
.
On return to the floor, pt [**Name (NI) 15581**] on floor, now with no c/o at
this time. Abdominal pain resolved s/p BM. No dyspnea. Feels MS
almost back to normal. No CP, pedal edema, vision changes,
diarrhea, or dizziness.
.
Remainder of hospital course after d/c to floor was uneventful.
Pt had c/o discomfort with urinary retention which resolved
after being straight catheterization. She also had constipation
that resolved with a soap suds enema. Had one dialysis treatment
on Monday [**7-29**] with some diaphoresis without any other sxs that
self resolved. Otherwise remained [**Month/Year (2) 15581**] for 48 hours before
discharge.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Hospital1 1947**]
Discharge Diagnosis:
Primary: Right Medial Tibial Plateau fracture
Secondary: Opioid overdose, Insulin dependent diabetes mellitus,
End stage renal disease requiring hemodialysis, coronary artery
disease, hypertension, diabetic foot ulcers, anemia
Discharge Condition:
The patient was admitted with a right medial tibial plateau
fracture that was deemed inoperable by the orthopedics service.
She was stabilized medically and begun on her regular home
medication regimen. She is currently s/p two hemodialysis
treatments and her course has been complicated by an ICU
admission for over-administration of narcotics resolved with
Narcan, intermittent episodes of hypoglycemia in the 70-80's
which required reducing her insulin regimen from 70am/30pm to
35am/15pm, UTI treated with Bactrim, and constipation treated
with colace, senna, water and molasses enema. Overall, she
denies chest pain, shortness of breath, fever, chills, diarrhea,
nausea or change in mental status.
Discharge Instructions:
Please have your nurse administer all medications as noted. You
will be transfered to a facility where your rehabilitation will
be monitored and you will be able to have your hemodialysis as
normally scheduled. Please adhere to a diet that is low in
sodium, fats, and sugars. Please speak to you healthcare
provider in the extended care facility if you develop fevers,
chills, night sweats, nausea, vomiting, diarrhea, or change in
your ability to think.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3769**] ([**Telephone/Fax (1) 23**]) when you
are finished with your rehabilitation.
.
Dr.[**Name (NI) 15582**] office (Orthopedic Surgery: ([**Telephone/Fax (1) 7848**]))
should be contacting your son-in-law about a follow-up appt for
your fracture.
.
You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
evaluation of your blood vessels and follow-up of the ulcers on
your feet on Tues, [**8-27**] at 2pm ([**Last Name (NamePattern1) 3895**] on [**Location (un) 15583**], Dr. [**Last Name (STitle) 4565**].
.
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**]
Completed by:[**2120-7-30**]
|
[
"707.14",
"362.01",
"V45.01",
"823.00",
"E917.4",
"599.0",
"285.21",
"250.50",
"585.6",
"518.81",
"250.40",
"250.60",
"403.91",
"788.20",
"357.2",
"427.31",
"287.5",
"276.2",
"V58.67",
"713.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16265, 16345
|
5119, 5600
|
351, 369
|
16616, 17321
|
17824, 18641
|
4489, 4520
|
7792, 10182
|
16366, 16595
|
5626, 7769
|
17345, 17801
|
4535, 5096
|
275, 313
|
397, 2648
|
2670, 3911
|
3927, 4473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,706
| 130,837
|
29352+57638
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-1-21**] Discharge Date: [**2115-1-30**]
Date of Birth: [**2047-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
66M w/ stage III esophageal ca s/p lap esophagectomy, readmitted
from rehab with fever and mental status changes and non working
foley (they had dc'd what needed to be a permanent foley)
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 70518**] is a 67 male s/p minimally invasive [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **]
esophagogastrectomy,
POD 10, discharged to rehab 2 days prior to admission (POD 8),
sent to ED at [**Hospital3 **] for acute urinary retention last
night. Foley placed, UA positive, sent back to rehab on
levofloxacin. Patient then became febrile and c/o chest pain.
Returned to [**Location **], found to have ST elevations on EKG, transferred
to [**Hospital1 18**] for stat echo. During echo, patient's SBP dropped from
120 to 40-60. Fluids given, neo started, transferred to PACU,
awaiting ICU bed. Further history is unobtainable secondary to
waxing/[**Doctor Last Name 688**] mental status. HCP adds that patient has "not
been getting anything" in terms of hydration in the last 2 days.
He is being admitted for further evaluation.
Past Medical History:
Stage III esophageal cancer
R eye prosthesis
HTN
DOE
BPH chronic foley
Diabetes
h/o trach/PEG in [**11/2113**]
h/o anemia in [**12/2113**]
s/p cholecystectomy
cognitive impairment s/p MVC
Social History:
A 40-60 pack year smoker, discontinued 30 years ago. Occupation
former machine operator, lives alone in senior housing, does not
drink, and has no exposure history.
Family History:
Remarkable for mother with diabetes and a brother with diabetes
and prostate cancer.
Physical Exam:
Gen: 67 year-old male in no apparent distress
CVS: RRR, nl S1S2
Pulm: decreased breath sounds otherwise clear
Abd: soft, NT, ND, +BS
Inc: c/d/i, no erythema
GU: foley in place
Ext: no c/c/e
Neuro: non-focal
Pertinent Results:
[**2115-1-28**] WBC-7.6 RBC-3.43* Hgb-10.9* Hct-31.8 Plt Ct-366
[**2115-1-25**] WBC-6.8 RBC-3.49* Hgb-10.7* Hct-32.0 Plt Ct-197
[**2115-1-21**] WBC-29.0*# RBC-2.72* Hgb-8.6* Hct-25.5 Plt Ct-183
[**2115-1-21**] Neuts-81* Bands-15* Lymphs-1* Monos-2 Eos-0 Baso-0
Atyps-0
[**2115-1-28**] Glucose-255* UreaN-21* Creat-0.8 Na-138 K-4.6 Cl-103
HCO3-29
[**2115-1-23**] BLOOD PT-12.7 PTT-28.1 INR(PT)-1.1
[**2115-1-21**] BLOOD Glucose-208* UreaN-40* Cr-1.4* Na-143 K-4.0
Cl-109 HCO3-21
[**2115-1-21**] 03:10PM URINE WBC Clm-MANY
[**2115-1-21**] 03:10PM URINE CastGr-28*
[**2115-1-21**] 03:10PM URINE RBC-34* WBC-549* Bacteri-NONE Yeast-NONE
Epi-0
[**2115-1-21**] 03:10PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
[**2115-1-21**] 03:10PM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.019
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IDENTIFICATION REQUESTED BY DR. [**First Name (STitle) **] #[**Numeric Identifier 70519**] [**2115-1-23**].
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
YEAST. ~8OOO/ML.
GRAM POSITIVE BACTERIA. ~1000/ML.
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S 64 I
TETRACYCLINE---------- =>16 R =>16 R
VANCOMYCIN------------ <=1 S =>32 R
Brief Hospital Course:
Mr. [**Known lastname 70518**] was admitted for evaluation of acute cardiac event.
The Echocardiogram was normal but was profoundly hypotensive
during procedure. He was aggressively hydrated and started on
low dose pressor support w/ good response. His Cardiac enzymes
were cycled and deemed not an MI by cardiology. He was weaned
off pressors within 24hours. After hydration and IVAB, his
mental status improved.
On admission his urine via foley was thick and cloudy and pan
cultured. He was started on broad spectrum IVAB pending
senstivities- cipro, vanco. Culture data w/ VRE-per ID likely
represents colonization. Recommended repeat urine and not treat
w/linezolid until repeat urine resulted. Urine sent [**2115-1-29**]. ID
recommends 10 day course of Vancomycin through [**2115-2-3**] and
repeat UA C&S after completion.
JT feeds were started and then on HD#3 was started on a clear
liquid diet which he tolerated. He was transferred out of the
ICU on HD#3 and continued to make steady progress. At time of
d/c to rehab he was tolerating thin liquids and a soft
dysphagia diet with cycled TF to meet caloric needs.
He was screened by PT and rehab was recommended. He will
follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 767**] [**Name (STitle) 70520**] and Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Flomax 0.4 daily, Glucophage 1000 mg twice daily Lopressor 25 mg
daily, Prevacid 15 mg daily lactulose, Trazadone 50 qhs/prn
insomia, Finesteride 5 mg daily, Amantadine 100 mg daily,
colace 100 mg twice daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection twice a day.
2. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED).
3. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily): for anxiety.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q6H (every 6 hours) as needed.
9. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
10. port flush
Heparin Flush Port (10 units/mL) 5 mL IV DAILY:PRN
10 ml NS followed by 5 mL of 10 Units/mL heparin (50 units
heparin) each lumen Daily and PRN. Inspect site every shift.
11. home meds
when pt's diet po/TF is consistent, please resume pt's oral
diabetic agents.
12. finesteride [**Last Name (STitle) **]: Five (5) mg once a day.
13. Amantadine 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a
day.
14. Trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomia.
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
gm Intravenous Q 12H (Every 12 Hours): through [**2-3**].
Discharge Disposition:
Extended Care
Facility:
Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**]
Discharge Diagnosis:
Dehydration
Urosepsis
Esophageal ca
Discharge Condition:
Deconditioned: Length of stay less than 30 days
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath cough or sputum production
-Chest pain
-Difficulty swallowing.
If your feeding tube sutures break, please call Dr.[**Name (NI) 70521**]
office to have sutures replaced. if the feeding tube falls out,
please save the tube and call Dr.[**Name (NI) 70522**] office
immediately to make arrangements to have the tube replaced as
the track closes quickly.
Vancomycin 1gm q24 through 2/24/0: please repeat UA C&S after
completion of antibiotics.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2115-2-7**] 2:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) **].
Please arrive 45 minutes prior to your appointment and report to
the [**Location (un) **] radiology for a chest XRAY.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2115-2-7**]
Follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] urology for an appointment on
Monday [**2-4**] at 10:30am [**Telephone/Fax (1) 921**]: [**Hospital Ward Name 23**] Clinical Center
Completed by:[**2115-1-30**] Name: [**Known lastname 11934**],[**Known firstname 126**] Unit No: [**Numeric Identifier 11935**]
Admission Date: [**2115-1-21**] Discharge Date: [**2115-1-30**]
Date of Birth: [**2047-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3454**]
Addendum:
Of note Mr. [**Known lastname **] was readmitted with urosepsis resulting from a
UTI. His creatinine was found be elevated and returned to
baseline with hydration.
Discharge Disposition:
Extended Care
Facility:
Academy Manor of [**Location (un) 2570**] - [**Location (un) 2570**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**]
Completed by:[**2115-2-25**]
|
[
"276.51",
"401.9",
"788.20",
"599.0",
"V44.4",
"V10.03",
"458.9",
"600.01",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9387, 9621
|
3895, 5231
|
509, 515
|
7450, 7500
|
2156, 3024
|
8120, 9364
|
1828, 1914
|
5490, 7252
|
7391, 7429
|
5257, 5467
|
7524, 8097
|
1929, 2137
|
283, 471
|
3059, 3872
|
543, 1417
|
1439, 1628
|
1644, 1812
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,398
| 132,296
|
31720
|
Discharge summary
|
report
|
Admission Date: [**2136-10-17**] Discharge Date: [**2136-11-2**]
Date of Birth: [**2064-11-8**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Code stroke
Major Surgical or Invasive Procedure:
IA TPA and MERCI
History of Present Illness:
Code Stroke called at 10:35Am. Patient seen and evaluated
within minutes. He is a 71 yo man with PMH of CAD, HTN, CHF,
AAA, possibly Afib who per records, was last seen well by wife
at 0430. Was found down on floor at home at 07:30. Was taken
to [**Hospital **] hospital where he was noted to have left hemiparesis,
aphasia, but ability to follow some commands and answer with
nods or squeezing hand. Unknown if he has ever taken
antiplatelets or coumadin but INR was 1.05 at OSH and neither
are listed on EMS records.
Was transferred to [**Hospital1 18**].
ROS: cannot obtain.
Past Medical History:
Question of afib
CAD, HTN, CHF, AAA.
Social History:
Married, lives w/ wife
Family History:
Non-contributory
Physical Exam:
T- NA BP- 172/74 HR- 49 regular RR- 18 O2Sat 99 2L
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple
Back:
CV: RRR, faint heart sounds, no clicks,rubs,murmurs
Lung: Clear to auscultation bilaterally but decreased breath
sounds and shallow.
aBd: +BS soft, BS intact
ext: no edema
Neurologic examination:
Stroke scale 19 (1 LOC, 2 LOC questions, 2 face, 4 arm, 2 leg, 2
sensory, 2 language, 2 dysarthria, 2 neglect).
Mental status: decreased level of alertness requiring
stimulation to maintain wakefulness. Responds to voice and opens
eyes. Can follow simple commands but inconsistent. Answers by
nodding consistently. Right gaze preference but not fixed.
Left sensory/visual neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally. Left facial droop.
Hearing intact grossly.
Motor:
Normal bulk bilaterally. Tone normal in legs, slightly paratonic
arms. No observed myoclonus or tremor Antigravity in RUE and RLE
for 10 and 5 seconds respectively. Only intermittent posturing
of LUE and no antigravity.
Antigravity in LLE for less than 5 seconds.
Sensation: Left hemisensory in arm/leg to light touch.
Reflexes:
+1 and symmetric throughout [**Hospital1 **]/Br. Absent knees/ankles.
Toes up bilaterally
Coordination: not tested
Gait: NA.
Romberg: NA
Pertinent Results:
[**2136-10-19**] 03:33AM BLOOD WBC-14.0* RBC-3.61* Hgb-10.6* Hct-30.9*
MCV-86 MCH-29.3 MCHC-34.2 RDW-14.5 Plt Ct-210
[**2136-10-18**] 01:27AM BLOOD WBC-13.0* RBC-4.01* Hgb-12.0* Hct-35.0*
MCV-87 MCH-29.8 MCHC-34.1 RDW-14.6 Plt Ct-278
[**2136-10-17**] 06:48PM BLOOD WBC-10.9 RBC-4.20* Hgb-12.2* Hct-35.7*
MCV-85 MCH-29.2 MCHC-34.3 RDW-14.3 Plt Ct-279
[**2136-10-17**] 10:40AM BLOOD WBC-11.0 RBC-4.75 Hgb-14.1 Hct-41.9
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.4 Plt Ct-265
[**2136-10-17**] 10:06PM BLOOD PT-12.3 PTT-25.3 INR(PT)-1.1
[**2136-10-17**] 10:40AM BLOOD PT-12.0 PTT-24.0 INR(PT)-1.0
[**2136-10-17**] 06:48PM BLOOD Glucose-129* UreaN-25* Creat-1.3* Na-135
K-3.9 Cl-103 HCO3-24 AnGap-12
[**2136-10-18**] 01:27AM BLOOD Glucose-125* UreaN-23* Creat-1.5* Na-139
K-4.2 Cl-105 HCO3-26 AnGap-12
[**2136-10-18**] 05:11PM BLOOD Glucose-127* UreaN-20 Creat-1.5* Na-138
K-4.1 Cl-107 HCO3-23 AnGap-12
[**2136-10-19**] 03:33AM BLOOD Glucose-115* UreaN-19 Creat-1.4* Na-139
K-3.8 Cl-107 HCO3-25 AnGap-11
[**2136-10-17**] 06:48PM BLOOD ALT-14 AST-19 LD(LDH)-186 CK(CPK)-168
AlkPhos-77 Amylase-41 TotBili-0.4
[**2136-10-17**] 06:48PM BLOOD Lipase-27
[**2136-10-17**] 03:46PM BLOOD CK-MB-8 cTropnT-<0.01
[**2136-10-17**] 06:48PM BLOOD CK-MB-6 cTropnT-<0.01
[**2136-10-18**] 01:27AM BLOOD CK-MB-5 cTropnT-0.01
[**2136-10-17**] 06:48PM BLOOD Albumin-3.3* Calcium-8.0* Phos-3.3 Mg-2.2
Cholest-168
[**2136-10-18**] 01:27AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.3
[**2136-10-18**] 05:11PM BLOOD Calcium-8.2* Phos-3.4 Mg-2.3
[**2136-10-19**] 03:33AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.4
[**2136-10-18**] 01:27AM BLOOD %HbA1c-5.8
[**2136-10-17**] 06:48PM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.7 LDLcalc-99
[**2136-10-18**] 01:27AM BLOOD TSH-1.1
[**2136-10-17**] 10:57AM BLOOD Glucose-113* Na-139 K-3.9 Cl-99*
calHCO3-26
CARDIAC ECHO [**2136-10-19**]
Study terminated prematurely due to deterioration of patient's
condition. The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
PLEASE NOTE THAT THE PATIENT HAD OVER 35 DIFFERENT IMAGING
STUDIES DURING THIS ADMISSION PRECLUDING THEIR INCLUSION IN THIS
SUMMARY. PLEASE CHECK THE [**Hospital **] MEDICAL RECORD IF YOU WISH TO
REVIEW THE IMAGES FROM THIS ADMISSION. IF YOU ARE NOT FROM THE
[**Hospital1 18**] SYSTEM YOU [**Month (only) **] HAVE DR. [**Last Name (STitle) **] PAGED BY CALLING
[**Telephone/Fax (1) 74505**] AND HE WILL FAX YOU A COPY OF ONE OF THE REPORTS OR
ARRANGE FOR THE IMAGES TO BE SENT TO YOU ON A DISC.
Brief Hospital Course:
Hospital course by problem.
NEURO:
Mr. [**Known lastname 74506**] was found to have an occlusion in the right MCA M1
segment. CT perfusion showed decreased blood volume in part of
the right MCA area. MTT was increased in a larger area of the
right MCA. Due to the mismatch between blood volume and MTT in
the right MCA, it was decided that he had significant penumbra
to
save. Intra-arterial TPA (8mg) was administered. MERCI
mechanical clot retrieval was then performed. The distal right
MCA was successfully opened. Repeat Head CT showed probable
contrast blush in the right
basal ganglia. The mechanism of the patient's stroke was
hypothesized to be due atrial fibrillation in the absence of
anticoagulation. The patient was noted to be on amiodarone so
it was hypothesized that the patient was rhythm controlled.
After the clot retrieval the patient was taken to the ICU
where his neurological exam was monitored for 5 days. Serial
head CT's did not demonstrate hydrocephalus or significant
bleeding. Systolic blood pressure was kept below 180.
The patient was anticoagulated with heparin drip on the 8th
day of the hospitalization when it was felt that the risk for
bleeding into the area of ischemia had passed. The goal PTT was
50-70.
The patient's blood sugar was kept below 150 with an insulin
sliding scale. He did not require susbstantial insulin during
this admission and can likely forgoe oral hypoglycemics on
discharge. His Hemoglobin A1C was less than 7.
The patient's cholesterol was 168 and his LDL fraction was 99.
He was started on lipitor 80mg daily, which he should remain
on.
The hemiparesis noted on initial exam resolved.
The dysarthria improved but was still present at the time of
discharge.
The patient had significant dysphagia and required PEG tube
placement.
Cardiovascular:
The patient ruled out for a myocardial infarction with serial
enzymes. The pateint as transiently bradycardic in the ICU.
Threre was no specific intervention required for this and
resolved spontaneously. Also while in the ICU there was concern
that the patient may be in heart failure. He was started on
lasix 20mg [**Hospital1 **] (He was purpurtedly on 80mg lasix daily prior to
admission). He was noted on the 5th day of admission to go into
atrial fibrillation with rapid ventricular response. His heart
rate was controlled with IV and then PO metoprolol. When the
patient was not in atrial fibrillation he did not require the
metoprolol. Management of the patient's cardiac condition and
infectious issues (see below) was aided by the Medicine Consult
team.
Infectious Diseases:
The patient had low grade feveres in the ICU and a fever of
101.6 on the day after transfer from the ICU. The patient was
treated with a 10 day course of Flouroquinolones for gram
negative rods in the sputum. He completed a 11 days of a ------
day course of vancomycin for MRSA in the sputum and the urine.
Surveillance blood cultures were negative as wa a repeat urine
culture. The patient's white blood cell count peaked at 15.7
and trended down prior to discharge. The patient is discharged
with PICC line so that he can complete his vancomycin course.
Gastrointestinal:
The patient was fed via an nasogasric tube. The GI service were
unable to place a percutaneous gastrostomy (PEG) tube due to
prior adhesions over the stomach. A PEG tube was subsequently
placed by the interventional radiologists.
Medications on Admission:
Lasix 80mg daily
Lisinopril 5 daily
Pacerone 200 daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
8. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
9. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 3 days.
10. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) drip Intravenous once a day: Please
maintain PTT from 50-70 until INR therapeutic. Patient
currently running at 1200 units/hour. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Cerebral Infarction.
Discharge Condition:
Vital signs are stable. The patient has a persistent left
facial droop, mild to moderate dysarthria with retropharyngeal
sylables (such as Gs) and mild fisting of the left hand with
pronator drift testing. The patient has had a remarkable
recovery.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your clinic visits as suggested below.
Please note that you have had a stroke. Should you have
worsening of your symptoms you should return to the hospital.
If you have weakness in any of your limbs, a facial droop, or
slurred speech you should return to the hosptial.
Please note that you will be on a medicine called coumadin
(warfarin) and will need to have your INR checked periodically
by your primary care physician.
Followup Instructions:
Please follow upwith your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) 3291**] in the next two weeks - [**Numeric Identifier 74507**]
Please follow up with Dr. [**Last Name (STitle) **] in the [**Hospital 4038**] clinic in the next
month. Please book an appointment at ([**Telephone/Fax (1) 15319**].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2136-11-13**]
|
[
"599.0",
"999.9",
"V09.0",
"434.91",
"428.0",
"427.31",
"403.90",
"482.41",
"428.20",
"441.4",
"585.3",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"88.41",
"45.13",
"43.11",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
10010, 10090
|
5461, 8902
|
329, 347
|
10155, 10408
|
2540, 5438
|
10949, 11476
|
1079, 1097
|
9007, 9987
|
10111, 10134
|
8928, 8984
|
10432, 10926
|
1112, 1416
|
278, 291
|
375, 962
|
1843, 2521
|
1568, 1827
|
1440, 1553
|
984, 1023
|
1039, 1063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,367
| 134,767
|
38470
|
Discharge summary
|
report
|
Admission Date: [**2109-4-9**] Discharge Date: [**2109-4-12**]
Date of Birth: [**2047-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
EGD with biopsy
History of Present Illness:
61 y/o with GERD, COPD on chronic prednisone, Etoh Abuse
presents with coffee ground emesis since yesterday afternoon.
Abrupt onset without associated abd pain. Multiple episodes
overnight. After each episode pt drank large amounts of water
(nearly a gallon last night). With this pattern he vomitted
enough to fill a trash can. No blood BM, or change in bowel
habits. No BM since onset of GIB. No palpatations, CP, SOB,
syncope. Pt complains to dry mouth. Actively drinks a pint of
vodka a week, last drink 1 week ago. No h/o GIB. No known liver
disease.
In the ED, initial vs were: T98.2 P80 BP124/36 R 18 O2 sat 97%
on 15L, improved to 99% on RA. 2 18G PIV placed. NG lavage
cleared with 500cc. Stool guaiac positive but yellow-brown.
Patient was given Pantoprazole 40mg IV. Electrolytes revealed
hyponatremia, hypokalemia, hypophos. He received 2gm mg IV and
2L IVF, the second of which had 40MEG KCL. VS prior to transfer
99.2, 88, 199/82, 18, 97%RA
On the floor, he complains of thirst but no abd pain or nausea
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Osteoporosis
Hypertension
GERD
COPD on prednisone
h/o left hip fracture
etoh abuse
multiple head CT at [**Hospital1 2025**], ? falls.
Social History:
Pt lives in group home, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Housing ([**Last Name (NamePattern1) 85610**]), given meds daily. drinks 1 pint vodka weekly (drinking
whole pint in one sitting). Last drink one week ago. NO h/o DT,
seziure. 60 pk year history.
Family History:
No h/o GI malignances.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 4cm above clavicle ated, no LAD
Lungs: diffuse inspiratory wheezes, slightly decreased air
movement, no rales or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, liver 2 finger breaths below
ribs. No splenomegaly.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
neuro: A+O x3, CN intact, 5/5 strength, NL sensation, 2+DTR
Pertinent Results:
Hematology:
[**2109-4-10**] 05:27AM BLOOD WBC-8.0 RBC-3.99*# Hgb-13.5*# Hct-37.3*
MCV-94 MCH-33.8* MCHC-36.2* RDW-14.7 Plt Ct-120*
[**2109-4-9**] 01:30PM BLOOD Neuts-87.9* Lymphs-6.1* Monos-5.0 Eos-0.2
Baso-0.8
[**2109-4-9**] 01:30PM BLOOD PT-11.2 PTT-22.4 INR(PT)-0.9
[**2109-4-10**] 05:27AM BLOOD Plt Ct-120*
Chemistries:
[**2109-4-9**] 01:30PM BLOOD Glucose-109* UreaN-38* Creat-1.1 Na-122*
K-2.8* Cl-70* HCO3-26 AnGap-29*
[**2109-4-10**] 05:27AM BLOOD Glucose-82 UreaN-18 Creat-0.5 Na-129*
K-3.6 Cl-93* HCO3-26 AnGap-14
[**2109-4-9**] 01:30PM BLOOD AST-88* LD(LDH)-251* AlkPhos-83
TotBili-2.3*
[**2109-4-10**] 05:27AM BLOOD ALT-42* AST-57* AlkPhos-51 TotBili-2.5*
[**2109-4-9**] 01:30PM BLOOD Albumin-4.3 Calcium-9.9 Phos-1.9* Mg-1.8
[**2109-4-10**] 05:27AM BLOOD Albumin-3.0* Calcium-7.1* Phos-1.8*
Mg-2.0
[**2109-4-9**] 01:30PM BLOOD Osmolal-266*
[**2109-4-9**] 10:10PM BLOOD Type-[**Last Name (un) **] pO2-177* pCO2-28* pH-7.58*
calTCO2-27 Base XS-5
[**2109-4-9**] 10:10PM BLOOD Lactate-1.7
EKG: [**2109-4-9**]: Sinus tachycardia at 111, NL axis and interval. No
ST or T wave changes. No U wave.
Brief Hospital Course:
Assessment and Plan: 61 y/o with Etoh abuse and hematemesis
Coffee ground emesis: The patient had an upper GI bleed by
postive NG lavage with no sign of active bleeding by arrival.
Serial HCT's were all stable. he was monitored in the ICU then
EGD revealed areas of esophagitis and gastritis. He was given a
PPI and sucralifate to take at home. Biopsies were taking and
pending at the time of discharge(patient aware).
Hyponatremia, Hypokalemia, Hypophosphatemia, hypomagnesemia: The
patient had a number of electrolyte abnormalities which were
consistent with his poor po intake and heavy etoh abuse. All
were corrected by the time of discharge.
Etoh: Patient states he has no interest in stopping alcohol use.
Counseling was offered and declined. He was given a few doses of
valium for anxiety, but did not register significantly high
scores on a CIWA scale.
Etoh induced hepatitis, pancreatitis: The patient had normal
hepatic synthetic function, but had an elevated bili and lipase.
These improved without intervention and were suspected to be due
to etoh use. It was suggested to the patient that he be followed
by gastroenterology as an outpatient, although he declined.
COPD: Respiratory status stable currently on home meds
Case Manager at group home [**Doctor Last Name 78242**] [**Doctor Last Name **] [**Telephone/Fax (1) 85611**]
Medications on Admission:
Albuterol neb q4-6hr pan
fosamax 70mg PO qweek
calcium 600 + D 1 tab [**Hospital1 **]
asa 81mg PO daily
omeprazole 20mg PO daily
multivitamin 1 tab daily
prednisone 5mg PO q3days
mucinex Xr 600MG po Q12H PRN
Eucerin lotion [**Hospital1 **]
lotrimin 1% crm, apply to feet [**Hospital1 **].
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
2. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: take at current
dose for 4 weeks, then 40 mg daily afterwards.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day for 4 weeks.
Disp:*112 Tablet(s)* Refills:*0*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS
Secondary Diagnosis: 303.90 DRUG USE/DEPENDENCE, ALCOHOL
Secondary Diagnosis: 291.0 DRUG WITHDRAWAL, ALCOHOL W/ DELERIUM
TREMENS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with bleeding secondary to irritation of the
stomach and esophagus. This can be corrected with the medication
we have prescribed to you along with avoidance of alchohol.
Please take the medication for 4 weeks at twice a day, then once
a day afterwards. We also advise that you stop your aspirin. We
have scheduled follow up with your primary care physician next
week, please keep this appointment. You have pending biopsy
results at our institution. These results will be mailed to you
within 4 weeks. If you do not get these results you should call
the [**Hospital **] clinic at ([**Telephone/Fax (1) 21742**] to get the results.
Followup Instructions:
Appointment
With: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
When: THURSDAY, [**2109-4-18**], 8:00am
Where: [**Hospital3 2576**], [**Street Address(2) 38740**], [**Doctor Last Name **] Building, [**Location (un) **].
Phone: ([**Telephone/Fax (1) 85612**]
|
[
"275.2",
"535.50",
"401.9",
"263.9",
"578.0",
"530.81",
"276.3",
"276.1",
"530.19",
"V58.65",
"571.1",
"577.0",
"275.3",
"496",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
6674, 6680
|
4044, 5393
|
335, 353
|
6909, 6909
|
2914, 4021
|
7733, 8022
|
2260, 2284
|
5733, 6651
|
6701, 6701
|
5419, 5710
|
7060, 7710
|
2299, 2895
|
275, 297
|
1420, 1782
|
381, 1402
|
6835, 6888
|
6720, 6757
|
6924, 7036
|
1804, 1940
|
1956, 2244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,307
| 182,898
|
45556+45557
|
Discharge summary
|
report+report
|
Admission Date: [**2119-1-13**] Discharge Date: [**2119-1-18**]
Date of Birth: [**2057-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year old male with a past medical history of cirrhosis from
steatohepatitis, CKD, and DM admitted from the ED with
confusion, nausea, and vomiting.
.
Patient contact[**Name (NI) **] covering geriatrics attending with the concern
of 24 hours of nausea, vomiting, and inability to tolerate oral
intake. There was also a concern that he had become increasingly
confused lately. He has been compliant with lactulose and had 2
BMs earlier today. He was referred to the ED for evaluation.
.
Review of systems is notable for subjective fevers and some
abdominal pain x 1 month. He also reports falls but is unclear
when they occurred. He denies chest pain, shortness of breath,
headache, sore throat, dysuria.
.
In the ED, VS were 98.3 195/91->156/65 78 20 98% RA. He was
given ceftriaxone 1g IV because of concern for SBP, but then
abdominal US done in the ED did not reveal any ascites. He also
received zofran 4mg IV x 1 and 1L of IVF. He was noted to be
guaiac positive with brown stool.
Past Medical History:
1. Diabetes mellitus, followed by Dr. [**Last Name (STitle) 14116**].
2. Cirrhosis of the liver, followed by Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**].
3. Irritable bowel syndrome.
4. Hyperlipidemia.
5. Osteoarthritis.
6. Depression.
7. Renal insufficiency.
8. Frequent falls and gait abnormality.
9. Rotator cuff injury.
10. baseline dementia and cognitive impairment
Social History:
Social History:
-single, lives with "homemaker/nurse"
-Close friend [**Name (NI) 46**] is HCP
-[**Name (NI) **] PhD in [**Name (NI) 97164**] psychologist
-No tobacco, no alcohol
Family History:
Family History:
-Father: cancer, CAD, tobacco and alcohol abuse
-Mother: thyroid disease, lung cancer
Physical Exam:
VS: 98.0 144/65 66 18 98% RA 155.3kg
Gen: Very pleasant, obese man. Oriented to [**Hospital1 **] but not date,
month, or year, even when prompted.
HEENT: Clear OP, MMM
NECK: Supple
CV: Distant, RR, NL rate. NL S1, S2. +systolic murmur at base
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS.
EXT: +1 pitting edema b/l. 2+ DP pulses BL
NEURO: Left pupil smaller than right but both reactive,
difference is subtle. Preserved sensation throughout. [**6-13**]
strength throughout. +asterixis. Gait assessment deferred
Pertinent Results:
Labs:
====
[**2119-1-13**] 12:22AM BLOOD WBC-4.3 RBC-3.51* Hgb-11.8* Hct-33.2*
MCV-95 MCH-33.7* MCHC-35.6* RDW-15.2 Plt Ct-91*
[**2119-1-13**] 07:15AM BLOOD WBC-4.6 RBC-3.32* Hgb-11.3* Hct-32.0*
MCV-96 MCH-34.0* MCHC-35.3* RDW-15.2 Plt Ct-82*
[**2119-1-14**] 07:20AM BLOOD WBC-4.6 RBC-3.32* Hgb-11.0* Hct-32.5*
MCV-98 MCH-33.1* MCHC-33.8 RDW-15.2 Plt Ct-89*
[**2119-1-15**] 07:25AM BLOOD WBC-4.5 RBC-3.10* Hgb-10.7* Hct-30.1*
MCV-97 MCH-34.5* MCHC-35.5* RDW-15.2 Plt Ct-77*
[**2119-1-16**] 06:40AM BLOOD WBC-4.1 RBC-3.22* Hgb-10.6* Hct-30.6*
MCV-95 MCH-33.0* MCHC-34.8 RDW-15.2 Plt Ct-72*
[**2119-1-17**] 06:50AM BLOOD WBC-3.8* RBC-3.17* Hgb-10.6* Hct-30.6*
MCV-97 MCH-33.3* MCHC-34.5 RDW-15.3 Plt Ct-72*
[**2119-1-18**] 07:15AM BLOOD WBC-3.9* RBC-3.29* Hgb-11.1* Hct-32.0*
MCV-97 MCH-33.7* MCHC-34.6 RDW-15.1 Plt Ct-70*
[**2119-1-13**] 12:22AM BLOOD PT-16.4* PTT-27.6 INR(PT)-1.5*
[**2119-1-14**] 07:20AM BLOOD PT-17.0* PTT-28.4 INR(PT)-1.5*
[**2119-1-16**] 06:40AM BLOOD PT-16.7* PTT-28.3 INR(PT)-1.5*
[**2119-1-18**] 07:15AM BLOOD PT-16.3* PTT-27.3 INR(PT)-1.5*
[**2119-1-13**] 12:22AM BLOOD Glucose-245* UreaN-50* Creat-2.4* Na-139
K-4.4 Cl-100 HCO3-31 AnGap-12
[**2119-1-13**] 07:15AM BLOOD Glucose-156* UreaN-49* Creat-2.2* Na-144
K-5.1 Cl-105 HCO3-30 AnGap-14
[**2119-1-14**] 07:20AM BLOOD Glucose-227* UreaN-44* Creat-2.0* Na-143
K-4.8 Cl-105 HCO3-31 AnGap-12
[**2119-1-15**] 07:25AM BLOOD Glucose-171* UreaN-41* Creat-1.9* Na-140
K-4.4 Cl-105 HCO3-25 AnGap-14
[**2119-1-16**] 06:40AM BLOOD Glucose-151* UreaN-37* Creat-1.8* Na-139
K-4.7 Cl-105 HCO3-28 AnGap-11
[**2119-1-18**] 07:15AM BLOOD Glucose-136* UreaN-38* Creat-1.9* Na-139
K-4.5 Cl-106 HCO3-26 AnGap-12
[**2119-1-13**] 12:22AM BLOOD ALT-27 AST-52* AlkPhos-189* TotBili-1.2
[**2119-1-13**] 07:15AM BLOOD ALT-23 AST-49* LD(LDH)-223 AlkPhos-156*
TotBili-1.2
[**2119-1-14**] 07:20AM BLOOD ALT-25 AST-56* AlkPhos-141* TotBili-1.1
[**2119-1-15**] 07:25AM BLOOD ALT-22 AST-53* AlkPhos-135* TotBili-1.4
[**2119-1-16**] 06:40AM BLOOD ALT-19 AST-57* LD(LDH)-231 AlkPhos-124*
TotBili-1.5
[**2119-1-17**] 06:50AM BLOOD ALT-24 AST-57* AlkPhos-123* TotBili-1.3
[**2119-1-18**] 07:15AM BLOOD ALT-21 AST-61* AlkPhos-126* TotBili-1.3
[**2119-1-13**] 07:15AM BLOOD Calcium-10.1 Phos-3.4 Mg-2.1
[**2119-1-18**] 07:15AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1
[**2119-1-13**] 02:11PM BLOOD %HbA1c-7.6*
[**2119-1-13**] 12:22AM BLOOD Ammonia-158*
[**2119-1-16**] 06:40AM BLOOD Ammonia-33
.
Imaging:
=======
US ABD LIMIT, SINGLE ORGAN Study Date of [**2119-1-13**] 12:08 AM
IMPRESSION:
1. Coarse liver echotexture consistent with known cirrhosis
without evidence of focal lesion. No evidence of ascites.
2. Cholelithiasis without evidence of acute cholecystitis.
3. The main portal vein is patent with antegrade flow.
.
CHEST (PA & LAT) Study Date of [**2119-1-13**] 12:45 AM
FINDINGS: The cardiomediastinal silhouette is stable. There is
no
pneumothorax, consolidation or pleural effusions. Elevation of
the right
hemidiaphragm is again noted. Old left-sided rib fractures and
pleural
thickening. Stable appearance of right AC joint grade III
separation. DISH
changes of the thoracic spine.
.
CT HEAD W/O CONTRAST Study Date of [**2119-1-13**] 5:52 AM
IMPRESSION: No acute intracranial process.
.
Micro:
=====
Blood and Urine Cultures: NGTD
Brief Hospital Course:
A/P: 61yo gentleman with cirrhosis from steatohepatitis, CKD and
DM admitted with mental status changes.
.
# Mental status change: Given negative micro workup, this
patient's confusion was likely due to hepatic encephalopathy
rather than of infectious etiology. As per the patient and the
patient's HCP, he had not been taking his lactulose in the
setting of a gastroparesis flare and his confusion started a few
days after lactulose abstinence. He was given lactulose for a
goal of 3BMs per day, and also had his Rifaximin increased to
400 mg [**Hospital1 **]. After 4 days the patient's mental status started to
clear. Of note his venous ammonia on arrival was >100 and was
33 the day prior to discharge. His mental status workup also
consisted of a negative CT head, negative RUQ US, and negative
CXR.
.
# CKD with baseline Cr 2.1-2.6. Patient is on Aranesp as an
outpatient and this was not given in hose. His Cr on day of
discharge was 1.8 and thought to be stable. His PO intake was
stable.
.
# Gastroparesis: unclear precipitant for flare, although
patient's nausea subsided prior to discharge. He was given
antiemetics with resolution of his symptoms.
.
# Cirrhosis: AST and AlkPhos at baseline. INR stable at 1.5. He
was continued on his nadolol and rifaximin initially and after
his Cr stabilized his Lasix and Aldactone were restarted on the
day of discharge.
.
# CV:
CAD: Continue on ASA, tricor
PUMP: Patient had some slight increased in his BP while on CCB,
BB, [**Last Name (un) **] and his Lasix and aldactone were held. These
medications were restarted prior to discharge and we anticipate
a return to normal levels.
.
# Depression: Continued escitalopram and bupropion
.
# DM: Patient was continued on standing Regular with HRSS. This
was adjusted daily and patient will return home on the insulin
dosing that he was using prior to admission.
.
# Anemia with baseline Hct 28-34:
- currently at baseline
- continue iron
.
# Thrombocytopenia with platelets 82, baseline 78-90 since [**Month (only) 116**].
Likely from splenic sequestration.
.
# OSA: CPAP nightly
.
After discussion with the patient anf the medical team, all were
in agreement that Dr. [**Known firstname 3613**] [**Known lastname **] was a suitable candidate for
discharge.
Medications on Admission:
1. Amlodipine 2.5mg PO daily
2. Bupropion 200mg PO bid
3. Aranesp 2-3 times per month
4. Escitalopram 10mg PO daily
5. Tricor 145mg PO daily
6. [**Doctor First Name **] 180mg PO daily
7. Folate 1mg PO daily
8. Lasix 80mg PO daily
9. Insulin Humulin tid - 50 units qbreakfast, 55 units q lunch,
and 25 units q dinner
10. Losartan 100mg PO daily
11. Nadolol 40mg PO daily
12. Pantoprazole 40mg PP daily
13. Seroquel 100mg PO qhs
14. Rifaximin 200mg PO tid
15. Aldactone 25mg PO daily
16. Tramadol prn
17. Aspirin 81mg PO daily
18. Ferrous Sulfate 325mg PO bid
19. Multivitamin
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): PLease titrate to 3BMs per day.
Disp:*qs for one month * Refills:*2*
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Bupropion 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
12. Insulin Sliding scale
Please use insulin as you were prior to admission to the
hospital
13. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Aranesp SureClick -Polysorbate 60 mcg/0.3 mL Pen Injector
Sig: One (1) Subcutaneous 2-3 times per month: as directed by
Dr. [**First Name (STitle) **].
17. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
18. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a
day.
19. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Hepatic Encephalopathy
.
Secondary:
1. Cirrhosis likely due to Steatohepatitis, followed by Dr. [**First Name (STitle) 679**]
2. Irritable Bowel Syndrome
3. Type 2 Diabetes Mellitus
4. Gastroparesis
5. Obesity
6. Hyperlipidemia
7. Rheumatoid Arthritis
8. Depression
9. Chronic Renal Insufficiency baseline Cr
10. Obstructive Sleep Apnea on CPAP
11. HTN
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating with
assistance.
Discharge Instructions:
You were admitted with hepatic encephalopathy that was thought
to be due to decreased lactulose intake in the setting of a
gastroparesis flare. You were treated with reglan and zofran
for the gastroparesis symptoms and were given lactulose for the
encephalopathy. You responded well.
.
1. Please take all medications as prescribed.
2. Please make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2119-1-19**]
12:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2119-1-31**]
1:00
Completed by:[**2119-1-19**] Admission Date: [**2119-1-19**] Discharge Date: [**2119-1-22**]
Date of Birth: [**2057-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Confusion, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year-old male with a past medical history of cirrhosis from
steatohepatitis, CKD (baseline 1.9-2.2), and DM2 admitted from
the ED with confusion and a fall. The patient was initially
admitted to the floor but was transferred to the MICU within one
hour for somnulence.
Of note, patient was discharged from [**Hospital1 18**] yesterday after
treatment for hepatic encephalopathy precipitated by not taking
his lactulose in the setting of a flare of gastroparesis flare.
He went home and describes eight hours of feeling more sleepy,
lethargic and mildly confused. This is corroborated by his
partner. [**Name (NI) **] was attempting to wake himself up and tripped and
fell to his knees leaving the bathroom and now notes continued
knee pain. At this point, he pushed his medic alert button to
call EMS. He denies chest pain, shortness of breath, cough,
headache, sore throat, dysuria.
In the ED, VS 96, 84, 139/74, 98% 2L, 97% RA. Ammonia 49,
lactate 1.7, other laboratories at baseline. He received
levofloxacin 750 mg IV for a possible RLL infiltrate on CXR. CT
head negative.
On floor, patient was noted to be responsive only to sternal
rub. Currently protecting airway. VS 98 60 105/60 16 98% 2L.
Team unable to obtain ABG. He has not yet received any
lactulose.
On arrival to the MICU, patient now more responsive - responds
to voice; oriented to hospital and responds with "winter,
[**Month (only) 1096**]" when asked year. FSG 125. ABG 7.29/51/83.
Past Medical History:
1. Cirrhosis likely due to steatohepatitis, followed by Dr. [**First Name (STitle) 679**]
2. Type 2 diabetes mellitus
3. Chronic renal insufficiency baseline Cr 2.1-2.6
4. Hypertension
6. Hyperlipidemia
7. Gastroparesis
8. Baseline dementia with cognitive impairment
9. Obstructive sleep apnea on CPAP
10. Irritable bowel syndrome
11. Obesity
12. Rheumatoid arthritis
13. Depression
Social History:
(per prior notes):
- No alcohol, tobacco
- Single, lives with homemaker / nurse; close friend [**Name (NI) 46**] is
HCP
- [**Name (NI) **] PhD in [**Name (NI) 97164**] psychologist
Family History:
per prior notes
-Father: cancer, CAD, tobacco and alcohol abuse
-Mother: thyroid disease, lung cancer
Physical Exam:
VS: 98.0 144/65 66 18 98% RA 155.3kg
Gen: Very pleasant, obese man. Oriented to [**Hospital1 **] but not date,
month, or year, even when prompted.
HEENT: Clear OP, MMM
NECK: Supple
CV: Distant, RR, NL rate. NL S1, S2. +systolic murmur at base
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS.
EXT: +1 pitting edema b/l. 2+ DP pulses BL
NEURO: Left pupil smaller than right but both reactive,
difference is subtle. Preserved sensation throughout. [**6-13**]
strength throughout. +asterixis. Gait assessment deferred
Pertinent Results:
ON ADMISSION:
[**2119-1-18**] 07:15AM BLOOD WBC-3.9* RBC-3.29* Hgb-11.1* Hct-32.0*
MCV-97 MCH-33.7* MCHC-34.6 RDW-15.1 Plt Ct-70*
[**2119-1-19**] 03:15AM BLOOD Neuts-57.6 Lymphs-34.3 Monos-3.5 Eos-4.0
Baso-0.6
[**2119-1-18**] 07:15AM BLOOD PT-16.3* PTT-27.3 INR(PT)-1.5*
[**2119-1-18**] 07:15AM BLOOD Glucose-136* UreaN-38* Creat-1.9* Na-139
K-4.5 Cl-106 HCO3-26 AnGap-12
[**2119-1-18**] 07:15AM BLOOD ALT-21 AST-61* AlkPhos-126* TotBili-1.3
[**2119-1-18**] 07:15AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1
[**2119-1-19**] 03:15AM BLOOD Lipase-77*
[**2119-1-19**] 05:30AM BLOOD Ammonia-49*
[**2119-1-19**] 03:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD [**2119-1-19**]: No evidence of hemorrhage or infarction. MRI
with diffusion- weighted imaging is more sensitive for
evaluation of acute ischemia.
BILATERAL KNEE FILMS [**2119-1-19**]:
1. Small left knee effusion without evidence of acute fracture.
2. Mild degenerative changes bilaterally.
ABDOMINAL ULTRASOUND [**2119-1-19**]:Moderate ascites throughout the
abdomen.
CXR [**1-19**]:Limited portable radiograph with poor inspiration
available for
review. Relative increased opacity within the left lower lung is
difficult to evaluate; however, may reflect effusion and/or
atelectasis/consolidation. Mild pulmonary edema present. There
is a small right pleural effusion.
Mediastinal enlargement may reflect increased vascularity girth
given edema however if does not return to baseline, cross
sectional imaging is advised.
Right- sided rib fractures with pleural thickening is again
appreciated.
Recommend repeat radiographs with PA and lateral for further
evaluation.
Brief Hospital Course:
MICU COURSE: Mr. [**Known lastname **] with emergently transferred uppon arrival
to floor from ED to MICU service. Patient was determined to be
encephalopathic and hypercarbic with evidence of new PNA on CXR.
Patient was started on BiPAP and an NG tube was placed. Patient
was able to rouse to safely drink lactulose and had appropriate
increase in stool output. Patient was continued on his
rifaximin. Patient was given vancomycin and levoquin for his
PNA. Over the course of his stay, the patient's mental status
improved such that he is alert and oriented *3, but remains with
an odd affect. Patient was noted during times of sleep to have
occasional episodes of apnea with accompaning desaturations from
which he was able to self- recover. Patient was transferred to
the liver service with geriatrics consulting ( pt PCP is
geriatrician at [**Hospital1 18**]) for further care regarding his hepatic
encephalopathy, sleep apnea and pneumonia.
Floor Course
A/P: 61yo gentleman with cirrhosis secondary to steatohepatitis,
CKD, DM2, OSA admitted s/p fall with mental status changes now
being transferred from MICU to floor.
# Mental status change: Patient's mental status clearer and now
alert although somnolent, but feels closer to baseline. He is
oriented x 2 with variable disorientation to time. Altered
mental status most likely due to hepatic encephalopathy with
component of hypercarbia from OSA. His encephalopathy may have
been precipitated by inadequate stooling as well as ? pneumonia
seen on chest x-ray. Abdominal ultrasound this admission with
moderate ascites although dry tap. No prior h/o SBP. Head CT
unrevealing. Continued aggressive lactulose and rifaximin
titrated to 4BMs per day. Continued CPAP. Treated PNA with
levofloxacin.
# RLL infiltrate: Pt has RLL infiltrate and mental status
changes, systemic symptoms and was recently hospitalized
[**Date range (1) 66574**]. Initially treated with Zosyn but changed to
levofloxacin x 7 days
# Cirrhosis: Secondary to steatohepatitis: Platelets, INR, liver
function tests at baseline. No known history of varices in our
system but on nadolol. Continued
nadolol, aldactone and lasix, lactulose and rifaximin.
# CKD with baseline Cr 2.1-2.6. Monitored. Medications renally
dose
# OSA: Hypercarbic with CO2 51 on admission to MICU. CPAP
overnight. Continued nasal CPAP with settings from MICU. Pt not
aware of usual settings.
# HTN: Currently normotensive. Continued aldactone, nadolol,
ASA, restarted amlodipine, then losartan
.
# Depression: Continued escitalopram and bupropion, holding
seroquel due to concern for excess sedation
.
# DM2: Complicated by nephropathy. Discharged on home regimen.
.
# Anemia with baseline Hct 28-34: Currently at baseline.
Continued aranesp as outpt. Held iron since can constipate and
wanted to encourage 4 BMs per day to avoid MS changes
.
# Dyslipidemia: No acute issues. Restarted tricor
.
# Borderline widened mediastinum: Radiology now [**Location (un) 1131**] chest
x-ray with borderline widened mediastinum. Non-urgent CT chest
to further evaluate for potential aortic aneursym
Medications on Admission:
1. Lactulose 30mL PO TID
2. Escitalopram 10 mg PO DAILY
3. Fenofibrate Micronized 145 mg PO daily
4. Folic Acid 1 mg PO DAILY
5. Losartan 100 mg PO DAILY
6. Nadolol 40 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Aspirin 81 mg Tablet PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Multivitamin PO DAILY
11. Bupropion 200 mg Sustained Release PO BID
12. Insulin Humulin QAC - 50 units breakfast, 55 units lunch,
and 25 units dinner
13. Rifaximin 400 mg PO TID
14. Furosemide 80 mg PO DAILY
15. Spironolactone 25 mg PO DAILY
16. Aranesp 60 mcg/0.3 mL 2-3 times per month
17. Amlodipine 2.5 mg PO DAILY
18. Fexofenadine 180 mg PO DAILY
19. Quetiapine 100 mg PO QHS
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Bupropion 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a
day.
16. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: As
directed units Injection As directed: 50 units with breakfast,
55 units with lunch, 25 untis with dinner.
17. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 3 doses: Take every other day for total of
three more doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis
1. Hepatic Encephalopathy
2. Obstructive Sleep Apnea on CPAP
3. s/p fall
Secondary Diagnosis
Cirrhosis secondary to steatohepatitis
Type 2 DM
Discharge Condition:
Hemodynamically stable, afebrile, oriented
Discharge Instructions:
You were admitted to the hospital with confusion and a fall.
Your confusion was most likely due to not having enough bowel
movements which is important when you have liver disease.
It is very importantt hat you take your lactulose and rifaximin
and have [**5-14**] bowel movements per day to avoid further episodes
of confusion. You also had a fall before coming to the hospital
but did not have any broken bones and a CAT scan of your head
was normal. You were initially admitted to the floor but then
transferred to the intensive care unit because you were
difficult to arouse in the morning which may have also been
related to not having your CPAP machine overnight. Also, a chest
X ray showed that you might have pneumonia, so we treated you
with antibiotics.
We made the following changes to your medications
1. We stopped your Seroquel since this can make you tired and
confused
2. We stopped your iron since this can be constipating and you
should have 4 BMs per day in order to avoid becoming confused
again
3. You will be given a prescription for an antibiotic called
Levofloxacin, which you will take every other day for three more
doses. This is for your pneumonia.
Please take all medications as prescibed and keep all follow up
appointments. Also, use your CPAP machine every night.
Please return to the ER or call your primary care doctor if you
develop confusion, fever>100.4, chills, nausea, vomiting,
shortness of breath, chest pain, or any other concerning
symptoms.
Please use your cane every time you walk.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2119-1-31**]
1:00
Please schedule a follow-up appointment with Dr. [**First Name (STitle) 679**] within [**3-13**]
weeks for follow-up of your liver disease.
|
[
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"285.9",
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"507.0",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
12245, 12252
|
22280, 22325
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,443
| 184,083
|
12422
|
Discharge summary
|
report
|
Admission Date: [**2161-3-10**] Discharge Date: [**2161-3-26**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Medical: Change in mental status, dehydration
Surgical: Free intraperitoneal air
Major Surgical or Invasive Procedure:
Skin Biopsy
Surgical Service:
1. Emergent exploratory laparotomy.
2. Repair of duodenal perforation second portion of duodenum.
3. G-tube placement.
4. J-tube placement.
5. Extended adhesiolysis.
History of Present Illness:
Pt is a 86 yo male with h/o CAD s/p stent, SVT s/p pacer, AAA
repair, recently diagnosed metastatic lung CA with mets to L4
currently undergoing radiation to L spine, last radiation [**3-9**].
He was transferred from [**Hospital3 **] after they noticed
increased lethargy, confusion and restlessness this AM. He had
had poor PO intake the past few days. He does have a cough and
reports emesis, although is not reliable secondary to confusion.
He is knows that he is in a hospital but does not know which
one. He knows his birthday but not the date. In the ED, he was
given IVF. CXR was unchanged, and CT head showed no new mets or
bleed. per his daughter, he has been extremely confused since
being at [**Hospital3 **] and is perhaps overmedicated with
morphine.
Past Medical History:
s/p melanoma removed from his face
AAA repair
CAD s/p stent - on aspirin and plavix
SVT s/p pacer
Social History:
Prior smoker, currently comes from [**Hospital3 **] but was
ambulatory and independent prior to this.
Positive for tobacco. Previously smoked for many years and quit
in between. Occasional ETOH.
Family History:
Mother had heart disease, no CA, unknown cause of death. Father
without CAD or CA, unknown cause of death.
Physical Exam:
On Admission:
T 96.8 113/77 84 24 96% RA
Gen: pt is uncomfortable, c/o chills. condused, knows he is in
hospital but not which one.
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS
EXT: Pt'd right arm is swollen, cold with hematoma on upper arm.
Positive pulses
NEURO: MS as above, CN intact, moves all 4 extremities
SKIN: Patient has punctate scabbed over rash all over his face.
These were not present last week. Splinter hemorrhages on
fingernails. carbuncles on toes.
Pertinent Results:
[**2161-3-10**] 12:30PM WBC-9.3# RBC-3.97* HGB-11.6* HCT-35.2* MCV-89
MCH-29.4 MCHC-33.1 RDW-15.6*
[**2161-3-10**] 12:30PM NEUTS-95.0* BANDS-0 LYMPHS-2.6* MONOS-1.9*
EOS-0.3 BASOS-0.2
[**2161-3-10**] 12:30PM PLT SMR-NORMAL PLT COUNT-250
[**2161-3-10**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-3-10**] 12:30PM CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-3.6*
[**2161-3-10**] 12:30PM GLUCOSE-85 UREA N-39* CREAT-1.2 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-12
[**2161-3-10**] 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2161-3-10**] - Head CT - No acute intracranial process; MR more
sensitive to detect metastatic disease.
[**2161-3-10**] - CXR - Residual vs. recurrent air space disease in the
right lower lobe as detailed above. Known left pulmonary nodule,
stable.
[**2161-3-11**] - CT Chest with and without contrast - 1. No evidence of
a central venous thrombus.
2. Multifocal predominantly peribronchial ground glass change
bilaterally. The differential is broad including multifocal
infection. Treatment related effects can also be considered.
3. Left upper lobe spiculated mass and mediastinal
lymphadenopathy again appreciated.
4. New right adrenal lesion worrisome for metastasis.
5. Apparent new right renal mid pole hypodensity is of unclear
etiology. Metastasis may have this appearance though a renal
infarct may also appear similar.
6. Subcutaneous fluid stranding around the right shoulder and
scapular region incompletely imaged.
[**2161-3-11**] - CXR -
1) Rapidly evolving bilateral interstitial process, which may be
due to interstitial edema from fluid overload considering
history of recent hydration. Atypical pneumonia is also possible
in the appropriate clinical setting.
2) Peripheral left upper lobe lung nodule is suggestive of lung
cancer.
[**2161-3-12**] - Echo -
no definite vegetations seen (suboptimal study); basal inferior
posterior infarct; mild aortic stenosis
CHEST PORT. LINE PLACEMENT [**2161-3-15**]
FINDINGS: interval development bibasilar patchy opacities
concerning for underlying evolving pneumonia. There is a
persistent focal opacity along the lateral aspect of the left
hemithorax may reflect underlying focal atelectasis and/or
pneumonia. The cardiomediastinal silhouette is grossly stable.
No pneumothorax is seen. Endotracheal tube terminates 3.6 cm
above the carina. A NGT tube is in place that terminates below
the gastroesophageal junction and beyond the inferior margin of
the film.
EGD [**2161-3-15**]
Findings: Zenker's diverticulum noted- making esophageal
intubation difficult. Large blood clot visible in duodenal bulb-
protruding from pylorus. Multiple epinephrine injections were
attempted at base of clot. Ulcer bed was not clearly visualized.
Post-bulbar duodenum appeared normal.
Esophagitis.
ECG Study Date of [**2161-3-15**]
Atrial fibrillation. Demand ventricular pacing. Left axis
deviation. Right bundle-branch block with probable left anterior
fascicular block. Ventricular ectopy/aberrant conduction.
Compared to the previous tracing the rate is slower.
CT PELVIS W/O CONTRAST [**2161-3-17**]
1. Perforation of the duodenum with pneumoperitoneum and
extraluminal oral contrast
2. Interval development of compression fracture of L4 lumbar
vertebra with stable soft tissue mass of the pedicle of L4. As
no IV contrast has been used, assessment of thecal sac
compression cannot be performed.
3. Diverticulosis with no evidence of diverticulitis.
4. New mass in right adrenal gland concerning for metastatic
disease
TTE (Complete) [**2161-3-18**]
IMPRESSION: Suboptimal image quality. Compared with the prior
study (images reviewed) of [**2161-3-16**], at least moderate mitral
regurgitation and right ventricular cavity enlargement/free wall
hypokinesis is now seen. If clinically indicated, a TEE would be
better able to define the mitral valve structure and clarify the
severity of mitral regurgitation.
ECG [**2161-3-18**]
Sinus rhythm; Atrial and ventricular ectopic activity; Leftward
axis; Right bundle branch block; Inferior T wave changes are
nonspecific; Low QRS voltages in precordial leads; Since
previous tracing of [**2161-3-15**], atrial fibrillation resolved
CXR [**2161-3-20**]
IMPRESSION: Small right pleural effusion has decreased and
previous mild-to-moderate pulmonary edema has improved since
[**3-18**]. LLL atelectasis and moderate cardiomegaly persists.
Increasing opacification of LUL is probably a combination of
asymmetric residual edema and atelectasis following tracheal
extubation. Transvenous right atrial and right ventricular pacer
leads follow their expected courses. No pneumothorax.
CHEST (PORTABLE AP) [**2161-3-22**]
There is a left-sided dual-lead pacemaker. There is mild left
ventricular prominence. There is prominence of the pulmonary
vascular markings suggestive of pulmonary edema. There is a
focal area of opacity in the right lung field which is likely
due to edema, however a developing infiltrate cannot be
excluded.
CHANGE GASTROSTOMY TUBE [**2161-3-24**]
IMPRESSION: Patent G-tube and J-tube without evidence of leak
UNILAT UP EXT VEINS US PORT RIGHT [**2161-3-24**]
IMPRESSION: 1. No evidence of right upper extremity DVT.
Portable TTE [**2161-3-24**]
IMPRESSION: No valvular vegetations seen. Moderate global left
ventricular systolic dysfunction. Moderate mitral regurgitation.
Mild aortic regurgitation
CHEST (PORTABLE AP) [**2161-3-25**]
Mild bilateral pulmonary edema which has decreased. A persistent
left mid lung peripheral opacity reflecting the previously
diagnosed squamous cell carcinoma. Slight decrease in LLL
atelectasis which is mild. Persistent small right basilar
atelectasis is again noted. Stable mild cardiomegaly. A
left-sided dual-lead pacemaker is seen with one lead in the
right atrium and the other lead in the right ventricle. A line
or catheter projects over the right upper quadrant of the
abdomen
CHEST (PORTABLE AP) [**2161-3-25**]
Comparison is made with the prior study from 11 hours earlier.
Cardiomegaly is unchanged. Left transvenous pacemaker leads
terminate in standard position in the right atrium and right
ventricle. There has been interval improvement in still mild
interstitial pulmonary edema. There are bibasilar atelectasis.
Ill-defined opacity in the left mid lung has markedly improved.
Patient's known lung cancer located in LUL is partially obscured
by the body of the pacemaker and the previously described
ill-defined opacity in the left mid lung. Right pleural effusion
is small.
Brief Hospital Course:
ONCOLOGY SERVICE COURSE [**3-12**] - [**3-18**]:
86 yo male, h/o CAD s/p stenting, SVT s/p PPM, with recently
diagnosed bronchogenic lung cancer with mets to spine, admitted
from [**Hospital3 **] with change in mental status, rash, and
right upper extremity swelling.
.
Change in mental status:
Likely multfactorial, including dehydration, improved after
hydration. Overmedication was also a possibility, per daughter,
he has been getting PRN morphine IR ATC in addition to standing
SR prior to admission. Pain medications were minimized.
Infection was a possibility, as his CXR showed likely old
infiltrate (previously treated for PNA here 4 weeks ago). CT
head was negative. CXR with resolving PNA, and repeat after
hydration showed interstitial process
.
RUE Swelling: Pt rt upper extremity is enlarged complared to
left. It is cold and swollen, but with palpable pulses. He also
has a hematoma on that side. Arm swelling was resolving. RUE
u/s was negatve; humerous xray was negative for fracture; CT
scan with contrast was negative for central vein thrombus
.
Acneiform rash: Pt has a acneform rash on face and right arm,
which was not present week prior to admission. Derm consult
unsure of etiology, skin biopsy taken.
.
Cough: Pt with cough on exam initially and CXR showed resolving
PNA
.
Squamous Cell Lung CA: was initially undergoing palliative XRT
for spine metastasis, and on steroids.
.
.
[**Hospital Unit Name 13533**]: [**Date range (1) 38624**]
Mr. [**Known lastname 26453**] is an 86 yo male with h/o CAD s/p stent, SVT s/p
pacer, AAA repair, recently diagnosed metastatic lung CA who is
transferred to [**Hospital Unit Name 153**] with coffee-ground emesis x 2 days and
dropping HCT. Patient underwent emergent endoscopy early on [**3-15**]
which showed large blood clot visible in duodenal bulb-
protruding from pylorus. Multiple epinephrine injections were
attempted at base of clot. Ulcer bed was not clearly visualized.
Post-bulbar duodenum appeared normal. Esophagitis. Zenker's
diverticulum noted-making esophageal intubation difficult. Pt
kept intubated [**2-14**] to tenuous status and difficulty of
intubation. CXR [**3-15**] showed evidence of possible new bibasilar
lung process concerning for PNA. Pt now has copius thick yellow
secretions requiring hourly suction. Sputum Cx positive for
GNR. Patient then became hypotensive on [**3-15**] with low grade temp.
Central line placed and patient started on vanc and zosyn. On
[**3-17**], pt noticed to have increased pain to palpation of his
abdomen on morning rounds. Abdominal CT performed showing
perforation of duodenal ulcer with free air in the peritoneum.
Pt taken to the OR emergently for exploration. NG tube found to
have threaded through perforated small bowel, w/ significant
leakage of GI contents. Patch procedure was performed,
peritoneal washout, placement of J and G tubes. Stress dose
steroids and pressors were given during the procedure. Patient
quickly became hypotensive after the surgery to SBP of 78,
aggressivly resusitated w/ fluids receiving 6L. Had a pH of
7.14, lactate of 2.4, improved w/ fluids. Decreased steroids as
part of taper, received stress dose in OR. Patient had
persistent tachyarrhythmia, pacer interrogated [**3-18**].
.
1) Duodenal Perforation: s/p emergent surgery. Hemodynamically
stable, w/ drains reportedly w/ expected output. Degree of
abdominal tenderness on exam significantly improved. Continued
vanc/meropenem for coverage of GI infectious catastrophy in ICU
setting. Kept NPO.
.
2) Hemodynamic Instability: Patient required significant fluid
resuscitation following the OR, with now adequate blood
pressures. HR remains stable. With fluid resuscitation patient
has shown improvement of metabolic acidosis. Feel that patient
is now adequately resuscitated. Continue to monitor pressures,
check serial hct, serial physical exams, and ABGs.
.
3) Respiratory Failure ?????? Pt Intubated for endoscopy, was
difficult to intubate so remained intubated overnight in case
that further intervention was required. CXR [**3-15**] showed evidence
of possible new bibasilar lung process concerning for PNA. Pt
now has copius thick yellow secretions requiring hourly suction.
Sputum Cx positive for GNR. Likely new PNA perhaps [**2-14**]
aspiration v other infectious etiology. Plan to continue vanc
and meropenem; hold off on extubation for now; continue to
adjust vent settings w/ ABG in response to metabolic
derangements; will switch propofol to fentanyl/midazolam,
titrate up for better sedation. Feel that some degree of
hypertension is agitation related.
.
4) Acute renal failure: Creatinine increased to 1.6 since prior
day from a baseline of 1.0, possible prerenal etiology in the
setting of emesis and hypovolemia. Despite aggressive
hydration, has not show any improvement. Likely ATN with
patient that is now anuric. Plan to continue to trend Cr and
renaly dose all meds
.
5) Tachyarrhythmia: Patient with known h/o SVT, with pacer, now
presents in rapid afib in the setting of volume depletion, which
resolved w/ fluids. Plan to rehydrate + IV digoxin load for
rate control; cardiology felt rhythm to be afib with ectopy and
believed pacer to be functioning adequately; nature of pacer
firing different following OR, and was turned off during
procedure, EP to interrogate pacer to see if firiting adequatly
.
6) Squamous Cell Lung CA: Stage IV disease with known
metastates to vertebrae. Patient is undergoing palliative XRT,
most recently on [**3-9**]. Plan to continue decamethasone 4mg [**Hospital1 **],
and down titrate to 2mg; no role for chemotherapy in critically
ill patient.
.
7) Coronary Artery Disease: currently stable. Plan to
discontinue ASA, Plavix in the setting of active GIB; hold
Nifedipine in the setting of HD instability; rise in troponins
likely from demand ischemia w/ renal failure, as ratio not
elevated; continue to trend cardiac enzymes, no evidence of MI
on EKG.
.
.
SURGICAL SERVICE COURSE [**3-18**] - [**3-26**]
On [**3-18**], pt underwent an emergent exploratory laparotomy w/
repair of a perforated duodenal ulcer (please refer to operative
note for details). He returned to [**Location 153**] immediately post-op but
was transferred to the Surgical ICU on the [**Hospital Ward Name **] the
following day.
.
NEURO: Patient was maintained on adequate pain control post-op
with fentanyl and percocet elixir. His mental status cleared
and was awake, alert, following commands. The geriatrics
service was following post-op.
.
CV: Post-op his CV status was stable and did not require any
pressors during his initial stay in the TSICU. He was in
chronic AFib but was rate-controlled. His pacer appeared to be
functioning. He was transferred to the floor on [**3-24**] and was
stable overnight. He was restarted on ASA and plavix but then
stopped after further discussions with team given his recent
perforated ulcer. He was maintained on SQH post-op. A repeat
ECHO on [**3-24**] demonstrated an EF of 30%-35%, moderate global left
ventricular systolic dysfunction, moderate mitral regurgitation
and mild aortic regurgitation. On [**3-25**], he began exhibiting
tachypnea and respiratory distress. EKG did not demonstrate
significant changes from previous tracings. He was transferred
to TSICU and there is cardiac function rapidly declined
requiring ionotropic support. Cardiology was called to help
with further cardiac management. He was maintained until early
AM on [**3-26**], when his BP was continuing to decline despite
medical support. His family and health care proxy decided to
instate DNR order and no escalation of care was performed. He
shortly became asystolic and expired.
.
Resp: Post-op patient was kept intubated but he weaned off the
vent progressively and was extubated on [**2161-3-19**]. He had
nebulizer treatments and aggressive chest PT by nursing. A
speech and swallow consult was called for evaluation of his
decreased speech volume/ability. However, they were not able to
perform full consult given the fact that he was unable to clear
his secretion adequately. He remained in the TSICU for extra
pulmonary care and he was maintained on supplemental oxygen of
2L NC when he was transferred to the floor on [**3-24**]. However, on
[**3-25**] he had progressive tachypnea to 40's. He responded briefly
to lasix IV but continued to be in respiratory distress. He was
eventually re-intubated after he was transferred to TSICU.
.
GI: Post-op he was started on J-tube feeds and was tolerating
them well. His G-port was left open to gravity. His abdominal
exam was improving markedly. A G-tube study on [**3-24**]
demonstrated a patent G-tube and J-tube without evidence of
leak. During his period of decompensation, his abdmonial exam
was benign, his incision and drains were all intact. He was
maintained on IV PPI throughout his post-op course.
.
GU: He had a Foley catheter post-op and was auto-diuresing well.
His urine output dramatically declined during his episode of
rapid decompensation on [**3-25**] and he eventually went into renal
failure w/ anuria and a creatinine of 1.8.
.
Heme: His hematocrit post-op was stable and did not necessitate
further blood transfusions.
.
ID: He was continued on vancomycin and meropenem post-op until
[**3-22**] when they were d/c'd. At that point he had been afebrile
and had no elevated WBC. He was continued on fluconazole given
yeast from his intra-op peritoneal swabs. This was changed to
caspofungin after blood cultures returned w/ [**Female First Name (un) **]
(TORULOPSIS) GLABRATA. Ophthalomology consult did not reveal
any pathology. ECHO did not reveal any vegetations.
.
ENDO: He was maintained on a dexamethasone taper post-op. His
blood sugars were well-controlled.
.
The senior surgical resident in-house, Dr. [**Last Name (STitle) 33888**], kept Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) 1022**] appraised of the patient's decline in status
throughout the evening/early morning. Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) 1022**] and
TSICU team met with the family before and after the patient's
death.
Medications on Admission:
Atenolol 25 mg, Lipitor 20 mg, Plavix 75, Decadron 6 mg [**Hospital1 **],
Morphine SR 60/60 mg, Morphine IR PRN, Nifedipine 30 mg [**Hospital1 **],
Protonix 40 mg, ASA 325 mg, Senna/Colace/Dulcolax
Discharge Medications:
Patient expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Delirium
2. Rash
3. Metastatic Squamous Cell Lung Cancer
4. Perforated Duodenal Ulcer
.
SECONDARY DIAGNOSIS:
1. CAD s/p stenting in [**2155**], on ASA and plavix
2. SVT s/p PPm in [**2155**]
3. AAA repair [**2155**]
4. OSA
5. ?melanoma/skin cancer of face
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
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|
1469, 1668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,655
| 158,743
|
8028+8029+55905
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2144-8-23**] Discharge Date:
Date of Birth: [**2079-9-13**] Sex: F
HISTORY OF PRESENT ILLNESS: This 64-year-old female, status
post renal transplant in [**2138-3-5**] and more recently a
repeated renal transplant in [**2143-12-6**] by Dr. [**Last Name (STitle) 3400**] at
the [**Hospital1 69**]. The patient
breath and nausea, vomiting, chest pain and diaphoresis. At
the [**Hospital 7188**] Hospital she ruled in for myocardial infarction
and was diuresed. While there, the creatinine was noted to
increase to 3.1 and the patient became febrile to 102.5.
Blood cultures were sent which grew gram negative rods in two
bottles. The patient also had a low hematocrit at 24 and was
transfused. The patient was then transferred to the [**Doctor First Name **]
work-up and treatment. Upon her presentation to the
Emergency Room, the patient had little recollection of events
but was without symptoms, denied fevers, chills or dysuria.
PAST MEDICAL HISTORY: The patient is status post renal
transplant in [**2138-3-5**] and [**2143-12-6**], chronic renal
insufficiency with a baseline creatinine of 2.4 in [**2144-6-5**],
coronary artery disease with a moderate anterior reversible
defect and an EF of 58%, hypertension, diabetes mellitus,
chronic obstructive pulmonary disease, status post
appendectomy, status post TAH BSO.
MEDICATIONS: Home medications included Prilosec 20 mg po q
d, Glipizide 10 mg po bid, Sodium bicarb, Plavix 75 mg po q
d, NPH 15 units q a.m., Prednisone 10 mg po q d, Prograf 2 mg
q a.m., 1 mg q p.m., Rapamycin, Lasix 40 mg po q d,
Isosorbide mononitrate 60 mg po q d, Norvasc 10 mg po q d,
Ceftaz 2 gm po bid, and Timentin 2 gm po q 4 hours.
ALLERGIES: Macrodantin which causes rash.
SOCIAL HISTORY: The patient is on disability and lives with
her husband.
PHYSICAL EXAMINATION: In the Emergency Room revealed
temperature 98.5, pulse 86, blood pressure 156/71,
respiratory rate 19 and 98% O2 saturation on two liters of
oxygen. General exam, no apparent distress, comfortable
appearing woman. Chest was clear to auscultation
bilaterally. Heart exam, regular rate and rhythm. Abdominal
exam was soft, nontender, non distended with no tenderness at
the graft site. There is a palpable thrill in the right AV
fistula and the patient's skin exam revealed multiple
bruises.
LABORATORY DATA: Blood cultures and urine culture were sent.
White blood cell count 5.9, hematocrit 23.7, platelet count
139, sodium 138, potassium 4.3, chloride 102, CO2 15, BUN 55,
creatinine 3.4, glucose 204, PT 12.2, PTT 63.8, INR 1.0. EKG
revealed sinus rhythm at a rate of [**Street Address(2) 28717**] depression and
ST elevations improving from prior EKGs. Chest x-ray
revealed no lung consolidation, no evidence of CHF.
HOSPITAL COURSE: The patient was admitted to the surgical
Intensive Care Unit for monitoring.
1. Cardiovascular: The patient was status post myocardial
infarction, heparin drip and Aspirin were continued. The
patient was continued on Lopressor for beta blockade. Her
original outpatient antihypertensive regimen was continued.
2. Respiratory: The patient was watched closely for signs
of congestion and signs of congestive heart failure, though
none were present at that time.
3. Gastrointestinal: The patient was maintained on Prilosec
for GI prophylaxis.
4. Renal: For her increased creatinine which was felt to be
secondary to over diuresis in the setting of possible
congestive heart failure or graft rejection or sepsis. Her
intravascular volume was carefully repleted and creatinine
was monitored.
5. Heme: The patient was transfused two units of packed red
blood cells for hematocrit of 23.7 given her history of
recent myocardial infarction.
6. Endocrine: The patient was continued on her NPH and
Glipizide and a regular insulin sliding scale for additional
coverage.
7. Fluids, Electrolytes & Nutrition: Fluid was provided
gently as described above. Electrolytes were repleted prn.
8. Nutrition: The patient was maintained on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet.
9. Infectious Disease: For gram negative rod sepsis the
patient was continued on Ceftaz. Repeat blood cultures and
urine cultures were sent.
On [**2144-8-24**] a central line placement was attempted. The
physicians attempting to place this line encountered
difficulty in cannulating the vein. After several attempts
eventually the line was placed successfully. The patient was on
Heparin for her recent myocardial infarction throughout the
placement of the central line. After successful placement of the
line the patient was transferred to the general medical floor.
On [**2144-8-25**] the patient was noted to have a hematocrit of 25.
A packed red blood cell transfusion was initiated for this
hematocrit. Within 5 minutes of this transfusion, the patient
began to complain of shortness of breath and became stridorous.
Because of the temporal relationship to the blood cell
transfusion, it was felt that the patient was likely having an
anaphylactic reaction to the transfusion. The patient received
80 mg of IV Solu-Medrol,
50 mg of IV Zantac, 50 mg of IV Benadryl and 1 mg of Ativan.
The patient required intubation for airway protection. Her
immunosuppressives were held. The patient was then
transferred to the medical Intensive Care Service for further
management. During the day of [**8-25**] the patient was noted to
have an expanding hematoma and multiple laboratory
abnormalities including a low platelet count, acidosis and a
hematocrit of 11.8. The patient was aggressively transfused
with packed red blood cells, fresh frozen plasma,
cryoprecipitate and units of platelets. The remainder of the
course in the medical Intensive Care Unit by systems is as
follows:
1. Neck hematoma. Ultrasound of the neck revealed extensive
subcutaneous fluid in the neck which was felt to represent
either edema or hematoma. Venous structures in the neck were
found to be patent with normal venous wave forms. There was
no evidence of pseudoaneurysm or AV fistula in the right
neck. An MRA of the neck was obtained as well which showed
the major vessels of the neck to display normal coarse and
caliber with the exception of a moderate stenosis in the
proximal right ECA. Over the course of the next several
weeks stay in the medical Intensive Care Unit, the neck
hematoma and swelling slowly resolved.
2. Cardiovascular. The patient's CK enzymes were cycled and
a downgoing trend was followed. She was continued on
Lopressor 12.5 mg po bid. Because of her history of large
bleed into the neck, Aspirin and Heparin were held. There
was concern that the patient may have suffered myocardial
ischemia during the acute drop in hematocrit as the CK
enzymes declined, there was no further evidence of ongoing
ischemia. On approximately [**9-4**] the patient became
hypotensive. Lopressor was stopped. The likely etiology was
felt to be secondary to sepsis. The patient did require a
brief amount of Dopamine and normal saline boluses, both of
these were met with good results and improvement in the blood
pressure. The patient did continue to have intermittent
hypotension throughout the next several days and began to
experience hypotension after hemodialysis which had been
started as described below. The patient did occasionally
require Neo-Synephrine infusion after hemodialysis. There
was concern that an infected Quinton catheter may be causing
the hypotension related to dialysis vs poor fluid
mobilization after dialysis. The Quinton catheter was
changed and after this there were no further hypotensive
episodes requiring pressors after hemodialysis.
3. Infectious disease system. The patient was continued on
her course of Ceftriaxone which had been started for gram
negative sepsis. She ultimately completed a 14 day course of
Ceftriaxone for this. On [**2144-9-4**] in the setting of
hypotension and a temperature spike, blood cultures and urine
cultures were sent. Urine culture ultimately revealed
enterococcus for which the patient was treated with
Vancomycin for three days. This was ultimately stopped
secondary to two negative urine cultures following treatment.
The patient was also noted to develop a foul smelling
discharge from the endotracheal tube. This was sent for
culture and the patient also had a CT scan of the sinuses which
was negative for sinusitis. The patient
was started on Flagyl for suspected anaerobic infection. This
continued for two days and then the patient was changed to
Clindamycin. Levaquin was
added but then discontinued after several days. Ceftaz was added
for pseudomonal coverage. This continued for a total of 5 days.
Ultimately, culture
data which had been taken on sputum from around the time of
the patient's initial temperature spike revealed Enterobacter
which was sensitive to Imipenem and indeterminate to
Quinolone. For this reason, the aforementioned antibiotics
were discontinued as mentioned and the patient was started on
Imipenem. The patient continued on Imipenem for one day and
then this was changed to Meropenem because of concerns that
Imipenem can lower seizure threshold in patients in end stage
renal disease. The patient was also seen in consultation by
the infectious disease service who recommended no antibiotics
with the exception of the Meropenem.
Legionella and cryptococcus were evaluated and these tests
were negative. C. diff studies were sent and these were also
negative. Fungal and mycobacterial isolates in the blood
were sent and these were also negative. After two days of
Meropenem treatment, the patient's white blood cell count and
temperature stabilized. White blood cell count returned to
within normal limits and did not rise after that.
Temperature remained generally stable with occasional low
grade fevers.
4. Pulmonary. The patient was intubated and sedated,
maintained on Propofol. She received mechanical ventilation
on a variety of modes including assist control, SIMV and
pressure support. Propofol was eventually weaned off in
order to clarify the patient's neurologic picture. After
this she was maintained on pressure support with her own
respiratory drive and she did not receive any further
sedation.
5. Renal. The patient developed an increased BUN and
creatinine and was noted to have falling urine output.
Initially her urine output responded and increased to normal
saline boluses. She was continued on her immunosuppressants
which included FK506, Rapamycin and Prednisone. Rapamycin
and FK506 levels were followed and dosages were adjusted as
necessary. Eventually the patient's urine output began to
decline and eventually stopped responding to normal saline
boluses. Lasix and normal saline boluses were then tried and
these did increase urine output for a brief period of time.
However, ultimately the patient's urine output tapered down
and was unresponsive to both boluses and Lasix. It was felt
that the patient may have a component of ATN. Continued normal
saline boluses and a Lasix drip met with moderate success.
Ultimately on [**2144-9-4**] the patient began hemodialysis.
Hemodialysis continued throughout the remainder of the
hospital admission. She continued to be maintained on her
immunosuppressant drugs as above.
6. Heme. Following the aggressive transfusion after the
hematocrit of 11.8, the patient's hematocrit ultimately
remained stable. Over the course of the next
several weeks the patient's hematocrit did slowly trend
downward, occasionally requiring transfusions of one unit at
a time in order to keep her hematocrit over 30. Iron studies
and retic count were checked. Epogen was started as it was
felt that the patient's renal failure may be playing a role
in her ongoing anemia.
7. Endocrine. For the patient's diabetes mellitus she was
maintained on a regular insulin sliding scale. When the
patient began TPN, she was also maintained on regular insulin
sliding scale with insulin and the TPN. When TPN was
discontinued, she was converted to a regular insulin sliding
scale again which was titrated upwards in order to maintain
glycemic control.
8. Fluids, Electrolytes & Nutrition. The patient initially
began on tube feeds with Criticare. Around [**2144-8-30**] it was
felt that the patient was not properly tolerating her tube
feeds and she began a regimen of total parenteral nutrition.
On approximately [**9-15**] the patient was again tried on tube
feeds, this time with Reglan in order to increase motility
and resolved the patient's problem of high residuals. This
was met with success and within several days after this the
patient's TPN was stopped and she was maintained only on tube
feeds.
9. Electrolytes. Electrolytes were checked and adjusted
with hemodialysis. Her potassium remained generally stable
throughout the admission. Phosphorus was generally high
throughout the admission and was managed with hemodialysis,
Phos-Lo and ultimately Amphojel. On [**2144-9-3**], the patient was
found to be hypercalcemia and she received a dose of
Pamidronate in order to manage the hypercalcemia.
10. Neurologic. Following the development of the large neck
hematoma, very low hematocrit and need for aggressive
resuscitation for hypotension and low hematocrit, there was
concern that the patient suffered anoxic/ischemic brain
injury. Neurologic consultation was obtained which revealed
no Doll's eye reflex, a positive corneal reflex on the left,
no gag reflex, no withdrawal of the upper extremity to pain
but withdrawal of the lower extremities bilaterally to pain.
Reflexes were brisk in the upper extremity and the right
lower extremity, however, the right lower extremity reflexes
were greater than the left lower extremity reflexes. There
was bilateral ankle clonus and toes were upgoing. The
patient was unresponsive, but was also intubated and sedated.
The neurology consult service recommended obtaining an MRI
and MRA of the neck to evaluate the patient. MRI of the head
performed on [**2144-8-27**] revealed no evidence for a large
territorial infarct but two foci of infarctions in the left
cerebellar hemisphere which were new compared to a prior CT
scan in [**2144-7-5**]. There was some trace increased signal on
the diffusion images. There were multiple scattered foci of
increased signal on the trace diffusion images in the left
parietal lobe and posterior frontal lobe bilaterally which
may represent small regions of ischemia. There was extensive
perivascular white matter, small vessel ischemic disease and
the major vessels of the neck were normal in course and
caliber with the exception of a moderate stenosis in the
proximal right ECA. Major vessels of the circle of [**Location (un) 431**]
displayed a normal course and caliber with moderate stenosis
in the right ICA in the region of the siphon. There were no
definite signs of intracranial hemorrhage. The patient's
neurologic exam was closely followed throughout the remainder
of the hospitalization. Some exam findings were fluctuant.
There was a day when the nurse reported the patient was able
to move to command, however, this eventually did not
continue. The patient was noted to have a rhythmic motion of
her lower extremities, questionably related to seizure.
These activities did decrease with empiric Ativan and so
patient was empirically started on Dilantin. This did
control this activity for several days but the activity again
returned around [**9-2**]. EEGs were taken to evaluate for this.
On [**2144-8-30**] EEG revealed an abnormal EEG due to the presence
of a slow disorganized background with burst of generalized
swelling. This was consistent with a moderate encephalopathy
though there was no focal or epileptiform features that were
seen. On [**2144-9-3**], EEG revealed slow and disorganized
background with occasional bursts of generalized slowing felt
to indicate widespread encephalopathy affecting both cortical
and subcortical structures, however, medications, metabolic
disturbances and infections were among the most common
causes. Again there were no focal abnormalities or
epileptiform features. Because of a lack of evidence for
seizure activity, ultimately Dilantin was discontinued. The
patient's neurologic exam continued to be followed with a
goal of assessing this as her renal failure resolved. Infection
was treated as previously noted and renal failure was managed
with hemodialysis.
Nonetheless, with reversal of all of these
potential confounding factors, the patient's neurologic
condition did not improve. She continued to have an intact
Doll's eye reflex, a right corneal reflex but no corneal
reflex. She remained unresponsive to voice. She would
respond only with withdraw to noxious stimuli in her lower
extremities but not in the upper extremities. Pupils remained
equal and reactive. A repeat EEG was obtained on [**9-10**] and [**9-11**].
This
revealed burst suppression representing encephalopathy
without prominent focal features. There was a progression to
slowing with less prominent suppression which was felt to
suggest a lessening of medication effect from Propofol or
Lorazepam or other medications. Again, there were no
prominent epileptiform features. The patient was again seen
by the neurology consult service. A repeat MRI was obtained.
This exam found that in comparison to the study of [**8-27**] there
were no major vascular territorial infarcts that had
developed. Again, there were a few punctate foci, slightly
elevated signal on the diffusion scans, possibly representing
minute areas of evolving ischemia. There were two small
areas of susceptibility within the cerebellar hemispheres.
The patient was again seen by the neurology consult service
who felt that given the patient had been weaned off Propofol,
had been controlled with hemodialysis and infection had
resolved, it was likely that the patient's current neurologic
status was representative of her neurologic picture. Patient
was felt to have an unfavorable prognosis. A family meeting
was held on [**2144-9-18**]. At that time it was decided to continue
caring for the patient, move forward with a tracheostomy to
examine options for placement in a ventilation facility
closer to the patient's family's home in [**Doctor Last Name **].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 10038**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2144-9-19**] 21:27
T: [**2144-9-19**] 21:42
JOB#: [**Job Number 28718**]
1
1
1
R
Admission Date: [**2144-8-23**] Discharge Date: [**2144-10-2**]
Date of Birth: [**2079-9-13**] Sex: F
Service:
ADDENDUM: This addendum is to summarize the events, which
took place between [**2144-9-19**] and [**2144-10-2**].
Infectious disease system: The patient completed her course
of Meropenem to a total of fourteen days. The patient
continued to have low grade fevers without any frank
temperature spikes. She was followed after her completion of
course with no actual temperature spike with plans to
reculture the patient if she did spike.
Pulmonary: The patient received a bed side tracheostomy and
was maintained on mechanical ventilation. Mechanical
ventilation was slowly weaned in the degree of support. On
[**2144-10-1**] the patient was deemed to be stable for
discontinuing on the ventilator. In discussion with the
patient's husband it was agreed that the patient would be
taken off the ventilator.
Renal: The patient continued to receive hemodialysis between
[**9-19**] and [**9-25**]. A Perm-A-Cath was placed as
it was anticipated that the patient would continue dialysis
at an outside facility. However, on [**2144-9-28**] a
discussion with the family took place and it was determined
that the patient should be discontinued from hemodialysis.
Hematologic: The patient's anemia of chronic disease
continued. Hematocrit was followed and transfusions were
given in order to maintain a hematocrit above 28.
Neurologic: The patient was seen in consultation again by
the Neurological Consult Team on Monday [**9-28**] at the
request of the family. At this time Neurology Service felt
that although the patient appeared to be more alert and more
neurologically awake with eye movements, it was felt that
these eye movements were not purposeful and the patient was
unlikely to recover from her subcortical encephalopathy.
Over the course of these two weeks the neurologic examination
remained constant with a unilateral startle reflex,
unilateral corneal reflex, eye opening to name, apparent
looking around the room, however, no purposeful movements and
no following of commands and no withdraw to pain.
Nutrition: The patient received a PEG tube and tube feeds
were continued through the PEG tube.
GI system: Because of the patient's ongoing abdominal
discomfort with grimace on abdominal examination, liver
function tests were evaluated. These were generally within
normal limits. Amylase and lipase was found to be elevated
and the patient's tube feeds were held for some period of
time to treat apparent pancreatitis. In addition, a right
upper quadrant ultrasound was performed, which revealed
dilated ducts and sludge in the gallbladder. Further
evaluation of this did not take place.
DISPOSITION: A family meeting took place on [**2144-9-28**] in light of the repeat assessment by the Neurology
Consult Team. The patient's family accepted the assessment
of the Neurology Team and determined that the patient would
be unlikely to have wanted to live in a condition such as
this. At that time it was elected to make the patient do not
resuscitate and comfort measures only. At that time finger
stick blood glucose levels, regular insulin sliding scale,
blood cultures, antibiotics, laboratory tests were all
discontinued. For comfort the patient continued tube feeds,
Prevacid, Lopressor and was started on low dose around the
clock morphine. The patient's family initially elected to
continue the patient on the ventilator as they felt the
patient would be more comfortable in breathing while on the
ventilator. On [**2144-10-1**] a family discussion took
place during which the family was told that the patient could
be maintained comfortably off the ventilator and that minimal
support was being delivered by the ventilator at that time.
The patient's family then elected to discontinue mechanical
ventilation. She has since been maintained on tracheostomy
cuff with 40% humidified O2.
On [**2144-10-2**] the patient was prepared for a transfer
to the General Medicine Floor to await ongoing screening for
rehabilitation facilities and/or hospice care at a facility
closer to the patient's family in [**Doctor Last Name **].
A third addendum will take place in which follow up
instructions and disposition are detailed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2144-10-2**] 12:03
T: [**2144-10-2**] 12:26
JOB#: [**Job Number 28719**]
Name: [**Known lastname 5037**], [**Known firstname 1118**] Unit No: [**Numeric Identifier 5038**]
Admission Date: [**2144-8-23**] Discharge Date: [**2144-10-6**]
Date of Birth: [**2079-9-13**] Sex: F
Service:
ADDENDUM: This is the third Discharge Summary addendum on
[**Known firstname **] [**Known lastname **] to review the [**Hospital 1325**] hospital course
from [**10-3**] to [**10-6**].
The [**Hospital 1325**] medical status remained stable. Her neurologic
examination was unchanged. She had a tracheostomy in place,
and no acute complications have occurred. She also had a
percutaneous endoscopic gastrostomy in place which was
functioning well.
As discussed in prior addendums, the overall goal of the
patient's care is comfort. We have been able to locate a
hospice facility called [**Location (un) 5039**] in [**Location (un) 5040**], [**Doctor Last Name 5041**].
The patient's family is amenable to the patient being placed
there for further care.
MEDICATIONS ON DISCHARGE:
1. Morphine elixir 3 mg per percutaneous endoscopic
gastrostomy tube q.4h. on a scheduled basis.
2. Morphine elixir 6 mg to 12 mg per percutaneous endoscopic
gastrostomy tube q.4h. p.r.n. for respiratory discomfort for
tachycardia.
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) 29**]
Dictated By:[**Name8 (MD) 2621**]
MEDQUIST36
D: [**2144-10-5**] 15:46
T: [**2144-10-8**] 19:26
JOB#: [**Job Number 5042**]
|
[
"584.5",
"518.81",
"038.49",
"428.0",
"599.0",
"410.71",
"998.12",
"585",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.95",
"31.1",
"38.93",
"96.04",
"38.95",
"43.11",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
24238, 24733
|
2803, 24212
|
1856, 2785
|
134, 976
|
999, 1758
|
1775, 1833
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,497
| 149,439
|
986
|
Discharge summary
|
report
|
Admission Date: [**2151-4-16**] Discharge Date: [**2151-5-9**]
Date of Birth: [**2071-11-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Aortic Stenosis
Major Surgical or Invasive Procedure:
Aortic Valve Repair [**2151-4-16**]
Chest tube placement x3
History of Present Illness:
The patient is a 79-year-old man with an extensive past medical
history including severe gastrointestinal bleeding from colon CA
and congestive heart failure requiring aortic valvoplasty. The
aortic valve area increased from .6 to .7 cm2 after this
procedure. Catheterization showed mild coronary artery disease
but severe aortic stenosis. He was referred for aortic valve
replacement. Symptomatically he has had problems with exertional
dizziness.
Past Medical History:
- colon adenoCA s/p R colectomy [**3-8**]
-CHF
- atrial fibrillation
- AOritc stenosis s/p valvuloplasty [**3-8**]
-Zenkers diverticulum s/p surgical repair [**4-3**],
-h/o splenomegaly and thrombocytosis,
-Anemia iron deficiency--baseline 31-32%,
-Bilateral inguinal hernia repair 35 years ago as well as repair
of a right inguinal hernia in [**2146**],
-Decreased hearing,
-Esophageal stenosis diagnosed several years ago at the [**Hospital1 **], but chose not to undergo surgical
procedure.
-History of pulmonary asbestosis diagnosed by CT scan in [**2142**],
-History of a jejunal microperforation diagnosed by barium
swallow in [**2144**],
-Left rotator cuff partial tear
-Manic depression/anxiety.
Social History:
The patient quit smoking approximately 50 years ago. He does not
currently drink alcohol. He is a retired gas fitter and lives
with his wife.
Family History:
The patient has a sibling with diabetes
Physical Exam:
ON admission:
98.2, 75 , 103/46, 20, 93% room air:
Gen: pleasant elderly gentleman, in no acute distress,
well-developed
HEENT: MMM, EOMI
CV: irregular pulse, apical and LSB systolic murmur
Pulm: clear to auscultation bilaterally
Abd: soft, NT/ND, well-healed scars
Neuro: CN 2-12 grossly intact
Extr: warm, 1+ edema
Pertinent Results:
[**2151-4-16**] 10:31AM BLOOD WBC-7.6# RBC-3.39* Hgb-9.3* Hct-28.3*
MCV-84 MCH-27.5 MCHC-32.9 RDW-15.8* Plt Ct-464*
[**2151-4-16**] 01:07PM BLOOD WBC-8.0 RBC-2.84* Hgb-7.7* Hct-23.6*
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.7* Plt Ct-480*
[**2151-4-17**] 03:12AM BLOOD WBC-9.2 RBC-3.50* Hgb-9.6* Hct-28.8*
MCV-82 MCH-27.4 MCHC-33.3 RDW-15.9* Plt Ct-689*
[**2151-4-21**] 12:55AM BLOOD WBC-9.7 RBC-3.67* Hgb-10.7* Hct-31.1*
MCV-85 MCH-29.1 MCHC-34.4 RDW-16.8* Plt Ct-470*
[**2151-4-26**] 02:25AM BLOOD WBC-15.8* RBC-3.63* Hgb-10.3* Hct-32.3*
MCV-89 MCH-28.4 MCHC-31.9 RDW-16.3* Plt Ct-436
[**2151-5-5**] 03:25AM BLOOD WBC-7.9# RBC-3.12* Hgb-8.9* Hct-27.5*
MCV-88 MCH-28.4 MCHC-32.3 RDW-16.3* Plt Ct-327
[**2151-5-7**] 03:38AM BLOOD WBC-10.2 RBC-3.15* Hgb-8.9* Hct-27.4*
MCV-87 MCH-28.4 MCHC-32.6 RDW-16.8* Plt Ct-385
[**2151-4-28**] 02:20AM BLOOD Neuts-84* Bands-11* Lymphs-0 Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2151-4-29**] 03:10AM BLOOD PT-16.8* PTT-33.4 INR(PT)-1.5*
[**2151-5-2**] 03:29AM BLOOD PT-17.6* PTT-34.1 INR(PT)-1.6*
[**2151-5-7**] 06:43AM BLOOD PT-16.9* PTT-31.3 INR(PT)-1.6*
[**2151-4-16**] 01:07PM BLOOD UreaN-17 Creat-0.6 Cl-112* HCO3-25
[**2151-4-17**] 03:12AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-138
K-5.1 Cl-109* HCO3-21* AnGap-13
[**2151-4-19**] 02:59AM BLOOD Glucose-89 UreaN-28* Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-23 AnGap-13
[**2151-4-21**] 12:55AM BLOOD Glucose-114* UreaN-34* Creat-0.7 Na-139
K-4.3 Cl-107 HCO3-23 AnGap-13
[**2151-4-25**] 02:11AM BLOOD Glucose-116* UreaN-41* Creat-1.0 Na-148*
K-4.5 Cl-114* HCO3-25 AnGap-14
[**2151-4-27**] 02:06PM BLOOD Glucose-106* UreaN-44* Creat-0.9 Na-154*
K-3.9 Cl-120* HCO3-27 AnGap-11
[**2151-5-6**] 04:24AM BLOOD Glucose-125* UreaN-54* Creat-1.0 Na-146*
K-4.9 Cl-109* HCO3-30 AnGap-12
[**2151-5-7**] 03:38AM BLOOD Glucose-114* UreaN-57* Creat-1.1 Na-143
K-4.4 Cl-106 HCO3-29 AnGap-12
[**2151-4-17**] 03:12AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.9
[**2151-4-26**] 12:45PM BLOOD Albumin-2.3* Mg-2.0
[**2151-5-7**] 03:38AM BLOOD Calcium-7.1* Phos-3.4 Mg-2.4
[**2151-5-7**] 11:45AM BLOOD Calcium-7.6*
[**2151-4-25**] 07:01PM BLOOD Vanco-23.6*
[**2151-4-27**] 03:52AM BLOOD Vanco-16.3*
[**2151-5-2**] 03:29AM BLOOD Vanco-22.9*
[**2151-5-4**] 08:00PM BLOOD Vanco-14.0*
[**2151-4-29**] 03:10AM BLOOD Digoxin-1.3
[**2151-5-1**] 03:02AM BLOOD Digoxin-1.3
[**2151-5-2**] 03:29AM BLOOD Digoxin-1.3
[**2151-5-3**] 02:55AM BLOOD Digoxin-1.4
RADIOLOGY:
[**4-18**] CXR:A single AP upright view at 11:55 a.m. is compared to
previous
examination of [**2151-4-16**]. Since the previous exam, the
endotracheal and right mediastinal drain have been removed.
Again seen is right IJ Swan-Ganz catheter with the tip likely in
the pulmonary outflow tract. The bilateral pleural effusions
have increased, probably extending into the right major fissure
on the right. There is associated compressive atelectasis. There
is no evidence of pneumothorax. Sternotomy wires and skin
staples are again noted.
[**4-21**] CXR: Improving pulmonary edema and decreased right pleural
effusion.
Left lower lobe atelectasis persists.
[**4-22**] CXR: 1) Congestive heart failure, worsening in comparison
to the
previous film.
2) Normal position of NG tube and subclavian venous catheter.
3) Bilateral pleural effusion more on the right, new.
[**4-26**] CXR: No change in left pneumothorax with apical and basilar
components. Decrease in a right pneumothorax with small residual
pneumothorax.
[**4-28**] CXR: There has been interval placement of right-sided chest
tube. There has been associated decrease in size of a right
pneumothorax with residual small-to-moderate pneumothorax
remaining with both the apical and basilar components. There has
been interval removal of two left-sided chest tubes. No definite
visceral pleural line is evident, but there is increased lucency
at the left costophrenic sulcus region, for which a small
basilar pneumothorax is not excluded. The examination is
otherwise without change since the recent study a few hours
earlier
[**4-30**] CXR dobhoff: Successful post-pyloric nasal intestinal
feeding tube placement.
[**5-3**] CXR: Small right apical pneumothorax is minimally larger
than it was on [**5-1**]. Right pleural tube is unchanged in
position at the mid level of the chest. Moderately severe
pulmonary edema is stable. Small left pleural effusion
unchanged. Postoperative appearance of the cardiomediastinal
silhouette is stable and unremarkable.
[**2151-5-7**] CXR: Improving CHF with worsening right upper lobe
consolidation.
MICROBIOLOGY:
[**4-19**] blood culture: Serratia (levofloxacin sensitive)
[**4-21**] sputum: MRSA
[**4-28**] urine: negative
[**4-29**] c. diff: negative
[**5-4**] urine: negative
[**5-4**] blood culture: pending
CARDIOLOGY:
[**4-22**] Echo: . The left ventricular cavity is dilated. There is
severe global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed. 2. The
right ventricular cavity is mildly dilated. Right ventricular
systolic function appears depressed.
3. The ascending aorta is mildly dilated.
4. A bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. Trace aortic regurgitation is seen.
5. Mild (1+) mitral regurgitation is seen.
6. There is mild pulmonary artery systolic hypertension.
7. Compared to the findings of the prior study of [**2151-2-18**], left
ventricular systolic function has deteriorated.
Brief Hospital Course:
This is a 79 year old gentleman with a complicated past medical
history who was admitted on [**2151-4-16**] for aortic valve replacement
for severe aortic stenosis. His operation went without
complicated (please see the operative report of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2230**]
for full details) and was transferred to the cardiac ICU per
routine post-operatively. He required some neosynephrine for
blood pressure control in the immediate post-oeprative period.
His chest tubes were removed on post-op day 2 and he was given 1
unit of packed red blood cells for a gradually decreasing
hematocrit. After gentle diuresis he was extubated on post-op
day 2. He developed fevers on post-op day 3 and blood cultures
were sent which revealed Serratia; he was started on
Levofloxacin on [**4-19**] for this. He was transferred to the floor
,however he developed severe respiratory distress requiring
re-intubation on post-operative day 5. Tube feeding was
commenced. He was then extubated 2 days later, however failed
this extubation and was re-intubated on [**4-24**]. Chest x-ray
revealed significant bilateral effusions and bilateral chest
tubes were placed. At this time, cultures from his sputum
revealed MRSA and he was started on vancomycin on [**4-26**]. He again
required neosynephrine for blood pressure support, however this
was eventually weened off with low systolic blood pressures in
the 90s-100s tolerated (a cortisol stimulation test was normal).
His chest tubes were placed to water seal on [**4-28**] and
subsequently removed, however he required a new right chest tube
for a new-onset pneumothorax after one of his chest tubes had
accidentally fallen out; this new chest tube was eventually
removed with no resulting pneumothorax. He failed a swallow
evaluation and a dobhoff tube was placed for tube-feeding; he
failed a repeat swallow evaluation on [**5-6**]. He had some
significant diarrhea and leukocytosis on [**4-29**] and flagyl was
started on [**5-1**] empirically for c.diff though cultures were
negative; nonetheless his leukocytosis resolved after
commencement of his flagyl and it was continued through [**5-7**]. He
worked with physicaly therapy and was able to get out of bed
with assistance. Anticoagulation with coumadin was started on
[**5-6**] with goal INR in the sub-therapeutic range (1.5-2.0) given
his history of GI bleeding. Rehab screening was commenced and
the patient was discharged to a rehab facility. All questions
were answered to his satisfaction upon discharge. He will
follow-up within 3-4 weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Medications on Admission:
Aspirin 325 mg po qdaily
Amiodarone 200 mg qdaily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
dose daily for goal INR 1-1.5.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): continue through [**2151-5-20**]
.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
11. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Five (5) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed for shortness of
breath or wheezing.
12. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Vancomycin HCl 1000 mg IV Q 24H
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary: Aortic Stenosis
Secondary: Atrial fibrillation, respiratory failure,
gram-negative sepsis, MRSA pneumonia, failure to tolerate oral
intake, atrial fibrillation
Discharge Condition:
Stable. On tube feeds. Good pain control. GOod oxygen saturation
with supplemental oxygen
Discharge Instructions:
Take all medications as prescribed. Call the office or come to
the ER with worsening fevers, shortness of breath, chest pain,
or drainage from your incisions.
Followup Instructions:
Follow-up in [**4-3**] weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (call for an
appointment at [**Telephone/Fax (1) 1504**])
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2151-7-13**] 4:00
Completed by:[**2151-5-7**]
|
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"424.1",
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"530.3",
"V09.0",
"512.1",
"428.0",
"V45.3",
"995.92",
"998.59",
"785.52",
"038.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.6",
"35.21",
"96.04",
"99.04",
"39.61",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11903, 11976
|
7658, 10315
|
336, 398
|
12189, 12281
|
2174, 7635
|
12488, 12821
|
1780, 1821
|
10415, 11880
|
11997, 12168
|
10341, 10392
|
12305, 12465
|
1836, 1836
|
281, 298
|
426, 877
|
1851, 2155
|
899, 1605
|
1621, 1764
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,889
| 124,153
|
48949
|
Discharge summary
|
report
|
Admission Date: [**2114-8-10**] Discharge Date: [**2114-8-21**]
Date of Birth: [**2033-11-17**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Verapamil / Beta-Adrenergic Agents
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
-Attempt at lumbar puncture on [**2114-8-10**]
-Hemodialysis (Tuesday/Thursday/Saturday)
-Removed left internal jugular hemodialysis catheter (tunneled)
- [**2114-8-17**]
-Replaced tunneled hemodialysis catheter [**2114-8-20**]
History of Present Illness:
Ms. [**Known lastname 89279**] is an 80yo female with ESRD on hemodialysis [**2-19**]
Type 2 diabetes mellitus, hypertension, peripheral vascular
disease, coronary artery disease who was admitted to the MICU
for fever and altered mental status. Per the patient's sister,
her baseline mental status is interactive, able to feed herself,
and walk ~18 steps. Her mental status on admission is minimally
reactive to painful stimulus. The patient has not complained of
fevers, SOB, headaches, nausea/vomiting, diarrhea. No recent
seizures noted, although sister has apparently been titrating
patient's dilantin "to somnolence" at home.
.
In the ED, her vitals were T 104.1, HR 72, BP 144/103, RR 20,
and 100% on RA. Her labs showed leukocytosis with left shift, UA
was positive although urine culture later came back negative.
Her lactate was 2.0. She was given Vancomycin/Zosyn empirically.
She remained stable in the ED and was admitted to MICU for
monitoring.
Past Medical History:
1. Multiple admissions for toxic metabolic encephalopathy-
extensively worked up with MRI, EEG, and neurologic
consultations. These episodes are typically secondary to
infections, missed [**Month/Day (2) 2286**] sessions or other metabolic
derrangements, and are quite profound clinically.
2. Type 2 Diabetes Mellitus
3. Coronary artery disease
4. Peripheral vascular disease
5. Hypertension
6. Pulmonary hypertension
7. h/o subdural hematoma and intracrnial hemorrhage in [**9-25**]
8. Toxic Multinodular Goiter
9. Chronic kidney disease on HD (left arm fistula infected [**6-25**]
requiring aneurysm repair, now getting hemodyal
10. Lumbar disc disease
11. Osteoarthritis
12. Anemia - low iron and EPO
13. s/p Breast biopsy
14. s/p Hysterectomy
15. s/p excision of a left ear mass
16. s/p transmetatarsal amputation (right foot)
Social History:
-Resident of [**Hospital3 537**] since [**2114-6-14**],
-Sister very involved in her care, and is the HCP.
A-t baseline, patient ambulated with walker, could feed herself
and interact with family.
-Sister and daughter deny tobacco, alcohol.
Family History:
Diabetes Mellitus
Physical Exam:
Upon admission to MICU:
VS 104.5 (101.3) 102/60 60 18 98% 2L In 1400cc
gen: opens eyes but otherwise lethargic
heent: MMM, normal JV pressure
cv: RRR no mrg, L tunneled IJ line c/d/i, nontender
resp: lungs clear b/l
abd: soft, nt, nd, nabs
ext: no c/c/e
skin: normal turgor
.
Physical exam on transfer to CC7:
VS: T 98.7 (Tm99.4), HR 69 (58-79), BP 175/61 (90/38-149/59), RR
24 (20-28), 98%RA
Gen: NAD, A&OX1 - responds to name only
HEENT: PERRL, normal oro/nasopharynx, adentuolous
NECK: Soft, supple, no LAD/JVD
CV: RRR, no gallops/rubs, nl S1/S2, II/VI systolic murmur
LUSB/LLSB (non-radiating)
Pulm: CTAB, no wheezing/rhonchi/rales, left chest tunneled HD
cath in place - c/d/i
Abd: nontender, nondistended, +BS, soft, left femoral central
line in place - c/d/i,
Ext: no cyanosis/ecchymosis/edema, left arm scar (likely from
previous AV fistula)
Neuro: responsive but non-verbal
Pertinent Results:
On admission -
.. \ 10.1 /
19.6 ---- 230
.. / 34.7 \
.
Diff: 92.7%, 3.7%L, 2.6%M, 0.8%E, 0.1%B
.
130 | 90 | 30 /
-------------- 246
5.2 | 24 | 4.8\
.
Ca 9.3
Mg 1.5
Phos 4.4
.
ALT 20
AST 62
AP 106
Lipase 11
T. bili 0.1
.
On transfer -
Albumin 2.8, Direct bili 0.1
Vanco: 14.5 <-- 15.3
Chem10
137 98 22 185 AGap=15
3.4 27 3.5
.
estGFR: 13/15
Ca: 9.4 Mg: 2.0 P: 3.7
.
11.9 > 9.8 < 203
34.5
N:89.4 L:6.7 M:3.2 E:0.6 Bas:0.1
PT: 13.8 PTT: 32.4 INR: 1.2
.
Micro:
Urine culture - NGTD
Blood x 2from admission [**8-10**] - MRSA, surveillance cultures
[**Date range (1) 102796**] with NGTD
HD catheter tip: No growth
.
Imaging:
.
CXR [**2114-8-10**].
IMPRESSION: Mild cardiomegaly without evidence of pneumonia or
overt CHF.
.
CT abdomen/pelvis
1. No intra-abdominal source for infection identified with no
evidence of abscess or colitis.
2. Small amount of pericholecystic fluid with cholelithiasis. No
associated inflammation of the gallbladder or gallbladder wall
edema to suggest acute cholecystitis. This can be further
correlated with dedicated ultrasound as clinically indicated.
3. Mild inflammatory changes about the anus compatible with
proctitis.
.
Upper Extremity Doppler (Left)
1. New nonocclusive thrombus within the left internal jugular
vein.
2. Cephalic vein not clearly visualized. Remaining veins remain
patent.
.
CT HEAD [**8-11**]: Slight prominence of subdural spaces at the
convexity is more prominent than the previous studies. This
could be related to differences in angulation of the scans, but
a followup study would help to confirm the stability. Brain
atrophy is again identified. The MICU was informed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] of [**Last Name (NamePattern1) **].
CT HEAD [**8-12**]: Unchanged from yesterday
.
Brief Hospital Course:
Ms. [**Known lastname 89279**] is an 80F with a PMH s/f ESRD on HD, who
presented to the [**Hospital1 18**] on [**8-10**] with fevers, leukocytosis,
dilantin toxicity and altered mental status.
.
Fever - Initially the source of fever was unclear. LP was
attempted but unsuccessful and patient's family declined further
attempts to LP. CT scan of abdomen showed ?cholecystitis. In the
MICU, patient was started on meningitis doses of vanco and
ceftriaxone given her significantly altered mental status, and
flagyl for the abdominal CT findings. Then blood cultures grew
4/4 bottles of GPCs which were eventually found to be MRSA, and
a CXR later showed findings of pneumonia. At that time her
fever source was identified, and her antimicrobials were pared
down to vancomycin and zosyn. An infectious disease
consultation was obtained to find the source of her MRSA
bacteremia. An echocardiogram confirmed the absence of
vegetations, and the source of the MRSA bacteremia was felt to
be related to her HD line. Her tunneled HD line was removed on
[**2114-8-17**], and re-inserted on [**2114-8-20**]. She completed a course
of vancomycin/zosyn for hospital-acquired pneumonia, and will
continue vancomycin for a six week course for a presumed
endovascular source, to complete on [**2114-9-24**]. She is recieving
the vancomycin via HD protocol and will need vancomycin troughs
on the days of [**Year (4 digits) 2286**]. In addition to this she will need
safety lab monitoring during her vancomycin course, which per
IDSA guidlines is a weekly CBC with differential. We recommend
that an infectious disease consultant be involved in her care,
if this cannot be arranged, then please contact [**Name (NI) **] [**Last Name (NamePattern1) 13895**]
(consulting ID fellow) at [**Telephone/Fax (1) 457**]. Line tip cultures were
negative, and surveillance cultures from [**Date range (1) 102796**] have [**Last Name (un) 22315**] no
growth to date. A TEE was not attempted as the patient will
already complete a course adequate to cover for endocarditis.
.
Altered mental status - Her mental status declined from a
baseline of walking ~18 steps, feeding herself, interacting with
family, with orientation only to self to minimally responsive to
painful stimulus. Patient has multiple prior admissions for AMS
that resolved spontaneously and have been attributed to multiple
metabolic derrangements including infections, ?post-ictal
states, missing [**Last Name (un) 2286**], hypoglycemia. Most likely this
admission's altered mental status was related to the bacteremia
and dilantin toxicity. Subdural hematoma was found to be stable
on CT head, so it was deemed to be an unlikely etiology. An EEG
was consistent with severe encephalopathy. Her mental status
gradually improved with reversal of the above problems,
currently she is responding verbally to voice, though still bed
bound.
.
Dilantin toxicity: Patient's initial serum dilantin level was
~15 which is ostensibly within normal limits. Upon further,
careful recalculation taking into consideration patients low
albumin (2.8), creatinine, hemodialysis, tubefeeds, etc,
patient's actual dilantin level was likely 30-40. In close
consultation with pharmacy and neurology, patient's dilantin was
stopped for two days and restarted at 250mg per day of crushed
tablets delivered through the tube feeds (150mg in the
afternoon, after HD on hemodialysis days; 100mg before bed).
Eventually the patient's neurosurgeon came to talk to the team,
and recommended stopping the dilantin all together, as it was
not clear that she had a true underlying seizure disorder.
.
HD line associated Left upper extremity DVT - Per sister's
observations while patient was in the MICU. Upper extremity
Doppler ultrasound ordered and found to be negative for
thrombotic process. Over the weekend of [**7-17**]/[**2114**], however,
patient left upper extremity was found to be more swollen and
asymmetrical. Ultrasound showed a DVT in the left internal
jugular so patient was started on heparin. This is currently on
hold given bleeding at her HD line site, despite pressure
dressings. She was dosed with 3mg of coumadin, and her most
recent INR is subtherapeutic at 1.1 She will likely require a
limited duration of anticoagulation as this is HD line
associated.
.
HD line site bleeding: Pressure dressing in place, and topical
thrombin applied today. Will continue to need this type of
dressing until her PTTs come down.
.
ESRD on HD - Patient was continued on cinacalcet and nephrocaps.
Nephrocaps were later discontinued as tubefeeds provided
adequate coverage per nutrition. She is able to change her HD
schedule to [**Last Name (LF) 12075**], [**First Name3 (LF) **] discussion with the renal fellow.
.
Type 2 Diabetes. Patient was continued on glargine and HISS
while in house.
.
Hypertension - Patient was initially normotensive in the MICU
but steadily became increasingly hypertensive (SBP 180s --> 210s
during hemodialysis). Patient was restarted on Labetalol and
Captopril - both medications continued to be slowly titrated up
with minor improvements.
.
CAD - Patient was continued on home aspirin and statin. Patient
was not a beta-blocker prior to admission.
.
Hyperthyroidism - TSH was within normal limits (1.6) when
checked in MICU. Patient was continued on methimazole.
.
FEN: Patient was NPO with tubefeeds throughout her hospital
course. (Novasource Renal at 10cc/hr with goal of 35). During
hemodialysis on [**2114-8-16**], 4 liters of fluid was taken off so
Nutrition was consulted regarding concentrating her tubefeeds to
minimize fluid intake.
.
PPx: Bowel regimen, heparin SQ was discontinued [**2114-8-13**] when
patient found to be hypertensive, bradycardic with concern for
increased intracranial pressure --> pneumoboots
.
Lines: Left hemodialysis tunneled cath (removed [**2114-8-17**] as
possible infectious source - patient given HD holiday until
[**2114-8-21**]), left femoral central
line (for antibiotics) was removed [**2114-8-15**] when PICC line was
placed, rectal tube in place.
.
CODE: FULL CODE, confirmed with sister [**First Name8 (NamePattern2) 5464**] [**Name (NI) 89279**]
[**Telephone/Fax (1) 102786**])
Medications on Admission:
Aspirin 81 mg daily
Acetaminophen 650 mg q 6 hour prn pain
Atorvastatin 10 mg daily
Bisacodyl 10 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
B Complex-Vitamin C-Folic daily
Lisinopril 20 mg daily
Methimazole 15 mg daily
Lidocaine 5% patch daily
Phenytoin Sodium Extended 100 mg TID
6 units Glargine qhs
Humalog insulin sliding scale
Labetolol 200 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
7. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
8. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Per
sliding scale units Subcutaneous QACHS.
9. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
10. Vancomycin 1000 mg IV HD PROTOCOL
11. PICC line care per protocol
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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. MRSA bacteremia- presumed source is the HD line
2. Healthcare associated pneumonia
3. Dilantin toxicity
4. Toxic metabolic encephalopathy
Discharge Condition:
-Afebrile
-Hemodynamically stable, blood pressures are frequently elevated
in the 180 systolic range around [**Hospital6 2286**] days
-Able to respond to verbal stimuli- opens eyes on command,
shakes head yes/no, mouths words. Responds best to family.
-Needs frequent suctioning
-Rectal tube in place
-HD line site with bleeding secondary to heparin (no on hold),
pressure dressing in place.
Discharge Instructions:
You were admitted with fevers and altered mental status, which
we think is secondary to an hemodyalysis line infection,
pneumonia, and dilantin toxicity. You are improving with
antibiotics and discontinuation of you dilantin.
.
We have made several adjustments to your medications, please see
the attached list for your new regimen.
.
If your fevers return, or if your mental status further
deteriorates, please seek medical attention immediately.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2114-10-15**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1843**], RN Phone:[**Telephone/Fax (1) 857**] Date/Time:[**2114-8-27**]
10:00
|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,464
| 164,415
|
44925
|
Discharge summary
|
report
|
Admission Date: [**2163-6-29**] Discharge Date: [**2163-6-30**]
Date of Birth: [**2086-4-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2962**]
Chief Complaint:
Hypotension in EP lab prior to pacemaker implantation.
Major Surgical or Invasive Procedure:
pacemaker placement ([**2163-6-29**])
History of Present Illness:
Mr. [**Known lastname **] is a 77 y/o M with PMH notable for hypertension,
dyslipidemia and bifasciular block who was scheduled to undergo
EP study and probable pacemaker implanation dur to recurrent
unheralded syncope in the context of bifasicualar block. EP
study was performed on the morning of [**2163-6-29**] (please see
separate procedure report for details) and it was decided to
proceed with pacemaker placement. The right ventricular EP
catheter was left in place for back-up pacing prior to pacemaker
insertion. During the initial surgical dissection into the
deltopectoral groove, the patient became acutely bradycardic to
< 50 bpm (as evidenced by back-up pacing, which was set at 50,
from baseline in the 70's-80's) and hypotensive reaching down to
a nadir of 40's systolic. There was no loss of consciousness and
the patient remained converant - he in fact denied any symptoms
including discomfort at all at the time, although he appeared
ashen. He was given atropine and dopamine with good recovery of
his heartrate and blood pressure. From these drugs however he
then became tachycardic, impeding evaluation of the pacemaker,
so he was changed from dopamine to neosynephrine, which
mainatined blood pressure in the 110-130s systolic. Hypotension
(but not bradycardia) recurred without it. Initial repeat
hematocrit from the EP lab was 38.1 (down from 44), although he
was also bolused fluids with the hypotension. Fluroscopic
examination of his heart borders did not suggest cardiac
effusion or tamponade. His right femoral venous access site for
the EP study appeared benign. He was transferred to the CCU for
I.V pressor administration and further evaluation of persistent
hypotension.
On arrival to the CCU, the patient is alert, oriented, and
talkative. He reports no current symptoms. He specifically
denies chest pain, dizziness, lightheadedness, abdominal or back
pain, lower extremity edema, leg pain or numbness, or any other
complaints. He denies shortness of breath, cough, congestion,
orthopnea, and PND.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, 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.
Past Medical History:
dyslipidemia
gastroesophageal reflux disease with hiatal hernia
hypertension
s/p bilateral total knee replacements
arthritis
bifascicular block
recurrent syncope with moderate trauma x 1.
Social History:
Social history is significant for the absence of current tobacco
use. He is married and lives with his wife; he has grown adopted
children. He drinks alcohol occasionally.
Family History:
He has a family history of diabetes, hypertension, and heart
disease; both parents are deceased.
Physical Exam:
VS: T 96.8, BP 134/79, HR 81, RR 12, O2 98% on 1L NC
Gen: WDWN elderly male in NAD, breathing comfortably. Oriented
x3. Mood, affect appropriate. Pleasant and conversive.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No OP lesions, oral
mucosa dry.
Neck: Supple, no JVD, no bruits.
CV: RR, normal S1, S2. No S4, no S3. no murmurs or gallops.
Chest: L ant chest - pacemaker in place, no bleeding, hematoma,
or edena. Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. No flank pain or discoloration.
Ext: No c/c/e. No femoral bruits. Has sheath in place in right
groin. No oozing or hematoma.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; DP non-palpable, appreciated by
Doppler
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP
non-palpable, appreciated by Doppler
Pertinent Results:
LABORATORY DATA:
[**2163-6-29**] (Admission)
Na: 137; K 4.4; Cl 104; HCO3 25; BUN 22; Creat 1.3; Gluc 100
.
WBC: 9.1; Hbg: 15.1; HCT 44.0; Plt 283
EKG demonstrated NSR at 60, normal axis, RBBB, LAHB.
.
CXR ([**6-29**])
Status post placement of left-sided dual-chamber pacemaker with
atrial and ventricular leads in situ. No pneumothorax. No
evidence for CHF. Probable LVH. The left CPA is not completely
included on the film.
.
ECHOCARDIOGRAM ([**6-29**])
Overall left ventricular systolic function is normal (LVEF>55%).
There is no pericardial effusion.
.
CXR (PA + Lat) [**6-30**]: Prelim read - proper placement of both
pacemaker leads
.
CT Abdomen/Pelvis - Prelim read - no evidence of retroperitoneal
or other abdominal bleed
Brief Hospital Course:
This is a 77 y.o. male with history of HTN and hyperlipidemia
with h/o two episodes of syncope, admitted to CCU for acute
hypotension and bradycardia during EP study and pacemaker
placement.
.
# Hypotension: DDx included acute blood loss during procedure,
however, no site of bleeding was clinically identified despite
HCT drop of 6 points (44.0 -->38.1) post procedure. Repeat
hematocrit at 2 pm was 41.8. CT scan of abdomen and pelvis was
obtained to ensure that there was no retroperitoneal bleed, and
there was not. No groin hematoma either. No pericardial effusion
or tanmponade. Hypotension was likely a result of a prolonged
vasovagal phenomenon due to manipulation of a well innervated
deltopectoral fat pad during procedure. Atropine and dopamine
were initally instituted and resolved the initial episode but
nesynephrine was required to avoid unde tachycardia. The
neosynephrine drip was weaned over 2-3 hours with close
monitoring on telemetry, and no further events occured with SBPs
in 120s. Serial HCTs were monitored and stabilized.
.
# s/p pacemaker placement: Pt tolerated pain well
post-procedure, in fact felt that symptoms were overall
improved. Stable and proper placement of leads was confirmed by
re-interrogation of the pacemaker in the AM and by PA + Lat
CXR. Due to penicillin allergy, as prophylaxis Vancomycin (in
hospital) and Clindamycin (to take at home) was given for 2
days. His pacemaker was programmed to include a "rate drop
response" to provide rapid pacing (above the lower rate limit)
in the event of sudden cardiac deceleration such as during a
vasovagal episode. A brief (20 second) asymptomatic SVT (AVNRT
vs atrial tachycardia) was noted on telemetry. If a recurrent or
more sustained problem is documented by his pacemaker, or should
it become associated with symptoms, Dr. [**Last Name (STitle) **] indicated that
this could be ablated at a later date. Dual AV nodal pathways (a
pre-requisite for AVNRT) were documented at EPS, but no
sustained arrhythmias, supraventricular or ventricular were
induced.
.
# History of hypertension: Held antihypertensives while in the
hospital and instructed to cont. to hold until told to resume by
physician.
.
# Hyperlipidemia: Most recent LDL in system ([**2158**]): 82. Pt was
continued on atorvastatin in the hospital.
.
On the day of discharge, Mr. [**Known lastname **] was displaying normal vital
signs, with no further drops in BP or HCT, was tolerating po,
ambulating and was able to perform activities of daily living.
Medications on Admission:
Cymbalta 60 mg p.o. daily
lisinopril 10 mg p.o. daily
Lipitor 20 mg p.o. daily
Protonix 40 mg p.o. daily
Oxybutynin 5 mg p.o. daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
6. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 4 doses: Take first dose at 5pm today ([**6-30**]).
Disp:*4 Capsule(s)* Refills:*0*
7. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Vasovagal hypotension
.
Secondary Diagnoses:
Bifascifular block
Syncope
Hypertension
Hyperlipidemia
Gastro-esophageal reflux disease
Discharge Condition:
Good, hemodynamically stable
Discharge Instructions:
You were admitted for a pacemaker placement. After the
procedure your blood pressure was low and you were observed in
the coronary care unit with improvement in your blood pressure,
likely due to a a vasovagal event, a type of exaggerated reflex.
Please do not take your blood pressure medications until follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 172**] early next week (Monday or Tuesday).
You will need to follow up in the device clinic in the next
7-10 days (already scheduled), as well as with Dr. [**Last Name (STitle) **] in [**4-24**]
weeks.
.
Please do not lift anything with your left arm.
.
Please return to the hospital if you experience chest pain,
shortness of breath, dizziness/lightheadedness, worsening pain,
swelling, redness around the pacemaker sight, fevers/chills, or
any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 172**] to make a follow up appointment as soon
as possible. [**Telephone/Fax (1) 133**]
.
Please follow up with Dr. [**Last Name (STitle) **] according to the following
appointment in the [**Hospital Ward Name 23**] building [**Location (un) 436**]. Provider: [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2163-8-1**] 10:40
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2163-7-7**]
3:00
.
Provider: [**First Name11 (Name Pattern1) 8122**] [**Last Name (NamePattern4) 8123**], M.D. Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2163-7-26**] 8:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]
|
[
"458.29",
"272.4",
"530.81",
"426.53",
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] |
icd9cm
|
[
[
[]
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[
"37.72",
"37.83",
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|
[
[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,038
| 133,222
|
19114
|
Discharge summary
|
report
|
Admission Date: [**2161-9-25**] Discharge Date: [**2161-10-2**]
Date of Birth: [**2118-1-21**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
hepatic encepalopathy
Major Surgical or Invasive Procedure:
Upper endoscopy
Intubation (Intubated on Admission) and Ventilation
History of Present Illness:
Ms. [**Known lastname **] is a 43yo F with EtOH cirrohsis who is being
transferred from [**Hospital3 7571**]where she was has been admitted
for 3 days for an upper GI bleed. He is being transferred to
[**Hospital1 18**] per family request given that her PCP and
gastroenterologist are here.
She presented to [**Location (un) **] [**2161-9-20**] with c/o vomitting blood,
nausea, and abdominal pain after having consumed EtOH. NG lavage
in the EG showed old, dried blood. Hct 22 and INR 2.4 on
admission; she got a total 4 units pRBCs and 2 units FFP while
at [**Location (un) **]. EGD showed distal esophageal varices, but no acute
bleed; black blood clot was noted in the mid body greater curve
(presumably of the stomach). Her mental status declined during
her hospital stay, presumably [**3-11**] hepatic encephalopathy. She
was unsresponsive to painful stimuli, and the decision was made
to intubate. She is being given lactulose via NGT.
She had been on CIWA while at [**Location (un) **], but had not recieved any
Ativan for 24 hours prior to transfer.
Pt was last admitted here in [**3-/2161**] for worsening ascites and an
UGI bleed. EGD that revealed esophagitis, esophageal ulcerations
and antral ulcerations, all healing; mild varices.
On the floor, pt is intubated, sedated, and unresponsive.
Past Medical History:
ALCOHOLIC CIRRHOSIS
CHRONIC PANCREATITIS
H/O ALCOHOL ABUSE
S/P CHOLECYSTECTOMY (laparoscopic cholecystectomy [**2160-1-29**])
ANEMIA
DEPRESSION
Hernia
Social History:
- Tobacco: [**2-8**] ppd for 15 years
- ETOH: On admission, pt reported 1 vodka drink nightly for
years but sober for one year; later admitted regular daytime
drinking at home. husband suspects patient drinking spiked
coffee.
- Illicits: denies IVDU.
Family History:
Mother with pancreatic CA and liver disease
Father with CAD s/p recent 3V CABG
Physical Exam:
ADMISSION EXAM
General: Intubated, sedated, not responsive to verbal stimuli
but responsive to pain, many telangictasias across body.
HEENT: Sclera anicteric, MMM, PERRL
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, no clubbing or cyanosis, pedal edema
.
ICU TRANSFER EXAM
S: 97.5 109/68 82 18 100/RA
GEN: confused making non-sensical conversation but NAD AOX1
(self) in soft restraints NGT in place
HEENT: mild scleral icterus MM dry PERRL
Lungs: anterior exam crackles equal bilaterally (pt restrained)
CV: RRR normal nl S1 S2 II/VI late systolic murmur LUSB no JVD
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: warm and dry no cyanosis no edema
.
DISCHARGE EXAM
VS: 99.2 99.2 113/57 75 18 94/RA 68.3 kg
GEN: flushed well-appearing in NAD walking around & smiling
HEENT: NCAT EOMI PERRL MMM OP clear no JVD mult facial spider
angiomata
CV: RRR II/VI late-systolic murmur (stable)
Ch: CTAB no r/r/w
Abd: soft nt nd NABS no HSM
Ext: wwp no c/c/e
Neuro: AOX3, CN intact, conversant, answers questions
appropriately.
Pertinent Results:
__________________________________
OUTSIDE HOSPITAL DATA:
Na 141 K 3.9 Cl 114 Co2 19 Glc 109
BUN 10 Cr 0.52
Ca 7.8 Mg 3.1
GGT 88
Amylase 22 Lipase 18
Ammonia 171
WBC 7.3 (down from 13.9 on admission to [**Location (un) **])
Hgb/Hct 9.3/27.3 (7.6/22 on admission)
Plts 75
INR 2.5 ([**9-20**])
UA [**2161-9-21**] moderate blood, positive nitrite, negative leuk
esterase
TIBC 254 Iron 25 Transferrin 181 % sat 9.8 Ferritin 75.6
ABG 7.39/34/113/20.6
_________________________________
.
[**Hospital1 18**] ADMISSION LABS:
[**2161-9-26**] 01:16AM BLOOD WBC-7.9 RBC-2.88* Hgb-10.0* Hct-28.1*
MCV-98 MCH-34.8* MCHC-35.6* RDW-18.2* Plt Ct-72*#
[**2161-9-26**] 01:16AM BLOOD PT-16.8* PTT-32.4 INR(PT)-1.5* (after 1
unit FFP)
[**2161-9-26**] 01:16AM BLOOD Fibrino-236
[**2161-9-26**] 01:16AM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-145
K-3.5 Cl-117* HCO3-20* AnGap-12
[**2161-9-26**] 01:16AM BLOOD ALT-24 AST-56* LD(LDH)-245 AlkPhos-124*
TotBili-2.9* DirBili-1.9* IndBili-1.0
[**2161-9-26**] 01:16AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2
[**2161-9-26**] 01:16AM BLOOD Hapto-<5*
[**2161-9-26**] 01:24AM BLOOD Type-ART pO2-150* pCO2-28* pH-7.46*
calTCO2-21 Base XS--1
[**2161-9-26**] 06:36AM BLOOD Lactate-1.1
.
DISCHARGE LABS:
[**2161-10-1**] 06:00AM BLOOD WBC-6.2 RBC-2.37* Hgb-8.0* Hct-24.3*
MCV-102* MCH-33.8* MCHC-33.0 RDW-16.9* Plt Ct-121*
[**2161-10-1**] 06:00AM BLOOD PT-19.7* PTT-40.1* INR(PT)-1.8*
[**2161-10-1**] 06:00AM BLOOD Glucose-104* UreaN-9 Creat-0.7 Na-141
K-3.4 Cl-112* HCO3-22 AnGap-10
[**2161-10-1**] 06:00AM BLOOD ALT-17 AST-37 AlkPhos-100 TotBili-1.8*
.
MICRO:
MRSA SCREEN : POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
URINE CULTURE ([**9-26**] & [**9-27**]): NEGATIVE
BLOOD CULTURE ([**9-26**] & [**9-27**]): NEGATIVE
[**2161-9-26**] 8:33 am SPUTUM CULTURE Source: Endotracheal.
**FINAL REPORT [**2161-10-2**]**
GRAM STAIN (Final [**2161-9-26**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2161-9-29**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
.
[**2161-9-27**] CATHETER TIP-IV Source: Right IJ.
WOUND CULTURE (Final [**2161-9-29**]): No significant growth.
.
IMAGING:
[**9-26**] CXR (AFTER LINE PLACEMENT)
There is an endotracheal tube whose distal tip is 5 cm above the
carina
appropriately sited. There is a right IJ central venous line
with the distal lead tip in the mid to distal SVC. The tip and
sideport of the nasogastric tube is in the fundus of the
stomach. The heart size is normal. There is some coarsening of
the bronchovascular markings without signs for focal
consolidation, pleural effusions, or pulmonary edema.
.
[**9-26**] RUQ US
FINDINGS: The liver demonstrates a nodular contour, compatible
with
cirrhosis. A small amount of ascites is seen in the right upper
and lower quadrants as well as a small amount in the left lower
quadrant. No ascites is seen around the spleen in the left upper
quadrant. Fluid is noted within small bowel and colon.
.
[**9-30**] REPEAT CXR
FINDINGS: Single AP view of the chest shows interim extubation
and removal of an OG and right IJ catheter. The cardiac
silhouette, pleural and pulmonary structures are unremarkable.
No pneumothorax or focal consolidation.
.
[**9-30**] EGD
Esophagus:
Lumen: A sliding small size hiatal hernia was seen.
Protruding Lesions: 3 cords of grade II varices were seen in the
gastroesophageal junction. The varices were not bleeding.
Stomach:
Mucosa: Diffuse continuous congestion, nodularity and friability
of the mucosa with contact bleeding were noted in the whole
stomach. These findings are compatible with portal hypertensive
gastropathy.
Brief Hospital Course:
43yo F with EtOH cirrhosis and recent UGI bleed transferred to
the ICU from OSH intubated (on arrival) for hepatic
encephalopathy.
# Hepatic encephalopathy:
Arrived intubated from outside hospital. Likely etiology of
encephalopathy felt to be UGI bleed with no sign of infection
(CXR with no sign of PNA, no UTI, no e/o SBP however no ascites
obtained). Lactulose continued via NGT with good stool output.
Weaned from vent with presidex, extubated uneventfully with no
sign of airway compromise. Hepatology followed in the ICU.
Continued on cipro 500 mg [**Hospital1 **] throughout ICU stay from planned 7
day course given UGIB. Mental status improved gradually,
transferred to floor for further management. On the floor, she
was initially confused, disoriented and uncooperative requiring
soft restraints, but gradually cleared over the subsequent 48
hours with lactulose and frequent bowel movements. At baseline
by time of discharge; sent home on lactulose and rifaximin.
.
# UGI bleed:
Patient initially presented to OSH with hematemesis, suspected
to have a variceal bleed. At OSH she required 4U PRBC but no
active bleed was noted on their EGD. Hct trended throughout
[**Hospital1 18**] hospitalization, no transfusions required. Stools were
guaiac negative, and an EGD showed 3 cords of grade II varices
but no active bleeding. IV PPI [**Hospital1 **] continued in the ICU, then
transitioned to PO PPi after encephalopathy cleared. Completed
cipro x 7 days as noted above. Started nadolol 20 mg QD.
.
# Alcoholic Hepatitis.
LFTs and coags elevated on admission. Trended downwards. Alcohol
abstinence emphasized with patient and family as noted below.
.
# Alcohol abuse:
Underlying reason for cirrhosis. Patient admitted to drinking
regularly at home prior to admission. Pt and husband met with
social worker during this discharge. Daily discussions about the
importance of alcohol abstinence going forward. Patient
connected with behavioral health programming at [**Location (un) 14221**] Mental
Health near home ([**Hospital1 1559**]) with plan for intensive 28-day
substance abuse prevention programming. Started on daily
thiamine in addition to home folate and multivitamin.
.
# Thrombocytopenia, coagulapathy:
Likely [**3-11**] worsening liver and kidney failure. Hemolysis labs
negative. No transfusions required. Resolved
.
# Possible Ventilator-associated PNA
Sputum cultures collected while intubated in the ICU grew GPC.
Patient received a 7-day course of vancomycin during this
hospitalization. No sign of respiratory infection after
extubation - lung exam clear, no cough, fever, or WBC elevation.
.
TRANSITIONAL ISSUES
1. FOLLOW-UP SUBSTANCE ABUSE PROGRAMMING; PLAN FOR SUPPORT AFTER
28-DAY PROGRAM AT [**Location (un) **]
2. FOLLOW-UP HISTORY OF GIB - ANY ADDITIONAL HEMATEMESIS,
MELANOTIC STOOLS
3. FOLLOW-UP LACTULOSE REGIMEN, ASK PT FREQUENCY OF BMS AND
ENCEPHALOPATHIC SYMPTOMS
4. FYI NO PENDING CULTURES
Medications on Admission:
folic acid 1 mg Tablet 1 Tablet(s) by mouth once daily
furosemide 40 mg Tablet one Tablet(s) by mouth twice daily
lactulose 10 gram/15 mL Solution 1 teaspoon by mouth twice daily
lipase-protease-amylase [Pancreaze] 4,200 unit-[**Unit Number **],000
unit-[**Unit Number **],500 unit Capsule, Delayed Release(E.C.)
omeprazole 20 mg Capsule, Delayed Release(E.C.) 2 Capsule(s) by
mouth polyethylene glycol 3350 [Miralax] 17 grams by mouth daily
as needed for constipation
spironolactone 100 mg Tablet 1 Tablet(s) by mouth twice daily
food supplement, lactose-free [Ensure] Liquid
magnesium oxide 400 mg Tablet 1 Tablet(s) by mouth twice a day
multivitamin Tablet 1 Tablet(s) by mouth daily w/ iron
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/ pain: Maximum 2 g tylenol per day.
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Upper Gastrointestinal Bleed
Alcoholic Hepatitis
Hepatic Encephalopathy
Alcohol Withdrawal
.
Secondary Diagnoses:
Chronic Pancreatitis
Anemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for vomiting blood and
confusion.
We found that you had an upper gastrointestinal bleed, hepatic
encephalopathy, and were withdrawing from alcohol intoxication.
You also received 7 days of antibiotics for pneumonia.
You were doing well by the time you left the hospital. We
discussed the seriousness of your condition -- you should not
drink alcohol ever again. Please remove all alcohol from your
home.
A social worker met with you to discuss options for alcohol
abstinence support at home. We recommend you attend a month-long
full-time substance abuse support program, get therapy, and join
alcoholic anonymous meetings from now on. Staying sober will be
difficult but it is key to keeping you healthy and alive. Your
liver is too sick to tolerate any alcohol.
We made the following changes to your medications:
1. STARTED NADOLOL - TAKE 20 MG ONCE A DAY
2. STARTED RIFAXIMIN - TAKE 550 MG TWICE PER DAY
3. STARTED THIAMINE - take 100 mg per day
4. INCREASED LACTULOSE - TAKE 30 ML *THREE* TIMES PER DAY
5. STOPPED MIRALAX.
Please check the medication list attached. Take all your
medications as prescribed or as instructed by your doctor.
Followup Instructions:
Department: LIVER CENTER
When: MONDAY [**2161-11-2**] at 10:30 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2161-11-4**] at 3:25 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You also need intensive sobriety support, which will be through
[**Location (un) 14221**] Mental Health. Your counselor is [**Doctor Last Name **] ([**Telephone/Fax (1) 52163**]. She will meet you for an intake interview this
afternoon after you leave the hospital.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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icd9cm
|
[
[
[]
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[
"96.6",
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icd9pcs
|
[
[
[]
]
] |
13086, 13092
|
8215, 11146
|
292, 362
|
13308, 13308
|
3614, 4115
|
14667, 15679
|
2161, 2241
|
11891, 13063
|
13113, 13225
|
11172, 11868
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13459, 14284
|
4827, 8192
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2256, 3595
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13246, 13287
|
14314, 14644
|
230, 254
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390, 1701
|
4131, 4811
|
13323, 13435
|
1723, 1876
|
1892, 2145
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,362
| 134,788
|
52344
|
Discharge summary
|
report
|
Admission Date: [**2196-11-7**] Discharge Date: [**2196-11-12**]
Date of Birth: [**2115-6-6**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 108213**] is an 81 year old male with a history of COPD and end
stage pulmonary fibrosis on 4-8L oxygen at home who presents
with three weeks of progressive dyspnea on exertion with acute
worsening on the day of presentation. The patient reports that
over the past six months there has been a progressive worsening
of his functional status which has been more steeply declining
over the past three weeks. One week ago he had an isolated fever
to 101 degrees and restarted cefpodoxime per his pulmonologist
Dr. [**Last Name (STitle) 2171**]. Over the past week he has been able to move slowly
around his house and gets short of breath with minimal exertion.
His baseline oxygen saturations range from 70s to 90s on 4 to 8
L nasal canula. On the day of presentation he felt that his
breathing acutely worsened. He does not have chest pain or chest
tightness. He denies palpitations. He has felt chills but no
documented fevers. He denies sore throat but endorses
congestion. Mild body aches. He has mild increase in his sputum
production and mildly worsening cough. On the day of
presentation he had mild hemoptysis (pink sputum) which he
attributed to aspirin use. He called his pulmonologist who
discussed the possibility of transitioning his care to hospice
but he decided to present for evaluation.
.
In the ED, initial vs were: T: 98.4 BP: 115/54 P: 112 R: 20 O2
sat 80% on 8L. He received vancomycin 1 gram IV and ceftazidime
1 gram IV. EKG showed sinus tachycardia at 108, normal axis,
normal intervals, no acute ST segment changes, poor baseline.
Chest xray showed possible increased haziness of the right
hemidiaphragm on a baseline of significant fibrotic changes. He
was admitted to the MICU for further management.
.
On arrival to the MICU he reports that his breathing is
significantly improved on non-rebreather. Denies fevers but
endorses, chills, no night sweats, does endorse weight loss but
can't quantify Denies headache, sinus tenderness but endorses
mild congestion. rhinorrhea. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Idiopathic pulmonary fibrosis
Prostate cancer s/p brachytherapy
Emphysema - PFTs ([**2196-4-28**]): FEV1 - 72%; FVC 77%; Ratio: 99%;
DLCO(hb) - 38%--no change since [**3-31**]
Hypertension
CAD - s/p angioplasty > 20 yrs prior
Hypercholesterolemia
GERD
Hiatal hernia
AAA
Social History:
Lives with his fiance outside of [**Location (un) 86**] in their private home.
Has not smoked in 30 years but smoked 3ppd x 20 yrs previously.
Occasional alcohol, no drugs. Works in the fur business and
rents space at a business partner's dry cleaner.
Family History:
NC
Physical Exam:
Vitals: T: 96.9 BP: 115/72 P: 102 R: 30 O2: 99% on NRB
General: Alert, oriented, mild respiratory distress, tachypneic,
using accessory muscles
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse dry rales, no wheezes or ronchi.
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace edema
Pertinent Results:
LABS ON ADMISSION:
[**2196-11-7**] 03:28PM LACTATE-3.7*
[**2196-11-7**] 12:01PM LACTATE-2.6*
[**2196-11-7**] 11:40AM GLUCOSE-315* UREA N-36* CREAT-1.4* SODIUM-137
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-30 ANION GAP-16
[**2196-11-7**] 11:40AM estGFR-Using this
[**2196-11-7**] 11:40AM CK(CPK)-27*
[**2196-11-7**] 11:40AM cTropnT-0.04*
[**2196-11-7**] 11:40AM CK-MB-NotDone
[**2196-11-7**] 11:40AM WBC-9.7# RBC-4.94 HGB-13.0* HCT-40.4 MCV-82
MCH-26.3* MCHC-32.2 RDW-16.5*
[**2196-11-7**] 11:40AM NEUTS-91.2* LYMPHS-6.1* MONOS-2.5 EOS-0.1
BASOS-0.1
[**2196-11-7**] 11:40AM PLT COUNT-235
[**2196-11-7**] 11:40AM PT-12.0 PTT-22.4 INR(PT)-1.0
LABS ON DISCHARGE:
[**2196-11-10**] 08:33AM BLOOD WBC-8.5 RBC-4.42* Hgb-11.8* Hct-35.6*
MCV-80* MCH-26.6* MCHC-33.1 RDW-17.8* Plt Ct-234
[**2196-11-10**] 08:33AM BLOOD Plt Ct-234
[**2196-11-10**] 08:33AM BLOOD Glucose-92 UreaN-30* Creat-1.6* Na-140
K-4.7 Cl-101 HCO3-30 AnGap-14
[**2196-11-10**] 08:33AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.2
CXR: In comparison with the study of [**11-7**], there is little
overall
change. Extensive chronic fibrosis is again seen bilaterally
with more focal areas of opacification in the right mid zone and
left lower lung. Relative hyperlucency of the upper lungs is
consistent with the known history of emphysema. Although these
findings most likely represent chronic disease, the possibility
of supervening pneumonia would be extremely difficult to detect
radiographically.
Brief Hospital Course:
1. Respiratory Failure: patient was admitted with acute
shortness of breath and acute decompensation of his end-stage
lung disease. He had increased sputum production, mild
leukocytosis with left shift and subjective chills. CXR with
mild increased haziness at right hemidiaphragm. Progression of
underlying lung disease felt more likely than other possible
etiologies. Cardiac etiology unlikely given lack of chest pain
or EKG changes. Started on vancomycin, cefepime, azithromycin
and tamiflu in an effort to treat any potential contributing
infections. Nebulizers were continued, and he was continued on
his prednisone 60mg daily. Patient was also started on MS Contin
for dyspnea as well.
2. Goals of Care: As this patient was struggling with end-stage
disease and was approaching the end of life palliative care was
consulted to assist with providing for this patient's care and
assuring focus on his goals of care. Morphine was provided for
respiratory discomfort as above. Hospice options were discussed
with the patient and his family. He was discharged with home
services with the possibility of a bridge to hospice.
3. Respiratory Discomfort: As above, will continue to treat
whatever is treatable and attempt to improve this patient's
underlying pulmonary function, however prognosis is very poor
and patient is increasingly having epidodes of what sound like
considerable respiratory distress, stating how terrible it feels
to not be able to breath. Per discussions previously documented
we will do all we can to help make this patient as comfortable
as possible through these episodes.
-morphine, prn, for respiratory distress and related anxiety
-consider ativan, prn, if needed
-will follow up with palliative more tomorrow
4. Stage III Chronic Kidney Disease: Creatinine below baseline
at 1.4. Continued to hydrate and renally dose medications.
5. Coronary Artery Disease: s/p angioplasty many years ago.
Currently no signs of ischemia on EKG. Held aspirin given some
report of hemoptysis.
5. GERD: Stable. Continued on omeprazole 20 mg [**Hospital1 **].
6. Hypercholesterolemia: Continued on Crestor 40 mg daily.
7. Depression: Continued on Celexa 20 mg daily
8. Steroid Induced Hyperglycemia: Continued on lantus with
humalog sliding scale with good overall control.
9. Prostate Cancer: In remission. Continued on tamsulosin 0.4 mg
QHS
Medications on Admission:
Prednisone 20 mg daily
Cefpoxodime 200 mg daily (started [**2196-11-4**])
Bactrim DS three times per week
Crestor 40 mg daily
Aspirin 81 mg daily
Omeprazole 20 mg [**Hospital1 **]
Tamsulosin 0.4 mg daily
Citalopram 20 mgd aily
Vitamin D 1000 mg Q 2 weeks
Lantus 10 U QAM
Discharge Medications:
1. Home O2
4-8 L continuous pulse dose for portability
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal
TID (3 times a day) as needed for nasal congestion.
6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*3*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take regularly twice a day.
Disp:*60 Capsule(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please take regularly twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Morphine 10 mg/5 mL Solution Sig: Five (5) mL PO Q2H (every
2 hours) as needed for dyspnea: Please take 10mg (5ml solution)
only as needed for severe dyspnea.
Disp:*250 ml* Refills:*3*
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
13. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for dyspnea.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
18. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours: Please take only as needed for severe shortness of
breath.
Disp:*100 Tablet(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
PRIMARY:
1. Interstitial Pulmonary Fibrosis
2. Respiratory Failure
SECONDARY:
1. Emphysema
2. Hypertension
3. CAD
4. Hypercholesterolemia
5. GERD
6. Prostate cancer s/p brachytherapy
Discharge Condition:
stable. breathing without significant distress on 4L
supplemental oxygen, saturations > 90% on 8L.
Discharge Instructions:
It was a sincere pleasure to participate in your care during
your stay here at [**Hospital1 69**]. As you
know, you were admitted to the hospital for shortness of breath.
While you were here you were treated with antibiotics,
nebulizers, and a range of other medications including morphine.
As you know, we have started you on some new medications. Please
take all of your medications exactly as prescribed.
Please call your physician or return to the emergency department
if you experience fevers, chest pain, worsening shortness of
breath that in not relieved with your medications, or any other
concerning symptoms.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Pulmonary
Phone number: ([**Telephone/Fax (1) 513**]
Special instructions if applicable: Dr.[**Doctor Last Name **] office will
call you with an appt date and time. If you do not hear from
the office by Tuesday, [**11-15**] please call above number.
Appointment #2
MD: Dr. [**First Name (STitle) **] [**Name (STitle) 1395**]
Specialty: PCP
Date and time: Wednesday, [**11-16**] at 10:45am
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP, [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone number: [**Telephone/Fax (1) 2205**]
|
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icd9cm
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,700
| 123,918
|
45603
|
Discharge summary
|
report
|
Admission Date: [**2167-12-4**] Discharge Date: [**2167-12-24**]
Date of Birth: [**2088-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdominal Pain and Distention
Major Surgical or Invasive Procedure:
Sigmoid Colectomy with End Colostomy/Hartmann's Pouch [**2167-12-5**]
History of Present Illness:
79M with a history of sigmoid volvus presents with 3 days of
worsening abdominal pain and distension. He presented to [**Hospital1 18**]
in [**Month (only) 547**] with similar complaints and underwent a successful
decompression with GI. He was offered an operation to prevent
further episodes of volvulus but refused and signed out of the
hospital AMA. He was lost to follow-up. He returned with
similar complaints of pain and distension. He denies fever,
chills, nausea, and emesis. He reports that his last BM was 4
days ago and it has been mostly diarrhea. He denies dysuria and
melena. He still states that he does not want operative
intervention but he is willing to be decompressed by GI. He
also
states that he thinks this is related to his bilateral lower
extremity lymphedema and "infection".
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease - three vessel disease and
angina.
2. Hypertension.
3. History of nephrolithiasis as well as urinary tract
infection.
4. Lymphedema, chronic.
5. History of exploratory laparotomy in the 70's without a
resection.
6. Umbilical hernia (over ten years ago).
7. Degenerative joint disease.
8. subacute Type B aortic dissection treated conservatively
Social History:
He is retired and lives with his wife. [**Name (NI) **] quit smoking 5
years ago but does have a 120 pack year history.
Family History:
Positive for coronary artery disease, father died of an
myocardial infarction at the age of 56.
Physical Exam:
VS: 96.5 78 132/74 18 96% RA
Constitutional: Well appearing, no acute distress
CV: RRR
Resp: CTAB, decreased at bases
Abd: still somewhat distended, although improved, ostomy pouch
intact with brown output. Incision site intact with steri
strips, no drainage.
Ext: Warm, edematous (at baseline), no rash
Skin: Sacral decub with intact dressing
Neuro: Pt. is alert, oriented, with no focal defecits
Pertinent Results:
CT Abdomen/Pelvis: [**2167-12-4**]
IMPRESSION:
1. Massively dilated loop of large bowel, tapering at the
sigmoid colon with
swirling mesentry, compatible with sigmoid volvulus. These
findings are
similar in comparison to the prior CT exam from [**2167-4-10**].
2. Thoracoabdominal aortic aneurysm with dissection. There has
been an
interval increase of the suprarenal and infrarenal aneurysm size
in comparison
to the prior study. The type B dissection pattern is unchanged.
3. Stable, moderate amount of gallbladder sludge.
4. Stable bilateral renal hypodensities, incompletely
characterized.
CT Abdomen/Pelvis [**2167-12-13**]:
IMPRESSION:
1. Massively dilated stomach and small bowel to the level of the
distal
ileum. The terminal ileum and colon are normal caliber, with
fluid and gas
distributed throughout the remaining colon to the level of the
ostomy.
Findings concerning for distal small-bowel obstruction.
Nasogastric tube
decompression is recommended.
2. Atelectasis and/or consolidation of the right lower lobe.
Aspiration
pneumonitis or pneumonia are possible.
3. Chronic type B aortic dissection, not appreciably changed
over the
short interval from CT of [**2167-12-4**].
Pathology [**2167-12-7**]
1. Umbilical hernia (A):
Fibroadipose and vascular tissue with reactive mesothelial cells
and chronic inflammation consistent with hernia sac.
2. Sigmoid colon, colectomy (B-G):
A. Colonic mucosal ischemia and transmural acute inflammation.
B. Margins viable.
C. One unremarkable lymph node.
Note: The findings are consistent with the clinical history of
volvulus.
RUE U/S: [**2167-12-24**]
Occlusive thrombus is again identified in one of the paired
brachial veins.
No thrombus is seen in the right axillary vein or right
subclavian vein.
Admission Labs:
[**2167-12-4**] 09:55AM BLOOD WBC-11.1*# RBC-5.42 Hgb-16.3 Hct-46.7
MCV-86 MCH-30.2 MCHC-35.0 RDW-14.5 Plt Ct-238
[**2167-12-4**] 09:55AM BLOOD Neuts-85.8* Lymphs-7.6* Monos-6.2 Eos-0.2
Baso-0.2
[**2167-12-5**] 07:09PM BLOOD PT-16.4* PTT-44.0* INR(PT)-1.5*
[**2167-12-4**] 09:55AM BLOOD Glucose-148* UreaN-27* Creat-0.9 Na-137
K-3.0* Cl-90* HCO3-35* AnGap-15
[**2167-12-5**] 06:55AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.6
[**2167-12-15**] 03:59AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2167-12-15**] 03:59AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2167-12-15**] 03:59AM URINE RBC-1 WBC-55* Bacteri-FEW Yeast-NONE
Epi-0
URINE CULTURE (Final [**2167-12-18**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Discharge Labs:
[**2167-12-24**] 06:30AM BLOOD Calcium-7.5* Phos-3.0 Mg-2.2
[**2167-12-24**] 06:30AM BLOOD Glucose-116* UreaN-17 Creat-0.4* Na-139
K-4.8 Cl-106 HCO3-25 AnGap-13
[**2167-12-21**] 05:45AM BLOOD WBC-6.7 RBC-4.13* Hgb-11.9* Hct-37.0*
MCV-90 MCH-28.9 MCHC-32.3 RDW-14.3 Plt Ct-392
Brief Hospital Course:
The patient was admitted to the general surgery service on
[**2167-12-4**] and had a sigmoid colectomy with end
colostomy/Hartmann's Pouch. He was transferred to the surgical
ICU post operatively and was transferred to the floor on
[**2167-12-6**].
Neuro: Post-operatively, the patient went to the Surgical ICU
where he was monitored. IV pain medication and was eventually
transitioned to PO pain medication.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. He had small bilateral
pleural effusions on CXR but never required drainage and his
repiratory status was stable.
GI/GU: Post-operatively, the patient had difficulty with diet
advancement and his post-op course was complicated by continued
distention and obstruction. An NGT was placed and the patient
was started on TPN for nutrition. His diet was very slowly
advanced on several occasions without success. His NG tube was
removed on [**2167-12-17**] and his diet slowly advanced. By the day of
discharge he was tolerating a regular diet without any nausea or
vomiting. His KUB continued to show some distention, however
his ostomy output remained within normal limits and the patient
was asymptomatic. Gastric distention was voerall improved and
his abdomen was soft.
ID: During his hospital stay, Mr. [**Known lastname 12130**] developed a urinary
tract infection with a very resistant form of E. Coli. It was
sensitive to Zosyn and he subsequently completed a course of
Zosyn. As documented on his discharge paper work, should he
have any fevers or continued symptoms we would recommend a
repeat urinalysis and urine culture.
Prophylaxis: The pt. had a Right PICC placed for nutrition and
experienced some mild right hand swelling. He was found to have
a DVT of one of the paired brachial veins in the right upper
extremity. The PICC line was removed and placed on the L side.
He was started on Lovenox. On the day of discharge a repeat RUE
ultrasound was done showing the thrombus was still there.
However due to the collateral vessels present in the RUE,
lovenox was not continued.
Medications on Admission:
HCTZ 50', lasix 20', sublingal nitro prn, aspirin 81',
dicloxacillin
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
3. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for Irritation.
4. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for sore throat [**2-9**] NGT.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as
needed for wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for wheezing.
7. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for pain.
8. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-9**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for SBP<100 or HR<60.
13. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Sigmoid Volvulus
Urinary Tract Infection
DVT Right UE - 1 of the paired brachial veins
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Discharge Instructions:
You were admitted to the hospital due to your abdominal
discomfort and were found to give a sigmoid volvulus that caused
an obstruction in your intestine. You had an operation to fix
this and you were kept in the hospital afterward to recover.
** You were treated for a UTI with Zosyn. Should you have
persistent symptoms, we would recommend a follow up urine
analysis and culture.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-17**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
OSTOMY CARE (as reviewed with you by our Ostomy Nurse)
TREATMENTS/EQUIPMENT/INTERVENTION: Change pouching system
2x/week.
1. Remove old pouch.
2. Cleanse stoma/peristoma skin with warm water. Pat dry.
3. Cleanse mucocutaneous junction separation with commercial
wound cleanse, pat dry.
4. Measure stoma.
5. Place small piece of Aquacel on wound (separation junction).
6. Use ConvaTec 2 [**1-11**]" wafer [**Doctor First Name **] # [**Numeric Identifier 97253**], with invisiclose
pouch [**Doctor First Name **] # [**Numeric Identifier 77653**].
7. Place [**Last Name (un) **] cohesive seal [**Doctor First Name **] # [**Numeric Identifier 20840**] around barrier,
mold with finger tips.
8. Attach flange to pouch.
9. Lift up on abdomen and place wafer directly over stoma,
hold palm of hand directly over wafer, to assist with seal.
10. Remove tape collar, avoiding wrinkles, secure adhesive top
and bottom with fingers.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 519**] on [**2168-1-4**] at 2:15 pm. It is on
the
It is very important that this appointment is kept. Call
[**Telephone/Fax (1) **] with any questions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2167-12-24**]
|
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"996.74",
"E879.8",
"457.1",
"427.41",
"441.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.11",
"99.15",
"97.49",
"53.49",
"45.76",
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icd9pcs
|
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[
[]
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345, 416
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10137, 10137
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8403, 9913
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10241, 12085
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1949, 2351
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276, 307
|
444, 1257
|
4152, 5749
|
10151, 10217
|
1301, 1681
|
1697, 1820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,580
| 155,370
|
37924
|
Discharge summary
|
report
|
Admission Date: [**2144-9-16**] Discharge Date: [**2144-10-9**]
Date of Birth: [**2069-3-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
Tracheostomy
PEG placement
IVC filter placement
History of Present Illness:
Initial admission to surgery:
75yM who underwent c-scope on [**2144-8-28**]. He returned that night
after dinner with abdominal pain. Found to have
pneumoperitoneum. Initially treated conservatively but failed
the following morning, taken to the OR for Exlap. Transverse
colon 1 cm perforation found which was repaired with a stapled
primary repair as well as diverting ileostomy. Postop had
difficult course including: Paroxysmal Afib, malnutrition on
TPN, delirium, and repeated mucous plugging requiring
reintubation and bronchoscopy. He was tranferred here per the
family request.
.
On transfer to floor:
75 yo with PMH of CAD, infrarenal AAA, HTN, hemochromatosis,
dementia/delerium was transferred from OSH on [**9-16**] after he had
a complicated hospital course for iatrogenic colonic perforation
[**12-24**] colonoscopy, s/p primary repair with diverting ileostomy. He
had multiple organisms grew from blood culture and sputum
culture (E. Coli, pseudomonas, coag neg staph, alpha srep, etc.)
for which he has been treated with multiple abx (cefepime,
vancomycin, cipro, levofloxacin). pt is s/p trach on [**9-21**], PEG
and IVC placement on [**9-25**]. No significant hemodynamic
instability during precedures, but his SBP became lower over the
past 2-3 days (120-130 -> 90-100's). Found to have new developed
RLL PNA yesterday. His creatinine was elevated to 2.2 on
admission [**9-16**], improved to 1.4. However, it started to elevate
again since [**10-1**], up to 3.0 today. UOP started decreasing at
the same time to 400-500ml/day. Large amount of ileostomy output
1-2L/day. No contrast or NSAIDs exposure. As per his wife, his
had normal renal funciton before his complicated medical events.
On transfer, he continued to have persistent altered mental
status with minimal responsiveness, per wife this has been
ongoing since outside hospital. Thought to be combination of
anoxic brain injury / toxic metabolic encephalopathy in the
setting of normal LP, CT scan and EEG, with concomitant uremia,
hypoactive delirium, and infection exacerbating.
Past Medical History:
PMH: CVA [**2141**], CAD with stents, MI x3, HTN, hemochromatosis, AAA
3.3cm
PSH: pacemaker, repair of transverse colon perforation
Social History:
SH: Originally from [**Country 4754**], moved to [**State 760**] back in [**2089**]
then moved up to [**Location (un) 86**] a few years ago. Retired
factory manager. No tobacco or drugs. Drinks 1 glass of red
wine nightly.
Family History:
Non-contributory.
Physical Exam:
On Admission to surgery:
PE:
Gen: intubated, sedated but arousable
HEENT: anicteric
CV: RRR
Pulm: CTA b/l
Abd: soft, distended, nontender, ileostomy functioning with
small
amount of gas and green fluid in the bag. Incision c/d/i
without
drainage.
Ext: 1+ edema, palp pulses
.
On transfer to medicine:
Gen: does not open eyes, does not track, blinks to threat, in no
apparent distress
HEENT: trach in place, mild secretions
CVS: RRR, normal S1/S2
Lungs: bibasilar rhonchi, R>L (anteriorly)
Abd: soft, PEG tube and ileostomy bag in place, non-distended,
PEG tube output appears almost black
Ext: no edema, cyanosis or clubbing
Neuro: non-verbal, does not follow commands or respond to verbal
stimuli; localizes to painful stimuli, no posturing or increased
tone, PERRLA
Pertinent Results:
[**2144-9-16**] 11:14PM CEREBROSPINAL FLUID (CSF) PROTEIN-27
GLUCOSE-67
[**2144-9-16**] 11:14PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* POLYS-0
LYMPHS-100 MONOS-0
[**2144-9-16**] 02:40AM TYPE-ART PO2-124* PCO2-34* PH-7.36 TOTAL
CO2-20* BASE XS--5
[**2144-9-16**] 02:40AM LACTATE-1.3
[**2144-9-16**] 01:22AM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2144-9-16**] 01:21AM GLUCOSE-98 UREA N-55* CREAT-2.2* SODIUM-141
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-19* ANION GAP-14
[**2144-9-16**] 01:21AM ALT(SGPT)-40 AST(SGOT)-42* LD(LDH)-208 ALK
PHOS-50 TOT BILI-2.4*
[**2144-9-16**] 01:21AM ALBUMIN-2.0* CALCIUM-9.6 PHOSPHATE-5.1*
MAGNESIUM-2.1 IRON-8*
[**2144-9-16**] 01:21AM WBC-14.0*# RBC-2.92*# HGB-9.5*# HCT-27.4*#
MCV-94# MCH-32.5* MCHC-34.7 RDW-16.9*
[**2144-9-16**] 01:21AM NEUTS-76* BANDS-4 LYMPHS-8* MONOS-8 EOS-2
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2144-9-16**] 01:21AM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
[**2144-9-16**] 01:21AM PT-20.6* PTT-30.1 INR(PT)-1.9*
[**2144-9-16**] 01:21AM PT-20.6* PTT-30.1 INR(PT)-1.9*
[**2144-9-17**] 01:54AM BLOOD WBC-13.5* RBC-3.00* Hgb-9.5* Hct-28.5*
MCV-95 MCH-31.6 MCHC-33.3 RDW-16.6* Plt Ct-388
[**2144-9-19**] 01:34AM BLOOD WBC-14.4* RBC-2.67* Hgb-8.5* Hct-25.5*
MCV-95 MCH-31.7 MCHC-33.2 RDW-16.0* Plt Ct-387
[**2144-9-21**] 12:56AM BLOOD WBC-13.4* RBC-2.76* Hgb-8.7* Hct-25.8*
MCV-93 MCH-31.6 MCHC-33.9 RDW-15.6* Plt Ct-367
[**2144-9-23**] 01:53AM BLOOD WBC-13.9* RBC-2.82* Hgb-8.9* Hct-26.2*
MCV-93 MCH-31.7 MCHC-34.0 RDW-15.4 Plt Ct-361
[**2144-9-26**] 05:35AM BLOOD WBC-12.5* RBC-2.65* Hgb-8.2* Hct-25.7*
MCV-97 MCH-31.1 MCHC-32.0 RDW-15.5 Plt Ct-393
[**2144-9-27**] 05:00AM BLOOD WBC-13.0* RBC-2.54* Hgb-7.9* Hct-24.5*
MCV-96 MCH-31.0 MCHC-32.2 RDW-16.0* Plt Ct-386
[**2144-9-25**] 12:32AM BLOOD PT-16.2* PTT-36.0* INR(PT)-1.4*
[**2144-9-25**] 12:32AM BLOOD Plt Ct-358
[**2144-9-27**] 05:00AM BLOOD Plt Ct-386
[**2144-9-17**] 01:54AM BLOOD Glucose-107* UreaN-50* Creat-1.9* Na-140
K-4.4 Cl-113* HCO3-19* AnGap-12
[**2144-9-20**] 12:50AM BLOOD Glucose-118* UreaN-54* Creat-1.7* Na-148*
K-3.9 Cl-112* HCO3-26 AnGap-14
[**2144-9-22**] 02:40AM BLOOD Glucose-113* UreaN-60* Creat-1.6* Na-145
K-4.1 Cl-111* HCO3-25 AnGap-13
[**2144-9-28**] 05:00AM BLOOD Glucose-123* UreaN-36* Creat-1.5* Na-143
K-4.3 Cl-114* HCO3-23 AnGap-10
[**2144-9-29**] 05:45AM BLOOD Glucose-115* UreaN-36* Creat-1.4* Na-148*
K-4.7 Cl-116* HCO3-22 AnGap-15
[**2144-9-17**]: EEG:
IMPRESSION: This is an abnormal 24-hour video EEG telemetry due
to a
low amplitude, poorly organized slow delta frequency background
with
very low variability. This represents a severe encephalopathy.
There
were no clear epileptiform discharges or organized seizures seen
[**2144-9-17**]: Cat scan of head:
No acute intracranial process
[**2144-9-18**]: EEG:
IMPRESSION: This 24-hour EEG video telemetry was abnormal due to
a
generally slow background rhythm and bursts of generalized
slowing,
which indicate a moderate to severe encephalopathy which may be
due to
diffuse ischemic, toxic/metabolic, infectious, or other
etiologies.
There were no clear epileptiform features or electrographic
seizures seen
[**2144-9-19**]: EEG:
IMPRESSION: This is an abnormal video EEG telemetry due to the
presence
of a slow background which reached a maximum of 6 Hz, as well as
bursts
of generalized slowing, indicative of a moderate to severe
encephalopathy, which may be due to diffuse ischemic,
toxic/metabolic,
infectious, or other etiologies. There were no clear
epileptiform
features or electrographic seizures noted
[**2144-9-19**]: Ultrasound lower extremities:
IMPRESSION: No evidence of DVT. Diffuse soft tissue edema
[**2144-9-22**]: Chest x-ray:
FINDINGS: In comparison with the study of [**9-21**], the monitoring
and support
devices remain in place. Relatively low lung volumes persist.
Opacification at the bases most likely represent a combination
of pleural effusion and atelectasis.
No evidence of acute focal pneumonia or vascular congestion
[**2144-9-22**]: Cat scan of the head:
FINDINGS: There is no evidence of hemorrhage or infarction. The
[**Doctor Last Name 352**]-white
matter differentiation is well preserved.
There is no mass, mass effect, or shift of normally midline
structures. The ventricles and sulci are prominent in size and
configuration likely due to age-related global atrophy, similar
in appearance from prior study ([**2143-9-5**]).
Periventricular white matter hypodensities are likely due to
chronic small
vessel ischemic disease. A right basal ganglia lacunar infarct
is again
noted. The visualized paranasal sinuses and mastoid air cells
are clear.
Vascular calcifications are noted at the carotid siphons
bilaterally
[**2144-9-25**]: Chest x-ray:
FINDINGS:
Mild bilateral lower lobe atelectasis is relatively unchanged
since [**2144-9-22**].
The position of the nasogastric tube, tracheostomy tube, dual
chamber
pacemaker are unchanged since [**2144-9-22**]. The cardiac size is at
the upper
limits of normal. Bilateral superior migration of both
glenohumeral joints is mild to moderate in severity.
IMPRESSION: Bilateral lower lobe atelectasis, stable since
[**2144-9-22**]
[**2144-9-25**]: Fluro. abdomen:
INDICATION: IVC filter placement
FINDINGS: A single spot fluoroscopic image obtained
intraoperatively without a radiologist present is submitted for
review. There is a post-pyloric feeding tube identified,
terminating in the midline, likely in the 4th portion of
duodenum. There is an IVC filter identified, with the superior
tip at the L1-L2 interspace
[**2144-9-28**]: urine culture:
URINE CULTURE (Final [**2144-9-29**]):
YEAST. >100,000 ORGANISMS/ML..
[**2144-9-22**]:
GRAM STAIN (Final [**2144-9-22**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2144-9-25**]):
~5000CFU/ML Commensal Respiratory Flora.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML.. CHLORAMPHENICOL =
SENSITIVE.
TIMENTIN = INTERMEDIATE.
CEFTAZIDIME, TIMENTIN AND CHLORMAMPHENICOL sensitivity
testing
performed by Microscan.
Levofloxacin sensitivity testing confirmed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S =>32 R
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
[**2144-9-23**]: Urine
URINE CULTURE (Final [**2144-9-23**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Patient was admitted to the trauma ICU in the evening of
[**2144-9-16**] as a transfer from OSH. He was intubated and sedated.
Neurology was consulted to help determine the cause of the
patient's continued encephalopathic state. They recommended a
CT head without contrast, spinal tap and EEG - all results were
negative for hemorrhagic, ischemic and infectious processes.
Although he had low stoma output initially, this gradually
increased following the initiation of TF and after the stoma was
digitized. Sedation was weaned by HD#3 but the patient
continued to be encephalopathic without a known cause. Neurology
hypothesized that he may have suffererd an ischemic insult at
some point during his hospital stay. On HD#3, patient underwent
a bedside percutaneous tracheostomy without complication.
Patient tolerated the procedure well. On HD 7, patient was
restarted on his medications including Aricept and Namenda and
his neurological exam and mental status subsequently improved.
By HD 9 patient was tolerating trach mask with a strong cough.
Patient was started on levofloxacin and cefepime for
stenotrophomonas growing in his BAL and pseudomonas growing in
his urine, respectively. His urinary catheter was also replaced
at that time. His foley catheter has been discontinued and he
has a condom cath in place. His current urine culture reports
yeast. He was evaluated by the Ostomy nurse on [**9-21**]. Because of
his history of tachy-brady syndrome, his pacemaker was
interrogated by the Cardiologist on [**9-21**] and was determined to
be functioning well.
Lower extremity non-invasives were performed as patient had
increased risk for develping DVT. These studies were negative
and it was decided to proceed with IVC filter placement to
reduce patient's subsequent risk of developing sequelae such as
PE from DVT due to his lack of mobility.
Patient underwent PEG and IVC filter placement on HD10 ([**9-26**]),
he tolerated these procedures well. His TF were restarted
through his PEG on HD11. These were gradually advanced. Due to
high residuals, patient was placed on Reglan. To treat his
elevated ostomy output his TF were supplemented with banana
flakes. Neurology was consulted for persistently depressed
mental status, pt was minimally responsive to verbal stimuli.
Video EEG monitoring was done and showed diffuse slowing without
clear epileptiform activity. While on the surgery service, pt
was found to have pneumonia and was started on broad spectrum
antibiotics. His renal function began to worsen and he was
transferred to medical service for further management. On
transfer to medical service, his mental status was unchanged and
he was minimally responsive to verbal stimuli and localized to
pain. He was more responsive when interacting with wife. [**Name (NI) **] was
continued on antibiotic coverage for his pneumonia. He had dark
output from ostomy and HCT drop in setting of worsening Cr,
transfused 2U RBCs without improvement in renal function. Tube
feeds were continued but pt had increased residuals and began to
have gastric reflux through tracheostomy. Tube feeds were
stopped. PEG tube also had dark output which was gastroccult
positive, likely old duodenal ulcer bleeding in setting of
infection and coagulopathy. Renal was consulted to evaluate
worsening renal function given that Cr had risen to 4.8. Mental
status did not improve, likely due to anoxic injury, uremia,
hypoactive delirium, and infection. After long discussion
between renal team, primary team and patient's wife, the
decision was made to make pt comfort measures only. Potential
for meaningful recovery was low. Family meeting was held with
primary team and plan for palliative care was discussed at
length. Hospice care was consulted and pt was continued on
morphine, ativan, scopolamine, tylenol for palliative care.
Trach, peg, and ostomy were kept in place to collect output. Pt
was comfortable for first 2 days and began to have labored
breathing, per wife's request was started on morphine drip.
Pastoral services and palliative care worked closely with wife
to provide comfort care. Pt passed away at 6:50am on [**10-9**] with
wife at bedside. Medical examiner accepted case for "viewing",
wife elected for autopsy to be performed at [**Hospital1 18**] with organs
donated for educational purposes. PCP notified by phone.
Medications on Admission:
[**Last Name (un) 1724**]: aricept 10', namenda 10'', toprol xl 25/50, ASA 81', Folic
acid 1', ritalin 5', simvastatin 20'
Discharge Medications:
Expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Colonic perforation c/b unresponsiveness after intubation,
sepsis, renal failure.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**2144-10-11**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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] |
16003, 16012
|
11443, 15797
|
333, 382
|
16138, 16148
|
3713, 11419
|
16205, 16245
|
2890, 2909
|
15970, 15980
|
16033, 16117
|
15823, 15947
|
16172, 16182
|
2924, 3694
|
276, 295
|
410, 2476
|
2498, 2631
|
2647, 2874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,173
| 138,834
|
4350
|
Discharge summary
|
report
|
Admission Date: [**2158-7-4**] Discharge Date: [**2158-7-16**]
Date of Birth: [**2081-11-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old [**Location **] male with HTN, AF on
warfarin, who presented to his [**Hospital 3390**] clinic today with cough and
SOB. He was noted to be hypoxemic to high 80s in clinic, prior
to nebs. A CXR was obtained which demonstrated diffuse nodular
opacities, ? infxn vs. Wegener's. No frank hemoptysis, but +
blood-tinged sputum. Sats improved to the low 90s after nebs.
Based on these findings and relative hypoxemia, he was referred
to the ED.
.
In the ED, initial VS were 101.4 89 165/63 28 93%RA. Looked
diaphoretic but non-toxic and comfortable. He desaturated to mid
80's on RA --> up to high 80s on 5L--> NRB 100%. Bilateral
infiltrates noted on CXR. Labs revealed a leukocytosis to 15.6
with 82% PMNs. Lactate was mildly elevated at 2.2. EKG showed
lateral ST depressions unchanged from prior. Blood cultures and
urine cultures were drawn. Received 500cc IVF and vancomycin 1g,
levofloxacin 750mg, as well as albuterol and ipratropium nebs,
and was admitted. Access: 1 20 gauge. Most recent VS: most
recent P: 98 BP: 150/70 RR: 25 O2: 100% NRB.
.
Currently, he feels well. He endorses small hemoptysis with
cough at home, as well as feeling hot, with rigors. This has
been going on since last night. ? sick contacts.
Past Medical History:
# Hypertension
# Hypercholesterolemia
# moderate pulmonary hypertension
# Atrial Fibrillation (anticoagulated on warfarin)
# history of alcohol abuse - no current drinking, but h/o
withdrawal
# elevated PSA
# bilateral cataracts s/p excisions in [**2157**]
# epicardial lipoma seen on echo and cardiac MRI
Social History:
He is a nonsmoker, drinks alcohol socially, and does not use
illicit drugs. He is retired.
Family History:
non-contributory
Physical Exam:
General: initally with air hunger and agitation
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to appreciate, no LAD
Lungs: Coarse right basilar crackles, slight left basilar
crackles, clear above.
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
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 or
edema
Pertinent Results:
LABS ON ADMISSION:
[**2158-7-4**] 05:10PM BLOOD WBC-15.6* RBC-4.21* Hgb-11.8* Hct-36.4*
MCV-86 MCH-28.1 MCHC-32.5 RDW-14.3 Plt Ct-175
[**2158-7-4**] 05:10PM BLOOD Neuts-81.9* Lymphs-13.2* Monos-4.5
Eos-0.2 Baso-0.2
[**2158-7-4**] 05:10PM BLOOD PT-19.2* PTT-28.7 INR(PT)-1.8*
[**2158-7-4**] 05:10PM BLOOD Plt Ct-175
[**2158-7-4**] 05:10PM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-139
K-3.5 Cl-99 HCO3-27 AnGap-17
[**2158-7-5**] 03:06AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.7
[**2158-7-8**] 04:16AM BLOOD Vanco-16.2
[**2158-7-4**] 11:00PM BLOOD Type-ART Temp-37.3 Rates-/40 O2 Flow-15
pO2-63* pCO2-38 pH-7.49* calTCO2-30 Base XS-5 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2158-7-4**] 05:28PM BLOOD Lactate-2.2*
.
LABS ON DISCHARGE:
[**2158-7-16**] 06:25AM BLOOD WBC-11.2* RBC-4.15* Hgb-12.1* Hct-36.0*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.3 Plt Ct-234
[**2158-7-16**] 06:25AM BLOOD Plt Ct-234
[**2158-7-16**] 06:25AM BLOOD PT-21.2* PTT-30.3 INR(PT)-2.0*
[**2158-7-16**] 06:25AM BLOOD Glucose-97 UreaN-20 Creat-0.8 Na-142
K-3.7 Cl-104 HCO3-29 AnGap-13
[**2158-7-16**] 06:25AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
.
[**7-4**] CXR:
Interval development of diffuse multifocal mass-like nodular
airspace
opacification that is concerning for pneumonia or Wegner's
granulomatosis
though areas of aspirated hemorrhage also remains in the
differential
diagnosis.
.
[**7-7**] CXR
IMPRESSION: Mild improvement in diffuse opacification involving
the right
hemithorax, though with increased atelectatic change. Worsened
left-sided
retrocardiac opacification representing atelectasis and/or
pneumonia.
.
[**7-9**] CXR
The heart is enlarged. There is plate-like atelectasis in the
right mid lung zone. There is left lower lobe consolidation.
Endotracheal tube terminates in the thoracic inlet. Nasogastric
tube courses below the diaphragm but the tip is not seen. There
is little change since the prior study.
.
MICRO:
[**2158-7-5**] 7:20 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2158-7-10**]**
GRAM STAIN (Final [**2158-7-5**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2158-7-10**]):
SPARSE GROWTH Commensal Respiratory Flora.
ENTEROBACTER CLOACAE. RARE GROWTH.
IDENTIFICATION AND Susceptibility testing requested by
DR.[**First Name (STitle) **],[**First Name3 (LF) **] [**2158-7-8**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2158-7-5**] 1:51 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2158-7-7**]**
GRAM STAIN (Final [**2158-7-5**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2158-7-7**]): NO GROWTH, <1000
CFU/ml.
Brief Hospital Course:
76 y/o male with HTN, HLD, and reactive airways disease who
presented with severe CAP requiring intubation, now extubated
and improving from a respiratory standpoint, with resolving
delerium.
.
# Severe CAP vs. VAP; hypoxic respiratory failure: admitted for
severe community acquired pneumonia. CXR showed "diffuse
multifocal mass-like nodular airspace opacification that is
concerning for pneumonia or Wegner's granulomatosis though areas
of aspirated hemorrhage also remains in the differential
diagnosis." His (endotracheal) sputum from [**7-5**] grew
pan-sensitive enterobacter, which is of unclear significance.
The remainder of his infectious work-up was negative, including
negative urine legionella, negative blood and urine cultures.
His was maintained on levaquin/ceftriaxone/vancomycin until [**7-9**]
when he had leucocytosis and ?increased secretions. At this
point, ceftriaxone was changed to cefepime for ?VAP after
extubation on [**7-9**]. However, his overall course was more
suggestive of slow improvement rather than a hospital-acquired
superinfection. His MRSA screen was negative and he does not
have any clear MRSA risks at baseline. He completed 7 days of
levofloxacin prior to discontinuation. Patient also completed 7
days of vancomycin and cefepime from date of extubation [**7-9**].
Patient was continued on prn albuterol and ipratropium
nebulizers, but does not have clear COPD/asthma history. His
ambulatory O2 sat was > 96% on discharge.
.
# Confusion: resolved. Given acute onset and waxing and [**Doctor Last Name 688**]
course, suspect ICU delirium. Of note, severe infection (though
resolving) likely played a role. Patient had one episode at
night where he became acutely agitated and pulled out his PICC
line. He required PO and IM haldol. To improve delerium,
patient's foley and rectal tube were discontinued, as was his
telemetry. He was maintained on a normal sleep wake cycle.
Patient's mental status was markedly improved and at baseline
with these interventions and with resolving infection. On
discharge, patient was AOx3 and at baseline per family.
.
# Atrial fibrillation - not in RVR; takes atenolol at home. 25
mg TID metoprolol started [**7-9**] and then titrated up to 50 mg TID
without side-effects. On the medical floor, patient was
converted back to home regimen of atenolol. Coumadin re-started
at 2mg qday on [**7-8**] and patient was discharged on 6 mg daily
with instructions to titrate per daily INR. Goal INR [**3-15**].
Patient will have next INR check on Tuesday, [**7-18**], with
results to be faxed to PCP.
.
# HTN - on multiple agents at home. BP agents initially held in
setting of infection, but once patient's infection was
resolving, he was placed back on his home amlodipine 10 mg daily
and his atenolol.
.
# Vtach: one isolated 44 beat run on [**7-9**] in the MICU, which was
likely in the setting of electrolyte abnormalities, as patient
was being diuresed. Did not recur on the medical floor. Patient
was maintained on his BB and electrolytes were closely
monitored.
.
# Leukocytosis: improving on discharge and likely from resolving
pneumonia. U/A with hematuria, but without evidence of infection
on U/A or Ucx. Blood cx NGTD. Stool Cdiff negative; diarrhea
resolved after completing levofloxacin. Etiology of leukocytosis
either severe CAP vs. VAP.
.
# Hematuria: persistent despite removal of foley catheter.
Patient should have repeat U/A per PCP and may require
outpatient urology referral for cystoscopy.
.
# Diarrhea: resolved. Had increasing BMs, not initially noticed
because of flexiseal. Most likely abx-related, as Cdiff negative
prior to discharge.
.
# remote h/o EtOH abuse: has not been drinking recently. Patient
was continued on thiamine and folate, but once alcohol history
was clarified, these were discontinued prior to discharge.
.
# Dispo: discharge to home, PCP [**Name9 (PRE) 702**], outpatient urology
follow-up, INR check on Tuesday, [**2158-7-18**]
Medications on Admission:
albuterol inhaler 2 puffs q6h prn
amlodipine 10mg daily
atenolol 100mg daily
HCTZ 25mg daily
lisinopril 60mg daily
loratadine 10mg daily
simvastatin 40mg daily
warfarin 4-6mg daily depending on INR
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: dose to be adjusted per INR.
7. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
9. Outpatient Lab Work
please have blood-work drawn for PT/INR on Tuesday, [**2158-7-18**]
with results to be faxed to your primary care doctor at
[**Telephone/Fax (1) 12895**] or [**Telephone/Fax (1) 13238**]. The clinic will contact you for a
reminder.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. severe community vs. ventilatory acquired pneumonia
2. delerium
.
SECONDARY:
1. atrial fibrillation
2. hypertension
3. dyslipidemia
4. elevated PSA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital with shortness of breath and severe pneumonia
requiring a breathing tube in the ICU. You improved with IV
antibiotics. Your hospital course was also complicated by
confusion/delerium, which was likely from resolving infection.
This was resolved on discharge.
.
MEDICATION CHANGES/NEW MEDICATIONS:
- none
.
Please seek medical attention for worsening fevers, chills,
nightsweats, cough, shortness of breath, difficulty breathing,
chest pain, abdominal pain, confusion, or any other concerning
symptoms.
Followup Instructions:
We have scheduled a primary care appointment with Dr. [**Last Name (STitle) **] for
Thursday, [**7-20**] at 12:30. Please call [**Telephone/Fax (1) 7976**] for
questions.
.
Outpatient Lab Work: please have blood-work drawn for PT/INR on
Tuesday, [**2158-7-18**] with results to be faxed to your primary
care doctor at [**Telephone/Fax (1) 12895**] or [**Telephone/Fax (1) 13238**]. The clinic will
contact you for a reminder.
Completed by:[**2158-7-16**]
|
[
"401.9",
"414.00",
"799.02",
"518.81",
"305.03",
"424.0",
"486",
"496",
"293.0",
"787.91",
"427.31",
"427.1",
"214.2",
"416.8",
"599.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.72",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11154, 11160
|
6003, 9953
|
323, 335
|
11364, 11364
|
2626, 2631
|
12169, 12625
|
2079, 2097
|
10201, 11131
|
11181, 11343
|
9979, 10178
|
11549, 12146
|
2112, 2607
|
276, 285
|
3349, 5980
|
363, 1626
|
2645, 3330
|
11379, 11525
|
1648, 1955
|
1971, 2063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,892
| 149,320
|
23060
|
Discharge summary
|
report
|
Admission Date: [**2110-11-24**] Discharge Date: [**2110-11-30**]
Date of Birth: [**2038-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest Pain/Discomfort x 2 months
Major Surgical or Invasive Procedure:
CABGx4 [**2110-11-24**]
History of Present Illness:
Pt. is a 72 y/o male c/o chest pain/discomfort/pressure x 2
months assoc. with bedning over and belching. Pt. states
symptoms became more frequent and worse. Saw Dr. [**Last Name (STitle) 27117**] and had
a + exercise stress test and then was referred for a cardiac
cath. Cath showed 3VD - EF 58%, LM 20%, pLAD 95%, Ramus 70%, OM1
50-60%. Pt was then referred to cardiac surgery service for
CABG.
Past Medical History:
HTN
^Chol
Bilateral Neuropathy(R>L)
L shoulder Impingment
L3 Bulging/Herniated Disc
Bilateral Cataracts
L 3rd Digit (at DIP) Amputation
s/p Appendectomy
s/p L. 3rd digit amp
Social History:
Denies Tobacco hx. Drinks a glass of wine rarely. Denies
IVDA/Cocaine Hx. Lives with wife in [**Name (NI) 47**]. Maintanance
worker.
Family History:
?CAD hx. Father died in his 30s. Mother died in her 80's (had
pacemaker)
Physical Exam:
Ht:5'[**15**]",Wt.:212#,HR:66 ireg-reg,BPR:150/66,BPL:144/70
WD/WN male who appears stated age in NAD
Skin:warm,dry -lesions
HEENT:EOMI, PERRLA, NC/AT
NECK:supple, - thyromegaly, - lymphadenopathy, ?trace r. carotid
bruit
Chest: CTAB -w/r/r
Heart: Irreg-Reg +S1/S2 -c/r/m/g
Abd: Soft, NT/ND, +BS -r/r/g
Ext:W/D - C/C/E, LLE varicosities, use RLE for EVH
Neuro:AAO x 3, CN2-12 intact, non-focal
Pertinent Results:
[**2110-11-29**] 03:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2110-11-29**] 03:50PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2110-11-29**] 03:50PM URINE RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0
[**2110-11-30**] 05:15AM BLOOD WBC-9.6 RBC-3.01* Hgb-9.1* Hct-27.9*
MCV-93 MCH-30.3 MCHC-32.7 RDW-13.0 Plt Ct-347#
[**2110-11-30**] 05:15AM BLOOD Plt Ct-347#
[**2110-11-24**] 07:57PM BLOOD PT-15.2* PTT-25.6 INR(PT)-1.5
[**2110-11-29**] 06:05AM BLOOD Glucose-106* UreaN-18 Creat-0.8 K-4.0
[**2110-11-24**] 07:57PM BLOOD UreaN-14 Creat-0.7 Cl-111* HCO3-24
[**Last Name (NamePattern4) 4125**]ospital Course:
Pt. was brought into the operating room on [**2110-11-24**] and after
general anesthesia, pt. underwent a Coronary Artery Bypass
Surgery x 4 (LIMA to LAD, SVG to DIAG, SVG to Ramus, SVG to RCA)
by Dr. [**Last Name (Prefixes) **]. Total bypass time was 115 min. Cross-Clamp
time was 63 min. Pt. tolerated the procedure well and was
transferred to CSRU with a propofol drip with a MAP of 76, CVP
7, PAD 11, [**Doctor First Name 1052**] 21 and HR of 80 A-paced. Pt. was later extubated
that day and was being weaned off of Neo. On POD #2 Chest tubes
were pulled. On POD #3 pt. was stable, receving lopressor and
lasix. On POD #4 pt. had short run of AF overnight. IV lopressor
was given and pt. converted to NSR. His lopressor was increased
to 50mg [**Hospital1 **]. Today his pacing wires were removed. His PE was
unremarkable. Pt. continued to improve and on POD #6 pt. was
discharged home. His D/C PE is as follows:
HR:84, RR18, BP 128/62, 97% RA
NAD, A & O x 3
RRR, sternal inc. C/D/I
CTAB
Abd. Sofr NT/ND
Ext. incision C/D/I, - Edema
Medications on Admission:
Clonazepan 5mg QID
Gabapentin 600mg QID
Lipitor
Metoprolol
Amitriptyline 10mg 1qhs
Colestopol 1 mg QID
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Amitriptyline HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coranary artery disease, s/p CABGx4
HTN
^Chol
Discharge Condition:
Good.
Discharge Instructions:
Showers as wished.
No heavy lifting for 6 weeks.
Followup Instructions:
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 17010**] cardiologist Appointment should be in [**6-21**] days
Completed by:[**2110-12-23**]
|
[
"401.9",
"272.0",
"413.9",
"355.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4566, 4628
|
356, 382
|
4718, 4725
|
1674, 2318
|
4822, 5088
|
1171, 1245
|
3559, 4543
|
4649, 4697
|
3432, 3536
|
4749, 4799
|
1260, 1655
|
2369, 3406
|
284, 318
|
410, 808
|
830, 1005
|
1021, 1155
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,209
| 119,961
|
54884
|
Discharge summary
|
report
|
Admission Date: [**2183-9-20**] Discharge Date: [**2183-9-26**]
Date of Birth: [**2111-10-20**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p hit by automobile while lying on park bench.
Major Surgical or Invasive Procedure:
[**9-20**] Debridement and nail removal of right 4th digit
History of Present Illness:
Mr. [**Name13 (STitle) 23203**] is a 71 year old male transfered from OSH on [**2183-9-20**]
s/p being struck by a motor vehicle while sitting on a bench.
Patient had loss of consciousness and doesn't remember the
event. He was found to have bilateral subdural and subarachnoid
hemorrhage, non-displaced left frontal skull fractures,
comminuted right iliac [**Doctor First Name 362**] and body fractures, right sacral
fracture, comminuted fracture of the left superior and inferior
pubic ramus, right comminuted scapula fracture, right medial
malleolus fracture, bilateral 1st rib fractures, non-displaced
fracture of the left lateral 6,7,8 ribs, retroperitoneal
hematoma, fractures of the T3 and T4 spinous processes and right
4th digit degloving injury and fracture. Transfered to [**Hospital1 18**] for
further management.
Past Medical History:
None.
Social History:
Patient states he is homeless, has no family. Denies ETOH,
illicit drug use. Occasional tobacco. States that he checks in
with a woman named [**Name (NI) **] [**Name (NI) 112120**] at a drop-in center in [**Location (un) **].
Family History:
Non-contributory.
Physical Exam:
On admission (ED):
BP: 113 systolic
Constitutional: Boarded, collared, appears mildly confused
HEENT: left frontal contusion
Chest: Normal
Cardiovascular: Normal
Abdominal: Normal
Extr/Back: right ring finger partial degloving injury,
pelvis in binder
Skin: Warm and dry
Neuro: appears intoxicated with ETOH on breath
Psych: slightly bizzare affect
On discharge:
Temp 99.7, 86, 112/64, 14, 96% on room air.
Neuro: AAO x 3, flat affect. Right arm immobilized in sling,
RLE in air cast boot. Gross extremity movement [**5-24**]. Has left
periorbital ecchymosis and right posterior ear ecchymosis.
Right ring finger in splint. Skin of that finger (post
degloving injury) with mottled [**Location (un) **] aspect of distal finger.
Ecchymosis of right fifth finger.
Pulm: Lungs clear bilaterally, diminished in bases.
GI: Abdomen soft, non-tender, non-distended.
GU: Voiding.
Pertinent Results:
[**2183-9-20**] 03:39AM BLOOD WBC-16.6* RBC-3.78* Hgb-12.4* Hct-37.1*
MCV-98 MCH-32.8* MCHC-33.4 RDW-13.4 Plt Ct-213
[**2183-9-22**] 12:42AM BLOOD WBC-10.0 RBC-2.95* Hgb-9.4* Hct-28.5*
MCV-97 MCH-31.9 MCHC-33.0 RDW-13.7 Plt Ct-131*
[**2183-9-23**] 06:18AM BLOOD WBC-7.4 RBC-2.69* Hgb-8.6* Hct-25.7*
MCV-96 MCH-32.0 MCHC-33.4 RDW-13.7 Plt Ct-159
[**2183-9-20**] 03:39AM BLOOD PT-13.6* PTT-32.3 INR(PT)-1.3*
[**2183-9-20**] 03:39AM BLOOD Plt Ct-213
[**2183-9-20**] 03:39AM BLOOD Fibrino-136*
[**2183-9-20**] 01:01PM BLOOD Glucose-147* UreaN-17 Creat-0.9 Na-138
K-6.0* Cl-108 HCO3-24 AnGap-12
[**2183-9-20**] 03:39AM BLOOD cTropnT-0.01
[**2183-9-20**] 01:01PM BLOOD Calcium-7.8* Phos-3.3 Mg-2.6
[**2183-9-21**] 01:55AM BLOOD Phenyto-11.3
[**2183-9-20**] 01:01PM BLOOD Ethanol-NEG
Imaging:
Head CT [**9-20**]:
-Interval progression of left frontal subarachnoid hemorrhage.
Interval enlargement of left subdural hematoma. Increased left
sulcal effacement.
-Stable right frontal and temporal subarachnoid hemorrhage.
Stable small right subdural hematoma.
-Comminuted fracture left frontal and parietal bone fracture,
extending into the left orbital roof.
-Comminuted bilateral nasal bone fractures.
Shoulder [**9-20**]: In the right humerus, there is no evidence of
fracture. There is no evidence of dislocation. There is a
minimally displaced transverse fracture of the right scapula.
There is hardware in the right clavicle.
R Hand [**9-20**]: There is comminuted fracture of the distal phalanx
and top of the fourth digit. There is loss of the soft tissues
in the distal fourth digit. There is no evidence of
dislocation. There is osteopenia. There are moderate
degenerative changes in the distal interphalangeal joints of all
digits with decrease in the joint space and osteophytosis.
CT Abdomen and pelvis
Enlarging pelvic hematoma within right lower quadrant tracking
along right pelvic sidewall with intramuscular hematoma and mass
effect on bladder and bowel loops. Active extravasation on
previous CT is no longer identified perhaps secondary to
tamponading. Close attention to serial hematocrit recommended
and if necessary repeat imaging can be performed.
2. Comminuted right iliac bone fracture extending into right
sacroiliac joint with mild sacroiliac joint diastasis.
3. Fractures of the right hemisacrum anteriorly extending to
the sacroiliac joint and S1 neural foramen.
4. Left superior ramus parasymphyseal fracture and left
inferior pubic ramus fracture.
5. Multiple nondisplaced bilateral rib fractures.
6. Small hiatal hernia.
7. Possible small hematoma along the inferior margin of the
liver. A subtle liver injury is possible and close interval
follow-up is recommended.
8. Please see the outside hospital study report for additional
details.
Please note that the outside hospital study demonstrates a
lesion suspicious for neoplasm within the right upper lobe with
mediastinal and hilar adenopathy. Please see that report for
further details.
CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY
-Small bifrontal SDH and SAH - left greater than right - 3 mm
subdural
diameter
-No significant mass effect, no midline shift
-Non-displaced left frontal skull fracture with overlying
subgaleal hematoma
-Minimal fluid in left maxillary sinus with irregular contour of
posterior left maxilary sinus wall. If concern for facial bone
fx, recommend dedicated CT for further assessment
-No cervical spine fracture, malalignment or prevertebral soft
tissue edema
-Partially imaged left 1st rib fracture
Pelvis (AP):
Single frontal view. A comminuted fracture of the right iliac
[**Doctor First Name 362**], right iliac body, sacroiliac joint, right sacral ala
fracture, and comminuted fracture in the left superior pubic and
inferior pubic rami are better seen in prior CT torso.
Shoulder (AP):
In the right humerus, there is no evidence of fracture. There
is no evidence of dislocation. There is a minimally displaced
transverse fracture of the right scapula. There is hardware in
the right clavicle.
[**9-21**] CT of head
Little change from [**2183-9-20**] in the multifocal subarachnoid and
subdural hemorrhage, as described above. Some hemorrhage is
less conspicuous, compatible with evolution and/or
redistribution of blood products.
[**9-21**] CT of head/mandible/maxillofacial
1. Superior orbital roof fracture extending to the posterior
orbital wall.
2. Comminuted nasal bone fracture.
The orbital roof component of the extensive left- sided
calvarial fracture extends posteriorly and inferiorly to involve
the anterior cranal fossa, at the lateral aspect of the left
fovea ethmoidalis; this may place the patient at risk for
(unusual) orbital CSF leak.
[**9-21**] MR of cervical spine without contrast
1. Fractures of the T3 and T4 spinous processes, with
interspinous ligament edema from T2-T3 through T4-T5. The
ligamentum flavum appears intact.
2. Intravertebral disc herniation (Schmorl's node) into the
inferior endplate of the T2 vertebral body may be acute. No
evidence of associated ligamentous edema or disruption.
3. Linear high signal on STIR images in the anterior superior
aspect of the C6-7 disc may represent acute disc disruption,
though there is no appreciable widening. Due to motion
artifact, it is not clear whether the edema extends into the
anterior longitudinal ligament at this level.
4. Multilevel degenerative disease in the cervical spine,
suboptimally
assessed due to motion artifacts.
[**9-21**] Right ankle radiograph.
Patient with multiple orthopedic injuries status post MVC. There
is a minimally displaced transverse fracture of the medial
malleolus
with adjacent soft tissue swelling. There is no joint
dislocation,
osteoblastic osseous lesions, or soft tissue calcification.
Brief Hospital Course:
Mr. [**Name13 (STitle) 23203**] presented to [**Hospital3 **] via EMS. He was
initially admitted to the trauma ICU. His most concerning
injury at the time as a retroperitoneal bleed with possible
extravasation of contrast. He was transferred to [**Hospital1 18**] for
further management where he was hypotensive. Upon admission, he
was given one unit of PRBCs. Repeat imaging of his abdomen
showed no extravasation.
ICU course by system:
Neuro: GCS 14. Delirious at times. Dilantin was administered
for seizure prophylaxis secondary to his traumatic head bleed.
He continues on seizure prophylaxis for a 10-day course which is
to end on [**9-28**]. A repeat head CT was stable from prior.
Resp: The patient was saturating fairly well on a nasal cannula
and never required intubation.
Cardiac: Mr. [**Name13 (STitle) 23203**] was hemodynamically stable overall. He had
no alterations in peripheral pulses. A left-sided radial
arterial line was placed for hemodynamic monitoring and frequent
blood draws.
GI: The patient was initially kept NPO, but his diet was
advanced once it was confirmed that there were no required
surgical interventions.
GU: A foley was placed initially for close urine output
monitoring. After discontinuation, the patient has no issues in
voiding. Urine output had been adequate.
Heme: Mr. [**Last Name (Titles) 58473**] initial hematocrit was 35 and later dropped
to 27. Serial HCT were completed and his levels remained stable
thereafter. He required only 1 PRBC infusion during this
inpatient stay.
Endocrine: The patient had ketones in his urine, as well as a
low bicarb on admission, thought to be due to starvation or
alcoholism. He was therefore placed on an insulin sliding
scale and given multivitamins, thiamine and folate parenterally.
His blood glucose levels were generally stable throughout his
ICU course.
On hospital day 3, Mr. [**Last Name (Titles) 23203**], inpatient floor under the Acute
Care Surgery team for further management and evaluation of his
multiple fractures.
Throughout his inpatient stay, Mr. [**Name13 (STitle) 23203**] was followed by
orthopedics, neurosurgery, and plastics. The patient had
multiple radiologic exams to evaluate his injuries. Each injury
was treated as noted below:
1) Bilateral subdural and subarachnoid hemorrhage and
non-displaced left frontal skull fractures, left superior
orbital wall fracture:
Repeat imaging of the patient's head was completed on hospital
day 2. The fractures were stable and required no surgical
intervention. Mr. [**Name13 (STitle) 23203**] had no signs of a CSF leak. The
patient will follow up with neurosurgery within a month with a
repeat head CT at that time.
2) Comminuted right iliac [**Doctor First Name 362**] and body fractures, right sacral
fracture, comminuted fracture of the left superior and inferior
pubic ramus:
Orthopedics was consulted. These injuries required no surgical
intervention. The patient had no weight restrictions based on
these fractures alone.
3) Right comminuted scapula fracture:
Orthopedics recommended that the patient wear a sling to his
right upper extremity and bear no weight with that arm. No
surgical interventions is necessary.
4) Right medial malleolus fracture:
Orthopedics recommended that the patient wear an air cast boot
to the right lower extremity while out. He should only place
touch-down weight on that extremity.
5) Bilateral 1st rib fractures, non-displaced fracture of the
left lateral 6,7,8 ribs:
These injuries were non-operative. Pain management was achieved
initially with parenteral analgesics but the patient has not
transitioned to oral narcotic and non-narcotic analgesics.
Pulmonary toileting using an incentive spirometer, as well as
OOB/ambulation was encouraged frequently.
6) Right 4th digit degloving injury and fracture: On [**2183-9-20**],
the patient had debridement and nail removal of the R 4th digit
and placed in splint. Sutures were placed to tack the injured
skin back in place. At the time of discharge, that
palmar/inside aspect of the right ring finger remains mottled
with little to no vascular flow superficially. The patient will
be following up in the hand clinic within approximately one
week.
Social work was consulted to discuss the patient's current
living situation and the questionable history of alcohol and/or
drug dependence. Please see that note for further details. The
patient's alcohol level was negative on admission to [**Hospital1 18**],
although notes indicated his breath smelled of alcohol. He was
placed on a CIWA protocol, but never required benzodiazepines
for symptoms of withdrawal. He was given multivitamins,
thiamine and folic acid for nutritional supplementation,
nonetheless.
Note that during the diagnostic imaging process, a lesion
suspicious for neoplasm was found in the right upper lobe with
mediastinal and hilar adenopathy. The patient should obtain a
primary care physician and follow up on this finding.
Mr. [**Name13 (STitle) 23203**] has recovered well while on the inpatient floor. His
neurologic status has improved, he has tolerated a regular diet,
and worked with physical and occupational therapy.
At time of discharge, Mr. [**Name13 (STitle) 23203**] is hemodynamically stable and
afebrile. He will be discharged to "The [**Location (un) **]" where he will
continue to receive physical therapy. Follow-up appointments
have been made for the services mentioned above.
Medications on Admission:
None.
Discharge Medications:
1. Bisacodyl 10 mg PR HS:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 1000 mg PO BID
Last dose on [**9-28**] for 7 day course.
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-20**] tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor - [**Location (un) **]
Discharge Diagnosis:
Motor vehicle strike with the following injuries:
Bilateral subdural, subarachnoid hemorrhage
Non-displaced left frontal skull fractures
Right superior orbital wall fracture
Comminuted bilateral nasal bone fracture
Right ring finder degloving and fracture
Retroperitoneal hematoma
Right scapular fracture
T3, T4 spinous process fractures
Bilateral 1st rib fracture
Left lateral non-displaced 6,7,8 ribs
Comminuted fx of the left superior and inferior pubic ramus
fracture
Comminuted right iliac [**Doctor First Name 362**] and body fracture
Right sacral fracture
Right medial malleolus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital after you
were struck by a car while sitting on a park bench. Your
injuries include the following:
Bilateral subdural, subarachnoid hemorrhage
Non-displaced left frontal skull fractures
Left superior orbital wall fracture
Comminuted bilateral nasal bone fracture
Right ring finder degloving and fracture
Retroperitoneal hematoma
Right scapular fracture
T3, T4 spinous process fractures
Bilateral 1st rib fracture
Left lateral non-displaced 6,7,8 ribs
Comminuted fx of the left superior and inferior pubic ramus
fracture
Comminuted right iliac [**Doctor First Name 362**] and body fracture
Right sacral fracture
Right medial malleolus fracture
You have recovered well and are being discharged with the
following instructions:
o Continue any prior medications that you were taking before
your hospitalization.
o Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
RIB FRACTURES:
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain. You should take your pain medicine as as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating, take half the
dose and notify your physician.
Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
o You should not bear any weight using your right arm until you
follow up with the orthopedic service. In the meantime, you may
wear a sling on your right arm for comfort.
o You should wear the air cast boot on your right leg for
walking. You should only touch the foot down on the ground, but
not bear weight on it. Again, you will follow up with
orthopedics for further instructions (appointment is below).
o You will be working with physical therapy as an outpatient.
They will assist you in regaining your strength and continue
teaching you how best to ambulate (walk) with the types of
injuries you have.
Followup Instructions:
***Please call the Plastic Surgery Office at [**Telephone/Fax (1) 4652**]. The
patient needs an appointment with Dr. [**First Name (STitle) **] for follow-up of his
nasal bone fractures within approximately one week***
Department: ORTHOPEDICS
When: TUESDAY [**2183-9-30**] at 9:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2183-9-30**] at 10:00 AM
With: HAND CLINIC [**Telephone/Fax (1) 3009**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2183-10-7**] at 8:10 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2183-10-7**] at 8:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2183-10-23**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2183-10-23**] at 10:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2183-9-26**]
|
[
"805.6",
"E814.7",
"824.0",
"801.26",
"805.2",
"780.09",
"808.2",
"816.12",
"811.09",
"808.41",
"518.89",
"800.26",
"305.00",
"276.2",
"458.9",
"802.0",
"V60.0",
"807.05",
"868.04",
"785.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"86.23",
"79.64"
] |
icd9pcs
|
[
[
[]
]
] |
14223, 14299
|
8285, 13761
|
353, 414
|
14939, 14939
|
2499, 8262
|
17780, 19653
|
1562, 1581
|
13817, 14200
|
14320, 14918
|
13787, 13794
|
15122, 17757
|
1596, 1948
|
1963, 2480
|
265, 315
|
442, 1271
|
14954, 15098
|
1293, 1300
|
1316, 1546
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,332
| 182,073
|
8365+55937
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-8-7**] Discharge Date: [**2192-9-4**]
Date of Birth: [**2121-7-3**] Sex: M
Service: General Surgery - Gold
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 71 year old
black married male who noted pain with jaundice in [**2192-6-24**]. The patient underwent a computerized tomography scan
that revealed dilated ducts and he then underwent an
endoscopic retrograde cholangiopancreatography in which he
received a stent. He presented to the [**Hospital6 649**] on [**2192-8-7**], where he underwent the
Whipple procedure. Preoperative diagnosis was pancreatic
cancer, postoperative cancer was same. Surgeon of record was
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1305**], Assistant [**Location (un) 16059**]. Intraoperative findings
included a large mass at the head of the pancreas but no
signs of distant metastasis. There was no free fluid in the
abdomen and there were no grossly enlarged lymph nodes. The
nodules in the liver were around the peritoneal surfaces and
the vessels at the base of the transverse mesocolon were
clean. There was marked thickening around the common bile
duct and some adhesions to the gallbladder. The pathology
report includes pancreas, tumors and abscess. The specimen
for this synopsis is from the Whipple resection. The
location of the tumor is at the head of the pancreas. The
size of the tumor is 1 by 2.5 by 3 cm, histologic type,
ductal adenocarcinoma. Histologic grade, moderately to
poorly differentiated. Lymph nodes were not positive.
Vascular invasion with absent perineural invasion was
present. Surgical margins were negative. However, the
peripancreatic fat involved by tumor, duodenal negative,
gastric negative, common bile duct negative.
On the morning of [**8-8**], the patient was noted to have a
distended abdomen. The patient's hematocrit had dropped and
although the patient was hemodynamically stable he was on the
hypotensive side and the patient was thought to be actively
bleeding and he was taken back to the Operating Room. On
[**2192-8-8**] he underwent an exploratory laparotomy,
evacuation of clot and suture ligature of bleeding vessels
and packing. Preoperative diagnosis was postoperative
bleeding, postoperative diagnosis was postoperative bleeding.
Surgeon of record was [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1305**], Assistant [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 16059**].
Estimated blood loss during this procedure was approximately
2500 cc. The patient was then taken back to the Intensive
Care Unit where he remained intubated for several days. The
patient went into atrial fibrillation on [**8-9**]. The
patient was put on Beta blocker and was found to be in normal
sinus rhythm on [**8-10**]. The patient was kept on Kefzol
and Flagyl during the postoperative period and also required
pressors to maintain normotension. The patient spiked a
temperature and was cultured on [**8-11**]. Sputum culture
grew out Pseudomonas Aeruginosa for which the patient was put
on Ciprofloxacin and Ceptaz. On [**8-13**], the patient
underwent another surgical procedure. The patient underwent
exploratory laparotomy and removal of packing that had been
placed in the patient's abdomen for the purposes of
hemostasis on [**8-8**]. On [**8-13**] these packs were
removed. Surgeon of record is Dr. [**Last Name (STitle) 1305**], Assistant is
[**Location (un) 16059**]. The patient did require Hydralazine and Lopressor to
control his blood pressure in the postoperative period.
On [**8-17**], the patient underwent a computerized tomography
scan of the abdomen and pelvis that revealed ascites and
peritoneal inflammatory change expected for the stated
postoperative period. No abscess or loculated collection was
identified within the abdomen or pelvis. The patient did
continue to do well in the Intensive Care Unit and was
extubated on [**8-20**]. The patient required several days of
diuresis with Lasix. This was required to take off much of
the fluid that the patient needed in the immediate
postoperative phase. The patient had a blood culture from
[**8-26**] that grew out [**Female First Name (un) 564**] Albicans, thus the patient
was started on Fluconazole. The patient continued to have
problems with fluid overload and episodes of desaturation and
aggressive Lasix therapy was continued. By [**8-29**], much
of the patient's fluid had been diuresed and he was now
satting 91 to 97% on 2 liters of nasal cannula. Mr. [**Known lastname **]
continued to do well.
As of [**9-2**], the patient was tolerating p.o. feeds. He
did not require jejunostomy tube feeds. He was taking soft
palate diet. He had passed a swallow study test and was
taking in good p.o. intake and not having any episodes of
coughing. He has been told to eat all of his food in a
bolt-upright position. His Foley catheter was discontinued
on [**9-2**], he has voided adequately after discontinuing
the Foley catheter. He still does have a pancreatic drain in
place of his cap and he also had a jejunostomy tube in place.
Other than that he no longer has any tubes in his body other
than intravenous line. His pain is adequately controlled
with p.o. pain medications and he is now ready to be
discharged to rehabilitation center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36
D: [**2192-9-2**] 21:30
T: [**2192-9-2**] 22:07
JOB#: [**Job Number 29578**]
Name: [**Known lastname 400**], [**Known firstname 5173**] Unit No: [**Numeric Identifier 5174**]
Admission Date: [**2192-8-7**] Discharge Date:
Date of Birth: [**2121-7-3**] Sex: M
Service:
DISCHARGE MEDICATIONS:
Amiodarone 100 mg p.o. q.d.
Ceftazidime 2 mg intravenous every eight hours through
[**2192-9-9**].
Amlodipine 10 mg p.o. q.d.
Aspirin 81 mg p.o. q.d.
Atorvastatin 10 mg p.o. q.d.
Ciprofloxacin 500 mg p.o. b.i.d. through [**2192-9-9**].
Fluconazole 400 mg p.o. q.d. through [**2192-9-10**].
Lopressor 50 mg p.o. b.i.d.; hold for heart rate of under 50
and systolic blood pressure of under 100.
Isordil 20 mg p.o. t.i.d.; hold for systolic blood pressure
of under 100.
Benazepril 80 mg p.o. q.d.; hold for systolic blood pressure
of under 100.
NPH insulin 15 units q.a.m. and 10 units q.p.m.
Albuterol and Atrovent nebulizers every four to six hours
p.r.n.
Hytrin 10 mg p.o. q.d.
Sliding scale regular insulin.
DISCHARGE DIET: The patient will be discharged on a soft,
solid diet.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] L. 02-164
Dictated By:[**Last Name (NamePattern1) 5175**]
MEDQUIST36
D: [**2192-9-3**] 09:52
T: [**2192-9-3**] 10:37
JOB#: [**Job Number 5176**]
|
[
"575.11",
"117.9",
"427.31",
"577.1",
"157.0",
"482.83",
"998.11",
"416.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7",
"96.72",
"54.0",
"38.87",
"99.15",
"38.93",
"97.85",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5874, 6889
|
181, 5851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,398
| 165,585
|
34554
|
Discharge summary
|
report
|
Admission Date: [**2129-8-3**] Discharge Date: [**2129-8-4**]
Date of Birth: [**2078-7-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
CC: Hyperglycemia, Nausea, Vomiting.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 51 y.o. M with DM Type 1, hypertension,
hypercholesterolemia, transferred from OSH ([**Last Name (un) 4199**]) for DKA.
Pt stated he had malaise with nausea and vomiting x 10-14 times
for past 24 hours, all liquid emesis, but nonbloody. He has
been unable to tolerate po since yesterday. Helast took his
Lantus on Monday night. On Monday night (1 day PTA), he started
to feel malaised. That night, he ate dinner without difficulty
at home. On Tuesday, the day PTA, he woke up with nausea and
vomiting. He then had crampy abdominal pain, which he thinks
started after the nausea and vomiting. He took his BS during
the day, and they ranged mostly in the 300s with some in the
220s. He decided to go to the ED for further evaluation. He
notes that he has had a dry cough for the last 2.5 days.
.
At OSH, glucose 509, ketones in urine, Na 130, K 6.3, Cr 2.0,
and WBC 25.6. OSH ABG 6.99/13/137/3 He was given 10 units of
regular insulin and then started on insulin gtt at 7 units/hour.
Mr. [**Known lastname **] was then transferred to [**Hospital1 18**] ED for further
management. He endorse mild cough, chills, crampy abdominal
pain, leg cramps that start at his buttocks (may be due to some
"circulation problem" that he has been diagnosed with), and
polydipsia. He denies fevers, headache, neck stiffness, chest
pain, new rashes, dysuria, urinary frequency, diarrhea,
constipaion. Denies sick contacts.
.
In the ED, VS: 96.7 HR 130 BP 123/87 RR 22 O2 sat 100% 3 L
NC
Labs remarkable for Na 132, K 5.5, Bicarbonate 5, BUN/Cr 22/1.6,
glucose 433, anion gap of 29, lactate 2.6 and WBC 25.4. UA 1000
glucose, 150 ketones. ABG 7.03/17/127/5. CXR appeared
negative. EKG with no ischemic changes. Blood cultures x 2 and
urine culture x 1 drawn in ED. Given 6 L NS, levofloxacin 750
mg x 1, and currently on insulin gtt at 7 units/hour. Last FS
was 318 in ED. Last set of vitals: HR 110, BP 113/72, 100% 2 L
NC, RR 22, 98.4
.
Past Medical History:
Diabetes Mellitus, Type 1: diagnosed in [**2126-2-5**]. Denies any
complications, including eye and renal problems.
Hypertension
Hypercholesterolemia
"Circulation" problem to [**Name (NI) **]
Social History:
Firefighter with construction work on the side. Lives with
wife. Denies IVDU. [**5-15**] cigarettes/day x 1.5 years but used to
smoke 1 ppd x 30 years. Drinks 2-3 x per week with 2-4 beers
during each occasion.
Family History:
Mom - cancer history on mom's side; Dad - deceased from MI at
age 42
Physical Exam:
Vitals: T: 98.1 BP: 134/73 HR: 99 RR: 17 O2Sat: 100% RA
GEN: NAD, pleasant, thin male sitting in bed
HEENT: EOMI, anicteric, poor dentition, OP - no exudate, no
erythema, no LAD palpated
CHEST: CTAB, no w/r/r
CV: RRR, nl S1, S2, no m/r/g
ABD: NDNT, soft, NABS
EXT: no c/c/e
NEURO: FROM, alert and oriented, non-focal, CN grossly intact
SKIN: no rashes noted
Pertinent Results:
[**2129-8-3**] 01:30AM WBC-25.4* RBC-4.85 HGB-14.8 HCT-48.3 MCV-100*
MCH-30.6 MCHC-30.7* RDW-14.2
[**2129-8-3**] 01:30AM NEUTS-84.9* LYMPHS-10.5* MONOS-4.2 EOS-0
BASOS-0.4
[**2129-8-3**] 01:30AM cTropnT-<0.01
[**2129-8-3**] 01:30AM ALT(SGPT)-18 AST(SGOT)-22 CK(CPK)-73
[**2129-8-3**] 01:30AM LIPASE-46
[**2129-8-3**] 01:30AM GLUCOSE-433* UREA N-22* CREAT-1.6*
SODIUM-132* POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-5* ANION
GAP-35*
[**2129-8-3**] 03:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-8-3**] 03:00AM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2129-8-3**] 07:53AM LACTATE-1.1
[**2129-8-3**] 09:52AM WBC-20.8* RBC-3.90* HGB-11.5*# HCT-36.7*#
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.1
[**2129-8-3**] 09:52AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2129-8-3**] 09:52AM CK-MB-6 cTropnT-<0.01
[**2129-8-3**] 12:48PM TYPE-ART PO2-103 PCO2-32* PH-7.37 TOTAL
CO2-19* BASE XS--5
[**2129-8-3**] 04:10PM CK-MB-6 cTropnT-<0.01
Brief Hospital Course:
# Diabetic Ketoacidosis: Anion Gap of 19 on arrival to [**Hospital Unit Name 153**].
Unknown precipitant. Culture data negative, WBC down to normal
the day after admission, afebrile. Cardiac enzymes x3 negative.
Most likely secondary to not taking insulin. Patient was given
agressive IV fluid hydration, and started on an insulin drip.
Bridged with subQ insulin once anion gap closed. [**Last Name (un) **] was
consulted for diabetic education.
# Leukocytosis: CXR without infiltrates. UA negative. [**Month (only) 116**] be
stress response as pt currently afebrile. WBC down to 11 on
leaving ICU
# Renal insufficiency, unknown baseline: Cr elevated at 1.6 on
admission. Resolved to 0.7 the following day.
#Pulmonary nodule. Solitary pulmonary nodule was seen on chest
x-ray on admission. Have spoken to PCP for outpatient follow
up.
Medications on Admission:
Lantus 25 units daily
Crestor 30 mg daily
Hydroxyzine 25 mg [**Hospital1 **]
Ferrous Gluconate 324 mg tablet daily
MVI 1 tablet daily
ASA 81 mg daily
Lisinopril 10 mg daily
Discharge Medications:
1. Rosuvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the ICU with Diabetic Ketoacidosis, meaning
that your blood sugars were very high. We treated you with IV
fluids and insulin. You sugars and labs came back to normal
over 24 hours. You were seen by a physician from the [**Name9 (PRE) **]
[**Hospital 982**] clinic, who adjusted your Diabetes regimen, and would
like to follow up with you in clinic.
Please return to the ER or see your primary doctor emergently if
you have chest pain, shortness of breath, sugars that are over
200 or under 60.
Followup Instructions:
You have an appointment in the [**Last Name (un) **] diabetes clinic on
[**8-16**] at 11am.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2129-8-4**]
|
[
"V58.67",
"401.9",
"288.60",
"518.89",
"355.8",
"443.9",
"276.0",
"593.9",
"250.13",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6031, 6037
|
4379, 5227
|
350, 356
|
6102, 6110
|
3297, 4356
|
6676, 6924
|
2828, 2899
|
5451, 6008
|
6058, 6081
|
5253, 5428
|
6134, 6653
|
2914, 3278
|
274, 312
|
384, 2362
|
2384, 2579
|
2595, 2812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,579
| 132,272
|
34679
|
Discharge summary
|
report
|
Admission Date: [**2142-9-7**] Discharge Date: [**2142-9-14**]
Date of Birth: [**2078-1-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline /
Meropenem / Metoprolol
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Nausea; abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64y/o gentleman with DM, HTN, CAD and recent [**Hospital Unit Name 153**] admission for
necrotizing pancreatitis and pseudocyst is now admitted to the
[**Hospital Unit Name 153**] for IR-guided drainage of enlarging pseudocyst.
He was admitted from [**Date range (1) 79527**] for necrotizing pancreatitis that
began in [**2142-4-28**] and was complicated by shock, bacteremia, VAP,
hypoxic respiratory failure requiring intubation and eventually
tracheostomy. He had been discharged to rehab, and 2 days later
his trach was removed and he was breathing fine on RA during the
day, 1L NC st night. He [**Year (4 digits) 5058**] on the morning of presentation
with nausea and abdominal pain, so he presented to the ED. It
is epigastric, moving horizontally but not to the back, and is a
deep pain. His pain is very similar to prior pancreatitis pain,
but the nausea is new. No vomiting, no fever/chills.
In the ED, initial vs were: T 97.1, HR 100, BP 122/62, RR 14,
SaO2100%RA
By the time of presentation his abdominal pain had subsided, and
his exam was benign. He had a mild leukocytosis (11.1) and
amylase was 112. His Cr was 1.6 (baseline 1.3) so he was
hydrated with 1200cc IVF and Mucomyst (slowly, as patient has
history of CHF), then sent for abdomen CT with contrast. This
showed enlarging pancreatic pseudocyst, pelvic fluid collection
smaller than on previous imaging, new small fluid collection
anterior to pancreas as well as new small pseudocyst in
pancreatic head. Upon returning from CT, he complained of [**5-7**]
abdominal pain and he was given a total of 8mg IV morphine, and
Zofran.
He is tachycardic, but his blood pressures have been stable and
he has no fever. Surgery is aware of the patient; they feel
that there is no need for surgical intervention at this time.
He is being admitted to the [**Hospital Unit Name 153**] with plans for IR drainage of
the pseudocyst.
On the floor, the patient is without complaints. He has no
abdominal pain. Not nauseous currently, but has no appetite.
Does have an itchy rash that he has had since his last
hospitalization that has been treated at rehab with antifungal
powder and Benadryl.
Review of systems:
(+) Per HPI (nausea, abdominal pain, rash)
(-) Denies fever, chills. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies vomiting, diarrhea, constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
1. Necrotizing pancreatitis ([**2142-3-29**])
- complicated by Enterococcus bacteremia, septic shock, hypoxic
respiratory failure requiring intubation/trach (which was
removed at rehab)
2. CABG [**2139**]
3. DM II with neuropathy
4. CHF (EF 35-40% [**8-5**] TTE)
5. Hypertension
6. Hyperlipidemia
7. MSSA epidural abscess s/p laminectomy - [**2133**]
Social History:
Divorced, retired high school english teacher. Former cigar
smoker, [**12-30**] cigars/day, quit 8 years ago. Rare ETOH use, no
illicits.
Family History:
Dad passed away from complications of CAD (MI in 60s) and CHF.
Mother had an MI in her 50s. Sister with obesity, DM.
Physical Exam:
Vitals: T:96.9 BP:119/76 P:102 R: 17 O2:98%2L NC
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, normal S1 and S2, regular, no murmurs
Abdomen: obese but nondistended; bowel sounds present; soft;
non-tender; tenderness to very deep palpation of epigastrium; no
rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: rash on back near costal angles bilaterally - raised
erythematous plaques with scale and satellite lesions
Pertinent Results:
[**2142-9-7**] 01:40PM WBC-11.1* RBC-4.02*# HGB-11.7*# HCT-34.9*#
MCV-87 MCH-29.0 MCHC-33.4 RDW-17.7*
[**2142-9-7**] 01:40PM NEUTS-82.9* LYMPHS-11.5* MONOS-3.7 EOS-1.4
BASOS-0.5
[**2142-9-7**] 01:40PM PLT COUNT-372
[**2142-9-7**] 01:40PM PT-13.5* PTT-22.8 INR(PT)-1.2*
[**2142-9-7**] 01:40PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-74
AMYLASE-112* TOT BILI-0.4
[**2142-9-7**] 01:40PM LIPASE-40
[**2142-9-7**] 01:40PM GLUCOSE-119* UREA N-39* CREAT-1.6* SODIUM-137
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-31 ANION GAP-16
[**2142-9-7**] 01:45PM LACTATE-1.1
[**2142-9-6**] UA - rare bacteria
[**2142-9-6**] Urine Cx - pending
[**2142-9-7**] CT Abdomen/Pelvis with Contrast:
IMPRESSION:
1. The large pancreatic body pseudocyst has continued to enlarge
further
across multiple prior studies. There is now possibly development
of a
satellite pseudocyst and/or adjacent small peripancreatic fluid
collections as detailed above.
2. There is a relatively eccentric but traumatic wall thickening
of the
adjoining gastric body, pylorus, and proximal duodenum. This may
be reactiv
in nature if pancreatic enzymes continue to leach or also may
represent a
coincident gastritis. Correlate clinically. This may account for
an acute
pain as described. Not mentioned above, there may be a minimal
amount of
fluid tracking within the gastrohepatic ligament.
3. The relatively wide [**Name (NI) 79528**] pelvic collection previously
described has
decreased in size from the prior exam. The previously noted
pigtail
percutaneous drain is no longer present.
4. Persistent right pleural effusion with bibasilar atelectasis.
Brief Hospital Course:
1. Pancreatic pseudocyst. CT imaging showed enlarging
pancreatic pseudocyst. GI and surgery (Dr. [**Last Name (STitle) **] discussed
options for drainage and initially determined that the best
course was endoscopic drainage. However, during the
hospitalization his pain improved and he remained stable, with
no laboratory evidence of worsened pancreatitis. After
discussion with patient, it was agreed to postpone the drainage,
given risks involved, and reassess in about 1-2 weeks.
Outpatient follow-up with CT, followed by appointment in
Gastroenterology, was arranged.
2. Acute renal failure. Baseline is 1.3. It was felt that
acute renal failure was likely prerenal on admission. He
improved to baseline with hyudration.
3. Pleural effusion. Previously attributed to
trans-diaphragmatic ascites. Not felt to represent
CHF/cardiogenic volume overload.
4. Depression-- contniued on SSRI
On [**9-14**] he was deemed appropriate for transfer to a rehab
facility and this was arranged.
Medications on Admission:
-Aspirin 325 mg PO/NG DAILY
-Diltiazem 120 mg PO/NG QID
-Humalog Sliding Scale & Fixed Dose Lantus
-Acetaminophen 325-650 mg PO/NG Q4H:PRN pain
-Miconazole Powder 2% 1 Appl TP QID:PRN to folds
-Citalopram Hydrobromide 10 mg PO/NG DAILY
-Multivitamins W/minerals 1 TAB PO DAILY
-Docusate Sodium 100 mg PO BID
-Pancrelipase 5000 2 CAP PO TID W/MEALS
-Famotidine 20 mg PO/NG Q24H
-Heparin 5000 UNIT SC TID
Discharge Medications:
1. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO four times
a day.
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Multivitamin,Tx-Minerals 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. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to folds.
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. insulin per previous regimen
Discharge Disposition:
Extended Care
Facility:
Port Health Care Center
Discharge Diagnosis:
Pancreatic pseudocyst
Discharge Condition:
Fevers, worsened abdominal pain, nausea/vomiting
Discharge Instructions:
You were admitted with abdominal pain and found to have an
enlarging pseudocyst. Initial plan was to drain this by a
percutaneous (needle) procedure, but over the course of
hospitalization your pain has improved and you have remained
clinically stable, so the decision was made to postpone the
procedure and reassess in approximately 10-14 days
Followup Instructions:
Department: [**Month/Year (2) **] DISEASE
When: MONDAY [**2142-9-10**] at 11:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: FRIDAY [**2142-9-21**] at 10:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2142-9-21**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD [**Telephone/Fax (1) 1231**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2142-9-24**] at 3:25 PM
With: [**Doctor First Name **] [**Name6 (MD) 79525**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Will also receive a call from office of Dr. [**First Name (STitle) **]
[**Name (STitle) **]/Gastroenterology for follow-up
|
[
"428.0",
"V45.81",
"577.2",
"414.00",
"401.9",
"V58.66",
"428.22",
"250.00",
"584.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8184, 8234
|
5893, 6893
|
370, 377
|
8300, 8351
|
4253, 5870
|
8746, 10133
|
3455, 3574
|
7346, 8161
|
8255, 8279
|
6919, 7323
|
8376, 8723
|
3589, 4234
|
2588, 2908
|
308, 332
|
405, 2569
|
2930, 3283
|
3299, 3439
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,012
| 116,710
|
42698
|
Discharge summary
|
report
|
Admission Date: [**2156-7-28**] Discharge Date: [**2156-7-30**]
Service: MEDICINE
Allergies:
Oxycodone / Percocet / Percodan / simvastatin / aspirin
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F w/ CHF s/p CORE VALVE for AS, saw Dr [**Last Name (STitle) **] (cards) in
[**Location (un) **] building today when was noted be hypertensive (SBP in
230s). Was also reporting weakness so was sent to ED for
evaluation. On arrival, pt c/o feeling generalized weakness x
"weeks", "tired", reports feeling unsteady gait. No CP, no SOB.
SBP in 210s-220s in both arms on manuak recheck. pt not
reporting any CP, anuria, visual changes. Pt unable to recall
whether she took her medications for BP. Says list is long and
is mostly managed by husband.
.
Admit weight 45kg
Vitals in ED: 98.0, HR 47, BP 235/74, 20 99% RA
Nicardipine 1mc/kg/min
.
EKG: compared to prior, prominent peaked t waves in V [**12-2**], with
?ST elevations in V1-3 and depression in I and AVL. HR in the
40s, sinus.
Based on EKG, absolute HR, and headache/weakness, pt was treated
for HTN emergency and started on nicardapine drip.
.
CXR wet read: hyperinflation, no ptx, no pulm edema, no acute
process.
.
- Pertinent recent medical hx includes core valve on [**2156-2-19**]
[multiple ER visits for GI discomfort, was noted to have murmer,
echo revealed severe AS. She admits to frequent episodes of
dizziness, sometimes at rest. She is only able to tolerate [**1-2**]
steps without stopping due to shortness of breath. She reports
extreme worsening fatigue, and inability to do any ADLs without
frequently stopping due to shortness of breath and fatigue. She
is unable to bend forward to
reach something low due to dizziness and lightheadedness. ]
.
Pt has been in paroxysmal afib since after procedure, EP
evaluated the
patient and recommended rate control with beta blocker, without
amiodarone. Additionally, it was decided by Dr. [**Last Name (STitle) **] not to
anti-coagulate the patient taking into consideration her age and
that she is already on Plavix and Aspirin.
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
[**Date range (1) 92298**] - SOB, found to have pAFib HR 90-130s -> continued
full dose ASA, inc metoprolol 50mg [**Hospital1 **] HR 50s on discharge, EGD
showed moderate erosive antral gastritis, cont Protonix
.
[**Date range (1) 92299**]/12 - 110lbs. admitted with palpitations, some confusion
about her medications at home, he mainly complains of weakness
and dizziness, no active chest pain -> Nuclear stress test
showed (1) No arrhythmias. (2) No chest pain. (3) Normal
conduction. (4) ST-segment normal. - 28. 5 mg of persantine
infused. Non diagnostic/baseline EKG changes.
.
[**Date range (1) 92300**] - Complaint of fatigue, dizziness, lightheadedness,
and
urinary frequency. Attributed to hypoNa and UTI, responded well
to IVF and Rocephin(CTX), evaluated by Cards without concern.
.
[**Date range (1) 92301**] - Nausea, anorexia, and 10pound weight loss, tx 2U
RBC,
.
On arrival to the floor, patient 180s-190s/80s-90s, HR 50-60,
98% on RA
.
REVIEW OF SYSTEMS
No chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
- Severe Aortic stenosis s/p Transcatheter aortic valve
replacement with a CoreValve [**2156-2-19**]
- myasthenia [**Last Name (un) 2902**]
- left carotid bruit
- hypertension
- hyperlipidemia
- COPD
- Seasonal allergies
- hypothyroid
- irritable bowel syndrome (current loose stools, abd pain)
- GERD
- chronic anemia (r/o IgA kappa MGUS)
- polypectomy
- herniated cervical disk
- L4-L5 back pain (epidural injections - pain clinic)
- overactive bladder
- double scoliosis (pain clinic)
- partial vulvectomy
- exlap, oopherectomy, lysis of adhesions
Social History:
- independent ADLs - gardens, cooks
- Split level home, lives with husband (age [**Age over 90 **]) and disabled son
(age 56). No assistance currently. Son with many medical issues,
patient and husband manage his care.
-Tobacco history: never
-ETOH: none
-Illicit drugs: none
Family History:
Father deceased (age 85), CAD.
Mother deceased (age 85), colon Ca.
Two brothers living with CAD, sister deceased, cause unknown
Physical Exam:
VS: 98.9, 182/88, 62, 17, 97% RA
GENERAL: NAD, poor historian. Oriented x3. Mood, affect
appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to angle of mandible, bounding of pulses
carotid appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2156-7-28**] 01:32PM PT-10.8 PTT-32.7 INR(PT)-1.0
[**2156-7-28**] 01:32PM PLT COUNT-237
[**2156-7-28**] 01:32PM NEUTS-69.2 LYMPHS-22.0 MONOS-5.0 EOS-2.0
BASOS-1.7
[**2156-7-28**] 01:32PM WBC-7.1 RBC-4.04*# HGB-12.7# HCT-38.1# MCV-94
MCH-31.4 MCHC-33.3 RDW-13.9
[**2156-7-28**] 01:32PM cTropnT-<0.01
[**2156-7-28**] 01:32PM estGFR-Using this
[**2156-7-28**] 01:32PM GLUCOSE-95 UREA N-22* CREAT-1.3* SODIUM-137
POTASSIUM-7.5* CHLORIDE-103 TOTAL CO2-27 ANION GAP-15
[**2156-7-28**] 02:34PM K+-5.0
[**2156-7-28**] 02:34PM COMMENTS-GREEN TOP
[**2156-7-28**] 02:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2156-7-28**] 02:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2156-7-28**] 02:55PM URINE UHOLD-HOLD
[**2156-7-28**] 02:55PM URINE HOURS-RANDOM
Brief Hospital Course:
[**Age over 90 **] yo female with CoreValve [**2156-2-19**], since then several
admissions to [**Hospital1 **] for weakness, one for pAfib, now presents
for HTN emergency, SBP 200s with headahces.
.
# HTN EMERGENCY - Patient was placed on a nicardipine dip in the
ED and then admitted to the CCU. There was no evidence of
aortic dissection, papillary muscle rupture, head bleed, renal
failure, ACS, or pulmonary edema. The patient's blood pressure
was maintained in range of SBPs 160s-170s, as that is what she
usually runs, even on multiple antihypertensives. She came in
on lisinopril and metoprolol, and, in house, she was
transitioned from the nicardipine drip to lisinopril,
amlodipine, and carvedilol. Her CCU course was unremarkable,
and she was transferred to the regular cardiology floor for
optimization of anti-hypertensives prior to discharge.
.
# CORONARIES: Last cath [**11/2155**] showed LAD w/ 30% stenosis in the
mid vessel and an eccentric 70% stenosis in a diagonal branch.
The LCx had a 60% stenosis proximal vessel. Her cardiac enzymes
did not increase during her hospital stay, and she did not
report chest pain. She was discharged on carvedilol,
lisinopril, aspirin, atorvastatin, and Plavix.
.
# PUMP: Last Echo [**6-/2156**] showed an EF > 55%. During her
hospital stay, she had no signs or symptoms or cardiac failure.
.
# CKD (baseline Cr 1.1-1.4): Patient came it with a creatinine
within her baseline range (1.2), and stayed within her baseline
range during the admission.
.
Transitional Issues:
Patient will follow up with cardiologist Dr. [**Last Name (STitle) **] and PCP [**Last Name (NamePattern4) **].
[**First Name (STitle) 6164**].
CODE: Full
EMERGENCY CONTACT: [**Name (NI) 4906**] [**Name (NI) 26079**] [**Telephone/Fax (1) 92302**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Metoprolol Tartrate 50 mg PO BID
hold for sbp < 100, hr < 55
2. Atorvastatin 80 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
hold for sbp < 100, hr < 55
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
5. Aspirin 81 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Magnesium Oxide 280 mg PO ONCE Duration: 1 Doses
8. Pantoprazole 40 mg PO Q24H
9. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for sbp < 130, hr < 55
RX *amlodipine 10 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
2. bimatoprost *NF* 0.03 % OU QHS Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
3. Carvedilol 6.25 mg PO BID
hold for sbp < 130, hr < 55
start [**7-29**] at PM
RX *carvedilol 6.25 mg one tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
4. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
5. Atorvastatin 80 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
hold for sbp < 100, hr < 55
8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
9. Aspirin EC 81 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Hypertensive Urgency
S/P CoreValve
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Mrs. [**Known lastname 92297**], you were seen at [**Hospital1 18**] and treated for elevated
blood pressure. We changed around your blood pressure
medications which we think will better control your blood
pressure. Please check your blood pressure twice daily and
record the readings to share with all of your doctors. Call Dr
[**First Name (STitle) 6164**] or Dr. [**Last Name (STitle) **] if your top number of your blood pressure is
higher than 180 as your medicine may need to be adjusted.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2156-8-4**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**] O.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: Tuesday [**2156-8-10**] 3:45pm
|
[
"244.9",
"428.0",
"358.00",
"272.4",
"V43.3",
"403.90",
"428.32",
"564.1",
"496",
"530.81",
"427.31",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9296, 9367
|
6169, 7680
|
274, 281
|
9446, 9536
|
5279, 6146
|
10118, 10784
|
4225, 4354
|
8465, 9273
|
9388, 9425
|
7976, 8442
|
9597, 10095
|
4369, 5260
|
7701, 7950
|
222, 236
|
309, 3341
|
9551, 9573
|
3363, 3915
|
3931, 4209
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,329
| 122,721
|
39359
|
Discharge summary
|
report
|
Admission Date: [**2160-11-26**] Discharge Date: [**2160-11-30**]
Service: SURGERY
Allergies:
Amoxicillin
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
none
Past Medical History:
PMH: glaucoma, glaucoma, h/o PUD, CAD with occasional angina,
diverticulosis, h/o colon cancer s/p resection 20 years ago,
dyslipidemia
PSH: partial colon resection 20 years ago (rt colectomy by CT),
Exlap for SBO 2 years ago
Social History:
Lives with daughter, retired from multiple
occupations.
No tobacco, rare etoh, no IVDU
Family History:
no cancer history. H/O CAD and DM.
Physical Exam:
Physical Exam: 97.8 89 122/77 18 96% RA
GEN: A&O,NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, mildly tender, no rebound or
guarding, no palpable masses
Ext: No LE edema, LE warm and well perfused, no skin tenting and
plump veins in arms
Pertinent Results:
[**2160-11-27**] 07:23AM BLOOD WBC-8.0 RBC-3.64* Hgb-11.4* Hct-33.8*
MCV-93 MCH-31.5 MCHC-33.9 RDW-13.6 Plt Ct-146*
[**2160-11-27**] 04:07AM BLOOD WBC-6.3# RBC-3.75* Hgb-11.8* Hct-34.9*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.6 Plt Ct-162
[**2160-11-26**] 01:05PM BLOOD WBC-3.9* RBC-4.14* Hgb-12.8 Hct-38.1
MCV-92 MCH-31.0 MCHC-33.7 RDW-13.4 Plt Ct-165
[**2160-11-26**] 01:05PM BLOOD Neuts-64.3 Bands-0 Lymphs-29.5 Monos-4.1
Eos-0.7 Baso-1.5
[**2160-11-26**] 01:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2160-11-27**] 07:23AM BLOOD Plt Ct-146*
[**2160-11-27**] 07:23AM BLOOD PT-14.7* PTT-26.5 INR(PT)-1.3*
[**2160-11-27**] 04:07AM BLOOD Plt Ct-162
[**2160-11-28**] 05:45AM BLOOD Glucose-85 UreaN-10 Creat-1.1 Na-139
K-3.3 Cl-111* HCO3-21* AnGap-10
[**2160-11-27**] 07:23AM BLOOD Glucose-93 UreaN-14 Creat-1.0 Na-141
K-3.4 Cl-110* HCO3-19* AnGap-15
[**2160-11-27**] 04:07AM BLOOD Glucose-95 UreaN-14 Creat-1.1 Na-136
K-6.6* Cl-110* HCO3-20* AnGap-13
[**2160-11-26**] 01:05PM BLOOD Glucose-119* UreaN-22* Creat-1.2* Na-134
K-4.2 Cl-97 HCO3-25 AnGap-16
[**2160-11-26**] 01:05PM BLOOD ALT-23 AST-44* AlkPhos-87 TotBili-0.9
[**2160-11-28**] 05:45AM BLOOD Calcium-8.0* Phos-1.4* Mg-1.7
[**2160-11-27**] 07:23AM BLOOD Calcium-7.3* Phos-2.8 Mg-1.6
[**2160-11-27**] 04:07AM BLOOD Calcium-7.1* Phos-3.2 Mg-1.6
[**2160-11-26**] 01:05PM BLOOD Albumin-3.9 Calcium-9.1
Brief Hospital Course:
The patient was admitted for RLQ abdominal pain, nausea,
vomiting, and diarrhea
x4 days.CT scan of her abdomen showed Dilated loops of small
bowel with no clear transition point most likely representing
ileus The patient was given vigrous hydration,and made NPO and
was admitted to the ICU. She came out of the ICU on HD 2. She
continued to have high stool output but her nausea and abdominal
pain resolved.She was transitioned to a regular diet which she
tolerated well. Over the following days she continued to make
good progress.On the day of her discharge, the patient was
tolerating a regular diet, voiding without any difficulty and
her pain was well controlled.
Medications on Admission:
1. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic QID (4
times a day).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Medications:
1. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic QID (4
times a day).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please go the ER or call our clinic at ([**Telephone/Fax (1) 2537**] abdominal
pain,abdominal swelling,vomiting,diarrhea,constipation,blood in
stool,black stool,light headedness, or weakness.
You may resume all your home meds.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] in [**Hospital 2536**] clinic in [**1-19**]
weeks.Please call PH:([**Telephone/Fax (1) 2537**] to schedule an appointment.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2160-12-2**]
|
[
"413.9",
"733.00",
"V12.71",
"276.51",
"V10.05",
"272.4",
"008.8",
"365.9",
"V45.89",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4684, 4690
|
2485, 3157
|
264, 271
|
4750, 4750
|
1052, 2462
|
5152, 5499
|
643, 681
|
3837, 4661
|
4711, 4729
|
3183, 3814
|
4901, 5129
|
712, 1033
|
189, 226
|
4765, 4877
|
293, 523
|
539, 627
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
413
| 156,909
|
15564
|
Discharge summary
|
report
|
Admission Date: [**2105-8-12**] Discharge Date: [**2105-8-25**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
male who presented in [**Location 17065**] Emergency Department for
shortness of breath. He also reported abdominal pain and
fevers and chills for one day. His medical history is not
completely clear; however, the patient reported a history of
failure, arrhythmia, and multiple admissions for pneumonia.
He was diagnosed with gastric outlet obstruction status post
dilation in [**2104-3-25**].
His current symptoms started the day prior to admission with
the onset of sharp, right upper quadrant pain. It was not
associated with nausea, vomiting, or eating. He continued to
bladder habits and had normal bowel movements one day prior
to admission. He denied bright red blood per rectum or
melena. He does have a history of alcohol abuse and is a
former cigarette smoker.
At [**Hospital3 **], the patient had a normal chest x-ray
and KUB and was found to have an amylase of 1200 and lipase
of 6900, and total bilirubin of 4.2. His white blood count
was significant for 25% bands and a fever to 103??????.
Presumptive diagnosis was ascending cholangitis,
and he was given one dose of Rocephin and Flagyl and sent to
[**Hospital6 256**] for further work-up,
including ERCP.
Of note at [**Hospital 17065**] Hospital, he had a drop in his blood
pressure to 75/30 after the administration of Morphine.
Blood pressure responded with intravenous fluids and Narcan.
PAST MEDICAL HISTORY: Pacemaker placed over 15 years ago,
morbid obesity, congestive heart failure, chronic obstructive
pulmonary disease, hypertension, history of H. pylori,
gastric outlet obstruction secondary to pyloric stenosis,
status post dilation in [**2104-3-25**], gastric ulcer per EGD in
[**2102**] and [**2104**], pseudogout, chronic atrial fibrillation,
status post bilateral cataracts, benign prostatic
hypertrophy, osteoarthritis.
FAMILY HISTORY: Noncontributory.
OUTPATIENT MEDICATIONS: Bumex 1 mg p.o. q.d., Vioxx 25 mg
q.d., Zantac 150 b.i.d., Combivent 2 puffs q.i.d., Pulmicort,
Dilantin 200 b.i.d., Potassium Chloride, home oxygen 2 L.
SOCIAL HISTORY: Tobacco: He smokes three packs per day for
20-30 years, none in the last 15 years. Alcohol: Heavy use
in the past, none in the last 15 years. He works as a
retired truck driver.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.1??????, blood
pressure 100/64, pulse 55, respiratory rate 24. General:
The patient was tachypneic, nontoxic-appearing, mild
jaundiced. HEENT: Oropharynx clear. Mucous membranes very
dry. JVP not elevated. Neck: Supple. Mildly icteric
sclerae. Chest: Bilateral expiratory wheezes. Coarse
breath sounds bilaterally but no appreciable rales or
rhonchi. Cardiovascular: Distant heart sounds. Normal S1
and S2. There was a 2 out of 6 systolic murmur. No rubs or
gallops. Abdomen: Obese, distended, soft, exquisitely
tender to palpation of right upper quadrant. Normoactive
bowel sounds. Extremities: There was [**12-28**]+ bilateral lower
extremity edema. He had erythematous, scaly, and crusting
lesions on bilateral shins consistent with chronic
venostasis. Neurological: The patient was alert and
oriented times three. No gross motor or sensory deficits.
Rectal: No stool. Normal rectal tone. Guaiac negative.
LABORATORY DATA: Electrocardiogram was AV paced with rate of
55 beats per minute, T-waves present but not conductive,
consistent with third degree AV block.
On admission white count was 12, hematocrit 42.9, platelet
count 183; sodium 143, potassium 5.1, chloride 102, bicarb
25, BUN 57, creatinine 2.3, glucose 77; bilirubin 4.6,
alkaline phosphatase 195, AST 97, ALT 111.
HOSPITAL COURSE: The patient was admitted to the General
Medical Service for emergent ERCP. He went to the ERCP and
was found to have suppurative cholangitis and an impacted
stone in the distal common bile duct which was bolting into
the major pupilla. He had successful biliary sphincterotomy
and successful stone extraction.
After the procedure, he was transferred to the Intensive Care
Unit for respiratory failure, and he was intubated. In the
Intensive Care Unit, he developed acute renal insufficiency
with creatinine peaking to 4.1. He also developed
pseudomonal pneumonia, and pseudomonas grew from his biliary
sample. He had persistently elevated LFTs throughout his
hospitalization and was intermittently pressor dependent for
blood pressure support. He was treated with broad-spectrum
antibiotics. He had an ileus for one week postprocedure. He
was ultimately started on tube feeds which he tolerated at
goal. He had low-grade DIC which resolved spontaneously.
Ultimately the patient showed no evidence of progressing from
a respiratory status. A family meeting was held on [**2105-8-24**], to discuss the patient's future course. At this
time his daughter and son who were present made it clear that
he made his wishes known to not be dependent on a ventilator
for a prolonged period. The decision was made to withdraw
ventilatory support and concentrate care on his comfort. The
patient passed away on [**8-25**] at 3:35 a.m. from
respiratory failure.
CONDITION ON DISCHARGE: Death.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **], M.D.
Dictated By:[**Doctor Last Name 45035**]
MEDQUIST36
D: [**2105-8-25**] 14:30
T: [**2105-8-25**] 14:43
JOB#: [**Job Number 45036**]
|
[
"576.1",
"518.5",
"997.4",
"482.1",
"428.0",
"574.50",
"496",
"577.0",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"96.04",
"51.85",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
1975, 1993
|
3757, 5221
|
2018, 2173
|
2396, 3739
|
112, 1510
|
1533, 1958
|
2190, 2373
|
5246, 5515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,846
| 178,965
|
13183
|
Discharge summary
|
report
|
Admission Date: [**2125-7-9**] Discharge Date: [**2125-7-18**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
[**2125-7-11**] percutaneous endoscopic gastrostomy tube
[**2125-7-17**] [**Month/Day/Year **], sphincterotomy, gallstone extraction, stent
removal
History of Present Illness:
This 85M was recently admitted for cholangitis, and is now s/p
percutaneous cholecystostomy tube, s/p [**Month/Day/Year **]/stent, s/p trach.
His hospital course was complicated by MRSA PNA and E.coli
bacteremia, diarrhea (presumed to be C.diff, for which he was
discharged on Flagyl), and acute gout flair. He was discharged
to rehab on [**2125-6-22**]. He self d/c'd his Dobhoff and was
transferred back to [**Hospital1 18**] for PEG placement as well as
persistent fevers to 102.
Past Medical History:
1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-5**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe lumbar spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p failed DCCV, now rate controlled
7. Arthritis
8. Gout
9. COPD
10. NIDDM
11. E-coli sepsis (admission [**2122-12-23**] - [**2123-1-1**])
12. BPH
13. Parkinson's disease
14. Cholangitis s/p percutaneous cholecystostomy tube &
[**Month/Day/Year **]/stent ([**2125-5-16**])
15. s/p tracheostomy ([**2125-5-28**])
16. diverticulosis, h/o diverticulitis & ulcers
17. s/p I&D R elbow
18. s/p excision of facial skin ca
Social History:
Transferred from [**Hospital 100**] Rehab. Formerly lived with daughter
[**Name (NI) 13118**]. Widowed. No tobacco/EtOH. Formerly worked at Sears.
Family History:
Notable for CAD, HTN, and stroke.
Physical Exam:
On admission:
98.9 93 Afib 91/53 14 99% CMV
Gen: ventilated, NAD
HEENT: trach in position
[**Name (NI) **]: intubated, clear bilaterally
CVS: irregularly irregular, -MRG
Abd: soft/NT/ND, no masses, no rebound/guarding apparent
Ext: mild edema diffusely
.
On discharge:
96.5 79 114/76 22 98%RA
Gen: NAD
CVS: RRR
[**Name (NI) **]: CTA b/l
Abd: soft, NT, ND, +BS
Ext: no c/c/e
Pertinent Results:
On admission:
[**2125-7-9**] 06:00PM BLOOD WBC-14.1*# RBC-2.68* Hgb-7.9* Hct-25.0*
MCV-93 MCH-29.5 MCHC-31.6 RDW-17.9* Plt Ct-472*
[**2125-7-9**] 06:00PM BLOOD PT-16.1* PTT-52.4* INR(PT)-1.4*
[**2125-7-9**] 06:00PM BLOOD Glucose-348* UreaN-73* Creat-1.4* Na-143
K-3.3 Cl-107 HCO3-26 AnGap-13
[**2125-7-9**] 06:00PM BLOOD ALT-7 AST-6 AlkPhos-58 TotBili-0.3
[**2125-7-9**] 06:00PM BLOOD Lipase-12
[**2125-7-9**] 06:00PM BLOOD Albumin-2.3* Calcium-8.2* Phos-4.1 Mg-1.6
[**2125-7-9**] 8:33 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST:
FINDINGS: There are small bibasilar effusions and associated
atelectasis. No focal consolidation. Coronary artery
calcifications are seen within an enlarged heart. There is no
pericardial effusion.
ABDOMEN: Again seen is pneumobilia, with an indwelling biliary
stent in place, unchanged in position. A left hepatic lobe cyst
measuring 3.1 x 3.9 cm is unchanged. There is a small gallstone
within a decompressed gallbladder. There is no biliary
dilatation. The spleen, pancreas, and adrenal glands are normal
in appearance. The kidneys are somewhat atrophic; however, there
is symmetric excretion of contrast. Multiple cysts, right side
more so than left, some of which are slightly increased in
density and likely reflect hemorrhagic/proteinaceous cysts.
PELVIS: The bowel is decompressed, without dilated loop. There
are air- fluid levels within the colon; however, there is no
bowel wall thickening or surrounding stranding. Numerous
diverticula are seen within the sigmoid colon, without
inflammatory changes. A Foley catheter is present within a
decompressed bladder. Atherosclerotic calcifications are again
seen throughout. Extensive degenerative changes of the
thoracolumbar spine without acute findings.
IMPRESSION:
1. No abscess within the abdomen or pelvis, as clinically
questioned. No bowel wall thickening or abnormality, aside from
colonic fluid and diverticulosis.
2. Small bibasilar pleural effusions and adjacent atelectasis.
[**2125-7-10**] 02:00AM BLOOD Phenyto-0.6*
[**2125-7-10**] 02:00AM BLOOD Vanco-13.7
[**2125-7-10**] 02:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030
[**2125-7-10**] 02:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2125-7-10**] 02:00AM URINE RBC-0-2 WBC-[**7-10**]* Bacteri-RARE Yeast-MOD
Epi-0-2 TransE-0-2
[**2125-7-10**] 2:00 AM URINE CULTURE (Final [**2125-7-11**]):
YEAST. >100,000 ORGANISMS/ML..
[**2125-7-14**] 11:41 AM URINE CULTURE (Final [**2125-7-15**]):
YEAST. >100,000 ORGANISMS/ML..
[**2125-7-17**] [**Month/Day/Year **]:
-A plastic stent previusly placed in the biliary duct was found
in the major papilla and was removed using a snare.
-Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique.
-Cholangiogram showed a CBD diamter of 11 mm with 2 mobile
filling defects consistent with stones.
-A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
-2 stones were extracted successfully using a 11 mm balloon. The
duct was cleared with an occlusion cholangiogram.
On discharge:
[**2125-7-16**] 06:40AM BLOOD PT-14.0* PTT-46.5* INR(PT)-1.2*
[**2125-7-16**] 06:40AM BLOOD Glucose-137* UreaN-44* Creat-0.7 Na-138
K-5.1 Cl-106 HCO3-26 AnGap-11
[**2125-7-16**] 06:40AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.4
[**2125-7-18**] 04:29AM BLOOD WBC-17.0* RBC-3.17* Hgb-9.4* Hct-30.4*
MCV-96 MCH-29.5 MCHC-30.8* RDW-19.6* Plt Ct-390
[**2125-7-18**] 04:29AM BLOOD ALT-5 AST-13 AlkPhos-82 Amylase-120*
TotBili-0.6
[**2125-7-18**] 04:29AM BLOOD Lipase-29
Brief Hospital Course:
Patient was admitted to TSICU. WBC was 14. He was started on
vancomycin for his h/o MRSA PNA. CT abdomen/pelvis failed to
demonstrate abscess or bowel wall thickening/abnormalities. His
biliary system was unchanged in appearance. Blood cultures were
drawn and were negative. Urine culture grew yeast. He was
hydrated and his WBC decreased to WNL. Vancomycin was d/c'd on
HD 3. PEG was placed at bedside on HD 3. Tube feeds were
started on HD 4. On HD 5, he was decannulated. Rheumatology
was consulted for gout management and recommended Solumedrol
followed by a prednisone taper, colchicine, allopurinol, and
outpatient followup. His WBC increased; he was started on
fluconazole for the yeast in his urine on HD 6. It was stable x
3 days at ~17 on discharge. On HD 7, he was transferred to the
floor. On HD 8, Speech & Swallow cleared him for pureed solids
and nectar thickened liquids. On HD 9, he underwent [**Month/Day/Year **] for
stent removal with extraction of 2 gallstones and
sphincterotomy. The following morning, he was restarted on
clears and tube feeds and advanced as tolerated. His LFTs were
WNL. He was afebrile with stable vital signs, tolerating tube
feeds and diet, and his pain was well controlled on PO
medication. He is being discharged to [**Hospital1 **] and will follow
up with Dr. [**First Name (STitle) **] (Rheumatology) and Dr. [**Last Name (STitle) **].
Medications on Admission:
Discharge Medications ([**2125-6-22**]):
1. Metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3
times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0*
2. Colchicine 0.6 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Coumadin 3 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day: goal
INR [**3-4**]
Dose daily. Disp:*30 Tablet(s)* Refills:*2*
4. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO
TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)*
Refills:*0*
6. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*2*
7. Bacitracin Zinc 500 unit/g Ointment [**Month/Day (3) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2*
8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0*
9. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2* 10. Trazodone 50 mg Tablet [**Hospital1 **]:
1.5 Tablets PO HS (at bedtime)
as needed. Disp:*60 Tablet(s)* Refills:*0*
11. Indomethacin 25 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
12. Fentanyl 75 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)*
Refills:*2*
13. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day): Use only if patient is
on mechanical ventilation.
Disp:*400 ML(s)* Refills:*0*
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30
Tablet,Rapid Dissolve, DR(s)* Refills:*2*
15. Latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*20 ml* Refills:*2*
16. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day). Disp:*1 unit* Refills:*2*
17. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours). Disp:*500 ml* Refills:*2*
18. Levothyroxine Sodium 50 mcg IV DAILY
19. Albuterol 90 mcg/Actuation Aerosol [**Age over 90 **]: 1-2 Puffs Inhalation
Q6H (every 6 hours). Disp:*1 unit* Refills:*2*
20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Age over 90 **]:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours)
as needed for pain for 7 days.
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
21. Lorazepam 0.5 mg Tablet [**Age over 90 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
22. Bupropion 75 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
23. Erythromycin 5 mg/g Ointment [**Age over 90 **]: 0.5 in Ophthalmic QID (4
times a day).
Disp:*60 in* Refills:*2*
24. Metoprolol Tartrate 5 mg IV Q6H:PRN AFIB / RVR
25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
26. Furosemide 40 mg Tablet [**Age over 90 **]: Three (3) Tablet PO BID (2
times a day). Disp:*180 Tablet(s)* Refills:*2*
27. Enoxaparin 100 mg/mL Syringe [**Age over 90 **]: One Hundred (100) mg
Subcutaneous Q 12H (Every 12 Hours): until therapeutic on
coumadin (INR [**3-4**]) then may d/c lovenox.
Disp:*25 syringes* Refills:*2*
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr [**Month/Day (3) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Enoxaparin 100 mg/mL Syringe [**Month/Day (3) **]: One (1) ml Subcutaneous
Q12H (every 12 hours).
3. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (3) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (3) **]:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
5. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO
TID (3 times a day).
6. Colchicine 0.6 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
7. Bupropion 75 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a
day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
10. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
12. Colchicine 0.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
13. Allopurinol 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Prednisone 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily)
for 3 days: [**Date range (1) 24818**].
15. Prednisone 10 mg Tablet [**Date range (1) **]: Three (3) Tablet PO DAILY
(Daily) for 3 days: [**Date range (1) 40196**].
16. Prednisone 20 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: [**Date range (1) 20648**].
17. Prednisone 10 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: [**Date range (1) 40197**].
18. Prednisone 5 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: [**Date range (1) 17392**].
19. Prednisone Taper
prednisone 40' x 3, 30' x 3, 20' x 3, 10' x 3, 5' x 3;
colchicine 0.6 QOD until f/u at Rheum, allopurinol 300' titrated
as outpt, f/u with Dr. [**First Name (STitle) **] in 4 wks
20. Ipratropium Bromide 0.02 % Solution [**First Name (STitle) **]: One (1) neg
Inhalation Q6H (every 6 hours).
21. 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.
22. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN breakthorugh pain
23. Insulin NPH Human Recomb 100 unit/mL Suspension [**First Name (STitle) **]: Twenty
(20) units Subcutaneous twice a day.
24. insulin sliding scale
check fingersticks q4h
glucose regular insulin dose
0-70 mg/dL [**1-31**] amp D50
71-120 mg/dL 0 Units
121-140 mg/dL 3 Units
141-160 mg/dL 6 Units
161-180 mg/dL 9 Units
181-200 mg/dL 12 Units
201-220 mg/dL 15 Units
221-240 mg/dL 18 Units
241-260 mg/dL 21 Units
261-280 mg/dL 24 Units
281-300 mg/dL 27 Units
301-320 mg/dL 30 Units
> 320 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
primary:
failure to thrive
.
secondary:
CAD s/p cath, CHF, HTN, severe lumbar spinal stenosis, mild
cervical spinal stenosis, sleep apnea, atrial fibrillation,
arthritis, gout, COPD, NIDDM, E.coli sepsis, MRSA PNA, E.coli
bacteremia, BPH, Parkinson's disease, cholangitis s/p [**Hospital1 **]/stent
& percutaneous cholecystostomy tube, s/p tracheostomy,
diverticulosis, h/o diverticulitis, s/p I&D R elbow, s/p
excision of facial skin ca
Discharge Condition:
Afebrile, vital signs stable, tolerating tube feeds & pureed
solids/nectar thickened liquids, pain well controlled on PO
medication.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
Followup Instructions:
Please call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 2047**] to schedule
a follow up appointment in [**3-4**] weeks.
.
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2125-8-15**] 2:45
Completed by:[**2125-7-18**]
|
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"427.31",
"401.9",
"414.01",
"250.00",
"482.41",
"327.23",
"724.02",
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"V09.0",
"V44.0",
"428.22",
"707.03",
"496",
"274.0",
"041.4",
"112.5",
"790.7",
"276.51",
"428.0",
"574.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"96.71",
"51.85",
"43.11",
"96.6",
"97.55"
] |
icd9pcs
|
[
[
[]
]
] |
14326, 14405
|
5992, 7399
|
278, 428
|
14886, 15021
|
2333, 2333
|
15837, 16180
|
1885, 1920
|
11218, 14303
|
14426, 14865
|
7425, 11195
|
15045, 15814
|
1935, 1935
|
5510, 5969
|
221, 240
|
456, 942
|
2347, 5496
|
964, 1701
|
1717, 1869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,684
| 130,465
|
35771+58030
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-5-4**] Discharge Date: [**2170-5-12**]
Date of Birth: [**2100-6-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
altered mental status, afib with RVR, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69-year-old woman with afib, DM2, lung cancer, PVD s/p RLE
bypass grafting and wound dehiscence discharged on [**2170-5-3**] from
vascular service to rehab presented with afib with RVR,
tachypnea, hypotension. Reportedly patient was oriented x 3 with
normal sinus rhythm upon discharge on [**2170-5-3**]. After a few hours
at rehab, she experienced RVR with HR 170s, RR 40s; was
reportedly hypotensive but alert and responsive. Was transferred
to OSH ED where her SVT was treated successfully with adenosine.
She was then transferred to [**Hospital1 18**].
.
On arrival to [**Hospital1 18**], her SBP was initially in the 80s with HR in
the 100s. SBP then dropped to the 70s as she went into RVR with
HR 170s. She received adenosine 6 mg x 1, then 12 mg x 3 with
subsequent return to sinus rhythm and normal rate. x. Her mental
status worsened and, with O2 sat dropping to the 80s, she was
intubated for airway protection. Torso CT again showed large
pleural effusions with large R lung base mass invading liver.
Head CT was unremarkable. She received empiric vancomycin and
pip-tazo. Vascular surgery was consulted and deemed the leg
wound ok. Cardiology performed bedside echo that showed no RV
strain. Clots were seen during unsuccessful attempts to place
RIJ; she got a femoral CVL instead. For hypotension she received
3L of fluid and was started on dopamine, which was then switched
to norepinephrine. By the time of transfer to the MICU, her HR
90, BP 110/palp.
.
Of note, patient had angioplasty and stenting of right CFA to PT
bypass graft on [**2170-3-6**]. Postoperative course was complicated by
dehiscence of right medial PT incision for which she was
admitted on [**2170-3-28**], was treated with vancomycin, ciprofloxacin,
metronidazoleflagyl and underwent operative debridement with
closure on [**2170-3-29**]. Wound cultures grew MRSA, and she was
discharged to home to a nursing home with TMP/SMX. On [**2170-4-3**]
she returned from the
nursing home with open right medial incision [**4-3**]. On [**4-25**] she
was re-admitted for dehiscence of the RLE wound. On [**4-30**] she
underwent closure of her R ankle wound. CT showed a large right
lung base mass invading the liver, concerning for recurrence of
lung cancer. At that time, the plan was to work up this lung
mass as outpatient. She was found to have leukocytosis up to
21,000 thought to be reactive leukocytosis as no clear source of
infection was found. On [**5-1**] she had altered mental status and
low urine output. For a brief period, the patient was
disoriented to time. She regained this mental mental capacity
about 30 minutes later. An MRI of her brain was performed, which
was negative for acute pathology, including metastatic disease
or stroke. With increased PO intake, her urine output then
reportedly improved to 100 cc over 6 hours. On [**5-2**], the patient
had a brief episode of afib with HR in the 160s that broke with
metoprolol. She also complained of mild chest pain. Cardiology
was consulted for management and the patient was ruled out for
an acute coronary syndrome. She was given metoprolol. Her rhythm
returned to sinus until discharge on [**2170-5-3**].
.
Review of systems: not obtained as patient was intubated
Past Medical History:
-s/p angio/angioplasty and stenting of Right CIA stenting
followed by right CFA to PT [**Name (NI) **] on [**2170-3-6**]
-carotid disease
-Dm2, noninsulin dependant
-lung cancer s/p RLLL
-thyroid disease s/p thyroidectomy
-orthostatic hypotension started of medirodine and flornef
-history of narcotic dependancy and nicotine dependancy but no
-smoking or ETOh x 1 yrs previous 40pkyrs.
-posopterative blood loss anemia s/p transfusion [**2-19**]
-S/p RL lobectomy 07
-Thyroidectomy
-hysterectomy.
Social History:
History of ETOH and narcotic addiction. At present pt does not
drink nor use narcotics. Former smoker [**12-15**] PPD x 40 years pt
quit last year after lung ca diagnosis.
Family History:
Mother: Stomach Ca
Father: CAD, hypercholesterolemia
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: elderly woman, intubated
HEENT: pupils reactive bilaterally
Neck: JVP not elevated
Lungs: Coarse breath sounds bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pulses, right LE with well-healed
thigh incision, dry R ankle wound
Pertinent Results:
[**2170-5-4**] 11:10PM CK(CPK)-32
[**2170-5-4**] 11:10PM CK-MB-NotDone cTropnT-0.11*
[**2170-5-4**] 05:42PM TYPE-ART PO2-139* PCO2-37 PH-7.43 TOTAL
CO2-25 BASE XS-1
[**2170-5-4**] 05:42PM LACTATE-0.9
[**2170-5-4**] 05:42PM O2 SAT-100
[**2170-5-4**] 04:04PM PTT-106.1*
[**2170-5-4**] 04:03PM ALT(SGPT)-41* AST(SGOT)-63* LD(LDH)-264*
CK(CPK)-52 ALK PHOS-582* TOT BILI-0.3
[**2170-5-4**] 04:03PM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.6
[**2170-5-4**] 04:03PM WBC-15.5* RBC-3.15* HGB-8.8* HCT-28.2* MCV-90
MCH-28.1 MCHC-31.3 RDW-20.7*
[**2170-5-4**] 04:03PM PLT COUNT-375
[**2170-5-4**] 09:38AM PTT-96.6*
[**2170-5-4**] 04:30AM TYPE-ART RATES-14/ TIDAL VOL-440 PEEP-5
O2-100 PO2-370* PCO2-40 PH-7.37 TOTAL CO2-24 BASE XS--1
AADO2-303 REQ O2-57 INTUBATED-INTUBATED
[**2170-5-4**] 04:30AM LACTATE-1.2
[**2170-5-4**] 04:30AM O2 SAT-99
[**2170-5-4**] 04:15AM GLUCOSE-166* UREA N-28* CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-113* TOTAL CO2-19* ANION GAP-14
[**2170-5-4**] 04:15AM ALT(SGPT)-54* AST(SGOT)-134* LD(LDH)-321*
CK(CPK)-103 ALK PHOS-732* TOT BILI-0.3
[**2170-5-4**] 04:15AM CK-MB-9 cTropnT-0.18*
[**2170-5-4**] 04:15AM WBC-17.6* RBC-3.32* HGB-9.3* HCT-29.9* MCV-90
MCH-28.1 MCHC-31.1 RDW-19.1*
[**2170-5-4**] 04:15AM NEUTS-87.7* LYMPHS-9.1* MONOS-3.0 EOS-0.1
BASOS-0.1
[**2170-5-4**] 04:15AM PLT COUNT-426
[**2170-5-3**] 10:15PM CK(CPK)-104
[**2170-5-3**] 10:15PM cTropnT-0.05*
[**2170-5-3**] 10:15PM WBC-16.9* RBC-3.41* HGB-9.3* HCT-31.4* MCV-92
MCH-27.4 MCHC-29.8* RDW-20.1*
[**2170-5-3**] 10:15PM NEUTS-90.9* LYMPHS-5.9* MONOS-2.9 EOS-0.1
BASOS-0.2
[**2170-5-3**] 10:15PM PT-16.6* PTT-34.7 INR(PT)-1.5*
[**2170-5-3**] 06:15AM GLUCOSE-98 UREA N-27* CREAT-1.1 SODIUM-143
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-14
[**2170-5-3**] 06:15AM CALCIUM-9.8 PHOSPHATE-3.0 MAGNESIUM-1.9
[**2170-5-3**] 06:15AM CALCIUM-9.8 PHOSPHATE-3.0 MAGNESIUM-1.9
Brief Hospital Course:
69-year-old woman with afib, DM2, lung cancer, PVD s/p RLE
bypass grafting and wound dehiscence discharged on [**2170-5-3**] from
vascular service to rehab presented with afib with RVR,
tachypnea, hypotension; now intubated.
Patient was intubated for airway protection in the setting of
hypoxia and mental status changes. She was found to have a
large lung mass and pleural effusions that were thought to be
contributing to her respiratory compromise. This was thought to
be secondary to a recurrence of her lung cancer. She was
emiprically started on vancomycin and zosyn. She also went into
afib with RVR thought to be secondary to her known vascular
disease and lung disease, and a chest CTA demonstrated a chronic
right subsegmental PE. She was extubated on [**5-5**] but
reintubated shortly afterward because of hypercapnia and mental
status changes, all which occured in the setting of paradoxical
post-extubation hypotension with SBPs in the 60s. These rose
after re-intubation. A family meeting was ultimately held
because it was thought that she was unlikely to be extubated
successfully due to her significant comorbidities. In the
interim, she also developed a likely VAP as she had increased
secretions from the ETT and was febrile. She was ultimately
made CMO and extubated and expired on [**2170-5-12**] with her family
members at her bedside.
Medications on Admission:
folic acid
omeprazole
heparin sc
midodrine 10 mg tid
fludrocortisone 0.1 mg qday
acetaminophen prn
albuterol prn
atorvastatin 80 mg qday
levothyroxine 112 mcg qday
citalopram 30 mg qday
oxycodone-acetaminophen 5-325 mg prn
regular insulin s.s.
metformin 500 mg [**Hospital1 **]
glipizide 10 mg [**Hospital1 **]
TMP/SMX DS [**Hospital1 **] x 7 days
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Metastatic lung cancer
Peripheral vascular disease
Coronary artery disease
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2170-6-1**] Name: [**Known lastname 13036**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 13037**]
Admission Date: [**2170-4-25**] Discharge Date: [**2170-5-3**]
Date of Birth: [**2100-6-21**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
The patient was all set to be discharged to rehab on [**5-1**].
However, there was concern over mental status changes and low
urine output. For a brief period, the patient was disoriented to
time. She regained this mental mental capacity about 30 minutes
later. An MRI of her brain was performed, which was negative for
acute pathology, including metastatic disease or stroke.
Her urine output had been about 100 cc over 6 hours. Increased
PO intake was encouraged and her urine output improved. However,
she has been incontinent to urine on this admission. Thus, her
urine output has not been quantified.
On [**5-2**], the patient had a brief episode of afib with HR in the
160s. She also complained of mild chest pain. Cardiology was
consulted for management and the patient was ruled out for an
acute coronary syndrome and was placed on telemetry. She was
give a low dose of Lopressor, with intention to continue at
12.5mg [**Hospital1 **] providing her SBP > 100 and HR > 60. However, she
received no futher doses because she did not meet these
parameters. She returned to NSR and remained in NSR throughout
the rest of her hospital course.
She is being discharged today to rehab in NSR and stable
condition, alert and oriented x 3.
Pertinent Results:
[**2170-5-2**] 04:20PM BLOOD WBC-19.2* RBC-3.96* Hgb-10.9* Hct-36.0
MCV-91 MCH-27.5 MCHC-30.3* RDW-19.2* Plt Ct-502*
[**2170-5-3**] 06:15AM BLOOD WBC-17.9* RBC-4.08* Hgb-11.6* Hct-36.7
MCV-90 MCH-28.6 MCHC-31.7 RDW-19.2* Plt Ct-483*
[**2170-5-2**] 10:30AM BLOOD Glucose-172* UreaN-27* Creat-1.1 Na-144
K-4.6 Cl-107 HCO3-26 AnGap-16
[**2170-5-2**] 10:30AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2170-5-2**] 10:30AM BLOOD CK(CPK)-23*
MRI Brain [**5-2**]:
FINDINGS: There is no acute infarct seen on diffusion images.
Moderate brain atrophy noted with dilatation of the ventricles
and prominence of sulci. There are periventricular
hyperintensities identified predominantly in the frontal lobes.
There are chronic lacunes visualized in bilateral basal ganglia
region. There is no midline shift or hydrocephalus. Increased
signal in the pons and the midbrain appears to be due to changes
of small vessel disease. Soft tissue changes are seen in the
sphenoid and right maxillary sinuses.
Following gadolinium no abnormal parenchymal, vascular, or
meningeal
enhancement identified.
IMPRESSION: Somewhat motion-limited post-gadolinium images. No
definite
enhancing brain lesions are seen. No acute infarcts. Small
vessel disease
and brain atrophy.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1353**] center
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2170-5-3**]
|
[
"427.31",
"518.81",
"V45.89",
"458.9",
"250.00",
"440.20",
"162.5",
"447.1",
"276.0",
"511.9",
"444.89",
"311",
"440.4",
"V15.82",
"V12.04",
"V66.7",
"244.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11784, 11993
|
6825, 8194
|
371, 377
|
8768, 8777
|
10517, 11761
|
8833, 10498
|
4356, 4410
|
8593, 8598
|
8651, 8747
|
8220, 8570
|
8801, 8810
|
4425, 4870
|
3587, 3627
|
282, 333
|
405, 3568
|
3649, 4148
|
4164, 4340
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,520
| 160,753
|
27652
|
Discharge summary
|
report
|
Admission Date: [**2148-7-23**] Discharge Date: [**2148-8-2**]
Date of Birth: [**2086-9-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Gluten
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
high grade dysplasia of the Barrett's Esophagus
Major Surgical or Invasive Procedure:
[**2148-7-23**]-high grade dysplasia of the Barrett's Esophagus s/p
Transhiatal esophagogastrectomy and feeding jejunostomy,
endoscopy
History of Present Illness:
61-year-old woman, with celiac disease and Barrett's esophagus,
who is on a surveillance program. Her Barrett's has progressed
to high-grade dysplasia
confirmed on pathologic review. We discussed a variety of
interventions for this as well as the risk that this could
represent the presence of invasive cancer somewhere in the
[**Doctor Last Name 15532**] segment. She elected to proceed with resection, and I
recommended a transhiatal approach to which she consented.
Past Medical History:
Hypothyroidism, celiac disease, s/p resection of thigh melanoma
[**2114**], osteoporosis, high grade dysplasia of the Barrett's
Esophagus
Social History:
non- smoker-lifetime, etoh [**1-5**]/week
lives in [**Location **] w/ husband
[**Name (NI) 67540**] analyst w/ Citizens Bank
Family History:
mother- died [**Name2 (NI) 24817**] cancer.
Physical Exam:
General- healthy appearing older middle age female
HEENT- anicteric, no adenopathy of neck or supraclavicular
Cor-RRR, no m/r/g
Resp-CTAB
Abd-soft, non-tender, + BS, no organomegaly
Ext- 2+ RLE edema, chronic- wears compression stocking
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2148-7-29**] 09:40AM 9.1 2.95* 9.0* 27.2* 92 30.6 33.2 13.4
399
[**2148-7-29**] 07:35AM 27.5*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2148-7-29**] 09:40AM 399
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2148-7-31**] 07:05AM 103 7 0.5 137 4.7 103 26 13
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2148-7-31**] 07:05AM 8.8 3.9 2.4
[**2148-7-23**] 01:21PM GLUCOSE-145* UREA N-12 CREAT-0.5 SODIUM-137
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-18* ANION GAP-15
[**2148-7-23**] 01:21PM CALCIUM-7.2* PHOSPHATE-4.2 MAGNESIUM-1.6
[**2148-7-23**] 01:21PM WBC-8.9# RBC-3.70* HGB-11.5* HCT-33.4* MCV-90
MCH-31.1 MCHC-34.5 RDW-13.0
[**2148-7-23**] 01:21PM PLT COUNT-328
[**2148-7-23**] 01:21PM PT-13.0 PTT-23.2 INR(PT)-1.1
RADIOLOGY Final Report
CHEST (PA & LAT) [**2148-8-1**] 8:55 AM
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman s/p esophagectomy now w/ reflux symptoms &
prominent gastric bubble.
REASON FOR THIS EXAMINATION:
eval gastric distension
COMPARISON: [**2148-7-31**].
Patient is status post esophagectomy with a neoesophagus. The
left hemidiaphragm is elevated and remains persistently elevated
with distended gastric bubble. The left lower lobe is collapsed.
Small bilateral pleural effusions, more on the right compared to
the left. Essentially, no change compared to the prior
radiograph.
ABDOMEN (SUPINE & ERECT) [**2148-7-31**] 11:07 AM
Reason: please eval for interval change
INDICATION: 61-year-old female status post transhiatal
esophagectomy with increased abdominal distention.
COMPARISON: CT torso dated [**2148-7-18**].
ABDOMEN, SUPINE AND ERECT: Surgical skin staples are seen
overlying the midline of the abdomen. The patient is status post
esophagectomy and the neo- esophagus remains mildly dilated.
There is marked elevation of the left hemidiaphragm with
associated left lower lobe compressive atelectasis. The stomach
remains moderately distended. Air is seen throughout the colon
to the level of the rectum. There are no air-fluid levels or
free intraperitoneal air under the hemidiaphragms on the upright
view. There is a moderate right pleural effusion.
IMPRESSION: No evidence of obstruction or free intraperitoneal
air. Persistent gaseous distention of the stomach and elevation
of the left hemidiaphragm. Moderate right pleural effusion.
Brief Hospital Course:
Patient admitted SDA [**2148-7-23**] for above procedure. Pt tolerated
transhiatal esophogogastrectomy and j- tube placement well. Pt
transferred to ICU directly from OR extubated, instable
condition, epidural for pain control, left CT to sxn, cervical
JP, NGT, foley in place. O2 99% on 2L. IS/ CDB.
POD#1-Epidural cont, IV lopressor, NC, NPO, NGT to LIS, J-tube
to gravity, CT > sxn.IVF.
POD#2- start TF at 10cc/hr; strict NPO, NGT> LISxn; OOB/IS/CDB.
Nutrition consult for tube feeding, IVF. APS following. Transfer
to floor. BS clear, dim bases, CT to w/s.
POD#3-antibiotics d/c; TF ^ 20/hr- probalance; hct 26.3>23.8-
will monitor for anemia. CT d/c w/o complication by CXRY- some
gastric distention. Pain control w/ epid cont.NGT <100cc and
d/c'd.
POD#4 [**2148-7-27**]-Epidural d/c, roxicet via j-tube q4h w/ good
effect; NPO/ J-tube TF 20cc/hr/+ BS, no flatus. NSR. [**Hospital 5065**]
Healthcare initiating tubefeeding teaching.
POD#5-+ BS, + tympany on abd exam- TF held @20/hr> KUB- ^
gastric bubble. NSR, OOB/ambulation
POD#6- reflux during night, resolved, + flatus. No other events
POD#[**2071-6-8**] passed grape juice test; CXR: air-filled distention
of pull-up/neoesophagus, persistent air-filled distention of
stomach. Stable. ambulating independently. Roxicet cont w/ good
control. NSR
POD# [**2073-8-8**]-- TF advanced to 40cc/hr, then goal 55 mL/hr w/o
complication/distention;
POD#10- [**8-2**]-abd staples d/c and steri-strips placed. [**Hospital1 5065**] plans
to start TF cycle [**8-3**] evening. Pt stable for discharge to home
w/ husband. Discharge instructions given and reviewed w/ pt by
team, NP and RN.
Follow-up plans made for barium swallow next Thursday AM 10:00,
w/ F/U surgical appt @ 11:30am.
VNA with [**Hospital3 **] VNA [**Telephone/Fax (1) 43399**]; TF [**Hospital 67541**] [**Hospital 5065**]
Healthcare-[**Telephone/Fax (1) 39931**]
Medications on Admission:
Aciphex, Levoxyl, Calcium, Vitamin D, MVI
Discharge Medications:
1. tube feeding
probalance
goal rate 55cc/hr= 6 cans/day
2. tubefeeding supplies
equipment-
kangaroo pump
tube feeding supplies
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Lopressor 50 mg Tablet Sig: [**12-6**] Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*1*
6. Equipment
[**Hospital 67542**]
Hospital bed
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
8. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 50 mg/15 mL Syrup Sig: 15-30 cc PO BID (2
times a day).
Disp:*250 cc* Refills:*2*
10. Aciphex 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:*2*
11. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day.
Disp:*120 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
SouthShore VNA
Discharge Diagnosis:
Hypothyroidism, celiac disease, s/p resection of thigh melanoma
[**2114**], osteoporosis, high grade dysplasia of the Barrett's
Esophagus
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] for:
fever, shortness of breath, chest pain, excessive or foul
smelling drainage from incision sites, redness, tenderness or
swelling from incision sites, excessive nausea, any vomitting,
increased abdominal distention or bloating.
Please do not take anything by mouth after midnight the night
before Barium swallow [**2148-8-8**].
Take medications as listed on discharge instructions.
You may take aciphex, lopressor-12.5 mg=one quarter of 50 mg
pill, levoxyl, reglan ( 4 times/day) by mouth.
Take liquid colace, roxicet through J- tube.
Change j- tube dressing and neck dressing every day w/ new
guaze. Monitor sites for reddness, and drainage as above.
Followup Instructions:
You have appointment for a barium swallow in Radiology [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) **] at 10 am as listed below. Nothing to
eat after midnight [**8-7**]/-[**8-8**] prior to BArium swallow- you may
take tube feeding.
Provider: [**Name10 (NameIs) 326**] UPPER GI (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2148-8-8**] 10:00
Appointment w/ Dr.[**Initials (NamePattern4) 4738**] [**2148-8-8**]
Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2148-8-8**] 11:30 [**Telephone/Fax (1) 170**]
Completed by:[**2148-8-2**]
|
[
"733.00",
"750.4",
"493.90",
"457.1",
"553.3",
"244.9",
"530.81",
"579.0",
"458.29",
"530.85",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"34.09",
"46.39",
"42.41"
] |
icd9pcs
|
[
[
[]
]
] |
7108, 7153
|
4087, 5968
|
320, 457
|
7336, 7342
|
1592, 2559
|
8137, 8778
|
1275, 1320
|
6060, 7085
|
2596, 2683
|
7174, 7315
|
5994, 6037
|
7366, 8114
|
1335, 1573
|
233, 282
|
2712, 4064
|
485, 956
|
978, 1117
|
1133, 1259
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,976
| 149,469
|
34811
|
Discharge summary
|
report
|
Admission Date: [**2202-9-16**] Discharge Date: [**2202-9-23**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13891**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 8182**] is a Spanish-comprehending 65M with complicated
PMH including CVA (nonverbal and does not move arms or legs at
baseline), AF on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG [**3-/2200**]), multiple prior episodes of Urosepsis
with drug-resistant organisms (VRE), C diff s/p colectomy, DM2,
PVD, and multiple admissions (most recently [**7-/2202**]) for sepsis
(unclear source, suspected UTI and/or HCAP) who presented today
from the nursing home with a fever.
Recently hospitalized for sepsis [**2202-7-29**], discharged on [**2202-8-2**].
Suspected source was UTI (has indwelling cathter and h/o of many
UTIs/urosepsis) and/or pneumonia. Pt was discharged with a PICC
and instruction to complete a total 10 day course of linezolid
(for MRSA HCAP coverage as well as empiric treatment for VRE UTI
(h/o of VRE [**1-/2202**])) and meropenem (urine cx grew out Proteus
mirabilis and Klebsiella sensitive to meropenem) for HCAP and
UTI treatment.
In the ED, initial VS were: 104 119 115/72 40 92% 15L trach
At nursing home, fever to 101 degress, labs with leukocytosis 30
(n 92%) in nursing home. Source of infection - urine looks
infected, but has indwelling chronic foley. Hx of C.diff, ostomy
- was not clear if this is a stool infection. Recieved empiric
vanc/cefepime/flagyl. Never hypotensive, lowest pressure 108
systolic, but tachy to 120 when he came in, resp removed lots of
secretions. Recieved 3L of fluids, with HR responding to highs
90s, has two 18 gauge peripherals. Temperature of 104 when he
got here, now better after rectal tylenol. Sacral decub also.
On arrival to the MICU, he is nonverbal but appears to
comprehend spanish, tracks fingers. No movement.
On transfer to floor, pt was not requiring supplemental oxygen
and was hemodynamically stable.
Past Medical History:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- h/o DVT (? - no [**Hospital1 18**] records)
- Atrial fibrillation (on coumadin)
- Peripheral vascular disease
- Hyperlipidemia
- Tracheostomy and GJ tube for chronic aspiration
([**3-/2200**])-Portex Bivono, Size 6.0
- C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin
[**2200-5-20**](outside facility, [**12/2198**] here)
Social History:
Resident of [**Hospital 16662**] Nursing Home, previously at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98 BP: 96/65 P: 91 R: 28 O2: 97% humidified air 40%
General: Tracheostomy, Osteomy, PEG, Foley, Alert, Nonverbal but
appears to follow commands, NAD
HEENT: Sclera anicteric, dry mucous membranes, oropharynx
clear/mouth open, EOMI follows finger, PERRL (dilated pupils)
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally (but coarse breath
sounds throughout), no wheezes, rales.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, large midline scar
GU: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unable to assess (baseline nonverbal with little if any
mmovement)
Back: Sacral decubitus Stage III surrounding anus, Worse on R
buttocks, bone not visualized, no pus but white granulation
tissue, contracted hands/feet
DISCHARGE PHYSICAL EXAM:
99.2 113-120/68-79 18-20 97%FM
General: Tracheostomy, Osteomy, PEG, Foley, Alert, Nonverbal
but appears to follow commands, NAD
HEENT: Sclera anicteric, EOMI
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally (but coarse breath
sounds throughout), no wheezes, rales.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, large midline scar
GU: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unable to assess (baseline nonverbal with little if any
mmovement)
Pertinent Results:
ADMISSION LABS:
[**2202-9-16**] 07:35PM BLOOD WBC-25.3*# RBC-6.14# Hgb-12.8*# Hct-43.6#
MCV-71* MCH-20.9* MCHC-29.4* RDW-18.2* Plt Ct-273
[**2202-9-16**] 07:35PM BLOOD Neuts-89.9* Lymphs-5.1* Monos-4.6 Eos-0.3
Baso-0.2
[**2202-9-16**] 07:35PM BLOOD Plt Ct-273
[**2202-9-16**] 07:35PM BLOOD PT-35.5* PTT-31.9 INR(PT)-3.5*
[**2202-9-16**] 07:35PM BLOOD Glucose-491* UreaN-70* Creat-1.1 Na-154*
K-4.1 Cl-116* HCO3-22 AnGap-20
[**2202-9-17**] 12:34AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.3
[**2202-9-16**] 07:40PM BLOOD Type-[**Last Name (un) **] pO2-98 pCO2-29* pH-7.47*
calTCO2-22 Base XS-0 Comment-GREEN-TOP
[**2202-9-17**] 12:53AM BLOOD Lactate-2.1*
[**2202-9-16**] 07:40PM BLOOD Lactate-3.7*
[**2202-9-17**] 12:53AM BLOOD freeCa-1.25
[**2202-9-16**] 07:35PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2202-9-16**] 07:35PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2202-9-16**] 07:35PM URINE RBC-35* WBC->182* Bacteri-MANY Yeast-NONE
Epi-1
[**2202-9-16**] 07:35PM URINE CastHy-8*
DISCHARGE LABS:
IMAGING:
CXR- IMPRESSION: Persistent bibasilar opacities potentially due
to atelectasis noting that aspiration or infection are also
possible.
MICRO:
Blood Cx x2
Sputum Cx
Urine Cx
EKG: No significant changes from prior, LAD, RBB
Brief Hospital Course:
66 y/o male with a complicated pmh including CVA with
tracheostomy/indwelling catheter, peg tube who presented to MICU
with sepsis (urosepsis vs PNA) pt transferred to medicine
service after improvement in the ICU. Recent CXR showing new
consolidation differential includes: aspiration vs PNA
#Sepsis from a urinary source: Pt initially presented with
Tachycardia, fever, and elevated WBC in ED, responded to fluids
in ED. MICU VS were afebrile, with stable BP and no tachycardia.
No evidence of hypotension/hypoperfusion. Source of infection
was unclear at first He had a UA indicative of UTI (indwelling
cathter, h/o UTI though urine cultures neg), initial CXR showing
possible pna, c dif neg, and sacral decubitus wounds. Of note he
was recently admitted a month ago for sepsis (suspected
HCAP/UTI), discharged on Linezolid and Meropenem. In the MICU he
was treated for urosepsis with Cefepime 2gm IV q12h, gave IVF as
needed. Foley was not removed due to old records indicating
difficulty in placing catheters in the past. Pt was transferred
to the floors in stable condition.
# Aspiration pneumonia: While on the floors pt remained
afebrile, in no acute distress though he had episodes of
desatting to the 70s resolving spontaneously, CXR showed new
consolidation concerning for aspiration vs aspiration PNA and he
was started on levofloxacin per peg tube and IV vanc and
continued on cefepime. He remained afebrile, but did have new
leukocytosis with left shift. Pt had several episodes of
transient desaturation to 80s (lasting seconds) and generally
occured at night. Needed supplemental o2 for short periods of
time. Respiratory therapy rounded on pt and occassionally
provided OP suctioning. He will go home with PICC and
antibiotic treatment for 4 more days. CXR from [**9-22**] showed
airless lung in both lungs could ne PNA vs atalectasis. Pt
remained afebrile and leukocytosis resolved. Repeat chest xray
prior to discharge demonstrated poor respitory effort with
likely bibasilar atelectasis. His oxygen requirement resolved
prior to discharge.
#Pressure ulcers: Patient has stage 2 and 3 pressure ulcers and
needs frequent dressing changes. He has fentanyl patch for pain
and we added PO dilaudid as needed. Patient winces and becomes
diaphoretic when in pain. He needs frequent wound checks,
dressing changes and to be treated appropriately for his pain.
On discharge he was restarted on his home oral morphine dose and
continued on fentanyl.
#Access: IR PICC placement [**9-21**] for home IV antibiotics
# Atrial Fibrillation: Patient was on warfarin as an outpatient
2mg, it was held briefly bc supratherpeutic. INR was trended and
coumadin restarted [**9-20**] at 2mg INR subtherapeutic for 2 days
then dose of coumadin was increased to 3mg daily. INR on day of
discharge was 1.6 and we will continue to follow pt with
frequent INR checks.
#Type 2 Diabetes mellitus: Patient is on lantus and SSI at NH
- Continued SSI
# Spasticity: Continued baclofen 15 mg QID
# Hypothyroidism: Continued Levothyroxine 25 mcg daily
# Depression/Leg pain: Continued Duloxetine and Mirtazapine
# Peripheral neuropathy: Continued Gabapentin 300 mg TID
TRANSITIONAL ISSUES:
#Pressure ulcers: dressing wounds need to be changed frequently.
wound care recs:
Site: right ischeum
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Commercial cleanser
Dressing: Hydrofiber Silver Rope (Aquacel AG rope)
Change dressing: qd
Comment: cover aquacel w/ softsorb, medipore tape borders
Site: sacrum
Type: Traumatic Ulcer / Skin Tear
Cleansing [**Doctor Last Name 360**]: Commercial cleanser
Dressing: Foam (Mepilex)
Change dressing: Other
Comment: change q72h
#Aspiration PNA: needs 4 more days of IV antibiotics and PO
levaquin. Will need PICC line removed after antibiotic course.
#Afib: on higher dose of coumadin than before he came to
hostpial on 3 was on 2mg). Will need to follow daily INR until
stabilizes.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from NH List.
1. arginine (L-arginine) *NF* 500 mg Oral [**Hospital1 **]
Powder Packet
2. Baclofen 5 mg PO QID
3. Warfarin 2 mg PO DAILY16
4. Duloxetine 30 mg PO DAILY
5. Fentanyl Patch 50 mcg/h TP Q72H
6. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million
cell Oral [**Hospital1 **]
7. Glucerna Hunger Smart *NF*
(nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose
intolerance,soy) 1 Liquid Oral Daily
85cc/hour for 20 hours, start at 2pm
8. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using Novolin R Insulin
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Gabapentin 600 mg PO TID
12. Mirtazapine 15 mg PO HS
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezes
14. Fleet Enema 1 Enema PR DAILY:PRN constipation
15. Ipratropium Bromide Neb 1 NEB IH Q6H sob/wheezes
16. Milk of Magnesia *NF* (magnesium hydroxide) 400 mg/5 mL Oral
Daily prn constipation
17. Morphine Sulfate (Oral Soln.) 8 mg PO/NG Q4H:PRN pain
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezes
2. Baclofen 5 mg PO QID
3. Duloxetine 30 mg PO DAILY
4. Fentanyl Patch 50 mcg/h TP Q72H
5. Fleet Enema 1 Enema PR DAILY:PRN constipation
6. Gabapentin 600 mg PO TID
7. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using Novolin R Insulin
8. Ipratropium Bromide Neb 1 NEB IH Q6H sob/wheezes
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Mirtazapine 15 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. CefePIME 2 g IV Q8H Duration: 4 Days
last day of antibiotics is [**2202-9-27**]
13. Levofloxacin 750 mg PO DAILY Duration: 4 Days
last day of antibiotics is [**2202-9-27**]
14. Vancomycin 1000 mg IV Q 12H Duration: 4 Days
last day is [**2202-9-27**]
15. arginine (L-arginine) *NF* 500 mg Oral [**Hospital1 **]
Powder Packet
16. Glucerna Hunger Smart *NF*
(nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose
intolerance,soy) 1 Liquid Oral Daily
85cc/hour for 20 hours, start at 2pm
17. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million
cell Oral [**Hospital1 **]
18. Milk of Magnesia *NF* (magnesium hydroxide) 400 mg/5 mL ORAL
DAILY PRN constipation
19. Morphine Sulfate (Oral Soln.) 8 mg PO Q4H:PRN pain
20. Warfarin 3 mg PO DAILY16
21. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
pneumonia
Discharge Condition:
Activity Status: Bedbound. non verbal (baseline)
Discharge Instructions:
Mr [**Known lastname 8182**] it was a pleasure caring for you during your
hospital admission. You came in with a fever and were found to
have a pneumonia. We treated you with antibiotics and would like
for you to continue taking them for 4 more days.
Please START taking cefepime 2g IV q8H
please START taking vanco 1G q12H
please START taking levofloxacin 750mg
please START taking 2mg PO dilaudid as needed for pain q6H
we INCREASED your dose of coumadin to 3mg daily, you will need
frequent INR checks
Followup Instructions:
Department: RADIOLOGY CARE UNIT
When: TUESDAY [**2202-11-16**] at 10:00 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: TUESDAY [**2202-11-16**] at 11:30 AM
With: XSP WEST [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) 3130**] JUPITER MD [**MD Number(2) 13893**]
|
[
"707.03",
"438.53",
"V58.61",
"311",
"781.0",
"443.9",
"V44.4",
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"276.0",
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"250.00",
"272.4",
"038.9",
"244.9",
"356.9",
"V44.2",
"507.0",
"599.0",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12435, 12534
|
6132, 9302
|
311, 317
|
12588, 12639
|
4793, 4793
|
13194, 13785
|
3125, 3192
|
11169, 12412
|
12555, 12567
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10097, 11146
|
12663, 13171
|
5875, 6109
|
3232, 4126
|
9324, 10071
|
266, 273
|
345, 2167
|
4809, 5858
|
2189, 2776
|
2792, 3109
|
4151, 4774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,376
| 197,582
|
13372
|
Discharge summary
|
report
|
Admission Date: [**2148-7-5**] Discharge Date: [**2148-7-18**]
Date of Birth: [**2072-12-29**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Mental status changes and confusion.
Major Surgical or Invasive Procedure:
Microsurgical navigation guided resection of left frontal tumor.
History of Present Illness:
Mr. [**Known lastname **] is a 75-year-old right-handed man with CAD, CHF, h/o
stroke, paroxysmal atrial fibrillation, and metastatic NSCLC
cancer, s/p Cyberknife on [**2148-3-14**] to brain metastases who
presents with progressive confusion over the past month.
Patient is unable to provide any details of the events
precipitating this admission; thus, history was obtained from
his son [**Name (NI) 12041**] [**Name (NI) **]. He has had waxing and [**Doctor Last Name 688**] confusion for
the past two weeks. His son states that he "seems to have lost
his logic and common sense." He recognizes his family but has
exhibited much confusion with performance of his ADL's. Son
reports that he has only been putting on his left shoe and
walking around the house with only one shoe on. Similarly he has
had difficulty with putting on only one side of his pants. He
has not been performing self-hygiene and has not been taking
medications. Family has noticed changes in his balance, and
patient reports that he has fallen twice in the past week. His
son recently noticed scratches on his arms and legs, but a fall
was never witnessed. He frequently complains of fatigue and has
been sleeping more than usual. Patient has not reported any
dizziness. He has had one episode of urinary incontinence
approximately one month ago, but otherwise has been using the
bathroom unassisted. He has not had any observed seizure-like
activity or fecal incontinence.
In the ED, vital signs were 97.6 F, heart rate 105, blood
pressure 148/89, respiratory rate 18, and oxygen saturation was
96% on room air. He received Decadron 10 mg PO x 1. CT head
was performed and he was evaluated by Neurology consult. He was
admitted for further work-up to the Oncology Medicine service.
Past Medical History:
1) NSCLC w/brain metastases (see below)
1) CAD - s/p inferior STEMI [**11-15**], stent to left circumflex
2) CHF(EF 55% on [**4-16**])
3) HTN
4) Paroxysmal afib
5) CVA
6) Left LE DVT on coumadin
7) s/p prostatectomy
8) s/p IVC filter
ONCOLOGIC HISTORY: He was in his usual state of health until
[**2145**] when he was experiencing a persistent cough. In [**Month (only) **]
[**2146**], he suffered from a myocardial infarction with congestive
heart failure and inferior lead ST elevation. His chest X-ray
showed a right upper lobe mass. A biopsy showed adenosquamous
carcinoma. He was staged at IIIA. He later had carboplatin and
taxol, together with chest irradiation. After neoadjuvant
chemo-irradiation, he underwent a right upper lobectomy. He had
staging head MRI in [**2147-10-13**] that reveals a left medial
frontal brain metastasis. That has increased in size over time.
He then received Cyberknife radiosurgery in late [**2148-2-12**].
Last seen in [**5-18**] with some increase in edema on CT head, felt
to be related to weaning his dexamethasone.
Social History:
Originally from [**Country 651**], cantonese speaking. Retired. Worked a
variety of jobs, including in restaurants. Lives with wife and
one of his sons. [**Name (NI) **] three kids. He is a non-smoker,
occasional ETOH, AND no drugs.
Family History:
Father and mother had CAD.
Physical Exam:
Vital Signs: Temperature 97.9 F, HR 98, BP 154/87, RR 18, SpO2
99% on RA
GENERAL: elderly male, supine in bed, smiling
HEENT: clear OP, MMM, sclera anicteric
CARDIOVASCULAR: RRR, nl s1 S2, no m/r/g
RESPIRATORY: Decreased breath sounds RUL
ABDOMEN: soft nt/nd, +BS
EXTREMITIES: warm, well-perfused, no clubbing/cyanosis/edema
NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 40.
He is awake, alert, and oriented times 1 (himself). He was
unable to folow commands or answer questions. He has significant
psychomotor slowing. His recent recall is poor. Cranial Nerve
Examination: His pupils are equal and reactive to light, 3 mm
to 2 mm bilaterally. Extraocular movements are full. Visual
fields are full to confrontation. Funduscopic examination
reveals sharp disks margins bilaterally. His face is symmetric.
He has corneals bilaterally. His hearing is grossly intact.
His tongue is midline. Palate goes up in the midline.
Sternocleidomastoids and upper trapezius are strong. Motor
Examination: He does not have a drift. He can move all 4
extremities well. His muscle tone is normal. His reflexes are
2- at brachioradialis, 2+ at biceps, 0 at triceps, 2- at knees,
and 0 at ankles. His toes are down going. His gait is
wide-based and he has retropulsion.
Pertinent Results:
Laboratory results:
[**2148-7-5**] 09:10AM BLOOD WBC-10.2 RBC-4.59* Hgb-15.1 Hct-44.1
MCV-96 MCH-32.9* MCHC-34.2 RDW-14.5 Plt Ct-245
[**2148-7-18**] 08:17AM BLOOD WBC-13.3* RBC-4.26* Hgb-14.3 Hct-39.9*
MCV-94 MCH-33.4* MCHC-35.8* RDW-14.0 Plt Ct-239
[**2148-7-5**] 09:10AM BLOOD PT-11.9 PTT-26.4 INR(PT)-1.0
[**2148-7-5**] 09:10AM BLOOD Glucose-218* UreaN-21* Creat-1.1 Na-139
K-4.1 Cl-105 HCO3-25 AnGap-13
[**2148-7-5**] 09:10AM BLOOD ALT-26 AST-32 CK(CPK)-75 AlkPhos-108
Amylase-38 TotBili-0.9
[**2148-7-5**] 09:10AM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.2 Mg-2.4
Relevant Imaging:
1)CT Head ([**7-5**]): No acute intracranial hemorrhage. Vasogenic
edema from the known metastatic lesion in the left frontal lobe
is more prominent. For further evaluation, MRI with gadolineum
can be performed.
2)MRI Head ([**7-5**]): Increase in size of enhancing component of
the left frontal lobe metastatic lesion with increased
surrounding edema compared with the immediate prior MRI of
[**2148-5-20**]. No underlying infarct is identified. No evidence of
midline shift or hydrocephalus.
2)Cxray ([**7-5**]): Post-radiation and post-surgery changes in the
right perihilar region. No new abnormalities to account for
change in mental status. CT may be considered for more complete
characterization if clinical suspicion persists.
4)CT Chest w/contrast ([**7-9**]): Stable post-operative appearance,
right upper lobectomy. No evidence of intrathoracic malignancy.
5)CT Head ([**7-12**]): Small foci of blood and pneumocephalus in the
left frontal lobe status post left frontal craniotomy are
expected post- operative findings. No evidence of large
intracranial hemorrhage. Unchanged mass effect on frontal [**Doctor Last Name 534**]
of the left lateral ventricle.
Brief Hospital Course:
Mr. [**Known lastname **] is a 75-year-old right-handed man with CAD, CHF, h/o
stroke, paroxysmal atrial fibrillation, and metastatic NSCLC
cancer, s/p Cyberknife on [**2148-3-14**] to brain metastases who
presents with altered mental status.
(1) NSCLC with Brain Metastases: Patient presented with acute
mental status changes in the setting of increased vasogenic
edema surrounding left frontal metastasis. He was placed on
Decadron for edema and Keppra for anti-seizure prophylaxis.
Aspirin, Coumadin, and [**Date Range **] were held in anticipation for
surgery. He was transferred to the neurosurgery service for a
left frontal craniotomy for tumor resection. He underwent the
procedure without complications. Repeat CT scan head consistent
with post-operative changes. Patient was then transferred back
to oncology service. Mental status slowly returned to baseline.
He is scheduled to see Dr. [**Last Name (STitle) 724**] within 1 week after being
discharge. In addition, he is scheduled in the neurosurgery
clinic on [**7-22**] for removal of his sutures.
(2) CAD: s/p inferior STEMI in [**2146**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] to left
circumflex. He had been on Aspirin and [**Last Name (Prefixes) **] as outpatient but
per wife had not been taking the [**Name (NI) **] everyday. Both were
stopped few days prior to surgery. Per neurosurgery, Aspirin
325mg should be started on [**Last Name (LF) 2974**], [**7-19**]. Since patient is 2
years out from stent placement and given non-compliance at home,
will stop [**First Name3 (LF) **] altogether.
(3)Paroxysmal Atrial Fibrillation: Patient remained in sinus
rhythm throughout his hospital stay. Coumadin was held in
anticipation for surgery. Per patient, he was not taking it at
home and INR had been subtherapeutic on arrival. Per
neurosurgery, Coumadin will be restarted on [**Last Name (LF) 2974**], [**7-26**]
with bridging with Lovenox. INR should be monitored closely with
goal between [**3-16**]. He was continued on beta-blocker.
Medications on Admission:
Not documented.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
PLEASE START ON [**Last Name (LF) **], [**7-26**]. .
9. Lovenox 60 mg/0.6 mL Syringe Sig: Sixty (60) milligrams
Subcutaneous twice a day: PLEASE START ON [**Last Name (LF) **], [**7-26**].
PLEASE STOP ONCE INR IS THERAPEUTIC ([**3-16**]).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): PLEASE STOP ON [**Last Name (LF) **], [**7-26**] AFTER PATIENT IS STARTED ON LOVENOX AND COUMADIN. .
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
12. Prochlorperazine 10 mg IV Q6H:PRN
13. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Insulin
Please place patient on insulin sliding scale during duration
that patient is on Decadron.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnoses:
1)Metastatic non small cell lung cancer
2)Atrial fibrillation
3)Cardiovascular disease
Secondary diagnoses:
1)Hypertension
2)Congestive heart failure
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications as listed in the discharge
instructions.
2)Please stop taking your [**Location (un) **].
3)You should be restarted on Aspirin 325mg on [**Last Name (LF) 2974**], [**7-19**].
4)You should start taking Lovenox injections and Coumadin
starting [**Last Name (LF) 2974**], [**7-26**]. You will need to have your blood
counts monitored closely (INR) while on these medications. If
there are any questions or concerns, Dr. [**Last Name (STitle) 724**] at [**Hospital1 18**] should be
contact[**Name (NI) **] at [**Telephone/Fax (1) 1844**].
5)Please attend all appointments as listed below. You are
scheduled to have your sutures removed next week. You also have
an appointment with Dr. [**Last Name (STitle) 724**].
6)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness or any other concerning symptoms please return
to the emergency room.
Followup Instructions:
1)[**Hospital 4695**] clinic for suture removal on [**7-22**] at 11am in
[**Last Name (un) 2577**] Building on [**Last Name (NamePattern1) 439**] at [**Hospital1 827**]. Phone number: [**Telephone/Fax (1) 3231**].
2)Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2148-7-25**] 1:00
3)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2148-8-1**] 11:30
4)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3338**],[**Name12 (NameIs) **] VOICE AND SPEECH CLINIC
Date/Time:[**2148-8-6**] 3:00
5)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3338**],[**Name12 (NameIs) **] VOICE AND SPEECH CLINIC
Date/Time:[**2148-8-13**] 10:00
|
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"437.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
10451, 10523
|
6709, 8745
|
353, 419
|
10736, 10745
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4925, 5491
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,241
| 171,977
|
24295
|
Discharge summary
|
report
|
Admission Date: [**2178-3-25**] Discharge Date: [**2178-3-30**]
Date of Birth: [**2139-9-13**] Sex: M
Service: MEDICINE
Allergies:
Betadine Viscous Gauze / Lisinopril / Valsartan / Diovan /
banana / walnuts / avacado
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Fevers/Chills/Leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 38 year-old male with ESRD awaiting initiation
of HD, HTN, dCHF with a recent admission on [**3-20**] for fluid
overload presented yesterday with new onset of fever, chills and
pain on his L calf. Pt states that he was feeling well since his
discharge on [**3-20**] until yesterday morning he had a itch on his
left calf which he developed a small abrasion on his skin. He
then developed sharp pain on his L calf that only lasted a few
minutes and resolved. He also noted that his legs were getting
more swollen. He then started to feel tired and febrile in the
early afternoon hours with rigors. He presented to the
emergency room for further evalution.
In the ED, initial VS 99.8 89 [**Telephone/Fax (2) 61599**]0%. He then developed
temp to 102.8 with a repeated BP of 180/80. His exam was notable
for L calf skin abrasion tender to palpation, tender to
palpation over right LN in groin. His labs were notable for for
creatine of 5.5 (prior last week was 5.0), bicarb of 20, phos of
5.1. WBC of 13.7 (N:91.6 L:3.1 M:3.7 E:1.4 Bas:0.2). His Cxray
showed no pulmonary edema or consolidation. UA x 2 were
negative. The second UA was neg, but had few bacteria. He had
blood culture x 2. He was given dose of Vancomycin 1gm. He was
then admitted for further evalution.
On the floor, his initials vital signs were 101.4, 155/73, 101,
18, 99% on RA. Overnight he remained febrile with a Tmax to
102. This morning on evaluation, he is shovering stating he
still has severe chills. He notes pain in his left groin. He
is also sleepy, but arousable and interactive when asked
questions.
Of note he was admitted on [**3-20**] for a 40lb wt increase over 3.5
weeks. This was thought to be related to worsen renal function
and dCHF. He was given intermittent lasix 60 IV boluses-
diuresed 10 L and lost ~ 5 pounds prior to discharge. His dose
of Torsimide was increased to 40mg, with instructions to
increase dose if his urine output decreases. He notes that for
the last few days he had decrease in urine output and he took
120mg of Torsimide today. He had a R forearm fistula done in
[**Month (only) 958**] which is pnd maturation so he can be started on HD. He
also had a phlebitis on his left arm in [**Month (only) **] with subsequent MSSA
bacteremia with Nafcillin.
Past Medical History:
- chronic type B aortic dissection dignosed 3 years ago
- poorly controlled HTN
- ESRD pending initiations of dialysis
- Acute disseminated encephalomyelitis (brain biopsy)-8years ago
- group B streptococcal bactremia in [**2171**]
- Phlebitis with MSSA bacteremia in [**2177-12-31**]
- eczema
- childhood asthma
- allergic rhinitis
- rotator cuff injury
- G6PD deficiency
Social History:
currently employed as a bartender
living situation: in between apartments, living with friends at
this time
- tobacco: smokes [**12-1**] ppdx 12 years
- ETOH: [**1-2**] drinks/ week
Denies illicit drugs
Family History:
Mother w/ CAD in her forties as well as DM and HTN; mother
passed in [**2-/2177**] due to infectious complications of hip
arthrosis. Maternal grandfather with DM and maternal
grandmother w/ HTN. Aunt w/ breast cancer in her late 40's.
Physical Exam:
Admission Physical Exam:
Discharge Physical Exam:
Vitals: 97.9 166/99 75 18 97% RA
General: In mild distress from nausea and abdominal pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Hard mass noted on left calf, non-fluctuant, mildly tender
just below the skin. R forearm AV fistula- site now edematous
or erythematous, scar well healed. + thrill and bruit.
Pertinent Results:
ADMISSION LABS:
[**2178-3-25**] 08:00PM BLOOD WBC-13.7*# RBC-3.46* Hgb-10.3* Hct-33.1*
MCV-96 MCH-29.7 MCHC-31.1 RDW-13.5 Plt Ct-198
[**2178-3-25**] 08:00PM BLOOD Neuts-91.6* Lymphs-3.1* Monos-3.7 Eos-1.4
Baso-0.2
[**2178-3-25**] 08:00PM BLOOD PT-11.6 PTT-34.7 INR(PT)-1.1
[**2178-3-25**] 08:00PM BLOOD Glucose-86 UreaN-85* Creat-5.5* Na-138
K-4.1 Cl-101 HCO3-20* AnGap-21*
[**2178-3-26**] 06:10AM BLOOD ALT-12 AST-22 AlkPhos-59 TotBili-0.4
[**2178-3-25**] 08:00PM BLOOD Calcium-9.3 Phos-5.1* Mg-1.9
[**2178-3-25**] 08:20PM BLOOD Lactate-1.0
DISCHARGE LABS:
[**2178-3-30**] 05:15AM BLOOD WBC-6.6 RBC-3.45* Hgb-10.2* Hct-32.9*
MCV-95 MCH-29.6 MCHC-31.0 RDW-13.2 Plt Ct-212
[**2178-3-27**] 01:00PM BLOOD Neuts-80.7* Lymphs-11.2* Monos-6.2
Eos-1.4 Baso-0.6
[**2178-3-30**] 05:15AM BLOOD Glucose-107* UreaN-77* Creat-5.8* Na-136
K-4.5 Cl-100 HCO3-23 AnGap-18
[**2178-3-30**] 05:15AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
CALF U/S [**3-28**]:
Dilated patent superficial veins in the region of palpable
abnormality in the right calf. No underlying fluid collection or
abscess.
LE U/S [**3-26**]:
1. No evidence of deep venous thrombosis in the left lower
extremity.
Peroneal veins are not visualized on today's exam.
2. Prominent inguinal lymph nodes bilaterally.
Fistula U/S:
Patent radial artery and cephalic vein fistula, thickened valves
and likely nonocclusive thrombus in the cephalic vein with
elevated
velocities. Clinical correlation is requested.
Brief Hospital Course:
38M with ESRD, HTN, dCHF & admission 1 wk ago for volume
overload now p/w RLE cellulitis.
.
# SIRS and RLE CELLULITIS
Patient initially admitted to the medical floor. On admission
pt had fever, tachycardia, and leukocytosis so he met SIRS
criteria. He was started on vancomycin and cefepime with a
presumed source of lower extremity cellulitis as patient's
symptoms began after skin abrasions from itching his lower
extremity & tender bilateral LAD suggests systemic spread. BCx
were sent prior to initiation of vancomycin in the ED, NGTD. On
HD 1, he was becoming increasingly somnolent and was transferred
to the MICU for concern for impending septic shock. He remained
stable in the MICU overnight and was transferred back to the
floor the same day. Infectious Disease was consulted, and
recommended switching the patient to oral antibiotics on HD 3.
A regimen of doxycycline and keflex was started (Bactrim was
avoided because of patient's ESRD and history of G6PD). The next
day, patient became incredibly nauseous and stated that he had a
similar reaction to doxy ion the past. Because Clindamycin
carries a high risk of C diff and does not have good coverage
against MRSA in our area, it was determined that we would give
the patient one more dose of IV vancomycin. Because of his
ESRD, the dose would remained in his system for 48-72 hours. We
then prescribed him 3 days of Clindamycin to begin on [**4-1**] to
complete a total 10 day course beginning on [**3-25**]. The keflex
was disonctinued. Patient was discharged in stable condition,
feeling well. All blood cultures remained negative.
.
# ESRD
Awaiting initiation of HD, s/p recent fistula placement on [**2-24**].
Records demonstrate recent, steady increase in Cr & increasing
diuretic requirement, suggestive of acutely-worsening renal
fucntion. Last Cr 5.8/BUN 85. Dry weight estimated between 260 -
285 lbs; 128.9 kg at discharge last week and 129.4 here. No
clinical signs of uremia or florid volume overload on admission,
although increasing somnolence on floor, subsequently resolved)
might be [**1-1**] mild uremia. Renal consult service followed the pt
closely and was prepared to initiate HD via a temp HD line
should he require urgent dialysis. At this time, it was felt
most appropriate to await maturation of new R radial AVF, which
was evaluated by transplant surgery while here. Fistulagram also
performed, which showed high velocities and possible cephalic
clot. Transplant surgery stated this likely represented
immature fistula and there was nothing to be done at this time.
# Systolic Murmur: On admission, patient had a soft systolic
ejection murmur at both the RUSB and LUSB. Per records, this
was new. There was no diastolic component of the murmur. The
murmur diminished as his SIRS and sepsis resolved, thus it was
determined that it was a flow murmur from his systemic infection
reaction. There was concern of possible worsening dissection or
endocarditis; however because there was no diastolic component,
blood cultures remained negative, and the murmur diminished, a
TTE was not pursued.
# dCHF
Patient with a history of diastolic dysfunction with recent
admission for florid volume overload. Torsemide initially held
on admission as patient had taken 240 mg in the previous 48
hours prior to being admitted. He put out roughly 4.5 L during
the first several days of admission. We then restarted his
torsemide at 40 mg once a day on discharge.
.
# HTN
Hypertensive chronically at home despite 800 [**Hospital1 **] labetolol and 5
amlodipine, with SBP baseline 150-170s per pt report. Given hx
very difficult-to-control hypertension and chronic Type B aortic
dissection, an extra 400 mg of labetolol was given per day
inbetween his 800 mg doses. Patient's BPs then decreased to
130s and he did not "feel himself" while at these blood
pressures. Thus, it was decided we would increase his
amlodopine to 10 mg and keep him on 800 [**Hospital1 **] labetolol.
.
# Type B Aortic Dissection
Chronic, has been followed for the last 3 years. Last imaged by
MRA chest in [**12/2177**], showed no interval worsening. No chest pain
or SOB during this admission. BP managed as-above.
.
# ECG changes
Patient's initial ECG showed 0.[**Street Address(2) 1755**] depressions in V5/V6,
similar to prior EKG from 1 week ago; these ST changes
normalized by the AM. Unlikely to be ACS, more likely demand
ischemia from a fixed obstructive defect. Patient asymtomatic
without chest pain or SOB.
.
# DEPRESSION
Pt on citalopram, stable
.
TRANSITIONAL ISSUES
- recommend further discussion of social supports, plan for
HD/compliance
- Follow - up of murmur as an outpatient
Medications on Admission:
1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. petrolatum Ointment Sig: One (1) Appl Topical QID (4
times a day) as needed for affected area.
5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. petrolatum Ointment Sig: One (1) application Topical four
times a day as needed for affected area.
5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
6. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO
every eight (8) hours for 3 days: START TAKING ON THE MORNING OF
WEDNESDAY [**4-1**].
Disp:*27 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for a cellulitis. We treated you
with antibiotics and your cellulitis improved. You received IV
vancomycin while in the hospital. You will take 3 days of
clindamycin starting the morning of [**4-1**].
We made the following changes to your medications:
INCREASE Amlodipine from 5 mg to 10 mg daily - Take 2 5 mg
tablets once a day until you finish your prescription, then have
your primary care doctor write you a new presciption for 10 mg
tablets if you are to continue this regimen.
START Clindamycin 450 mg ( 3 tablets) every 8 hours for three
days on Wednesday morning [**4-1**]
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2178-4-2**] at 10:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2178-4-15**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2178-4-16**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
[
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"288.60",
"441.01",
"311",
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"459.81",
"305.1",
"428.0",
"428.32",
"403.91",
"V12.42",
"585.5",
"995.92",
"692.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11623, 11629
|
5770, 10434
|
374, 380
|
11708, 11708
|
4290, 4290
|
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|
3348, 3585
|
10949, 11600
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11650, 11687
|
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|
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|
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|
307, 336
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408, 2712
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4307, 4834
|
11723, 11835
|
2734, 3110
|
3126, 3332
|
3651, 4271
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,332
| 165,689
|
33998
|
Discharge summary
|
report
|
Admission Date: [**2195-7-30**] Discharge Date: [**2195-8-13**]
Date of Birth: [**2133-7-10**] Sex: F
Service: SURGERY
Allergies:
Imuran / Cyclosporine / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
Irrigation and debridement of grade 3B open tibia fracture, open
reduction, internal fixation grade IIIB open tibial fracture,
placement of external fixator
Lumbar fusion L1-L5
Laminectomy L4
History of Present Illness:
62 yo female with multiple medical problems including venous
stasis and recalcitrant pyoderma gangrenosum of the right leg,
taking prednisone, mycophenalate mofetil and infliximab. She
was receiving hyperbaric O2 therapy at an area hospital and fell
down the stairs sustaining an open right tib-fib fracture grade
IIIB, likely contaminated and exposed to the old presumably
infected ulcer site (large 10 x 10 medial tibial open ulcer for
the last three years). She was the transported to [**Hospital1 18**] Pt had
difficult access with unsuccessful attempt and femoral,
subclavian and internal jugular central line placement. R
brachial cutdown was eventually performed.
Past Medical History:
Pyoderman gangrenosum
Venous stasis ulcers
Bilateral DVT
Pulmonary embolus s/p IVC filter
Crohn's disease s/p total colectomy/ileostomy
Splenectomy [**12-27**] hemorrahge
Right oophorectomy
Multiple skin grafts and vascular grafts
Social History:
She drinks wine on occasion. Denies any illicit drug use or
smoking history. Her domestic violence screen is negative
Family History:
Mother died of breast cancer at the age of 86 and father died of
pulmonary hypertension complications at the age of 79
Physical Exam:
Upon exam:
BP: 130/83 HR: 92
Patient is intubated, sedated;
Pupils are equal and reactive bilat.
Motor: upon holding sedation, patient able to move both LE to
command: she is able to lift her left leg of the bed, bending
the
knee (4-/5), and can move both feet/toes distally. Exam of the
right LE severly limited by post surgical condition.
Patient able to confirm feeling light touch in both LE.
Quad and achilleus rx are trace bilat. Toes are downgoing.
Pertinent Results:
[**2195-7-30**] 05:49PM BLOOD WBC-17.2* RBC-2.46* Hgb-6.9* Hct-21.8*
MCV-89 MCH-28.2 MCHC-31.7 RDW-16.4* Plt Ct-145*
[**2195-7-31**] 02:47AM BLOOD PT-13.0 PTT-23.5 INR(PT)-1.1
[**2195-7-30**] 05:49PM BLOOD Glucose-254* UreaN-31* Creat-1.2* Na-137
K-4.5 Cl-107 HCO3-20* AnGap-15
[**2195-7-31**] 11:32AM BLOOD CK(CPK)-23*
[**2195-7-31**] 11:32AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2195-7-30**] 05:49PM BLOOD Calcium-8.4 Phos-4.6* Mg-1.8
[**2195-7-30**] 08:07PM BLOOD Type-ART Temp-37.2 Rates-14/ FiO2-100
pO2-375* pCO2-34* pH-7.37 calTCO2-20* Base XS--4 AADO2-320 REQ
O2-58 Intubat-INTUBATED Vent-CONTROLLED
[**2195-7-30**] 09:48AM BLOOD Glucose-207* Lactate-7.7* Na-136 K-4.6
Cl-100 calHCO3-20*
[**2195-7-30**] 09:48AM BLOOD Hgb-9.5* calcHCT-29 O2 Sat-78 COHgb-2
MetHgb-0
[**2195-7-30**] 3:40 pm TISSUE RIGHT TIBIA.
**FINAL REPORT [**2195-8-3**]**
GRAM STAIN (Final [**2195-7-30**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2195-8-3**]):
REPORTED BY PHONE TO OLUSEKON [**2195-7-31**] @11:54 AM.
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
Please contact the Microbiology Laboratory ([**5-/2493**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
PENICILLIN G----------<=0.03 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2195-8-3**]): NO ANAEROBES ISOLATED.
[**2195-7-30**] TIB/FIB (AP & LAT) RIGHT
1. Displaced tibial and fibular fractures. Probable lateral
malleolar
fracture, but the ankle is not well evaluated for on this study.
2. Sclerotic lesions within the distal femoral and proximal
tibia,
compatible with bone infarcts.
[**2195-7-30**] CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS
W/O CONTRAST
1. L4 compression fracture with mild narrowing of the central
canal at this
level, age indeterminant. MRI of the L-spine is recommended for
further
evaluation of the cord at this level.
2. No evidence of solid organ injury.
[**2195-7-31**] CT L-SPINE/MYELOGRAM
1. Moderate-to-severe canal stenosis seen at L4-L5 secondary to
retropulsed bone fragments from a compression deformity. A small
amount of contrast is seen accumulating distal to this level.
Please note that the contrast was injected at the level of L3.
2. Superior endplate fracture seen at L3 with roughly 20% loss
of height.
Brief Hospital Course:
She was admitted to the Trauma Service; Orthopedics and
Neurosurgery were consulted initially given her injuries. She
was taken on the day of admission to the operating room for
irrigation and debridement of her grade IIIB open tibia
fracture, as well as open reduction, internal fixation and
placement of an external fixator. There were no intraoperative
complications. She has maintained palpable pulses that were
confirmed with Doppler throughout the hospital admission. She
was taken to the operating room on [**8-7**] for lumbar fusion of
L1-L5 and laminectomy of L4.
Plastics, Vascular and Dermatology were also consulted for
discussion surrounding the utility and possibility of right leg
amputation. It was decided by the family, team and consultants
that given that the leg had adequate vasculature at that
amputation would not be performed during this hospital stay.
The plan is for her to follow up the week after discharge in
orthopedics clinic for further evaluation of her RLE and
discussion regarding possible removal of the external fixation
device.
Initially Dermatology recommended keeping steroids,
mycophenolate and infliximab for her pyoderma; however because
of the recent surgeries to the her leg and back necessitated
tapering of her steroids and discontinuance of the infliximab
for optimal post-operative healing. This decision was discussed
with Dermatology. Her steroids are being tapered daily by 2 mg,
she is being discharged on 20 mg with instructions for tapering.
Her pain is now being controlled with longa acting narcotics;
shorter acting ones are prescribed for breakthrough pain. Her
home medications were restarted as well.
She was followed by the wound ostomy care nursing team
throughout her hospital stay. Physical and Occupational therapy
have evaluated her and have recommended rehab.
Medications on Admission:
Medications - Prescription
ATENOLOL - (Prescribed by Other Provider) - 100 mg Tablet - 1
(One) Tablet(s) by mouth once a day
BUPROPION - (Prescribed by Other Provider) - 150 mg Tablet
Sustained Release - 1 (One) Tablet(s) by mouth twice a day
CITALOPRAM - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg
Tablet - [**1-27**] Tablet(s) by mouth once a day
INFLIXIMAB [REMICADE] - (Prescribed by Other Provider) - Dosage
uncertain
LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet
- 1 (One) Tablet(s) by mouth once a day
METHADONE - (Prescribed by Other Provider) - 10 mg Tablet - [**12-28**]
Tablet(s) by mouth twice a day
METHYLPREDNISOLONE - (Prescribed by Other Provider) - 8 mg
Tablet - 4 (Four) Tablet(s) by mouth once a day
MINOCYCLINE - (Prescribed by Other Provider) - 100 mg Tablet -
1
(One) Tablet(s) by mouth once a day
MYCOPHENOLATE MOFETIL [CELLCEPT] - (Prescribed by Other
Provider) - 500 mg Tablet - 2 (Two) Tablet(s) by mouth twice a
day
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth
twice a day
OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 3
(Three) Tablet(s) by mouth every 4-6 hours
SULFASALAZINE - (Prescribed by Other Provider) - 500 mg Tablet,
Delayed Release (E.C.) - 2 (Two) Tablet(s) by mouth twice a day
and one tab at lunch
Medications - OTC
CALCIUM CARB-MAG OXIDE-VIT D3 - (Prescribed by Other Provider)
-
Dosage uncertain
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) - 500
mg Tablet, Chewable - 3 (Three) Tablet(s) by mouth twice a day
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
ZINC SULFATE - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Minocycline 50 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
11. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q12H (every 12 hours).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily) for 7 days.
17. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
18. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain.
20. Insulin Regular Human 100 unit/mL Solution Sig: One (1) DOSE
Injection four times a day as needed for per slidng scale.
21. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
23. Methylprednisolone 4 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily): *Tapering dose:
Decrease by 2 mg daily until stopped.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Right distal tibia/fibula fracture
Old L3/L4 compression fracture
Secondary diagnosis:
Pyoderma gangrenosum w/ chronic ulcer RLE
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
DO NOT bear any weight on your right leg at all.
The TLSO brace must be worn at all times when out of bed.
Followup Instructions:
Follow up next Tuesday in [**Hospital 5498**] Clinic with Dr. [**Last Name (STitle) 1005**].
call [**Telephone/Fax (1) 1228**] for an appoinmtent.
Follow up with Dr. [**Last Name (STitle) **], Vascular surgery for any concerns or
questions related to prior discussions surrounding your right
leg. Call [**Telephone/Fax (1) 1237**].
Follow up with Dr. [**Last Name (STitle) 63264**], Neurosurgery in [**1-27**] weeks;
call [**Telephone/Fax (1) 1669**] for an appointment.
Completed by:[**2195-8-18**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
11323, 11393
|
5270, 7108
|
330, 524
|
11575, 11655
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2250, 5247
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1634, 1755
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11414, 11490
|
7134, 8964
|
11679, 11789
|
1770, 2231
|
270, 292
|
552, 1226
|
11511, 11554
|
1248, 1480
|
1496, 1618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,461
| 114,319
|
44663
|
Discharge summary
|
report
|
Admission Date: [**2177-12-15**] Discharge Date: [**2177-12-23**]
Date of Birth: [**2111-12-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABGx3(LIMA-LAD,SVG-Diag,SVG-OM)[**12-19**]
History of Present Illness:
66 yo M with known CAD who presented to [**Hospital3 **] with chest
pain, ruled in for NSTEMI. Pt was transferred to [**Hospital1 18**] for cath.
Past Medical History:
CAD, s/p MI ??????93 HTN, ^lipid, Mod MR, Spinal stenosis s/p RIH
Social History:
semi retired car salesman
lives with wife
no tobacco
social etoh
Family History:
NC
Physical Exam:
Vitals 52, 189/93, 18
General NAD
Skin unremarkable
Neck Supple Full ROM
Chest CTA bilat
Heart RRR
Abd soft NT ND
Ext warm well perfused
Pertinent Results:
[**2177-12-22**] 06:30AM BLOOD WBC-6.9 RBC-3.08* Hgb-9.5* Hct-27.5*
MCV-89 MCH-30.8 MCHC-34.5 RDW-13.2 Plt Ct-210
[**2177-12-15**] 05:35PM BLOOD WBC-6.2 RBC-4.37* Hgb-13.5* Hct-37.6*
MCV-86 MCH-30.9 MCHC-35.9* RDW-13.3 Plt Ct-220
[**2177-12-22**] 06:30AM BLOOD Plt Ct-210
[**2177-12-22**] 06:30AM BLOOD PT-12.7 INR(PT)-1.1
[**2177-12-15**] 05:35PM BLOOD Plt Ct-220
[**2177-12-15**] 05:35PM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1
[**2177-12-21**] 04:07AM BLOOD Fibrino-695*#
[**2177-12-23**] 06:10AM BLOOD K-4.5
[**2177-12-22**] 06:30AM BLOOD Glucose-113* UreaN-6 Creat-1.0 Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2177-12-15**] 05:35PM BLOOD Glucose-138* UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
[**2177-12-17**] 04:39PM BLOOD ALT-16 AlkPhos-42 TotBili-0.4
[**2177-12-15**] 05:35PM BLOOD AST-26 AlkPhos-41 TotBili-0.8
[**2177-12-16**] 03:20AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2177-12-21**] 04:07AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.3
[**2177-12-17**] 04:39PM BLOOD %HbA1c-5.3
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2177-12-20**] 3:07 PM
CHEST (PORTABLE AP)
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with recent CABG s/p chest tube removal
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
PORTABLE CHEST.
CLINICAL HISTORY: Status post chest tube removal, please
evaluate for pneumothorax.
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2177-12-19**]. In the interim
since the prior examination, the left chest tube has been
removed. No pneumothorax is visualized. In addition, the
endotracheal tube, NG tube and Swan-Ganz catheter have been
removed. The patient is status post CABG with median sternotomy.
There is a stable left retrocardiac opacity, likely secondary to
underlying atelectasis and a possible small effusion. No new
focal opacities are seen. The right lung is clear. No right
pleural effusions are noted. The cardiac silhouette remains at
the upper limits of normal.
DR. [**First Name (STitle) 2353**] [**Doctor Last Name **]
Approved: SUN [**2177-12-21**] 6:59 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1955**] [**Hospital1 18**] [**Numeric Identifier 95586**] (Complete)
Done [**2177-12-19**] at 1:19:21 PM 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: [**2111-12-10**]
Age (years): 66 M Hgt (in): 68
BP (mm Hg): / Wgt (lb): 135
HR (bpm): BSA (m2): 1.73 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 440.0
Test Information
Date/Time: [**2177-12-19**] at 13:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aorta - Abdominal: *5.0 cm <= 2.0 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
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. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST_BYPASS:
Pt removed from cardiopulmonary bypass A paced on phenylephrine.
1. Biventricular function is preserved; LVEF 50-55%.
2. Aortic contours are intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2177-12-22**] 11:58
Cardiology Report ECG Study Date of [**2177-12-19**] 1:41:20 PM
Normal sinus rhythm with left bundle-branch block and frequent
premature atrial contractions. Non-specific ST-T wave
abnormalities.
Left atrial abnormality. Compared to the prior tracing of
[**2177-12-15**]
the frequent premature atrial contractions are new.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 114 144 444/479 67 16 40
Brief Hospital Course:
Underwent cardiac catherization that revealed three vessel
disease. Cardiac surgery was consulted and CABG was planned
after plavix wash out. He remained on a heparin drip however
developed hematuria and his heparin was discontinued. His
hematuria resolved. He was taken to the operating room on [**12-19**]
where he underwent a CABG x 3. See operative report for further
details. He was transferred to the ICU in critical but stable
condition. He was given 48 hours of perioperative vancomycin for
prophylaxis as he was in house preoperatively. He was extubated
later that same day. He was transferred to the floor on POD #2.
He did well postoperatively. He had short burst of atrial
fibrillation controlled with beta blockers. Physical followed
patient during entire post-op course for strength and mobility.
He continued to make steady process and was discharged home with
VNA services on post-op day four.
Medications on Admission:
ASA 325' Folic acid 1' Atenolol 50' Lipitor 40' MVI
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 BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post op Atrial Fibrillation
NSTEMI
s/p MI ??????93 HTN, ^lipid, Mod MR, Spinal stenosis s/p RIH
Discharge Condition:
Good.
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 14069**] in 1 week [**Telephone/Fax (1) 37171**]
Dr. [**Last Name (STitle) **] in [**3-8**] weeks
Completed by:[**2177-12-23**]
|
[
"599.7",
"424.0",
"427.31",
"401.9",
"272.4",
"E878.2",
"997.1",
"414.01",
"E934.2",
"410.71",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"88.53",
"36.15",
"39.61",
"37.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9096, 9154
|
7231, 8144
|
335, 381
|
9327, 9335
|
920, 2058
|
9846, 10113
|
744, 748
|
8246, 9073
|
2095, 2151
|
9175, 9306
|
8170, 8223
|
9359, 9823
|
763, 901
|
285, 297
|
2180, 7208
|
409, 557
|
579, 646
|
662, 728
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,119
| 157,466
|
24834
|
Discharge summary
|
report
|
Admission Date: [**2117-8-5**] Discharge Date: [**2117-8-19**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 974**]
Chief Complaint:
abdominal pain - gangrenous cholecystitis
Major Surgical or Invasive Procedure:
open cholecystectomy
cholangiogram
common bile duct exploration
choledochoscopy
t-tube cholangiogram x 2
History of Present Illness:
This elderly white male presents to the hospital
with a 3 day history of right upper quadrant discomfort /
mid-epigastric pain, generally 2 hours after meals. On an
ultrasound he was found to have a gallbladder which appeared
very concerning for gangrene of the gallbladder.
Pre-operative ultrasound revealed no gall stones. No other
preoperative
evaluations were done, as the patient was progressively
becoming ill. His white count was greater than 20,000 and he
had a temp of 102.5, and he was brought urgently to surgery.
Because of the picture of the gallbladder on ultrasound, it
was elected to abort any attempts at laparoscopic operation,
as the ability to control the gallbladder surely would have
been minimal.
Past Medical History:
MI ([**2106**]), CAD, HTN, a-fib, bladder incontinence
Social History:
remote smoking history
Physical Exam:
100 65 163/75 18 99%RA
no acute distress
regular rate and rhythm
clear to auscultation bilaterlly
soft, distended, mildly diffusely tender with significant RUQ
tenderness. + [**Doctor Last Name **] isn
guiac negative
no clubbing cyanosis or edema
Pertinent Results:
[**2117-8-5**] 01:00PM BLOOD WBC-20.7* RBC-4.19* Hgb-13.2* Hct-37.8*
MCV-90 MCH-31.6 MCHC-35.0 RDW-13.5 Plt Ct-212
[**2117-8-6**] 04:05PM BLOOD WBC-10.1 RBC-3.30* Hgb-10.4* Hct-30.0*
MCV-91 MCH-31.4 MCHC-34.5 RDW-14.0 Plt Ct-119*
[**2117-8-7**] 03:57PM BLOOD WBC-11.3* RBC-3.54* Hgb-11.5* Hct-32.2*
MCV-91 MCH-32.4* MCHC-35.6* RDW-14.1 Plt Ct-138*
[**2117-8-11**] 03:44AM BLOOD WBC-10.1 RBC-3.47* Hgb-10.7* Hct-32.2*
MCV-93 MCH-30.7 MCHC-33.1 RDW-13.4 Plt Ct-202
[**2117-8-17**] 05:45AM BLOOD WBC-14.2* Hct-38.8* Plt Ct-648*#
[**2117-8-5**] 01:00PM BLOOD Neuts-80.8* Lymphs-15.4* Monos-3.6
Eos-0.1 Baso-0.1
[**2117-8-5**] 01:50PM BLOOD PT-17.6* PTT-38.5* INR(PT)-2.1
[**2117-8-6**] 04:05PM BLOOD PT-15.6* PTT-38.0* INR(PT)-1.7
[**2117-8-14**] 07:40AM BLOOD PT-13.4* PTT-28.4 INR(PT)-1.2
[**2117-8-5**] 01:00PM BLOOD Glucose-158* UreaN-19 Creat-1.2 Na-137
K-4.0 Cl-101 HCO3-24 AnGap-16
[**2117-8-6**] 04:05PM BLOOD Glucose-119* UreaN-20 Creat-1.4* Na-136
K-3.8 Cl-104 HCO3-21* AnGap-15
[**2117-8-9**] 03:06AM BLOOD Glucose-110* UreaN-24* Creat-1.1 Na-142
K-3.6 Cl-107 HCO3-24 AnGap-15
[**2117-8-17**] 05:45AM BLOOD Glucose-137* UreaN-32* Creat-1.2 Na-138
K-4.5 Cl-101 HCO3-23 AnGap-19
[**2117-8-5**] 01:00PM BLOOD ALT-28 AST-33 AlkPhos-75 Amylase-17
TotBili-2.1*
[**2117-8-6**] 04:00AM BLOOD ALT-94* AST-118* AlkPhos-82 Amylase-230*
TotBili-5.0*
[**2117-8-6**] 09:30AM BLOOD CK(CPK)-430*
[**2117-8-6**] 11:25PM BLOOD CK(CPK)-454* Amylase-112*
[**2117-8-7**] 04:00AM BLOOD Amylase-84 TotBili-5.5*
[**2117-8-9**] 03:06AM BLOOD ALT-191* AST-95* AlkPhos-89 Amylase-31
TotBili-3.6*
[**2117-8-14**] 07:40AM BLOOD ALT-46* AST-34 AlkPhos-123* TotBili-1.4
[**2117-8-17**] 05:45AM BLOOD ALT-66* AST-72* AlkPhos-210* Amylase-164*
TotBili-1.6*
[**2117-8-5**] 01:00PM BLOOD Lipase-43
[**2117-8-6**] 04:00AM BLOOD Lipase-772*
[**2117-8-7**] 04:00AM BLOOD Lipase-60
[**2117-8-15**] 02:00PM BLOOD Lipase-813*
[**2117-8-17**] 05:45AM BLOOD Lipase-640*
[**2117-8-6**] 09:30AM BLOOD CK-MB-2 cTropnT-0.02*
[**2117-8-5**] 11:19PM BLOOD Calcium-8.5 Phos-2.1* Mg-1.5*
[**2117-8-17**] 05:45AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2
[**2117-8-16**] 09:10AM BLOOD Albumin-3.5
[**2117-8-12**] 03:33AM BLOOD Triglyc-181*
[**2117-8-5**] 08:14PM BLOOD Type-ART pO2-61* pCO2-29* pH-7.48*
calHCO3-22 Base XS-0
[**2117-8-7**] 05:40AM BLOOD Type-ART pO2-136* pCO2-39 pH-7.38
calHCO3-24 Base XS--1
[**2117-8-9**] 03:33AM BLOOD Type-ART pO2-104 pCO2-39 pH-7.43
calHCO3-27 Base XS-1
[**2117-8-10**] 03:43PM BLOOD Type-ART pO2-142* pCO2-35 pH-7.45
calHCO3-25 Base XS-1
[**2117-8-15**] 02:14AM BLOOD Type-ART Temp-37.0 Rates-/22 FiO2-35 O2
Flow-4 pO2-86 pCO2-37 pH-7.45 calHCO3-27 Base XS-1 Intubat-NOT
INTUBA Vent-SPONTANEOU
RADIOLOGY Final Report
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2117-8-5**] 1:57 PM
LIVER OR GALLBLADDER US (SINGL
Reason: r/o gallstones, cholecystitis
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with RUQ abd pain, fever
REASON FOR THIS EXAMINATION:
r/o gallstones, cholecystitis
INDICATION: 81-year-old man with right upper quadrant abdominal
pain, fever and leukocytosis.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is of coarse
echotexture without evidence of focal lesions. The gallbladder
is distended with gallbladder wall edema. No gallstones are
present. The common duct is not dilated. The son[**Name (NI) 493**] [**Name (NI) **]
sign is positive.
IMPRESSION: Findings are consistent with acute cholecystitis.
RADIOLOGY Final Report
ABDOMINAL FLUORO WITHOUT RADIOLOGIST [**2117-8-5**] 9:34 PM
ABDOMEN, SINGLE VIEW IN O.R.; ABDOMINAL FLUORO WITHOUT RADIO
Reason: ACUTE CHOLECYSTITIS, R/O STONES
INDICATION: Acute cholecystitis. Please evaluate for common duct
stones.
FINDINGS: Three fluoroscopic views were submitted. There is a
small filling defect in the distal common bile duct, which
changes from view to view. This may represent a small amount of
sludge. A small catheter is seen to extend from the patient's
right side into the common bile duct likely through the cystic
duct remnant.
IMPRESSION: Small filling defect in distal common bile duct,
which may represent a small amount of sludge.
RADIOLOGY Final Report
T-TUBE CHOLANGIO (POST-OP) [**2117-8-16**] 11:00 AM
T-TUBE CHOLANGIO (POST-OP)
Reason: ?
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with gangrenous cholecystitis s/p open chole &
cbd exxploration
REASON FOR THIS EXAMINATION:
?
INDICATION: Status post cholecystectomy for gangrenous
cholecystitis and common bile duct exploration. Surgical T-tube
in place.
COMPARISON: Intraoperative cholangiogram from [**2117-8-6**].
PROCEDURE/FINDINGS: Preliminary scout view of the abdomen
demonstrates a surgically placed T-tube with the tip in the
patient's common bile duct. Surgical staples in the right upper
quadrant consistent with prior cholecystectomy are identified.
Optiray was infused via gravity into the patient's existing T-
tube. This demonstrated normal opacification of the common bile
duct and intrahepatic ducts which were normal in caliber without
evidence of filling defects. There was prompt drainage of
contrast into the duodenum. There is no evidence of contrast
extravasation. The cystic duct was not opacified.
IMPRESSION: Prompt passage of contrast from the common bile duct
into the duodenum without evidence of significant stenosis,
filling defects, or evidence of biliary duct dilatation. There
is no evidence of contrast leakage or extravasation.
[**2117-8-5**] 8:40 pm SWAB
BILE Fluid should not be sent in swab transport media.
Submit fluids
in a capped syringe (no needle), red top tube, or sterile
cup.
**FINAL REPORT [**2117-8-12**]**
GRAM STAIN (Final [**2117-8-6**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2117-8-12**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
FURTHER WORK-UP REQUESTED BY DR [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Numeric Identifier 62524**]) [**2117-8-10**].
ESCHERICHIA COLI. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity available on request.
ESCHERICHIA COLI. RARE GROWTH. SECOND STRAIN.
Trimethoprim/Sulfa sensitivity available on request.
ESCHERICHIA COLI. SPARSE GROWTH. THIRD STRAIN.
Trimethoprim/Sulfa sensitivity available on request.
ESCHERICHIA COLI. SPARSE GROWTH. FOURTH STRAIN.
Trimethoprim/Sulfa sensitivity available on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | ESCHERICHIA
COLI
| | |
ESCHERICHIA COLI
| | | |
AMPICILLIN------------ 8 S =>32 R <=2 S =>32 R
AMPICILLIN/SULBACTAM-- 4 S 8 S <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S <=1 S
CEFUROXIME------------ 4 S 4 S 4 S 4 S
GENTAMICIN------------ <=1 S <=1 S <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S <=0.25 S <=0.25 S <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S <=1 S
Brief Hospital Course:
From the Ed patient was taken fairly quickly to the operating
room and was also started on antibiotics, given FFP and vitamin
K pre-op and started on Levo/flagyl for 9 days. Underwent an
uneventful Open cholecystectomy, intraoperative cholangiogram,
common bile duct exploration with choledochoscopy and T tube
cholangiogram. T tube and JP drain were left in place as well as
an NGT, R IJ central line. Patient remained intubated for
further monitoring and was transferred up to the SICU. Patient
spiked to 102 POD 1, blood cultures sent. Patient had some
episodes of bradycardia and fluctuating urine output and was
stared on dopamine. Cardiology was consulted POD 3; CXR showed
atelectasis at R. base; vancomycin was added for 8 days as blood
culture showed corynebacterium and Bile Cx EColi Levo [**Last Name (un) 36**]. TPN
started on POD 6, lines were dc'd, and spontaneous breathing
trial and successful extubation. POD 7 doing well, NGT dc'd,
initiated sitter at bedside. POD 8 was transferred to the floor.
Had some issues with agitation and confusion, haldol prn was
used. POD 9 JP removed. POD 10 cvl removed, clear diet started.
POD 11 T-tube cholangiogram was done which shoewd patency and no
abnormalities, Unasyn was given pre and post procedure. Patient
remained afebrile, LFTs were monitored over the next few days.
Patient came back from cholangiogram quite sedated and lethargic
with continued disorientation and confusion. THis gradually
improved over the next few days, though with some lingering
effect. Neuro consult was obtained and an MRI brain which showed
significant atrpohy and a possible old stroke but no acute
stroke changes. POD 13 Ttube was clamped. As patient continued
to improve and LFTs remained stable/decreased, patient was
discharged to [**Hospital3 **] in good condition on POD 14 with
his T-tube clamped with instruction follow up with both Dr.
[**Last Name (STitle) **] and neurology.
Medications on Admission:
Coumadin, lisinopril, Detrol
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
gangrenous cholecystitis
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you experience fever > 101.5,
severe nausea, vomitting, pain.
please resume home medications and take new ones as directed
no driving while on narcotic pain meds
may shower
please leave T-tube clamped
Followup Instructions:
please call Dr.[**Name (NI) 18535**] office at ([**Telephone/Fax (1) 376**] for an
appointment.
Please also follow up with Dr. [**First Name (STitle) 6817**] (neurology) . You have an
appointment on [**10-11**] at 1:30pm [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] building,
[**Location (un) 1773**], rm 253
Completed by:[**2117-8-19**]
|
[
"276.6",
"518.5",
"401.9",
"427.31",
"790.7",
"575.4",
"V58.61",
"577.0",
"575.0",
"349.82",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.51",
"99.04",
"89.64",
"96.72",
"87.54",
"51.22",
"87.53",
"99.15",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
11729, 11799
|
9604, 11534
|
300, 406
|
11868, 11875
|
1556, 4398
|
12162, 12525
|
11613, 11706
|
5828, 5908
|
11820, 11847
|
11560, 11590
|
11899, 12138
|
1289, 1537
|
219, 262
|
5937, 9581
|
434, 1155
|
1178, 1234
|
1250, 1274
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,979
| 107,010
|
4133
|
Discharge summary
|
report
|
Admission Date: [**2168-8-11**] Discharge Date: [**2168-8-13**]
Date of Birth: [**2098-12-13**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old man
with a history of hypertension and seizure disorder who was
admitted to the MICU for hypoxia and hypotension. He was in
his usual state of good health until two days prior to
admission when he had the onset of vertigo. Since then, he
increasing lethargy. On the day of admission, he suffered a
syncopal episode which he recalls occurred after vomiting.
He says this was unlike his seizure episodes. He denies head
trauma or loss of consciousness. He also denies fever,
chills, cough, abdominal pain, chest pain, shortness of
breath, hematuria, hematochezia and melena.
evaluation. There he was afebrile and hypotensive with a
systolic blood pressure in the 70s. After three liters of
isotonic intravenous fluids, his blood pressure remained in
the 70s with a heart rate in the 80s to 90s. A nasogastric
tube was placed and lavage was trace positive for blood. An
electrocardiogram was obtained which showed a new right
bundle branch block. The patient's oxygen saturations were
in the 80s in room air but increased to mid 90s on four
liters nasal cannula oxygen.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Seizure disorder since birth, last seizure five years
ago. Generalized tonoclonic seizures.
3. Status post colovesical fistula repair in [**2164**].
4. History of diverticulitis.
MEDICATIONS ON ADMISSION:
1. Primidone 250 mg p.o. t.i.d.
2. Atenolol dose unknown.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] is a retired
restaurant worker and has grown children. The patient smoked
four packs per day for thirty years before quitting in [**2144**].
He denies alcohol use or other drug use.
FAMILY HISTORY: The patient describes several relatives on
his father's side of the family who suffered Alzheimer's
disease. No family history of coronary artery disease,
cancer or diabetes mellitus.
REVIEW OF SYSTEMS: Please see history of present illness.
PHYSICAL EXAMINATION: On admission, vital signs revealed
temperature 98.0, pulse 86, blood pressure 96/52, respiratory
rate 20, oxygen saturation 94% on four liters nasal cannula
oxygen. Head, eyes, ears, nose and throat - The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Bilateral arcus senilis.
Neck - no jugular venous distention, no lymphadenopathy.
Positive retraction. Chest - decreased breath sounds
diffusely with poor air entry. No crackles and no wheezes.
Cardiovascular - normal rate and regular rhythm, no murmurs,
rubs or gallops. Abdomen - soft, nontender, nondistended,
normoactive bowel sounds, no hepatosplenomegaly.
Neurologically, the patient is alert and oriented times
three, but anxious. Cranial nerves II through XII are
intact. Motor strength is 5/5 times four. Deep tendon
reflexes are 1+ and symmetric throughout. No clonus.
LABORATORY DATA: White blood cell count 10.7, hematocrit
47.4, platelets 325,000, 77% neutrophils, 18% lymphocytes, 5%
monocytes. Prothrombin time 13.4, partial thromboplastin
time 27.4. Sodium 145, potassium 3.6, chloride 93,
bicarbonate 28, blood urea nitrogen 44, creatinine 3.2,
glucose 150. Anion gap was 24. Lactate 1.8. ALT 23, AST
49, alkaline phosphatase 114, amylase 96, total bilirubin
0.6. CPK 120, CK MB 1.0, troponin I less than 0.3. Albumin
4.8. Abdomen revealed pH 7.42/45/58.
IMAGING: KUB revealed no free air. Bowel gas pattern
throughout small and large intestines. Chest x-ray revealed
hyperinflated lung fields with flat diaphragms, no
pneumothorax, no infiltrate, appropriate line placement.
Electrocardiogram - normal sinus rhythm, new right bundle
branch block.
HOSPITAL COURSE: The patient's hypoxia, hypotension and new
onset right bundle branch block with new onset syncope were
most worrisome for pulmonary embolism. The patient was
started on Heparin and a VQ scan was obtained because the
creatinine was too high for a CT angiogram. The VQ scan was
low probability. The patient was ruled out for an acute
myocardial infarction. An echocardiogram was also obtained
during this admission which showed hyperdynamic left
ventricle with an ejection fraction of 75%. The right
ventricle had a normal cavity size and normal function. No
evidence of strain. Lower extremity Doppler was also
obtained which showed no clot in his veins.
The patient was started on Dopamine in the Emergency
Department after left subclavian line was placed for blood
pressure support. This was quickly weaned off in the Medical
Intensive Care Unit as the patient's blood pressure responded
well to isotonic fluid resuscitation. Over the course of his
admission after receiving aggressive volume repletion, the
patient's creatinine corrected to 1.6 and his hematocrit
corrected to 35.0.
With a more reassuring creatinine, a CT study of the chest
was obtained with contrast and this was negative for
pulmonary embolism. Pulmonary function tests were also
obtained to identify an etiology for his hypoxia and these
were remarkable for a FEV1/FVC ratio of 70% predicted and
RV/TLC of 118 and a markedly reduced diffusion coefficient of
only 39%. The chest CT was also remarkable for right middle lobe
and right lower lobe cyst formation and interstitial scarring
which are not completely consistent with injury due to tobacco
smoke but more consistent with a pneumoconiosis.
A urine and blood toxicology screen were obtained at the time
of admission to rule out ingestion as the cause of his
hypotension. These were negative except for a positive
barbiturate level which may have been due to sedatives
administered in the Emergency Department.
The patient's antiseizure medication Primidone was held
initially but was then restarted one day after being admitted
and the patient suffered no seizures while in the Medical
Intensive Care Unit. He initially received a dose of
Ampicillin and Gentamicin and Flagyl in the Emergency
Department because they were worried about sepsis as the
cause for his hypoxia and hypotension, however, his clinical
status improved greatly upon receiving aggressive volume
repletion and nasal cannula oxygen and it was felt that both
his history and presentation were inconsistent with an
infectious etiology so antibiotics were discontinued.
The patient's basophil count came back at 3% on [**2168-8-12**].
This was followed up by examining the peripheral blood smear
with a hematology/pathology physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 18081**]. It was his feeling that the smear showed no
evidence of a malignancy. A follow-up differential showed a
basophil count of 0.2%.
The patient's CPKs rose to 465 during his admission, but
serial CPKs after that have returned to the normal range.
On the evening prior to discharge, the patient spiked a
temperature of 101.0. Blood and urine cultures have been
sent off. Stool leukocytes and ova and parasite studies have
also been sent off because it was the feeling of our team
that this illness may have been a severe gastroenteritis that
led to dehydration and volume depletion with subsequent
hypotension.
While on Heparin, the patient suffered mild Foley trauma and
had mild hematuria which appears to be resolving.
CONDITION ON DISCHARGE: The patient is stable and ready for
discharge to home.
DISCHARGE DIAGNOSES:
1. Severe interstial/fibrotic, predominantly lower-lobe,
uncertain etiology (atypical for tobacco- related COPD)
2. Status post severe gastroenteritis.
3. Hypotension secondary to dehydration
4. Epilepsy.
MEDICATIONS ON DISCHARGE: Primidone 250 mg p.o. t.i.d.
FOLLOW-UP:
1. Home oxygen therapy will be arranged by case manager.
2. The patient needs follow-up with pulmonary specialist.
This should be arranged by Dr. [**First Name4 (NamePattern1) **] [**Month (only) 18082**] office.
Dr. [**First Name (STitle) 216**] is the patient's primary care physician.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2168-8-13**] 11:40
T: [**2168-8-13**] 16:13
JOB#: [**Job Number 18083**]
|
[
"276.5",
"780.39",
"401.9",
"780.2",
"496",
"428.0",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.15"
] |
icd9pcs
|
[
[
[]
]
] |
1886, 2072
|
7549, 7759
|
7787, 8389
|
1527, 1626
|
3868, 7447
|
2155, 3850
|
2092, 2132
|
162, 1270
|
1292, 1501
|
1643, 1869
|
7472, 7528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,414
| 195,733
|
46689
|
Discharge summary
|
report
|
Admission Date: [**2193-11-19**] Discharge Date: [**2193-11-22**]
Date of Birth: [**2126-12-12**] Sex: F
Service: MEDICINE
Allergies:
Dopamine / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
UGI bleed
Major Surgical or Invasive Procedure:
EGD [**2193-11-20**]
History of Present Illness:
66 y/o with ischemic CHF EF 35%, CAD s/p CABG, afib on coumadin,
DM, CKD s/p nephrectomy, presented to [**Hospital **] Hosp today with 1d
of crampy epigastric pain. +mild dizziness, no pre-syncope or
syncope. Had episode of coffee ground emesis and guiaic + stool.
Found to have a hct of 20. Given 1u pRBC, Vit K 5mg IM and
transferred to [**Hospital1 **] for further w/u. On questioning, has been
taking stable dose of coumadin. Told to stop coumadin yest
afternoon as INR was 6.9 at coumadin clinic. Denies any recent
antibiotics, med changes, mistake in medications, or diet
changes. Does state hasn't eaten in a few days due to lack of
appetite.
.
In our ED, VS were AF, HR 100, BP 89/43, 16, 100% RA. She was
given IVF resuscitation, and a femoral triple lumen was placed.
She was given 40mg IV Protonix and Vit K 5mg IV x1. She also
recieved 1u FFP in transit upstairs.
Past Medical History:
1. Ischemic CM with recent EF 35%,
2. CAD status post three-vessel CABG, cath [**2193-7-21**]: severe
native three vessel CAD, RCA 100%, Prox Mid Cx 90%, SVG-diagonal
and SVG-RCA 100% occluded, SVG #3 and LIMA normal (was
pretreated for iodine allergy)
3. DM: Insulin dependent, complicated by: nephropathy,
retinopathy, neuropathy
4. CKD (baseline Cr 1.2-1.6)
5. s/p L nephrectomy [**2177**] due to suspected Renal cell cancer
6. Moderate MR
7. Pulmonary Hypertension
8. Depression
9. Memory difficulties
10. GERD
11. Gout
12. s/p Hysterectomy
13. [**2187**] Pyelonephritis -> hospitalized for +blood cultures
14. [**2189**] Breast Abscess -> treated in ED
15. s/p R carotid endarterectomy for 70% R internal carotid
stenosis
16. Anemia
17. Hyperlipidemia
Social History:
Recently left [**State 108**], was living with daughter/grandson. She
lives currently with her son in [**Name (NI) 86**]. She has a history of
smoking, quit in [**2174**]. No alcohol abuse. Has twice-a-week VNA
at home.
Family History:
Multiple family members with DM. Father died of MI, unknown age.
Mother died of lung CA.
Physical Exam:
VS: Temp:97.4 BP: 111/48 HR:93 RR:11 O2sat: 100%RA
GEN: In mild discomfort from nausea/vomiting, NAD
HEENT: L eye with cataract, EOMI, anicteric, MMM
RESP: CTA b/l with good air movement anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Mild epigastric tenderness to palpation. +BS. No rebound or
guarding.
EXT: 2+ chronic LE edema bilat
NEURO: AAOx3. Cn II-XII intact.
RECTAL: guiaic + per ED report
Pertinent Results:
[**2193-11-18**] 02:30PM PT-56.9* INR(PT)-6.9*
[**2193-11-19**] 12:45PM WBC-13.7* RBC-3.25* HGB-8.2* HCT-26.4*
MCV-81* MCH-25.3* MCHC-31.2 RDW-18.4*
[**2193-11-19**] 12:56PM HGB-8.1* calcHCT-24
[**2193-11-19**] 06:20PM WBC-11.2* RBC-2.75* HGB-7.8* HCT-23.0* MCV-83
MCH-28.3# MCHC-33.9 RDW-18.4*
[**2193-11-19**] 06:20PM CALCIUM-8.7 PHOSPHATE-4.7* MAGNESIUM-2.6
[**2193-11-19**] 06:20PM CK-MB-NotDone cTropnT-0.21*
[**2193-11-19**] 08:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2193-11-19**] 09:15PM LACTATE-3.2*
CXR: No acute cardiopulmonary process.
EGD:
Findings:
Esophagus: Normal esophagus.
Stomach:
Contents: Old Clotted blood was seen in the fundus. No evidence
of active bleeding seen throughout the stomach.
Mucosa: Diffuse continuous erythema of the mucosa with no
bleeding was noted in the whole stomach. These findings are
compatible with gastritis.
Duodenum: Normal duodenum.
Impression: Erythema in the whole stomach compatible with
gastritis
Brief Hospital Course:
66 y/o with ischemic CHF EF 35%, CAD s/p CABG, afib on coumadin,
DM, CKD s/p nephrectomy here with coffee ground emesis- UGI
bleed in the setting of supratherapeutic INR 8.4. She was
transferred to the MICU from [**Hospital3 4107**].
.
1. UGIB. While in the MICU the received a total of 3 units of
blood and 4 units of FFP and 10mg of vitamin K. Her hematocrit
increased appropriately and her INR reversed to 1.4. An EGD done
in the MICU showed old blood in the stomach with signs of
gastritis and no active bleeding. It was felt that her bleed
came from the gastritis exacerbated by the supratherapeutic INR.
She was placed on a [**Hospital1 **] PPI in addition to sucralfate and
maalox/lidocaine for GERD symptom relief. Her HCT remained
stable for 60+ hours after EGD. H. Pylori serologies were
negative. She was able to tolerate a full diet. She remained
asymptomatic and was felt safe to return home.
2. CAD s/p CABG. Ms. [**Known lastname 73770**] did have an isolated troponin
elevation, peaking at 0.36, in the setting of her GIB. However,
her CK was not elevated, she showed no EKG changes, and remained
asymptomatic. Thus this was felt not to be an NSTEMI but only a
demand ischemia not requiring any non-medical intervention.
After transfer out of the MICU, she was restarted on her
metoprolol, lisinopril, aspirin, and Plavix with good effect.
Lipitor 80mg PO daily was also added to her regimen. At the time
of discharge her troponins were trending down.
3. TIA-While in hospital Ms. [**Known lastname 73770**] experienced one episode of
blank staring lasting approximately 60 seconds, witnessed, that
she states is consistent with her prior TIAs. She notes that the
last one happened approximately 1.5 years ago, prior to her R
CEA done for 70% stenosis. She was on her aspirin and Plavix at
the time and there were no focal or persistent neurologic
abnormalities noted on exam. A carotid ultrasound showed only
60-69% stenosis on the left and no stenosis on the right. This
requires no surgical intervention but an appointment was made
for her with Dr. [**Last Name (STitle) **], a vascular surgeon, for follow up.
4. DM 2- She was continued on her home regimen of Lantus with a
Lispro sliding scale with good effect. She was also continued on
her gabapentin for her peripheral neuropathy with no new
symptoms noted.
.
5. Systolic congestive heart failure EF 35%- Upon stabilization
of her GIB, she was restarted on her regimen of metoprolol,
lisinopril, and Torsemide with good effect and proper diuresis
after volume loading with blood products. Her HCTZ was held as
her blood pressure was not elevated above SBP of 120 while on
the floor and she was diuresing well on Torsemide alone. This
may be restarted as an outpatient if needed.
.
6. Paroxysmal Atrial Fibrillation-After stabilization of her
GIB, Ms. [**Known lastname 73770**] was restarted on her Coumadin at a lower dose
of 2.5mg PO daily. She was set up with Bayada Nursing for 3x/wk
INR checks and alterations with a goal of INR [**2-23**]. In addition
her supratherapeutic INR may have been contributed to by her
poor PO intake. Thus, Megace was added to her medication regimen
to assist in her appetite
7. Decreased PO Intake-The patient stated that her appetite has
been decreased over the last 6 months with an involuntary weight
loss of [**11-9**] lbs. TSH was normal in [**2193-8-21**]. Age
appropriate cancer screening should be undertaken as an
outpatient. Depression may have contributed to her anorexia as
well. Again, Megace was added to her regimen and the patient was
encouraged to eat a healthy diet of low fat, low carb/sugar
meals.
8. Depression - Continued on Fluoxetine.
Medications on Admission:
Fluoxetine 40
Tramadol 50 q6
Neurontin 300 [**Hospital1 **]
Plavix 75
ASA 81
Nitroglycerin prn
Zocor 20
Lopressor 12.5 tid
Lisinopril 2.5
Coumadin 2.5/5
Torsemide 100 [**Hospital1 **]
HCTZ 50 qD
Lispro SS
Glargine 30 qhs
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
8. Megestrol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Begin with one tablet daily. [**Month (only) 116**] take one or two tablets as
directed by anticoagulation nurses. .
10. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Capsule(s)
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
14. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
15. Insulin Lispro 100 unit/mL Solution Sig: Dose per Sliding
Scale Subcutaneous three times a day.
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc.
Discharge Diagnosis:
Upper GI bleed
Gastritis
Supratherapeutic INR
Discharge Condition:
All vital signs stable. Hematocrit stable. Ambulatory with
walker per previous baseline.
Discharge Instructions:
You were admitted with a bleed in you stomach caused by general
irritation of the stomach lining. This was worsened by your
coumadin levels being too high. We have restarted your coumadin
at a low dose but you should continue to be monitored at the
[**Hospital 2786**] clinic. Your bleeding has stopped but you may
have some old blood passing through your system that may show up
in your stool. We have also added a number of medications
(protonix, sucralfate) to protect your stomach from acid and
prevent further episodes of bleeding. Please take all
medications as prescribed.
You also had an elevation of the blood tests that show there was
some minor damage to your heart during the bleeding. This was
not a heart attack. We have adjusted some of your medications to
help protect your heart further.
You also had one episode of symptoms similar to your previous
TIAs. You should continue to take your aspirin and Plavix. An
ultrasound of your carotid arteries showed mild narrowing of
60-69% on the L, requiring no surgery but you should be followed
by a vascular surgeon for possible carotid surgery in the
future. An appointment was made for you.
We have also added the medication Megace to stimulate your
appetite. You should continue to eat a diet low in fat, low in
carbs and sugars, and high in fiber and vegetables.
However, please call your doctor or return to the emergency room
if you feel dizzy, feint, have chest pain, shortness of breath,
vomitting of blood or vomit that looks like coffee-grounds, or
any other symptoms that concern you.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2193-12-2**] 4:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2194-1-27**] 2:00
Dr. [**Last Name (STitle) **], Vascular Surgery, [**12-17**] 8:30am, [**Hospital Unit Name **]
[**Location (un) 442**], ([**Telephone/Fax (1) 8343**]
|
[
"357.2",
"414.8",
"V58.61",
"585.9",
"250.50",
"428.22",
"427.31",
"274.9",
"535.51",
"416.8",
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"428.0",
"435.9",
"V58.67",
"424.0",
"362.01",
"530.81",
"285.1",
"250.60",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"45.13",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9271, 9320
|
3869, 7550
|
310, 332
|
9410, 9501
|
2800, 3846
|
11229, 11673
|
2275, 2365
|
7822, 9248
|
9341, 9389
|
7576, 7799
|
9525, 11206
|
2380, 2781
|
261, 272
|
360, 1238
|
1260, 2020
|
2036, 2259
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,306
| 170,941
|
50201
|
Discharge summary
|
report
|
Admission Date: [**2174-6-25**] Discharge Date: [**2174-6-28**]
Service: MEDICINE
Allergies:
Iodine / Codeine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
R arm cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 87yo Russian-speaking female with h/o DMII, s/p breast
cancer s/p right mastectomy and LN resection c/b chronic
lymphedema, recurrent cellulitis in R arm who now presents with
1 day of R forearm pain, redness, and swelling. Per her daughter
who She was in her usual state of health until this morning when
she developed fever to 101.4 and shaking chills. She complained
of pain in her right forearm, and her daughter noted an area of
erythema which rapidly spread up forearm over the course of the
morning. Her daughter called EMS and she was transported to the
ED.
.
Of note, pt recently hospitalized in [**12-4**] for right arm
cellulitis treated with vancomycin/zosyn, narrowed to Bactrim
for 10 day course. Per daughter she was also very confused
during that hospitalization. Did not have high fevers during
that episode.
.
In the ED, initial VS were T 101.6 HR 106 BP 134/90 RR 18 O2 sat
97% RA. Pt was found to be tachy up to 120s and a Tmax of 104.5
during ED stay. Labs were remarkable for WBC 12.4 (78% N, no
bands) and lactate of 5.6. Pt was given 4L NS, with improvement
in HR to 80s and lactate to 2.8. UA was neg for infection.
Borders of erythema were marked. Blood and urine cx were sent.
[**Doctor First Name **] was consulted, who felt this is not nec fasc. Pt was
started on Vanc/Cefepime/Clinda to broadly cover the cellulitis.
Pt was also given Tylenol PR, Morphine and Zofran for
symptomatic treatment. Xray of forearm showed no subcutaneous
air. Erythema was starting to improve with the abx and pt was
then admitted to ICU for further management. On trasnfer, VS
were T 101.2, HR 83, BP 112/49, RR16, Sat 95% 4L NC.
.
On arrival to the MICU, vitals are 97.8 129/56 68 26 93% RA.
Patient is AAOx2 (person, place, not time). She appears
uncomfortable, daughter states [**2-24**] chronic back pain, improved
somewhat with repositioning. States right arm pain has improved
somewhat. In the MICU, her antibiotic coverage was changed to
vancomycin and augmentin. Her HR went up to the 120s and she
was given 4L NS with HR improving to the 80s. Her BPs remained
was stable, and she did not require pressors. She was Percocet
and IV Dilaudid for her pain (refused to take PO meds). Ms.
[**Known lastname 104712**] was also given haldol for agitation. Her urine
output has been 20-30 cc/hour. Her initial lactate was elevated
at 5.9 but has since improved.
.
On transfer to the floor, Ms.[**Known lastname 104712**] was hemodynamically
stable with improved erythema. She complained of pain and some
discomfort with her bed position.
Past Medical History:
-H/O breast cancer s/p right mastectomy with LN dissection (27
yrs ago) c/b chronic right arm lymphedema and recurrent R arm
cellulitis
-Type II IDDM
-CAD
-Angina
-Hypertension
-Osteoarthritis
-Chronic Back Pain
-Gout
Social History:
Lives in [**Location **], daughter lives with her. Worked as a surgeon
until age 80. Due to chronic pain and weakness, only able to
ambulate to commode. Pays her own bills. No h/o tobacco, EtOH or
illicits.
Family History:
Not available due to patients confusion on admission
Physical Exam:
ADMISSION
General: obese elderly F, appears uncomfortable but NAD, AAOx2
(person, place, not time)
HEENT: pupils 1mm reactive BL, EOMI, dry mucus membranes
Neck: supple, no JVD, no LAD
Cardiac: RRR S1 S2 no rubs/murmurs/gallops
Lungs: CTAB no crackles/wheezes/rhonchi
[**Last Name (un) **]: obese, nontender, softly distended, +BS, no peritoneal
signs
Extrem: cool extrem, 2+ pulses, 2+ pitting pedal edema, no
clubbing or cyanosis
Neuro: face symmetric, PERRL, moving all extremities equally
Discharge exam:
obes
right upper extremity with edema, erythema limited to just
forearm.
Pertinent Results:
ADMISSION
[**2174-6-25**] 03:50PM BLOOD WBC-12.4*# RBC-4.20# Hgb-12.4 Hct-37.7
MCV-90 MCH-29.6 MCHC-33.0 RDW-15.7* Plt Ct-229
[**2174-6-25**] 03:50PM BLOOD Neuts-78.2* Lymphs-19.3 Monos-1.5*
Eos-0.7 Baso-0.3
[**2174-6-25**] 03:50PM BLOOD PT-11.6 PTT-32.1 INR(PT)-1.1
[**2174-6-25**] 03:50PM BLOOD Glucose-204* UreaN-22* Creat-1.0 Na-138
K-4.0 Cl-101 HCO3-17* AnGap-24*
[**2174-6-25**] 03:50PM BLOOD CK(CPK)-31
[**2174-6-26**] 02:32AM BLOOD Calcium-7.7* Phos-4.0 Mg-1.5*
.
PERTINENT
[**2174-6-25**] 03:54PM BLOOD Glucose-197* Lactate-5.6*
[**2174-6-25**] 06:16PM BLOOD Lactate-2.8*
[**2174-6-26**] 03:15AM BLOOD Lactate-1.9
.
DISCHARGE
[**2174-6-28**] 06:24AM BLOOD WBC-7.8 RBC-3.78* Hgb-11.0* Hct-34.4*
MCV-91 MCH-29.0 MCHC-31.9 RDW-15.6* Plt Ct-221
[**2174-6-28**] 06:24AM BLOOD Glucose-173* UreaN-20 Creat-1.2* Na-141
K-3.6 Cl-104 HCO3-24 AnGap-17
[**2174-6-28**] 06:24AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.8
.
CXR [**2174-6-25**]
Single portable view of the chest is compared to previous exam
from
[**2173-11-30**]. The lungs are grossly clear. Cardiac
silhouette is
enlarged, potentially accentuated by portable technique and low
inspiratory effort. There is no large effusion. Degenerative
changes noted at the right shoulder. Osseous and soft tissue
structures are otherwise grossly unremarkable.
IMPRESSION: No definite acute cardiopulmonary process.
.
FOREARM (AP & LAT) SOFT TISSUE RIGHT [**2174-6-25**]
Diffuse soft tissue swelling of the right forearm without
subcutaneous gas or radiopaque foreign body. Unusual contour at
the base of the fourth metacarpal, potentially projectional,
however, if concern for fracture, dedicated views should be
performed.
.
Micro:
Blood cultures [**6-25**] pending
urine culture [**6-25**] negative
Brief Hospital Course:
87yo Russian-speaking female with h/o DMII, s/p breast cancer
s/p right mastectomy and LN resection c/b chronic lymphedema,
recurrent cellulitis in R arm who now presents with 1 day of R
forearm pain, redness, and swelling.
Discharge diagnoses:
Sepsis due to Right arm cellulitis
Chronic lymphedema
Acute encephalopathy/delerium
Type II diabetes mellitus with complications
Below is a brief review of her hospitalization:
1. Right arm cellulitis. She was initially admitted to the ICU
with sepsis. ED evaluation was performed by surgery due to
possibility for necrotizing fascitis.
Regarding her right arm erythema, the appearance was consistent
with nonpurulent cellulitis, with primary risk factor being her
underlying chronic lymphedema and h/o IDDM. She was seen in the
ED by surgery who felt appearance not concerning, x-ray showed
no subcutaneous air. In the ED, she was started on vancomycin,
cefepime, and clindamycin. The patient was initially admitted
to the ICU for a sepsis like picture (Tmax 104.5). In the MICU,
her antibiotic coverage was changed to vancomycin and augmentin.
She was aggressively rehydrated and did not require pressors.
She was given Percocet and IV Dilaudid for her pain (refused to
take PO meds) and haldol for agitation. Her initial lactate
was elevated at 5.9 but has since improved. With clinical
improvement (defervesced with abx and Tylenol), she was
transferred to the medicine floor. We continued her antibiotics
and switched her to a PO regimen of bactrim and augmentin. Her
erythema in her right arm greatly improved with time. General
surgery saw the patient and recommended obtaining a MRI of her
arm to rule out angiosarcoma (given recurrent cellulitus and
history of breast cancer/lymphedema). We deferred obtaining a
MRI at this time based on patient's wishes (refused procedure)
and radiology's comments on the difficulty with positioning her
for the MRI.
The remainder of her medical conditions remained stable.
Issues for follow up -
The patient should follow-up with her PCP regarding this matter
and obtain a MRI in the future, as documented above.
Medications on Admission:
1. simvastatin 5 mg daily
2. atenolol 50 mg [**Hospital1 **]
3. ranolazine 500 mg ER [**Hospital1 **]
4. cholecalciferol (vitamin D3) 800 unit daily
6. lantus 26 units SC qHS
7. glucotrol 10 mg twice a day
8. isosorbide-hydralazine 20-37.5 mg daily (unclear dose?)
9. allopurinol 100 mg once a day
10. metformin 1000mg PO BID
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Lantus 26 Units Bedtime
3. Simvastatin 5 mg PO DAILY
4. Vitamin D 800 UNIT PO DAILY
5. Amoxicillin-Clavulanic Acid 500 mg PO Q8H
6. Isosorbide Dinitrate 20 mg PO DAILY
7. HydrALAzine 37.5 mg PO DAILY
8. GlipiZIDE 10 mg PO BID
9. Atenolol 50 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Disposition:
Home With Service
Facility:
At Home Home Care
Discharge Diagnosis:
Primary diagnosis: Cellulitis
Secondary diagnosis: Type II diabetes, Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted for an infection of your right arm.
Initially, you appeared to be very ill with high fevers so you
were admitted to the intensive care unit for monitoring. You
were transferred to a regular medical floor when you began to
look better clinically. We gave you some antibiotics to help
treat your infection. We also carefully monitored the area to
see if it improved. When you go home, you are to continue
taking the antibiotics and monitor the arm for any changes.
Followup Instructions:
Please follow-up with your PCP.
Completed by:[**2174-6-28**]
|
[
"787.91",
"414.01",
"250.90",
"780.09",
"V10.3",
"348.30",
"274.9",
"038.9",
"457.0",
"276.51",
"V45.89",
"338.29",
"413.9",
"724.5",
"995.91",
"682.3",
"276.2",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8677, 8725
|
5782, 6007
|
242, 249
|
8851, 8973
|
4009, 5759
|
9543, 9605
|
3336, 3390
|
6028, 7905
|
8282, 8654
|
8746, 8746
|
7931, 8259
|
9034, 9520
|
3405, 3899
|
3916, 3990
|
185, 204
|
277, 2853
|
8797, 8830
|
8765, 8776
|
8988, 9010
|
2875, 3095
|
3111, 3320
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,986
| 148,138
|
19502
|
Discharge summary
|
report
|
Admission Date: [**2179-11-4**] Discharge Date: [**2179-11-12**]
Date of Birth: [**2104-2-15**] Sex: F
Service: MEDICINE
Allergies:
Naproxen
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Left Charcot foot
Hypotension
Atrial tachycardia
Major Surgical or Invasive Procedure:
Left foot reconstruction surgery
Medical ICU with 3 red blood cell transfusions
transesophageal echocardiography with cardioversion
History of Present Illness:
75 yo F w/ h/o AF (apparantly s/p ablation in [**2171**] at [**Hospital1 336**]), LUL
lobectomy for TB [**2128**], type II DM with charcot neuropathy,
initially admitted for a left mid-foot reconstruction [**11-4**].
Post-surgery, she was transferred to the MICU for hypotension,
which resolved post fluid resuscitation (IVF and 2 units PRBC)
and transferred back to podiatry. Medicine was consulted
yesterday for mild hypoxia and possible dysarthria. Pt 91% RA,
98% 2L NC. CXR notable for a mild infiltrate in ICU that
resolved rapidly, likely pneumonitis rather than true pneumonia.
Recommended a CTA chest with HCO3/IVF/mucomyst given Cr 1.5
(CRI). Podiatry got CTA (without mucomyst or IVF), which showed
only granulomatous disease.
.
Today, patient noted to be tachycardic to the 120s, systolic BP
140s. ECG looked like atrial flutter. Patient was transferred to
medicine service, she was given 5 mg IV metoprolol, cardiac
enzymes were cycled, her beta-blocker was increased, and a 500cc
IV bolus was given.
.
Regarding the dysarthria, the patient felt her mouth was just
dry, and per Medicine consult her neuro exam was pretty benign
but, given h/o AF, recommended CT head, consideration of MRI
(unclear if she can get it with an external fixation), and neuro
consult - these have not yet been obtained.
.
ROS: negative for fever, chills, nausea, vomiting, diarrhea,
dysuria
Past Medical History:
DM II with neuropathy
PVD
hx hypertension
hx dyslipdemia
hx atrial fibrillatiion
hx TB s/p LUL resection [**2129**]
hx diverticulosis/p bowel resection [**2169**]
hx osteo arthritis
hx arrythmia s/p AV node ablation
s/p TAH, s/p c-section
s/p spinal surgery
s/p rt. hip surgery
s/p rt. EIA endartectomy with patch angioplasty w dacron
s/p b/l foot surgeries
Social History:
married lives with spouse, denies tobacco use, admits to
drinking heavily: 1 bottle of wine to a pint of vodka per day
per her and husband.
.
Family History:
unknown
Physical Exam:
per admitting resident:
96.6 124/45 48 100% on SIMV 500/12 80%, Peep 5
Gen: sedated, unresponsive
Heent: mmm, PERRL
Neck: no masses, no LAD, no JVD, no carotid bruit
CV: irregular, laterally displaced PMI, loud [**3-11**] holosystolic
murmur radiating into her axilla
Chest: cta b/l, no crackles or wheezes.
Abd: soft, nd, +bs, no organomegaly, nt
Extr: no cyanosis, no clubbing; 1+ sacral edema, 2+ pulses b/l.
Pertinent Results:
[**2179-11-4**] 09:50PM TYPE-ART PO2-354* PCO2-42 PH-7.28* TOTAL
CO2-21 BASE XS--6
[**2179-11-4**] 09:50PM GLUCOSE-95 LACTATE-0.7
[**2179-11-4**] 09:50PM freeCa-1.10*
[**2179-11-4**] 09:32PM HCT-26.6*
[**2179-11-4**] 07:57PM GLUCOSE-104 UREA N-44* CREAT-1.6* SODIUM-143
POTASSIUM-4.6 CHLORIDE-115* TOTAL CO2-19* ANION GAP-14
[**2179-11-4**] 07:57PM estGFR-Using this
[**2179-11-4**] 07:57PM CALCIUM-8.0* PHOSPHATE-5.0* MAGNESIUM-1.7
[**2179-11-4**] 07:57PM WBC-7.3 RBC-2.97* HGB-9.9* HCT-29.6*
MCV-100*# MCH-33.2* MCHC-33.3 RDW-19.8*
[**2179-11-4**] 07:57PM PLT COUNT-173
[**2179-11-4**] 06:58PM TYPE-ART PO2-133* PCO2-42 PH-7.29* TOTAL
CO2-21 BASE XS--5
[**2179-11-4**] 06:58PM LACTATE-0.9
[**2179-11-4**] 06:58PM HGB-10.0* calcHCT-30
[**2179-11-4**] 06:58PM freeCa-1.12
[**2179-11-4**] 05:21PM TYPE-ART RATES-/8 TIDAL VOL-660 O2-36
PO2-131* PCO2-35 PH-7.34* TOTAL CO2-20* BASE XS--5
INTUBATED-INTUBATED VENT-CONTROLLED
[**2179-11-4**] 05:21PM GLUCOSE-131* LACTATE-1.2 NA+-141 K+-4.4
CL--121*
[**2179-11-4**] 05:21PM HGB-7.7* calcHCT-23
[**2179-11-4**] 05:21PM freeCa-1.14
.
ECHO (TEE):
Moderate to severe spontaneous echo contrast in the left atrium
in
the absence of left atrial/left atrial appendage thrombus.
Thickened aortic
and mitral valves. Trivial mitral regurgitation. There appears
to be aortic
valve stenosis but the severity cannot be determined on this
study (may be
evaluated [**Last Name (un) **] with a transthoracic study). Complex,
non-mobile
atherosclerotic plaque in the aortic arch and descending aorta.
.
CT Chest:
1. No evidence of pulmonary embolism.
2. Calcified subcarinal nodes and calcified left-sided lung
nodule consistent with previous granulomatous infection.
3. Extensive vascular calcifications consistent with
atherosclerotic disease.
.
Brief Hospital Course:
75 year old lady with type 2 diabetes and neuropathy s/p left
middle foot reconstruction
.
1) Charcot foot: Reconstruction of left foot by podiatry with
1L blood loss. Complicated by post-OP hypotension. Patient was
transferred to the intensive care unit where she was transfused
a total of 4 red blood cell units (PBRC). Also, tachycardia in
120's was noted. The initial impression of dysarthria in the
unit could not be confirmed by subsequent exams.
After surgery the patient was started by podiatry on vancomycin
for prophylaxis. It should be continued for at least two weeks
after discharge. The patient is scheduled for follow up with
podiatry in 2 weeks. Needs weekly vancomycin trough levels, to
be faxed to Dr. [**Last Name (STitle) **] (Fax [**Numeric Identifier 52945**]).
Surgical sites were well coapted with no signs of infection.
.
2) Hypotension: Possibly due to sedation from anesthesia and
component of blood loss . No evidence of infection; Echo showed
mild-moderate aortic stenosis. Her propofol was weaned, 4Units
RBCs were transfused along with aggressive fluid rescussitation,
a central line was placed and she was started on neosynephrine
which was quickly weaned. Her Hematocrit remained stable after
that. Pressures recovered soon and remained stable during the
hospital stay.
.
3) Atrial tachycardia: Noted during the stay in the intensive
care unit. Hemodynamically stable. Tachycardia most likely
atrial flutter. Not responsive to conservative therapy. The
patient underwent transesophageal echocardiography and
cardioversion with 100J. Was after that in sinus rhythm with
ectopies (rate in 70's). Needs anticoagulation with warfarin.
Transition with Lovenox until INR therapeutic. Patient is
scheduled for follow up with cardilogy (Dr. [**Last Name (STitle) **] on
[**2179-12-3**].
Medications on Admission:
HCTZ 25mg
Zoloft 100mg
Ambien
Metorpolol 37.5mg
Lipitor
Amlodipine
Meprobanat
Discharge Medications:
1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
6. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
7. Vancomycin HCl 1000 mg IV Q 24H
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous every twelve (12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 18346**]
Discharge Diagnosis:
Primary:
Charcot neuropathy of left foot with reconstruction surgery
Hypotension
Atrial fibrillation/flutter requiring cardioversion
.
Secondary:
DM II with neuropathy
PVD
Hypertension
Dyslipdemia
TB s/p LUL resection [**2129**]
Osteoarthritis
Discharge Condition:
Good, left foot in halo, heart rate normal with ectopies
Discharge Instructions:
You were admitted for a left foot reconstruction. Post-surgery,
your blood pressure remained low and you were in the ICU for
several days until your blood pressure stabilized. While here,
you also developed an atrial tachycardia which required
cardioversion. You are being discharged on anticoagulation as a
result of this procedure.
.
Please continue to take all your medications as prescribed. You
have not been given your lipitor or meprobamate as the doses
were not clear. Please discuss restarting these with your PCP.
.
Please keep all your follow-up appointments.
.
If you develop any fevers, chills, shortness of breath,
difficulty breathing, chest pain, palpitations, dizziness,
lightheadedness, foot pain, difficulty urinating or any other
worrisome symptoms, please call your PCP or go to the nearest
ER.
Followup Instructions:
Please keep the following appointments:
1) Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2179-11-22**] 8:50
2) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2179-12-3**] 2:00
3) Please call Dr. [**Last Name (STitle) 12925**],[**First Name3 (LF) **] [**Telephone/Fax (1) 52946**] to schedule a
follow-up appointment and discuss when to resume some of your
home medication
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2179-11-12**]
|
[
"287.5",
"443.9",
"V58.67",
"458.29",
"427.32",
"272.4",
"518.0",
"713.5",
"285.1",
"250.60",
"276.2",
"715.90",
"707.14",
"584.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.14",
"77.79",
"38.93",
"78.18",
"99.04",
"99.62",
"83.85",
"81.13",
"88.72",
"84.72",
"78.38"
] |
icd9pcs
|
[
[
[]
]
] |
7551, 7599
|
4715, 6530
|
319, 453
|
7890, 7949
|
2880, 4692
|
8813, 9525
|
2420, 2429
|
6658, 7528
|
7622, 7869
|
6556, 6635
|
7973, 8790
|
2444, 2861
|
231, 281
|
481, 1864
|
1886, 2245
|
2261, 2404
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,532
| 193,381
|
33243
|
Discharge summary
|
report
|
Admission Date: [**2142-12-23**] Discharge Date: [**2142-12-29**]
Date of Birth: [**2077-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine / Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
lightheadedness, DOE
Major Surgical or Invasive Procedure:
s/p AVR(23mm [**Company **] mosaic porcine)/CABGx1(LIMA-LAD) [**12-25**]
History of Present Illness:
65 yo M with known AS and increasing symptoms.
Past Medical History:
^lipids, HTN, h/o head trauma as child, s/p L4-5 fusion, s/p
T&A, s/p RIH, s/p ex lap as child for trauma
Social History:
retired firefighter
occasional cigar
etoh < 1/day
lives with wife
Family History:
NC
Physical Exam:
HR 76 RR 20 BP 140/74
NAD
Lungs CTAB
Heart RRR 4/6 SEM
Abdomen benign
Extrem warm, no edema
Brief Hospital Course:
He was taken to the operating room on [**12-25**] where he underwent a
CABG x 1 and AVR. He was transferred to the ICU in stable
condition on neo and propofol. He was extubated later that day.
He was transferred to the floor on POD #2. That evening he
developed rapid atrial fibrillation and became hypotensive, and
was therefore transferred back to the ICU. He was given IV
fluids and started on amiodarone. He improved, and was
transferred back to the floor on the following day. stopped [**12-27**].
Patient remained in NSR, hemodynamically stable, ambulating,
and has been diuresing. Patient discharged POD5 in good
condition.
Medications on Admission:
ASA 81', diovan 80', vit B, CoQ10
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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).
Disp:*45 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO TID
(3 times a day) for 1 weeks: discontinue sooner if symptoms
improve.
Disp:*210 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
.[**Company **]
Discharge Diagnosis:
Coronory Artery Disease
Aortic Stenosis
:^lipids, HTN, h/o head trauma as child, s/p
L4-5 fusion, s/p T&A, s/p RIH, s/p ex lap as child for trauma
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Dr. [**Last Name (STitle) 37063**] 2weeks
Dr.[**First Name (STitle) **] 2weeks
Dr. [**Last Name (STitle) 1290**] 4weeks
|
[
"427.31",
"401.9",
"424.1",
"414.01",
"997.1",
"E878.2",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2651, 2697
|
821, 1455
|
306, 381
|
2906, 2913
|
3241, 3366
|
685, 689
|
1539, 2628
|
2718, 2885
|
1481, 1516
|
2937, 3218
|
704, 798
|
246, 268
|
409, 457
|
479, 586
|
602, 669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,384
| 107,272
|
47991
|
Discharge summary
|
report
|
Admission Date: [**2131-4-23**] Discharge Date: [**2131-5-3**]
Date of Birth: [**2054-4-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation
central line placement
Cardiac catheterization with no intervention
History of Present Illness:
77 YO gentleman with history of multiple TIAs s/p recetn CEA on
[**4-20**] brought into ED by ambulace for hypoxemia and respiratory
failure. Dr. [**Known lastname **] underwent CEA on [**4-20**] and by accounts had an
uneventful post operative course. By report he developed SOB
yesterday that progressivly worsened overnight. This morning he
was unable to get out of bed secondary to weakness. EMS was
called and by their report he was found supine and purple in
bed. They placed on 15l NRB and O2 Sats only came up to 90%. On
arrival to the ED his VS were notable for RR of 40 and sats in
the 90'2 on 15L. He was awake and alert on arrival with a
relativly clear mental status. He was only able to speak in one
or two word sentences. A CXR demonstrated new onset pulmonary
edema. He has no known pulmonary or cardiac history. He had no
reports of fevers, post op or pre-hospital. He denied cough to
ED staff.
.
In the ED he was initially placed on BiPap and had improvement
in his oxygenation. He was given a sublingual NTG and became
hypotensive, this precluded him receiving nitro GTT. He did not
receive IVF. He was noted to have several apneic episodes while
on BiPAP and was intubated due to respiratory fatigue. The
intubation was complicated by difficult to visualize airways and
he suffered a laceration of his lips. By report there was NO
blood in the ETT.
.
He is currently on FiO2 100 %/Peep 5/Rate 17/TV 600. Sedated on
fentanyl and versed. On 6mcg of dopa with BP 113/68. He has had
minimal UOP. Total UOP 100.
.
His labs are significant for a troponin of 1.13, leukocyotsis
21.6, Anion gap acidosis, Cr of 2.5 (baseline 0.9) and an
elevated lactate (6--->3 with intubation).
Past Medical History:
-h/o stroke in [**2118**], treated at [**Hospital1 2025**], L MCA territory
-BPH with secondary hematuria
-cystic pancreatic mass, following q2years
Social History:
Works at the Mind Body Institute he founded and teaches at HMS.
No tobacco, EtOH, illicits. Lives with wife, he provides care
for his wife and administers her medications.
Family History:
Brother had MI in 40s, sister has carotid stenosis.
Physical Exam:
ED Admission exam:
Temp: 98.2 HR: 109 BP: 108/77 Resp: 33 O(2)Sat: 91 Low
Constitutional: O2 sat 90% NRB FM; pulse 70s
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, Normocephalic, atraumatic
no wheezing; left neck with ecchymosis; no bruit; no puls
mass; JVD on right 5 cm
Chest: bilateral insp rales [**12-25**] way up
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds; no m/r/g
Abdominal: Normal
Extr/Back: Normal
Skin: ecchymosis left neck but no other rashes
Physical Exam on Discharge:
VS: 98.2/98.2 67-72 RR 18-20 BP: 125-152/74-76 O2 sat 92-97% RA
I/O: 8 hour 84/425
24 hour 1130/[**2103**]
TELE: SR, HR 70's
Weight: refused for 2 days
GEN: NAD, sitting comfortably in chair
HEENT: MMM, no conjunctival erythema or scleral icterus
NECK: no JVD; ecchymosis over left CEA site but no fluctuance or
mass
CV: Regular, S1 and S2, no murmur
PULM: lungs CTA throughout
ABDOMEN: nondistended, (+)bowel sounds, nontender
EXTREM: 2+ DP and PT pulses bilaterally, no edema, warm feet
NEURO: alert, oriented x3, answers all questions appropriately
Pertinent Results:
Admission Labs:
[**2131-4-23**] 01:30PM BLOOD WBC-21.6* RBC-4.35* Hgb-13.7* Hct-43.1
MCV-99* MCH-31.4 MCHC-31.7 RDW-13.4 Plt Ct-265
[**2131-4-23**] 01:30PM BLOOD Neuts-90.1* Lymphs-4.9* Monos-4.0 Eos-0.8
Baso-0.3
[**2131-4-23**] 01:30PM BLOOD Glucose-279* UreaN-47* Creat-2.5*# Na-135
K-4.9 Cl-94* HCO3-23 AnGap-23*
[**2131-4-23**] 05:31PM BLOOD ALT-41* AST-152* CK(CPK)-912* AlkPhos-88
TotBili-0.7
Relevant Labs:
[**2131-4-22**] 08:05AM BLOOD proBNP-8203*
[**2131-4-23**] 01:30PM BLOOD CK-MB-40* MB Indx-4.9
[**2131-4-23**] 01:30PM BLOOD cTropnT-1.33*
[**2131-4-23**] 05:31PM BLOOD CK-MB-46* MB Indx-5.0 cTropnT-2.08*
[**2131-4-24**] 12:45AM BLOOD CK-MB-44* MB Indx-5.6 cTropnT-2.96*
[**2131-4-25**] 04:02AM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-4.25*
[**2131-4-26**] 05:27AM BLOOD CK-MB-4 cTropnT-5.38*
[**2131-4-27**] 05:25AM BLOOD CK-MB-2 cTropnT-5.70*
[**2131-4-28**] 03:18AM BLOOD CK-MB-2 cTropnT-5.21*
Imaging/Reports:
Chest x-ray [**2131-4-23**]
Endotracheal tube positioned appropriately. NG tube appears
also
to be positioned appropriately, though the tip is excluded from
view. Diffuse pulmonary edema with pleural effusions again
seen.
TTE [**2131-4-23**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with near
akinesis of the distal 2/3rds of the septum, anterior wall,
apex, and distal inferior wall. The remaining segments contract
normally (LVEF = 30 %). No intraventricular thrombus is seen.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#).No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. [Due to acoustic shadowing/suboptimal
image quality, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be quantified. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Normal left ventricular cavity size with extensiver
regional systolic dysfunction c/w CAD (mid-LAD distribution) or
Takotsubo cardiomyopathy. No definite valvular dysfunction.
Compared with the prior study (images reviewed) of [**2131-4-19**],
the left ventricular wall motion abnormalities are new and c/w
interim ischemia/infarction.
TTE [**2131-4-27**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately-to-severely depressed (LVEF = 30 %) secondary to
extensive severe hypokinesis/akinesis involving the anterior
septum, anterior free wall, apex, and inferior septum. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are myxomatous. There is mild posterior leaflet mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared to the prior study of [**2131-4-23**], moderate mitral
regurgitation is now seen.
Renal US:
FINDINGS: The right kidney measures 12.2 cm and the left kidney
measures 11.4 cm. A 6 x 6 x 4 mm non-obstructing stone is
present in the right kidney interpolar region. No left renal
calculus. No hydronephrosis or mass seen in either kidney. The
bladder contains a Foley, is minimally distended, and cannot be
assessed.
IMPRESSION: 6-mm nonobstructing right renal stone. No
hydronephrosis
Cardiac Catheterization [**2131-5-1**]:
1. Selective coronary angiography in this left-dominant system
demonstrated two vessel disease. The LMCA had no
angiographically
apparent disease. The LAD was occluded proximally and filled via
right-to-left collaterals. The LCx was dominant and had mild
disease.
The nondominant RCA was subtotally occluded but provided robust
collaterals to the LAD via an acute marginal.
2. Limited resting hemodynamcis revealed normal systemic
arterial blood
pressure.
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Normal systemic arterial blood pressure.
Dobutamine Stress Test [**2131-5-2**]:
77 yo man presented in respiratory failure secondary
to subacute anterior MI post-op following left carotid
endarterectomy on
[**2131-4-20**], cardiac catheterization revealing 2-vessel CAD and
depressed
LVEF was referred to evaluate for viability in LAD territory.
The
patient was administered 2.5, 5, 10 and 20 mcg/kg/min of
Dobutamine (5
min stages) for a total infusion duration of 20 minutes. No
chest, back,
neck or arm discomforts were reported. No significant ST segment
changes
were noted during the procedure. The rhythm was sinus with rare
isolated
VPBs noted. The heart rate response was appropriate. A blunted
blood
pressure response was noted with the Dobutamine infusion.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Blunted
blood pressure response to the Dobutamine infusion. Echo report
sent
separately.
Stress ECHO [**5-2**]:
The patient received intravenous dobutamine in 5 min (low dose
2.5mcg/kg/min) and 3 minute stages (>5mcg/kg/min) to a maximum
of 20 mcg/kg/min. The test was stopped because the viability
protocol was completed. In response to stress, the ECG showed no
diagnostic ST-T wave changes (see exercise report for details).
The blood pressure response to stress was blunted. There was a
normal heart rate response to stress.
.
Resting images were acquired at a heart rate of 72 bpm and a
blood pressure of 136/68 mmHg. These demonstrated regional left
ventricular systolic dysfunction with severe hypokinesis to
akinesis of the septum, anterior wall, mid to distal lateral
wall, apex, and distal inferior wall. The remaining segments
contracted well. (LVEF = 25-30 %). Right ventricular free wall
motion is normal. There is a trivial pericardial effusion.
Doppler demonstrated trace aortic regurgitation and moderate
mitral regurgitation with no aortic stenosis or significant
resting LVOT gradient.
At low dose dobutamine [5mcg/kg/min; heart rate 72 bpm, blood
pressure 134/60 mmHg), there was failure to augment systolic
function of the affected (LAD territory) segments. At mid-dose
dobutamine [5-10 mcg/kg/min; heart rate 74 bpm, blood pressure
130/50 mmHg), there was failure to further augment systolic
function of the affected left ventricular segments. At peak
dobutamine stress [20 mcg/kg/min; heart rate 88 bpm, blood
pressure 128/50 mmHg), no new regional wall motion abnormalities
were identified. Baseline abnormalities persist.
IMPRESSION: No diagnostic ECG changes with 2D echocardiographic
evidence of prior proximal LAD-territory myocardial infarction
without inducible ischemia to dobutamine administration or
evidence of viability of the anterior/septal/apical/distal
inferior wall. The other segments augment appropriately. Trace
aortic regurgitation at rest. Moderate mitral and tricuspid
regurgitation at rest. At least moderate pulmonary hypertension.
Labs on Discharge:
[**2131-5-3**] 04:58AM BLOOD WBC-12.5* RBC-3.48* Hgb-11.1* Hct-33.9*
MCV-98 MCH-31.9 MCHC-32.7 RDW-13.6 Plt Ct-313
[**2131-5-3**] 04:58AM BLOOD Glucose-165* UreaN-32* Creat-1.6* Na-137
K-3.9 Cl-104 HCO3-23 AnGap-14
[**2131-5-1**] 07:40AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9
Brief Hospital Course:
Dr. [**Known lastname **] is a 77 year old gentleman who presented 2 days s/p
left CEA with new-onset systolic CHF secondary to peri-operative
anterior MI. His course has been complicated by hypoxic
respiratory failure (resolved/extubated after treatment of CHF),
AFib (s/p cardioversion and Amiodarone), and [**Last Name (un) **] (likely from
hypoperfusion, now resolving).
# CAD/acute MI: Enzymes, EKG and history suggested recent MI
associated with pulmonary edema and need for intubation in the
[**Hospital1 18**] ER. Was on lasix GTT and dopamine transiently in the CCU
and ultimately extubated without difficulty once volume status
optimized. Unclear age or extent of infarct but likley had been
>24 hours prior to admission and so did not complete urgent PCI.
TTE showing LVEF 30% with Hypokinesis and akinesis of apex.
Troponins peaked at 5.7. Patient was medically managed. He had
a diagnosstic cardiac catheterization to assess for lesions that
could be intervened upon. It showed left-dominant system two
vessel disease (hydrated pre and post cath to avoid [**Last Name (un) **]). The
LMCA had no angiographically apparent disease. The LAD was
occluded proximally and filled via right-to-left collaterals.
The LCx was dominant and had mild disease. The nondominant RCA
was subtotally occluded but provided robust collaterals to the
LAD via an acute marginal. No intervention was done at that
time. A dobutamine stress test was obtained to assess for
viability. This showed no viability, so patient not candidate
for re-catheterization. Continued home ASA. Started on Toprol
50 XL daily, plavix. Patient initially not on RAAS blocker due
to [**Last Name (un) **], but as Cr trended down, started Lisinopril 2.5. Patient
was seen by representative from the life vest and agreed to use
it on discharge.
.
#. Mild transaminitis: Initially suspicious for drug reaction to
amiodarone or ceftriaxone. Stopped offending agents.
Transaminitis improved. On d/c, patient was tolerating statin.
.
# Paroxysmal Afib: Patient was went into atrial fibrillation
with RVR on morning following admission. He was electrically
cardioverted once in the CCU but promptly flipped back in to
Afib with RVR. He was oaeed with amiodarone and converted to NSR
which he remained in for the duration of his stay. The
amiodarone was eventually discontinued prior to discharge for a
mild transaminitis.
.
# [**Last Name (un) **]: Baseline Cr 1.0 but was 2.5 on arrival. Most likely from
poor perfusion in the setting of decompensated heart failure
however arrived to CCU w/ clot in foley. Changed to 3-way with
CBI. Was never oliguric. Renal ultrasound showed no signs of
obstruction. [**Month (only) 116**] have had some component of ATN. Trended Cr,
avoided nephrotoxins, renally dosed meds. On d/c, Cr was 1.6.
.
# BPH: foley in place. Some pink urine in bag. Urine cultures
were negative x2. Continued Tamsulosin and Finasteride. Team
was in communication with Dr. [**Last Name (STitle) **], the outpt urologist.
Decided to keep foley in on d/c and Dr. [**Last Name (STitle) **] will d/c it as
outpatient.
.
# s/p CEA: Vascular following. Per Vascular Surgery, there was
no concern for bovine graft infection or hematoma on admission.
But given his initial leukocytosis they wanted to empirically
treat with Abx until it is clear he was never bacteremic. Blood
cx from [**4-23**] were negative, so d/c'ed abx on [**4-24**].
.
#. Leukocytosis: On admission, Dr. [**Known lastname **] had persistently mild
leukocytosis (WBC [**12-7**]). WBC was trending up prior to d/c after
CEA, and was discharged on empiric Cipro (had foley in place).
Upon initial presentation this admission, WBC was 21.6 but has
persistently been [**12-7**] since then. Note that he was on
Vanc/Zosyn from admission [**Date range (1) **]. However, here urine culture
negative, initial blood cultures negative, and nothing on
history or physical to suggest PNA. Loose stools but C.diff
negative. Vascular believed there was no bovine CEA graft
infection. No cellulitis. His current leukocytosis was likely
related to MI in addition to ongoing stress response.
Antibiotics were d/c'ed on [**4-24**] as above.
.
TRANSITIONS OF CARE:
- Repeat TTE in 1 month or at cardiology followup to determine
whether he needs the life vest/AICD placement
- Repeat LFTs at PCP visit to ensure transaminitis is resolving
- Will have INR and Chem7 checked on Monday after d/c
- Follow up with urology to have foley removed
- Will need WBC trended and if persistently elevated will need
to be worked up as outpatient
- Emergency Contact : [**Name (NI) 4134**] [**Name (NI) **] (wife/HCP) [**Telephone/Fax (1) 101252**]
Medications on Admission:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)*
Refills:*0*
4. Vitamin C Oral
5. verapamil 180 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation. Disp:*60 Capsule(s)*
Refills:*2*
7. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule,
Ext Release 24 hr(s)* Refills:*2*
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0*
Import Discharge Medications
Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7 and INR on Monday [**5-7**] with results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD 9: 410.01
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
7. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
8. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Metamucil Powder Sig: Two (2) teaspoons PO once a day as
needed for constipation.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain: Take 1 tab,
wait 5 min, can take 1 more tab, call 911 if you still have CP.
.
Disp:*25 tab* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute systolic congestive heart failure
Myocardial infarction
Acute Kidney Injury
Acute Urinary retention
Transient atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. [**Known lastname **],
You were admitted to [**Hospital1 18**] due to respiratory failure which was
due to heart failure after peri-operative MI. You required
intubation and diuresis but were able to be extubated. Your
stay was complicated by atrial fibrillation (now resolved),
kidney injury due to your heart attack (slowly resolving), and
continued urinary retention (for which you still have a foley
catheter). Please follow up with your PCP, [**Name10 (NameIs) **], and
Urology (appointments listed below).
Due to the decrease in your EF, you should weigh yourself every
morning, call Dr. [**First Name (STitle) **] if weight goes up more than 3 lbs in 1
day or 5 pounds in 3 days.
You have also been fitted with a Lifevest that will defibrillate
ventricular tachycardia or fibrillation if it occurs.
We made the following changes to your medications:
1. START taking clopidogrel to prevent further thrombus
formation
2. START taking metoprolol to slow your heart rate
3. START taking lisinopril to help with remodeling of your heart
and as an afterload reducer
4. START taking tamsulosin and finasteride to shrink your
prostate
5. INCREASE the atorvastatin to 40 mg daily
6. START taking nitroglycerin tablets as needed for chest pain
7. START taking warfarin to prevent clot formation in your left
ventricle and prevent another stroke.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2131-5-8**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2131-5-10**] at 2:50 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: CARDIAC SERVICES
When: THURSDAY [**2131-5-31**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2131-5-5**]
|
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"414.2",
"787.91",
"427.31",
"E878.2",
"428.0",
"788.20",
"455.8",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"37.22",
"96.04",
"88.56",
"89.64",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
19076, 19134
|
11500, 15695
|
319, 400
|
19314, 19314
|
3697, 3697
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|
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|
272, 281
|
11202, 11477
|
428, 2121
|
3714, 8207
|
19329, 19441
|
15716, 16187
|
2143, 2293
|
2309, 2482
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,271
| 116,448
|
6429
|
Discharge summary
|
report
|
Admission Date: [**2192-11-4**] Discharge Date: [**2192-11-19**]
Date of Birth: [**2149-1-1**] Sex: M
Service: [**Last Name (un) **]
ADMITTING DIAGNOSIS: A 43 year-old with HCV cirrhosis,
status post liver transplant [**2192-11-4**].
HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
male with history of HCV and cirrhosis on transplant list who
now presents for liver transplant. Patient has had several
admissions including the most recent on [**2192-10-8**]
during which time a TIPS procedure was performed for diuretic
resistant ascites and hyponatremia which has helped in
control of his ascites. But eventually he became jaundiced
with the bilirubin rising to 11. The patient was notified on
[**2192-10-30**] that there was a potential liver
transplant. However, it did not occur.
The patient has no episodes of confusion although his wife
does say that he is somewhat drowsy and sleeps quite a bit.
His abdominal pain has improved. His abdominal distention and
ankle edema has improved too. Baseline he is treated with
lactulose. Patient has no recent fevers, chills, nausea,
vomiting.
PAST MEDICAL HISTORY: HCV cirrhosis. History of hemorrhoids,
anal fissure, hyponatremia. Echocardiogram that was performed
in [**2192-3-9**] demonstrated an ejection fraction of 55.
PAST SURGICAL HISTORY: Clubbed foot, repaired when young.
ALLERGIES: Erythromycin, gastrointestinal upset.
MEDICATIONS ON ADMISSION: Quinine 325 mg q day, coprostanol
750 q week, spironolactone 100 mg q day, Lasix 80 mg q day,
Protonix 40 mg q day, lactulose b.i.d. - t.i.d., Senna,
Colace, Gas-Ex, calcium, vitamin D.
SOCIAL HISTORY: Patient is married with three children, no
tobacco. No current alcohol. Patient had a history of alcohol
abuse, quit in [**2172**] and IV drug abuse. Patient does have
_____.
FAMILY HISTORY: Uncle had alcohol abuse-induced liver
cirrhosis.
PHYSICAL EXAMINATION: Patient is afebrile. Vital signs are
stable. Weight 91.3 kilograms, 4 feet 8. Patient is awake,
alert, positive scleral icterus. Extraocular movements are
full. Pupils are equal, round and reactive to light. Lungs
clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm. Normal S1 and S2 without murmurs. Abdomen
distended but nontender. No organomegaly palpated. No
hernias. No fluid wave. Extremities: Warm, +1 edema noted.
So patient was admitted. Patient was kept n.p.o. Work up
included chest x-ray, electrocardiogram, laboratories, type
and screen and then patient was ordered for fluconazole,
Unasyn, Cellcept, Solu-Medrol to be on call for the operating
room. Patient did go to the operating room on [**2192-11-4**]. Patient had an orthotopic deceased donor liver
transplant (piggyback, portal vein, portal vein anastomosis,
common hepatic artery (recipient to common hepatic donor,
common bile duct - common bile duct anastomosis over a French
T tube performed by [**Last Name (NamePattern4) 24748**] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] and [**Doctor Last Name **].
Please see the operating room note for detailed information
about the surgery. Postoperatively the patient did go to the
unit. Patient was intubated and sedated. Patient had serial
hematocrits, coagulations x24 hours. Patient received Solu-
Medrol, MMF, subcutaneous heparin, Protonix. Patient had a
nasogastric tube placed. Patient had a central line, triple
lumen placed. Postoperative day #1 patient did have a duplex
liver ultrasound demonstrating unremarkable hepatic
vasculature and transplanted liver perfusion on the right.
[**Last Name (un) **] was consulted because of steroid-induced diabetes
mellitus and had followed patient while patient was an
inpatient. Patient had two J tubes, one medial and one
lateral and a T tube, was on antibiotics postoperatively,
Vancomycin, Zosyn. Patient was started on tacrolimus 2 and 2,
MMF 1,000 b.i.d., Solu-Medrol. Patient had received a total
of 5 doses of _____. On [**2192-11-5**] platelets slowly
dropped. Blood test was sent off which was negative. Patient
was getting out of bed, tolerating p.o. intake. On [**2192-11-9**] patient had a postoperative T tube cholangiogram that
demonstrated that there was no evidence of extravasation.
Luminal narrowing of the anastomosis with delayed passage of
contrast which could be secondary to postoperative edema. So
T tube was capped. One of the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains because of
decreased output was removed. Physical and occupational
therapy saw the patient. On postoperative day 7 the second
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain was removed because of no output.
Patient's liver function tests were slightly elevated after
capping T tube. Tacrolimus was slowly increased due to the
low level. A duplex ultrasound was performed on [**2192-11-12**] because of slightly elevated liver function tests
demonstrating that there was a 5 x 5.8 x 3.5 fluid collection
adjacent to the right lobe consistent with a biloma. 2) There
was dilation of the common bile duct, common hepatic duct and
central intrahepatic duct consistent with a substantial
obstruction/stenosis. Because patient was distended in the
abdomen a KUB was performed demonstrating:
1. Nonspecific bowel gas patterns which could represent
ileus with many air fluid levels. CT of the abdomen was
obtained the following day on [**2192-11-13**]
demonstrating there is mild central intrahepatic biliary
ductal dilatation and the common duct measures 11 mm to
the level of the T tube. The common duct is collapsed
distal to the T tube.
2. There are patent portal veins, hepatic artery and hepatic
veins.
3. Ascites fluid within the abdomen greatest inferior to the
right lobe of the liver. No discrete fluid collection is
identified. There is also fluid adjacent to the spleen
within the lesser sac and within the pelvis.
4. Possible ileus.
5 Minimal right basilar atelectasis.
This prompted to have a T tube cholangiogram which
demonstrated that there was post liver transplant T tube
cholangiogram demonstrated filling of the native common bile
duct and no opacification of the transplant biliary tree.
Contrast was infused by gravity. Another T tube cholangiogram
was performed on [**2192-11-16**] to evaluate all of the
biliary tree demonstrating that there is post liver
transplant T tube cholangiogram demonstrates prompt filling
of the native common bile duct with prompt drainage into the
small bowel. Filling of the right and possible also left
intrahepatic bile duct in Trendelenburg position demonstrates
normal appearing intrahepatic bile duct. Patient continued to
have a great deal of stool. Patient had increased amount of
stool and placed originally on Flagyl, then this was
discontinued, but on [**2192-11-17**] because he was having
increased stool on tube feeds and although multiple stool
cultures were obtained which demonstrated that there was no C
difficile, but because he improved clinically with his stools
with the frequency of loose stools lessened with Flagyl, it
was decided to place him back on Flagyl. After the
cholangiogram on [**2192-11-16**] T tube was recapped. FK
level ranged from 5.4 to 16.8. 5.4 was when he just started
taking the tacrolimus. While he was an inpatient hepatitis
surface antibody and hepatitis surface antigen were obtained
which were quantitative. On [**2192-11-11**], [**2192-11-14**] and [**2192-11-18**] the hepatitis B surface antigen
were negative and the hepatitis surface antibody had a titer
of greater than 450 MIU per ml. So patient was discharged on
[**2192-11-18**] to home with [**Hospital3 **] VNA. So patient
went home with the following medications:
Aluminum hydroxy gel 600 mg per 5 ml suspension, 10 to 30 ml
p.o. q 8 hours p.r.n. for heartburn.
Protonix 40 mg q 12.
Prednisone 20 mg q day.
Fluconazole 400 mg q day.
Lamivudine 100 mg q day.
Bactrim SS 1 tablet q day.
MMF 500 mg q.i.d.
Oxycodone 5 mg q 4 hours p.r.n.
Tylenol 325 1 p.o. q 6 hours p.r.n.
Tacrolimus 3 mg b.i.d.
Flagyl 500 mg t.i.d. for 12 days.
Valganciclovir 900 mg q day.
Patient was discharged on the insulin sliding scale with
fingersticks.
Patient is to have laboratories drawn every Monday and
Thursday and have the results faxed immediately to [**Telephone/Fax (1) 24749**]. Patient is to call transplant surgery immediately at
[**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting,
abdominal pain, increase in abdominal birth. To call if there
is any change in the incision any discharge to the incision.
Also notify transplant if he has difficulty with appetite,
urination or bowel movements.
FINAL DIAGNOSES:
1. HCV cirrhosis, status post liver transplant [**2192-11-4**].
2. Steroid induced hyperglycemia.
3. Question of C difficile treated with Flagyl.
SECONDARY DIAGNOSIS: Hemorrhoids.
Anal fissure.
Chronic hyponatremia.
Patient is to follow up with transplant surgery next week.
Please call [**Telephone/Fax (1) 673**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2192-11-27**] 13:43:15
T: [**2192-11-27**] 15:48:13
Job#: [**Job Number 24750**]
|
[
"251.8",
"576.8",
"070.70",
"276.1",
"572.3",
"E932.0",
"571.5",
"787.91",
"998.12",
"575.4",
"570",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.51",
"51.22",
"00.93",
"99.00",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
1845, 1895
|
1448, 1635
|
1334, 1421
|
8714, 8864
|
1918, 8697
|
286, 1126
|
8886, 9325
|
176, 257
|
1149, 1310
|
1652, 1828
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,629
| 153,402
|
28350
|
Discharge summary
|
report
|
Admission Date: [**2170-10-31**] Discharge Date: [**2170-11-7**]
Date of Birth: [**2117-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Back and foot pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53yoM ESLD (off transplant list [**2-16**] continued alcohol use)
transferred from [**Hospital3 **] for work-up of hepatic encephalopathy
and for hepatology care. By report, patient lives independently
at home, arrived at [**Hospital3 **] with "weakness" and "back pain,"
had SBPs 90s, HR 40s - given 1L NS, transferred [**Hospital1 **].
In ED, hepatology consult, recommended tox screen, labs. Pt
given lactulose, tox screen(-), acetaminophen(+) --> started
mucomyst, received potassium repletion. Pt had hypotensive
episode in high 70's systolic, given 2L NS, BP response to 80s,
HR 50, RR 18, 96%ra. -> 2nd IV placed, passed stool, making
urine >30cc/hr, admitted to ICU after 2L IVF.
ROS - as above, reports decreased PO intake for three days.
Denies fevers, chills, nausea, vomiting
Past Medical History:
- Type 2 diabetes.
- Chronic back and neck pain.
- Cirrhosis secondary to hepatitis C and alcohol abuse.
- Psychiatric history consistent with his depression/bipolar
disease.
- Remote IVDU.
- Active tobacco use.
- Basal cell carcinoma of the nose, status post two operations
with a further operation planned in probably [**2169-12-15**].
Social History:
Patient smokes half a pack per day since the age of 13. He was
drinking half a case of beer plus vodka up until [**2169-2-15**].
He admits to IV drug use for two years in [**2137**] to [**2139**], but
denies any recent IVDU. Prior occupation was as a water
treatment specialist with exposure to multiple chemicals as well
as driving a rubber truck. He is currently disabled. He is
living with his mother in her house on her couch and is
currently
receiving a disability cheque of $300 per month. He has no
brothers or sisters, although he does have several cousins who
are described as being close. Mr. [**Known lastname 68818**] states that he has
no friends at this time as all of them are deceased from drugs
and alcohol.
Family History:
Father with MS and history of Liver CA - passed away [**2156**]
Physical Exam:
PE: T: 97.1 BP:96/52 HR: 58 RR: 16 97 O2%ra
Gen: NAD, A/Ox3 - oriented to person, place, time, lying in bed,
conversant, cooperative, but slowed.
HEENT: no conjunctival pallor, scleral icterus appreciated,
mildly dry membranes, no posterior pharyngeal erythema.
NECK: no posterior/anterior LAD, no JVD appreciated.
CV: RRR, S1+S2+S3-S4-, no murmurs or rubs appreciated.
LUNGS: CTAB, good air movement bilaterally, mild crackles in
left lower lobe.
ABD: NABS, soft, non-tender, non-distended. Unsure of fluid
wave, no apparent tense ascites. +fluid wave.
EXT: +lower extremity edema. 1+ palpable pulses bilaterally
dorsalis pedis, posterior tibial, radial, ulnar, all 2+.
SKIN: diffuse yellowed skin.
NEURO: A&Ox3, seems apropriate. Occassional has abnormal
comments "spider from Mars." CN 2-12 grossly intact, did not do
fundoscopy. Preserved sensation throughout. MSK [**4-19**]
bilaterally, upper extremities and lower extremities. 1+
reflexes L4 bilaterally.
.
Pertinent Results:
[**2170-10-31**] 07:20PM PT-28.3* PTT-62.0* INR(PT)-2.9*
[**2170-10-31**] 07:20PM PLT COUNT-30*
[**2170-10-31**] 07:20PM NEUTS-66.6 LYMPHS-19.9 MONOS-10.9 EOS-2.1
BASOS-0.5
[**2170-10-31**] 07:20PM WBC-3.7* RBC-3.48* HGB-12.9* HCT-36.7*
MCV-106* MCH-37.2* MCHC-35.3* RDW-18.2*
[**2170-10-31**] 07:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-12.5
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-10-31**] 07:20PM HAPTOGLOB-<20*
[**2170-10-31**] 07:20PM ALBUMIN-1.9* CALCIUM-8.0* PHOSPHATE-4.3
MAGNESIUM-2.5
[**2170-10-31**] 07:20PM LIPASE-52
[**2170-10-31**] 07:20PM ALT(SGPT)-49* AST(SGOT)-96* LD(LDH)-290* ALK
PHOS-121* AMYLASE-92 TOT BILI-29.9* DIR BILI-21.6* INDIR BIL-8.3
[**2170-10-31**] 11:17PM LACTATE-1.9
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL
Reason: ? ascites, ? patency of vesselsplease assess with
dopplers
[**Hospital 93**] MEDICAL CONDITION:
52 year old man with ESLD, encephalopathy
REASON FOR THIS EXAMINATION:
? ascites, ? patency of vesselsplease assess with dopplers
ULTRASOUND OF THE LIVER
CLINICAL INDICATION: End-stage liver disease, encephalopathy,
assess for ascites and patency of liver vessels.
COMPARISON STUDY: [**2170-7-20**].
The liver is grossly abnormal in architecture with a nodular
pattern and a markedly irregular capsular surface. While no
discrete hepatic masses are seen, the derangement of
architecture is so severe that the sensitivity for detection of
liver lesions is markedly diminished. There is a markedly
enlarged spleen measuring at least 18 cm in length, and there is
also evidence of large volume of ascites. Portal vein is patent
but there is hepatofugal flow in the right portal system and
flow in the left portal vein is hepatopetal and exits the liver
via a huge patent umbilical vein collateral.
Pancreas and retroperitoneum are not well seen. There are no
gallstones identified nor is there evidence of bile duct
dilatation. There may be some sludge in the dependent portion of
the gallbladder. Limited views of the kidneys show no obvious
hydronephrosis.
CONCLUSION: Severe cirrhosis and portal hypertension with large
patent umbilical vein and massive splenomegaly. The liver
architecture is markedly deranged and ultrasound is therefore
insensitive for detection of focal liver lesions, although no
masses can be identified. Large volume ascites is also noted.
Portions of the right and middle hepatic veins are visualized
and are patent.
CHEST (PORTABLE AP)
Reason: infiltrate, edema
[**Hospital 93**] MEDICAL CONDITION:
52 year old man with hypotension
REASON FOR THIS EXAMINATION:
infiltrate, edema
REASON FOR EXAMINATION: Hypertension in patient with known
cirrhosis.
The lungs are low. The heart size is slightly enlarged compared
to [**2170-3-28**] which may be partially explained by low lung
volumes. The bibasal crowdness of the vessels is more pronounced
in the left base where developing pneumonia cannot be excluded.
The upper lungs are unremarkable. The biapical attenuation of
the lung vessels might represent emphysema. Small left pleural
effusion cannot be excluded.
IMPRESSION: Questionable left lower lobe pneumonia. Repeated
radiograph in upright position including the lateral view was
reccommended for precise evaluation of LLL findings and
questionable increase in the heart size.
Findings were discussed with Dr [**First Name (STitle) 1887**] at the time of dictation.
Brief Hospital Course:
Encephalopathy - Patient was thought to have hepatic
encephalopathy, complicated renal failure with mild uremia, and
possible infection of unknown source. There was also a question
of lactulose non-compliance as well as possible other
ingestions. Patient's mental status initially cleared, at which
point he was able to clearly state his wishes to be DNR/DNI, and
was able to state the meaning of that choice and express it to
his family as well. During his second admission to the MICU,
after a family meeting, the decision was made to transition care
to comfort measures only, given patient's desires as well as
overall poor prognosis. His encephalopathy was efractory to
lactulose/rifaxamine administration.
.
His acidosis, renal failure, and encephalopathy were no longer
addressed, as prior plan outlined below.
.
The following represent a list of his current active problems at
the time he expired.
.
- Acidosis: combination of volum depletion and failure to clear
exogenous lactate admin or endogenous lactate production from
hypotension.
.
- Renal Failure: concern for evolving hepatorenal syndrome
.
- Hypotension: multifactorial. concern for infectious cause
.
CODE STATUS: Family meeting was held after evaluation by MICU
team during second admission on to MICU. Patient's family
decided that comfort should be goals of care and their wishes
will be followed. The patient was lucid and of sound mind on
admit [**10-31**] and wished then to be DNR/DNI, with comfort as the
goals of care. This wish was followed after re-admission to the
MICU, by the patient's family, HCP and patient.
.
At that time, all medications except those for pain control and
comfort were discontinued. The patient passed away on [**2170-11-7**].
Medications on Admission:
1. Spirolactone 300 qd
2. Nadolol 20qd
3. Furosemide 80qd
4. Lactulose 15-30 [**Hospital1 **]
5. Trazodone 50 mg tablets 2 at bed
6. Vitamin D and calcium.
7. Remeron 30 qhs
8. Seroquel 25 qhs prn
.
MEDS ON TRANSFER TO MICU [**2170-11-5**]:
lactulose 30mg po TID
albumin 25%
ceftriaxone
vancomycin
dextrose prn
rifaxamin
lactulose
nadolol
Discharge Medications:
None, patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2170-11-7**].
Discharge Condition:
Patient expired on [**2170-11-7**].
Discharge Instructions:
Patient expired on [**2170-11-7**].
Followup Instructions:
Patient expired on [**2170-11-7**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"286.7",
"458.9",
"284.1",
"303.91",
"070.44",
"724.2",
"250.00",
"584.9",
"572.3",
"276.2",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8963, 8972
|
6782, 8518
|
337, 343
|
9051, 9088
|
3370, 4215
|
9172, 9339
|
2297, 2362
|
8916, 8940
|
5885, 5918
|
8993, 9030
|
8544, 8893
|
9112, 9149
|
2377, 3351
|
278, 299
|
5947, 6759
|
371, 1170
|
1192, 1532
|
1548, 2281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,425
| 133,332
|
34818+57948
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-11-9**] Discharge Date: [**2112-11-23**]
Date of Birth: [**2063-3-10**] Sex: M
Service: SURGERY
Allergies:
Avelox
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
aortic resection with tube graft, meckles diverticulum resection
[**2112-11-9**]
History of Present Illness:
Hospital transfer from [**Hospital 11560**] [**Hospital3 **], with history
of GI bleed of unknown source who presents with abdomial pain.
inital symptoms started two weeks prior while on a trip to
SanDiego with two episodes of crampy abdominal pain and melena.
Pateint's symptoms resolved over the next 4-5 days ago but
reoccured with progressive intensity of pain and became severe
enought for patient to leave work to days ago prior to [**11-9**].
Pain is described as LLQ and radiateds to his back. Pain has
been associated with nausea and some anexora. No vomiting, fever
or chills. No chest pain or shortness of breath.Patient initally
evaluated at [**Hospital 11560**] [**Hospital3 **].CT of abdomen was done
with contrast which was reported as " a mass around the aorta"
Blood cultures were sent. Patient transfered to MC for further
evaluation and care.
Past Medical History:
history of travel to [**Location (un) 13366**] [**2111**]
histroyof hypertension
history of hyperlipdemia
history of GI bleed,s/p EGD and colonoscopy "100's small
ulcerations
history of Minere's Disease with recent fall, treated with
5-6wk. course of predisone with taper to off 3 weeks ago,
history of scalp laceration [**3-5**] fall 3 weeks ago.
Social History:
married and lives with spouse
denies tobacco use
admits to occasional alochol use
Family History:
Non-contributory
Physical Exam:
Vital signs:
98.8-102-18 )2 sat 100% B/P 154/98
GEN: O x3 ,no acute distress
HEENT: an-icteric
Lungs: clear to auscultation
Heart:RRR SEM @ base
ABD: moderate lower abdominal tenderness, soft and nondistended,
no guarding, no rigidity.
Neuro: nonfocal
Pertinent Results:
[**2112-11-9**] 04:56PM SED RATE-21*
[**2112-11-9**] 04:56PM PT-12.8 PTT-23.3 INR(PT)-1.1
[**2112-11-9**] 04:56PM NEUTS-82.3* LYMPHS-14.2* MONOS-2.9 EOS-0.4
BASOS-0.2
[**2112-11-9**] 04:56PM WBC-11.4* RBC-3.96* HGB-11.0* HCT-32.0*
MCV-81* MCH-27.8 MCHC-34.4 RDW-12.9
[**2112-11-9**] 04:56PM CK-MB-7 cTropnT-<0.01
[**2112-11-9**] 04:56PM LIPASE-28
[**2112-11-9**] 04:56PM ALT(SGPT)-26 AST(SGOT)-22 LD(LDH)-219
CK(CPK)-395* ALK PHOS-76 AMYLASE-62 TOT BILI-0.4
[**2112-11-9**] 04:56PM estGFR-Using this
[**2112-11-9**] 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2112-11-9**] 04:59PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2112-11-9**] 06:13PM ANCA-NEGATIVE B
[**2112-11-9**] 08:05PM GLUCOSE-101 LACTATE-1.4 NA+-137 K+-3.2*
CL--99*
[**2112-11-9**] 08:05PM TYPE-ART PO2-414* PCO2-47* PH-7.40 TOTAL
CO2-30 BASE XS-3 INTUBATED-INTUBATED
[**2112-11-9**] 09:05PM freeCa-1.02*
[**2112-11-9**] 09:05PM HGB-8.7* calcHCT-26
[**2112-11-9**] 09:05PM TYPE-ART PO2-207* PCO2-39 PH-7.45 TOTAL
CO2-28 BASE XS-3
[**2112-11-9**] 10:02PM freeCa-1.20
[**2112-11-9**] 10:02PM HGB-10.0* calcHCT-30
[**2112-11-9**] 10:02PM TYPE-ART PO2-256* PCO2-39 PH-7.44 TOTAL
CO2-27 BASE XS-2
Brief Hospital Course:
[**2112-11-9**] aortic resection and tube graft with Meckles
diverticulum resection.
ID consulted
[**11-10**] POD#1 Antibiotics continuedVanco/flagyl, ceftazidime.
Remains intubated. remains NPO with ntg tube in place.Wean to
extubate.NTG d/c'd
[**2112-11-11**] POD#2 T max 101.7 transfered to VICU. ID following. IV
antibiotics continued. Cultures and path pending.TAP block
done.Acute pain consulted. ketamine gtt began of pain control
and diludid PCA titarate as tolerated. antiemetic
continued.Passed flatus.Ketamin.gtt d/c'd sencondary to patient
not tolerating.
NTG replace for persistant nausea.Dilaudid PCA continued. acute
pain signed off. pain controlled.ambulating. IV antibiotics
continued.
[**11-13**]- [**11-14**] POD#[**4-5**] CVL placed. KUB shows dilated loops of
bowel--post-op ileus
[**2112-11-15**] POD#5 foley and ntg discontinued. passing flatus. sips
began.ID recommends
d/c antibiotics ,path not consistent with mycotic aa. patient
remains afebrile and normal WBC.Oncology consulted.24hr urine
for HIAA and CT Torso with IV and Oral Contrast for carcinoid
staging. Preliminary pathology carcinoid.
[**2112-11-16**] POD #6 awaiting 24hr urine collection for 5-HIAA and
Histamine.ATBX discontinued.Not tolerating clear liquid-sips.
Made NPO. IV fluids restarted.
[**2112-11-17**] POD#7 [**2-3**] nodes positive for carcnoid, meckel's with
rare mitotic changes. Will require a octreotide scan and ct
Torso with oral and IV contrast prior to followup with
oncology.TPN began. NPO.
Gen surgery to see.
[**Date range (1) 33712**] POD#[**9-12**] remains NPO and on TPN. Progressive
abdominal distention and with continued passing gas having bowel
movements. CT scan [**11-20**] showed large ascities present and no
evidence of SBO or ileus. [**11-21**] sent to IR for ultrasound guided
paracentesis with drainage of 6 liters of ascites. Patient
reported great improvement in abdominal pain. Fluid analysis
shows-transudate (SAAG 1.9) and amylase 27. Diet advanced to
clear liquids.General surgery does not feel any further bowel
resection needed at this time. Hematology recommends outpatient
workup-- Octreotide scan and f/u with GI oncology.
[**11-22**]:POD#12 TPN weaned, diet advanced. Plan for d/c to home
with outpatient followup [**11-23**]
[**11-23**] POD#13 . hepatology consulted for questions of portal
hypertension by paracentesis fluid analysis.liver functions
studies monotered.patient re tapped.
d/c to home stable.
Medications on Admission:
vytorin 40/10mg daily
lasix 40mg daily
klor-con 80meq daily
asaprin 325mgm daily
aciphex 10mg daily
HCTZ 50mgm daily
Niaspan ER 100mgm daily
atenolol 25mgm daily
Max0
mylantax
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal
DAILY (Daily) as needed.
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
8. HCTZ Sig: Twenty Five (25) mg once a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Potassium Oral
11. Aspirin Oral
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
15. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed.
Disp:*qs * Refills:*0*
19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*10 Tablet(s)* Refills:*0*
20. 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*
21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain,Carcnoid
histroy of GI bleed
history of hypertension
histroy of hyperlipdemia
history of Meniere's Disease
postoperative acute blood loss anemia, transfused
postoperative ileus
postoperative failure to thrive-TPN
postoperative acities
Discharge Condition:
stable
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-10**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-6**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**], call for an apppointment. [**Telephone/Fax (1) 1393**].
Followup with Dr. [**Last Name (STitle) **] of oncology,[**Telephone/Fax (1) 13006**] on [**12-9**] 11 AM
Octreotide Scan Tuesday [**11-29**] 9AM (call Dr.[**Name (NI) 21829**] office with
questions)
Please call Dr.[**Name (NI) 9886**] office (General surgery) ([**Telephone/Fax (1) 27734**] for an appointment
Completed by:[**2112-11-23**] Name: [**Known lastname 12806**],[**Known firstname **] Unit No: [**Numeric Identifier 12807**]
Admission Date: [**2112-11-9**] Discharge Date: [**2112-11-23**]
Date of Birth: [**2063-3-10**] Sex: M
Service: SURGERY
Allergies:
Avelox
Attending:[**First Name3 (LF) 231**]
Addendum:
[**11-23**] s/p second paracentesis 2 liters of fluid obtained.
Seen By Dr. [**First Name (STitle) 2300**] prior to discharge. HCTZ discontinued and
spirolactone 100mgm began [**Doctor First Name **] with lasix 40mgm daily. PICC line
removed prior to discharge.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2112-11-23**]
|
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69,654
| 126,913
|
45615
|
Discharge summary
|
report
|
Admission Date: [**2155-6-23**] Discharge Date: [**2155-6-25**]
Date of Birth: [**2082-1-21**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
generalized body pain and poor appetite
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 yo F w/ anemia of chronic kidney disease [**1-30**] HTN who presents
with generalized [**8-8**] aching body pain x1 week. She notes that
the pain is worse in the left lower abdomen. She describes 4
days of non-bilious emesis and decreased po intake. Also reports
mild SOB at rest this am. No previous similar episodes. Also,
mild constipation, requiring stool softener. No significant
other issues. ROS otherwise negative.
In the ED, initial VS were: 98.0, 67, 24, 121/54, 97% on 2L.
Pt remained hemodynamically stable. Basic labs demonstrated
leukocytosis with a left shift, blood cx obtained. Metabolic
acidosis with AG of 20, lactate 1.8. BUN/Cr at baseline. Lipase
was normal. Initial CXR and AXR unremarkable. Non Cont CT
demonstrated acute on chronic pancreatitis w/ pseudocyst and
peripancreatic fat stranding. IVF was started, 2 peripherals
placed. Pt given Zofran and Morphine 6mg IV. Suggested a MICU
admission given criteria.
.
On arrival to the MICU, initial vitals were T:98.8 BP:118/60
P:70 R: 18 O2:87% on 2L NC. Pt was alert, conversing, in NAD.
Past Medical History:
-Hypertension
-Hyperuricemia/gout
-Stage IV CKD - baseline 2.8
-Anemia ([**1-30**] CKD)
-Renal osteodystrophy
-Osteoarthritis
-Uterine fibroids
-s/p excision cyst from R breast
-s/p unilateral salpingo-oophorectomy after ectopic pregnancy
-s/p tonsillectomy
Social History:
Takes care of [**Age over 90 **] yo mother and 50 year old daughter with down's
syndrome. She gets help from her son. Smokes 1 pack cigarettes
every 1 1/2 days. Denies alcohol use in the past 2 years. Prior
she drank socially. Denies illicits.
Family History:
Mother alive at 96 (had two MI's; age unknown); father died of
lung cancer.
Physical Exam:
Physical Exam on Admission to MICU:
Vitals: T:98.8 BP:118/60 P:70 R: 18 O2:92% on 4L NC
General: Cachectic, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
CV: Distant heart sounds, Regular rate/rhythm, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tenderness in LLQ, +BS, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert ox3
Physical Exam on Discharge:
VS - 98.4, 112/50, 65, 20, 96% on 1.5L
3 BMs yesterday, 1 BM this morning
GENERAL - thin woman in NAD, pleasant interactive
HEENT - sclera anicteric, MMM, OP clear, EOMI
NECK - supple, no JVD flat
LUNGS - CTAB, decreased breath sounds, no wheezes or crackles
heard
HEART - RRR, no m/r/g
ABDOMEN - soft, non-distended. No rebound tenderness or
guarding. +BS in all 4 quadrants. Minimally tender to deep
palpation. EXTREMITIES - WWP, no edema, 2+ DP pulses, thin
NEURO - grossly intact
Pertinent Results:
[**2155-6-23**] 09:50AM WBC-15.1*# RBC-3.60* HGB-10.9* HCT-33.9*
[**2155-6-23**] 09:50AM ALBUMIN-3.7 CALCIUM-10.7* PHOSPHATE-4.0
MAGNESIUM-2.0
[**2155-6-23**] 09:50AM LIPASE-54
[**2155-6-23**] 09:50AM ALT(SGPT)-10 AST(SGOT)-17 LD(LDH)-186 ALK
PHOS-72 TOT BILI-0.3
[**2155-6-23**] 09:50AM GLUCOSE-132* UREA N-34* CREAT-3.7* SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-18* ANION GAP-23*
[**2155-6-23**] 09:55AM LACTATE-1.8
[**2155-6-23**] 05:12PM PT-12.9* PTT-31.1 INR(PT)-1.2*
[**2155-6-23**] 05:12PM TRIGLYCER-55 HDL CHOL-58 CHOL/HDL-2.0
LDL(CALC)-45
[**2155-6-23**] 06:59PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM
CT abdomen and pelvis: non contrast:
Limited assessment without administration of IV contrast.
1. Peripancreatic fat stranding adjacent to edematous pancreas
with diffusely scattered calcifications, compatible for acute on
chronic pancreatitis. Please obtain a lipase level for
correlation. Slight wall-thickening of duodenum, likely due to
adjacent inflammatory process.
2. 17 x 14 mm cystic structure abutting pancreatic tail is
consistent with a pseudocyst, but MRCP may be obtained for
further evaluation when clinically appropriate.
3. Hyperdense material within gallbladder, likely sludge. No
evidence of cholecystitis.
4. 1.6-cm hyperdense structure in right pelvic floor, possible a
Bartholin's gland cyst.
5. Diverticulosis without diverticulitis.
6. Calcified fibroids.
7. At least 3 right renal simple cysts, measuring up to 4.2 cm.
Brief Hospital Course:
Primary Reason for Hospitalization:
73 yo F w/ CKD stage IV, HTN, anemia who presents with atypical
abdominal pain and metabolic acidosis found to have radiologic
findings suggestive of acute on chronic pancreatitis and
admitted to MICU for monitoring, then transferred to the floor
for further evaluation and management of her abdominal symptoms.
Active Diagnoses:
#Abdominal pain, unknown etiology-resolved:
Pt??????s LLQ abdominal pain, non-bilious emesis, and poor po intake
are not easily attributable to her radiologic finding of
pancreatic inflammation, calcification, and pancreatic
fluid-filled cyst (of note there are no gallstones). She does
not fit the [**1-31**] criteria for pancreatitis as her lipase is WNL
and her pain pattern is atypical for pancreatitis. Appreciated
GI input and recommended outpt MRCP (emailed her PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 4888**] to evaluate for anomalous pancreas anatomy such as
pancreas divisum that may cause her radiologic findings of
chronic pancreatitis. It is unlikely this is related to
alcoholic pancreatitis (she denies alcohol x2yrs) or
medications(previous ACEI use>1 mon ago). Her abdominal
symptoms resolved with 2L IVF bolus, analgesia, and NPO
overnight. Although unlikely infectious cause, work-up was
started, urine cx & blood cx still pending. Of note, her
triglycerides were within normal limits and KUB ruled out any
intestinal obstruction. Her pain may have been caused by
constipation as she had not had a bowel movement for 1 week
prior to admission and her symptoms began to resolve after
having several bowel movements (4 total during this admission).
#Metabolic Acidosis-resolving:
Anion-gap metabolic acidosis likely secondary to CKD stage IV.
Anion gap closing with fluid resuscitation. Her phosphate
binders were restarted and she resumed a renal diet.
#Hypoxia:
Patient presented with SOB on admission requiring 2L NC. No
prior episodes per pt and she is not on home O2. Probable cause
is underlying COPD as she is a chronic smoker. Less likely PE
or PNA as she is not tachycardic or without chest pain and CXR
was negative. She was weaned off of O2 while on the floor and
was satting > 95%.
#Acute on chronic kidney disease:
Patient has known CKD stage IV [**1-30**] HTN. Creatinine trended
downwards from 3.7 on admission, not yet back to baseline of 2.8
(on discharge was 3.3). Her CKD medications for calcium, vitamin
D and phosphate binding were restarted. Her nephrologist was
notified via email of her admission.
#Weight loss:
Patient was noted to have lost 12 lbs over the past year in the
context of gradually decreasing weight over the past decade.
She is up to date on all cancer screening (mammogram,
colonoscopy, pap smear). Given 52-pack-year smoking history,
lung cancer is of concern although she had a normal CXR on
admission. A likely cause of her weight loss however is
malabsorption from chronic pancreatitis and work-up for this as
an outpatient with GI should be considered.
Chronic Diagnoses
#Hypertension:
Her HTN is [**1-30**] CKD. Antihypertensive meds were held on the MICU
and medicine floor as needed as SBPs were 100s-110s. Should
restart upon discharge.
#Anemia:
Pt has Hct baseline in the low 30s. No significant change. Most
recent iron studies several mo ago reveal AOCD. She is managed
on Epo and iron in outpt. Continued ferrous sulfate and
darbopoetin during admission.
#Gout:
Pt remained stable, continued on allopurinol 100mg daily.
#Social: Social work following as pt is responsible for care of
her [**Age over 90 **] yr old mother and handicapped daughter.
TRANSITIONAL ISSUES
1) Follow-up appointment with Dr. [**Last Name (STitle) **] (PCP is out of town)
2) Follow-up appointment with [**Hospital **] clinic at [**Hospital1 18**]
3) Consider MRCP on outpatient basis
4) Outstanding tests: urine culture ([**6-25**]), MRSA screen ([**6-23**]),
blood culture ([**6-23**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient medication print out froom
PMD.
1. Sodium Bicarbonate 650 mg PO TID
2. sevelamer CARBONATE 800 mg PO TID W/MEALS
3. NIFEdipine CR 60 mg PO DAILY
4. nebivolol *NF* 2.5 mg Oral daily
5. Multivitamins 1 TAB PO DAILY
6. FoLIC Acid 3 mg PO BID
7. Ferrous Gluconate 325 mg PO BID
8. darbepoetin alfa in polysorbat *NF* 25 mcg/0.42 mL Injection
every month
40mcg sc every month in epo clinic
9. Calcitriol 0.5 mcg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Allopurinol 100 mg PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Ferrous Gluconate 325 mg PO BID
4. FoLIC Acid 1 mg PO BID
3 tablets po BID
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. Sodium Bicarbonate 650 mg PO TID
7. Vitamin D 1000 UNIT PO DAILY
8. darbepoetin alfa in polysorbat *NF* 25 mcg/0.42 mL Injection
every month
40mcg sc every month in epo clinic
9. Multivitamins 1 TAB PO DAILY
10. nebivolol *NF* 2.5 mg Oral daily
11. NIFEdipine CR 60 mg PO DAILY
12. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 capsule by mouth twice a day Disp #*60
Capsule Refills:*0
13. Milk of Magnesia 15-30 mL PO Q6H:PRN Constipation
RX *Milk of Magnesia 400 mg/5 mL 5-10 cc by mouth q6hr Disp
#*480 Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic pancreatitis, constipation
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 Ms. [**Known lastname 90256**],
It was a pleasure taking care of you during your admission at
[**Hospital1 18**]. You were brought into the hospital on [**6-23**] for pain in
your abdominal area and weakness. A CAT scan done in the
emergency department suggested that you might have pancreatitis,
which is inflammation of your pancreas, thus you were admitted
to the the medical intensive care unit (ICU) for further
treatment and monitoring. In the ICU, you were given fluids,
pain medications, and anti-nausea medications which improved
your symptoms. You were also put on nasal cannula to help with
your breathing because your oxygen levels were slightly low when
you arrived, but this improved and you nolonger required oxygen.
Since you had mentioned that you hadn't had a bowel movement
for a week, you were also started on stool softeners and
laxatives which resulted in several bowel movements on your last
day in the intensive care unit, which relieved your symptoms
significantly. You were transferred to the general medical
floor on the morning of [**6-25**]. You had another bowel movement
that morning and tolerated a normal diet. Your abdominal pain
and weakness appeared to have resolved significantly.
We recommend that you eat a low-fat diet, low in sodium and
potassium given your kidney disease. We also recommend that you
eat more fiber to prevent constipation. We encourage you to you
consider quitting smoking and continue abstaining from alcohol
to reduce the risk of a recurrence of your pancreatitis.
You also stated that you have lost weight over the past years.
Upon checking her records, your weight loss appears to be closer
to 11 lbs in 1 year. We suggest that you speak with your primary
care physician regarding this.
Medication changes:
1) Please continue to take all of the medications that you were
taking before admission
2) Please also take senna and milk of magnesia as needed for
constipation
Followup Instructions:
Follow-up appointments:
1) Please follow up with your primary care office. As Dr. [**Last Name (STitle) 97277**]
is out of town, we have made a follow up appointment for you
with Dr. [**Last Name (STitle) **] on [**7-3**] at 4pm at [**Hospital1 **]:
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 18406**]
Phone: [**Telephone/Fax (1) 3581**]
Fax: [**Telephone/Fax (1) 7022**]
2) Please make an appointment with the [**Hospital **] clinic at [**Hospital1 18**]. You
can call [**Telephone/Fax (1) 463**]
Completed by:[**2155-6-26**]
|
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8742, 9321
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10362, 12131
|
2135, 2656
|
12362, 12954
|
2684, 3173
|
12151, 12315
|
288, 330
|
402, 1480
|
10194, 10338
|
5133, 8716
|
1502, 1762
|
1778, 2026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,732
| 166,776
|
43915
|
Discharge summary
|
report
|
Admission Date: [**2104-9-12**] Discharge Date: [**2104-9-13**]
Date of Birth: [**2052-1-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Displaced Nephrostomy Tube, Hyponatremia
Major Surgical or Invasive Procedure:
Nephrostomy tube placement
History of Present Illness:
Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal
adenocarcinoma recently complicated by pseudomonal urosepsis
from bilateral hydronephrosis requiring the placement of
bilateral nephrostomy tubes who presents from home after one of
the tubes has been displaced. She was recently discharged from
[**Hospital1 18**] on [**2104-9-3**], at which time she was found to have
pseudomonal urosepsis and was discharged on ciprofloxacin 400mg
IV BID to complete a 14 day course, during that hospital stay
she was also found to be hyponatremic with a sodium in the high
120's, thought to be due to SIADH. Today when her family was
helping move her from the couch her right nephrostomy tube got
caught on something and was accidentally pulled out so her
family brought her to the ER to have the tube replaced. She
currently feels weaker than her baseline but has trouble
describing how she feels, denies any fever/chills, CP, SOB,
n/v/d, HA or changes in her vision, denies any changes in her
ostomy output.
.
In the ED, initial vs were: 98.7, 76, 92/72, 16, 98% RA. The
initial plan had been to have IR replace the nephrostomy tube
tonight, however when her labs returned this was put off. Her
labs were notable for a white count of 33.7, Na of 114, K of
6.4, lactate of 3.8, and a BUN of 35. Her EKG was NSR at 97bpm,
no peaked T-waves or PR prolongation, poor R wave progression.
She was given 10 units of IV insulin, 1 amp of D50, calcium
gluconate, her scheduled dose of ciprofloxacin, along with
cefepime and vancomycin for her leukocytosis. A repeat K after
treatment was 5.4 and her sodium was 116. While in the ER it
was noted that her left sided nephrostomy tube was not draining
anymore either. By report, after multiple discussions in the ER
she refused kayexelate and placement of a peripheral IV,
although she would like the nephrostomy tubes replaced for
comfort, as she is no longer seeking treatment for her
underlying cancer and is DNR/DNI on home hospice. VS on
transfer were: 106, 104/74, 10, 100% on RA.
.
On arrival to the ICU her initial VS were: 95.8, 99, 101/75, 9,
99% on RA. She says that her pain is improved after the pain
medication, she has no other complaints. Also on arrival to the
ICU it was noted that her left sided nephrostomy tube was not
draining or flushing.
.
Review of systems:
(+) Per HPI and for anorexia
(-) Denies fever, chills, night sweats. 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 or changes in bowel habits.
Past Medical History:
Stage IV appendiceal adenocarcinoma (pT3 Nx pM1b);
K-Ras mutation confirmed
- [**2102-11-3**]: Presented to [**Hospital1 18**] ED for progressive
abdominal/pelvic discomfort. CT demonstrated "marked abnormal
distention of the endometrial cavity measuring up to 6.5 cm"
which was filled with high-density fluid. There was a possible
mass within the cervix as well as a 2.2 x 3.2 cm cystic lesion
within the right adnexa. Of note, the appendix was described as
normal. TVUS revealed an enlarged right ovary with a complex
cyst
thought to be hemorrhagic, as well as an abnormal endometrial
cavity containing a heterogeneous lesion with mixed solid and
cystic elements, thought to be concerning for neoplasm. She was
recommended to follow up with GYN.
- [**2102-12-11**]: Endometrial biopsy demonstrated adenocarcinoma,
endometroid type, grade I.
- [**2102-12-12**]: Re-presented to [**Hospital1 18**] ED with continued lower
abdominal pain as well as about a month's worth of vaginal
bleeding.
- [**2103-1-17**]: CA-125 elevated at 113
- [**2103-1-23**]: Went to the operating room with Dr. [**Last Name (STitle) 2028**] for a
planned hysterectomy, bilateral salpingo-oophorectomy, and
staging procedure for presumed endometrial adenocarcinoma.
Intraoperatively, her appendix was noted to be "pulled down in
towards the right adnexa." The right adnexa itself was
completely adherent to the pelvic side wall and right fallopian
tube. There was evidence of gross tumor on the anterior surface
of the uterus. The left fallopian tube and ovary were also
replaced by hemorrhagic mass. There was also a 2 cm nodularity
on the omentum, worrisome for metastasis. Intraoperatively, she
underwent rigid proctoscopy which showed no evidence of
intralumenal tumor. Peritoneal washings were negative for
malignant cells. Surprisingly, the pathology from this operation
revealed the primary source of her cancer to actually be the
appendix with a 1.5 cm histologic grade II primary lesion
invading through the muscularis propria and into the
subserosa/mesoappendix (pT3). This stained positive for
cytokeratin 7, cytokeratin 20, ER, and CDX2, confirming this as
an appendiceal primary. The same adenocarcinoma was found to be
involving the right fallopian tube and ovary, uterus, cervix,
omentum, and the serosal surface of the bowel wall (pM1b). There
was no perineural invasion. K-Ras mutation confirmed.
- [**2103-3-21**]: Began cycle 1 of FOLFOX; required 20% dose reduction
of
all medications after cycle 1 due to neutropenia; oxaliplatin
stopped after 4 cycles due to neuropathy; completed sixth cycle
on [**2103-8-22**]
- [**2104-1-5**]: Presented to [**Hospital1 18**] ED with small bowel obstruction,
thought to be due to intraperitoneal relapse. PET CT confirmed
FDG-avidity of multiple peritoneal/pelvic implants and several
liver masses.
- [**2-/2104**]: Underwent evaluation by Dr. [**Last Name (STitle) 12982**] at [**Hospital1 336**] for
hyperthermic intraperitoneal chemotherapy (HIPEC). Underwent
debulking of intraperitoneal carcinomatosis by HIPEC was
deferred
given obvious hepatic metastases.
- [**2104-5-15**]: Began cycle 1 of palliative FOLFIRI and bevacizumab;
on day 27, was admitted to the hospital with a colovaginal
fistula after complaining of stool per vagina
- [**2104-7-15**]: Underwent a complicated surgical takedown of the
enterovaginal fistula, diverting ileostomy, and repair of a
bladder perforation with Dr. [**Last Name (STitle) **].
- [**2104-8-2**]: Presented to the ED with abdominal pain and
leukocytosis. Found to have diffuse enteritis with new bilateral
obstructive hydronephrosis and progression of peritoneal and
hepatic metastases. Eventually discharged on home hospice on
[**2104-8-10**].
Social History:
She is married. She denies tobacco, drug, or alcohol use. She
lives with her husband and son. She reports feeling safe at
home.
Family History:
She denies any family history of breast cancer, ovarian cancer,
uterine cancer, or colon cancer.
Physical Exam:
Physical Exam on Admission:
Vitals T 95.8 BP 101/75 HR 99 O2 99% on 2L NC
General Appearance: Anxious, cachetic
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Abdominal: Soft, Bowel sounds present, Distended, Tender:
throughout
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+
Musculoskeletal: Muscle wasting
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed
.
Physical Exam on Disharge:
Vitals T 96.1 BP 94/67 HR 96 O2 100% on 2L NC
General Appearance: Anxious, cachetic
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Abdominal: Soft, Bowel sounds present, Distended, Tender:
throughout
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+
Musculoskeletal: Muscle wasting
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed
Pertinent Results:
Labs on Admission:
.
[**2104-9-12**] 10:42PM URINE HOURS-RANDOM UREA N-640 CREAT-93
SODIUM-35 POTASSIUM-40 CHLORIDE-37
[**2104-9-12**] 10:42PM URINE OSMOLAL-486
[**2104-9-12**] 10:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
[**2104-9-12**] 10:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
[**2104-9-12**] 10:00PM URINE RBC-21-50* WBC-[**12-7**]* BACTERIA-FEW
YEAST-NONE EPI-[**3-22**]
[**2104-9-12**] 10:51PM LACTATE-3.8* NA+-116* K+-5.4*
[**2104-9-12**] 08:05PM GLUCOSE-95 UREA N-35* CREAT-0.8 SODIUM-114*
POTASSIUM-6.4* CHLORIDE-87* TOTAL CO2-18* ANION GAP-15
[**2104-9-12**] 08:05PM OSMOLAL-258*
[**2104-9-12**] 08:05PM WBC-33.7* RBC-3.82* HGB-10.5* HCT-32.6*
MCV-86 MCH-27.5 MCHC-32.2 RDW-17.5*
[**2104-9-12**] 08:05PM NEUTS-90.7* LYMPHS-5.5* MONOS-2.0 EOS-1.9
BASOS-0
[**2104-9-12**] 08:05PM PT-19.8* PTT-35.5* INR(PT)-1.8*
.
Micro:
[**9-12**] blood cx: pnd
[**9-12**] urine cx: pnd
.
Imaging:
.
CXR: IMPRESSION: Increased right moderate right effusion and
right basilar
pneumonia. (unchanged from [**8-30**])
.
EKG: NSR at 97bpm, no peaked T-waves or PR prolongation, poor R
wave progression
Brief Hospital Course:
Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal carcinoma
who presented after her right nephrostomy tube had dislodged,
found to be hyponatremic and hyperkalemic, with a Cr above her
baseline on labs.
.
#) Dislodged Nephrostomy tubes: right tube was completely
dislodged and the left tube no longer flushes or drains. Went
to IR and had tube replaced successfully without any
complications.
.
#) Hyponatremia: Etiology not completely clear based on her
urine lytes or serum osms, likely has a component of hypovolemic
hyponatremic, while on exam she appeared total body volume up,
her JVD was flat and her MM dry. Her urine lytes show a low
urine sodium and high osms, consistent with hypovolemic
hyponatremia, however she does not appear as sodium avid on labs
as one would expect, this could be due to a degree of [**Last Name (un) **] as her
Cr is up to 0.8 from her baseline of 0.2-0.3. Also likely a
component of SIADH in the setting of malignancy. With
administration of normal saline, Na improved from 114 to 117,
where it remained stable. Further correction with IVF in the
hospital setting was discussed with the patient and family, but
it was decided to opt in favor of discharge home w/ hospice
given current goals of care. She was discharged with some
additional bags of NS for use PRN until hospice arrives on
Monday.
.
#) Hyperkalemia: potassium was 6.4 on admission with no EKG
changes, improved to 5.4 after calcium gluconate, insulin and
D50, possibly related to worsening renal function. Patient was
monitored on telemetry and did not develop any arrhythmias.
.
#) Leukocytosis: At the time of her recent discharge she had a
leukocytosis in the mid-twenties, now elevated to the mid 30's,
no evidence of infection on exam. Does have right basilar
opacity, but chest x-ray appears largely unchanged from [**8-30**].
U/A from the ER with WBC's, RBC's and bacteria, however since
the nephrostomy tubes were not draining well it is not clear
where the urine was collected from. Continued ciprofloxacin
400mg IV bid to complete prior course for pseudomonas urosepsis,
did not continue vanc/cefepime started in the ER. Urine and
blood cultures had no growth to date.
.
#) [**Last Name (un) **]: Cr up to 0.8 from 0.2 to 0.3 as a recent baseline, given
her hypovolemia on exam was likely pre-renal, however may also
be partially due to an obstructive picture given dislodged
urostomy tube on the right and the left is not draining. She was
given IVF and nephrostomy tubes were replaced as above.
.
#) Stage IV Appendiceal Carcinoma: Currently not seeking further
therapy and on home hospice. Continued oxycodone 5mg Q4h prn
pain, acetaminophen prn, and ativan prn.
Medications on Admission:
oxycodone 5 mg: 1-2 Tablets PO Q4H as needed for pain
acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: Max of 3 grams daily.
Ativan 0.5 mg: One Tablet PO at bedtime as needed for insomnia
ciprofloxacin 400 mg IV every 12 hours to end on [**2104-9-13**]
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: maximum of 3g daily.
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
Displaced nephrostomy tube
Hyponatremia
Hyperkalemia
Metastatic appendiceal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you during your admission to
[**Hospital3 **] Medical Center. You came into the hospital because
one of your nephrostomy tubes was displaced. The interventional
radiologists replaced the tube successfully without any
complications. You also had some abnormalities in your blood
work with low sodium and high potassium. After a discussion
with you and your family, we decided that it would be more
beneficial for you to go home than for us to keep you in the
hospital to correct these abnormalities.
.
We did not start you on any new medications. You completed your
course of Ciprofloxacin here, so you can STOP the Ciprofloxacin
when you go home.
Followup Instructions:
none
Completed by:[**2104-9-13**]
|
[
"996.76",
"584.9",
"197.6",
"799.4",
"V66.7",
"276.1",
"996.39",
"276.52",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93"
] |
icd9pcs
|
[
[
[]
]
] |
13218, 13269
|
9861, 12568
|
346, 375
|
13413, 13413
|
8626, 8631
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14332, 14368
|
6990, 7088
|
12917, 13195
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13290, 13392
|
12594, 12894
|
13589, 14309
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7103, 7117
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2746, 3064
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265, 308
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403, 2727
|
8645, 9838
|
13428, 13565
|
3086, 6825
|
6841, 6974
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,820
| 162,435
|
46199+58886
|
Discharge summary
|
report+addendum
|
Admission Date: [**2204-1-2**] Discharge Date: [**2204-1-13**]
Date of Birth: [**2129-3-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2204-1-9**] Repair of sternal separation with five plates on
ribs 2, 3, 4 and 5 and bilateral pectoralis musculocutaneous
advancement flap.
[**2204-1-9**] Redosternotomy, Aortic valve replacement (19mm [**Doctor Last Name **]
pericardial)
History of Present Illness:
Ms. [**Known lastname 32737**] is a 74 year old female s/p coronary atrtery bypass
grafting in [**2190**] now with severe aortic stenosis, moderate to
severe mitral regurgitation. She was recently admitted for
congestive heart failure and underwent extensive preoperative
evaluation for high risk redo operation.
Past Medical History:
Coronary artery disease s/p coronary artery bypass
graft in [**2190**], (stress test [**2199-8-12**] @[**Hospital3 **], under Dr.
[**First Name (STitle) 2031**] [**Telephone/Fax (1) 98231**] shows mild ischemia LV RCA distribution
consistent with old finding.)
2. Carcinoid tumor of right middle lobe s/p resection.
3. Diabetes mellitus, type 2, HbA1c=8.8 ([**6-/2198**])
4. Obesity.
5. Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC
filter, [**2197**]
6. Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 at night at home. NO Bpap
7. obstructive sleep apnea.
8. restrictive lung disease
9. carpel tunnel syndrome b/l, [**2179**]
10. congestive heart failure (left atrium is mildly dilated.
LVEF 67%/[**2199**])
11.Anemia of Chronic disease, baseline Hct=30-33.0/Hb=10.
12.HTN
13.hypercholesterolemia
Social History:
She denies [**Year (4 digits) **] or alchohol use.
She is married, lives with her husband, daughter and 1 of her
sons. [**Name (NI) **] 2 other children.
She
Family History:
Her mother was diagnosed with diabetes.
Physical Exam:
Pulse:84 Resp: 28 O2 sat: 99%4L
B/P Right: 90/50 Left:
Height: 4'[**04**]" Weight:83.9 kgs
General:A&O x 3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] extensive bilateral orbital ecchymosis
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] crackles bases and mid
bilaterally
Heart: RRR [x] Irregular [] Murmur SEM IV/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
(R)LE varicosities noted. (L)LE well healed vein harvest site []
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: Left:
Carotid Bruit bruits (B)->likely AS radiation, carotid pulses
Right: 2+ Left:2+
Pertinent Results:
[**2204-1-13**] 04:15AM BLOOD WBC-7.3 RBC-3.48* Hgb-9.6* Hct-28.6*
MCV-82 MCH-27.7 MCHC-33.7 RDW-16.1* Plt Ct-142*
[**2204-1-9**] 04:03PM BLOOD PT-14.4* PTT-37.9* INR(PT)-1.3*
[**2204-1-13**] 04:15AM BLOOD Glucose-151* UreaN-28* Creat-0.8 Na-133
K-4.6 Cl-97 HCO3-29 AnGap-12
Brief Hospital Course:
Ms. [**Known lastname 32737**] was admitted for heart failure. During this
admission he underwent a redo sternotomy, aortic valve
replacement, sternal plating with synthes plating on [**2204-1-9**].
Please see the operative note for details. She tolerated this
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. She was extubated
by the following day and ready for transfer to the step down
unit. Plastics continued to follow her [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] drains and
incision post-operatively. Chest tubes and epicardial wires
were removed. She was initially on lantus for glucose control
but transitioned to her home dose of metformin. By
post-operative day four she was ready for transfer to [**Hospital1 **]
Therapy and Rehab Center in [**Location 1268**]. All follow-up
appointments were advised.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 40 mg
Tablet - one Tablet(s) by mouth twice daily
COMMODE LIFT -
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 2
Tablet(s) by mouth once daily in a.m.
ISOSORBIDE DINITRATE - (Prescribed by Other Provider) - Dosage
uncertain
MANUAL WHEEL CHAIR -
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet -
two
Tablet(s) by mouth twice daily
POTASSIUM CHLORIDE [KLOR-CON] - (Prescribed by Other Provider)
-
8 mEq Tablet Sustained Release - one Tablet(s) by mouth twice
daily
QUINAPRIL - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth at
bedtime do not take if systolic blood pressure is less than 100
QUINAPRIL - (Prescribed by Other Provider) - 20 mg Tablet - one
Tablet(s) by mouth once daily
RISEDRONATE [ACTONEL] - (Prescribed by Other Provider) - 35 mg
Tablet - one Tablet(s) by mouth once weekly on Sunday
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
500
mg Tablet - one Tablet(s) by mouth twice daily
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth DAILY (Daily)
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - 500 mg (1,250 mg)-400 unit Tablet, Chewable -
one Tablet(s) by mouth in a.m., 2 tablets in p.m.
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - 1,000 mcg Tablet - one Tablet(s) by mouth once
daily in a.m.
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100
mg Capsule - 1 to 2 Capsule(s) by mouth daily as needed for
constipation
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
Iron) Tablet - 1 Tablet(s) by mouth twice a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - one
Tablet(s) by mouth once daily
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider) - 100 unit/mL Suspension - sliding scale by blood
glucose
VITAMIN E - (Prescribed by Other Provider) - 400 unit Capsule -
one Capsule(s) by mouth once daily in a.m.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. vitamin E 400 unit Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
12. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 10
days: after 10 days, taper to home dose of 40mg daily.
Disp:*40 Tablet(s)* Refills:*2*
14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO q6 HOURS
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
18. XIBROM 0.09 % Drops Sig: One (1) gtt Ophthalmic [**Hospital1 **] (2 times
a day): OD.
Disp:*60 gtt* Refills:*2*
19. Actonel Oral
20. Actonel 35 mg Tablet Sig: One (1) Tablet PO QSun.
Disp:*30 Tablet(s)* Refills:*2*
21. sliding scale insulin
Fingerstick QACHSInsulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-90 mg/dL 0 Units 0 Units 0 Units 0 Units
91-130 mg/dL 5 Units 5 Units 5 Units 0 Units
131-160 mg/dL 8 Units 8 Units 8 Units 0 Units
161-200 mg/dL 12 Units 12 Units 12 Units 2 Units
201-250 mg/dL 15 Units 15 Units 15 Units 4 Units
251-300 mg/dL 18 Units 18 Units 18 Units 6 Units
301-361 mg/dL 20 Units 20 Units 20 Units 8 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Severe Aortic Stenosis s/p AVR
Diabetes mellitus
Acute on chronic diastolic heart failure
Obstructive sleep apnea on cpap
Anemia
Restrictive lung disease
Hypertension
Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulates short distance with walker and assistance
Incisional pain managed with dilaudid and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Record and drain JP drainage [**Hospital1 **].
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Thrus [**2-9**] at 1:15pm
Cardiologist/PCP: [**Name10 (NameIs) **] [**First Name (STitle) 2031**] [**Telephone/Fax (1) 77385**] Tues [**2-7**] at 2:00pm
Plastic Surgery: Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks. ([**Telephone/Fax (1) 14596**]
**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:[**2204-1-13**] Name: [**Known lastname 15666**],[**Known firstname **] J Unit No: [**Numeric Identifier 15667**]
Admission Date: [**2204-1-2**] Discharge Date: [**2204-1-13**]
Date of Birth: [**2129-3-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor
Attending:[**First Name3 (LF) 741**]
Addendum:
Added: Lantus Insulin 40 units at breakfast daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 205**] ([**Location (un) 42**] Center
for Rehabilitation and Sub-Acute Care)
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2204-1-13**]
|
[
"250.00",
"287.5",
"428.0",
"414.02",
"V12.51",
"733.82",
"V46.2",
"414.01",
"278.00",
"285.29",
"272.4",
"V58.67",
"272.0",
"396.2",
"327.23",
"428.33",
"V15.88",
"905.1",
"518.82",
"E929.3",
"401.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"78.41",
"39.61",
"84.94",
"35.21",
"83.82",
"84.52"
] |
icd9pcs
|
[
[
[]
]
] |
11497, 11779
|
3258, 4160
|
336, 580
|
9260, 9463
|
2959, 3235
|
10433, 11474
|
2077, 2118
|
6205, 8858
|
9062, 9239
|
4186, 6182
|
9487, 10410
|
2133, 2940
|
276, 298
|
608, 923
|
946, 1884
|
1900, 2061
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,500
| 128,220
|
42399
|
Discharge summary
|
report
|
Admission Date: [**2180-4-5**] Discharge Date: [**2180-4-14**]
Date of Birth: [**2128-3-9**] Sex: F
Service: MEDICINE
Allergies:
vancomycin / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
52 yr/o F with PmHx significant for multiple sclerosis
complicated by a seizure disorder, as well as neurogenic bladder
and hemorrhagic cystitis s/p urostomy, and recent complicated
admission to [**Hospital1 18**] [**Date range (1) 91819**] from which she was discharged
to rehab, now admitted to [**Hospital1 18**] from an OSH for severe
leukocytosis, fevers, and worsening mental status.
OSH Course:
Was admitted to [**Hospital3 24768**] on [**2180-3-22**] due to recent
seizures at rehab and temperature documented at rehab. She was
found to hav ea saral decubitus ulcer as well as ulcerations on
the back and heels. She had a presenting temperature of 102
although she had been receiving IM Ceftriaxone at rehab for an
abscess on her back. She arrived on Dilantin 300mg TID, Aricept
10mg daily, MTX 20mg every saturday, fosamax 70mg weekly,
calcium 600mg [**Hospital1 **], Vit C 500mg daily, Vit E 400 daily, MTV
daily, Iron 65mg TID.
Initially she had a WBC of 8.3, Hgb of 9.7 with a dilantin level
WNL, a mild transaminitisi, and mild [**Last Name (un) **]. She was found to have
an abscess on her back which was I&Ded. She was started on Epo
due to anemia. ID saw the patient and she was started on
Aztreonam and Clindamycin while Fluconzole and CTX were
discontinued.
Imaging of her kidney showed mild R hydronephrosis with multiple
stones and severe left hydronephrosis with a thin cortex and it
was decided that this kidney should be decompressed with a
nephrostomy tube (there is mentioned that this was due to an
obstructing left renal stone, but patient also listed as having
known history of hydroureter). Her warfarin was stopped to allow
this and on [**2180-3-29**] a L nephrostomy tube was placed with
resolution of the hydronephrosis on follow-up imaging.
On [**2180-3-30**] her WBC increased to 20.6 with 27% bands. Her Cr
bumped to 2.6 with BUN 34. A R IJ CVL was placed. Her WBC was
relatively stable the following two days and her Cr started
trending down to 1.6. However, on the morning of [**2180-4-4**], she
became somewhat obtunded. Her vitals continued to be
unremkarkable except she developed a low grade temp of 100.1.
Her WBC rose to 27.9 with 16% bands. Surgery assessed the
back/abscess areas and thought they looked good and did not
think they were the source of the infection.
This morning, [**2180-4-5**], her WBC rose to 47.3 and she remained
obtunded. Decision was made to transfer to [**Hospital1 18**]. She was
started on PO vancomycin and IV metronidazole on the day of
transfer. The nursing staff at [**Location (un) 11790**] also notified the
nursing staff on CC7 that the patient's Cdiff toxin had come
back positive.
On the floor, initial VS 102.1, BP 102/60, HR 115, RR 22, 98% on
RA. Pt unable to meaningfully communicate due to altered mental
status, but her husband confirmed the general above information
about her recent time at [**Location (un) 11790**]. He says she started getting
altered yesterday but that at baseline she is very functional
and takes care of most of her ADLs. He says she has not been
reporting pain, including pain in the abdomen. He is unsure if
she is having diarrhea.
[**Known firstname **] was initially admitted to the floor as mentioned above
but after 12hrs was transfered to ICU for septic shock. Ultimate
cause of illness found to be Cdiff with suggestive history/exam
and positive C. diff toxin here. Abd CT also showed pan-colitis
Pt was initially started on PO Vanco/IV metronidazole and per
recs of ID team Tigecycline was later added. All other broad
spectrum Abx were peeled off after first 24hrs and after peaking
at 62.4 the WBC has been trending down over 3 subsequent days
(currently at 22.3). Her mental status has improved and her
hypotension has resolved. She never required pressor support and
while she required agressive fluid resuccitation for the first
24hrs, has been hemodynamically stable since without any
significant fluids - length of Stay ~ 16-20L positive thus far.
The R IJ placed at the OSH has been pulled and a PICC line
placed. NGT was placed in the ICU and she currently is receiving
tube feeds via this. Diarrhea improving. ID and General Surgery
are following regarding her Cdiff care.
She was obtunded at admission and mental status has improved
with Cdiff treatment. Not back to baseline yet per husband,
although he sees interval improvement. She has a history of
seizures but no obvious seizures have been witnessed here. No
EEGs or Head CT during this admission. ID initially recommended
an LP in the setting of fevers, WBC elevation, and AMS, but
after she has showed improvement with Cdiff treatment, the
decision was made not to do this, especially since she has
decubitus ulcers over the sacrum which might contaminate the LP
region. Her phenytoin was changed to fosphenytoin in the ICU to
better go through a PICC.
On presentation [**Known firstname **] had a significant acidosis with a bicarb
of 10. This has persisted during admission although all lactates
have been normal. pH has been low in the 7.2-7.3 range. All
though multi-factorial in setting of severe diarrhea, ileostomy
presence, and mild renal failure. She was started on bicarb tabs
in the ICU.
She has recent history of bilateral DVTs and was on warfarin as
an outpatient. This has been held and her INR has trended
steadily up from 1.7 on admission to 4.5 today. The hypothesis
has been that complete lack of gut function combined with no
food intake has led to significant vitamin K deficiency.
Past Medical History:
1. Multiple sclerosis - primary progressive, diagnosed in [**2151**].
Had a severe flare and deterioriation in [**2156**] with onset of
seizures. Has been steadily deteriorating since then, has been
wheelchair bound for the last 10 years. On maintenance
methotrexate therapy. Also had been receiving monthly steroid
doses. Followed by a neurologist at [**Hospital1 756**].
2. Seizure disorder - had first "big seizure" in [**2156**] and has
subsequently had a few "smaller" ones consisting of staring
spells occasionally with some facial twitching. Last one was 12
years ago, 3 episodes total. Has never been in status
epilepticus. Has always been maintained on Dilantin, which was
recently increased from 400mg total daily to 500mg total daily
within the last week due to a low level.
3. Hemorrhagic cystitis due to chronic cytoxin therapy, s/p
urostomy
4. Deep vein thrombosis [**2172**]
5. Anemia
6. Neurogenic bladder
7. Bilateral hydronephrosis (known history)
8. Tonsillectomy
9. Appendectomy
10. Multiple cystocopies with ureteral stent placement in [**2172**]
11. Cauterization of her hemorrhagic points in her urinary
bladder
12. Breast bx in [**2-/2180**]
Social History:
- Tobacco history: denies
- ETOH: denies
- Illicit drugs: denies
lives with husband and has no children
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T: 102.1 BP: 102/60 P: 115 R: 22 O2: 98% on RA
General: Currently is looking around room and responding to her
name but not able to carry on meaningful conversation, follow
commands, or articulate clear words
HEENT: Sclera anicteric, dry MM, very rough dark tongue (brown)
without other obvious oral lesion
Neck: R IJ in place without surrounding erythema or induration,
unable to appreciate JVD, no cervical LAD
Lungs: Clear to auscultation bilaterally in posterior fields
CV: mild tachy, S1, S2, no m/r/g
Abdomen: soft, difficult to assess tenderness due to mental
status but appears to be mildly diffusely tender, no rebound,
intermittent guarding, no worsening pain with shake test, no
masses felt
Ext: Warm, well perfused, 2+ pulses, 1+ edema in hands and at
ankles
Skin: no acute rashes
Stool: dark brown/green, liquid, guiac positive
Neuro: responds to name but cannot answer questions, not able to
follow even simple one-step commands. pupils are equal and
reactive, not moving much but doesn't appear to have a focal
deficit
DISCHARGE EXAM:
Vitals: 98.6 98.4 104/70 96 18 100 RA
Length of stay: 12L positive
Exam:
General: Tired appearing, NGTube in place
HEENT: Sclera anicteric, dry MM, without other obvious oral
lesion
Neck: unable to appreciate JVD, no cervical LAD
Lungs: Clear to auscultation bilaterally in posterior fields
CV: mild tachy, S1, S2, no m/r/g
Abdomen: non-rigid, moderately soft, difficult to assess
tenderness due to mental status but appears to be mildly tender
to palpation in B/L lower quadrants with some voluntary guarding
but no involuntary guarding. No shake or tap tenderness.
Ext: Warm, well perfused, 2+ pulses, 2+ edema in hands and at
ankles up to knees
Skin: Anasarca
Neuro: responds to name with intermittent one-word answers.
Pupils are equal and reactive, not moving much but doesn't
appear to have a focal deficit
Pertinent Results:
[**2180-4-5**] 07:20PM BLOOD WBC-55.0*# RBC-3.08* Hgb-9.0* Hct-30.8*
MCV-100* MCH-29.4 MCHC-29.4* RDW-18.2* Plt Ct-691*#
[**2180-4-5**] 07:20PM BLOOD Neuts-82* Bands-6* Lymphs-5* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2180-4-5**] 07:20PM BLOOD PT-18.1* PTT-35.0 INR(PT)-1.7*
[**2180-4-10**] 04:53AM BLOOD PT-45.4* PTT-55.6* INR(PT)-4.5*
[**2180-4-5**] 07:20PM BLOOD Glucose-134* UreaN-30* Creat-2.4* Na-138
K-4.8 Cl-114* HCO3-10* AnGap-19
[**2180-4-5**] 07:20PM BLOOD ALT-25 AST-27 AlkPhos-214* Amylase-74
TotBili-0.4
[**2180-4-5**] 07:20PM BLOOD Calcium-7.8* Phos-4.1 Mg-2.0
[**2180-4-13**] 05:26AM BLOOD VitB12->[**2168**] Folate-8.3
[**2180-4-6**] 05:30AM BLOOD Phenyto-10.8
[**2180-4-7**] 03:18AM BLOOD Phenyto-13.4
[**2180-4-11**] 06:15AM BLOOD Phenyto-14.8
[**2180-4-5**] 09:28PM BLOOD Type-ART pO2-107* pCO2-16* pH-7.34*
calTCO2-9* Base XS--14
[**2180-4-14**] 06:07AM BLOOD WBC-21.0* RBC-2.51* Hgb-7.5* Hct-26.4*
MCV-105* MCH-30.0 MCHC-28.4* RDW-20.8* Plt Ct-399
[**2180-4-11**] 06:15AM BLOOD Neuts-73* Bands-1 Lymphs-10* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-2* NRBC-3*
[**2180-4-14**] 06:07AM BLOOD PT-17.3* PTT-41.4* INR(PT)-1.6*
[**2180-4-13**] 05:26AM BLOOD PT-26.3* PTT-44.4* INR(PT)-2.5*
[**2180-4-12**] 05:58AM BLOOD PT-27.1* PTT-47.8* INR(PT)-2.6*
[**2180-4-11**] 06:15AM BLOOD PT-31.7* PTT-50.5* INR(PT)-3.1*
[**2180-4-10**] 04:53AM BLOOD PT-45.4* PTT-55.6* INR(PT)-4.5*
[**2180-4-14**] 06:07AM BLOOD Glucose-166* UreaN-43* Creat-1.4* Na-140
K-4.4 Cl-113* HCO3-23 AnGap-8
[**2180-4-13**] 05:26AM BLOOD Glucose-156* UreaN-42* Creat-1.5* Na-142
K-4.0 Cl-117* HCO3-18* AnGap-11
[**2180-4-12**] 05:58AM BLOOD Glucose-101* UreaN-41* Creat-1.6* Na-143
K-3.1* Cl-118* HCO3-18* AnGap-10
[**2180-4-11**] 06:15AM BLOOD Glucose-123* UreaN-45* Creat-1.7* Na-143
K-3.4 Cl-120* HCO3-14* AnGap-12
[**2180-4-10**] 04:53AM BLOOD Glucose-189* UreaN-43* Creat-2.0* Na-138
K-3.0* Cl-116* HCO3-12* AnGap-13
[**2180-4-10**] 04:53AM BLOOD ALT-15 AST-22 AlkPhos-370* TotBili-0.1
[**2180-4-9**] 06:29AM BLOOD ALT-13 AST-25 AlkPhos-359* TotBili-0.2
[**2180-4-8**] 04:52AM BLOOD ALT-12 AST-16 LD(LDH)-253* AlkPhos-205*
TotBili-0.2
[**2180-4-7**] 03:18AM BLOOD ALT-14 AST-10 LD(LDH)-216 AlkPhos-165*
TotBili-0.2
[**2180-4-14**] 06:07AM BLOOD Calcium-7.0* Phos-3.6 Mg-1.9
[**2180-4-13**] 05:26AM BLOOD Calcium-7.3* Phos-3.8 Mg-2.0
[**2180-4-12**] 05:58AM BLOOD Calcium-7.3* Phos-4.8* Mg-2.5
[**2180-4-5**] 11:06 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2180-4-6**]**
C. difficile DNA amplification assay (Final [**2180-4-6**]):
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2180-4-6**] 12:10PM
4-3180.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
CT ABD & PELVIS W/O CONTRAST Study Date of [**2180-4-6**] 1:08 PM
IMPRESSION:
1. Pancolitis with wall thickening and surrounding fat
stranding. There is
no evidence for perforation, abscess formation or secondary
signs of ischemia such as portal venous air or pneumatosis.
2. Small amount of ascites surrounding the liver and spleen as
well as deep in the pelvis, all the above findings are new
compared to [**2180-4-3**].
3. Status post percutaneous nephrostomy of the left kidney. The
collecting
system is decompressed. Multiple stones are seen in the kidneys
bilaterally that are non-obstructing. Stones are identified in
the renal pelvis. The right collecting system is dilated to a
transition at the level of the iliac crest where surgical clips
are noted. This is stable
NEPHROSTOGRAM Study Date of [**2180-4-12**] 9:49 AM
TECHNIQUE: After obtaining a scout image, Optiray was injected
through
nephrostomy tube for assessment of collecting system.
FINDINGS: Optiray was seen entering the pyelocalyceal system
without any
evidence of obstruction or perinephric leakage of contrast. The
calyceal
system appears mildly dilated, consistent with known history of
hydronephrosis. There was no passage of contrast through the
ureteropelvic
junction, even though the patient was repositioned to facilitate
ureteral
drainage. The contrast was seen draining uneventfully through
the nephrostomy tube after reopening of the valve.
FINDINGS
1. Mild-to-moderate hydronephrosis.
2. Obstruction of the ureteropelvic junction.
BILAT UP EXT VEINS US Study Date of [**2180-4-11**] 9:46 AM
INDICATION: 52-year-old female with PICC line and arm swelling
bilaterally. Question DVT.
FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] were performed
of bilateral upper extremities, demonstrating small amount of
non-occlusive thrombus within the right internal jugular vein,
in the location of a recently removed central venous catheter. A
PICC traverses one of the left brachial veins. There is normal
compressibility and color flow in the left internal jugular
vein, bilateral axillary, brachial, basilar, and cephalic veins.
Significant subcutaneous soft tissue edema is present.
IMPRESSION: Non-occlusive thrombosis of the right internal
jugular vein.
Brief Hospital Course:
52F with significant PmHx including MS, and an MS [**First Name (Titles) **] [**Last Name (Titles) **]e disorder, transfered to [**Hospital1 18**] with severe complicated
[**Hospital **] transferred to the MICU for septic shock with resolution
of shock and improvement in CDiff.
# Severe C. difficile colitis: admitted with a leukocytosis to
over 50,000, diarrhea and a firm abodomen, she was initially
managed on the floor overnight but continued to be hypotensive
to the 80's systolic despite aggressive IV fluid boluses, as a
result she was transferred to the MICU. She was initially
started on po vancomycin and IV metronidazole, ID and surgery
were consulted. Her antibiotic regimen was expanded to include
tigecycline, she underwent a CT of her abdomen and pelvis which
showed pancolitis, no evidence of pneumatosis or megacolon. She
was closely monitored with [**Hospital1 **] lactates and serial abdominal
exams, over the next few days her white count trended down from
over 60 to 22 on [**2180-4-10**]. Her abdominal firmness and tenderness
improved and she was started on trophic tube feeds on [**4-8**], which
were advanced to almost goal when she was called out of the ICU
on [**2180-4-10**] and transferred to the medical floor. On the medical
floor, her abdomen exam was stable and WBC remained around
20,000 but patient continued to be afebrile. Given degree of
pancolitis, persistent WBC is to be expected for some short term
duration. Her abdominal exam remained unchanged but patient
continues to have some guarding but has never been rigid or
peritoneal. She will continue treatment with IV flagyl,
tigecycline and PO vancomycin until [**2180-4-21**] when the PO
vancomycin taper will begin. Her PPI was held given promotion of
CDiff risks.
# Altered Mental Status: on admission to the ICU, was altered,
not always answering questions and unable to reliably take po's.
An NGT was placed to give oral medications, and her mental
status improved as her infection improved. Given her recent
extensive work up, which included EEG, head CT and MRI at the
OSH (images uploaded to our system), no further work up was
pursued it was felt that this was likely due to her acute
illness as her mental status improved throughout her stay.
# Metabolic Acidosis: her bicarb was very low, between 8 and 12
during her stay, thought to be multifactorial from the diarrhea,
acute renal failure and IV fluid resuscitation with normal
saline. She was started on po bicarb repletion on [**4-8**] with mild
improvement in her bicarb levels. Her bicarb levels improved to
normal even after the tablets were stopped.
# Acute on chronic renal failure: she has baseline CKD, with a
Cr of 1.4-1.5, on admission it was elevated to 2.4, improved to
1.8-2.0 with IV fluid resuscitation, which pointed to a prerenal
etiology, however her creatinine plateaued at around 2.0, given
her episode of hypotension was thought to be due to possible
ATN. Diuresis was started on [**4-10**], with good urine output
response as she was grossly volume overloaded, as there was also
concern that congestive nephropathy may have been contributing
her renal failure as well. She was continued to be diuresed with
20 IV lasix per day and is likely discharged ~10L positive in
Total body water but continues to diuereis on her own as well
and thus giving additional lasix at rehab is optional. Her
creatinine on D/C is about 1.4 which seems to be her baseline.
# Left nephrostomy tube: This was placed at outside hospital
prior to admission for concern of left hydronephrosis and
elevated creatinine. The urine output from the nephrostomy drain
was no more than 100-200 cc/day while the urostomy put up to
3000 cc/day on certain days. A nephrostogram was done to assess
functionality of this drain which revealed mild to moderated
hydronephrosis of the left kidney with obstruction of the
ureteropelvic junction. On [**2180-4-14**], she self-discontinued her
nephrostomy tube accidentally. Urology was consulted who felt
that the drain did not need to be replaced based on the fact
that her creatinine seemed to be near her baseline level. They
also felt that keeping the drain in would be an infection risk
and they argued that it shouldn't have been placed at the
outside hospital initially given their suspicion that her left
kidney renal function was very minimal and not physiologically
signficant even prior to hospitalization. They advised she
followup with her outpatient urologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] witihn
the next 2 weeks to address any further urologic management
issues.
# Bilateral Lower Extremity DVT's: was on coumadin prior to
admission, INR was subtherapeutic on admission but her coumadin
was held and her INR increased in the setting of antibiotic
administration, no evidence of bleeding so she was not given
vitamin K and her INR was just monitored. She was re-started on
coumadin once deemed safe.
# Right IJ non-occlusive thrombus: in location where CVL was
thus has provoked etiology. Currently anticoagulated on warfarin
for DVTs as well.
# Nutritional Status: albumin less than 2. Tube feeds were
continued through NGTube.
And orals started with speech and swallow eval giving ok for
modified diet.
# Multiple Sclerosis: Followed at [**Hospital1 112**] for this. Has been
receiving weekly methotrexate and monthly steroids, but per
husbands report no recently (since beginning of [**Month (only) 958**]). Sounds
like she is reasonably functional at home despite her disease.
We held any immune suppressing medications in setting of
infection and this should be followed as outpatient.
# Seizure Disorder:
Long-standing and though [**2-3**] to multiple sclerosis. Has been on
both phenytoin and LeVETiracetam for this. Phenytoin levels were
fine at OSH and no reports of seizure-like activity while
admitted there, although one of reasons rehab sent her there was
this. We continued Phenytoin Sodium Extended 100 mg PO TID as
well as LeVETiracetam 500 mg PO/NG [**Hospital1 **].
# Anemia:
This appears to be chronic and is at recent baseline. Guiac
positive stool but to be expected in setting of colonic
infection. Anemia likely multi-factorial and due to multiple
chronic disease states and recent illnesses.
# CODE: Full Code
# CONTACT:
Name of health care proxy: [**Name (NI) **] [**Known lastname 91813**]
Relationship: husband
Phone number: [**Telephone/Fax (1) 91820**]
Cell phone: [**Telephone/Fax (1) 91821**]
Transitions of care:
- Discuss with neurology when its safe to restart Multiple
Sclerosis medications.
- Continue to follow phenytoin levels periodically.
- Follow-up with outpatient urologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within
the next 2 weeks to address any further urologic management
issues
Medications on Admission:
1. Pip/Tazo 2.25g Q6hrs
2. Vancomycin 125mg PO Q6hrs (started on [**2180-4-5**])
3. Metronidazole 500mg IV Q8hrs (started on [**2180-4-5**])
4. Dilantin 100mg PO TID
5. Aricept 10mg daily
6. Keppra 500mg PO BID
7. Warfarin 1 - 1.5mg PO daily per INR
8. Metoprolol Succinate 50mg PO daily
9. Omeprazole 40mg PO daily
10. Callcium 667mg PO BID
11. Vitamin E 400 iu daily
12. Vitamin C 500mg daily
Discharge Medications:
1. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 7
days: Please continue through [**2180-4-21**].
2. tigecycline 50 mg Recon Soln Sig: Fifty (50) mg Recon Soln
Intravenous Q12H (every 12 hours) for 7 days: Please continue
through [**2180-4-21**].
3. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 7 days: Please continue Vancomycin Oral Liquid 500
mg PO/NG Q6H through [**2180-4-21**].
4. vancomycin 125 mg Capsule Sig: SEE TAPER BELOW Capsule PO
four times a day: Starting [**2180-4-22**]:
125mg capsule QID for 7 days. Followed by 125mg capsule [**Hospital1 **] for
7 days. Followed by 125mg capsule QD for 7 days. Then 125mg
capsule every other day for 7 days. Finally, 125mg capsule every
3 days for 14 more days.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO
every eight (8) hours.
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)): The dose of this medication will need to be
titrated to a goal INR of [**2-4**].
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnoses:
- Severe Clostridium difficile colitis
- Acute kidney injury
Secondary diagnoses:
- Multiple sclerosis
- Left ureter obstruction
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for an infection in the colon called
clostrium difficile. You were treated with antibiotics and your
symptoms improved. Also, your left kidney nephrostomy tube fell
out while you were here but the urology doctors [**Name5 (PTitle) **] it was
safer not to try and replace it.
REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
Metronidazole, vancomycin, tigecylcine
Medications STOPPED this admission:
aricept, metoprolol, omeprazole (DO NOT RESUME GIVEN INCREASED
RISK FOR CLOSTRIUM DIFFICULE WITH PPI DRUGS), calcium, Vit E/C,
immunosuppressive medications for multiple sclerosis,
methotrexate and solumedrol (NOT TO BE RESUMED UNTIL HER
NEUROLOGY FOLLOWUP APPOINTMENT).
Medication DOSES CHANGED that you should follow:
Warfarin changed from 1-1.5mg each day to 2mg daily for goal INR
[**2-4**]. This will need to be titrated to goal INR at your nursing
home.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Followup Instructions:
Name: NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 91822**]
Department: Neurology
Address: 1 [**Location (un) **] PL, [**Location (un) **],[**Numeric Identifier 1415**]
Phone: [**Telephone/Fax (1) 91818**]
Appointment: Thursday [**2180-5-4**] 9:00am
Name: [**Location (un) 9655**],[**Name6 (MD) 9656**] [**Name8 (MD) **] MD
Location: [**Hospital6 9657**] DEPARTMENT OF SURGERY
Address: [**Doctor First Name 9658**], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 9659**]
***It is recommended you follow up with Dr [**Last Name (STitle) **] within [**1-3**]
weeks of discharge. Please call the office as soon as you are
home to book an appt.
Finally, please followup with your primary care [**Month/Day (2) **] when
you can regarding the course of this hospitalization.
Completed by:[**2180-4-14**]
|
[
"340",
"403.90",
"707.20",
"785.52",
"038.3",
"585.9",
"V58.61",
"276.2",
"276.4",
"707.03",
"263.9",
"593.4",
"008.45",
"995.92",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
23116, 23188
|
14285, 16061
|
311, 317
|
23380, 23380
|
9118, 14262
|
24698, 25552
|
7172, 7190
|
21561, 23093
|
23209, 23290
|
21141, 21538
|
23560, 24675
|
7205, 8264
|
23311, 23359
|
8280, 9099
|
263, 273
|
345, 5842
|
23395, 23536
|
20798, 21115
|
5864, 7032
|
7048, 7156
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,068
| 178,697
|
930+55246
|
Discharge summary
|
report+addendum
|
Admission Date: [**2102-1-17**] Discharge Date: [**2102-1-31**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Nausea, distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 6249**] is a [**Age over 90 **] year-old male with a history of
diverticulitis, s/p Hartmann's procedure in [**5-11**], and who, most
recently is s/p exploratory laparotomy with LOA in [**11-12**], which
has been complicated by prolonged ileus, and presented to [**Hospital1 18**]
on [**2102-1-17**] for evaluation and treatment.
Past Medical History:
As above, including: htn, diverticulitis, sigmoid volvulus,
SBOs, COPD
PSH: likely L colectomy, hartmanns [**5-11**], ostomy takedown [**8-11**],
internal hernia w/ SBO 1 week later s/p exlap, loa, repair,
incisional hernia repair [**4-11**]
Social History:
Married with four children. Former owner of restaurant. Former
smoker.
Physical Exam:
Alert, no distress
Decreased [**Last Name (un) 6250**] sounds at lung base
RRR
Abd distended, soft, nontender
Brief Hospital Course:
Mr. [**Known lastname 6249**] is a [**Age over 90 **] year-old male with a history of
diverticulitis, s/p Hartmann's procedure in [**5-11**], and who, most
recently is s/p exploratory laparotomy with LOA in [**11-12**], which
has been complicated by prolonged ileus, and presented to [**Hospital1 18**]
on [**2102-1-17**] for evaluation and treatment. He was admitted to the
surgery service. A rectal tube was placed. On [**1-18**], Mr.
[**Known lastname 6249**] was found to be in respiratory distress and was
intubated. CXR revealed atelectasis and infiltrate. A CT torso
revealed no evidence of sbo, but a fluid filled sigmoid. He was
continued on antibiotics. He was started on neostigmine. He
was extuabated two days later, and would remain stable from a
respiratory standpoint. He was transferred to the floor in
stable condition. Success was achieved with a combination of
prokinetics and dulcolax, and his bowel functioned returned. He
was started on oral pyridostigmine and reglan. He began
tolerating a regular diet, and by the time of discharge, he was
taking in an adequate amount of oral intake. The rectal tube
was removed. He was discharged to rehab in good condition on
[**2102-1-31**], tolerating a regular diet, having bowel movements, and
with less abdominal distention. He should receive dulcolax for
constipation or abdominal distention. A rectal tube, as well,
should be placed for marked distention.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for Wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp < 100. Tablet(s)
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day): 75 mg PO BID.
8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
9. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
10. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Reglan 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. Dulcolox 10 mg, PR [**Hospital1 **] prn
15. Colace 100 mg, PO BID.
16. MOM 30 cc, PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Ileus
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 957**] or return to the local ER if:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are nauseous and vomiting and cannot keep in fluids or
your medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth,
rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
*A large amount of swelling or bruising
* Difficulty passing stool
* Unable to tolerate oral intake
* An increase redness or drainage of the incision
* Bright red blood or foul smelling discharge coming from
the incision
* Difficulty urinating
* Dislocation of j-tube
* Any serious change in your symptoms, or any new symptoms that
concern you.
Additional Instructions
*Dressings: If the dressing from the operating room is still on,
you should leave it on until it is removed by Dr. [**Last Name (STitle) 957**] in the
office.
*Activity: You can start getting back to your routine as soon as
you feel able. Just take it easy at first. The following tips
may help:*Take short walks to improve circulation. *If you were
able to climb stairs before your surgery, you may continue to
climb stairs; this will not harm your incision. *You may start
some light exercise when you feel comfortable.
*Lifting: For a period of six weeks, please do not lift anything
heavier than ten (10) pounds, which is as large as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**]
telephone book. It will take about six (6) weeks for your
incision to heal.; at the end of six (6) weeks your incision
will be as strong as it will be a year from now.
*Fatigue: It is normal to experience fatigue for 2-3 weeks days
after your surgery. The more exercise and activity you re
involved in, the better you will be and the quicker you will
recover.
*J-Tube: This tube (located on your left abdomen) will remain
clamped until you see Dr. [**Last Name (STitle) 957**] in clinic. Call the clinic if
this tube is dislocated or accidently removed. It should be
secured to your abdomen.
*Abdominal Binder: Please wear this binder for support while you
are out of bed ambulating.
* Please continue to take your home medications as listed.
Please continue to take the new medications as prescribed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 957**] in 2 weeks. Please call
[**Telephone/Fax (1) 2359**] to schedule an appointment.
Name: [**Known lastname 773**],[**Known firstname 774**] J. Unit No: [**Numeric Identifier 775**]
Admission Date: [**2102-1-17**] Discharge Date: [**2102-1-31**]
Date of Birth: [**2011-11-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 484**]
Addendum:
During the course of Mr [**Known lastname **]' admission from [**1-17**] - [**1-31**],
he was treated for an acute on chronic diastolic and systolic
heart failure exacerbation. An ECHO was obtained on [**2102-1-19**],
which revealed LVEF 60-70%.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) 776**] & Islands - [**Location (un) 777**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 485**] MD [**MD Number(1) 486**]
Completed by:[**2102-3-5**]
|
[
"560.1",
"428.43",
"784.3",
"E942.6",
"401.9",
"V55.1",
"458.9",
"518.0",
"V15.82",
"693.0",
"491.21",
"997.4",
"724.2",
"E947.9",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"46.39",
"96.71",
"96.6",
"96.04",
"96.09",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7565, 7833
|
1174, 2611
|
280, 287
|
4118, 4127
|
6772, 7542
|
2634, 3933
|
4089, 4097
|
4151, 6749
|
1040, 1151
|
222, 242
|
315, 668
|
690, 935
|
951, 1025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,271
| 140,272
|
46280
|
Discharge summary
|
report
|
Admission Date: [**2121-5-21**] Discharge Date: [**2121-5-24**]
Date of Birth: [**2065-10-15**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Aspirin
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Femoral Central Line placement
History of Present Illness:
Ms. [**Known lastname 30207**] is 55 year-old female with PMHx of SLE c/b nephritis,
pericarditis, peritonitis/enteritis, HTN, depression and h/o
EtOH/substance abuse brought in by family after being found
confused, weak.
Patient is confused and is tangental when asked questions. Per
the patient's mother: "Living alone. Wasn't answering phone for
weeks. Hadn't seen in patient since [**5-3**]. Sister went over to see
her and said she wasn't looking good. Mother decided to head
over and see her and was shocked the way she looked thin and as
if her eyes were recessed." Mother noted that the patient said,
"Couldn't make herself eat and hadn't eaten in weeks." Per
mother unclear if taking medications or not.
In the ED, initial VS were: BP: 71/50 RR: 24, Afebrile. Patient
was initially hypotensive and recieved 4 liters of IV fluid.
Central line was place in the femoral vein however no pressures
were initiated. Labs revealed ARF 124/6.4, leukopenia (3.7), UA
with 12 WBC, few bacteria, nitrite negative. Lactate 1.3. ED
bedside ECHO showed flattened IVC, no pericardial effusion.
Foley placed with minimal UOP. Stool noted to be loose and
guaiac positive. Renal consulted and plans to see patient in AM
as not acute indications for dialysis. CT Head and CXR performed
and were unrevealing. Patient was given Levofloxacin 500mg IV x
one for UTI, Hydrocortisone 100mg IV, Dilaudid 2mg IV, Fentanyl
100mcg, Lorazepam 2mg IV, B12, Folate, Thiamine. Vitals prior to
transfer: 103/75 P:77, afebrile.
On arrival to the MICU, patient's VS 103/67, HR 69, 100% on 2L.
Patient is confused and not answering questions clearly. Denies
pain in chest, abdomen, though notes pain in her left knee.
Denies difficulty breathing.
Review of systems: Unable to obtain given confusion.
Past Medical History:
- Lupus, c/b nephritis, pericarditis, and peritonitis
- Hypertension
- Alcoholism
- Polysubstance abuse (cocaine, amphetamines, opiates,
benzodiazepines and tobacco), on narcotics contract
- Neuropathy due to alcoholism and poor nutrition, seen by Dr.
[**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **] in Neurology
- Remote right basal ganglia infarction on head CT
- Migraine Headaches
- Hypothyroidism
- Depression/Anxiety
- Remote history of a gunshot wound to the abdomen with
subsequent PTSD
- Anemia
- Rectal Prolapse
- GIB secondary to PUD
- s/p cholecystectomy
- s/p hernia repair
- s/p total abdominal hysterectomy, bilateral
salpingo-oophorectomy
- History of pelvic inflammatory disease with prior disseminated
infection
Social History:
Smokes cigarettes (1 ppd/30 pack-year history). Denies any
alcohol (sober for 7 years) or recent drug use. Lives alone with
1 dog - on disability. Mother lives about an hour away.
Family History:
Father died of renal failure at age 75. Reports mother and 2
sisters with lupus. [**Name (NI) **] sister died of kidney disease and
lupus related complications and older sister wheelchair bound
from lupus.
Physical Exam:
On Admission:
Vitals: Afebrile, 103/67, 68, 99% 2l, RR 14
General: Alert, oriented x2, confused and tangental when
speaking with patient, no acute distress
HEENT: Sclera anicteric, Extremely dry mucous membranes,
oropharynx clear, EOMI, Pupils 3mm reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Loud upper airway sounds, no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left knee without evidence of effusion or synovitis
Neuro: +asterixis, CNII-XII intact, 5/5 strength upper/lower
extremities, grossly normal sensation, gait deferred.
Rectal: Per ED report Guaiac + yellow stool
Pertinent Results:
Admission Labs:
------------------
[**2121-5-21**] 03:55PM BLOOD Glucose-92 UreaN-124* Creat-6.4*# Na-138
K-3.7 Cl-97 HCO3-25 AnGap-20
[**2121-5-21**] 03:59PM BLOOD Lactate-1.3
[**2121-5-21**] 03:55PM BLOOD WBC-3.7* RBC-4.17* Hgb-12.1 Hct-38.3
MCV-92 MCH-29.0 MCHC-31.6 RDW-15.1 Plt Ct-351
Discharge Labs:
-----------------
Other relevant studies:
Brief Hospital Course:
Ms. [**Known lastname 30207**] is 55 year-old female with PMHx of SLE c/b nephritis,
pericarditis, peritonitis/enteritis, HTN, depression and h/o
EtOH/substance abuse brought in by family after being found
confused, weak and found to be hypotensive with acute renal
failure.
#. Hypotension: Due to severe volume depletion secondary to poor
PO intake. The patient's BP normalized with fluid repletion.
There were no fevers or leukocytosis to suggest sepsis, although
patient did have evidence of UTI. There is also some concern for
slow GI bleed given that the patient's HCT was less than
baseline. She has not had melena or hematochezia but stools have
been guiac positive. She has history of rectal prolapse and
hemorrhoids. Given stable Hct, additional workup was not
considered necessary.
.
#. Mental Status Changes/Neuro Deficits: CT head negative.
Patient presented very confused and off baseline per mother.
After fluid repletion and decrease in BUN she had considerable
improvement in alertness and confusion. She did however still
have some more focal deficits that are harder to explain from
toxic/metabolic encephalopathy alone. Neurology was consulted
and brain MRI was ordered. Anticardiolipin ab was also sent
(pending at time of discharge) due to some choreatic movements.
The brain MRI revealed no acute changes (other than evidence of
small vessel ischemic disease) or evidence of inflammation. No
seizure like activity were seen. B12/RPR/HIV/TSH were
unremarkable. While on floor, her mentation improved remarkably
and was confirmed by the family to be back to baseline. The
previously noted muscular movements were no longer visible, and
she was discharged in good condition.
.
#. Acute Renal Failure: FeNa 0.04% suggesting prerenal etiology.
As noted above likely secondary to little PO intake over the
last several weeks. Patient also has background of type 5
(membranous) Lupus nephritis per biopsy [**2120-6-19**]. However this
does not appear to be the main process involved in this
situation. C3, C4 were low - but have been chronically low.
Urine prot/creat was at 0.9. Anti dsDNA negative. With
hydration, her Cr returned to baseline Cr of 0.8. ACE I will be
resumed on the day of discharge to help with the proteinuria.
.
#. Lupus: Concerned that this could be flair leading to initial
abdominal symptoms, some degree of renal dysfunction poor Po
intake and current presentation. Rheumatology was consulted and
felt that there was no evidence for significant active disease
for lupus. The only marker for some evidence of acute
inflammation was ESR (78), but this may be attributed to
significant hydration and secondary dilutional anemia. Ms.
[**Known lastname 30207**] has a history of being noncompliant and was informed
again, of the importance of continuing the rheum medications.
.
.
#. Mild Pyuria: She was temporarily treated with cipro. Urine
cultures returned negaitve and the ciprofloxacin was
discontinued.
# . Home situation: Patient does not appear to be doing well at
home. Unclear what factor precipitated the decompensation, but
that factor probably caused a positive feedback loop of altered
mental status causing poor PO intake which in turn caused acute
renal failure and more alteration in mental status. Social work
was consulted and it is apparent the family (particularly the
mother) is very supportive. The family came to pick her up and
she will possibly stay with her mother for the next few days.
# Communication: Patient, mother, sister (information in [**Name (NI) **])
# Code: Full Code
Medications on Admission:
Medications: (per [**Name (NI) **])
Unclear if taking any medications.
--AZATHIOPRINE 50 mg Daily
--BUTALBITAL-ACETAMINOPHEN-CAFF - 50 mg-325 mg-40 mg Tablet one
tablet by mouth twice daily PRN headache
--CHLORTHALIDONE 25 mg Daily
--GABAPENTIN [NEURONTIN] 900 mg Capsule TID
--HYDROXYCHLOROQUINE 200 mg daily
--LEVOTHYROXINE 25 mcg Tablet Daily
--LISINOPRIL 40 mg daily
--OMEPRAZOLE 20 mg Daily
--OXYCODONE-ACETAMINOPHEN [ENDOCET] 5 mg-325 mg Tablet - 1
Tablet(s) by mouth twice a day as needed for pain
--PAROXETINE HCL [PAXIL] 60 mg Daily
--TRAMADOL 100 mg Tablet twice daily
--Tylenol 500mg three times daily as needed for pain
Discharge Medications:
1. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Imuran 50 mg Tablet Sig: One (1) Tablet PO once a day.
3. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every twelve
(12) hours as needed for headache.
Disp:*12 Tablet(s)* Refills:*0*
4. methadone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
5. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO once a day.
6. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day.
7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
- Acute renal failure
- Delirium
- Lupus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admited to the intensive care unit with acute renal
failure and confusion. You were severely dehydrated and given
intravenous fluids to help resuscitate your blood pressure and
kidney function. A number of tests were done to evaluate your
confusion - including a MRI of the brain which showed no
evidence of lupus related inflammation.
After hydration and resumption of some of the medications,
you improved significantly and back to your normal state.
Please continue to take your medications to help control lupus
and blood pressure.
Followup Instructions:
Department: NEUROLOGY
When: FRIDAY [**2121-5-30**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2121-7-22**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"244.9",
"357.5",
"583.81",
"V10.79",
"285.9",
"309.81",
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"349.82",
"300.00",
"304.01",
"346.90",
"V12.54",
"293.0",
"710.0",
"V12.71",
"276.52",
"401.1",
"584.5",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9470, 9476
|
4576, 8141
|
290, 322
|
9561, 9561
|
4202, 4202
|
10286, 10895
|
3118, 3325
|
8825, 9447
|
9497, 9540
|
8167, 8802
|
9712, 10263
|
4509, 4553
|
3340, 3340
|
2092, 2128
|
242, 252
|
350, 2072
|
4218, 4493
|
3354, 4183
|
9576, 9688
|
2150, 2904
|
2920, 3102
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,708
| 173,591
|
4642
|
Discharge summary
|
report
|
Admission Date: [**2177-4-10**] Discharge Date: [**2177-4-12**]
Date of Birth: [**2095-1-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalexin /
Cefazolin / Opioids-Morphine & Related
Attending:[**First Name3 (LF) 10552**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 19672**] is an 82 year old woman with a past medical history
significant for dementia, DM 2, CAD s/p CABG, systolic CHF
hypothyroid, known UTI, and two recent admissions for UGIB/CoNS
bacteremia and AMS/ARF now admitted with hypotension from
presumed urosepsis. The patient's daughter states that last week
she has had intermitent vomiting described as NBNB emesis every
3-4 days and lethargy. She had a urinalysis and urine culture
drawn last Friday, and was called by her PCPs office yesterday
and was prescribed nitrofurantoin. Of note, the patient has had
a chronic indwelling foley catheter since [**3-7**], with a voiding
cystogram done on [**4-2**] that was unremarkable. Over the past week,
her daughter reports that she has had decreased PO intake, and
this afternoon was found to be lethargic. At that point, she was
brought into the [**Hospital1 18**] ED for further evaluation.
.
Of note, the patient presented to the ED on [**3-4**] for abdominal
pain. At that time, she was evaluated by Surgery and felt to not
have an acute process and was found to have pyuria on UA treated
with 3 days of cipro 250 mg daily with no urine culture sent.
She was also admitted to [**Hospital1 18**] from [**Date range (1) 19675**] for AMS felt to be
secondary to ARF. During that admission, she failed a voiding
trial and has since had a chronic indwelling foley cathter. In
addition, she was admitted for [**Hospital1 18**] from [**Date range (1) 19676**] for a
duodenal ulcer bleed requiring 6 units PRBC transfusion with
hospital course complicated by CoNS bacteremia treated with 7
days of vancomycin.
.
In the [**Hospital1 18**] ED, initial VS 98.8 75 69/34 14 99%RA. Labs
notable for a lactate of 3.3 down trending to 3 and a UA with
>100 WBC with <1 epithelial. The patient received vanco,
levofloxacin, flagyl, 100 mg hydrocortisone, and 6L IVF, and was
then admitted to the MICU for further management.
.
Currently, the patient is resting comfortably. On ROS, she
endorses pain with palpation of her chest, shoulders, back, and
abdomen.
Past Medical History:
-Dementia
-Diabetes mellitus type II
-Coronary artery disease s/p CABG x 3 in 7/92
-Vasculopathy
-Status post laminectomy at L4-L5 for spinal stenosis on
[**2166-6-7**]
-Ventral hernia since [**2159**] s/p repair in 6/93
-Hashimoto's hypothyroidism
-HTN
-s/p appendectomy
-s/p cholecystectomy via paramedial incision
-s/p total abdominal hysterectomy via the same paramedial
incision
-s/p bilateral salpingo-oophorectomy via midline incision
-osteoarthritis
-irritable bowel syndrome
-esophageal stricture s/p dilation
-s/p benign polypectomy
-nephrolithiasis.
Social History:
Lives with 84yo husband and daughter [**Name (NI) 717**] at home, husband is
her primary caretaker, daughters and sons as well as friends
take turn at home to care for her. Remote tobacco, no alcohol
or drugs.
Family History:
Her mother died of CAD at 74. Four siblings (three brothers and
a sister) with MI prior to age 60.
Physical Exam:
ADMISSION
VS: 96 (ax) 84 89/34 16 98%RA
Gen: Elderly woman, comfortable appearing.
HEENT: MM dry
CV: Nl S1+S2. Harsh II/VI systolic murmur loudest at the base
radiating to the carotids. JVP<10 cm.
Pulm: Scattered crackles b/l
Abd: S/ND +bs. Mild TTP throughout, no rebound or guarding.
Ext: No c/c/.e
Neuro: Oriented to person. CN II-XII intact.
At discharge:
same as above except:
Abd: non-tender
Psych: agitated at times, easily redirected by family
Pertinent Results:
ADMISSION LABS:
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] WBC-9.7 RBC-3.72* Hgb-10.9* Hct-31.9*
MCV-86 MCH-29.4 MCHC-34.3 RDW-15.3 Plt Ct-276
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] Neuts-94.9* Lymphs-3.2* Monos-1.3*
Eos-0.4 Baso-0.2
[**2177-4-10**] 05:29PM [**Month/Day/Year 3143**] PT-11.4 PTT-23.6 INR(PT)-0.9
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] Glucose-86 UreaN-29* Creat-1.3* Na-128*
K-4.6 Cl-92* HCO3-24 AnGap-17
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] ALT-19 AST-66* AlkPhos-74 TotBili-0.5
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] Lipase-29
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] cTropnT-<0.01
[**2177-4-10**] 04:00PM [**Month/Day/Year 3143**] Albumin-3.9
[**2177-4-10**] 09:51PM [**Month/Day/Year 3143**] TSH-4.3*
[**2177-4-10**] 09:51PM [**Month/Day/Year 3143**] Free T4-1.2
[**2177-4-10**] 04:17PM [**Month/Day/Year 3143**] Lactate-3.3*
[**2177-4-11**] 05:21AM [**Month/Day/Year 3143**] Lactate-2.0
.
DISCHARGE LABS:
[**2177-4-12**] 08:10AM [**Month/Day/Year 3143**] WBC-6.2 RBC-3.21* Hgb-9.4* Hct-28.2*
MCV-88 MCH-29.3 MCHC-33.3 RDW-15.1 Plt Ct-236
[**2177-4-12**] 08:10AM [**Month/Day/Year 3143**] Glucose-87 UreaN-24* Creat-1.0 Na-134
K-3.6 Cl-106 HCO3-18* AnGap-14
[**2177-4-12**] 08:10AM [**Month/Day/Year 3143**] Albumin-3.0* Calcium-8.8 Phos-1.6* Mg-2.1
.
URINE:
[**2177-4-10**] 04:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.003
[**2177-4-10**] 04:30PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2177-4-10**] 04:30PM URINE RBC-2 WBC-116* Bacteri-FEW Yeast-MOD
Epi-<1
[**2177-4-10**] 04:30PM URINE CastHy-3*
[**2177-4-10**] 04:30PM URINE Hours-RANDOM Creat-60 Na-47 K-42 Cl-52
[**2177-4-10**] 04:30PM URINE Osmolal-301
URINE CULTURE (Preliminary):
YEAST. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.
.
PCP Urine Culture results obtained, E. faecium >100K organisms,
sensitive to linezolid.
.
[**Month/Day/Year **] cultures no growth to date at time of discharge
.
.
IMAGING:
PCXR: FINDINGS: Single AP upright portable view of the chest was
obtained. The patient is status post median sternotomy and CABG.
No focal consolidation, pleural effusion, or pneumothorax is
seen. The cardiac and mediastinal silhouette, and the hilar
contours are stable.
IMPRESSION: No significant interval change. No focal
consolidation seen.
Brief Hospital Course:
Mrs. [**Known lastname 19672**] is an 82 year old woman with a past medical history
significant for dementia, DM 2, CAD s/p CABG, systolic CHF,
hypothyroid, known UTI, and two recent admissions for UGIB/CoNS
bacteremia and AMS/ARF now admitted with hypotension.
1. Hypotension: Given pyuria on UA consistent with UTI,
hypotension likely in part caused by urosepsis, although lack of
>WBC/<WBC, tachycardia, or tachypnea is inconsistent with SIRS
physiology for UTI. In addition, intravascular volume depletion
in setting of decreased PO intake likely contributing a great
deal, as the hemodynamics and lactate improved after 8L IVF.
Patient was was treated broadly with linezolid and meropenem
given history of VRE and prolonged use of ciprofloxacin for
recurrent UTIs. Antihypertensives and furosemide held at
admission and only furosemide and lisinopril restarted at
discharge. Carvedilol should be reintroduced as soon as BP and
HR tolerates, hopefully at PCP visit [**Name9 (PRE) 766**] or Tuesday. SBPs
ranged 110-140 on day of discharge without tachycardia. BP check
to be done by VNA on day after discharge.
2. UTI: Patient was was treated broadly with linezolid and
meropenem given history of VRE and prolonged use of
ciprofloxacin for recurrent UTIs. Antibiotic coverage was
narrowed to PO linezolid 600mg [**Hospital1 **] x total 7 days at time of
discharge. This decision was based on urine culture report
obtained from Quest lab, ordered by PCP prior to admission which
showed E. faecium >100K organisms, sensitive to linezolid. Foley
replaced at admission.
3. Hyponatremia: Likely in setting of intravascular hypovolemia.
Resolved with IVF.
4. Renal failure: Cr improved to baseline 0.9-1 after IVF. ACEI
and furosemide held during admission.
5. Anemia: Hct at baseline and stable this admission.
6. Goals of care: Discussed at length with daughter/HCP.
Confirmed DNR/DNI status. Family is in agreement that patient
would not want extensive life support, but would be amenable to
CVL and arterial line.
7. CAD/CHF: Patient with known LVEF 25-30%. Carvediilol,
lisinopril,furosemide held at admission and carvedilol held at
discharge (see above). No need for supplemental O2 despite poor
EF and aggressive IVF resuscitation.
8. DM 2: Held orals, accuchecks with HISS with good control.
9. Hypothyroid: Continued levothyroxine.
10. Duodenal ulcer: Continued PPI, Hct stable.
.
11. Delirium/Dementia: Continued home donepizil, held
mirtazapine per report from home that being held. Patient
developed significant delirium upon transfer to the floor,
requiring sitting at nurses station and eventual 2 point
restraints for pulling on Foley. No response to low dose
quetiapine or Zydis.
.
12. Urinary retention: Foley placed last admission given failed
void trial. Changed when admitted to the MICU. Discharged with
Foley in place. Patient should have voiding trial as outpatient
and Foley should be removed ASAP to avoid further risk of
recurrent UTI.
.
.
TRANSITIONAL ISSUES:
- restart Carvedilol once BP and HR tolerates
- continue linezolid for total 7 day course
- f/u volume status and encourage PO fluid intake
- ensure family has adequate support to take care of patient
24/7
- void trial and D/C Foley once spontaneously voiding
- attempt to minimize admissions and lengths of stay given
significant delirium in hospital repeatedly
Medications on Admission:
Carvedilol 3.125 mg po bid
Sucralfate 1 gram QID
Esomeprazole daily
Donepezil 10 mg daily
Lisinopril 20 mg daily
Furosemide 20 mg daily
Pravastatin 40 mg daily
Memantine 10 mg po bid (on hold)
Glipizide ER 2.5 mg daily
Metformin 500 mg po bid
Levothyroxine 100 mcg daily
Ezetimibe 10 mg daily (on hold)
Allopurinol 100 mg daily (on hold)
Omeprazole 20 mg daily
Discharge Medications:
1. linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day
for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
2. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
3. pravastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
4. donepezil 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
6. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
7. glipizide 2.5 mg Tablet Extended Rel 24 hr [**Hospital1 **]: One (1)
Tablet Extended Rel 24 hr PO once a day.
8. metformin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
9. levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company **] [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Urinary tract infection
2. Hypotension
3. Delirium
4. Acute on Chronic Renal Failure
5. Hyponatremia
Secondary:
1. Hypertension
2. Dementia
3. Diabetes
4. Duodenal ulcer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with low [**Location (un) **] pressure and
vomiting. You were given antibiotics for the infection in your
urine and IN fluids. Your [**Location (un) **] pressure improved to a normal
range. You also developed delirium, or confusion, while in the
hospital. We gave you medicines to help with this but the most
helpful thing is for you to not be in the hospital. Your family
should provide 24 hour care of you. It is important you drink
lots of fluids over the next 48 hours. It is also very important
that you see your PCP on [**Name9 (PRE) 766**] or Tuesday.
.
Some of your medications were changed during this admission:
START linezolid
STOP carvedilol
.
You should continue to take all of your other medications as
prescribed.
Followup Instructions:
It is VERY IMPORTANT you call Dr.[**Name (NI) 11351**] office at
[**Telephone/Fax (1) 1701**] on [**Telephone/Fax (1) 766**] morning to schedule an appointment to be
seen on [**Telephone/Fax (1) 766**] or Tuesday of this week. Please remember to do
this.
.
Your [**Telephone/Fax (1) **] pressure will be checked by a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **].
|
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icd9cm
|
[
[
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,468
| 190,862
|
35023
|
Discharge summary
|
report
|
Admission Date: [**2124-9-8**] Discharge Date: [**2124-9-14**]
Date of Birth: [**2042-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Hypotension after ERCP
Major Surgical or Invasive Procedure:
ERCP
PICC Placement & Removal
History of Present Illness:
81 yo man with pmhx CAD s/p CABG [**2110**] and recent NSTEMI last
week, HTN, CHF EF 35% transferred from [**Hospital **] Hospital directly
to ERCP for ? septic cholangitis then transferred to ICU for
hypotension after ERCP. At [**Hospital **] Hospital, patient had NSTEMI
and was treated medically because of his age, comorbidities
including acute on chronic renal failure. He was in their ICU
for a brief time on heparin gtt, nitro gtt and lasix gtt for
diuresis. Of note, one of the reports states that he had
hematemesis after heparin gtt so it was discontinued. He was
started on asa and plavix which have been held because of ERCP.
His LFTs were elevated and there was concern for cholangitis so
he was started on gentamycin and unasyn in [**9-7**]. In the PACU,
initial vs were T 98.1, HR 106, BP was 80/30s on 1 mcg neo.
Patient had cholangiogram, sphincterotomy and stent placement.
He received 100 cc fluid, no blood loss. Pt was under general
anesthesia. He was extubated in the PACU and complained of sob
and epigastric tightness similar to previous MI he had last
week. His blood pressure was initially 80/30s on 1 mcg neo. EKG
showed LBBB with left anterior fasicular block at rate 105. EKG
unchanged from EKG at [**Hospital **] Hosp on [**8-31**]. ABG was obtained and
showed 7.41 pCO2 33 pO2 66 HCO3 22. Patient had a lot of
secretions that were suctioned. CXR was obtained and showed
enlarged heart, pulm vasc engorged, minimal perihilar haziness,
mild edema. No focal consolidations. Patient denied dizziness,
LD, cp, palp, nausea, abd pain, vomiting. Initially his
breathing was labored and he complained of sob but this improved
with some suctioning. Patient's blood pressure continued to drop
and neo was increased and patient was given 500 cc bolus of LR.
On transfer to the ICU, patient was mentating well. Had no
specific complaints. Right IJ placed. CVO2 was 68 and CVP 12. Pt
denied cp, sob, abd pain, nausea, vomiting.
On Transfer to the floor patient was comfortable without
complaint.
Past Medical History:
CAD s/p CABG [**2110**]
CHF with EF 35%
CKD with creatinine baseline high 2s
HTN
macular degeneration
cholangitis
Social History:
Pt lives at home with his wife [**Name (NI) **]. [**Name2 (NI) **] is a retired driver
for GM. Smoked most of his life and quit in [**2109**]. No etoh or
drug use.
Family History:
NC
Physical Exam:
Discharge Physical Exam
VS T 98.4 P 66-69 BP 120-125/66-70 R 20 O2 sat 96%@RA
Gen- Elderly male in no acute distress
HEENT- CN III-XII grossly intact
CV: S1 & S2 regular without murmur
Pulm: Clear to ausculation bilaterally
Abd: Non-tender, non distended, bowel sounds present
Ext: No edema, 1+ DP
Pertinent Results:
Labs osh [**9-8**]:
.
wbc 29.7 hct 32.3 plt 428
.
CK 31 MBI 1.9 Trop I 0.44
.
135 99 67
-------------< 98
3.3 22 4.11
.
BILI 8.0, AST 184, ALT 215, Alb 2.2, AP 1145
.
Labs today at [**Hospital1 18**]:
134 95 77
-----------< 108
3.6 20 5.0
estGFR: [**10-27**] (click for details)
CK: 217 MB: Pnd Trop-T: Pnd
Ca: 8.0 Mg: 2.4 P: 4.0
ALT: 237 AP: 1180 Tbili: 7.4 Alb: 2.9
AST: 227 LDH: 326 Dbili: TProt:
[**Doctor First Name **]: 143 Lip: 65
.
wbc 46.1 hgb 10.5 hct 32.6 plt 470
.
ABG: pH 7.41 pCO2 33 pO2 66 HCO3 22
Discharge Labs:
[**2124-9-14**] 05:00AM BLOOD WBC-13.4* RBC-3.65* Hgb-10.0* Hct-31.4*
MCV-86 MCH-27.5 MCHC-31.9 RDW-15.4 Plt Ct-452*
[**2124-9-14**] 05:00AM BLOOD PT-14.0* PTT-30.1 INR(PT)-1.2*
[**2124-9-14**] 05:00AM BLOOD Glucose-104 UreaN-62* Creat-3.3* Na-137
K-4.2 Cl-106 HCO3-18* AnGap-17
[**2124-9-14**] 05:00AM BLOOD ALT-78* AST-57* LD(LDH)-295* AlkPhos-541*
Amylase-341* TotBili-2.3*
Brief Hospital Course:
81 year old man with CAD status post CABG ([**2110**]), recent NSTEMI
at outside hospital, hypertension, and chronic kidney disease
admitted for management of cholangitis. Admitted to ICU due to
hypotension following procedure, suspected biliary sepsis.
# Hypotension/biliary sepsis: In PACU received 500 cc LR and neo
gtt. Patient persistently hypotensive. Transferred to Unit. CVL
placed. CVP 12-17 so spoke against volume depletion and patient
did not lose any blood during procedure per anesthesia.
Hematocrit stable and no evidnece of active bleeding.
Possibilities for hypotension included sepsis given white count
46, fever, biliary source. CXR without consolidation.
Cardiogenic shock also suspected given recent NSTEMI and known
CHF with EF 35%. No evidence of tamponade on EKG and patient
does not have muffled heart sounds or elevated JVD. TTE showed
reduced LVEF 20-25%, no evidence of tamponade. Pressors (neo)
discontinued on [**2124-9-10**]. Improved with treatment for biliary
sepsis (vanc and zosyn). Blood, sputum cultures with no growth.
Cycled cardiac enzymes to peak.
# Hypoxia, resolved: Likely due to mucous plugging at
presentation as patient had secretions per anesthesia. Also
likely component of volume overload seen on cxr and pt has known
chf. Improved with supplemental oxygen, prn nebs. No further
intervention necessary.
# Cholangitis/sepsis: s/p ERCP. WBC, LFTS still elevated but
coming down. On admission, biliary sepsis covered with Zosyn;
also started vancomycin initially empirically. In ICU, has been
afebrile and without abdominal discomfort. Taking POs well. On
[**2124-9-12**], is day 5 on Zosyn. Vancomycin discontinued. PICC was
placed for continuing IV therapy, however management was changed
to oral Metronidazole & Ciprofloxacin for 1 week (2 week total
antibiotics course). Per GI, needs repeat ERCP in [**1-16**] months,
follow up with Dr. [**Last Name (STitle) **] in 6 weeks.
# CAD/NSTEMI: Patient with recent NSTEMI and hypotension. EKG
unchanged but difficult to interpret in setting of LBBB which is
old. TTE results as above. Heparin ggt discontinued.
Beta-blocker restarted after hypotension resolved. Continued
aspirin and clopidigrel. Statin held pending LFT resolution.
# chronic systolic heart failure: Patient with history of EF
35%. TTE here showed LVEF 20-25%. Beta-blocker restarted. Given
poor renal function, did not start ACE inhibitor given acute
renal failure. Patient discharged on Hydralazine & Isosorbide
dinitrate for afterload reduction.
# HTN: Restarted beta-blocker on [**2124-9-12**] as above.
# acute renal failure/chronic kidney disease stage III:
Creatinine resolving thoughout admission. Etiology was likely
pre-renal as the administration of oral and IV fluids improved
BUN & creatinine.
# BPH: Hytrin initially held given hypotension. Restarted and
Foley discontinued on [**2124-9-12**].
# Macular degeneration: Patient not started on any therapy
during this admission.
Medications on Admission:
atorvastatin 20 mg daily
norvasc 5 mg [**Hospital1 **]
hytrin 2 mg qhs
lopressor 50 mg [**Hospital1 **]
lasix 20 mg qd
pletal 50 mg qd
asa 81 mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*2*
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary Diagnoses
1) Cholangitis
2) NSTEMI
3) Acute Renal Failure
Secondary Diagnoses
1) Coronary Artery Disease
2) Hypertension
3) Congestive Heart failure
4) Chronic Kidney Disease
5) Macular Degeneration
Discharge Condition:
Stable
Discharge Instructions:
You have been admitted for cholangitis or an infection of the
gall bladder and because of a heart attack. While you were here
you had a stent placed in your gallbladder to help clear the
infection. It must be removed in approximately 6 weeks.
Please take all medications as instructed including two
antibiotics: Metronidazole & Ciprofloxacin for 1 week as
prescribed.
We have added Clopidogrel 75mg daily and Atorvastatin has been
increased to 80mg daily.
Please call your doctor or the ER at 911 for any chest pain,
abdominal pain, shortness of breath or any other medical
concern.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5435**] on Thursday [**2124-9-28**] at
2:30pm. [**Telephone/Fax (1) 5436**]
Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] for a repeat look at
your gall bladder in 6 weeks. He can be reached for scheduling
at [**Telephone/Fax (1) 463**].
|
[
"995.92",
"428.22",
"038.40",
"785.52",
"585.9",
"428.0",
"414.01",
"410.72",
"574.50",
"403.90",
"576.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.87",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
8294, 8357
|
4018, 6983
|
337, 369
|
8609, 8618
|
3086, 3600
|
9254, 9574
|
2749, 2753
|
7182, 8271
|
8378, 8588
|
7009, 7159
|
8642, 9231
|
3617, 3995
|
2768, 3067
|
275, 299
|
397, 2415
|
2437, 2552
|
2568, 2733
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,518
| 130,587
|
6776
|
Discharge summary
|
report
|
Admission Date: [**2123-2-19**] Discharge Date: [**2123-2-27**]
Date of Birth: [**2080-1-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
The patient is a 43 yo woman with h/o morbid obesity, COPD, OSA,
and recent PE on Coumadin, who presents with a two-week history
of worsening dyspnea and productive cough. The patient states
that her symptoms began at the end of [**Month (only) 404**], when she "caught
a cold" from her mother. She has a history of asthma, and she
states that she subsequently developed increasing shortness of
breath, wheezing, and a cough productive of clear-brown sputum.
She increased the duration of her nebulizations but states that
this did not help her symptoms. She also states that she has
been experiencing subjective fevers, loose stools, and
increasing lower and upper extremity edema for the past week.
She also admits to PND and increasing DOE. She is now only able
to walk a few steps before becoming short of breath. She was
prescribed Lasix 20 mg daily at her rehab facility, as needed
for peripheral edema, but she hasn't taken this since being
discharged from rehab 3 weeks ago. She thus presented to the ED
for further evaluation.
.
In the ED, the patient's initial VS were T 98.6, BP 162/106, P
111, R 24-30, O2 83% on 5L (she normally wears 5L at home). She
was placed on BiPap, and her O2 sats increased to 100%. She had
diffuse expiratory wheezes on physical exam but no peripheral
edema. CXR showed cardiomegaly, and EKG did not show evidence
of ST-T wave abnormalities. She was given Prednisone 60 mg PO,
Magnesium 2 g IV, 3 Combivent nebulizations, Ceftriaxone, and
Azithromycin. She was then started on a heparin gtt at 1200U/h
for possible PE, given the fact that she was likely over the
weight limit for the CT scanner. She was then admitted to the
MICU for further workup and evaluation. At the time of
transfer, her VS were BP 142/79, P 85, R 18, O2 97% on BiPAP.
.
On the floor, the patient continues to complain of shortness of
breath and states that she has to go to the bathroom.
Otherwise, she has no new complaints.
.
Review of systems:
(+) Possible recent weight gain, subjective fevers, loose
stools, increasing peripheral edema, chest pain with coughing.
(-) Denies chills, night sweats, recent weight loss. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
palpitations, or weakness. Denies nausea, vomiting,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Morbid obesity
Obstructive sleep apnea
Reactive airway disease (COPD vs. Asthma) on 4L home O2
- no PFTs available for review
Presumed PE in '[**12**]
Pulmonary Hypertension
? Hypertension
Joint disease
Social History:
The patient lives in [**Location 1268**] with her mother. She had been
at a rehab facility since her last admission in [**9-16**], but was
discharged home 3 weeks ago. She never smoked tobacco and
drinks EtOH rarely (3 drinks/year).
Family History:
HTN, breast cancer, prostate cancer, and obesity (mother)
Physical Exam:
T: BP: 157/97, P: 87 R: 18 O2: 95% on BiPAP
General: Middle aged woman, pleasant, articulate, obese, on
BiPAP.
HEENT: PERRL, EOMI, Oropharynx clear and without exudate.
Neck: supple, JVP not able to be assessed given neck girth, no
LAD
Lungs: Expiratory wheezes bilaterally. No crackles appreciated.
Prolonged expiratory phase.
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
ejection murmur, heard throughout. ? S3.
Abdomen: Obese, +BS, Non-tender
GU: Foley in place
Ext: Obese. Skin changes consistent with venous stasis in legs
bilaterally.
Pertinent Results:
Admission labs:
[**2123-2-19**] 01:40PM BLOOD WBC-7.0 RBC-3.93* Hgb-9.9* Hct-33.7*
MCV-86 MCH-25.1* MCHC-29.2* RDW-17.4* Plt Ct-182
[**2123-2-19**] 01:40PM BLOOD Neuts-78.8* Lymphs-15.5* Monos-2.4
Eos-3.1 Baso-0.2
[**2123-2-19**] 01:40PM BLOOD PT-17.1* PTT-29.4 INR(PT)-1.5*
[**2123-2-19**] 01:40PM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-141 K-4.2
Cl-96 HCO3-36* AnGap-13
[**2123-2-19**] 01:40PM BLOOD ALT-11 AST-19 AlkPhos-54 TotBili-0.3
[**2123-2-19**] 01:40PM BLOOD CK-MB-3 proBNP-668*
[**2123-2-19**] 01:40PM BLOOD cTropnT-<0.01
[**2123-2-19**] 01:40PM BLOOD Lipase-20
[**2123-2-20**] 12:27AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.8
[**2123-2-19**] 09:29PM BLOOD Type-ART Temp-36.2 pO2-66* pCO2-71*
pH-7.38 calTCO2-44* Base XS-12
[**2123-2-20**] 07:23AM BLOOD Lactate-0.6
[**2123-2-19**] 09:03PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2123-2-19**] 09:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
[**2-19**] Urine culture: Negative
[**2-19**] Blood culture: Pending
[**2-20**] Sputum: <10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2123-2-20**]):
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
.
[**2-19**] ECG: Sinus rhythm. Normal tracing. Compared to the previous
tracing of [**2122-9-22**] there is no diagnostic interim change.
.
[**2-19**] CXR: Cardiomegaly with bilateral pulmonary infiltrates,
consistent with pulmonary edema.
.
[**2-22**] TTE: The left atrium and right atrium are normal in cavity
size. The estimated right atrial pressure is 0-5 mmHg. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2122-9-21**],
the estimated pulmonary artery systolic pressure is now higher.
.
[**2-23**] Skin pathology: pending.
.
[**2-24**] CXR: The cardiomediastinal silhouette is unchanged
including cardiomegaly, moderate in severity. Compared to
[**2-21**] and [**2-22**], there is interval improvement in
pulmonary edema with currently only minimal vascular engorgement
and upper lobe redistribution present. There is no pleural
effusion or pneumothorax. Right basilar opacity is slightly
asymmetric but most likely represents residual pulmonary edema,
although focus of infection cannot be excluded and should be
further followed with radiographs to document complete
resolution.
Brief Hospital Course:
The patient is a 43 y/o woman with h/o COPD, recent PE, and
pulmonary HTN, who presents with a 3-day history of worsening
dyspnea and hypoxia, believed to be due to a CHF exacerbation
(in the setting of lasix noncompliance). At home, patient
uses 5L NC.
.
#. Dyspnea: Believed due to a CHF exacerbation (right heart
failure vs acute diastolic heart failure) given her lasix
non-compliance, peripheral edema, CXR, and the fact that she has
now improved to her baseline breathing status after 11 kg
diuresis in the MICU. The patient was initially treated for COPD
exacerbation with steroids, antibiotics, and diuresis. She did
not have leukocytosis or fevers, and antibiotics and steroids
were discontinued, out of the belief that her respiratory
symptoms were predominantly the result of fluid overload. She
diuresed excellently to moderate doses of furosemide, and her
length-of-stay fluid balance was negative 21 liters, by [**2-24**].
Her symptoms and chest x-rays continued to improve daily. She
was continued on nebulizer treatments and advair for her known
COPD. She was restarted on BiPap for her severe sleep disordered
breathing (settings are 15/7). By the time of discharge she was
breathing comfortably on her home O2 regimen of 5L NC.
Outpatient follow up was arranged with pulmonary, cardiology and
sleep. She is discharged to rehab for continued diuresis and
pulmonary rehab.
.
# Right heart failure: [**2-22**] echo TTE showed EF > 55%.
Likely has RV dilation in setting of known pulmonary
hypertension. Pulmonary and cardiology and sleep study as
outpatient follow-up. Patient's weight at the time of discharge
is 202 kilograms.
.
#. History of PE's: The patient has a history of presumed PEs in
[**Month (only) **], for which she is to be on anticoagulation for at
least 6 months. INR monitored. On coumadin.
.
# H/o COPD: This presentation appeared to be predominantly [**2-9**]
volume overload rather than COPD flare. Steroids may be causing
fluid retention so held on instituting them. Without signs of
infection, so held antibiotics. Continued advair, nebs.
.
# Left thigh nodule: s/p biopsy by dermatology; primary item on
the differential diagnosis (per derm) is dystrophic
calification. Derm will follow up with patient as an outpatient.
# Code: Full (discussed with patient in ICU)
Medications on Admission:
Lasix 20 mg daily prn for edema
Advair 250/50 one puff [**Hospital1 **]
Ipratropium nebulization q6h
Albuterol nebulization q2h prn for SOB
Colace 100 mg PO BID
Senna 8.6 mg PO BID
Warfarin 10 mg daily
Oxycodone 5 mg q6h prn
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: titrate to goal INR [**2-10**].
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every four (4)
hours as needed for shortness of breath.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Congestive heart failure exacerbation
asthma/COPD
Morbid obesity
Pulmonary hypertension, Cor pulmonale
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:
Ms. [**Known lastname 25661**],
You were admitted to the hospital for shortness of breath. It
was believed that your shortness of breath was related to excess
fluid in your lungs. You were treated with medications to remove
fluid from your body, and you lost a significant amount of fluid
through your urine. You were also treated with steroids and
antibiotics for the possibility of an exacerbation of your COPD,
as well as nebulizer treatment and BiPAP.
.
On discharge, you were breathing comfortably. It is very
important that you continue to take your medications to prevent
the re-accumulation of fluid and to help your breathing.
.
You are being discharged to rehabilitation, with cardiology and
pulmonary follow-up appointments - these are all important steps
to prevent this situation from recurring.
.
The following changes were made to your medications:
-- coumadin waschanged to 7.5mg daily, but may need to be
changed in the future depending on blood tests
Followup Instructions:
Please see a cardiologist:
MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]
Specialty: Cardiology
Date/ Time: Monday, [**3-1**], 3pm
Location: [**Location (un) **], [**Location (un) 86**]. [**Hospital Ward Name 23**] [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 62**]
.
Please see a pulmonologist:
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**]
Specialty: Pulmonary
Date/ Time: Friday. [**3-5**], 9:30am
Location: [**Location (un) **], [**Location (un) 86**]. [**Hospital Ward Name 23**] [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 612**]
Special instructions for patient: Please arrive for this
appointment at 9:10.
.
You had a biopsy done by dermatology of a lesion on your left
inner thigh. Dermatology will call you to schedule a follow-up
appointment, once they have the biopsy results. If you don't
hear from them within 2 weeks, you can call them at:
[**Telephone/Fax (1) 1971**].
.
You are scheduled for a sleep study on Thursday [**3-18**] at
8:15pm in [**Location (un) 583**]. Then, a follow-up appointment in Dr.[**Name (NI) 25722**]
clinic is on [**6-30**] at 9:30am. ([**Telephone/Fax (1) 513**].
|
[
"V15.81",
"518.84",
"278.01",
"428.0",
"V12.51",
"416.8",
"709.2",
"493.22",
"V58.61",
"428.31",
"327.23",
"V85.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
10704, 10781
|
7237, 9546
|
322, 330
|
10928, 10928
|
3909, 3909
|
12091, 13285
|
3254, 3314
|
9822, 10681
|
10802, 10907
|
9572, 9799
|
11098, 12068
|
3329, 3890
|
5388, 7214
|
2331, 2759
|
275, 284
|
358, 2312
|
3925, 5352
|
10942, 11074
|
2781, 2986
|
3002, 3238
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,849
| 142,517
|
49482
|
Discharge summary
|
report
|
Admission Date: [**2139-10-13**] Discharge Date: [**2139-10-21**]
Date of Birth: [**2090-7-7**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old
male with Crest syndrome who presents with worsening
shortness of breath and a Hickman catheter infection. The
catheter was pulled and a new catheter for Flolan dose
therapy was placed on [**10-8**]. The patient was then
started on Flolan for pulmonary hypertension. He had
originally been started on this medication in [**2139-3-21**].
His dose was titrated up to 50 nanograms per kilogram per
minute. At baseline the patient uses O2 4 liters by nasal
cannula and his O2 sat is 92%. Last echocardiogram showed
tricuspid regurgitation, PAH with PA pressures in the 60s.
He also had a small pericardial effusion. After discharge
the patient developed worsening shortness of breath. In
addition, his skin color has changed. It has become beet
red. The patient thus represented for evaluation of Flolan
dose.
PAST MEDICAL HISTORY:
1. Crest syndrome with pulmonary hypertension.
2. Bacteremia staph aureus.
3. Cellulitis.
4. Hypokalemia.
5. Acute renal failure.
6. Esophageal candidiasis.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure 100/50. Heart rate 80.
Respiratory rate 16. Sating 94% on 4 liters. Temperature
98.7. HEENT clear oropharynx. Mucous membranes are moist.
No lymphadenopathy appreciated on examination. Pupils are
equal, round and reactive to light. Extraocular movements
intact. Beet red skin. Skin was nontender. Chest lungs
were relatively clear to auscultation. Cardiovascular
regular rate and rhythm with a systolic murmur 2 out of 6
heard best at left upper sternal border. Abdomen soft,
nontender, nondistended. Extremities sclerodermal changes
with thinning of fingers, autoamputation of distal
fingertips. Neurological the patient was alert and oriented
times three.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service for observation. The plan was for him to undergo a
cardiac catheterization for evaluation of PA pressures while
his Flolan was titrated. On [**2139-10-14**] the patient underwent
cardiac catheterization by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]. This revealed
moderate pulmonary arterial systolic hypertension. Normal
left and right sided filling pressures. Cardiac output
elevated at baseline and increased further with oxygen and
nitric-oxide therapy. Calculated peripheral vascular
resistance decreased from 215 dimes/seconds/cm squared to a
199 with oxygen to 137 with nitric-oxide. Thus the plan with
this data was to transfer the patient to the VICU for down
titration of Flolan with PA catheter guidance. The patient
was kept flat on his back and transferred to the VICU the
following day for down titration of Flolan while under
guidance of a PA catheter. Pulmonary artery pressures were
noted to be 62/22 with a mean of 40 and a cardiac output of
7.24. Flolan was started at 54 nanograms per kilogram per
minute with the plan to titrate down in increments of 2
nanograms over twenty minutes and to reassess. Goal cardiac
output was 3 to 4.5. Under this regimen the patient's Flolan
dose was titrated down to 19 nanograms per kilogram per
minute. After this titration the patient reported increased
energy and less dyspnea on exertion. In addition, the
redness in the patient's face markedly improved. The patient
was walking around the floor without difficulty. It was thus
the consensus of the medical team that the patient was stable
for discharge to home. The patient was thus discharged home
on [**2139-10-17**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Crest syndrome.
2. Pulmonary hypertension.
DISCHARGE MEDICATIONS:
1. Furosemide 80 mg b.i.d.
2. Metolazone 2.5 mg one time per week.
3. Sucralfate 1 gram q.i.d.
4. Diltiazem ER 420 mg po q.d.
5. Pantoprazole 40 mg po b.i.d.
6. Lorazepam 0.5 mg q 4 to 6 hours prn.
7. Fluoxetine 20 mg po q.d.
8. Loperamide 2 mg q.i.d. prn.
9. Multivitamin.
10. Epoprostenol sodium 0.5 mg vials running at a rate of 19
nanograms per kilogram per minute intravenous drip infusions.
11. Tylenol prn.
12. Potassium 40 milliequivalents po q day.
The patient was set up with a follow up appointment with Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] on [**2139-10-23**].
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2691**]
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2140-1-27**] 11:09
T: [**2140-1-27**] 12:39
JOB#: [**Job Number 103537**]
|
[
"416.8",
"710.1",
"530.81",
"276.8",
"787.91",
"693.0",
"276.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
3790, 3839
|
3862, 4821
|
1979, 3709
|
1273, 1961
|
182, 1026
|
1048, 1250
|
3734, 3769
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,380
| 167,919
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19709
|
Discharge summary
|
report
|
Admission Date: [**2175-2-20**] Discharge Date: [**2175-3-3**]
Date of Birth: [**2094-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Mr [**Known lastname **] is an 80 year old man with history of chronic renal
insufficiency, long standing hypertension, hyperlipidemia,
transferred to [**Hospital1 18**] from [**Location (un) 620**]. Patient presented to OSH when
family called EMS after finding him down in his residence.
.
History obtained from patient, his sister and his daughter. Mr
[**Known lastname **] believes he got up to use the restroom sometime during
the night and after urinating, he developed weakness and he
believed he "miscalculated" the edge of the bed and "slid down
slowly". After falling to the ground, patient denies any head
trauma and insists he was able to come to rest without hitting
anything. He reports that after this took place he fell asleep
until he was found on the floor by his sister. [**Name (NI) **] denies
any chest pain, nausea, vomiting, diarrhea, difficulty
breathing, dizziness, uncontrolled shacking or loss of bowel or
bladder control.
.
Of note, Mr [**Known lastname **] has experienced at least three falls in the
last two weeks. The first took place outside his home when he
"slipped on ice". He reports hitting the side of his head with
this fall but not seeking medical attention. The second fall
took place at home with similar circumstances, while prepping
for colonoscopy. He was evaluated at [**Hospital1 **] [**Location (un) 620**] and discharged
that same night.
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. Does
have black stools and was recently scheduled for colonoscopy to
study this further. He denies recent fevers, chills or rigors.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
At [**Hospital1 **] [**Location (un) 620**], patient was noted to be very hypertensive, Temp
99.1, HR 88, RR 20, BP 198/95, Sat 98% RA. Patient given Aspirin
325mg, Lopresor IV 5mg x 3, and started on heparin and nitro
drips.
.
In our ED, Patient still very hypertensive, Temp 97, BP 209/97,
HR 102, RR 18, Os Sat 99% 2L NC. Patient given IV Lopressor 5mg
IV x1, Amlodipine 5mg, Lisinopril 40mg, and Labetalol 10mg IV.
He was continued on nitro and heparin drips. After consultation
with cardiology fellow, patient admitted to [**Hospital Unit Name 196**] under step down
status for further evaluation.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Gout
4. Chronic renal insufficiency
.
CARDIAC RISK FACTORS: (-) Diabetes, (+)Dyslipidemia,
(+)Hypertension
.
CARDIAC HISTORY: NONE
Social History:
Nonsmoker now, quit smoking in the
[**2136**]. Previously smoked one pack daily. Exercise: One to two
times a week walks for 20 minutes.
Family History:
Father with history of MI, uncle and [**Name2 (NI) 53305**] with history of
stroke.
Physical Exam:
VS: 184/73 102 RR 18 100% RA
GENERAL: Well appearing elderly man in NAD. Oriented x3, with
some difficulty in providing succint answers
HEENT: Left peri-orbital edema, EOMI and without pain on extreme
gaze. Some yellowish discharge at left orbital fissure.
NECK: Supple without appreciable JVD. Loud carotid bruits, right
greater than left
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Soft systolic ejection murmur at right
upper sternal border. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
Labs on admission:
[**2175-2-20**] 06:09PM WBC-15.0* RBC-3.39* HGB-11.3* HCT-32.9*
MCV-97 MCH-33.2* MCHC-34.2 RDW-14.6
[**2175-2-20**] 06:09PM NEUTS-80.2* LYMPHS-13.4* MONOS-5.5 EOS-0.5
BASOS-0.3
[**2175-2-20**] 06:09PM PLT COUNT-147*
[**2175-2-20**] 06:09PM TRIGLYCER-63 HDL CHOL-37 CHOL/HDL-3.9
LDL(CALC)-94
[**2175-2-20**] 06:09PM CHOLEST-144
[**2175-2-20**] 06:09PM GLUCOSE-123* UREA N-96* CREAT-2.3*
SODIUM-146* POTASSIUM-4.7 CHLORIDE-113* TOTAL CO2-26 ANION
GAP-12
[**2175-2-20**] 07:40PM URINE RBC-[**4-13**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
.
[**2175-2-20**] 06:09PM CK-MB-17* MB INDX-4.2 proBNP-3991*
[**2175-2-20**] 06:09PM cTropnT-0.80*
[**2175-2-20**] 06:09PM CK(CPK)-404*
[**2175-2-21**] 01:40AM BLOOD CK-MB-13* MB Indx-3.7 cTropnT-0.82*
[**2175-2-21**] 07:20AM BLOOD CK-MB-14* MB Indx-4.4 cTropnT-0.75*
[**2175-2-21**] 05:35PM BLOOD CK-MB-14* MB Indx-5.5 cTropnT-0.61*
[**2175-2-22**] 09:10AM BLOOD CK-MB-13* MB Indx-6.6* cTropnT-0.42*
[**2175-2-21**] 01:40AM BLOOD CK(CPK)-349*
[**2175-2-21**] 07:20AM BLOOD ALT-19 AST-34 CK(CPK)-319* AlkPhos-54
TotBili-0.4
[**2175-2-21**] 05:35PM BLOOD CK(CPK)-253*
[**2175-2-22**] 09:10AM BLOOD CK(CPK)-197*
.
Labs on discharge:
[**2175-3-2**] 01:00PM BLOOD WBC-11.6* RBC-3.27* Hgb-10.6* Hct-30.3*
MCV-93 MCH-32.5* MCHC-35.0 RDW-16.1* Plt Ct-173
[**2175-3-2**] 01:00PM BLOOD Glucose-100 UreaN-111* Creat-3.7* Na-146*
K-5.5* Cl-116* HCO3-20* AnGap-16
[**2175-3-2**] 01:00PM BLOOD Calcium-8.4 Phos-3.8 Mg-2.4
.
CT HEAD [**2175-2-21**]
IMPRESSION: No evidence of acute intracranial abnormalities.
.
Cardiac Cath [**2175-2-22**]
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Consult CTS for CABG.
.
Cardiac Cath [**2175-2-23**]
FINAL DIAGNOSIS:
1. Successful placement of IABP with 1:1 augmentation.
2- Mildly elevated right- and left-sided filling pressures with
preserved cardiac output.
.
Carotid U/S [**2-21**]
IMPRESSION: 40-59% stenosis of the internal carotid arteries
bilaterally.
This is a baseline examination at the [**Hospital1 18**].
.
Left femoral U/S [**2-25**]
IMPRESSION: No evidence of pseudoaneurysm.
.
Abd U/S [**2-25**]
IMPRESSION:
1. Markedly limited evaluation of the aorta due to overlying
bowel gas.
Cannot determine flow through the aneurysmal portion of the
aorta.
2. Approximately 4 cm lesion along the lower pole of the left
kidney
concerning for a solid mass. Diagnostic considerations include
hyperdense
cyst. Further evaluation can be achieved via MRI or
contrast-enhanced CT.
.
Renal U/S [**2-28**]
IMPRESSION: Solid-appearing left exophytic kidney mass.
As noted on the non-contrast CT of the abdomen and pelvis, this
can be further characterized with contrast-enhanced CT or MRI on
a non-emergent basis.
.
IMPRESSION:
1. No retroperitoneal hematoma.
2. Infrarenal abdominal aortic dilatation measuring up to 4.1
cm. No
evidence of rupture. Narrowing of origin of SMA, and left renal
arterial
stent, by atherosclerotic calcification.
3. Approximately 4 cm exophytic lesion along the lower pole of
the left
kidney, concerning for solid mass or hyperdense cyst. Further
evaluation can
be achieved via contrast-enhanced CT or MRI.
4. Bilateral pleural effusions, right greater than left, with
associated
atelectasis.
5. Cholelithiasis without evidence of acute cholecystitis.
.
CHEST PA/LAT: [**3-1**]
Preliminary Report !! WET READ !!
Interval development of bilateral effusions, moderate on the
left since
the16th. Left lower lobe opacity persists and remains concerning
for
developing pneumonia.
.
TTE [**2175-2-28**]
Conclusions
The left atrium is mildly elongated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with akinesis of the distal inferior and
anterior walls. The apex is akinetic but not aneurysmal. The
remaining segments contract normally (LVEF = 50 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (distal
LAD distribution). Moderate pulmonary artery systolic
hypertension.
CLINICAL IMPLICATIONS:
Based on [**2173**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Mr [**Known lastname **] is an 80-year-old man with history of hypertension,
hyperlipidemia, chronic renal insufficiency, presenting with
syncope and found to have STEMI.
.
# Sycope: The cause of his sycope on presentation was thought to
be most likely orthostatic hypotension with cerebral
hypoperfusion given his cerebrovascular disease. Carotid
ultrasound showed 40-59% stenosis of the internal carotid
arteries bilaterally. He had no further syncopal episodes while
in house.
.
# STEMI: Patient initially had positive enyzmes and ST
elevations v2-v6. He was given ASA, Plavix, Beta blocker,
heparin gtt. He was prehydrated for catheterization.
.
On [**2174-2-20**], repeat EKG showed STE in lateral leads. Enzymes
were trended and flat. Pt did not have symptoms. Decision was
made to send pt to cardiac cath on [**2175-2-22**], demonstrating severe
3 vessel disease. At that point, cardiac [**Doctor First Name **] was consulted for
CABG. However, during the morning of [**2175-2-23**], pt complained of
back pain and STE returned in his lateral leads. Patient was
sent again to the cath lab for balloon pump and then transfer to
the CCU.
.
In the ccu, the decision was made not to pursue CABG given
multiple medical comorbidities. The patient remained free of
chest pain. Medical management including clopidogrel, full dose
aspirin, beta blocker, and high dose statin were undertaken. He
was weaned off the intra-aortic balloon pump and it was removed.
He had a femoral bruit, so US was done which showed no evidence
of pseudoaneurysm.
.
Regarding his coronary disease, the plan was to wait until renal
failure resolved and then consider repeat catheterization for
revascularization of his LAD. He would need to have this done
before any urologic procedure (as below).
.
# Acute on chronic renal insufficiency: Creatinine on admission
was near baseline of 2. After catheterizations, creatinine rose
to a high of 5.4. The most likely cause was contrast-induced
ATN. He was hydrated, and renal function improved slowly.
Creatinine on discharge was 3.2.
.
# GI bleed: In the CCU, the patient had guaiac positive stools
and reported a history of melena. He was given pRBC to maintain
Hct >28. GI did an upper endoscopy that showeed erosive
gastritis and duodenitis, likely the source of bleeding. He was
given [**Hospital1 **] PPI. Per GI, this would not preclude heparinization
for cardiac procedure if needed.
.
# Renal mass: On non-contrast abdominal CT, patient was found
to have a 4 cm L renal mass that was confirmed by ultrasound to
be solid. The urology team evaluated the patient and
recommended outpatient follow-up for MR [**First Name (Titles) 151**] [**Last Name (Titles) **] after
renal function improves. After speaking with his nephrologist
(Dr. [**Last Name (STitle) 11427**] at [**Hospital1 **] [**Telephone/Fax (1) 53306**]), he should NOT get MR
with [**Telephone/Fax (1) **] at any point but should instead have a contrast
CT after kidney function improves. He could potentially undergo
resection, after LAD is revascularized, if the disease is
localized.
.
# Mild Chronic Systolic heart Failure: Echo from outside
hospital showed overall mildly depressed EF of 40-45% but with
focal wall motion abnormality. He was on lasix as an outpatient
which was held because of acute renal failure. On discharge, he
will need to have daily weights and reinstitution of diuretics
as needed.
.
# Hypertension: The patient had a history of chronic
hypertension, likely exacerbated by not taking his clonidine the
morning of admission. He initially received a nitro drip,
transitioning to hydralazine and later to home medications
including beta blocker, amlodipine, and clonidine (changed from
tablet to patch). Lisinopril was held for renal failure. He
was normotensive on this regimen.
.
# Left orbital edema: The patient had left orbital edema on
admission. Head CT at [**Location (un) 620**] negative for fracture, no point
tenderness on exam. The edema resolved within days.
.
# Leukocytosis: The patient briefly developed leukocytosis.
CXR showed a possible L lower lobe infiltrate. He was afebrile
and asymptomatic, and the leukocytosis resolved within days.
The most likely cause was aspiration pneumonitis. He should be
observed while eating until his mental status improves to
baseline.
.
# Hypernatremia: Sodium the day of discharge was slightly
elevated at 148. This will need to be followed at the rehab
facility.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - [**2-10**] Tablet(s) by mouth once a day
AMLODIPINE [NORVASC] - 5 mg Tablet daily
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
EPOETIN ALFA [PROCRIT] - 10,000 unit/mL Solution - 1 ml Qweek -
dispense 1ml single use vials
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth twice a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE [TOPROL XL] - 200 mg daily
SIMVASTATIN - 10 mg Tablet daily
FERROUS GLUCONATE - 324 mg (36 mg) daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Procrit 10,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
11. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] healthcare center
Discharge Diagnosis:
ST elevation myocardial infarction
3 vessel coronary artery disease
Systolic heart failure
Acute on chronic renal failure,
Renal Mass
Discharge Condition:
Hemodynamically stable, afebrile, improving mental status
Discharge Instructions:
You were admitted to the hospital because you passed out. You
were found to have a heart attack. You have plaques in your
heart's arteries that may need to have stents in the future. You
were not able to have a bypass surgery due to the risk. You had
a temporary aortic balloon pump to help your heart.
You also developed kidney failure. You have a mass on your
kidney, that will need to have another imaging study in the
future and may need to be removed once your kidney function
improves. If the urologist decides to operate on your kidney,
you will need to have another procedure to stent the artery in
your heart before that happens.
You are being discharged to rehab.
Please take your medications as instructed.
Weigh yourself every day. Call you doctor if the weight
increases by more than 3 pounds or if you develop trouble
breathing.
If you have chest pain, shortness of breath, groin pain, or
other concernig symptoms please seek medical attention.
Followup Instructions:
Urology: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2175-3-17**] 8:30
Nephrology: Dr. [**Last Name (STitle) 11427**] at [**Hospital1 **], ([**Telephone/Fax (1) 53307**]: [**2175-3-31**]
at 11:20 a.m.
PCP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 3070**] Date/Time:[**2175-3-24**]
10:20
Cardiology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2175-4-28**] 1:20
Completed by:[**2175-3-3**]
|
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icd9cm
|
[
[
[]
]
] |
[
"37.61",
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] |
icd9pcs
|
[
[
[]
]
] |
15136, 15201
|
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|
318, 343
|
15379, 15439
|
4419, 4424
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274, 280
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5626, 6023
|
371, 2955
|
4438, 5607
|
2977, 3147
|
3163, 3302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,505
| 153,387
|
23901
|
Discharge summary
|
report
|
Admission Date: [**2170-5-3**] Discharge Date: [**2170-5-5**]
Date of Birth: [**2089-12-10**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Cyclosporine / Clindamycin / Meropenem /
Metronidazole
Attending:[**First Name3 (LF) 14961**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 80 yo f with h/o afib, [**First Name3 (LF) 7792**], pacer for bradycardia, and
MDS recently tranformed to leukemia presents from [**Hospital 100**] Rehab
after acute onset SOB last PM. She denied any chest pain, but
she noted nausea which has been a persistent daily complaint.
She also denied any orthopnea, PND, and had no change in her
activity level. On arrival to the [**Hospital1 18**] ED, she was afebrile, HR
in 60s, BP 190/70 , had O2 sat 92% RA-> 98% 2L NC, and
tachypneic to 40's. Exam revealed bilateral crackles L>R and CXR
was consistent with volume overload. She received 20mg iv lasix
x1 in the [**Name (NI) **] - unclear volume of urine output, and she noted
significant improvement in her breathing. However, she was
started on BiPAP for tachypnea and admitted to the ICU for
further evaluation.
.
Of note, pt is followed at [**Hospital3 **] for MDS which
recently transformed to leukemia w/ 20% blasts. She has decided
to receive supportive treatment only; she receives weekly
transfusions of platelets and infrequent pRBC. During her last
admission in [**2-12**] for similar presentation of CHF, she had been
discharged with lasix 40mg iv qd; this has been discontinued
after arrival to [**Hospital 100**] Rehab.
.
On review of systems, she has been afebrile, denies cough,
rhinorrhea, sore throat, headache, dizziness, abdominal pain,
N/V, diarrhea, dysuria, urinary frequency, weight loss, or
chills.
Past Medical History:
1. Myelodysplastic syndrome followed at [**Hospital3 **], weekly
transfusions
2. Paroxysmal Atrial fibrillation
3. Pacer placement for bradycardia
4. colon cancer with colostomy
5. phlebitis
6. recent right trimalleolar fx, casted
Social History:
Nonsmoker, no alcohol, no IVDA. Transitioned to residency at
[**Hospital 100**] rehab for after admission to MACU/[**Location (un) 550**] after trimalleolar
fx.
Family History:
Father- h/o renal insufficiency, died in Siberia of unknown
cause. Mother- also died of unknown causes. Children-healthy.
Physical Exam:
Vitals: T HR: 60 BP: 123/57 RR: 26 O2sat: 98% RA
General: 80 y/o woman breathing comfortably on RA. Speaking
in full sentences, in Russian. Does not appear to be in pain.
HEENT: PERRL, EOMI. No scleral icterus, MMM.
Lungs: faint bilateral rales, poor effort
CV: RRR S1 and S2 audible, no m/r/g heard
Abd: Obese, Colostomy bag in place with brown stool, NT, ND,
decreased bowel sounds, no masses, no HSM
Peripheral: trace edema, 2+ pulses b/l
Pertinent Results:
[**2170-5-3**] 10:03AM TYPE-ART PO2-71* PCO2-34* PH-7.43 TOTAL
CO2-23 BASE XS-0
[**2170-5-3**] 10:03AM GLUCOSE-120* LACTATE-1.8 NA+-139 K+-3.9
CL--105
[**2170-5-3**] 10:03AM HGB-9.1* calcHCT-27 O2 SAT-95
[**2170-5-3**] 10:03AM freeCa-1.16
[**2170-5-3**] 09:20AM LACTATE-2.4*
[**2170-5-3**] 09:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2170-5-3**] 09:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-5-3**] 09:10AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2170-5-3**] 08:55AM D-DIMER-3093*
[**2170-5-3**] 08:48AM GLUCOSE-244* UREA N-30* CREAT-1.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-19
[**2170-5-3**] 08:48AM CK(CPK)-36
[**2170-5-3**] 08:48AM CK-MB-NotDone cTropnT-<0.01 proBNP-[**Numeric Identifier 37509**]*
[**2170-5-3**] 08:48AM WBC-4.8# RBC-3.39* HGB-9.9* HCT-28.1* MCV-83
MCH-29.1 MCHC-35.1* RDW-16.5*
[**2170-5-3**] 08:48AM NEUTS-15* BANDS-1 LYMPHS-37 MONOS-2 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0 NUC RBCS-2* OTHER-42*
[**2170-5-3**] 08:48AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ELLIPTOCY-1+
[**2170-5-3**] 08:48AM PLT SMR-VERY LOW PLT COUNT-65*#
.
CXR: AP UPRIGHT CHEST: The pulmonary vascularity is engorged
with development of interstitial edema. The contours of the
pulmonary arteries have also enlarged in the interval. A small
amount of pleural fluid is present bilaterally. A right
supraclavicular central venous catheter is present with the tip
terminating in the mid SVC. A pacer device is again present in
the left axilla with leads terminating overlying the right
atrium and right ventricle. No pneumothorax is present.
IMPRESSION: Development of congestive heart failure.
Brief Hospital Course:
The patient is an 80 yo F with h/o AFib, [**Month/Day/Year 7792**], pacer for
bradycardia, and MDS recently tranformed to leukemia presents
from [**Hospital 100**] Rehab due to CHF exacerbation from volume overload.
Hospital course outlined by problem below:
.
# CHF exacerbation: This was thought to be due to repeated need
for transfusions without additional diuresis, as well as
stopping of previous daily Lasix. She was diuresed with lasix
40mg po QD to net negative one liter per day. Her I's and O's
were monitored, as well as daily weights. On discharge she was
recommended to get lasix on transfusion days, and as needed for
weight gain. She was continued on lisinopril and toprol,
titrated to SBP's 100-120.
.
# MDS: She recently underwent transformation to leukemia; pt
elects to receive supportive treatment only. She was mildly
neutropenic, but no evidence of infection was found. She was
maintained on neutropenic precautions. She should be diuresed
with transfusions as above.
.
# Afib/bradycardia: She was continued on her amiodarone.
.
# Depression/anxiety: She was continued on her escitalopram 10
qd; also prn ativan for anxiety.
.
# FEN: regular, low sodium diet
.
# Code: She was maintained as DNR/DNI.
Medications on Admission:
Amio 200 qd, Wellbutrin 100 qd, Toprol 37.5 qd, Lisinopril 5
[**Hospital1 **], Protonix 40 qd, Trazodone 25 HS, Colace, Senna, Ativan prn,
Latanoprost OU HS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for transfusion day: Give dose prior to blood
transfusions on days of transfusion.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for weight gain, edema.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
pulmonary edema
myelodysplastic syndrome with conversion to acute leukemia
hypertension
atrial fibrillation
Discharge Condition:
stable O2 sat on room air
Discharge Instructions:
Take all your medications as directed
Followup Instructions:
Provider: [**Name10 (NameIs) 13978**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2170-5-14**]
8:20
|
[
"V10.05",
"428.0",
"V45.01",
"401.9",
"428.30",
"427.31",
"530.81",
"V44.3",
"205.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7477, 7542
|
4730, 5961
|
352, 359
|
7694, 7722
|
2878, 4707
|
7808, 7942
|
2274, 2400
|
6168, 7454
|
7563, 7673
|
5987, 6145
|
7746, 7785
|
2415, 2859
|
293, 314
|
387, 1817
|
1839, 2078
|
2094, 2258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,375
| 195,486
|
27368
|
Discharge summary
|
report
|
Admission Date: [**2163-5-12**] Discharge Date: [**2163-6-4**]
Date of Birth: [**2119-5-15**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Keflex
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
The patient is a 43 yo R-handed woman, with a history of iv
abuse (last time 10 days ago) who is transfered from [**Hospital 1474**]
hospital for progressive weakness and numbness.
Major Surgical or Invasive Procedure:
1. Anterior cervical discectomies at C5-C6 and C6-C7.
2. Anterior fusion C5-C7.
3. Anterior instrumentation C5-C7.
4. Structural allograft.
5. Incision and drainage of epidural abscess.
6. Posterior cervical laminectomies at C5, C6 and C7, as
well as T1, T2, T3, T4 and T5 for evacuation of epidural
hematoma.
7. Debridement.
History of Present Illness:
The patient started having neckpain [**5-5**]. She thought it was a
pinched nerve as she had a problem with that about a year ago.
At
that time the symptoms resolved with some PT. The pain started
to
radiated into her shoulders on both sides. On [**5-6**] she noted
that
the pain was spreading into the rest of her back (cannot say
what
level). Then on Tuesday ([**5-10**]) she noted that her legs started
to
get weak (both sides) and she actually collapsed. She also had
started to feel numb, first in her legs (both sides) and then
slowly up her trunk. The sympoms have not fluctuated, but have
become gradually worse over time.
On [**5-11**] she was found by her husband on the floor. He lifted her
to bed and from there she was taken to OSH by EMS. She had
urinary retention (1400ml), whereas she did not any urge or
abdominal discomfort. She had WBC 20. She received a pan-CT that
showed a possible abces posterior to the trachea/R-thyroid gland
(1cm). She received one dose of Zosyn.
Currently, she feels numb in both her legs and up to the top of
her trunk. She says she cannot move her legs and her arms are
very weak. She is not able to use her hands, but can move her
shoulders and elbows somewhat. She does not have tingling. Did
not notice any fever. No headache, but her neckpain is still
significant. No photophobia. She is not able to point were the
pain is exactly located. She prefers to have her head somewhat
to
the R. She is able to swallow and denies shortness of breath.
She
had not noted any incontinence prior to today.
She received a dose of vancomycin in the ED.
Past Medical History:
- IV drug abuse
- C-section
- history of neck pain a year ago
Social History:
Smoking: 2ppd since [**67**] yrs
EthOH: 4-5 drinks a few times a week
Drug abuse: says she used iv cocain 10 days ago (about 3 days
prior to onset). Has tattoes. Married, 3 children.
Family History:
- CA?
- CAD
Physical Exam:
VITALS: T98.6 HR80 BP112/68 RR20 sO2 95%
GEN: looks sick
HEENT: mmm
NECK: no LAD; no carotid bruits; prefers to hold her head to the
R, spine not tender upon palpation; paraspinal muscles not
tender
upon palpation; movement of the neck is painfull; neck feels
moderately stiff
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema;
multiple scars from iv drug use; some splinter hemorrhages in
L-fingers
MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect, tired.
Oriented to place, month, day, and date, person.
Attention: MOYbw.
Memory: Registration: [**3-18**] items; Recall [**3-18**] at 5 min.
Language: fluent; repetition: intact; Naming intact;
Comprehension intact; no dysarthria, no paraphasic errors.
[**Location (un) **]: intact; Prosody: normal. No Neglect.
CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round
and reactive to light both directly and consensually, 2-->1 mm
bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus.
Fixation and saccades are normal. No ptosis.
V: Facial sensation intact to light touch, cold and pinprick.
VII: Facial movement symmetrical; able to open eyes on both
sides.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
MOTOR SYSTEM: Normal bulk. Tone normal in UE bilaterally,
flaccid
in LE. No adventitious movements, no tremor, no asterixis.
Delt: 4 on L, 4+ on R; bic: 4 bilaterally; tric, WE, WF 3
bilaterally; FF and FF 0/5 bilaterally.
LE: triple reflex upon pp in toe.
Neck flexors/extensors: not able to assess due to pain.
Anal exam: poor sphincter tone (some)
SENSORY SYSTEM:
PP: able to feel face, neck, dorsal part arms, thumb and first 2
fingers bilaterally; dull in dig 4 and 5, inside arms (level
C7/C8). On trunk sensory level just below claviculae.
LT: similar to PP
Vibr and proprioception: able to feel in dig [**1-18**], not in [**4-20**];
absent in LE.
REFLEXES:
B T Br Pa Pl
Right 2 2 2 2 2 no clonus
Left 2 2 2 2 2 no clonus
Grasp reflex absent; snout, glabellar, palmomental absent.
Toes: downgoing on R, mute on L (but could see TFL on both
sides).
COORDINATION: not able to test
GAIT: not able to test
Pertinent Results:
[**2163-6-2**] 02:29AM BLOOD WBC-8.3 RBC-2.99* Hgb-9.1* Hct-26.7*
MCV-89 MCH-30.5 MCHC-34.1 RDW-14.6 Plt Ct-438
[**2163-5-31**] 02:54AM BLOOD WBC-5.3 RBC-2.83* Hgb-8.5* Hct-25.7*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.7 Plt Ct-477*
[**2163-5-29**] 02:43AM BLOOD WBC-4.4 RBC-2.90* Hgb-8.8* Hct-26.1*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.7 Plt Ct-442*
[**2163-5-28**] 03:01AM BLOOD WBC-7.8 RBC-2.67* Hgb-8.3* Hct-24.1*
MCV-90 MCH-31.2 MCHC-34.7 RDW-14.7 Plt Ct-536*
[**2163-5-26**] 04:08AM BLOOD WBC-8.9 RBC-2.65* Hgb-7.9* Hct-23.9*
MCV-90 MCH-29.7 MCHC-32.9 RDW-14.7 Plt Ct-593*
[**2163-5-27**] 03:00AM BLOOD WBC-6.7 RBC-2.51* Hgb-7.6* Hct-22.4*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.7 Plt Ct-519*
[**2163-5-25**] 02:42AM BLOOD WBC-9.0 RBC-2.63* Hgb-8.1* Hct-23.9*
MCV-91 MCH-30.8 MCHC-34.0 RDW-14.6 Plt Ct-639*
[**2163-5-23**] 02:07AM BLOOD WBC-6.9 RBC-2.69* Hgb-8.3* Hct-24.1*
MCV-90 MCH-30.7 MCHC-34.3 RDW-14.5 Plt Ct-647*
[**2163-5-22**] 01:54AM BLOOD WBC-6.6 RBC-2.35* Hgb-7.2* Hct-21.1*
MCV-90 MCH-30.6 MCHC-34.1 RDW-14.3 Plt Ct-541*
[**2163-5-21**] 03:04AM BLOOD WBC-7.8 RBC-2.40* Hgb-7.5* Hct-21.7*
MCV-90 MCH-31.2 MCHC-34.5 RDW-14.1 Plt Ct-561*
[**2163-5-19**] 01:16PM BLOOD WBC-10.8 RBC-2.69* Hgb-8.6* Hct-24.2*
MCV-90 MCH-31.8 MCHC-35.3* RDW-13.8 Plt Ct-588*
[**2163-5-18**] 03:12AM BLOOD WBC-13.0* RBC-2.77* Hgb-8.6* Hct-24.6*
MCV-89 MCH-31.1 MCHC-35.0 RDW-13.6 Plt Ct-535*
[**2163-5-16**] 02:57AM BLOOD WBC-13.2* RBC-3.04* Hgb-9.7* Hct-27.3*
MCV-90 MCH-31.8 MCHC-35.4* RDW-13.4 Plt Ct-551*
[**2163-5-13**] 03:04AM BLOOD WBC-25.6* RBC-3.60* Hgb-11.2* Hct-32.3*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.4 Plt Ct-371
[**2163-5-12**] 04:50PM BLOOD WBC-19.4* RBC-3.37* Hgb-10.2* Hct-30.3*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.5 Plt Ct-279
[**2163-5-12**] 05:10AM BLOOD WBC-17.2* RBC-4.12* Hgb-12.7 Hct-36.6
MCV-89 MCH-30.8 MCHC-34.6 RDW-13.3 Plt Ct-266
[**2163-5-19**] 01:16PM BLOOD Neuts-85.3* Bands-0 Lymphs-9.6* Monos-3.9
Eos-0.8 Baso-0.4
[**2163-5-13**] 03:04AM BLOOD Neuts-95.3* Bands-0 Lymphs-2.2* Monos-2.4
Eos-0 Baso-0
[**2163-5-12**] 04:50PM BLOOD Neuts-95.8* Bands-0 Lymphs-1.9* Monos-2.1
Eos-0.1 Baso-0.1
[**2163-5-31**] 02:54AM BLOOD PT-15.5* PTT-29.0 INR(PT)-1.4*
[**2163-5-29**] 02:43AM BLOOD PT-16.8* PTT-26.9 INR(PT)-1.5*
[**2163-5-27**] 03:00AM BLOOD PT-14.7* PTT-27.7 INR(PT)-1.3*
[**2163-5-23**] 02:07AM BLOOD PT-13.8* PTT-27.1 INR(PT)-1.2*
[**2163-5-18**] 03:12AM BLOOD PT-13.7* PTT-24.4 INR(PT)-1.2*
[**2163-5-13**] 03:04AM BLOOD PT-12.5 PTT-22.0 INR(PT)-1.1
[**2163-5-12**] 05:10AM BLOOD Plt Ct-266
[**2163-5-30**] 12:25PM BLOOD ESR-58*
[**2163-5-12**] 05:10AM BLOOD ESR-60*
[**2163-6-2**] 02:29AM BLOOD Glucose-124* UreaN-12 Creat-0.4 Na-137
K-3.2* Cl-102 HCO3-27 AnGap-11
[**2163-5-31**] 02:54AM BLOOD Glucose-111* UreaN-10 Creat-0.5 Na-137
K-3.2* Cl-103 HCO3-27 AnGap-10
[**2163-5-29**] 02:43AM BLOOD Glucose-114* UreaN-6 Creat-0.3* Na-135
K-3.5 Cl-102 HCO3-25 AnGap-12
[**2163-5-28**] 03:01AM BLOOD Glucose-131* UreaN-7 Creat-0.4 Na-134
K-3.7 Cl-99 HCO3-26 AnGap-13
[**2163-5-24**] 02:01AM BLOOD Glucose-119* UreaN-10 Creat-0.4 Na-133
K-3.7 Cl-99 HCO3-26 AnGap-12
[**2163-5-22**] 01:54AM BLOOD Glucose-141* UreaN-11 Creat-0.3* Na-133
K-3.9 Cl-101 HCO3-27 AnGap-9
[**2163-5-20**] 03:10AM BLOOD Glucose-140* UreaN-10 Creat-0.5 Na-132*
K-3.9 Cl-98 HCO3-27 AnGap-11
[**2163-5-18**] 03:12AM BLOOD Glucose-135* UreaN-11 Creat-0.4 Na-132*
K-4.0 Cl-100 HCO3-25 AnGap-11
[**2163-5-16**] 02:57AM BLOOD Glucose-152* UreaN-7 Creat-0.5 Na-135
K-2.8* Cl-98 HCO3-29 AnGap-11
[**2163-5-14**] 03:46AM BLOOD Glucose-112* UreaN-11 Creat-0.5 Na-136
K-3.4 Cl-99 HCO3-29 AnGap-11
[**2163-5-12**] 05:10AM BLOOD Glucose-101 UreaN-25* Creat-0.5 Na-135
K-3.3 Cl-100 HCO3-25 AnGap-13
[**2163-5-19**] 01:16PM BLOOD ALT-22 AST-23 LD(LDH)-183 AlkPhos-53
Amylase-201* TotBili-0.5
[**2163-5-14**] 03:46AM BLOOD ALT-28 AST-58* LD(LDH)-221 AlkPhos-96
Amylase-70 TotBili-0.5
[**2163-6-2**] 02:29AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
[**2163-5-30**] 03:01AM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.4 Mg-1.9
[**2163-5-28**] 03:01AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.9
[**2163-5-25**] 02:42AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.7
[**2163-5-17**] 03:00AM BLOOD Calcium-7.6* Phos-1.9* Mg-1.6
[**2163-5-15**] 03:24AM BLOOD Calcium-7.5* Phos-3.2 Mg-1.7
[**2163-5-12**] 04:50PM BLOOD Calcium-7.0* Phos-2.5* Mg-1.6
[**2163-5-24**] 02:01AM BLOOD TSH-9.6*
[**2163-5-12**] 05:10AM BLOOD CRP-140.8*
[**2163-5-21**] 06:00PM BLOOD HIV Ab-NEGATIVE
[**2163-5-12**] 05:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-6-2**] 03:40AM BLOOD Lactate-1.0
[**2163-5-29**] 03:48PM BLOOD Glucose-118* Lactate-0.6 K-3.8
[**2163-5-28**] 03:21AM BLOOD Lactate-0.3*
[**2163-5-27**] 09:43PM BLOOD Lactate-0.5
[**2163-5-26**] 04:30PM BLOOD Lactate-0.5
[**2163-5-25**] 03:12PM BLOOD Glucose-107*
[**2163-5-22**] 10:29AM BLOOD Glucose-130* Lactate-0.7 K-3.7
[**2163-5-21**] 05:30PM BLOOD Glucose-142* Lactate-0.6 K-3.5
[**2163-5-21**] 12:24PM BLOOD Glucose-148* Lactate-1.1 K-3.4*
[**2163-5-17**] 09:56AM BLOOD K-3.7
[**2163-5-16**] 08:44PM BLOOD Glucose-130* Lactate-0.7 Na-131* K-3.7
Cl-99*
[**2163-5-14**] 04:24AM BLOOD Lactate-.6
[**2163-5-12**] 05:14AM BLOOD Lactate-1.0
[**2163-6-2**] 03:40AM BLOOD freeCa-1.21
[**2163-5-31**] 12:40PM BLOOD freeCa-1.15
[**2163-5-29**] 03:48PM BLOOD freeCa-1.14
[**2163-5-27**] 09:43PM BLOOD freeCa-1.08*
[**2163-5-25**] 06:29PM BLOOD freeCa-1.13
[**2163-5-23**] 02:30AM BLOOD freeCa-1.10*
[**2163-5-21**] 05:30PM BLOOD freeCa-1.16
[**2163-5-19**] 01:35AM BLOOD freeCa-1.05*
[**2163-5-17**] 03:11AM BLOOD freeCa-1.12
[**2163-5-13**] 07:51AM BLOOD freeCa-1.10*
[**2163-5-12**] 10:50AM BLOOD freeCa-1.12
Portable AP chest radiograph compared to the previous film from
[**2163-5-27**].
There is marked improvement in the left lower lobe atelectasis
with some additional retrocardiac consolidation and accompanying
left pleural effusion. The small right pleural effusion is
unchanged. There is no evidence of congestive heart failure. The
new right subclavian vein device was inserted with its tip
projecting over the proximal superior vena cava. The left
subclavian line is unchanged. The patient is extubated.
IMPRESSION:
1. A new right subclavian vein line with no evidence of
pneumothorax.
2. Improvement of the left lower lobe atelectasis.
COMPARISON: [**2163-5-24**].
FINDINGS: There is a new right ill-defined opacity that may
represent atelectasis or aspiration given acute onset. There may
also be a right pleural effusion. Evaluation of these findings
is limited due to significant rotation. The left lung is grossly
clear. Otherwise, the exam is unchanged with ETT, left
subclavian, nasogastric feeding tube unchanged in position.
IMPRESSION: New right lower lobe atelectasis versus aspiration.
PATIENT/TEST INFORMATION:
Indication: ? Endocarditis.
Height: (in) 64
Weight (lb): 116
BSA (m2): 1.55 m2
BP (mm Hg): 115/57
HR (bpm): 58
Status: Inpatient
Date/Time: [**2163-5-19**] at 15:02
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W016-0:46
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
3. There is a trivial/physiologic pericardial effusion.
4. No evidence of endocarditis seen.
MR [**Name13 (STitle) **] W& W/O CONTRAST [**2163-5-19**] 5:53 PM
MR [**Name13 (STitle) **] W& W/O CONTRAST; MR [**Name13 (STitle) **] W &W/O CONTRAST
Reason: s/p ACDF C5-7 [**5-12**], now with fevers. ? abscess.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
44 year old woman with cervical stenosis s/p C5-T5 lami, C5-7
ACDF
REASON FOR THIS EXAMINATION:
s/p ACDF C5-7 [**5-12**], now with fevers. ? abscess.
EXAM: MRA of the cervical and thoracic spine.
CLINICAL INFORMATION: Patient with cervical stenosis status post
fusion, now with fevers, rule out abscess.
CERVICAL SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2
axial images were obtained before gadolinium. T1 sagittal and
axial images were obtained following gadolinium. Comparison was
made with the previous MRI of [**2163-5-12**].
FINDINGS: Since the previous MRI study patient has undergone
extensive laminectomies starting from C4-T6 level.
The previously identified epidural abscess from C5-C7 level has
been drained. However, since the previous study there is now
extensive edema visualized within the spinal cord extending from
the level of obex at the cervicomedullary junction to the upper
thoracic region at T8 level. There is also expansion of the
spinal cord seen. Gadolinium-enhanced images demonstrate
extensive enhancement within the spinal cord extending from
cervicomedullary junction to the upper thoracic region with
focal intrinsic area of low signal indicative of an abscess.
This finding indicates extensive spinal cord abscess extending
from C2 to the T2 level. Additionally, there is widening of the
soft tissues seen in the prevertebral upper thoracic region from
T1-T3 level with rim enhancement indicative of prevertebral
abscess.
Again seen are mild degenerative changes. There is spinal fusion
from C5-C7 level. Extensive soft tissue changes at the
laminectomy site could be secondary to the surgery. Fluid is
seen at the laminectomy site within the soft tissues, which
could be postoperative but infection could not be excluded.
IMPRESSION: Extensive cord edema and enhancement within the cord
indicating spinal cord abscess. The cord edema extends from obex
to T5 level with the enhancement extending predominantly from
C2-T2 level indicating spinal cord abscess. The epidural
component seen on the previous study has decreased. There is now
new prevertebral abscess seen from T1-T3 level as described
above. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67049**] at the
time of interpretation of this study on [**2163-5-20**].
THORACIC SPINE:
TECHNIQUE: T1 and T2 and inversion recovery sagittal and T1 and
T2 axial images were obtained before gadolinium. T1 sagittal and
axial images were obtained following gadolinium.
FINDINGS: There is edema seen in the thoracic spinal cord
predominantly extending to T5 level but linear area of increased
signal secondary to edema is also seen extending inferiorly to
T8 level. There is enhancement seen in the cord in the upper
thoracic region indicative of cord abscess. There are extensive
laminectomies to T5 level. There is enhancement of the epidural
soft tissues indicating epidural inflammation. However, compared
to the previous MRI study the epidural abscess seen around the
cord in the upper thoracic region has decreased secondary to
surgery.
IMPRESSION: New spinal cord edema in the upper thoracic region
from T1-T8 level. The spinal cord edema also extends in the
cervical region as described in the cervical spine study.
Enhancement is seen in the upper thoracic cord indicating
intraspinal cord abscess. Epidural enhancement is seen. The
epidural fluid collection has decreased since previous study
following surgery.
MR [**Name13 (STitle) **] W& W/O CONTRAST [**2163-5-12**] 6:53 AM
MR [**Name13 (STitle) **] W& W/O CONTRAST; MR T SPINE SCAN WITH CONTRAST
Reason: evaluate for abscess with GAD
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
43 year old woman unable to move lower extremities, inc wbc, inc
reflexes, decrease rectal tone
REASON FOR THIS EXAMINATION:
evaluate for abscess with GAD
INDICATION: 43-year-old woman unable to move lower extremities,
increasing white count, increasing reflexes, decreased rectal
tone. Eval for abscess.
TECHNIQUE: MR of the cervical spine. Sagittal T1 and T2 and STIR
images, axial T1, T2, and gradient echo as well as post-contrast
T1 sequences are available.
No prior studies are available for comparison purposes on PACS.
FINDINGS: In the C6 inferior endplate, in the inferoposterior
aspect, there is an area of rim with central decreased
enhancement seen on series 8, image 7 and image 9. Adjacent to
this level, anterior and posterior to the cervical vertebral
column, there are two collections with nonenhancing centers
centered around the intervertebral disc space C6/C7. These
collections are presumably representing abscesses with
liquefactive, nonenhancing centers. The anterior collection
appears to extend cranially up to T2 or possibly even higher and
caudally appears to extend down in the posterior mediastinum.
The maximum thickness of the collection is centered at the C6/C7
level and measures approximately 10 mm in AP diameter. The
collection posterior to the C6-C7 level in the epidural space
also appears to extend cranially with dorsal dural enhancement
seen up to level of the visualized level of the skull base.
There is significant compression of the spinal cord with the
epidural collection occupying approximately 75% of the spinal
canal cross-sectional area. The collection is centered at the
C6-C7 level. The maximum thickness of the epidural abscess is
approximately 9 mm at this level.
The epidural collection that is seen anteriorly at the described
levels spirals around the spinal cord at the level C7/T1 and
then extends caudally posterior to the spinal cord to
approximately level of T5. Caudally however there is still dural
contrast enhancement indicating inflammation, more caudally. The
maximum thickness of the posterior component of the epidural
abscess is approximately 7 mm or 50% of the spinal canal area.
There is significant anterior displacement and also slight
compression of the cervical cord. Most concerning however are
several small round foci of T2 hyperintensity seen at the level
of C7-C8 within the spinal cord which then appear to form a
single short-segment tubular high-density structure within the
anterior intramedullary substance, reaching down to the level of
T1/T2. There is a faint rim of contrast enhancement around this
T2 bright area within the cord substance, that suggests the
presence of an intramedullary abscess.
There is slight abnormal kyphotic angle within the cervical
spine. The alignment of the vertebral bodies however is grossly
normal. The intervertebral disc spaces are grossly preserved. At
the level of C6-C7, there appears to be somewhat more irregular
contours of the vertebral endplates. As mentioned, there is a
hypointense focus at the posterior inferior aspect of C6 on the
T1 contrast sagittal images, which raises the suspicion that
infectious process may have its origin at this location and then
subsequently caused spreading in the multiple compartments as
described.
IMPRESSION:
Infectious process with multicompartmental abscess formation
including the prevertebral space, C6 vertebral inferior endplate
and possibly, the intervening disc, anterior and posterior
epidural compartment, as well as likely, the intramedullary
compartment.
1. Hypoenhancing focus in the vertebral body of C6 inferiorly
and posteriorly; this endplate/vertebral osteomyelitis appears
to be the epicenter of the widespread infectious process.
2. Prevertebral abscess with liquefying center at C6/C7 as
described with likely extention cranially to the skull base and
inferiorly into the posterior mediastinum. The full extent of
this abscess may not be visualized on the current study.
3. Very large epidural abscess of the cervical and upper
thoracic spine, spiraling around the cervical cord. There are
two major abscess collections with liquefying centers: the more
cranially located collection is centered around C6/C7 and causes
significant posterior spinal cord displacement and compression.
The caudal component of this collection forms a second more
dorsally-located fusiform collection extending from
approximately T1 to T5 with anterior displacement of the spinal
cord. There is dural enhancement at both the rostral and caudal
margins of the process, throughout the imaged portions of the
spine suggesting even further extention of the inflammatory
process.
4. Possible intramedullary abscess extending at least from C6
(axial T2- weighted images are not available cranial to this
location) caudally to the level of T1/T2. This collection has
rim enhancement and partial nonenhancing component indicating
partial liquefaction and abscess formation.
5. Kyphosis of the cervical spine. Multiple mild disc bulges at
the levels of C4 through C6.
6. Very mild irregularity at the endplates at the level of
C6/C7. This likely be represents destructive change, due to the
infectious process centered at this level.
COMMENT: A preliminary [**Location (un) 1131**] was communicated to Dr.
[**Last Name (STitle) **] at 7:45 a.m. on [**2163-5-12**] indicating an epidural
collection posterior to C6 and C7 with cord compression and a
large prevertebral collection.
The full extent of the findings were discussed in detail with
Dr. [**Last Name (STitle) 363**], pre- operatively, by Dr. [**Last Name (STitle) **] at 10:25
a.m.,[**2163-5-12**].
WOUND CULTURE (Final [**2163-5-14**]):
STAPH AUREUS COAG +. RARE GROWTH.[**2163-5-12**] 12:15 pm
SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2163-5-14**]**
GRAM STAIN (Final [**2163-5-12**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2163-5-14**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). RARE GROWTH.
YEAST. SPARSE GROWTH.
**FINAL REPORT [**2163-5-25**]**
HIV-1 Viral Load/Ultrasensitive (Final [**2163-5-25**]):
HIV-1 RNA is not detected.
Performed by RT-PCR (ultrasensitive).
Brief Hospital Course:
Ms. [**Known lastname **] was transfered from an OSH to the [**Hospital1 18**] Emergency
Department. She was evaluated for her lower extremity paralysis
and numbness and upper extremity weakness. This evaluation
included a CT of the C and T spine which showed:
Infectious process with multicompartmental abscess formation
including the prevertebral space, C6 vertebral inferior endplate
and possibly, the intervening disc, anterior and posterior
epidural compartment, as well as likely, the intramedullary
compartment.
1. Hypoenhancing focus in the vertebral body of C6 inferiorly
and posteriorly; this endplate/vertebral osteomyelitis appears
to be the epicenter of the widespread infectious process.
2. Prevertebral abscess with liquefying center at C6/C7 as
described with likely extention cranially to the skull base and
inferiorly into the posterior mediastinum. The full extent of
this abscess may not be visualized on the current study.
3. Very large epidural abscess of the cervical and upper
thoracic spine, spiraling around the cervical cord. There are
two major abscess collections with liquefying centers: the more
cranially located collection is centered around C6/C7 and causes
significant posterior spinal cord displacement and compression.
The caudal component of this collection forms a second more
dorsally-located fusiform collection extending from
approximately T1 to T5 with anterior displacement of the spinal
cord. There is dural enhancement at both the rostral and caudal
margins of the process, throughout the imaged portions of the
spine suggesting even further extention of the inflammatory
process.
4. Possible intramedullary abscess extending at least from C6
(axial T2- weighted images are not available cranial to this
location) caudally to the level of T1/T2. This collection has
rim enhancement and partial nonenhancing component indicating
partial liquefaction and abscess formation.
5. Kyphosis of the cervical spine. Multiple mild disc bulges at
the levels of C4 through C6.
6. Very mild irregularity at the endplates at the level of
C6/C7. This likely be represents destructive change, due to the
infectious process centered at this level.
At this time an Orthopedic Spine cousult was sought and Ms.
[**Known lastname **] was taken to the Operating Room emergently for an
anterior/posterior decompression and fusion with evacuation and
drainage of the abscess. Please see Operative Report for
procedure in detail.
Post operatively she was taken to the SICU for close
observation. An ID consult was sought and the Vancomycin/Zosyn
regimen she was started on in the ED was discontinued and she
was placed on Nafcillin 2g IV q4H.
POD2- remained intubated and sedated in SICU. Weaned from
sedation with no change in physical exam. Does not withdraw to
nail bed pressure. Hemovac drains in place. Blood cultures
drawn, chest x-ray taken, sputum culture. Extubation trial.
POD3- Failed extubation trial due to increaing respiratory
distress (O2 sat to 80% with tachypnea) and unable to maintain
airway in SICU. Drains removed, placed on air mattress for
decubitus ulcer prevention.
POD4-Left pleural effusion and resolving right lower lobe
opacity. Left sided thoracentesis performed. No evidence of
infection. Left subclavian central line placed. Bronchoscopy
performed with diffuse purulent mucus in left bronchi and right
lower lob bronchus. Airway was patent wafter lavage and
suctioning. Extubation trial.
POD5- Patinet now with low grade fevers despite antibiotics
(nafcillin/Levo). Reintubated due to respiratory distress.
A-line changed. Second bronchoscopy performed with copious
mucous plugging noticed and sent for culture.
POD6- no new events
POD7- spine reimaged showing spinal cord abscess. Neurosurgery
aware and evaluated patient. No recommendation of drainage.
Continue supportive care and antibiotics. Gentamycin added.
POD8- MSSA intramedullary abscess. Continue Nafcillin/Gent
POD9-12 no new events, no change in exam
POD11- Bronchoscopy performed with copious left lob secretions,
moderate on the right. Contiune Nafcillin and Gent. Patient
tolerated T-piece for short period.
POD12- patient scheduled for PEG and Trach, supportive care
continued. Antibiotics continued. Patient afebrile at this
time. Nafcillin continued. No evidence of endocarditis.
POD14- PEG and Trach performed. Please see Operative Note for
procedure in detail.
POD15- fevers to 101.4 through Nafcillin. Exam unchanged.
POD 16-18 no new events, rehab screening at vented rehab.
Intermittently febrile to 100.9. Accepted at rehab.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
6. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-6 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 100mg PO BID
(2 times a day).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
12. Bupropion 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) g
Intravenous Q4H (every 4 hours).
14. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
15. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q4-6H
(every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
Extensive MSSA epidural and intramedullary abscess.
Parapelegic
Discharge Condition:
Stable
Discharge Instructions:
Please contiue to monitor fevers. Continue high dose Nafcillin.
Supportive care.
Physical Therapy:
Occupational and physical for range of motion.
Patient may sit up in bed.
Treatments Frequency:
Site: posterior cervical
Type: Surgical
Dressing: Gauze - dry
Comment: change daily
Site: anterior cervical
Type: Surgical
Dressing: Gauze - dry
Comment: change daily
Followup Instructions:
Please follow up in the Orthopaedic Spine clinic, [**Hospital **] clinic and
the General Surgery clinic. Call for appointments.
Completed by:[**2163-6-3**]
|
[
"790.7",
"041.11",
"344.1",
"518.5",
"324.1",
"730.08",
"336.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"33.23",
"84.51",
"96.04",
"96.71",
"96.56",
"03.09",
"03.4",
"38.93",
"81.02",
"34.91",
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icd9pcs
|
[
[
[]
]
] |
29160, 29238
|
23104, 27713
|
452, 795
|
29346, 29355
|
5268, 11985
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29780, 29939
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2720, 2733
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27770, 29137
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29259, 29325
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27739, 27747
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12011, 12927
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29577, 29757
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3738, 5249
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3353, 3722
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2439, 2503
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2519, 2704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,100
| 102,413
|
53794
|
Discharge summary
|
report
|
Admission Date: [**2120-8-21**] Discharge Date: [**2120-8-25**]
Date of Birth: [**2066-10-13**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 53yo female with PMH significant for OSA, obesity
hypoventilation, and pulmonary HTN who is being transferred to
the MICU for dyspnea requiring BiPAP. The patient presented to
her PCP earlier today with chest pain and SOB. In the ED, her
chest pain resolved quickly and the initial plan was to admit
her to the cardiology service for ROMI. Upon further questioning
the patient was more short of breath than she has been at
baseline. Per daughter, her SOB has gotten worse over the past 2
weeks especially on exertion. The patient has been also feeling
more fatigued. She also admits to some production of green
sputum. No associated PND, orthopnea, lower extremity swelling,
fevers, or chills. Of note, the patient has been admitted to the
MICU multiple times for hypercarbic respiratory failure. She was
noted to become more somnolent and ABG showed an elevated PC02.
She was then placed on BiPAP and then transferred to the MICU.
Of note, the patient has missed several of her appointments with
her pulmonologist and endocrinologist.
In the ED, initial vitals were T 98.0 BP 120/56 AR 62 RR 14 O2
sat 94% on 2L NC. She received Lasix 20mg IV, Kayexelate 30 gm,
and ASA 325mg.
Past Medical History:
1)Obstructive Sleep Apnea on home CPAP, 16cm H20
2)Obesity Hypoventilation
- Multiple admissions for hypercarbic respiratory failure; PFT's
consistent with a restrictive defect
- PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced
3)ASD with right-left shunt (12% shunt fraction documented in
nuclear study from [**2116-3-30**])
4)Pulmonary artery hypertension: Echo in [**10/2118**] demonstrated a
TR gradient of 33mmHg ?????? followed by [**Location (un) 4507**]
5)Hypertension
6)Pan-hypopituitarism with partially empty sella on
desmopressin, levothyroxine, prednisone ?????? followed by Dr.
[**Last Name (STitle) **]
7)Diastolic CHF with dilated RA/LA on previous echo
8)Angioedema (unclear history, possibly related to ACE-I)
Physical Exam:
vitals T 97.4 BP 166/89 AR 106 68 RR 18 O2 sat 100%
CPAP + PS FIO2 0.50 [**1-3**]
Gen: Awake and alert
HEENT: Puffy face
Heart: RRR, ? 2/6 systolic murmur
Lungs: CTAB, poor air movement
Abdomen: Soft, NT/ND, +BS
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2120-8-21**] 03:35PM BLOOD WBC-12.5* RBC-3.75* Hgb-10.0* Hct-34.1*
MCV-91 MCH-26.6* MCHC-29.3* RDW-16.5* Plt Ct-216
[**2120-8-23**] 03:56AM BLOOD WBC-11.2* RBC-4.09* Hgb-10.7* Hct-36.2
MCV-89 MCH-26.3* MCHC-29.7* RDW-15.4 Plt Ct-170
[**2120-8-21**] 03:35PM BLOOD Neuts-89.5* Lymphs-6.8* Monos-3.5 Eos-0.2
Baso-0
[**2120-8-21**] 03:35PM BLOOD PT-13.2 PTT-25.9 INR(PT)-1.1
[**2120-8-21**] 03:35PM BLOOD Glucose-140* UreaN-21* Creat-0.9 Na-142
K-6.4* Cl-101 HCO3-35* AnGap-12
[**2120-8-21**] 03:35PM BLOOD CK(CPK)-83
[**2120-8-21**] 03:35PM BLOOD CK-MB-NotDone proBNP-1117*
[**2120-8-21**] 03:35PM BLOOD cTropnT-<0.01
[**2120-8-22**] 04:14PM BLOOD Calcium-9.7 Phos-4.5# Mg-2.3
[**2120-8-22**] 04:22AM BLOOD Osmolal-298
[**2120-8-22**] 04:22AM BLOOD T4-6.9 T3-67* calcTBG-0.97 TUptake-1.03
T4Index-7.1
[**2120-8-21**] 08:41PM BLOOD Type-ART pO2-107* pCO2-81* pH-7.32*
calTCO2-44* Base XS-11 Intubat-NOT INTUBA
Relevant Imaging:
1)Cxray ([**8-21**]): There is gross cardiomegaly with upper lobe
venous diversion consistent with CHF. There is acute kyphosis
and extensive degenerative change in the lower thoracic spine as
well as the thoracolumbar junction.
2)ECHO ([**8-22**]): Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Left atrial dilation with moderate diastolic LV dysfunction.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Brief Hospital Course:
Ms. [**Known lastname **] is a 53yo female with PMH as listed above who presents
with 2 week history of worsening dyspnea and chest pain.
1)Hypercarbic respiratory failure: Patient presented with 2 week
history of worsening shortness of breath. She was found have an
elevated PC02 of ~80 on an ABG. Baseline pCO2 is in the 60's.
She has been hospitalized multiple times for hypercarbic
respiratory failure. She has been compliant with CPAP at home
(which has not been the case in the past per OMR). She does not
appear to volume overloaded on exam. She does admit to some
daily green sputum production, which was suggestive of a
possible underlying infection. She was started on BiPAP in the
emergency room which was continued when she came to the MICU.
She was also started on Levofloxacin and Mucinex for
tracheobronchitis. Over the course of 24 hours her respiratory
status significantly improved and she was transitioned to 1-2L
nasal cannulus.
2)Chest pain: She presented with 2 week history of chest pain,
which resolved quickly in the ED. No history of CAD. Cardiac
enzymes were negative x3, ECG was normal, and there were no
events on telemetry.
3)Leukocytosis: Patient presented with mild leukocytosis of of
12.5. She has history of UTIs on prior admissions but U/A on
this admission was w/o WBCs. She also denies any urinary
frequency or burning. No evidence of pneumonia on cxray but
given history of green sputum production, she may have some
tracheobronchitis. She was placed on 5d course of Levaquin.
4)Diastolic CHF: Last ECHO in [**2118**] with EF>55%. She does not
appear volume overloaded on exam. She received Lasix in the ED;
she is also on Lasix as an outpatient but unclear why. She
underwent an ECHO which showed an increase in her pulmonary
pressures from 33-->50. Her ejection fraction remained the same.
Lasix was held in the MICU and the floor team should call her
PCP to discuss why this was started.
5)Panhypopituitarism: Thought to be secondary to "empty sella".
She is followed by Dr. [**Last Name (STitle) **] but has missed several
appointments with him. The last time she was hospitalized she
was on Prednisone 15mg PO daily; she was started on 60mg per PCP
notes but after talking with her daughter she had actually been
on 5mg. Endocrinology was consulted to help determine her
regimen. She was continued on Prednisone 5mg, Levoxyl, and
Desmopressin.
6)Hypertension: Continued on outpatient regimen of Lopressor and
Diovan.
Addendum by Dr. [**Last Name (STitle) **] after discharge [**2120-8-26**]: Appointments
were arranged with Dr. [**Last Name (STitle) **] (endocrine) on [**9-17**] at
10:30 am and Dr. [**Last Name (STitle) 4507**] (sleep) on [**10-14**] at 9am. I called
patient and advised her daughter (English speaking) of the
dates/time and that she must keep these appointments.
Medications on Admission:
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Lasix 40mg PO daily
Prednisone 60mg PO daily
Clonidine 0.1mg Po daily
Famotidine 20mg PO BID
Lopressor 25mg PO BID
Valsartan 80mg PO QHS
Valsartan 40mg PO QAM
Albuterol nebs
Levothyroxine 150mcg PO daily
Desmopressin 0.2mg PO BID
Bisacodyl 10mg PO PRN
Vitamin D3 800 unit PO daily
Calcium Carbonate 500mg PO daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Desmopressin 0.2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q6H
(every 6 hours) as needed for shortness of breath or wheezing.
9. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hypercarbic respiratory failure
Obstructive sleep apnea
Diastolic heart failure
Secondary Diagnoses:
Pan-hypopituitarism
Discharge Condition:
Stable-- breathing more comfortably on room air; feeling better
and less short of breath.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing.
You should make sure you take all the medications on the list.
You should use the CPCP breathing machine at night-- it will
help your lungs and breathing and will help you not feel short
of breath. If you should find bright red blood in your stool,
please contact your primary care provider (Dr. [**Last Name (STitle) 6680**] and come
back to the hospital. If you have severe chest pain, shortness
of breath, loss of consciousness, severe
lightheadedness/dizziness, please come back to the hospital.
Followup Instructions:
Please see your doctor in 7 - 10 days. You can call Dr. [**Last Name (STitle) 6680**]
at [**Telephone/Fax (1) 608**].
Completed by:[**2120-8-28**]
|
[
"745.5",
"428.32",
"466.0",
"786.59",
"V15.82",
"327.23",
"455.5",
"253.2",
"319",
"288.60",
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"336.8",
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icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
8768, 8774
|
4103, 6941
|
320, 327
|
8959, 9051
|
2628, 3538
|
9664, 9814
|
7352, 8745
|
8795, 8895
|
6967, 7329
|
9075, 9641
|
2345, 2609
|
8916, 8938
|
249, 282
|
3556, 4080
|
355, 1565
|
1587, 2330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,320
| 116,138
|
38188+58196
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-7-31**] Discharge Date: [**2200-8-4**]
Date of Birth: [**2141-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2200-7-31**] - Coronary artery bypass graft x4, left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to diagonal, obtuse marginal, and posterior descending
arteries. Mitral valve repair with size 28 CG Feature Complete
Ring.
History of Present Illness:
This is a 59-year-old patient who presented with recent
myocardial infarction, was investigated, and was found to have
severe 3-vessel disease with a diminished ejection fraction of
40%. Intraoperative echocardiogram also showed at least moderate
mitral regurgitation. The plan was to proceed with coronary
bypass grafting and mitral valve repair.
Past Medical History:
Coronary artery disease s/p CABG
Myocardial infarction
prior stent/angioplasty
Right bundle branch block
Stroke [**2192**] ( post-cath)-residual memory impairment/right sided
weakness
Hypertension
obesity
asthma
Obstructive sleep apnea-Bipap
depression
dyslipidemia
Seizures
Noncompliance
Social History:
Lives with: self in [**Hospital3 **]
Occupation: disabled/past clothes buyer(TJX)
Tobacco:no
ETOH:no
Recreation drugs: no
Family History:
History:father with MI at 70
Physical Exam:
Pulse: 98 Resp: 16 O2 sat: 97%-RA
B/P Right: 122/76 Left:
Height: 5'6" Weight: 240lbs
General:Obese man/NAD
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 [] No M/R/G
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: no
Varicosities: None [x]
Neuro: Grossly intact, strength 5/5 on right [**4-11**] on left-upper
and lower extremities. Gait normal
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 no Right: Left:
Pertinent Results:
ECHO [**2200-7-31**]
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is moderately depressed
(LVEF=30-40 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. A mitral valve
annuloplasty ring is present. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Moderately depressed left ventricular systolic
function. No pericardial effusion.
[**2200-8-4**] 05:20AM BLOOD WBC-16.6* RBC-3.25* Hgb-9.3* Hct-28.2*
MCV-87 MCH-28.6 MCHC-33.0 RDW-14.2 Plt Ct-385
[**2200-8-3**] 07:15AM BLOOD WBC-18.0* RBC-3.04* Hgb-9.0* Hct-27.3*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.3 Plt Ct-265
[**2200-7-31**] 02:20PM BLOOD PT-14.5* PTT-33.1 INR(PT)-1.3*
[**2200-8-4**] 05:20AM BLOOD Glucose-100 UreaN-28* Creat-0.8 Na-133
K-3.9 Cl-97 HCO3-28 AnGap-12
[**2200-8-3**] 07:15AM BLOOD UreaN-26* Creat-0.8 Na-135 K-4.5 Cl-97
Brief Hospital Course:
Mr. [**Known lastname 26258**] was admitted to the [**Hospital1 18**] on [**2200-7-31**] 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 and a mitral valve repair. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. Over the next 24 hours, he
had awoke neurologically intact and was extubated. On
postoperative day one he was transferred to the step down unit
for further recovery. Aspirin, a statin and beta blocker were
resumed. He was gently diuresed towards his preoperative weight.
The physical therapy service was consulted for assistance with
his postoperative strength and mobility. Postoperative course
was uneventful and the patient was discharged on POD 4. He was
discharged to [**Hospital 3548**] [**Hospital 3549**] Rehab, as he lives alone. He did
develop some sternal drainage, and was discharged on keflex.
Medications on Admission:
Celexa 20'
Ambien 10'
Proventil 3.7'
Trileptal 300'
ASA 325'
Toprol XL 100'
Niaspan 2gm'
Lisinopril 20'
MVI
Prozac 20'
Crestor 20'
Discharge Medications:
1. 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*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
16. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Myocardial infarction
prior stent/angioplasty
Right bundle branch block
Stroke [**2192**] ( post-cath)-residual memory impairment/right sided
weakness
Hypertension
obesity
asthma
Obstructive sleep apnea-Bipap
depression
dyslipidemia
Seizures
Noncompliance
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema -trace in LEs
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] (for Dr. [**First Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound
check and post-op follow-up : [**Telephone/Fax (1) 6256**] Thursday, [**9-4**], 9am
Dr. [**First Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 77271**] in 3 weeks [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) 1295**] [**Telephone/Fax (1) 6256**] in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2200-8-4**] Name: [**Known lastname 13508**],[**Known firstname 2794**] Unit No: [**Numeric Identifier 13509**]
Admission Date: [**2200-7-31**] Discharge Date: [**2200-8-4**]
Date of Birth: [**2141-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 265**]
Addendum:
Mr. [**Known lastname **] was discharged on levaquin and not keflex due to an
allergy to PCN-anaphylaxis
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 435**] [**Doctor Last Name 436**] Nursing & Rehabilitation Center - [**Location (un) 437**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2200-8-4**]
|
[
"493.90",
"414.01",
"780.39",
"V45.82",
"311",
"424.0",
"780.93",
"728.87",
"790.29",
"410.72",
"426.4",
"458.29",
"285.1",
"272.4",
"401.9",
"327.23",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"38.93",
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8285, 8543
|
3191, 4187
|
287, 554
|
6448, 6682
|
2188, 3168
|
7291, 8262
|
1401, 1431
|
4369, 5950
|
6136, 6427
|
4213, 4346
|
6706, 7268
|
1446, 2169
|
237, 249
|
582, 932
|
954, 1245
|
1261, 1385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,020
| 115,394
|
1233
|
Discharge summary
|
report
|
Admission Date: [**2191-3-25**] Discharge Date: [**2191-4-14**]
Date of Birth: [**2127-11-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe lung cancer.
Major Surgical or Invasive Procedure:
1) [**2191-3-25**]: Video-assisted thoracic surgery (VATS) right
upper lobectomy and mediastinal lymph node dissection.
[**1-1**]) [**2191-3-28**], [**2191-3-31**], [**2191-4-1**], [**2191-4-9**]: Flexible
bronchoscopy
6) [**2191-4-7**]: Right thoracotomy, right middle lobectomy
History of Present Illness:
The patient is a 63-year-old gentleman who has at least stage
IIA non-small-cell lung cancer. He presents for resection.
Past Medical History:
PMH: glaucoma, AFib (last event [**2180**]), ex-lap and washout for
abdominal stab wound
[**Last Name (un) 1724**]: none
Social History:
Married lives with wife. [**Name (NI) 1139**] 40 pack-year. ETOH none
Family History:
Mother died at 86, unknown
Father died at 93, unknown
Physical Exam:
VS:T: 96.9 HR: 68-71 SR BP: 122-140/60 RR 18 Sats: 99% RA
Wt: 80.2
General: 63 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes
Neck: supple
Card: RRR
Resp: decreased breath sounds at bases otherwise clear
GI: benign
Extr: warm R 2+ edema, Left 1+ edema
Incision: R VATs site clean dry margins well approximated. 1
chest tube site margins not well approximated
Neuro: awake, alert, oriented.
Pertinent Results:
[**2191-4-14**] WBC 12.1 HCT 25 Plts 616
[**2191-4-13**] WBC 13.8 HCT 26 PLT 698
[**2191-4-10**] WBC 17.8 HCT 27 PLT 604
[**2191-4-14**] INR 1.8 (2.0 mg Coumadin)
[**2191-4-13**] INR 1.5 (2.5mg Coumadin)
[**2191-4-12**] INR 1.3 (2.5 mg Coumadin)
[**2191-4-14**] Na 136 K 3.7 Cl 101 HCO3 27 BUN 31 CRE 2.8
[**2191-4-13**] Na 137 K 3.6 CL 100 HC03 28 BUN 28 CRE 2.7
[**2191-4-12**] Na 136 K 3.2 CL 99 HCO3 31 BUN 26 CRE 2.6
[**2191-4-11**] NA 134 K 3.5 CL 98 HCO3 27 BUN 20 CRE 1.9
[**2191-4-10**] NA 133 K 3.8 CL 96 HCO3 29 BUN 10 CRE 0.9
[**2191-3-28**] CK-MB-3 cTropnT-0.02* [**2191-3-27**] CK-MB-3 cTropnT-0.01
[**2191-3-27**] CK-MB-3 cTropnT-0.01
[**2191-4-4**] Calcium-8.7 Phos-2.4* Mg-2.1
Micro:
C. diff negative [**2191-4-14**]
Urine Cx negative
BC x 4 no growth
[**2191-4-7**] Pleural culture Strep Viridens
[**2191-4-7**] Tissue no growth
[**2191-4-7**] BAL commensal
CXR:
[**2191-4-12**]:The previously present right-sided chest tube
terminating in the apical area has been removed. No pneumothorax
has developed. A right-sided chest tube terminating in the
pleural space on the right lung base remain in unchanged
position. No new pulmonary or pleural abnormalities are seen.
The amount of remaining pleural effusion in the posterior
pleural sinus appears grossly unchanged when comparing the
findings on the lateral views.
[**2191-4-9**]: Improved aeration in right lung compared with earlier
the same day However, considerable persistent opacity diffusely
throughout right lung, which appears to represent a combination
of diffuse
alveolar opacity and pleural thickening and/or fluid.
2. Retrocardiac patchy opacity, worse compared with the most
recent prior
film.
[**2191-4-4**]: Improving right upper lung postoperative hematoma
Decreased asymmetric right pulmonary edema. Decreased minimal
bibasilar atelectasis.
Unchanged small left and tiny right pleural effusions
[**2191-4-3**]: The patient is status post right upper lobe
resection. Large
homogeneous opacity extending from the right apex to the right
hilum appears similar compared to the previous post-operative
studies and could reflect a large hematoma. Heart size remains
normal. Linear bibasilar atelectasis is present, left greater
than right, with interval worsening on the left compared to the
prior study. Small left pleural effusion is apparently new.
[**2191-4-1**]: An endotracheal tube and nasogastric
tube remain in place. The changes of right upper lobectomy are
redemonstrated as is right pleural fluid, presumably hematoma.
The degree of subsegmental atelectasis in the left lower lobe
has improved and right middle lobe atelectasis is unchanged.
[**2191-3-30**]: New right lower lobe opacity is consistent with large
right lower lobe atelectases. Patient has known right middle
lobe atelectases. There is probably a small right pleural
effusion. The cardiomediastinum is shifted towards the right
side. In the left lung, there is a small left pleural effusion
and left lower lobe atelectases.
[**2191-3-26**]: new right paramediastinal opacity, which is
concerning for either mediastinal hematoma or newly developed
atelectasis of right middle lobe with questionable torsion.
CCT
[**2191-3-27**]: Area of contrast extravasation in the expected
location of the right middle lobe.
A severe narrowing, just distal to the origin of the artery
supplying the
right middle lobe and incomplete visualization of the right
middle lobe
bronchus are concerning for right middle lobe torsion with
active
extravasation into a small hematoma in the region.
Atelectasis in the superior segment of the right lower lobe.
Echocardiogram
[**2191-3-27**]: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded, but none are seen. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are grossly normal. There
is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 4949**] was admitted [**2191-3-25**] following Video-assisted
thoracic surgery (VATS) right upper lobectomy and mediastinal
lymph node dissection. He was extubated in the operating room,
monitored in the PACU prior transfer to the floor with a left
chest tube, Foley, Dilaudid PCA for pain.
Event: [**2191-3-31**] flexible bronchoscopy in the operating room,
transfer to the ICU intubated, bedside bronchoscopy [**2191-4-1**]
successfully extubated, transfer to the floor [**2191-4-2**].
Respiratory: incentive spirometer and nebs were done. On
[**2191-3-28**] his chest film showed right middle collapse. He was
taken to the operating room for bronchoscopy with showed large
mucus plug. He transfer to the floor in stable condition. On
[**2191-3-31**] his CXR showed collapsed right lung he was taken to the
operating room for flexible bronchoscopy and removal of small
clot in the distal bronchus intermedius. He transfer to the ICU
intubated for positive pressure support. He underwent bedside
flexible bronchoscopy on [**2191-4-1**] and was successfully
extubated. With continued aggressive chest PT, nebs and good
pain control he titrated off oxygen with saturation off 93-95%
RA at rest and with activity. Pt was transferred to the floor
with improving oxygen saturation. Series of quotidien fevers
and spike to 101.8 [**4-6**] prompted CT chest concerning for
infection/necrotic RML. Taken to OR [**4-7**] for R thoracotomy,
RMLobectomy and placement R chest tubes x 2, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain.
Tolerated procedure well and was xferred to the SICU for
extubation on [**4-8**]. Bronchoscopy performed [**4-9**] for concern of
mucus plugging in RLL. CXR improved post-procedure.
Transferred to floor [**4-10**] satting well and ambulating. Pulmonary
toilet and ambulation were encouraged on the floor. Room air
oxygen saturations 99% on discharge.
Chest-tube: right initially with a large amount of drainage,
slowly taper off and was removed on [**2191-3-30**]. Two additional R
chest tubes and [**Doctor Last Name **] drain placed in OR [**4-9**]. R antero-apical
CT d/c'd [**4-11**]. R postero-apical CT d/c'd [**4-12**].
Chest-film serial CXR showed see above reports.
Cardiac: intermittent atrial fibrillation 100-140's. He was
started on amiodarone infusion converted to sinus rhythm within
24-48 hrs, but continued to have intermittent atrial
fibrillation with rates of 140-150's with hypotension requiring
low-dose pressors, IV amiodarone & PO 400 mg [**Hospital1 **] transitioned to
200 mg daily [**2191-4-6**] after completing 6 gm load. Diltiazem was
started for RVR and titated too 30 mg qid. He converted to sinus
rhythm [**2191-4-3**] 50-60's on amiodarone and diltiazem and remained
in sinus. The cardiac enzymes were negative. Echocardiogram
[**2191-3-27**] with Normal left ventricular cavity sizes with low
normal global systolic function. No pericardial effusion. No
left atrial dilation. Amiodarone and diltiazem were titrated in
relationship to HR and systolic blood pressure with patient
intermittently alternating between afib and sinus rhythm. On
discharge his he was in sinus rhythm 60's. Blood pressure
130-140 stable.
GI: PPI and bowel regime. Tolerated a regular diet
Renal: Foley required re-insertion for low urine output. Over
his hospital course he was hypervolemic reqiring gentle
diuresis. His renal function was normal. His electrolytes were
replete. Serum creatinine increased from 0.9, Peak 2.8 in
setting of tobramycin, vancomycin, flagyl, zosyn for RML
necrotizing PNA s/p resection. Tobramycin discontinued.
Vancomycin and zosyn renally dosed. FeNa: 1.1% and FeUrea 42%
consistent with ATN likely secondary to aminoglycoside toxicity.
Electrolytes checked [**Hospital1 **]. His discharge CRE 2.7. His Chem 7
will be monitored with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
ID: low-grade fevers with mild leukocytosis he was started on
Levofloxacin [**2191-4-2**] for possible PNA. Pan cultured with no
growth. Giving finding of necrotic RML, started on vancomycin,
tobramycin and zosyn [**4-9**]. Flagyl started [**4-10**]. Tobra
discontinued [**4-11**] in setting of ATN. Flagyl discontinued [**4-11**].
Vancomycin was stopped with increased CRE, Zosyn dosed renally
continued until discharge on [**2191-4-14**] when he was changed to 14
day course of Moxifloxacin. Infectious disease signed off and
will follow as needed.
Heme: Cardiology recommended anticoagulation. He was started on
heparin/Coumadin bridge on [**2191-4-3**] he received 2.5 mg [**2191-4-3**]
(INR 1.3) [**2191-4-4**] 2.5 (INR 1.5). Coumadin held and vitamin K
given [**4-8**] in preparation for OR [**4-9**]. Anticoagulation resumed
[**4-10**] with heparin gtt. Coumadin resumed [**4-11**]. Heparin was
stopped [**4-11**]. His INR on discharge was 1.8. He was instructed
to take 2 mg Warfarin and to follow-up with his PCP as an
outpatient.
Pain: Dilaudid PCA transition to PO with good pain control
Disposition: Home with his wife and [**Name (NI) 269**] on [**2191-4-14**]. He will
follow-up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for warfarin follow-up and Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. warfarin 1 mg Tablet Sig: One (1) Tablet PO as directed: Goal
INR 2.0-3.0.
Disp:*100 Tablet(s)* Refills:*2*
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 IH* Refills:*2*
7. diltiazem HCl 180 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
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. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Outpatient [**Last Name (STitle) **] Work
Chem 7 Monday [**2191-4-18**].
Please fax results to Dr. [**Last Name (STitle) **] PCP office
Phone: [**Telephone/Fax (1) 7751**] Fax: [**Telephone/Fax (1) 7752**]
12. Outpatient [**Name (NI) **] Work
PT/INR 3 x week prn
Please fax results to Dr. [**Last Name (STitle) **] PCP office
Phone: [**Telephone/Fax (1) 7751**] Fax: [**Telephone/Fax (1) 7752**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Right upper lobe nodule
Glaucoma
Paraoxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Cover 1 chest tube site with a dry dressing until healed
-Daily weights. Support stockings for lower extremity swelling
Pain
-Take acetaminophen 650 mg every 8 hrs as needed for pain
-Oxycodone 5 mg every 4-6 hours as needed for pain.
New Medication:
-Amiodarone 200 mg daily. Please follow-up with Dr. [**Last Name (STitle) **]
regarding stopping this medication.
-Diltiazem 180 mg daily.
-Warfarin for atrial fibrillation. INR Goal 2.0-3.0
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tub until incision healed
-No lifting greater than 10 pounds until seen
-Walk frequently
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2191-4-28**]
3:00
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center.
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Follow-up with Dr. [**Last Name (STitle) **] Tuesday [**4-19**] at 3:30 pm
Blood draw Monday [**2191-4-18**] to monitor renal function and INR
Friday and Monday. Please call Dr.[**Name (NI) 7753**] office [**Telephone/Fax (1) 7751**],
Fax [**Telephone/Fax (1) 7752**] for a follow-up appointment
Please call Dr.[**Name (NI) 7753**] office for a follow-up appointment
regarding your heart medication.
Completed by:[**2191-4-14**]
|
[
"427.31",
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icd9cm
|
[
[
[]
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[
"32.49",
"34.04",
"40.3",
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icd9pcs
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[
[
[]
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] |
12655, 12730
|
5658, 10959
|
342, 628
|
12839, 12839
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1544, 5635
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1030, 1086
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11014, 12632
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12751, 12818
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10985, 10991
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12990, 13829
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1101, 1525
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272, 304
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656, 780
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12854, 12966
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802, 926
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942, 1014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,915
| 146,947
|
44482
|
Discharge summary
|
report
|
Admission Date: [**2153-2-5**] Discharge Date: [**2153-2-17**]
Date of Birth: [**2104-11-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tegretol / Latex
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
altered mental status, shortness of breath
Major Surgical or Invasive Procedure:
[**2153-2-6**] - intubation with mechanical ventilation
History of Present Illness:
48 yo F severe chronic multiple sclerosis, [**Month/Day/Year 16169**] aspirations
s/p G-tube placement, [**Month/Day/Year 16169**] UTIs with chronic foley p/w
altered mental status. Per the husband, patient started
complaining of sore throat on Saturday. Husband was concerned
she may be developing a cold given he had a recent cold, tried
to suction her at home because she sounded gurgling and also
felt that she was making choking noises. No cough at home but
per husband she is unable to cough. Also noticed that mental
status was worsening; at baseline she is conversational with her
husband and has a good memory, however over the last couple of
days she has been sleeping more slowly and has more difficulty
expressing hesrelf but has not been confused. Husband was
concerned for aspiration (which she has had several times before
with aspiration PNA) so brought her to hospital. Of note
patient was recently diagnosed with UTI by her PCP and started [**Name Initial (PRE) **]
10 day ciprofloxacin course on Saturday [**2-3**] which has not been
completed. Also son has been concerned about worsening lesions
on patient's back; he notes bilateral lesions on scapulae with
the appearance of pressure ulcers, initially were red but notes
that the one on the right has become painful and has started to
open to an ulcer. At baseline she gets nutrition from tube
feeds but occasionally will take small tastes of food PO, maybe
3-4 times per week, noted that she aspirates when this happens
.
In the ED initial VS were 101.3 97 123/77 18 87% on room air.
CXR was c/w prior with no acute process, put on NRB and sats
improved to 100%, she was eventually titrated down to 50% venti
mask and saturating 96-97% (not on oxygen at home). She was
started on treatment with clindamycin and levofloxacin
(clindamycin was given for possible MRSA PNA although pt has no
hx of this and swab has been negative in the past). Low BP
noted in ED (although unclear what BPs were), improved with IVF
and pt appeared more comfortable. She was sent to ICU for
initial concern for hypotesnsion and respiratory status on
presentation.
.
On arrival to the ICU, pt appears comfortable and states that
she feels better, denies any complaints.
Past Medical History:
Chronic progressive MS, wheelchair bound dependent in all ADL's
[**Month/Year (2) **] aspirations s/p G-tube placement
Chronic Sacral Decubitus ulcer with wound vac
h/o [**Month/Year (2) 16169**] UTI with chronic foley
Social History:
Dependent for all ADL's, wheelchair bound. Has 24 hour care.
Lives with husband, has 2 adult children. No tobacco, EtOH or
drugs.
Family History:
No family history of multiple sclerosis.
Physical Exam:
ADMISSION EXAM:
.
General: Alert, no acute distress, appears comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, end gaze
nystagmus with EOMI
Neck: limited ROM at baseline, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, with poor effort, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, g tube in
place with dressing clean
GU: foley in place with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, contracted in all 4 extremities
Skin: on R scapula there is a 4 cm round ulceration with clean
base and no discharge or surrounding erythema, on L scapula
there is an erythematous lesion not raised or ulcerated about 3
cm and round, on coccyx there is a healing pressure ulcer with
two 5 mm openings with no drainage
Pertinent Results:
ADMISSION LABS:
[**2153-2-5**] 04:20PM BLOOD WBC-10.4# RBC-4.90 Hgb-14.7 Hct-42.4
MCV-87 MCH-29.9 MCHC-34.6 RDW-13.5 Plt Ct-185
[**2153-2-5**] 04:20PM BLOOD Neuts-80.0* Lymphs-14.1* Monos-4.4
Eos-0.7 Baso-0.8
[**2153-2-5**] 04:20PM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-140
K-6.4* Cl-102 HCO3-31 AnGap-13
[**2153-2-5**] 04:31PM BLOOD Type-[**Last Name (un) **] pO2-36* pCO2-58* pH-7.38
calTCO2-36* Base XS-6
[**2153-2-5**] 04:32PM BLOOD Lactate-2.1*
MICROBIOLOGY:
[**2153-2-5**]
UCx no growth
BCx no growth in one bottle, the other with coag neg staph in
anaerobic bottle
SPUTUM Cx contaminated, culture cancelled
Sputum Cx from [**2-6**]: mold
BAL from [**1-/2070**]: no growth
BCx from [**2-6**], [**2-8**] pending
IMAGING:
CXR [**2153-2-5**]: The lungs are low in volume but clear. The
cardiomediastinal silhouette, hilar contours, and pleural
surfaces are normal. No pleural effusion or pneumothorax is
present. A PEG tube is partially imaged.
Brief Hospital Course:
Given her severe and debilitating neuromuscular disease, and her
history of [**Month/Day/Year 16169**] aspiration and prior admissions for
pneumonia, there was concern for acute on chronic aspiration
pneumonitis vs. pneumonia this admission, for which she was
initially treated with broad spectrum antibitoics. Given
worsening secretion burden and poor oxygenation, she required
intubation for bronchoalveolar lavage and to decrease her work
of breathing. After a lengthy discussion with her family, the
decision was made to attempt extubation following antibiotic
treatment and bronchoscopy, with no plans for future
intubations. She was extubated on [**2153-2-7**] and given her poor
performance and clinical status, she was transitioned to comfort
measures only with a continuous Moprhine infusion. The patient
expired on [**2153-2-17**]
Medications on Admission:
1. baclofen 20 mg Tablet [**Date Range **]: Three (3) Tablet PO three times a
day: via G-tube.
2. fluoxetine 40 mg Capsule [**Date Range **]: One (1) Capsule PO once a day:
via G-tube.
3. lorazepam 0.5 mg Tablet [**Date Range **]: One (1) Tablet PO twice a day as
needed for spasm, anxiety: via G-tube.
4. tizanidine 2 mg Capsule [**Date Range **]: One (1) Capsule PO at bedtime:
via G-tube.
5. ascorbic acid 500 mg Tablet [**Date Range **]: One (1) Tablet PO once a
day: via G-tube.
6. bisacodyl PR QHS
7. Percocet 5-325 mg Tablet [**Date Range **]: 1 tab in AM, 2 tabs at dinner,
2 tabs at bedtime
9. gabapentin 600 mg in AM, 300 mg at noon, 300 mg at dinner,
600 mg at bedtime
10. Ciprofloxacin daily (started [**2-3**])
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventilator Dependent Respiratory Failure
Progressive Multiple Sclerosis
Aspiration Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
You were admitted to [**Hospital1 18**] with aspiration pneumonia and
respiratory failure. You were placed on a breathing machine in
the ICU and your family decided to shift your care to comfort.
You were taken off the breathing maching and sent to the floor
only with medications to make you comfortable.
Followup Instructions:
n/a
|
[
"276.7",
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icd9cm
|
[
[
[]
]
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[
"38.97",
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icd9pcs
|
[
[
[]
]
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6697, 6706
|
5080, 5922
|
353, 410
|
6843, 6852
|
4102, 4102
|
7207, 7214
|
3077, 3120
|
6727, 6822
|
5948, 6674
|
6876, 7184
|
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|
271, 315
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438, 2670
|
4118, 5057
|
2692, 2913
|
2929, 3061
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,759
| 136,863
|
2477
|
Discharge summary
|
report
|
Admission Date: [**2110-7-21**] Discharge Date: [**2110-7-30**]
Date of Birth: [**2066-8-30**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Imitrex / Morphine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Abdominal Pain, bilious, non-bloody emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 43 y/o F with a PMH significant for chronic pancreatitis
and abdominal pain, followed by Dr. [**Last Name (STitle) 3315**] and on pain
contract, prior UE DVT, depression/anxiety and migraines who
presents with a 2-day history of worsening epigastric pain
radiating to her back accompanied by bilious but non-bloody
emesis. Pt. reports, methdone did not relief her pain over the
weekend and has not taken anything by mouth since saturday
([**7-18**]). Given persistent, worsening pain that was [**11-10**] at its
worse, she decided to come to the ED for further evaluation. She
denies fevers/chills/night sweats, chestpain/SOB/palpitations,
diarrhea/constipation/BRBPR/, dysuria/hematuria.
.
Of note, patient has had multiple admissions for chronic
pancreatitis, last [**Date range (3) 12673**]. She states her episodes will
typically last for a week at a time, and often occur every [**3-6**]
weeks. She reports baseline abdominal pain usually controlled
with IV dilaudid but has been weaned off IV dilaudid over the
past week at the [**Location (un) 12674**] Ad-care program (discharged on
[**2110-7-18**]). Her dilaudid detox protocol was with phenobarbitol,
methadone and clonidine 0.1mg.
.
She also met with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1699**] on [**7-18**] after [**Hospital1 **] where
she was found to be light-headed and hypotensive with SBPs 90s.
Her blood pressure medications were then titrated down and was
given some methadone for pain control over the weekend which did
not help her pain.
.
In the ED, initial VS: T:97.8, HR:81, BP:150/117, RR:16, O2
sat:98%RA. Labs and exam were unchanged from baseline. Received
4mg IV dilaudid in the ED according to her pain contract.
Past Medical History:
- Chronic Pancreatitis - followed by Dr. [**Last Name (STitle) 3315**]. Diagnosed in
[**2102**]. She is s/p J-tube placement in [**2103**] for poor nutrition.
She is s/p > 30 admissions for abdominal pain.
- Left upper extremity DVT in [**2105**]
- Left axillary and proximal brachial vein thrombus on U/S from
[**2109-11-14**]; and also new found clot in right IJ thought to be old
- Migraine headaches
- Depression/Anxiety
- Prior cardiomyopathy: EF 30% which improved to 50% in [**2103**]
- Iron deficiency anemia
- H/o GNR bacteremia and multiple line infections, most recent
bacteremia [**5-12**] felt to be [**3-5**] dental caries
- Vitamin D deficiency
Social History:
The patient lives in [**Location 12670**] with her female partner
([**Name (NI) **]) and their son. Partner helps with ADLs. She denies
tobacco, alcohol, or illicit drug use.
Family History:
Adopted. Aware that biological mother and father are
heterozygous for CFTR gene mutation. [**Name (NI) **] mother had breast
cancer and ovarian in 30s.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T-98.2, HR:113, BP:112/74, RR:18, O2 Sat-98%RA
GEN: Thin appearing female sitting comfortably in bed, no acute
distress
HEENT: Atraumatic, normocephalic, sclerae anicteric, MMM,
oropharynx clear
NECK: No thyromegaly or lymphadenopathy
CV: regular rate, normal rhythm, normal S1/S2 no
murmurs/gallops/
Pulm: Clear to ascultation bilaterally. No wheezing, ronchi or
rales. Non-labored breathing.
Abd: Soft, +bowel sounds, tender to palpation in the epigastric
region, no rebound or guarding
EXT: warm, well perfused, no edema, cyanosis,
Neuro: Alert and oriented, CN III-XII grossly intact, [**6-5**]
strength in . DTR 2+, Normal sensation bilaterally in all
extremities.
.
Pertinent Results:
Admission
[**2110-7-21**] 06:07AM K+-5.3
[**2110-7-21**] 06:00AM GLUCOSE-139* UREA N-26* CREAT-0.9 SODIUM-138
POTASSIUM-5.8* CHLORIDE-101 TOTAL CO2-23 ANION GAP-20
[**2110-7-21**] 06:00AM estGFR-Using this
[**2110-7-21**] 06:00AM ALT(SGPT)-29 AST(SGOT)-54* ALK PHOS-154* TOT
BILI-0.4
[**2110-7-21**] 06:00AM LIPASE-84*
[**2110-7-21**] 06:00AM WBC-13.6*# RBC-4.80# HGB-14.0# HCT-39.4#
MCV-82 MCH-29.2 MCHC-35.5* RDW-14.3
[**2110-7-21**] 06:00AM NEUTS-86.9* LYMPHS-8.9* MONOS-2.4 EOS-0.7
BASOS-1.1
[**2110-7-21**] 06:00AM PLT COUNT-344
Discharge EKG
Sinus rhythm. Diffuse T wave abnormalities with borderline
prolonged
QTc interval (458)
[**2110-7-23**]
MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**]
There is no evidence of marrow edema seen to indicate bony
injury.
There is no abnormal signal seen within the ligamentous
structures to indicate ligamentous trauma or disruption. The
prevertebral soft tissue thickness is maintained. No significant
disc bulge, herniation, or spinal stenosis is identified. The
flow voids are identified within the both vertebral arteries.
The craniocervical junction is unremarkable. The spinal cord
shows normal signal intensities without intraspinal hematoma or
compression of the spinal cord.
CT C Spine
FINDINGS: There is no acute fracture or traumatic malalignment
of the
cervical spine. No prevertebral soft tissue abnormalities are
seen. Included views of the lung apices are clear. The thyroid
is normal.
IMPRESSION: No acute fracture or traumatic malalignment of the
cervical
spine.
[**2110-7-21**]
CT Chest
Catheter descending from the left neck along the left lateral
mediastinum probably in a small pericardial vein or tributary of
the left
superior intercostal vein. No pericardial effusion or hematoma.
Findings
were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**] by phone at 12:20 p.m. on
[**2110-7-22**] at
which time the catheter had been removed.
Brief Hospital Course:
43F with history of narcotics abuse and multiple admissions for
abdominal pain/nausea/vomitting attributed to chronic
pancreatitis versus opioid seeking admitted [**7-21**] with symptoms
similar to prior presentations, with hospital course complicated
by suicide attempt by hanging. She was medically stabilized and
discharged to [**Hospital1 **] 4 for ongoing intensive psychiatric
care.
.
#ABDOMINAL PAIN: She presented with abdominal pain, nausea,
vomitting similar to prior admissions. She was continued on
methadone 5mg [**Hospital1 **] and started on ketorolac, tylenol IV, ativan
IV, anti-emetics, and IVF hydration. The Chronic Pain service
was consulted who felt that her symptoms were likley secondary
to addiction and recommended outpatient suboxone therapy at
[**Hospital1 882**]. Her care was closely coordinated with her outpatient
provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1699**]. Her GI specialist Dr. [**Last Name (STitle) 3315**] is no
longer involved in her care and deferred management to her
primary care physician. [**Name10 (NameIs) **] explained to her and her partner that
we were going to manage her pain without IV narcotics. She was
later found in the bathroom unresponsive and having hung herself
(details below).
After discussion with her primary care physician who will be
managing her pain control as an outpatient, her methadone was
increased to 10mg TID for her chronic non-cancer abdominal
pain/addiction. She was given 48hours of tramadol as a bridge
and it was discussed that this medication would not be restarted
given addiction potential. Her abdominal pain improved. Her QTc
remained in the mid 400s, would continue to check weekly EKG.
She was continued on her adjunctive medications including
tylenol, neurontin, clonidine, ibuprofen, and amitriptyline.
Her PO clonidine should continue to be tapered, would recommend
d/c PO clonidine and increase clonidine patch to 0.2mg Qweek.
Tizanidine was added as an additional adjuntive [**Doctor Last Name 360**]; it should
be continued only if clear benefit demonstrated.
.
#SUICIDE ATTEMPT: The patient was found unresponsive in the
bathroom with a bedsheet around her neck, hanging from the
shower. A code blue was called. The patient was brought to the
bed where she was found to be hemodynamically stable satting
well on room air. She was transferred to the trauma SICU. She
underwent CT and MRI C-spine that were normal. Her mental status
returned to [**Location 213**] shortly after the event. She was evaluated by
psychiatry. She was maintained on 1:1 sitter/Section 12. After
medical stabilization, she was transferred to [**Hospital1 **]-4 for
further management.
.
#VENOUS ACCESS: A PICC line was unable to be placed. A CVL was
attempted on the floor and she was then admitted to ICU after
chest XRAY post L internal juglar approach showed anomalous
placement concerning for cardinal vein cannulation vs. carotid
artery cannulation. She was sent to IR for further analysis.
PICC placed in R braciocephalic vein with confirmed placement.
Left IJ CVL suggestive of cardinal vein cannulation, but
uncertain so CT chest performed. No evidence of pericardial
injury or cannulation. No evidence of pericardial effussion or
pneumopericardium. Discussed case with vascular surgery, who
was comfortable with line removal. Central venous Line removed
without complication.
.
#ANXIETY: The patient was anxious about transfer to a psychiatry
floor; something that is unknown to her. She was also concerned
about how her medical issues would be managed moving forward. It
was explained that the the medicine consult service would be
available if needed to follow along with the psychiatry team and
make recommendations regarding her medical care. We discussed
nonpharmacological (behavior therapy such as the learning to
identify the patterns of thinking leading to anxiety; and
relaxation therapy such as reiki) and pharmacological methods
(ativan, tri-cyclic antidepressant) of anxiety management. She
met daily with social work (see notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12471**]) and
psychiatry.
.
# HYPERTENSION: Her blood pressure remained normal with systolic
blood pressures ranging 110-120s on the floor. Her blood
pressure was intermittently elevated and she was tachycardic in
the emergency department likely from anxiety and pain. She was
continued on her new home regimen of 5mg lisinopril daily,
12.5mg metoprolol tartrate twice a day (25 Metoprolol
succinate), and 0.1mg of clonidine twice a day with adequate
control.
.
# MIGRAINES: We discussed weaning her off fioricet given the
addiction potential and only using it at maximum twice her week.
The tricyclic should be useful for preventitive control.
.
TRANSITIONAL/FOLLOW UP ISSUES
1. HTN - consider increasing clonidine patch and dc PO clonidine
2. Depresion / Suicide attempt - discharge to [**Hospital1 **] 4
3. Ongoing pain syndrome - med consult available if needed.
Medications on Admission:
Lisinopril 5mg daily
Metoprolol succinate 25 mg PO dialy
Omeprazole 20mg daily
Phenergan 25mg Q4H
Clonidine 0.1mg po BID
Clonidine 0.1mg patch once weekly (Friday)
Hydroxyzine pamoate 50mg TID PRN
Methadone 15mg Q12H
Gabapentin 300mg every morning, 100mg mid-day, 500mg QHS
Amitryptiline 75mg [**Hospital1 **]
Ativan 1mg QHS
Ativan 0.5mg Q4H
Amylase/Lipase/Protease 1 tablet QID
Discharge Medications:
1. amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
2. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea. Tablet(s)
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO 12 () as
needed.
7. gabapentin 100 mg Capsule Sig: Five (5) Capsule PO at
bedtime.
8. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety .
10. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for withdrawal symptoms.
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for breakthrough pain.
15. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
16. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
#Primary Diagnosis:
-attempted suicide
-Opioid dependence
-Chronic abdominal pain
.
#Secondary Diagnosis:
- Chronic Pancreatitis
- Left upper extremity DVT in [**2105**]
- Left axillary and proximal brachial vein thrombus on U/S from
[**2109-11-14**]; and also new found clot in right IJ thought to be old
- Migraine headaches
- Depression/Anxiety
- Prior cardiomyopathy: EF 30% which improved to 50% in [**2103**]
- Iron deficiency anemia
- H/o GNR bacteremia and multiple line infections, most recent
bacteremia [**5-12**] felt to be [**3-5**] dental caries
- Vitamin D deficiency
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 Ms. [**Known lastname 12667**],
You were recently admitted to the [**Hospital1 18**] for abdominal pain,
nausea and vomiting. Your abdominal pain was thought to be
secondary to opioid dependence and withdrawal. We did not think
your pain was from chronic pancreatitis flare (your pancreatic
enzymes and other markers which tell us how your pancrease is
functioning were unchanged from when you last discharged). In
collaboration with your primary care doctor, Dr. [**Last Name (STitle) 12675**] and
our inpatient pain service, we came up with a pain control
regimen to help make you comfortable while you were in the
hospital. You were given gabapentin, toradol (injection and
intravenous), clonidine and methadone. Since you had not taken
anything by mouth for two days prior to your coming to the
hospital, we also gave you some intravenous fluids to keep you
hydrated. You were also seen by the addiction nurse to help
connect you with providers for a long term pain management.
Because of ongoing psychiatric issues, you were discharged to
the inpatient psychiatry service.
Your methadone was kept at 10 mg three times daily
We added a lidocaine patch for pain and tizanidine for
breakthrough pain
Followup Instructions:
Please follow-up with the following providers:
1.The Pain Service: [**Name6 (MD) 12672**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2110-8-8**] 12:50
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2110-8-8**] at 12:50 PM
With: [**Name6 (MD) 12672**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Completed by:[**2110-7-31**]
|
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"338.4",
"276.51",
"785.0",
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"E953.0",
"300.4",
"V58.69",
"V55.4",
"338.19",
"E849.7",
"292.0",
"787.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13031, 13076
|
5886, 10878
|
331, 337
|
13705, 13705
|
3883, 5863
|
15122, 15630
|
2988, 3142
|
11308, 13008
|
13097, 13098
|
10904, 11285
|
13888, 15099
|
3182, 3864
|
249, 293
|
365, 2096
|
13203, 13684
|
13117, 13182
|
13720, 13864
|
2118, 2779
|
2795, 2972
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,676
| 101,460
|
5304
|
Discharge summary
|
report
|
Admission Date: [**2142-3-23**] Discharge Date: [**2142-4-23**]
Date of Birth: [**2080-6-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) /
Hydrochlorothiazide
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Acute myelogenous leukemia
Major Surgical or Invasive Procedure:
Central venous line placement
PICC line placement
History of Present Illness:
61 y/o F hypertension, hyperlipidemia, and anxiety, presents
after referral from [**Hospital1 1474**] for induction chemotherapy for
acute myelogenous leukemia. Pt initially presented to her PCP
for evaluation of persistent fatigue and decreased appetite x
1-2months, and was found to have anemia and abnormal
differential on CBC.
In note from referring oncologist's initial visit with pt,
automated differential from PCP [**Name Initial (PRE) 654**] 45.8% monocytes. Pt
underwent a techinically difficult bone marrow biopsy, and
pathology showed hypercellular bone marrow with left-shifted
granulopoiesis and increased blasts, consistent with AML. Flow
cytometry interpretation showed approximately 39% blasts
identified, and there were increased monocytic/myelomonocytic
cells, suggestive of an M4/M5 subtype of AML. Morphologic and
cytogenetic/FISH analysis was pending at time of report. See
below for available details.
.
Of note, over the past several months, pt reports having 2
episodes of the flu, an episode of pneumonia (diagnosed by CXR,
treated with Z-pak with resolution), and UTI (treated with Cipro
with resolution.)
.
On review of systems, pt reports low-grade fevers and chills
following her bone marrow biopsy last week, but none since. She
has pain over the biopsy site on her right hip. Otherwise,
denies any chest, abdominal, joint, muscle, or other pain. She
denies nausea/vomiting. She has occasional diarrhea/constipation
that she associates with her hx of dysfunctional bowel syndrome.
She denies shortness of breath, palpitations, orthopnea, PND.
She reports occasional migraines with visual auras, none at
present. She reports blurry vision recently, that she has seen
an optomeetrist for and was told that she did not need
correction. She denies hemoptysis, melena, or hematochezia. She
endorses fatigue and decreased appetite as mentioned above.
Otherwise, remaining ROS is negative.
Past Medical History:
Hypertension
Hyperlipidemia
Anxiety
Dysfunctional bowel syndrome
s/p hysterectomy, cyst removal
s/p appendectomy
s/p cholecystectomy
Bladder suspension surgery with ?R upper thigh nerve
impingement:pt says R leg sometimes flops to side
Hx breast augmentation (silicone)
R face/blepharospasm (extends from R front scalp-> R neck): used
to have botox injections, but stopped to try and see if it
resolves on its own, last dose ~2months ago
Social History:
Pt is a homemaker. She lives with her husband in [**Name (NI) 21627**]. She
spends most days each week baby-sitting her 3 grandchildren. She
has 2 children- son age 40, daughter age 37. She denies history
of smoking, and drinks alcohol occasionally.
Family History:
Maternal aunt had lymphoma. Another maternal aunt had cervical
cancer. Children and sister are healthy.
Physical Exam:
VS-T 98.6 BP 140/90 RR 24 HR 70 O2sat 97%RA
Gen: awake, alert, NAD, anxious, obese
HEENT: PERRL, EOMI, sclera non-icteric, ?canker sore in R upper
mouth, otherwise mucous membranes moist without obvious ulcers
NECK: supple, no palpable LAD
CV: regular rate and rhythm, no murmurs/rubs/gallops, S1 S2
present
LUNGS: clear to auscultation bilaterally, no
wheezes/rales/rhonchi
ABD: soft, non-tender, non-distended, bowel sounds present, no
HSM
EXT: no cyanosis/clubbing/edema, 2+ DP pulses bilaterally
NEURO: CN2-12 intact grossly, strength 5/5 diffusely in
extremities x 4, sensation intact grossly, coordination intact
GENITAL: lichen sclerosis inside labia majora, no other visible
ulcers; ecchymosis with induration over right hip, TTP (site of
BM bx); resolving faint ecchymosis over left hip (site of prior
pain med injection)
Pertinent Results:
Labs on Admission:
138 103 15 96
4.3 24 0.9
.
Ca: 9.2 Mg: 2.2 P: 4.3
.
WBC 6.3, Hb 10.6, Crit 30.1, MCV 104, Plt-pending
Diff: 8%N, 1%Band, 30%L, 41%M, 5%E, 0%B, 3%atypical,
12%"other"-pending (ANC 567)
INR 1.2, PT 14.2, PTT 32
.
ALT 16
AST 33
AP 46
LDH 354*
Amylase 63
TBili 0.7
Alb 4.5
Uric acid 6.4*
TSH- pending
Iron- pending
.
Labs from outside clinic:
WBC 7100, Hb 11.5, Crit 35.7, Plt 70K, normocytic
Diff 10%N, 48%M, 5%atypical L, 32%M, 5%E, ANC 710
Smear reveals "question of blast", plts of "adequate size"
.
Flow Cytometry Report ([**2142-3-21**], paraphrased)
Interpretation: Aspirate smears [**Last Name (un) **] increased cellularity
without particles. Megakaryocytes are identified.
Lymphocytes comprise approximately 8% of gated cells, include 2%
B-cells, 6% T-cells, and <1%NK cells. There are approximately
30%myeloid cells and 22% monocytes. CD38-bright cells (including
plasma cells) are not increased. B-lymphocytes show a
kappa:lambda raatio of 1:1. There is no evidence of a monotypic
B-cell population. T-lymphocytes show no aberrant antigen
expression, and the CD4:CD8 ratio is inverted, at 0.8:1.
Flow abnormalities that support a dysplastic myeloid population
include decreased orthogonal light scatter, decreased CD45
expression, CD11b/CD16 pattern abnormalties, CD13/CD16 pattern
abnormalities, and few myelomonocytic cells, CD34-positive
blasts are increased,comprising 39% of nucleated cells, and they
exhibit the expected immunophenotype for myeloblasts (CD34+,
CD13+, CD33+, CD117+, HLA-DR+, and negative for most other
markers.)
Findings are suggestive of AML, non-M3 type. Presence of
increased monocytic and myelomonocytic cells raises the question
of an M4/M5 subtype.
Flow Cytometry Differential
- CD117+ HLA-DR+ 34
- CD34+ CD13+ 38
- CD34+ CD33+ 39
- CD34+ HLA-DR+ 35
- Lymphocytes 8
--B cells 2
---Kappa <1
---Lambda <1
---Kappa:Lambda ratio 1.0
--T cells 6
---CD4 3
--- CD3 3
---CD4: CD8 ratio 0.8
---CD3+ CD58+ 1
---NK cells <1
--Monocytes 22
--Granulocytes 30
--CD34+ blasts 39
--Plasma cells <1
--Viability 97
.
Imaging on Admission:
None
TTE/TEE: EF > 55%. 2+ MR. [**Name13 (STitle) **] evidence of endocarditis.
Chest CT: [**2142-4-19**]
1. Worsening of micro-nodules throughout the lungs in a
tree-in-[**Male First Name (un) 239**]
distribution, suggestive of worsening viral disease.
2. Slightly decreased size of small bilateral pleural effusions.
3. Unchanged stranding surrounding the sigmoid colon, consistent
with
subacute diverticulitis. No abscess.
4. Resolution of previously seen mass-like lesion within the
cecum which
likely represented mixing of fluid and contrast. No definite
mass identified.
Brief Hospital Course:
61 y/o F with hypertension, hyperlipidemia, anxiety, presenting
with new diagnosis of acute myelogenous leukemia, admitted for
7+3 induction chemotherapy. Hospital course complicated by
fever, neutropenia, and sepsis secondary to fever and
neutropenia (likely etiologies VRE bacteremia,
diverticulitis/typhlitis) and pulmonary nodules noted on Chest
CT.
# AML: Pt is newly diagnosed with AML, possibly M4/M5 subtype
given monocytic predominance on flow cytometry and BM biopsy.
Patient underwent 7 + 3 induction chemotherapy (7 days ara-c, 3
days idarubicin) and tolerated it well. However, blasts were
still present in her bone marrow biopsy and CBC differential
after completion of chemotherapy, indicating residual disease.
She had a repeat bone marrow biopsy the day before discharge,
the results of which were pending on the day of discharge. She
was scheduled to follow-up with her outpatient oncologist on
[**4-30**], and have another round of chemotherapy on [**4-20**] pending
the results of the bone marrow biopsy.
#VRE Bacteremia: Hospital course complicated by Vancomycin
resistant enterococcal bacteremia (4/4 bottles). Patient briefly
required ICU admission. Followed by ID during admission. Central
line was removed. Patient was treated with daptomycin,
meropenem, and voriconazole/micafungin during her neutropenic
phase. Surveillance blood cx's were negative for four days,
after which a PICC was placed. TTE showed mildly worsened mitral
regurgitation, but TEE showed no evidence of endocarditis,
mitral valve or otherwise. Patient was hemodynamically
stabilized and was treated with a 14 day course of daptomycin
and meropenem starting from [**2142-4-16**] (the day she was no longer
neutropenic.)
# Diverticulitis/Typhlitis: Treated with 14 day course of
meropenem after patient was no longer neutropenic.
#Pulmonary Nodules: Pt noted to be short of breath and hypoxic
with a new oxygen requirement, improved with diuresis with IV
lasix. Patient briefly required ICU admission for her hypoxia.
Chest CT showed pulmonary nodules concerning for fungal vs.
viral infection. Treated initially with albuterol/ipratroprium
nebulizers and voriconazole, which was later d/c-ed due to LFT
abnormalities and changed to micafungin. Nodules were slightly
worsened on repeat Chest CT, but patient clincally improved.
Pulmonary followed patient in-house. Decision was made not to
bronchoscopy/BAL as she clinically improved. Anti-fungal were
eventually d/c-ed. Patient should have repeat Chest CT I- high
resolution 1 week after discharge to assess for
stability/interval change of pulmonary nodules.
# Hypertension: Poorly controlled on patient's home regimen of
metoprolol 25 mg PO BID, with SBPs into the 170s-190s. Once
patient was hemodynamically stable, increased metoprolol to 50
mg PO TID and added amlodipine 5 mg daily, bridged with PRN
doses of IV hydralazine. Patient's blood pressure was 148-150s
systolic on discharge with the initiation of calcium channel
blocker and increase in beta-blocker.
# Anxiety: Pt has baseline anxiety, which has been augmented by
this new diagnosis. Pt may experience decreased PO intake with
nausea during chemo course, so would like to wean her off
Lexapro for now and address anxiety with PO/IV meds. Tapered
celexa to 20 mg by mouth daily, and controlled anxiety with
Ativan IV/PO as needed. Discharged patient on tapered celexa
dose with PRN oral ativan, as she may likely need chemotherapy
to treat her residual disease and may have difficulty with oral
medications (requiring IV meds for anxiety).
# Silicone breast implant: Noted to have silicone breast implant
leakage, stable on mammogram/ultrasound and Chest CT. Patient
may follow up with the outpatient breast surgeons once
chemotherapy is completed.
Medications on Admission:
Crestor 10mg PO daily
Metoprolol 25mg PO bid
Celexa 40mg PO daily
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
Disp:*42 Tablet(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 6 days: 600 mg SOLUTION
start date: [**2142-4-24**]
end date: [**2142-4-29**].
Disp:*6 Recon Soln(s)* Refills:*0*
5. Ertapenem 1 gram Recon Soln Sig: One (1) gram recon solution
Intravenous once a day for 6 days: start date: [**2142-4-24**] end date:
[**2142-4-29**].
.
Disp:*6 grams* Refills:*0*
6. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection
once a day for 7 days: SASH and PRN.
Disp:*14 syringes* Refills:*0*
8. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
once a day for 7 days: SASH and PRN.
Disp:*14 syringes* Refills:*0*
9. Daptomycin 500 mg Recon Soln Sig: Six Hundred (600) mg
Intravenous once a day for 6 days: start date: [**2142-4-24**]
end date: [**2142-4-29**].
Disp:*6 units* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1' Diagnosis
Acute Myelogenous Leukemia
Vancomycin Resistant Enteroccocal Bacteremia
2' Diagnosis
Pulmonary Nodules of Undetermined Significance
Hypertension
Anxiety
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted for chemotherapy for your acute myelogenous
leukemia. Your hospital course was complicated by a blood stream
infection, which required a brief stay in the intensive care
unit. You recovered from this infection, and will be treated
with antibiotics.
Please take your medications as directed. We have made the
following changes:
- Given the liver function test abnormalities, your crestor was
held. This can be restarted as an outpatient by your primary
care physician.
[**Name Initial (NameIs) **] We had added amlodipine 5 mg by mouth daily
- We have increased your metoprolol to 50 mg by mouth three
times a day.
- We decreased your celexa to 20 mg by mouth daily, with ativan
as needed for your anxiety. This was done as you will likely
need more chemotherapy, and as you may have nausea associated
with it, we wanted to decrease the number of medications you
would need to take orally. We have given you a limited supply of
ativan until you are seen in a hospital setting later this week.
- Please restart your crestor at the discretion of your
outpatient oncologist.
- You need to take antibiotics for 6 more days (daptomycin and
ertapenem). You will need to have some lab tests checked when
you see your oncologist next week.
Please return to the hospital if you have fever > 100.4, chills,
nausea, a worsening rash, abdominal pain, diarrhea, cough with
sputum production, or any other symptoms not listed here
concerning enough to you to warrant physician [**Name Initial (PRE) 2742**].
Followup Instructions:
with your oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2142-4-30**] 2:00
Please have your CK levels checked when you see your oncologist
next.
You will also need a Chest CT next week, which has been ordered
by your discharging physician and will be followed up by Dr.
[**First Name (STitle) **]. It is scheduled for [**Last Name (LF) 766**], [**2142-4-30**] at 9:15 AM in
the [**Hospital Unit Name 1825**].
There is no need at this time to follow up with pulmonary unless
you deveolop further symptoms.
Other appointments:
Provider: [**Name Initial (NameIs) 455**] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2142-4-25**] 9:00
Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2142-4-26**] 9:00
Completed by:[**2142-5-3**]
|
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icd9cm
|
[
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[
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icd9pcs
|
[
[
[]
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11921, 11973
|
6758, 10530
|
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|
12184, 12219
|
4075, 4080
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|
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|
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|
2836, 3087
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,675
| 168,205
|
36306
|
Discharge summary
|
report
|
Admission Date: [**2124-5-11**] Discharge Date: [**2124-5-26**]
Date of Birth: [**2042-5-18**] Sex: F
Service: MEDICINE
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Unresponsiveness, PEA arrest at OSH, hematemesis, hypoglycemia
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Left-sided chest tube placement
Left subclavian central line
Right IJ central line
Right PICC line
Upper Endoscopy x3.
Tracheostomy
J-tube and G-tube placement
History of Present Illness:
81F with h/o diabetes, CHF, h/o hemorrhagic stroke, h/o AVR in
[**2124-2-20**] for aortic insufficiency? on coumadin. (gets care at
[**Hospital1 2025**]), also h/o bladder cancer. Pt was found
"pseudounresponsive" at her NH earlier today. Daughter says she
started feeling unwell yesterday AM; vomiting blood-tinged
vomitis/hemoptysis with epigastric burning in the AM. Yesterday
evening she was unresponsive per nursing staff.
On EMS arrival, FS was 26 and she was given glucagon with
improvement of FS to 122. On the way to [**Hospital3 10310**]
hospital, she stopped breathing, became pulseless (? has PEA vs
bradycardic arrest). CPR was performed, was given atropine, and
multiple rounds of epi. She was intubated. She was noted to be
posturing. Femoral line was placed. CXR reportedly showed CHF.
BP was initially 67/48 and she was started on levophed vs
dopamine with improvement in BP to 104/55. HR 114. OGT was
dropped with bright red blood on return. Hct was 36 with INR
1.9. She received 1u FFP, vit K, protonix. Had low-grade temp of
100.1, WBC 18 and was given a dose of empiric zosyn. Transferred
to [**Hospital1 18**].
.
On arrival to [**Hospital1 18**] ED, vitals were T 99.2, HR 102, BP 100/58 on
levo 0.03, RR 18, SaO2 99% on 100% FiO2. Labs were notable for
WBC 17, hct 27, INR 1.6, trop 0.26, +UA. got vanco after spiking
to 101
ordered 2u rbc. Sedated on versed gtt and NGT to suction with
75cc bright red drainage. CT head showed VP shunt (>20 years
old), no acute intracranial process.
Past Medical History:
- Bladder Cancer dx [**2123-11-4**] awaiting surgery postponed for
numerous cardiac complications
- Mitral Valve Replacment (St. Jude valve) with Dr. [**Last Name (STitle) 82257**] at
[**Hospital1 2025**] [**2124-2-21**]
- Intraventricular Hemmorhage on [**4-19**] while being bridged with
lovenox for bladder surgery, per report, intraventricular
hemorrhage in the posterior aspect of right lateral ventricle,
at [**Hospital1 2025**], hemorrhage within both lateral ventricles
- Hypertrophic Obstructive Cardiomyopathy
- Atrial Fibrillation on coumadin
- Hypertension
- Hyperlipidemia
- Diabetes Mellitus Type II, dx ~[**2092**]
- Congestive Heart Failure
- Diabetic retinopathy
- Peripheral Neuropathy
- s/p Bilateral Cataract Surgery
- Glaucoma
- s/p Ventriculoperitoneal shunt placed [**2094**] for hydrocephalus
- h/o GIB [**2-21**] duodenal polyps
- CABG (?) on [**Hospital1 2025**] d/c note but family does not confirm
Social History:
Retired, Never smoked, Rare EtOH, No illicits. Lives with
daughter in [**Name (NI) 14663**]. Retired, worked in fish packing
industry.
Family History:
Per Medical Records mother CHF, father pancreatic disease.
Physical Exam:
ADMISSION PE:
PE: 130/ 48, 100, 87, TV 500, RR 14, PEEP 5, FiO2 100%
General:intubated, sedated
HEENT: anicteric sclera, red blood in NG tube, but no ongoing
output from NG while on suction
Neck: supple
Heart: RRR
Lungs: clear
Abdomen: +BS, soft, ND, limited exam, no mass was noted
EXT: no edema, no rash
per ED, brown guaiac negative stool, no BMs in the ED
.
.
DISCHARGE PE:
Tmax: 38.3 ??????C (101 ??????F)
Tcurrent: 36.5 ??????C (97.7 ??????F)
HR: 86 (72 - 100) bpm
BP: 124/59(74) {103/37(55) - 148/65(90)} mmHg
RR: 20 (20 - 33) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 76.8 kg (admission): 73.6 kg
Height: 64 Inch
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 400 (400 - 400) mL
Vt (Spontaneous): 281 (244 - 339) mL
PS : 10 cmH2O
RR (Set): 14
RR (Spontaneous): 27
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 98
PIP: 15 cmH2O
SpO2: 100%
.
General Appearance: Intubated, NAD
Eyes / Conjunctiva: Pupils Left 1mm, Right 2mm, non-reactive,
staccotic eye movements. No tracking
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, s/p
tracheostomy with mild oozing from site, RIJ in place without
erythema.
Cardiovascular: reg rate S1 nl S2 II/VI holosystolic murmur at
apex
Peripheral Vascular: DP/PT pulses palpable bilaterally
Respiratory / Chest: vented breath sounds, no crackles or
wheezes appreciated
Abdominal: Bowel sounds present but very hypoactive, non-tender,
moderately distended, Gtube & J tube in place with dressings
intact some serosanguinous exudate.
Extremities: Upper extremity non-pitting edema L>R. LUE with
marked edema. Right PICC line in place without erythema. LE with
non pitting edema bilat. Palpable DP bilat.
Skin: Warm, No Rash
Neurologic: Unresponsive off sedation. Upgoing toes bilaterally.
No purposeful response to deep nail-bed pressure in upper or
lower extremities. Decerebrate posturing. No-purposeful
movements
Pertinent Results:
Admission labs:
[**2124-5-11**] 04:30AM BLOOD WBC-17.6* RBC-3.31* Hgb-8.9* Hct-27.6*
MCV-83 MCH-26.9* MCHC-32.3 RDW-14.1 Plt Ct-331
[**2124-5-11**] 04:30AM BLOOD Neuts-89.6* Lymphs-7.1* Monos-3.2 Eos-0.1
Baso-0.1
[**2124-5-11**] 04:30AM BLOOD PT-17.2* PTT-34.9 INR(PT)-1.6*
[**2124-5-11**] 04:30AM BLOOD Glucose-104 UreaN-19 Creat-0.9 Na-139
K-4.4 Cl-97 HCO3-32 AnGap-14
[**2124-5-11**] 04:30AM BLOOD ALT-29 AST-49* CK(CPK)-127 AlkPhos-70
TotBili-0.6
[**2124-5-11**] 10:46AM BLOOD CK(CPK)-200*
[**2124-5-13**] 04:56AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2124-5-11**] 10:46AM BLOOD CK-MB-7 cTropnT-0.21*
[**2124-5-11**] 04:30AM BLOOD cTropnT-0.26*
[**2124-5-11**] 10:46AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8
[**2124-5-11**] 06:56AM BLOOD Type-ART pO2-350* pCO2-34* pH-7.56*
calTCO2-31* Base XS-8 Intubat-INTUBATED
[**2124-5-11**] 04:40AM BLOOD Glucose-100 Lactate-3.0* Na-138 K-4.2
Cl-90* calHCO3-36*
[**2124-5-11**] 04:40AM BLOOD Hgb-9.6* calcHCT-29
[**2124-5-11**] 04:40AM BLOOD freeCa-1.04*
.
NON-CONTRAST HEAD CT ([**5-11**]): A ventriculoperitoneal shunt enters
via the right frontal approach and crosses the midline
terminating in the occipital [**Doctor Last Name 534**] of the left lateral ventricle.
The ventricles are barely visible suggesting over-shunting.
There is no hydrocephalus. Hypoattenuation along the catheter
tract in the right frontal lobe may be due to prior infarct or
catheter related edema. The frontal horns of the lateral
ventricle are difficult to appreciate and likely effaced. The
basal cisterns are preserved. There is extensive atherosclerotic
calcification within the vertebral arteries and carotid siphons.
No loss of [**Doctor Last Name 352**]-white matter differentiation to suggest an acute
infarct. The visualized paranasal sinuses are clear. There is
fluid within the mastoid air cells bilaterally. The calvarium is
intact and soft tissues are normal. IMPRESSION:
Ventriculoperitoneal shunt in place terminating in the occipital
[**Doctor Last Name 534**] of the left lateral ventricle. No acute intracranial
hemorrhage. Small ventricles.
.
EEG ([**5-12**]): ROUTINE SAMPLING: Showed a slow and disorganized
pattern in the theta and delta range for the beginning of this
recording with no clear lateralized features and with bursts of
sharp waves in a generalized
distribution with bifrontal predominance and sometimes also more
focal
sharp waves in the right frontal area. Beginning at 18:00 hours,
the
background activity became very low voltage with a burst
suppression
pattern of activity with bursts of low voltage delta activity
lasting
for about one second alternating with bursts of relative
suppression of
the background for about one second. At 21:00 hours, the
background
activity started again to be a higher voltage and with more
prevalent
sharp waves although still presented a burst suppression type of
pattern. This time, there were clear sharp and slow wave
complexes seen
in the right frontal area. At 23:23, the background activity
again
became more suppressed, this time with periods of suppression of
up to
four seconds. At 00:13, the background activity again became a
higher
voltage only to alternate after about 30 minutes with a more
suppressed
pattern and to change again after about one hour to the higher
voltage
sharper activity pattern which lasted after the morning.
SLEEP: There were no normal sleep patterns seen in this
recording.
CARDIAC MONITOR: Showed a generally regular rhythm.with
occasional
PVCs. SPIKE DETECTION PROGRAMS: Showed the above-mentioned
bursts of sharp
waves in the right frontal region as well as in the left frontal
region
and more widely distributed over both hemispheres with bifrontal
predominance.
SEIZURE DETECTION PROGRAMS: There were two entries in this file
for
more rhythmic background activity which was not correlated with
any
change in the patient's behavior and did not show a clear
seizure-like
build-up of activity.
PUSHBUTTON ACTIVATIONS: There were three. The first one was at
17:32:06 for twitching of the eyelids followed by administration
of
Ativan. During this event, the background activity was
relatively of
high voltage with sharp waves seen most prominently in the right
frontal
area reaching a frequency of 2 Hz for some of the time; however,
there
was no clear build-up of activity seen during this event. After
the
administration of Ativan, the background activity became slower
and with
much fewer sharp waves. The second pushbutton activation was at
17:34:46 to note for Dilantin load. The third pushbutton
activation was at 03:10:19, again for intermittent twitching of
the eyelids and, again, there was more rhythmic and sharper
activity seen during this event bifrontally more prominent on
the right. However, there was no clear build-up of seizure
activity during this event.
IMPRESSION: This telemetry captured three pushbutton activations
for
two episodes of eyelid twitching correlated with somewhat
rhythmic
sharper activity seen bifrontally, more on the right, with no
clear
build-up of ictal activity. The background activity was slow and
showed, for the most part, a burst suppression pattern
suggestive of
encephalopathy. However, it also showed independent right more
than
left frontal sharp waves and sometimes more generalized
sharp waves with bifrontal predominance.
.
ECHO TTE ([**5-12**]): The left atrium is normal in size. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to some
dyssynchrony as well as hypokinesis of the basal septum. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trivial mitral regurgitation is
seen. The degree of mitral regurgitation seen is normal for this
prosthesis. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. The
main pulmonary artery is dilated. The branch pulmonary arteries
are dilated. There is a trivial/physiologic pericardial
effusion.
.
ECHO TEE ([**5-18**]):
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The motion of the
mitral valve prosthetic leaflets appears normal. The transmitral
gradient is normal for this prosthesis. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The degree of mitral regurgitation seen is normal for this
prosthesis. There is mild pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. The gastroesophageal junction
was not traversed due to gastric ulcer and clot visualized on
EGD prior to TEE.
IMPRESSION: No evidence of endocarditis. Normally-functioning
mechanical bileaflet mitral valve prosthesis. Mild aortic
regurgitation. Transgastric views not obtained given ongoing GI
bleeding.
.
MRI Head ([**5-14**]): Right transfrontal ventriculostomy catheter is
again demonstrated with tip crossing midline to terminate in the
left lateral ventricle, better demonstrated on prior CT. The
ventricles are slit-like in configuration suggesting
"overshunting." Bilateral small extra-axial proteinaceous
collections, likely representing subdural effusions also support
this hypothesis. Central cerebral atrophy is present along with
diffuse cortical atrophy with an "etat crible" appearance of ex
vacuo dilatation of Virchow-[**Doctor First Name **] spaces, centrally. Moderate
confluent periventricular white matter high-signal intensity on
FLAIR imaging is most consistent with moderate chronic
microvascular infarction. Deep white matter and subcortical
white matter high signal intensity surrounding the
ventriculostomy tract on FLAIR sequence may represent a
component of chronic white matter changes relating to catheter
placement. Significant artifact is identified on susceptibility
weighted imaging secondary to shunt catheter. However, no
evidence of blooming to suggest associated hemorrhage is
detected. No focus of restricted diffusion is present to suggest
acute ischemia.
IMPRESSION: 1. No evidence of acute intracranial hemorrhage or
ischemia.
2. No specific finding to suggest anoxic/hypoxic brain injury.
3. Slit-like ventricles and thin bilateral extra- axial
collections, likely
subdural effusions, raise the possibility of "overshunting" in
this setting. Comparison to reported outside ([**Hospital1 2025**]) studies, when
available, would help in assessing interval change. 4.
Moderately severe age-related cerebral atrophy and chronic
microvascular infarction.
.
EEG ([**5-15**]): ROUTINE SAMPLING: Showed a slow and disorganized
background in the delta and theta range most of the time
alternating with bursts of
rapid suppression of the background lasting for one to three
seconds.
Between 9 p.m. and 30 minutes after midnight, the background
activity
looked much more suppressed as well as between 2 a.m. and later
in the
morning.
SLEEP: There were no normal sleep patterns seen in this
recording.
CARDIAC MONITOR: Showed a generally regular rhythm with frequent
premature beats.
SPIKE DETECTION PROGRAMS: Showed no clear epileptiform activity.
SEIZURE DETECTION PROGRAMS: There were 14 entries in this file
for
muscle, movement, and electrode artifacts. There was no
epileptiform
activity seen.
PUSHBUTTON ACTIVATIONS: There were three. It was unclear what
prompted
the activations, but there was no change seen from the
background
activity.
IMPRESSION: This telemetry captured three pushbutton activations
for
unclear events with no change in the background activity. There
was no
ictal activity seen in this recording. Interictally, there were
infrequent sharp waves seen in the right parasagittal area. The
background activity had a burst suppression pattern for most of
the
recording, suggestive of a widespread moderate to severe
encephalopathy,
and focal slowing was seen in the right parasagittal area.
.
Portable CXR ([**5-16**]): PFI: New large left-sided pneumothorax and
collapse of the left lung.
.
LENI (LUE) ([**5-17**]): The right subclavian demonstrates normal
flow and waveforms. The left internal jugular, subclavian,
axillary, as well as one of the two brachial veins and the
proximal left cephalic and basilic veins demonstrate occlusive
thrombus with no evidence of flow. Flow is seen in the distal
basilic and cephalic veins as well as one brachial vein.
IMPRESSION: Extensive deep vein thrombosis involving the left
upper extremity as above.
.
CT TORSO [**2124-5-19**]:
IMPRESSION:
1. Persistent small left pneumothorax.
2. Right common iliac, external iliac and common femoral vein
thrombosis.
3. Right greater than left moderate-sized pleural effusion.
4. Probable hemangioma in the liver.
5. Ventriculoperitoneal shunt, in the expected location.
6. Coronary artery calcification and mitral valve replacement.
.
Portable CXR: ([**2124-5-26**])FINDINGS: In comparison with the study of
[**5-25**], the endotracheal tube has been removed and tracheostomy
tube is in place. No evidence of pneumothorax or
pneumomediastinum. The other monitoring and support devices
remain in place. Persistent enlargement of the cardiac
silhouette with bilateral pleural effusions and elevation of
pulmonary venous pressure.
.
.
DISCHARGE LABS: [**2124-5-26**]
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2124-5-26**] 04:39AM 15.2* 3.18* 9.3* 28.5* 89 29.3 32.8
16.6* 550*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2124-5-26**] 04:39AM 124* 23* 0.6 141 4.1 106 29
10
CHEMISTRY Calcium Phos Mg
[**2124-5-26**] 04:39AM 8.1* 4.3 1.8
ENZYMES & BILIRUBIN ALT AST AlkPhos TotBili
[**2124-5-24**] 04:08AM 64* 66* 207* 0.3
MICRO DATA: PENDING:
[**2124-5-25**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2124-5-25**] URINE URINE CULTURE-PENDING INPATIENT
[**2124-5-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2124-5-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2124-5-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2124-5-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2124-5-23**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2124-5-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2124-5-22**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2124-5-21**] URINE URINE CULTURE-FINAL {YEAST}; VIRAL
CULTURE-PRELIMINARY INPATIENT
[**2124-5-20**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT
[**2124-5-20**] URINE ACID FAST CULTURE-PENDING INPATIENT
[**2124-5-18**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2124-5-18**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
Brief Hospital Course:
81F with PMH of DM, HOCM, CHF, Afib and recent intraventricular
hemorrhage found unresponsive at nursing home went into PEA for
which received atropine and multiple dose of epi. She was
transferred intubated and unresponsive for further management.
.
# Altered mental status/unresponsiveness - Pt had recent
intraventricular hemorrhage in the setting of anticoagulation
for which she had been admitted to [**Hospital1 2025**] and now was at a nursing
home/rehab. Pt's daughter reports that she is mentally clear,
without dementia at baseline and was in her usual state of
mental wellness one hour prior to becoming unresponsive on day
of admission. She was found to be profoundly hypoglycemic at
time of presentation which could explain both her altered level
of consciousness and PEA arrest. A head CT was done that showed
no evidence of intracranial hemorrhage or ischemia. Neurology
was consulted and performed an EEG that showed burst suppression
pattern suggestive of encephalopathy but also showed independent
right more than left frontal sharp waves and sometimes more
generalized
sharp waves with bifrontal predominance. She was therefore
started on phenytoin for possible seizure activity. Over the
next several days, patient had no improvement in neurological
functional status with complete abscence of purposeful movements
and no withdrawal to pain. Concern was for hypoxic injury given
prior PEA arrest therefore MRI was done which showed no evidence
of ischemia. MRI did show slit-like ventricles and findings
suggestive of chronic over-shunting therefore Neurosurgery was
consulted however did not feel that intervention was warranted.
Patient had no evidence of neurological recovery during 10 day
hospital course with no purposeful movements and fixed pupils
and neurology felt that this represented irreversible neurologic
damage. There were multiple family discussions addressing goals
of care and [**Hospital 228**] health care proxy decided to proceed with
PEG tube placement and tracheostomy. The patient received a
tracheostomy, G-tube and J-tube on [**2124-5-25**].
.
# Respiratory failure: Intubated for airway protection in the
setting of unresponsiveness. She was continued on mechanical
ventilation. She failed spontaneous breathing trial on [**5-23**]
secondary to episodes of apnea and a tracheostomy was placed on
[**2124-5-25**]. Her ventilator settings are as follows: Pressure
support PSV: 15, PEEP: 5, FiO2: 40%, pulling Vt: 250-330,
breathing at a rate of 20 (19-27), O2sat: 100%. Please wean
ventilator as tolerated.
.
# Pneumothorax: On hospital day #5, a portable chest X-ray was
performed to evaluate for pulmonary infiltrate due to low grade
temperature and rising leukocytosis. No infiltrate was
identified however a large left sided pneumothorax was
identified. A left-sided subclavian line had been placed 5 days
previously; subsequent films had been negative for pneumothorax.
Thoracic surgery was consulted and placed a left-sided pigtail
catheter with interval re-expansiopn of lung. Pneumothorax
stabilized radiographically and pigtail catheter was removed on
[**5-23**] with stable chest X-rays after removal.
.
# s/p Cardiac arrest: Trop leak and worsening ST depressions on
EKG at OSH prior to arrival. Peak troponin 0.7, this was felt to
be demand ischemia. Initially, she was not given heparin or ASA
given GI bleed; however, both have subsequently been started.
In addition, she is on metoprolol.
.
# UGIB: NGT placed at OSH was draining BRB with hct drop 36-->
27. She underwent endoscopy upon arrival with identification of
large adherent clot in the fundus below the GE junction. The
clot was not removed given that no active bleeding was
identified. Had melena subsequent to procedure, but no epsiodes
of hematemesis and hematocrit remained stable. A repeat
endoscopy on [**5-18**] showed residual clot that had organized. On
[**5-24**] she underwent repeat EGD which showed NO residual clot. The
gastroenterologists recommend that she be continued on a PPI [**Hospital1 **]
for the next month until follow up with GI.
.
# s/p MVR (MECHANICAL VALVE): Had previously beeen
anti-coagulated for what had been documented as a porcine valve;
however, on arrival INR was subtherapeutic s/p FFP and vitamin K
at OSH for acute UGIB. Anti-coagulation was not reinitiated
initially given that she had acute GI bleed and anti-coagulation
would not be indicated for porcine valve. However, she
subsequently underwent trans-esophageal echocardiography which
revealed that the patient actually has a MECHANICAL mitral valve
therefore anti-coagulation was restarted. Her anticoagulation
was held on [**2124-5-25**] for her Tracheostomy and PEG and restarted on
[**2124-5-26**]. She will need to be transitioned to coumadin, which
should be started on [**2124-5-27**]. Her INR goal will be 2.5-3.5 given
her mechanical valve. Anticoagulation should be continued
indefinately.
.
# LUE and Iliac DVT: The patient was noted to have LUE swelling
on exam and subsequent LENI revealed a LUE DVT. She was
incidentally noted to have a iliac DVT on abdominal CT scan.
The patient has been anticoagulated for this as well as for her
mechanical valve.
.
# Bacteremia/Endocarditis/Low grade fevers: The patient has
been spiking intermittent fevers throughout this admission; last
fever on [**2124-5-26**] to 101 degrees. She was initially found to have
MRSA bacteremia at OSH on [**2124-5-11**]. She has been pan-cultured
mulitple times during this admission and never had positive
blood, sputum, stool or urine cultures at [**Hospital1 18**]. (Her urine
cultures have only grown yeast.) Given her clot burden and
mechanical valve, it was thought that the endovascular infection
is the most likely cause of her recurrent fevers. CT abdomen
was negative for other occult source of infection. Vancomycin
was intiated on [**2124-5-11**] and given her mechanical valve should be
continued until [**2124-6-22**] to complete a 6 week course. She will
need weekly labs while on vancomycin including: CBC, chem 10,
LFTs, and Vancomycin level.
.
# Diabetes Mellitus, Type II: The patient is on a insulin
sliding scale with long acting insulin and her fingersticks have
been well controlled, ranging 100-176 in the past 24hrs. Her
blood sugar will need to be monitored more closely as tube feeds
are intiated and her insulin regimen should be adjusted PRN.
.
# Hypothyroidism: Elevated TSH of 8 with slightly low free T 4
(0.9). Started on thryoid replacement on [**5-17**]. Her TSH and free
T4 should be rechecked at the end of [**Month (only) 116**].
.
# FEN: The patient's was started on TF (nutren pulmonary) on
[**2124-5-26**] at 10ml/hr advancing to a goal fo 43ml/hr. She is
hypervolemic because of all of the fluids she has been given
during this hospitalization. Tube feeds should be given through
the J-tube and medications should be given through the G-tube.
NO MEDICATIONS IN THE J-TUBE. She is quite volume overloaded on
exam given that all her medications and fluids have been IV over
the past 2 weeks. We have been diuresing her with a goal of -1L
day with lasix boluses PRN. She will likely benefit from
continued diuresis.
Medications on Admission:
Evista 60mg daily
Zocor 40mg daily
Timolol Maleate 1 gtt each eye [**Hospital1 **]
Coumadin 1mg daily
Latanoprost 1 gtt each eye daily
ASA 81mg daily
Lasix 80mg daily
Lisinopril 2.5mg daily
Toprol XL 50mg daily
Prilosec 20mg daily
KCl 20mg daily
NPH 24units qam/ 10units qpm
SSI
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Timolol Maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
4. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Twenty Six (26)
Subcutaneous once a day.
5. Insulin Aspart 100 unit/mL Solution [**Hospital1 **]: asdir Subcutaneous
every six (6) hours: please see attached sliding scale. .
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day): per G-tube.
7. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2
times a day): per G-tube.
8. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): per G-tube.
9. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Last Name (STitle) **]: Five Hundred (500) units Intravenous continuous:
as directed according to sliding scale. started at 2pm on
[**2124-5-26**].
10. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day): per G-tube.
11. Heparin Flush (10 units/ml) [**1-24**] mL IV PRN flush
12. Vancomycin 500 mg IV Q 12H
day 1 [**5-11**]
13. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Month/Year (2) **]: Twenty Five
(25) mcg Injection Q2H (every 2 hours) as needed for pain.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
15. Phenytoin 100 mg IV QAM Duration: 3 Days
Dose to be given at 0800. Last dose on [**5-28**]
16. Phenytoin 100 mg IV QPM Duration: 5 Days
Dose to be given at 1600. Last dose on [**5-29**]
17. Phenytoin 130 mg IV 0000AM Duration: 7 Days
Last dose on [**5-31**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
PEA Arrest
Upper GI bleed
Encephalopathy
Hypoglycemia
Pneumothorax
Respiratory failure
Secondary diagnoses:
-Bladder Cancer dx [**2123-11-4**] awaiting surgery postponed for
numerous cardiac complications
- Mitral Valve Replacment (St. Jude valve) with Dr. [**Last Name (STitle) 82257**] at
[**Hospital1 2025**] [**2124-2-21**]
- Intraventricular Hemmorhage on [**4-19**] while being bridged with
lovenox for bladder surgery, per report, intraventricular
hemorrhage in the posterior aspect of right lateral ventricle,
at [**Hospital1 2025**], hemorrhage within both lateral ventricles
- Hypertrophic Obstructive Cardiomyopathy
- Atrial Fibrillation on coumadin
- Hypertension
- Hyperlipidemia
- Diabetes Mellitus Type II, dx ~[**2092**]
- Congestive Heart Failure
- Diabetic retinopathy
- Peripheral Neuropathy
- s/p Bilateral Cataract Surgery
- Glaucoma
- s/p Ventriculoperitoneal shunt placed [**2094**] for hydrocephalus
- h/o GIB [**2-21**] duodenal polyps
Discharge Condition:
Very poor prognosis. Medically stable but limited chance of
neurological recovery
Discharge Instructions:
Patient was transferred to the hospital after being found
unresponsive at her nursing home. She was found to have a very
low blood sugar and bleeding from her stomach. She had a cardiac
arrest (PEA arrest) and required palcement of a bretahing tube
to help her breathe. She was then transferred to [**Hospital1 18**]. She
underwent endoscopy which she bleeding in the stomach which
later stabilized. After several days, she had still not started
to recover her mental function. She had extensive evaluation by
neurology and has a very poor prognosis for neurologic recovery.
Her hospitalization was complicated by MRSA bacteremia and LUE
and iliac clot.
Followup Instructions:
Please folllow up with Gastroenterology. Please call Dr. [**Last Name (STitle) **]
[**Name (STitle) 82258**] office at [**Numeric Identifier 82259**] to arrange for a follow up
appointment in 1 month.
Completed by:[**2124-5-26**]
|
[
"272.4",
"357.2",
"V58.67",
"244.9",
"518.81",
"401.9",
"427.5",
"V12.54",
"280.0",
"425.4",
"188.9",
"117.9",
"250.50",
"747.61",
"453.8",
"041.19",
"V43.3",
"458.29",
"453.41",
"V58.61",
"E932.3",
"790.7",
"E944.4",
"250.60",
"348.1",
"276.0",
"996.74",
"362.01",
"531.90",
"427.31",
"250.30",
"E879.8",
"578.0",
"428.0",
"211.2",
"411.89",
"512.1",
"V45.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.72",
"38.93",
"46.39",
"43.19",
"88.72",
"34.09",
"31.1",
"45.13",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
28328, 28428
|
18890, 26082
|
333, 532
|
29434, 29518
|
5196, 5196
|
30222, 30455
|
3197, 3257
|
26411, 28305
|
28449, 28537
|
26108, 26388
|
29542, 30199
|
17301, 18867
|
3272, 3636
|
28558, 29413
|
3650, 5177
|
231, 295
|
560, 2077
|
5212, 17285
|
2099, 3027
|
3043, 3181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,298
| 129,661
|
31224
|
Discharge summary
|
report
|
Admission Date: [**2179-11-16**] Discharge Date: [**2179-11-30**]
Date of Birth: [**2101-1-7**] Sex: F
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Shortness of breath, RLL pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo F w/ HTN, tachyarrthythmia, TBI s/p MVC s/p g-tube and
trach for severe tracheomalacia p/w SOB. She was at a rehab and
was diagnosed with RLL PNA and was started on levo and azithro 2
days PTA. Today she was noted to be more SOB and hence sent to
the ED.
Past Medical History:
Tracheostomy s/p subglottis stenosis
Severe Trachbroncheomalacia
Fibrotic Bar Connecting Vocal Cords at posterior aspect
J-Tube
Tachycardia
Hypertension
MVR s/p subdural hematoma [**2179-6-9**]
Social History:
Lived with her husband until recent [**Name (NI) 8751**]. Now resides at
[**Hospital 38**] Rehab
Family History:
Non-Contributory
Physical Exam:
VS: 98.6 110/87 94 24 97% on 35% trach mask
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules. Trach in
place
RESP: b/l wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly. G-tube
in place
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx0. moving all 4 extremities.
Pertinent Results:
[**2179-11-16**] 08:20PM GLUCOSE-86 UREA N-17 CREAT-0.4 SODIUM-133
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-11
[**2179-11-16**] 08:20PM CALCIUM-7.3* PHOSPHATE-2.7 MAGNESIUM-1.6
[**2179-11-16**] 03:33PM LACTATE-1.0
.
[**2179-11-16**] 08:20PM CK(CPK)-37
[**2179-11-16**] 08:20PM CK-MB-3 cTropnT-0.02*
.
[**2179-11-16**] 03:15PM DIGOXIN-0.8*
[**2179-11-16**] 03:15PM VALPROATE-34*
.
[**2179-11-16**] 03:15PM WBC-6.3 RBC-3.03* HGB-9.7* HCT-28.1* MCV-93
MCH-31.9 MCHC-34.4 RDW-15.6*
[**2179-11-16**] 03:15PM NEUTS-80.3* LYMPHS-11.2* MONOS-8.2 EOS-0.2
BASOS-0.2
[**2179-11-16**] 03:15PM PLT SMR-LOW PLT COUNT-95*
.
[**2179-11-16**] 03:15PM PT-19.4* PTT-33.5 INR(PT)-1.8*
Brief Hospital Course:
78 yo F w/ tachyarrthythmia, HTN, TBI s/p MVC s/p g-tube and
trach for severe tracheomalacia; came to [**Hospital1 18**] w/SOB after being
diagnosed at her rehab with RLL PNA and started on levo and
azithro 2 days PTA.
.
# Pneumonia: We initially switched the patient to levofloxacin
and clinda, the latter being to cover aspiration organisms.
Sputum cultures showed sparse pseudomonas, and fevers continued
despite levo/azithro; trach puts patient at risk for pseudomonas
pneumonia; therefore, we started ceftazadime. Further, we
decided to cover for MRSA given [**Hospital 73683**] healthcare facility
stay, and then coag+ Staph aureus on sputum (again, sparse). The
coag+ Staph aureus eventually showed sensitivity to multiple
antibiotics, so we switched from vancomycin to bactrim. She had
some low-grade spikes on [**11-20**], for which we started her on flagyl
(for possible c. diff), but by [**11-21**] we had a negative C. diff
from [**11-19**] and no other indications, so we discontinued flagyl.
She defervesced during completion of a 14 day course of Abx.
including Bactrim, Ceftazadime, and Ciprofloxacin. At the time
of discharge, surveillance cx. neg., resp status stable, and o2
sats stable, afebrile. All abx. were discontinued on [**11-30**] as 14
of therapy completed.
.
# Wheezing: The patient has no chart diagnosis of COPD, but was
often wheezy and benefitted from regular q4 nebs.
.
#Tachyarrhythmia: The patient came with a chart diagnosis of
"tachyarrythmia" and had a number of runs of what we ultimately
diagnosed (with EP consult confirmation) as AVNRT. We continued
home digoxin and metoprolol but increased dig dose (levels were
low at beginning of admission) and metoprolol dose with control
of this rhythm.
.
#Agitation: Patient's mental status is not entirely clear; she
is sometimes interactive and responsive, but not consistently
so. We are currently using soft restraints for tube-pulling and
risky positional changes in bed.
.
#Depression: continued citalopram
.
#DM: continued SS insulin initially, this ultimately
discontinued given good glycemic control without insulin.
.
#HTN: continued metoprolol, BP stable.
.
#Seizure ppx: continued valproic acid for seizure prophylaxis.
.
#FEN: tube feeds continued as per nutrition recommendations.
.
Medications on Admission:
levoflox
azithro
digoxin
valproic acid
levalbuterol
mvi
bowel regimen
cholestyramine
citalopram
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
2. Amantadine 50 mg/5 mL Syrup Sig: Five (5) mL PO DAILY
(Daily).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO QPM (once a day (in the evening)).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO qAM ().
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Two (2) puffs Inhalation every four (4) hours.
10. Divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO QAM (once a day (in the morning)).
11. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO
Q6H (every 6 hours) as needed for fever.
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): alternate with 250 microgram dose.
Tablet(s)
13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): alternate with 125 microgram dose.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
15. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day): to minimize drug interaction, admin other
meds 1 hr before or 4hr after each dose .
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q 8H
(Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Health Care Associated Pneumonia, MSSA and Pseudomonas
AVNRT
Tracheostomy and PEG tube s/p TBI
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. Return to the [**Hospital1 18**]
Emergency Department for:
Fevers
Shortness of breath
Followup Instructions:
Call your primary doctor for a follow up appointment for within
one month of leaving the hospital: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 73684**]
|
[
"401.9",
"V58.61",
"307.9",
"285.9",
"285.29",
"311",
"V44.0",
"V09.0",
"E879.6",
"780.39",
"996.31",
"519.19",
"482.41",
"786.07",
"287.5",
"V44.1",
"250.00",
"482.1",
"518.81",
"244.9",
"782.1",
"787.91",
"458.29",
"427.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6296, 6377
|
2207, 4493
|
302, 308
|
6516, 6525
|
1487, 2184
|
6697, 6900
|
946, 964
|
4640, 6273
|
6398, 6495
|
4519, 4617
|
6549, 6674
|
979, 1468
|
228, 264
|
336, 598
|
620, 815
|
831, 930
|
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