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Discharge summary
|
report
|
Admission Date: [**2184-6-30**] Discharge Date: [**2184-9-7**]
Date of Birth: [**2106-4-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Nsaids /
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Common bile duct transection
Major Surgical or Invasive Procedure:
Roux en Y hepaticojejunostomy ([**7-9**])
aortic valvuloplasty on ([**7-27**])
open tracheostomy with j tube and G tube ([**8-2**])
History of Present Illness:
Mrs. [**Known lastname 22782**] is a 78 woman s/p lap CCY on [**2184-6-4**] for gangrenous
cholecystitis, complicated by CBD transection. She was
discharged from [**Hospital1 18**] on [**2184-6-21**] after satisfactory placement of
a 6.3 French biliary drain through her right biliary system
through the transected proximal CBD and into the subhepatic
space. She was discharged with her PTC open and on ciprofloxacin
and micafungin to [**Hospital1 1562**] Care and Rehabilitation Center. The
plan was to let the inflammation around her gallbladder fossa
and transected CBDsubside and then proceed with surgery to
re-establish biliary continuity (likely a RnY
hepaticojejunostomy).
On [**2184-6-28**] blood cultures obtained as part of a fever workup
returned positive for Gram positive cocci in clusters. The
patient was started on vancomycin 500mg Q12hrs. She presented to
clinic today with Dr. [**Last Name (STitle) **] and admitted for further treatment
of her bacteremia.
At admission, Mrs. [**Known lastname 22782**] reported that she felt tired. She
complained of right shoulder pain and non-focal abdominal
tenderness. She had some back pain which seemed to be an old
issue for her. Her last fever of 100.9 was onenight ago per the
patient. She denied fevers, chills, nausea, vomiting, diarrhea,
anorexia, or abdominal distention.
Past Medical History:
HTN
- DMII
- GERD
- multiple sclerosis since age 29
- rheumatic heart disease w/ aortic stenosis (moderate aortic
stenosis & diastolic dysfunction noted on echo [**2183-11-3**]) with an
aortic valve area of 0.8cm2
- arthritis of the cervical and lumbar spine
Social History:
Retired homemaker/housewife, lives at home with husband, no
children. Smoked briefly when she was in her 20s. Denies alcohol
or recreation/illicit drug use.
Family History:
Strong family history of DM, CAD and HTN
Physical Exam:
Vitals:T max: 99.7,T curr=97,HR=83,BP= 132/54,RR=17,Sat=100%,CMV
Fio2 .40,TV=340,RR=12,PSV=15,PEEP=10
Gen:Alert,responds to voice
HEENT:PERRL,Extrenal occular muscles intact.
Neck:tracheostomy tube in place
Chest:decreased breath sounds at the lung bases,no crackles or
ronchi
CVS:N s1,s2,No M/R/G
Abdomen:Soft, NT, ND. No HSM. Feeding tube in place. No
abdominal bruits.Wound present on R upper quadrant C/D/I.
Ext:edema present in b/l feet,b/l PT and AT palpable
Pertinent Results:
ECHOCARDIOGRAPHY :[**2184-7-2**]
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild global left
ventricular hypokinesis (LVEF = 45-50 %).The aortic valve
leaflets are moderately thickened.There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.There is
no pericardial effusion.
.
ECHOCARDIOGRAPHY :[**2184-7-10**]
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35-40 % secondary to hypokinesis of the septum, anterior
free wall, and apex. Contractile function of the inferior,
posterior, and lateral walls appears relatively well-preserved).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is
normal. with focal hypokinesis of the apical free wall. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is "critical" aortic valve stenosis
(valve orifice area approximately 0.7 cm2) (may have low
flow/low gradient component). The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2184-7-2**], the left ventricular ejection fraction and
the aortic valve orifice area are further reduced.
.
Chest X ray:[**2184-7-10**]
ET tube tip is in standard position 4.8 cm above the carina. NG
tube tip is in the stomach. Right IJ catheter tip is in the
lower SVC. Cardiac size is top normal. There is no
pneumothorax. Small bilateral pleural effusions are unchanged.
There is no pneumothorax. Mild pulmonary edema is unchanged. New
right upper lobe opacity could be due to asymmetric pulmonary
edema but aspiration is also a possibility .
.
USG: [**2184-7-11**]
No portal vein occlusion. Right pleural effusion
.
Chest X Ray:[**2184-7-14**]:
Mild pulmonary edema in the left lung is unchanged. Greater
opacification in the right perihilar lung could represent
concurrent development of pneumonia. Moderate bilateral pleural
effusion, right greater than left, is stable. Heart size is
normal, but mediastinal veins are more engorged indicating
greater volume overload. ET tube and right internal jugular line
are in standard placements and a nasogastric tube passes into
the stomach and out of view. No pneumothorax.
.
Chest X Ray:[**2184-7-16**]
In comparison with the study of [**7-14**], the monitoring and support
devices remain in place. Continued evidence of elevation of
pulmonary venous pressure with bilateral pleural effusions. It
is difficult to determine whether the opacification in the right
perihilar region reflects elevation of venous pressure or
possibly a supervening focus of pneumonia.
.
Tube Cholangiogram and Dobbhoff placement [**2184-7-19**]:
1. Patent right-sided biliary system without evidence for leak
or stenosis.
2. Successful placement of Dobbhoff feeding tube with
post-pyloric position of tip. The tube is ready for use.
.
ECHOCARDIOGRAPHY :[**2184-7-27**]
There is trace aortic regurgitation. The aortic valve gradient
was not assessed. Left ventricular systolic function is
depressed with apical, mid to distal anteroseptal, anterior and
inferior hypokinesis (although regional wall motion was not
fully assessed). LV systolic function appears similar to that on
the [**2184-7-10**] study.
.
ECHOCARDIOGRAPHY :[**2184-7-29**]
Compared with the prior study (images reviewed) of [**2184-7-10**],
the aortic valve orifice area is minimally increased. Left
ventricular contractile function is significantly improved. The
increment in aortic valve orifice area is most likely explained
by improved left ventricular contractile function (low flow/low
gradient aortic stenosis)
.
CHEST X RAY:[**2184-7-29**]
IMPRESSION: Worsening pulmonary edema with increasing perihilar
opacities and moderate-to-large bilateral pleural effusions.
.
ABDOMINAL FLUORO: [**2184-8-2**]
IMPRESSION: Interval placement of a surgical gastrostomy tube
with the tip
seen along the right lateral margin of the thoracolumbar spine.
.
MR head [**2184-8-6**]
Small layering of old blood in the posterior [**Doctor Last Name 534**] of both
lateral ventricles with findings suggestive of communicating
hydrocephalus. No mass effect or midline shift. MRA brain
demonstrates non-visualization of distal right vertebral artery
which may be due to this artery ending in PICA or due to
occlusion in neck.
.
MRA brain [**2184-8-6**]
The major intracranial vessels are visualized except the right
distal vertebral artery. There is subtle flow signal narrowing
at right MCA bifurcation which may be artifactual or due to mild
atherosclerotic disease. The posterior communicating arteries
and anterior communicating arteries are visualized. No evidence
of aneurysms or vessel occlusions. AICA is not visualized. The
left PICA is visualized. There appears to be a right AICA and
PICA configuration.
.
Chest Xray:[**2184-8-16**]
Moderate pulmonary edema has worsened since [**8-15**],
accompanied by
moderate to large bilateral pleural effusion, increased on the
right, stable on the left. Heart is borderline enlarged, but the
improvement in previous mediastinal vascular engorgement
suggests a decrease in intravascular volume or pressure. Left
internal jugular line tip projects over mid brachiocephalic
vein. Tracheostomy tube in standard placement. No pneumothorax.
Drainage catheter in the left upper abdomen is presumably a
gastrostomy but cannot be evaluated by this view alone. No
pneumothorax.
.
Upper extremity USG:[**2184-8-16**]
No evidence of deep vein thrombosis in the right arm.
.
FLUORO GUID PLCT:[**2184-8-17**]
Uncomplicated ultrasound and fluoroscopically guided double
lumen PICC line placement via the right brachial venous
approach. Final internal
length is 41 cm, with the tip positioned in SVC. The line is
ready to use.
.
ECHOCARDIOGRAPHY :[**2184-8-26**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate global left ventricular hypokinesis (LVEF =
40-45%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets are mildly thickened.
There is severe aortic valve stenosis (valve area 0.8-1.0cm2).
Trace 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 [**2184-7-29**], the
right ventricle is seen reasonably well on the current study and
appears mildly dilated/hypokinetic. The degree of aortic
stenosis and mitral regurgitation are similar. The other
findings are similar.
FLUORO GUID PLCT: [**2184-9-3**]
Uncomplicated ultrasound and fluoroscopically guided 5 French
double-lumen PICC line placement via the left brachial venous
approach. Final internal length is 45 cm, with the tip
positioned in SVC. The line is ready to use.
Chest Xray:[**2184-9-5**]
Tracheostomy tube is in place. A left subclavian PICC line is
present, tip
over distal SVC. There is diffuse hazy opacity throughout both
lungs which likely represents CHF with interstitial and alveolar
edema, as well as
bilateral layering effusions with underlying collapse and/or
consolidation. The cardiomediastinal silhouette is grossly
unchanged. Tubing noted over upper abdomen, not fully evaluated
on this exam.
MICROBIOLOGY:
[**2184-7-10**] BILE:ENTEROCOCCUS SP:VRE,STAPHYLOCOCCUS, COAGULASE
NEGATIVE:MR
[**2184-7-10**] BLOOD CULTURE:ENTEROCOCCUS FAECIUM,Daptomycin sensitive
[**2184-7-24**]:FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**2184-8-26**]:Urine:[**Female First Name (un) **] (TORULOPSIS) GLABRATA
[**2184-9-2**]:PICC line:STAPHYLOCOCCUS, COAGULASE NEGATIVE
Labs:
[**2184-6-30**]:WBC:8.01 HB: 9.0* Hct:28.5* Platelets: 388
[**2184-7-6**]:WBC:10.4 HB: 8.5* Hct:27.4* Platelets: 324
[**2184-7-10**]:WBC:23.1 HB: 9.2* Hct: 29.2*Platelets: 292
[**2184-7-17**]:WBC:12.3 HB: 9.2* Hct: 30.3*Platelets: 171
[**2184-7-25**]:WBC14.3* HB:7.6 Hct: 23.8*Platelets: 266
[**2184-8-2**]:WBC:4.6 HB:9.6* HCT: 31.5*Platelets: 347
[**2184-8-11**]:WBC:8.8 HB:9.9* HCT:31.0*Platelets: 324
[**2184-8-21**]:WBC7.9 HB:10.1* HCT:30.6* Platelets: 182
[**2184-8-29**]:WBC9.4 HB:9.6* HCT:29.8* Platelets: 229
[**2184-9-6**]:WBC8.2 HB: 9.2* HCT:28.4* Platelets: 257
[**2184-6-30**]:Gl:61BUN:19 Cr:1.5* Na:137 K:4.7 Cl:99 Co2:28
[**2184-7-6**]:Gl:127BUN:23*Cr:1.4* Na:137 K: 4.4*Cl: 102*Co2: 26
[**2184-7-10**]:Gl:167BUN:167*Cr:1.3* Na:137 K: 4.4*Cl: 105*Co2: 20
[**2184-7-12**]:Gl:159BUN:24*Cr:3.0* Na:136 K:4.2 Cl:101 Co2:22
[**2184-7-17**]:Gl:215 BUN:85*Cr:1.9*Na: 137 K: 3.9 Cl:98 Co2:27
[**2184-7-25**]:Gl:247 BUN:69*Cr: 1.3*Na: 150*K: 3.6Cl:116*Co2: 23
[**2184-8-2**]:Gl:205 BUN: 30*Cr: 1.2*Na: 143K: 4.0 Cl: 114*Co2: 20*
[**2184-8-11**]:Gl:239 BUN: 32*Cr: 0.7 Na:139 K:4.4 Cl:112* Co2:21*
[**2184-8-21**]:Gl:103 BUN: 56*Cr: 1.3*Na: 150K: 3.9 Cl:113* Co2:26
[**2184-8-29**]:Gl:158 BUN:75*Cr: 1.4* Na:139 K:4.3 Cl:108 Co2:22
[**2184-9-6**]:Gl:158 BUN:75*Cr: 1.4* Na:139 K:4.3 Cl:108 Co2:22
[**2184-6-30**] ALT:128* AST:70* Alk Phos:475* TB:1.1
[**2184-7-6**] ALT:63* AST:132* Alk Phos:772* TB: 1.1
[**2184-7-11**] ALT: 367*AST:1475* Alk Phos:217* TB: 4.2*
[**2184-7-18**] ALT:57* AST:74* Alk Phos:348* TB:6.1*
[**2184-7-27**] ALT: 29 AST:32 Alk Phos:221* TB: 1.8*
[**2184-8-9**] ALT:22 AST:28 193 Alk Phos:395* TB: 2.0*
[**2184-8-24**] ALT:48* AST:36 162 Alk Phos:305* TB: 1.3
[**2184-9-3**] ALT:69* AST:39 Alk Phos:384* TB: 0.8
[**2184-9-5**] ALT:72* AST:42* 197 Alk Phos:431*TB: 0.7
[**2184-7-9**] 16:09 ART pO2251* pCO234* pH7.42 calTCO2 23 Base
XS -1
[**2184-7-15**] 05:25 ART pO2109* pCO250* pH7.24*1 calTCO2 22
Base XS -6
[**2184-7-26**] 03:07 ART pO2115* pCO244 pH7.45 calTCO2 32*Base
XS 6
[**2184-7-30**] 04:09 ART pO2127* pCO241 pH7.37 calTCO2 25 Base
XS-1
[**2184-8-7**] 11:42 ART pO2112* pCO238 pH7.39 calTCO2 24 Base
XS-1
[**2184-8-12**] 03:01 ART pO2144* pCO234* pH7.40 calTCO2 22 Base
XS-2
[**2184-8-16**] 16:32 ART pO2134* pCO234* pH7.36 calTCO2 20*
Base XS-5
[**2184-8-29**] 03:11 ART pO2116* pCO241 pH7.38 calTCO2 25 Base
XS0
[**2184-9-4**] 14:59 ART pO2159* pCO236 pH7.37 calTCO2 22 Base
XS-3
Brief Hospital Course:
The patient was admitted to the [**Hospital1 18**] on the [**2184-6-30**].
Neuro:The patient had an episode of pupillary asymmetry,
reactive bilaterally, and decreased R arm movementon [**8-6**]. The
pupillary asymmetry had resolved spontaneously. She had
intermittent spontaneous limb movements, L>R, fluctuations in
alertness and ability to follow commands. MRI showed evidence
of communicating hydrocephalus without midline shift,
intraventricular fluid collections; LP did not show evidence of
anyacute SAH or infection.As per neurology, it is not possible
todelineate the time course of this patient's hydrocephalus,
which could be chronic or subsequent to resolved SAH or
infection over the course of her multiple hospitalizations. Her
mental status has been stable,she is alert and responds to opens
eyes to voice.
Respiratory:After her operation on [**2184-7-9**],she was briefly
extubated but had to be reintubated because of desaturation.The
patient failed repeated tries of extubation.She underwent open
tracheostomy on [**2184-8-1**]. However she failed to improve even
after her tracheostomy.Her chest Xray over the last 2 months
showed increasing pulmonary edema.She also developed repeated
pleural effusions that were drained thrice during her hospital
stay.Her pleural fluid were negative on culture.On the day of
discharge she was on a regimen with CPAP during the day and CMV
during the night.
CVS: The patient was started on pressors
(phenyleperine,vasopressin and Milrinone) postoperatively for
hypotension which were subsequently weaned off.Her ECHO on
[**2184-7-10**] showed LVEF= 35-40 % secondary to hypokinesis of the
septum, anterior free wall, and apex.She underwent a aortic
valvuloplasty on [**2184-7-27**] for a AS w/ [**First Name8 (NamePattern2) **]
[**Location (un) 109**] of 0.6 cm2 pre valvuoplasty and 0.7 cm2 post
valvuoplasty.Her EF remained low
to 40% on her most recent ECHO on [**2184-8-26**].
GI:The patient underwent a roux-en-Y hepaticojejunostomy
performed [**7-9**].However she went to septic shock post op and was
started on tubefeeds via dobhoff.She underwent a cholangiogram
on [**7-19**] which showed no leak. She underwent a gtube and j tube
placement on [**2184-8-1**] and is being fed on through the J tube
since then.
GU:The patient went into acute renal failure.However over the
course the patient recovered spontanously with IVF resuciataion.
ID:The patient has been on ciproflocacin prophylaxis for her
biliary drain.She was treated with Vancomycin for 5 days after
admission for positive blood cultures.Post op the patient
recieved meropennem for 15 days. The patient also had C diff
infection for which she recieved flagyl for 12 days.The patient
also recieved fluconazole for positive fungal cultures from
urine.The patient also had positive coag. negative staph.
cultures on [**8-1**] from her PICC line and was restarted on
vancomycin.
Hematology: The patient recieved multiple blood transfusions
postoperatively after her gastrojujenostomy.Her Hct has been
largely stable since then.
`
Medications on Admission:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Clotrimazole 1 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 1 days.
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Thirty (30)
units Subcutaneous twice a day.
7. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day: Follow sliding scale.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Continue while drains are in place.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC [**Male First Name (un) **]
care.
11. Morphine 5 mg/mL Solution Sig: One (1) mg Injection Q4H
(every 4 hours) as needed for pain.
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection every eight (8) hours as needed for nausea.
13. Micafungin 100 mg Recon Soln Sig: One Hundred (100) mg
Intravenous Q24H (every 24 hours): via PICC line.
Discharge Medications:
1. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: Five (5)
ML PO QID (4 times a day) as needed for Rbuccal lesion pain:
swish and spit.
Disp:*100 ML(s)* Refills:*2*
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*2 bottles* Refills:*2*
3. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*900 ML(s)* Refills:*2*
4. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth.
Disp:*500 ML(s)* Refills:*0*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
Disp:*2 inhalers* Refills:*0*
6. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed) as needed for hemorrhoids.
Disp:*2 tubes* Refills:*0*
7. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
Disp:*2 bottles* Refills:*0*
8. pantoprazole 40 mg Recon Soln Sig: Forty (40) Recon Soln
Intravenous Q24H (every 24 hours).
Disp:*1200 Recon Soln(s)* Refills:*2*
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) IU
Injection three times a day.
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
11. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig:
sliding scale Subcutaneous four times a day: Please follow
sliding scale.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
CBD transection on ventillator
Discharge Condition:
Mental Status: on Ventillator.
Level of Consciousness:Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of
the warning signs listed below:fever greater than 101,redness
that is spreading,pain not adequately relieved with
medication,drainage from wound,opening of
incision,tachypnoea,wheezing,blood in stool,black stool.
Wound care:Change abdominal wound dressings with wet to dry
dressing twice a day.
Blood sugar:Finger sticks QID
Ventillation settings:The patient is ventillator dependant.Keep
the patient on CPAP during day and CMV during night.
CPAP settings:Mechanical Ventilation: CPAP w/ & w/o PS
Consult Respiratory Therapy
Pressure support level: 18 cm/h2o PEEP: 10 cm/h2o FIO2: 40 %
CMV settings:Mechanical Ventilation: CPAP w/ & w/o PS
Pressure support level: 18 cm/h2o PEEP: 10 cm/h2o FIO2: 40 % AC
40% 350x16+10 @ 2000h
Followup Instructions:
-Follow up appointment in1 weeks time would be set up by [**First Name4 (NamePattern1) 698**]
[**Last Name (NamePattern1) 699**] (Ph:[**Numeric Identifier 87345**],coordinator for Dr [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2184-9-7**]
|
[
"998.59",
"008.45",
"995.91",
"785.52",
"395.0",
"331.3",
"518.5",
"112.5",
"576.8",
"416.8",
"403.90",
"576.3",
"V58.67",
"038.0",
"414.01",
"995.92",
"999.31",
"276.0",
"790.7",
"250.00",
"997.4",
"530.81",
"E879.8",
"E878.2",
"585.9",
"584.5",
"340",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"97.05",
"51.37",
"38.97",
"43.19",
"31.1",
"35.96",
"34.91",
"03.31",
"87.54",
"96.6",
"99.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
20026, 20069
|
13891, 16952
|
389, 523
|
20144, 20144
|
2911, 13868
|
21116, 21483
|
2368, 2410
|
18356, 20003
|
20090, 20123
|
16978, 18333
|
20276, 20579
|
2425, 2892
|
321, 351
|
20590, 21093
|
551, 1893
|
20159, 20252
|
1916, 2177
|
2193, 2352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,595
| 192,242
|
29096
|
Discharge summary
|
report
|
Admission Date: [**2150-12-3**] Discharge Date: [**2150-12-17**]
Date of Birth: [**2088-3-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Morphine / Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest tightness and dyspnea
Major Surgical or Invasive Procedure:
[**2150-12-4**] Cardiac Catheterization
[**2150-12-8**] Redo Sternotomy, Four Vessel Coronary Artery Bypass
Grafting utilizing the left internal mammary artery to diagonal
artery, with vein grafts to left anterior descending, obtuse
marginal, and right coronary artery
History of Present Illness:
Ms. [**Known lastname **] is a 62 yo female with PMH significant for ASD s/p
repair and anxiety. She was transferred from an OSH for cardiac
catheterization. She presented to the OSH day prior to this
admission with a [**3-25**] day history of nausea, vomiting, diarrhea,
and abdominal pain. Also complained of mild chest tightness and
dyspnea. She has been having approximately 10 loose stools/day.
The patient works at an [**Hospital3 **] facility where many of
the tenants have had the same symptoms. She was also found to
have new T wave inversions in V2-V6 with an elevated troponin of
0.58 (nl 0.1-0.5). She was subsequently started on intravenous
Heparin, Aspirin and Plavix. She states that she recently
traveled to [**Location (un) 18317**] and has noticed some swelling of her left
lower leg. At the time of this admission, she denied any chest
pain, SOB, or any other symptoms at this time.
Past Medical History:
Recent NSTEMI, History of Congestive Heart Failure, Prior ASD
repair in [**2127**] via sternotomy, Depression, Anxiety, Hemorrhoids,
Prior Polypectomy, Carpal Tunnel Release
Social History:
Primary caretaker for her [**Age over 90 **] yo mother and 35 [**Name2 (NI) **] daughter.
Smokes [**12-22**] ppd since she was 13 yo. Denies alcohol and IVDA.
Family History:
Father with CAD died at 88
Physical Exam:
Admission Vitals: T 98.5 BP 140/64 AR 92 RR 28 O2 sat 91% RA,
95% on 4L
Gen: Awake, appears nervous and anxious
HEENT: MM dry
Neck: +JVD
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: diffuse crackles posteriorly, 2/3 up from base
Abdomen: soft, NT/ND, +BS
Extremities: [**12-22**]+ edema bilaterally
Pertinent Results:
[**2150-12-3**] 07:55PM BLOOD WBC-7.7 RBC-3.16* Hgb-10.4* Hct-31.4*
MCV-99* MCH-32.9* MCHC-33.1 RDW-18.2* Plt Ct-945*
[**2150-12-3**] 07:55PM BLOOD Neuts-75.4* Lymphs-18.9 Monos-4.7 Eos-0.8
Baso-0.2
[**2150-12-3**] 07:55PM BLOOD PT-15.5* PTT-38.0* INR(PT)-1.4*
[**2150-12-3**] 07:55PM BLOOD Glucose-76 UreaN-7 Creat-0.6 Na-145 K-4.0
Cl-105 HCO3-22 AnGap-22*
[**2150-12-3**] 07:55PM BLOOD cTropnT-0.93*
[**2150-12-4**] 12:30PM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.3 Mg-1.8
Iron-27*
[**2150-12-4**] 04:29PM BLOOD %HbA1c-5.1 [Hgb]-DONE [A1c]-DONE
[**2150-12-5**] 05:27AM BLOOD Triglyc-133 HDL-39 CHOL/HD-3.0 LDLcalc-51
[**2150-12-3**] Chest x-ray: Mild-to-moderate congestive heart failure.
[**2150-12-3**] Chest CTA scan: No pulmonary embolus. Bilateral patchy
areas of ground-glass opacity throughout both lungs with a
smooth intralobular septal thickening and small bilateral
effusions. Findings are most consistent with congestive heart
failure. More dense appearing areas of consolidation are present
in both lower lobes.
[**2150-12-4**] Bilateral LE doppler: No deep vein thrombosis.
[**2150-12-7**] Abdominal Ultrasound: No liver mass or biliary
abnormality. No cholelithiasis. Small bilateral effusions. Heavy
atherosclerotic plaque in aorta. No aneurysm identified.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the cardiology service. Shortly
after admission, she was started on intravenous Nitro and
Integrilin for recurrent angina. She also required a fair amount
of anxiolytics. The following day, she underwent cardiac
catheterization. Left ventriculography was not performed.
Coronary angiography revealed a right dominant system. The left
anterior descending was totally occluded after the first
diagonal, the first diagonal had a 90% ostial stenosis, the
circumflex had a proximal 50% lesion, OM2 had a 90% stenosis,
and the RCA had a 60% lesion. Based on the above results,
cardiac surgery was consulted and further evaluation was
performed. Given her thrombocytosis on admission, the hematology
service was consulted. Her thrombocytosis was most likely a
reactive thrombocytosis from recent infection, which did not
place her at an elevated risk or developing thrombosis or
bleeding. Essential thrombocytosis was less likely. She was also
noted to have a mildly macrocytic anemia. There was no
contraindication to proceed with surgery. She was also noted to
have elevated prothrombin time and alk phos. Vitamin K was given
and abdominal ultrasound was obtained which showed no liver mass
or biliary abnormalities, or cholelithiasis. Cardiac
echocardiogram revealed no aortic regurgitation and only mild
mitral regurgitation. There was severe regional LV systolic
dysfunction consistent with coronary artery disease/myocardial
infarction. Her LVEF was estimated at 25-30%. She otherwise
remained pain free on intravenous therapy and was eventually
cleared for surgery. By that time her platelet count improved
from 988K to 811K.
On [**12-8**], Dr. [**Last Name (STitle) **] performed redo sternotomy, and four
vessel coronary artery bypass grafting. Please see operative
note for surgical details. Following the operation, she was
brought to the CSRU for invasive monitoring. Within 24 hours,
she awoke neurologically intact and was extubated without
incident. She gradually weaned from pressor support and was
intermittently transfused with PRBC and intravenous fluids to
maintain adequate hemodynamics. Amiodarone was initiated for
episodes of atrial fibrillation. She remained mostly in a normal
sinus rhythm. Last episode of atrial fibrillation was on
postoperative day postoperative day three. She was pan cultured
for a leukocytosis, white count peaking just above 30K. All
cultures remained negative and white count slowly improved
through out the remainder of her hospital stay. After several
days of diuresis along with titrating medical therapy, she
gradually started to show clinical improvements. On
postoperative day seven, she transferred to the step-down floor
for further care and recovery. Given history of
anxiety/depression and continued requirement for anxiolytics,
the psychiatry service was consulted adn recommended
continuation of her current regimen. By post-operative day nine,
Ms. [**Known lastname **] was ready for discharge in stable condition to home.
Medications on Admission:
Prozac 40mg PO daily
Neurontin 600mg, 5 tablets PO QHS
Hydrocodone 1-2 tablets PRN
Klonopin 1mg PO PNR
Actonel 35mg PO Qweek
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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Thrombocytosis, Anemia,
Postop Atrial Fibrillation, Postop Leukocytosis, Recent NSTEMI,
History of Congestive Heart Failure, Prior ASD repair in [**2127**]
via sternotomy, Depression, Anxiety, Hemorrhoids, Prior
Polypectomy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-25**] weeks, call for appointment.
Dr. [**Last Name (STitle) **] in [**1-23**] weeks, call for appointment.
See your cardiologist in [**12-22**] weeks, call for an appointment.
Call ([**Telephone/Fax (1) 26917**] to make an appointment next Thursday [**2149-12-24**]
for a wound check and CBC at [**Hospital1 **]/[**Location (un) 47**].
Completed by:[**2150-12-17**]
|
[
"286.9",
"787.91",
"414.01",
"427.31",
"428.31",
"458.29",
"V15.1",
"300.00",
"305.1",
"410.71",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"99.07",
"99.04",
"99.05",
"88.56",
"36.15",
"39.61",
"88.72",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
7882, 7950
|
3580, 6606
|
328, 599
|
8254, 8261
|
2281, 3557
|
8579, 8986
|
1920, 1949
|
6781, 7859
|
7971, 8233
|
6632, 6758
|
8285, 8556
|
1964, 2262
|
261, 290
|
627, 1530
|
1552, 1727
|
1743, 1904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,698
| 102,188
|
28137
|
Discharge summary
|
report
|
Admission Date: [**2160-10-20**] Discharge Date: [**2160-10-22**]
Date of Birth: [**2083-11-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with argon ablation and lung biopsy
History of Present Illness:
This is a 76 y.o. man with a history of COPD, HTN and recurrent
NSCLC presenting with hemoptysis. On the evening prior to
admission, the patient had multiple episodes of hemoptysis with
bloody sputum. The patient went to sleep and awoke at 5AM with
further bloody sputum production. On the way to the ED, the
patient coughed up an estimated [**11-19**] cups of frank blood by
report of the patient's son. In the ED, the patient was noted to
have stable vital signs with a stable hematocrit and
radiographic evidence of progression of his known RUL mass. The
patient was admitted for further management.
.
The patient was initially diagnosed approximately 30 years ago
with non-small cell lung cancer and underwent a Left upper
lobectomy at that time. He was recently admitted in [**Month (only) 359**] with
hemoptysis requiring intubation, found to have a new RUL mass
and underwent bronchoscopy with laser excision found on
pathology to be undifferentiated large cell CA. The [**Hospital 228**]
hospital course was complicated by a PE without DVT's and was
discharged on lovenox. Staging screening revealed locally
advanced disease with Right hilar and mediastinal
lymphadenopathy. PET and CT did reveal other lesions including
renal and splenic masses felt to not be consistent with
metastatic disease. The patient was seen by outpatient Heme/Onc
and CT surgery. Outpatient recommendations from [**Hospital **]
included combined chemo and radiation therapy. Dr. [**Last Name (STitle) 952**] of CT
surgery saw the patient within the past 2-3 weeks. By report of
the patient and his son, Dr. [**Last Name (STitle) 952**] wanted to proceed with
possible surgical resection of the mass. The patient underwent
pre-op evaluation including outpatient stress testing. The
patient was scheduled for outpatient bronchoscopy on Thursday
[**10-24**] for further biopsy and imaging of the lesion.
.
ROS: Denies fevers, chills, nightsweats, nausea, vomiting,
diarrhea, constipation, chest pain.
Past Medical History:
Onc History: NSCLC first diagnosed at age 45 s/p Left upper
lobectomy at age 45 without adjuvant therapy at that time. The
patient presented to an OSH on [**2160-9-5**] with massive hemoptysis
requiring intubation. Bronchospopy revealed obstructive lesion
of the Right mainstem due to a RUL tumor. The patient underwent
tumor excision with rigid bronchoscopy. Pathology revealed
undifferentiated large cell CA. The patient underwent staging
scans. PET scan from [**2160-10-2**] demonstrates an FDG avid right
hilar mass and mediastinal lymphadenopathy, there was an unusual
focus of FDG uptake and soft tissues prominence along the left
posterior psoas of unclear significance. He had a CT of the
chest, abdomen and pelvis on [**2160-9-14**], which demonstrated
pulmonary embolus, mediastinal and right hilar lymphadenopathy,
ground glass and consolidative opacities concerning for
hemorrhage, marked scarring and emphysema in the right upper
lobe, nonspecific pulmonary nodules, several subcentimeter vague
hypoattenuating foci in the liver, a large 3 to 4 cm nonspecific
lesion in the spleen, and a 30 mm lesion along the lower pole of
the left kidney. A [**Year (4 digits) 500**] scan on [**2160-9-15**] showed no definitive
evidence for metastatic disease. An MRI of the head on
[**2160-9-14**] showed no evidence of intracranial metastases.
.
PMH:
CAD status post three angioplasties, with the last requiring
stenting all of which occurred approximately 13 years ago.
Patient underwent recent stress test as part of pre-op eval for
possible lung mass excision.
HTN
COPD
Social History:
Lives with family and worked 25 years as a plumber. Has a 60
pack year history of smoking and has been exposed to asbestos in
the past. He socially drinks alcohol.
Family History:
Mother died at 82 of stomach CA. Brother with unknown CA death
at 76. Sister with [**Name2 (NI) 500**] CA at 53. Daughter with breast CA in her
40's.
Physical Exam:
VS 97.1 72 149/67 18 95% RA
Gen: Well appearing. NAD.
Integumentary: No rashes or lesions.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Decreased breath sounds in the RUL and LUL.
Abd: Soft, nontender, nondistended.
Ext: No edema.
Neuro: A&Ox3. Grossly intact.
Psych: Appropriate mood and affect.
Pertinent Results:
EKG: Sinus rhythm. Normal axis and intervals. No acute ST or T
wave changes.
.
CTA chest ([**2160-10-20**]): 1. Increase in size of right hilar
enhancing mass with probable extension into the right main stem
bronchus. This results in partial occlusion of the right main
stem bronchus, but there are no postobstructive changes. 2.
Near complete resolution of right lower lobe airspace opacities
seen on the prior examination.
3. No evidence of pulmonary embolus. The possible filling
defect in the right lower lobe pulmonary artery has resolved. 4.
Unchanged appearance of emphysematous and fibrotic changes in
the right upper lobe.
.
Portable CXR ([**2160-10-20**]): Near complete resolution of right lower
lobe consolidation, with unchanged right upper lobe opacities.
Right hilar neoplastic mass slightly increased on the concurrent
CT.
.
PET Scan ([**2160-10-2**]): 1. FDG avid right hilar mass and
mediastinal lymphadenopathy. 2. Unusual focus of FDG uptake in a
soft tissue prominence along the left posterior psoas of unclear
[**Name2 (NI) 68402**]. The location of this lesion is not typical of
metastatic disease. 3. FDG uptake associated with a previously
described indeterminate 13 mm left renal lesion, along the left
lower pole. The FDG uptake heightens concern for a solid nodule
such as a renal cell carcinoma.
.
Lower extremity ultrasound ([**2160-9-15**]): No evidence of lower
extremity DVT.
.
MRI ([**2160-9-14**]): No evidence of intracranial metastasis.
.
[**Month/Day/Year **] Scan ([**2160-9-15**]): No definite evidence for osseous
metastases.
.
CT abd/pelvis ([**2160-9-14**]): 1. Appearance raising concern for the
possibility of a pulmonary embolus in a right lower lobe branch
of the right pulmonary artery, although indeterminate. 2.
Mediastinal and right hilar lymphadenopathy. 3. Bibasilar mixed
ground-glass and consolidative opacities, which given their
recent onset, are most suspicious for an infection,
inflammation, or in the appropriate clinical setting,
hemorrhage. 4. Marked scarring and emphysema in the right upper
lobe. 5. Nonspecific pulmonary nodules, for which short-term
followup is recommended. 6. Several subcentimeter vague
hypoattenuating foci in the liver which are nonspecific.
Metastatic disease cannot be excluded. 7. Large 3-4 cm
nonspecific lesion in the spleen. To evaluate the significance
of this finding, further correlation with prior studies could be
most helpful. 8. A 13 mm lesion along the lower pole of the
left kidney with indeterminate
characteristics and too small to characterize here. It could be
helpful to use an ultrasound to determine whether this
definitely represents a mildly dense cyst, if clinically
indicated.
.
[**2160-10-20**] 09:50AM GLUCOSE-136* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-30 ANION GAP-12
[**2160-10-20**] 09:50AM WBC-7.6 RBC-4.61 HGB-13.6* HCT-38.0* MCV-82
MCH-29.6 MCHC-35.9* RDW-16.5*
[**2160-10-20**] 09:50AM PT-16.5* PTT-33.9 INR(PT)-1.5*
Brief Hospital Course:
76 y.o. man with a history of COPD, HTN and recurrent NSCLC
presenting with hemoptysis.
.
# Hemoptysis secondary to the patient's known RUL mass with
bronchus involvement. On most recent admission, the patient
suffered significant bleeding requiring intubation for airway
protection. Patients HCT was stable throughout his hospital
course. Because of his increased hemoptysis, the patient was
transfered to the MICU. IP was made aware and scheduled patient
for the OR. Pt underwent rigid bronchoscopy and argon ablation
for neovascularization in the right mainstem bronchi. A biospy
was also done of the left lung. After the procedure, the
patient had small amounts of blood tinged sputum which resolved
one day after the procedure. The patient's hematocrit was
stable throughout the stay.
.
# Lung mass. Known undifferentiated RUL large cell CA. The
patient was recently seen by outpatient heme/onc and outpatient
CT surgery. Bronchoscopy for visualization of bleed and mass,
biopsies were to rule out a bronchogenic component of the
cancer.
.
# PE. This likely represented a complication of
hypercoaguability of malignancy. The patient is without signs of
PE on today's CTA. Had recently negative LENI's. Because of the
risk of hemoptysis anticoagulation was held.
.
# COPD. Stable. Continue Spiriva, Advair, Albuterol IH PRN.
.
# h/o CAD. Stable. Continue beta blocker.
.
# HTN. Stable. Continue diuretic and beta-blocker.
.
# CODE: Full Code
Medications on Admission:
Hydrochlorothiazide 25 mg QD
Lopressor 50 mg [**Hospital1 **]
Lovenox 60 mg [**Hospital1 **]
Advair [**Hospital1 **]
Spiriva QD
Albuterol inhaler PRN
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Right upper lobe mass
Left lung mass
Hypertension
Coronary artery disease
COPD
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency department for persisent cough,
worsening blood in sputum, weakness, fever, chills, chest pain,
shortness of breath, nausea, vomiting, or other concerning
symptoms.
Because of the bleeding with your cough, we have stopped your
lovenox injections. You should not take this medication until
you have talked with your oncologist. Please follow up with
your oncologist within one week about this matter.
Our interventional radiologists recommend the following:
You should begin chemo-radiation urgently, please consult with
your oncologist about this therapy
You should also be considered for possible photodynamic therapy.
please consult with your oncologist about this therapy.
You are currently not a candidate for surgery.
You should resume all of your home medications upon discharge
including oxygen as needed.
Followup Instructions:
Follow up with your oncologist. If you wish to transfer your
care to [**Hospital1 69**], please call
[**Telephone/Fax (1) **] to schedule an appointment
|
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icd9cm
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[
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[]
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[
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5,881
| 120,275
|
26694
|
Discharge summary
|
report
|
Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-24**]
Date of Birth: [**2172-8-4**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
TPA administration
Cerebral Angiography with balloon angioplasty
Central Line placement
PICC line placement
Intubation
OG tube
NG tube
History of Present Illness:
19 yo woman with hx migraines only, nonsmoker, no ocps,
presents as code stroke after being found down at 10AM not
moving
left side, somnolent, last known well 9:15, taken to [**Hospital1 18**] and
CT
with no bleed, glucose and INR "normal" now s/p TPA for superior
R MCA stroke with ?clot proximal/M1. Following TPA, she had
mild
improvement of motor exam, which is as follows upon transfer to
ICU: slight dysarthria, sleepiness, not saying more than several
words at a time, no blink to threat on left, forced right gaze
preference (starting to improve towards midline better), normal
brainstem reflexes, left facial droop, low tone on left, left
delt minimally antigravity, 4- at [**Hospital1 **], 3 at triceps, left IP
antigravity x 3-4 seconds before dropping (better than
admission)
and UMN weakness, brisk reflexes on the left, upgoing toe on the
left, subjective sensory loss on left. Repeat cta following
administration of IV tpa showed no recannulization of the MCA,
but also no bleed. I saw the patient at 2:30PM prior to
intubation, and her exam is listed below. She was taken
emergently to interventional radiology for angiography and
potential consideration of IA TPA; her family was notified and
consented prior to this experimental procedure. They were
informed of the risks associated with both the angiography and
the combination of IV then IA tpa, and the family wished to
proceed with the procedure. At just under the 6 hour mark, she
underwent angiography with mechanical intervention with balloon
to open the MCA; revascularization was obtained with balloon
alone, and IA TPA was not given both because of the time
restraints (at this point >6hrs) and risk associated.
Of note, the patient had apparently complained of leg pain
several months back, but more details about this are unknown at
this time. She was awake at presentation and had denied smoking
or ocps, as well as other medical conditions, medications or
allergies.
Past Medical History:
migraines
Social History:
she is a student (and employee) at [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1688**]. She
does not smoke cigarettes, nor does she drink alcohol.
Family History:
Unknown, unable to obtain at the time of admission. Her sister
[**Name (NI) **]
(26 [**Name2 (NI) **], nursing student) is the contact person in the
Phillipines, as her parents do not speak English. They can be
reached at 011.63.[**Numeric Identifier 65793**] (try first) or at 011.63.[**Numeric Identifier 65794**].
Family history later clarified upon family's arrival to US: no
blood clotting disorders, miscarriages, autoimmune disorders, or
early strokes or heart attacks.
Physical Exam:
VS: 60kg (pt states she is 133 lbs) afeb 117/56
General: WNWD, NAD, somewhat increasingly somnolent
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: +BS Soft/NT/ND no HSM/masses
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
MS: A&O x 3, appropriate, following most commands
Speech dysarthric w/o paraphasic errors, +comprehension
?mild left sided neglect with visual or tactile stimulation
No apraxia apparent
CN: I - not tested, II,III - PERRL, VF decreased to threat from
the left; III,IV,VI - forced rightward gaze with minimal
excursion towards the left, no ptosis, no nystagmus; V-responds
to nasal tickle, masseters strong symmetrically; VII - L facial
weakness/asymmetry; VIII - hears finger rub B; XII - tongue
protrudes midline, no atrophy or fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia.
No
pronator drift. No asterixis.
Deltd Bicep Tricp ECR/U
Axill mscut radil radil
C5 C5-6 C7 C6-7
L 3 4- 3 3
R 5 5 5 5
Ilpso Qufem Hamst TibAn [**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
Femor femor [**First Name9 (NamePattern2) 21444**] [**Last Name (un) 18709**] tibil dpper
L1-2 L3-4 L5-S2 L4-5 S1-2 L5
L 3+ - 3 3 5 4
R 5 5 5 5 5 5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 3 3 3 3 3 up
R 2 2 2 2 2 down
Sensory: w/d to ungula pressure, pinch
Coord: no apparent ataxia or dysmetria with mvmnts.
Gait: not assessed.
EXAM POST TPA:
T 96.6 HR 67-79 BP 97-112/55-74 RR 18 100%RA
Gen: very lethargic, young, thin asian woman
neck: supple but in hard collar (though no need to continue this
per ED attg)
cv: regular
pulm: clear ant/lat
Abd: soft
Ext: warm +pulses
Neuro:
MS: patient very lethargic; can answer few questions "right or
left," and say "yes" or "no" to questions appropriately; closes
eyes and falls asleep again if no verbal/tactile stimulation
within 1 minute
CN: PERRLB 3->2, eyes forced deviation to right/right gaze
preference, able to track to right just past the midline. No
obvious nystagmus but did not cooperate fully on EOM testing.
+Right blink to threat, ?left (seems absent). Left facial
droop,
patient not following commands to show teeth. Did not open
mouth
or protrude tongue wide enough to see palate/tongue symmetry.
Motor: nl bulk; full strength entire right side and participates
with exam; left delt no mvmt seen; [**Hospital1 **] at least anti-gravity,
weak
finger flexors (poor effort). No spontaneous mvmt LUE, but
withdraws with good resistance to nailbed pressure. LLE with
[**4-8**]
at IP, 4-/5 at ham, strong quad, did not participate with foot
or
toe dorsiflex, full plantarflex. No obvious tremor and could
not
perform test for pronator drift.
Sensory: w/d purposefully to noxious stim on [**Doctor Last Name **] and LL extrem.
+EXT to DSS over entire left hemibody. Right sided sensation
reported as normal.
DTRs: hyperreflexic on left compared to right, with L upgoing
toe, right down.
coord, gait deferred, patient to be intubated.
Pertinent Results:
[**2192-4-9**] 11:00AM WBC-8.8 RBC-4.18* HGB-13.5 HCT-39.6 MCV-95
MCH-32.3* MCHC-34.0 RDW-12.7
[**2192-4-9**] 11:00AM NEUTS-74.6* LYMPHS-20.5 MONOS-3.6 EOS-1.0
BASOS-0.3
[**2192-4-9**] 11:00AM PT-12.9 PTT-24.7 INR(PT)-1.1
[**2192-4-9**] 11:00AM PLT COUNT-308
[**2192-4-9**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-4-9**] 11:00AM CALCIUM-9.6 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2192-4-9**] 11:00AM GLUCOSE-121* UREA N-16 CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
[**2192-4-9**] 04:51PM PT-13.6* PTT-54.2* INR(PT)-1.2*
[**2192-4-9**] 04:51PM PLT COUNT-272
[**2192-4-9**] 04:51PM WBC-14.0*# RBC-3.49* HGB-11.7* HCT-32.9*
MCV-94 MCH-33.4* MCHC-35.5* RDW-12.7
[**2192-4-9**] 04:51PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.6
[**2192-4-9**] 04:51PM GLUCOSE-129* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17
[**2192-4-9**] 08:26PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-1.6
[**2192-4-9**] 08:26PM GLUCOSE-92 UREA N-9 CREAT-0.5 SODIUM-142
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
[**2192-4-9**] 08:56PM FIBRINOGE-154
[**2192-4-9**] 08:56PM PT-13.1 PTT-27.5 INR(PT)-1.1
[**2192-4-9**] 08:56PM PLT COUNT-249
[**2192-4-9**] 08:56PM WBC-12.8* RBC-3.34* HGB-11.0* HCT-31.0*
MCV-93 MCH-32.7* MCHC-35.4* RDW-12.7
[**2192-4-9**] 09:23PM TYPE-ART PO2-224* PCO2-28* PH-7.53* TOTAL
CO2-24 BASE XS-2 INTUBATED-INTUBATED
[**2192-4-9**] 09:23PM O2 SAT-99
UCG (pregnancy test) negative
Thrombin [**2192-4-14**] 01:29AM : 27.3*1
ESR [**2192-4-12**] 11:41A : 25* --> 49* on [**2192-4-17**] 06:35AM
CRP admission 87.5*-->64.6* on [**2192-4-17**] 06:35AM
LIPID/CHOLESTEROL Cholest 144 Triglyc 58 HDL 85 CHOL/HD 1.7
LDL 47 HbA1c 5.2
Lactate initially 0.9 ---> [**2192-4-13**] 2:14A 2.6* ---> 1.3 on
[**4-14**]
FacVIII [**2192-4-12**] 01:00PM : 120-->151*
FactorIX : 100
Lupus anticoagulant PND [**2192-4-14**] 01:29AM (initially
negative but drawn after TPA)
Homocysteine "low" 4.2
ATIII 66
Protein C 91
Protein S 61
ACA IgG 3.6 IgM 7.3
Factor V Leiden, Prothrombin gene mutation, and Pyruvate levels
still pending
*******
IMAGING
*******
initial CT brain
FINDINGS: Hypodensity with loss of [**Doctor Last Name 352**]-white matter
differentiation in the distribution of the right middle cerebral
artery again seen. Mass effect with slight displacement of the
right lateral ventricle may be slightly increased compared to
the previous study. Basal cisterns appear patent. No definite
evidence of acute hemorrhage.
IMPRESSION: Right MCA distribution infarction with possibly
slightly increased mass effect compared to the previous exam. No
definite acute hemorrhage.
SUBSEQUENT CTA BRAIN:
CT OF THE HEAD WITHOUT CONTRAST: There is no evidence of acute
intracranial hemorrhage or shift of the normally midline
structures. The ventricles and cisterns are normal. There is a
rounded hypodense focus within the right caudate nucleus,
consistent with an old lacunar infarction Vs. an old
demyelinating plaque. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. The paranasal sinuses and mastoid air cells are
clear.
CTA OF THE HEAD AND NECK: Bilateral vertebral and carotid
arteries are patent within the neck. The superior vertebral,
basilar and posterior cerebral arteries opacify normally with
contrast within the head. The left internal carotid artery
opacifies normally with contrast, through its bifurcation into
anterior and middle cerebral arteries on the left. At the
superior-most portion of the supraclinoid right internal carotid
artery, there is either high-grade stenosis Vs. occlusion. There
is contrast within the right anterior cerebral artery
proximally. No contrast is visualized within the proximal M1
segment of the right middle cerebral artery. Furthermore, there
is paucity of vessels in the right superior division
distribution of the right middle cerebral artery. The findings
may represent occlusion of the distal right internal carotid
artery Vs. proximal right middle cerebral artery, with filling
of other branches of the right middle cerebral artery from
collateral vessels, Vs. high-grade stenosis of the distal right
internal carotid artery.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Paucity of vessels visualized within the right superior
division distribution of the right middle cerebral artery. The
findings are the manifestation of acute/evolving infarction in
this territory. Infarction may be related to occlusion Vs.
extremely high-grade stenosis of the distal right internal
carotid artery and/or proximal right middle cerebral artery.
Findings were called to Dr. [**Last Name (STitle) **], the emergency room resident
caring for the patient at the immediate conclusion of the exam.
In addition, these findings were also discussed with the
neurology team caring for the patient at the time of the exam.
POST-TPA CT BRAIN:
FINDINGS: Comparison is made with CT cerebral angiogram
performed earlier on the same day ([**12-21**]).
There is now further loss of [**Doctor Last Name 352**]-white matter differentiation
confined to the supply territory of the right middle cerebral
artery, consistent with an evolving acute infarct. There is now
further mass effect upon the ipsilateral lateral ventricle and
the cerebral sulci in that region. No CT features of hemorrhagic
transformation are seen at present. Chronic encephalomalacia at
the head of the right caudate nucleus is again noted.
The CT angiographic images demonstrate persistent occlusion of
the proximal segment of the right middle cerebral artery (series
3, image 147). There is reconstitution of flow noted distally
within the right middle cerebral artery and its principal
branches, likely retrograde flow from collaterals. The extent of
the occlusion remain unchanged from two hours ago, and there is
persistent paucity of vascularity within the right middle
cerebral artery supply territory more distally.
There is no displacement of the normally midline structures.
Basal cisterns remain patent at present.
CONCLUSION:
1. Persistent occlusion of the proximal segment of the right
middle cerebral artery, with reconstitution of flow noted
distally. The overall appearance is unchanged since the prior
study of [**12-21**], with [**2192-4-9**].
2. Evolving cerebral infarct confined to the territory of the
right middle cerebral artery, with no CT evidence of hemorrhagic
transformation at present.
CEREBRAL ANGIOGRAPHY WITH BALLOON ANGIOPLASTY [**4-12**]:
CEREBRAL ANGIOGRAM:
CLINICAL INFORMATION: Acute onset of left hemiparesis. For
intra-arterial TPA.
RADIOLOGISTS: Drs. [**Last Name (STitle) 22924**] and [**Name5 (PTitle) **], the Attending Radiologist,
present and supervising the entire procedure.
TECHNIQUE: Informed consent was obtained from the patient's
family after explaining the risks, indications and alternative
management. Risks explained included stroke, loss of vision and
speech, temporary or permanent, with possible treatment with
stent and coils if needed.
The patient was brought to the Interventional Neuroradiology
Theater and placed on the biplane table in supine position. Both
groins were prepped and draped in the usual sterile fashion.
Access to the right common femoral artery was obtained using a
19-gauge single wall needle, under local anesthesia using 1%
lidocaine mixed with sodium bicarbonate and with aseptic
precautions. Through the needle, a 0.35 [**Last Name (un) 7648**] wire was
introduced and the needle taken out. Over the wire, a 5 Fr
vascular sheath was placed and connected to a saline infusion
(mixed with heparin 500 units in 500 cc of saline) with a
continuous drip. Through the sheath, a 4 Fr Berenstein catheter
was introduced and connected to continuous saline infusion (with
mixture of 1000 units of heparin in 1000 cc of saline).
The following vessels were selectively catheterized and
arteriograms were performed from these locations:
1) Right internal carotid artery.
2) Right middle cerebral artery.
FINDINGS: Injection of the right internal carotid artery
demonstrates complete occlusion of the proximal M1 segment of
the right middle cerebral artery, with reflux of contrast from
leptomeningeal collaterals to reconstitute the distal portion of
the right MCA and its branches.
A balloon angioplasty was performed at the occluded proximal
segment of the right middle cerebral artery with an hyperglide
balloon catheter. Post- procedural right internal carotid
injection demonstrate patency and good flow within the right
middle cerebral artery.
CONCLUSION: Successful balloon angioplasty and
re-vascularization of the occluded right middle cerebral artery.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
*****
MRI EXAM OF THE CERVICAL SPINE [**4-12**] (performed to help clear
c-spine)
MRI exam of the cervical spine was obtained according to
standard departmental protocol. The vertebral bodies demonstrate
normal height and signal. No underlying fractures or marrow
edema is seen. Spinal canal is patent. There is homogeneous
signal noted within the cervical cord.
No focal herniations are seen at any level. The foramina are
patent. There is no extrinsic cord compression seen. The
examination is degraded by motion artifact.
There is diffusely abnormal increased T2 signal involving the
posterior aspect of the nasopharynx and extending along the
prevertebral space from C1 through C4 levels. This could
represent possible retropharyngeal hemorrhage into the
prevertebral space. Unfortunately, the exam was degraded by
motion artifact.
IMPRESSION: No compression fractures seen involving the cervical
spine. There is T2 hyperintensity in the prevertebral soft
tissues extending from the base of skull inferiorly into C4-C5
level along the prevertebral soft tissues suggestive of possible
retropharyngeal hemorrhage. This could be related to possible
intubation or bleeding into the retropharyngeal space.
Correlation with endoscopy might be helpful along with followup.
No cord compression was seen. The overall cervical spine MRI
exam was degraded by repeated motion artifact.
POST-ANGIO HEAD CT [**4-9**]:
FINDINGS: Comparison with the prior study of [**2192-4-10**] shows
no significant interval change. Once again the superior division
right middle cerebral artery infarction is well demarcated.
There has been no overt hemorrhagic transformation. Degree of
mass effect, including slight hippocampal herniation, is
unaltered. There is no hydrocephalus or shift of normally
midline structures. Once again, the component of the infarct
within the head of the right caudate nucleus obliterates the
right frontal [**Doctor Last Name 534**] and there is a millimeter or two leftward
shift of the anterior margin of the third ventricle. No osseous
pathology is seen. There is moderate mucosal thickening within
the ethmoid sinuses with multiple small air fluid levels within
the sphenoid sinus air cells. These abnormalities likely relate
to intubation.
CONCLUSION: Stable appearance of right middle cerebral artery
superior division infarct.
CXR [**4-13**] (prior CXR's done to confirm line and tube placement):
PORTABLE AP CHEST:
The tip of the left subclavian catheter is in the SVC. ET and NG
tube are unchanged. The heart size is normal. The left
retrocardiac opacity is unchanged. Right basilar atelectasis
also stable. Stable left pleural effusion.
IMPRESSION:
1. Stable left lower lobe consolidation/atelectasis with small
and stable left pleural effusion.
2. Right basilar atelectasis.
CT BRAIN [**4-10**]:
There is increased low density in the posterior frontal lobe on
the right and in the caudate nucleus and basal ganglia. There is
a slight area of increased density in the central portion of
this which could reflect some reactive "luxury" perfusion or
could represent some petechial hemorrhage. There is no evidence
of increased mass effect. A gross hematoma is not identified.
There is no evidence of abnormality in the left hemisphere.
IMPRESSION: Evolutionary changes with possible petechial
hemorrhage.
CT BRAIN [**4-11**]:
NON-CONTRAST HEAD CT SCAN
FINDINGS: Comparison with the prior study of [**2192-4-10**] shows
no significant interval change. Once again the superior division
right middle cerebral artery infarction is well demarcated.
There has been no overt hemorrhagic transformation. Degree of
mass effect, including slight hippocampal herniation, is
unaltered. There is no hydrocephalus or shift of normally
midline structures. Once again, the component of the infarct
within the head of the right caudate nucleus obliterates the
right frontal [**Doctor Last Name 534**] and there is a millimeter or two leftward
shift of the anterior margin of the third ventricle. No osseous
pathology is seen. There is moderate mucosal thickening within
the ethmoid sinuses with multiple small air fluid levels within
the sphenoid sinus air cells. These abnormalities likely relate
to intubation.
CONCLUSION: Stable appearance of right middle cerebral artery
superior division infarct.
CT BRAIN [**4-12**]:
There is no significant interval change compared to one day
previous. Again, the superior division right middle cerebral
artery infarction is well demarcated, with slightly increased
hypodensity of the affected brain parenchyma. The degree of mass
effect is unaltered. The ventricles are unchanged in size and
appearance. Moderate mucosal thickening within ethmoid air cells
and small fluid levels in the sphenoid air cells are unchanged.
An endotracheal tube remains in place.
IMPRESSION: No significant interval change.
CT BRAIN [**4-13**]:
FINDINGS: Hypodensity in the distribution of the superior
division of the right middle cerebral artery is again seen with
internal areas of isodensity that are unchanged. Mass effect
with compression of the ipsilateral lateral ventricle with right
to left shift does not appear significantly changed compared to
the exam of one day prior. No new areas suspicious for
hemorrhage are seen. Suprasellar cistern remains patent.
IMPRESSION: No significant interval change compared to the exam
of one day prior.
CHEST XRAY [**4-16**]:
AP CHEST RADIOGRAPH: There has been interval extubation. There
is an NG tube whose tip is in the stomach in satisfactory
position. The left subclavian line tip is in the mid SVC without
pneumothorax. The heart size is normal. The mediastinal and
hilar contours are normal. The pulmonary vascularity is normal
in appearance. The lungs are clear without focal consolidations.
There is no pneumothorax.
IMPRESSION: NG tube tip in the stomach.
TRANSESOPHAGEAL ECHO [**4-10**] with BUBBLE STUDY:
Findings:
Sedation was achieved with propofol continuous IV infusion
throughout the course of the procedure.
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA
ejection velocity. All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD or PFO by 2D, color Doppler or saline contrast with
maneuvers.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%).
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
masses or vegetations on aortic valve.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **]
mass or
vegetation on mitral valve.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. No TEE related
complications. Contrast study was performed with 2 iv injections
of 8 ccs of agitated normal saline, at rest, and post-Valsalva.
Resting tachycardia (HR>100bpm). MD caring for the patient was
notified of the echocardiographic results by e-mail.
Conclusions:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The interatrial septum is dynamic, but no atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thickness, cavity size, and systolic function are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No cardiac source of embolism identified.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2192-4-10**]
18:35.
* * *
[**4-17**] MRI BRAIN
FINDINGS: As noted on the prior CTs, there is a subacute
infarct of the right middle cerebral artery territory,
specifically the superior division, with acute components. There
is a small amount of elevated T1 signal within the region of the
putamen, which indicates petechial hemorrhage. There is no
shift of normally midline structures. There is expected gyriform
enhancement in the distribution of the infarct including
enhancement of the right basal ganglia and caudate nucleus. No
new infarcts are identified. There is no shift of normally
midline structures or hydrocephalus.
The 3D time-of-flight MRA demonstrates normal anterior and
posterior
circulations. There is no evidence of aneurysms or significant
regions of stenosis or absent flow signal.
IMPRESSION: Infarct within the territory of the right middle
cerebral artery, demonstrating both acute and subacute
components. A small area of hemorrhage is identified in the
right putamen.
[**4-19**] CT TORSO
IMPRESSION:
1. No evidence of thoracic, abdominal, or pelvic malignancy.
2. Patchy consolidation within the left lung, worst in the left
lower lobe, and to a lesser extent also in the left upper lobe.
Findings are most suspicious for aspiration, with associated
pneumonia.
Brief Hospital Course:
The patient is a 19 yo woman with migraines, no other known
stroke risk factors or
PMH, no ocps or smoking, who presented with acute right MCA
stroke, superior division, s/p IV TPA with no recannulization,
then s/p angiography with revascularization of MCA achieved by
balloon, no IA TPA. Prior to the angiography she was intubated
and sedated. She was admitted to the neuro ICU for close
monitoring of exam, blood pressure, vital signs. Both a central
line and arterial line were placed; she remained intubated until
[**4-14**]. She was maintained on mannitol to decrease swelling. She
underwent daily CT scans for days due to the presence of edema
and midline shift; neurosurgery was consulted for the
possibility of hemicraniectomy to relieve swelling, but she did
not need this procedure. Antiplatelet agents and anticoagulants
were held for the first 48 hours following the TPA
administration, then aspirin therapy was initiated.
Coagulopathy workup was sent from the ED after TPA had been
given (though many hours between TPA and labs) - heme onc was
consulted for ?which labs to repeat. Lupus anticoagulant was
repeated and was still pending at discharge (though was
initially negative). Other labs are listed in the "results"
section of this summary, as are all imaging results with the
exception of several chest xrays.
The patient had a traumatic intubation and pharyngeal
swelling/likely hematoma. After extubation, she had a soft
voice; it was unclear if this was stroke-related (ie, insular
damage) versus intubation-related.
She developed a ventillator associated pneumonia and sputum grew
MRSA. She was treated with Vancomycin and Zosyn to cover both
the MRSA and hospital acquired organisms.
On [**4-14**] she was extubated and her exam improved. She was
transferred to the floor on [**4-15**] in the evening. Her exam at
transfer was significant for soft voice but fluent language,
weakness of the left arm and left facial droop, with right gaze
preference though improved movement of the eyes past the midline
on extraocular muscle assessment.
She was seen by physical and occupational therapy. She required
an NG tube for feeds after failing an initial swallow
evaluation. A PICC line was placed for ease of antibiotics
after her central line was discontinued.
* * *
Hospital Course on Neurology Floor:
1. FEN - Evaluated by speech and swallow, cleared for PO's with
video swallow. Eventually NG tube discontinued and taking po
dysphagia diet with nectar thick liquids by time of discharge.
2. RESP - Pneumonia resolved, no pulmonary issues.
3. CV - At one point exhibited some orthostatic hypotension, but
improved with increased hydration, and has not recurred.
Patient needs to be encouraged to drink adequate fluids each
day.
4. NEURO - At the time of discharge her speech was fluent but
still hypophonic, though improved since transfer out of the ICU.
The left facial droop and left arm weakness (especially
distally) persisted, but she was able to walk well. Physical
and occupational therapy worked with her on a regular basis.
She was maintained on aspirin and lipitor. Workup for potential
causes of stroke were pursued, including CT of torso to rule out
malignancy (negative).
Workup for potential hematologic and rheumatologic causes of
stroke were also pursued.
The following tests were sent:
[**4-10**] Lupus Anticoagulant NEG
Antithrombin III 66 % 62 - 108
Protein C, Functional 91 % 67 - 123
Protein S, Functional 61 % 51 - 133
Anticardiolipin Antibody IgG 3.6 GPL 0 - 15
Anticardiolipin Antibody IgM 7.3 MPL 0 - 12.5
Homocysteine 4.2
Factor VIII 120
Factor IX 100
[**4-14**] Thrombin 27.3 (mildly elevated)
Lupus anticoagulant negative
[**4-17**] ESR 49 (in the setting of resolving pneumonia)
[**4-19**] Factor VIII, AT III, Protein C and S profiles, Factor V
[**Location (un) 5244**], Ro and [**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) **] pending
[**Doctor First Name **] negative, ANCA negative
Some hematologic tests were re-sent since the first set were
drawn shortly after TPA was given. Most of these repeat labs
from [**4-19**] are still pending.
5. HEME - See above. Ms. [**Known lastname **] will follow up with the [**Hospital 18**]
[**Hospital **] Clinic after discharge.
6. ID - Completed 10 days of treatment with Zosyn and Vancomycin
for ventilator-associated pneumonia (grew MRSA from sputum).
Afebrile throughout time on neurology floor.
7. GI - Had some loose stools which resolved. C. Diff was not
sent.
8. Social - Mother and sister have travelled from [**Country 31115**] to
be with [**Known firstname **]. They would like her to go back to school as soon
as possible, but realize this will take some time. Financial
resources are limited as she has exhausted her school insurance
policy.
Medications on Admission:
None (no oral contraceptives)
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] - Rehab and SCI
Discharge Diagnosis:
Stroke
Discharge Condition:
Good
Discharge Instructions:
Please attend all follow-up appointments and take all
medications as directed.
Followup Instructions:
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2192-5-29**]
2:30
Prothrombin Mutation Analysis recommended by [**Last Name (LF) **],[**Name8 (MD) 3557**], MD
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"V09.0",
"434.91",
"482.41",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.62",
"96.6",
"88.41",
"96.72",
"38.93",
"99.10",
"38.91",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
30615, 30674
|
25473, 30317
|
326, 462
|
30725, 30732
|
6532, 25450
|
30859, 31196
|
2688, 3170
|
30397, 30592
|
30695, 30704
|
30343, 30374
|
30756, 30836
|
3185, 6513
|
274, 288
|
490, 2450
|
2472, 2484
|
2500, 2672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,324
| 141,783
|
23614
|
Discharge summary
|
report
|
Admission Date: [**2159-3-4**] Discharge Date: [**2159-3-8**]
Date of Birth: [**2115-11-6**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 13561**]
Chief Complaint:
left upper and lower extremity numbness/tingling
Major Surgical or Invasive Procedure:
Intubation
CT Scan
MRI/MRA
CTA
Lumbar Puncture
History of Present Illness:
ID/CC: Loss of strength and sensation in lower extremities
HPI: Pt is a 43 year old male with hx of lumbar disc disease,
s/p
L4-L5 laminectomy at [**Hospital3 15054**] in [**2156**], with residual R leg
numbness
and foot drop from surgery, who presents with acute onset of L
leg plegia and sensory loss. He says that at baseline he walks
with a cane because of a foot drop on the R and also has some
sensory loss in the R leg. He also at baseline has severe pain
over his spine in the L4 area that he has had since the surgery.
He says that last night (midnight 24 hours prior to presentation
to the ED) he was sleeping and awoke because he thought his dog
was sitting on his L leg (it felt heavy and numb). He awoke and
saw that his dog was not on his leg. He tried to move his leg
and
could not. It was numb and completely plegic. He says he felt
very scared and therefore did not tell anyone aobut this for the
entire day. Around 8 pm, however, he realized he had to be
evaluated and he presented to the [**Hospital6 **],
who then sent him to the [**Hospital1 18**] for further evaluation. He denies
any recent back trauma.
Past Medical History:
spinal disease operated on [**2156**] at [**Hospital6 **]
chronic pain
Social History:
Denies tobacco, ETOH, drugs. Used to work as a UPS supervisor,
fired 2 yrs ago when got back injury at work. Has not worked
since. Lives at home with
wife and 3 kids, says situation at home has been stressful since
he has been out of work. Is currently involved in at least one
lawsuit (his former neurosurgeon) as well as a sticky
financial/worker's compensation situation.
Family History:
no h/o seizures, neurological problems
Physical Exam:
Exam findings have fluctuated throughout his hospital course.
On admission to neuro:
VS: T 98.6 HR77 BP 148/87 RR18 Sat 95% on room air
PE: overweight male, very distressed and tearful.
HEENT OP benign, head atraumatic
Neck Supple, full ROM, no carotid bruits
Chest CTA B
CVS RRR w/o MGR
ABD soft, NTND, + BS
EXT no C/C/E, distal pulses full, no rashes or petechiae
Neuro:
MS: AA&Ox3, appropriately interactive, normal affect
Attention: WORLD backwards
Speech: fluent w/o paraphasic error, repetition, naming intact
L/R confusion: No L/R confusion
Praxis: Able to mimic saluting the flag, rolling dice, brushing
teeth with either hand.
CN: I--not tested; II,III--PERRLA, VFF by confrontation, visual
acuity 20/X, optic discs sharp; III,IV,VI-EOMI w/o nystagmus, no
ptosis; V--sensation intact to LT/PP, masseters strong
symmetrically; VII--face symmetric without weakness; VIII--hears
finger rub bilaterally; IX,X--voice normal, palate elevates
symmetrically, gag intact; [**Doctor First Name 81**]--SCM/trapezii [**5-17**]; XII--tongue
protrudes midline, no atrophy or fasciculation. Of note, tongue
at times is protruded far to the left, usually when the patient
is questioned about his symptoms.
Motor: normal bulk and tone, no tremor, rigidity or
bradykinesia,
no pronator drift.
Strength:
Upper extremities [**5-17**] throughout. In the lower extremities pt
has
no spontaneous movement, able to wiggle R toes and slide R leg
along the bed, no withdrawal to pain in the LLE.
Of note, motor strength returned to R leg then slowly to L leg,
moving toes only on command at discharge but able to walk with
nurses and get out of bed on his own at times.
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 1 | 2 | 2 | 1 | 0 | dn |
R | 1 | 2 | 2 | 1 | 0 | dn |
[**Last Name (un) **]: Diminished sensation to light touch, pin prick,
temperature, vibration to T8 anteriorly and posteriorly, but no
saddle anesthesia. No joint position in L foot. In R foot able
to
detect movement of toes, but not the direction. This sensation
defect improved over the next few days and resolved by
discharge.
Pertinent Results:
[**2159-3-5**] 02:52AM BLOOD WBC-10.4 RBC-4.89 Hgb-14.7 Hct-41.6
MCV-85 MCH-30.0 MCHC-35.3* RDW-13.8 Plt Ct-268
[**2159-3-4**] 12:25AM BLOOD Neuts-82.6* Lymphs-13.5* Monos-3.1
Eos-0.7 Baso-0.2
[**2159-3-5**] 02:52AM BLOOD Plt Ct-268
[**2159-3-5**] 02:52AM BLOOD PT-13.2 PTT-25.2 INR(PT)-1.1
[**2159-3-4**] 12:25AM BLOOD ESR-4
[**2159-3-5**] 02:52AM BLOOD Glucose-104 UreaN-16 Creat-0.9 Na-146*
K-3.4 Cl-110* HCO3-27 AnGap-12
[**2159-3-5**] 02:52AM BLOOD ALT-74* AST-24 AlkPhos-79 TotBili-0.7
[**2159-3-5**] 02:52AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9 Cholest-211*
[**2159-3-5**] 02:52AM BLOOD Triglyc-594* HDL-35 CHOL/HD-6.0
LDLmeas-107
[**2159-3-4**] 12:25AM BLOOD CRP-0.67*
[**2159-3-4**] 09:30AM BLOOD IgG-1149
[**2159-3-4**] 09:33AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-92 Monos-8
[**2159-3-4**] 09:33AM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-91
[**2159-3-4**] 09:33AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
MRI/MRA BRAIN:
Mild sinus disease. There are a few nonspecific T2
high-signal-intensity foci. No definite evidence of acute
infarction, mass effect, or hemorrhage. Normal MRA of
intracranial circulation
MRI SPINE
There are degenerative changes in the cervical spine with
osteophyte formation producing mild canal narrowing at C3-C4,
C5-C6, and C6-C7, and T8-T9. These do not appear to produce
spinal cord compression. No definite contrast enhancement
XRAY-L-Spine with oblique
Five views of the lumbosacral spine, including oblique
projections show no fracture or spondylolisthesis. The height of
the vertebral bodies is normal. The intervertebral disc spaces
are normal. The SI joints are normal and the visualized hip
joints are normal. There is no evidence for bony destruction.
The visualized soft tissue structures are normal
Brief Hospital Course:
The patient was initially thought to be in acute need of
neursurgery per his reported symptoms of paraparesis and h/o
back surgery, but spine imaging proved negative for cord
compression or major pathology (past scarring from surgery was
visualized.) The following differential was considered:
1. Cord compression/infarct: Decadron was started in the ICU due
to acute symptoms. However, nonrevealing imaging made surgical
treatment less likely. In addition, the patient's neurological
symptoms were also inconsistent with a cord compression as he
complained of L arm paresis and some sensory loss as well as a
paraparesis and some sensory loss that did not correspond to a
level. [**Doctor Last Name 60437**] sign was positive. He also demonstrated an
unusual cranial nerve exam consisting of a tongue that
occasioanlly protrudes far to the left when he is asked about
his symptoms, as well as a [**Doctor Last Name 11586**] and Rinne test that he
localized to the right side of his head only.
2. Infection. The pt reported severe tenderness on exam as well
as paresis but epidural abscess was not found on imaging. He was
empirically started on IV abx in the ICU which were subsequently
d/ced when the LP was done and was negative.
3. Demyelinating disease. LP and head/spine imaging negative for
MS, GB.
On the neurology floor, a differential including conversion vs.
malingering evolved due to inconsistent physical exam as well as
the following:
1. Social stressors. Extensive discussions with the patient
regarding his social situation revealed several social
stressors. The patient is involved in a sticky worker's
compensation situation after he was fired from his job several
years ago for back injury. He has been bed-ridden and depressed
since his operation 2 yrs ago which was apparently not done
correctly. He has also had [**10-22**] chronic pain for which he has
been taking 80mg oxycontin TID for several months. He believes
he is addicted.
2. Inconsistent history. Several aspects of his medical course
were not correctly relayed to us, per his father's report as
well as his neurosurgeon's report at the [**Hospital3 **] (pt states
he has an appt [**3-15**] with Dr. [**Last Name (STitle) **] who reports no such
appt.)
3. Secondary gain. He reported to the team that his worker's
comp would end once he received back surgery but that he wanted
to get the surgery even if he had to pay for it himself.
However, his father reported that the situation is reversed:
that the patient cannot get worker's comp UNTIL he received back
surgery and that therefore he is very anxious to be operated on.
4. Lawsuits. He is also involved in at least one lawsuit against
his former neurosurgeon.
Given the above factors and the apparent volitional aspect of
his symptoms, malingering seemed more likely than a conversion
disorder. A psychiatry consult was called and gave the
unequivocal diagnosis of malingering. The patient was informed
that he has no neurological diagnosis and that his transient
weakness may be evoked by stress and will resolve on its own.
The patient's symptoms continued to resolve over the next few
days as PT attempted to get him out of bed to clear him for home
discharge. He was D/Ced home feeling much better.
Medications on Admission:
oxycontin 80mg PO TID
Discharge Medications:
1. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: Two
(2) Tablet Sustained Release 12HR PO Q8H (every 8 hours) for 4
days.
Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
transient left-sided weakness
Discharge Condition:
stable
Discharge Instructions:
Continue to take your medications as prescribed by Dr. [**Last Name (STitle) 5263**].
You should follow up with her in the next week. Please follow up
with Dr. [**Last Name (STitle) **] as previously scheduled on [**3-15**] for neurosurgical
evaluation.
Followup Instructions:
If your symptoms recur contact your PCP for advice or come
directly to the emergency room. Follow up with Dr. [**Last Name (STitle) **] as well
for neurosurgery evaluation.
|
[
"782.0",
"722.93",
"346.90",
"368.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.91",
"03.31",
"88.41",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9617, 9623
|
6080, 9334
|
373, 422
|
9697, 9705
|
4280, 6057
|
10007, 10183
|
2087, 2128
|
9406, 9594
|
9644, 9676
|
9360, 9383
|
9729, 9984
|
2143, 4261
|
284, 335
|
450, 1584
|
1606, 1679
|
1695, 2071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,780
| 118,453
|
53537
|
Discharge summary
|
report
|
Admission Date: [**2170-2-22**] Discharge Date: [**2170-3-1**]
Date of Birth: [**2087-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 82 yo woman with history of type II diabetes,
peripheral vascular disease, hypertension, and hyperlipid who
was recently admitted to CCU for respiratory distress in the
setting of decompensated heart failure and NSTEMI. She presented
to the ED last night from rehab less than 24 hours
post-discharge for increasing shortness of breath.
She says that she arrived at rehab yesterday afternoon feeling
generally well. She ate dinner after which she developed mild
abdominal discomfort that resolved spontaneously. She then felt
as if her heart was beating fast, and she also felt tired. There
was no chest pain or pressure, lightheadedness or dizziness. She
says she was diaphoretic at the time. Her daughter, concerned,
called 911. En route to the hospital, she was noted to be
tachypnic and hypoxic (per ED report).
Initially in the ED she was hypoxic to mid 60s. She was also
hypertensive to 180s initially. EKG showed sinus tachycardia
with LAD (unchanged). Widened QRS (114 ms) with ST elevations in
anterior precordial leads (unchanged) and ST-depressions/T-wave
inversions in lateral leads (unchanged). CXR showed bilateral
perihilar consolidations worse from two days prior with
persistent pleural effusions; overall impression was worsening
pulmonary edema, although infection could not be excluded. ABG
showed 7.43/36/124. Lactate was 2.4. Labs were notable for white
count of 16.1 with 66.2% neutrophils and no bands. BMP showed a
bicarb of 21 with anion gap of 12. Renal function was normal. Of
note, her troponin was 2.63 (down from previous 6.41 on [**2-17**])
with flat CK. BNP was 14,871 (no prior for comparison). She was
placed on a nitro drip intially; this was quickly weaned off.
She was also placed on BiPAP intially. There were attempts made
to wean her to face mask or nasal cannula. However, per ED
report she became tachypnic to 30s with these measures, and
therefore she was readmitted to the CCU.
At time of admission, her sats were 95-96% on NRB, RR 27-32,
heart rate in the 90s with systolic BP 110s. In the ED she
received aspirin 325 mg x1, levofloxacin 750 mg x1, and Lasix 40
mg IV x1.
Of note, during her previous admission ([**2-15**] to [**2-21**]), she was
intubated for respiratory distress secondary to mitral
regurgitation which was believed secondary to ischemia. This all
had happened after an elective left total hip replacement at [**Hospital1 **]
[**Location (un) 620**]. She underwent echocardiogram that showed a new
antero-apical wall motion abnormality and underwent cardiac cath
that revealed LAD disease for which a bare metal stent was
placed. She was started on Plavix and high-dose aspirin, as well
as Lovenox with bridge to coumadin for apical akinesis (LVEF
30-35%) noted on echocardiogram. She worked with physical
therapy for two days without chest pain or dyspnea and was felt
to be ready for discharge to rehab.
REVIEW OF SYSTEMS: currently, patient denies shortness of
breath, chest pain or pressure, lightheadedness or dizziness.
She denies nausea, abdominal discomfort, cough, or sputum
production.
Past Medical History:
1) History of diabetes type II, although most recent HgA1c was
5.8 ([**2-/2170**]) off of all medications
2) Peripheral vascular disease: s/p left common femoral to below
knee popliteal artery bypass with in situ saphenous vein and an
open transluminal angioplasty of the anterior tibial and below
knee popliteal arteries in [**5-14**].
3) Hypertension
4) Hyperlipidemia
5) Hx of R breast ca s/p lumpectomy
6) Depression
Social History:
Originally she is from [**Country 3397**]. Prior to her discharge to rehab,
she lived at home with her husband and was independent in her
ADLs, IADLs and very functional. She denies history of smoking,
alcohol or drug abuse. Her daughter, who lives in [**Country 19828**], has
been recently staying in [**Location (un) 86**] and has been involved in her
care on a daily basis during her two recent admissions to [**Hospital1 18**].
Family History:
Non-contributory.
Physical Exam:
Vitals: T 97.9, HR 93-94, BP 119-127/58-66), RR 12-20, sat
90-98% 5L
Urine output: 400 cc
General: elderly woman, generally anxious-appearing, lying
comfortably in bed, speaking in complete sentences without
pauses, no accessory muscle use or labored breathing
HEENT: NC/AT, PERRLA, EOMI
Neck: supple, no appreciable JVD
Chest: RRR, normal s1/s2, systolic murmur loudest along left
sternal border, radiating toward apex although not audible in
axilla
Lungs: crackles halfway up posterior fields
Abdomen: soft, non-tender, normal bowel sounds
Extremities: trace pitting edema to ankles bilaterally; feet
warm and well-perfused
Neurological: AAOx3, moving all extremities
At time of discharge, her oxygen saturations are in the mid to
high 90s on RA. Her blood pressures have been well-controlled
with systolic blood pressure ranging from 110 to 130. There is
no lower extremity pitting edema.
Pertinent Results:
[**2170-2-22**] 02:30AM TYPE-ART PEEP-5 O2-100 PO2-124* PCO2-36
PH-7.43 TOTAL CO2-25 BASE XS-0 AADO2-570 REQ O2-92 INTUBATED-NOT
INTUBA COMMENTS-NIV 14/5 1
[**2170-2-22**] 01:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2170-2-22**] 01:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-2-22**] 01:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**2-9**]
[**2170-2-22**] 01:45AM URINE HYALINE-0-2
[**2170-2-22**] 01:30AM LACTATE-2.4*
[**2170-2-22**] 01:15AM GLUCOSE-390* UREA N-32* CREAT-0.7 SODIUM-139
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17
[**2170-2-22**] 01:15AM CK(CPK)-72
[**2170-2-22**] 01:15AM cTropnT-2.63*
[**2170-2-22**] 01:15AM CK-MB-NotDone proBNP-[**Numeric Identifier 56177**]*
[**2170-2-22**] 01:15AM WBC-16.1*# RBC-3.77* HGB-10.9* HCT-33.8*
MCV-90 MCH-28.9 MCHC-32.3 RDW-13.9
[**2170-2-22**] 01:15AM NEUTS-66.2 LYMPHS-28.4 MONOS-2.2 EOS-2.9
BASOS-0.4
[**2170-2-22**] 01:15AM PLT COUNT-543*
[**2170-2-22**] 01:15AM PT-13.3 PTT-34.3 INR(PT)-1.1
[**2170-2-21**] 06:20AM GLUCOSE-115* UREA N-25* CREAT-0.7 SODIUM-142
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-26 ANION GAP-11
[**2170-2-21**] 06:20AM CALCIUM-8.3* PHOSPHATE-2.8 MAGNESIUM-2.1
[**2170-2-21**] 06:20AM WBC-9.9 RBC-3.37* HGB-10.3* HCT-29.9* MCV-89
MCH-30.6 MCHC-34.4 RDW-13.8
[**2170-2-21**] 06:20AM PLT COUNT-437
[**2170-2-21**] 06:20AM PT-13.6* PTT-31.6 INR(PT)-1.2*
[**2170-2-22**] 01:15AM BLOOD WBC-16.1*# RBC-3.77* Hgb-10.9* Hct-33.8*
MCV-90 MCH-28.9 MCHC-32.3 RDW-13.9 Plt Ct-543*
[**2170-2-21**] 06:20AM BLOOD WBC-9.9 RBC-3.37* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.6 MCHC-34.4 RDW-13.8 Plt Ct-437
[**2170-2-22**] 01:15AM BLOOD Neuts-66.2 Lymphs-28.4 Monos-2.2 Eos-2.9
Baso-0.4
[**2170-2-22**] 01:15AM BLOOD Plt Ct-543*
[**2170-2-22**] 01:15AM BLOOD PT-13.3 PTT-34.3 INR(PT)-1.1
[**2170-2-21**] 06:20AM BLOOD Plt Ct-437
[**2170-2-21**] 06:20AM BLOOD PT-13.6* PTT-31.6 INR(PT)-1.2*
[**2170-2-22**] 01:15AM BLOOD CK(CPK)-72
[**2170-2-22**] 01:15AM BLOOD cTropnT-2.63*
[**2170-2-22**] 01:15AM BLOOD Calcium-8.5 Phos-5.2*# Mg-2.0
[**2170-2-22**] 02:30AM BLOOD Type-ART PEEP-5 FiO2-100 pO2-124* pCO2-36
pH-7.43 calTCO2-25 Base XS-0 AADO2-570 REQ O2-92 Intubat-NOT
INTUBA Comment-NIV 14/5 1
[**2170-2-22**] 01:30AM BLOOD Comment-GREEN TOP
[**2170-2-22**] 01:30AM BLOOD Lactate-2.4*
Transthoracic Echocardiogram [**2170-2-19**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with severe
hypokinesis of the distal halves of the anterior septum,
anterior and inferior walls as well as apex. The remaining
segments contract normally (LVEF = 30-35 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] No masses or thrombi are
seen in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size 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. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction c/w multivessel CAD (mid-LAD and
PDA distributions). Increased PCWP. Moderate mitral
regurgitation. Pulmonary artery systolic hypertension.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibotor or [**Last Name (un) **].
Based on [**2166**] 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.
CXR [**2170-2-22**]
1. Pulmonary edema with effusions, progressive in comparison to
two days
prior.
2. Calcification of the ascending aorta that appears new from
recent prior
studies. Repeat chest radiograph is recommended to evaluate for
change in
contour of the ascending aorta.
[**2170-2-23**]: left hip plain films
Recent hip replacement. Clips are seen in the soft tissues.
Massive vascular calcifications. Normal position of the joint
replacement. No evidence of fracture or dislocation
[**2170-2-24**] Left hip ultrasound
Direct ultrasound examination was performed around the surgical
site in the anterior and posterior aspect of the left upper
thigh. Allowing for mild obscuration from the surgical dressing,
there is no large hematoma. There is expected mild
post-operative soft tissue edema. IMPRESSION: No large hematoma
seen around the left hip surgical site.
[**2170-2-24**]: CT abdomen and pelvis:
ABDOMEN: The liver, spleen, adrenal glands, and pancreas are
normal. The gallbladder is distended, maximum diameter of which
measures 4.7 cm. There is no pericholecystic fluid collection
and the gallbladder wall thickness is normal. No intra- or
extra-hepatic biliary duct dilatation seen. Simple cyst seen in
the mid pole of left kidney measuring 2.1 x 2 cm. The right
kidney is normal. No hydronephrosis. Extensive atherosclerotic
calcifications are seen in the abdominal aorta and the iliac
arteries. No free fluid. The IVC and aorta are of normal
caliber. No evidence of retroperitoneal hematoma.
PELVIS: Significant artifact seen in the lower pelvis from beam
hardening due to bilateral hip prosthesis. No free fluid seen in
the pelvis. Calcified fibroid seen in the uterus. Air noted
within the urinary bladder, likely secondary to Foley
catheterization. Scattered colonic diverticulosis without
evidence of diverticulitis. The visualized large bowel is
otherwise unremarkable.
There is a large hyperdense collection seen in the region of the
left gluteal muscle extending inferiorly along the posterior
aspect of the thigh. This measures approximately 9.5 x 6.2 x 4
cm. Given patient's recent left hip replacement, this likely
represents a hematoma and it measures 67 Hounsfield units. The
lowermost extent of the hematoma is not evaluated on this
examination. Bilateral total hip replacements noted.
Degenerative changes are seen in the thoracic or lumbar spine.
At L1-2 and
T12-L1, there is reduced disc space with vacuum phenomenon.
IMPRESSION:
1. Hyperdense collection in the left gluteal region extending
inferiorly
along the posterior aspect of the femoral shaft, representing
hematoma.
Findings were called to Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **] at 2:44 p.m. on [**2170-3-4**].
2. Bilateral moderate pleural effusions with atelectatic changes
of lung
bases.
Brief Hospital Course:
ASSESSMENT AND PLAN: in summary this is an 82 yo woman with a
history of type II diabetes, peripheral vascular disease,
hypertension, and hyperlipidemia recently admitted to the CCU
for respiratory distress in the setting of decompensated heart
failure and NSTEMI, now presenting for acute worsening of
shortness of breath.
# Hypoxia: Her hypoxia was likely secondary to flash pulmonary
edema in the setting of hypertension. It is not clear what
precipitated the hypertension, although she was documented to
have a systolic blood pressure of 180 upon arrival to the
emergency room. She was treated with supplemental oxygen,
intravenous lasix for diuresis and the dose of her metoprolol
was increased for better blood pressure control. Eventually with
this regimen her oxygen was weaned off and her respiratory
function improved significantly. She will be discharged on Lasix
40 mg daily and her renal function and electrolytes should be
followed at rehab and the lasix dosing adjusted accordingly. She
has been receiving prn [**Year (4 digits) 4319**] of [**9-26**] mg IV Lasix once daily to
help with diuresis, and she has responded very well to this
regimen. Her most recent creatinine is 0.7 to 0.8, with a BUN
ranging from 26 to 31.
# Hypertension: As above, metoprolol was adjusted during this
admission aiming for a target systolic blood pressure less than
130. She was continued on lisinopril 20 mg daily and the Lasix
dose was adjusted as above. With these treatments, her blood
pressure was consistently at target.
# Leukocytosis: On admission she had an elevated white count but
was afebrile without bandemia or localizing signs of infection.
She received one dose of levofloxacin in the emergency room but
this was discontinued and her white count normalized.
# Coronary artery disease: She is s/p perioperative MI with BMS
in LAD. This admission there were no new ischemic changes on
EKG. Her cardiac enzymes were downward trending from her prior
admission. She continued to take aspirin, plavix, simvastatin,
and metoprolol.
# Apical akinesis: She was noted to have apical akinesis on her
last echocardiogram and she was being anticouagulated with
coumadin for a six month course; however she developed a
hematoma in her left lateral gluteus following a fall; please
see CT findings above for full report. Orthopedics service was
consulted and felt that the hematoma had stopped bleeding; they
did not believe that surgical intervention was necessary, and
they felt that her anticoagualation could be resumed. Thus we
have restarted her coumadin, and due to the bleed we have
decreased the Lovenox dose to 40 mg daily (prophylactic dose
given the recent hip replacement), until her coumadin levels are
therapeutic. Dr. [**First Name (STitle) 437**] in cardiology clinic can decide on the
duration of anticoagulation and the plan for follow-up
echocardiogram. She has been referred to the heart failure
clinic with a plan to follow up with Dr [**First Name (STitle) 437**] as her outpatient
cardiologist. INR should be checked in rehab at the discretion
of the rehab physician, [**Name10 (NameIs) **] she should follow up with the
[**Hospital3 **] after discharge from rehab. Her most
recent INR was 1.0 on [**2-28**] (down from 1.2 and 1.4 on [**2-26**] and [**2-25**], respectively, in the setting of holding her
coumadin. Coumadin was restarted on [**2-27**] at a dose of 3 mg
daily.
# S/p left hip replacement: She had a left hip replacement at [**Hospital1 **]
[**Location (un) 620**] prior to her previous admission. Communication with her
orthopedic surgeon related that she was full weight-bearing and
she was evaluated by PT with a recommendation for rehab. She had
a fall without head trauma the day prior to her last discharge,
which she only informed the housestaff about on the day of her
readmission. At the time of this admission, it was noted that
she had a drop in hematocrit to 22 from her baseline of 30. She
was transfused two units of PRBCs. Heparin and Lovenox were
temporarily held. She had a CT abdomen/pelvis and was found to
have a bleed in her left lateral gluteus. She was seen by
orthopedics with a recommendation for conservative management;
they felt that the bleed would tamponade itself off, and given
her stable hematocrit and improving clinical exam, this was felt
to be the case. Her lovenox dose was decreased from 60 mg [**Hospital1 **] to
40 mg daily (prophylactic dose). Coumadin was restarted. She
received tylenol and morphine with a bowel regimen for pain
control. She will follow up with her orthopedic doctor [**First Name8 (NamePattern2) **] [**Location (un) 33570**] within 2 weeks of her hip replacement.
# Anemia: She had a fall in her hematocrit in the setting of her
left lateral gluteal hematoma. She was transfused 2 units of
blood and her hematocrit remained stable after that.
# Anxiety / history of depression: The patient previously had
been treated with Prozac 20 mg daily but refused this medication
during this and her previous hospitalization.
# Disposition: She is discharged to a rehab facility.
# Code Status: FULL.
Medications on Admission:
MEDICATIONS (at discharge on [**2-21**]):
- aspirin 325 mg qday
- clopidogrel 75 mg qday
- warfarin 3 mg qday
- simvastatin 80 mg qday
- multivitamin qday
- ranitidine 150 mg qday
- lisinopril 20 mg qday
- enoxaparin 60 mg qday
- acetaminophen 325 mg q6h prn
- metoprolol 50 mg sustained release qday
- Lasix (dose not clear)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
11. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day.
13. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO three times a day.
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
15. Oxycodone 5 mg Capsule Sig: [**12-9**] Capsules PO every six (6)
hours as needed for pain: please do not drink alcohol or perform
activities that require fast reaction while taking this
medication.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Rehab - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses
Acute Exacerbation of Chronic Heart Failure
Left Hip Hematoma
Secondary Diagnoses
Hypertensive Emergency
Coronary Artery Disease s/p MI with stent to LAD
S/p Left Hip Replacement
Discharge Condition:
Stable, alert and oriented to person, place and time.
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing. You were found to have worsening of your
heart failure in the setting of high blood pressure.
During this admission you were also found to have a bleed in
your left thigh. You received a blood transfusion, we decreased
the [**Location (un) 4319**] of some of your anticoagulation medicines, and the
bleeding stopped.
The following changes were made to your medications:
-we added furosemide 40 mg once daily
-we added trazodone 50 mg at bedtime as needed for insomnia
-we added Tylenol and oxycodone for leg pain (please only
continue the Tylenol for two weeks before re-evaluation by a
physician)
-we changed the Lovenox dose to 40 mg subcutaneous daily
-we changed the metoprolol to metoprolol succinate 150 mg daily
up more than 3 lbs.
Followup Instructions:
-Cardiology: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2170-3-5**] 9:00. [**Hospital Ward Name 23**] Building, [**Location (un) 436**], [**Location (un) **].
-Orthopedics: Dr [**Last Name (STitle) 44955**]: Tuesday [**2170-3-6**] at
11:30am [**Street Address(2) **], [**Location (un) 620**] Telephone: [**Telephone/Fax (1) 110040**]
-Primary care: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH[**MD Number(3) 708**]: [**Telephone/Fax (1) 3070**]
Date/Time:[**2170-3-5**] 11:20
Completed by:[**2170-3-1**]
|
[
"E878.1",
"428.23",
"V10.3",
"790.01",
"443.9",
"V45.82",
"288.60",
"272.4",
"V43.64",
"402.91",
"922.32",
"250.00",
"E888.9",
"410.72",
"414.01",
"428.0",
"424.0",
"518.0",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
18989, 19066
|
12186, 17289
|
322, 329
|
19307, 19363
|
5290, 8913
|
20233, 20847
|
4343, 4362
|
17665, 18966
|
19087, 19286
|
17315, 17642
|
19387, 20210
|
4377, 5271
|
8936, 12163
|
3262, 3434
|
274, 284
|
357, 3243
|
3456, 3878
|
3894, 4327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,190
| 191,465
|
26130
|
Discharge summary
|
report
|
Admission Date: [**2190-2-27**] Discharge Date: [**2190-3-7**]
Date of Birth: [**2123-5-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Episode of syncope, now referred for valve repair and cardiac
revascularization
Major Surgical or Invasive Procedure:
s/p CABG(SVG-OM, SVG-RCA)/AVR #21 pericardial [**3-2**]
History of Present Illness:
Mr. [**Known lastname 64824**] is a 66-year-old man who has known critical aortic
stenosis with worsening symptoms of syncope. He underwent
cardiac catheterization that showed
disease of his right coronary artery and his marginal branch
with disease far out of his left anterior descending. He is
presenting for aortic valve replacement and revascularization.
Past Medical History:
hypercholesterolemia
s/p vasectomy
Social History:
patient denies smoking, history of social ETOH use
Family History:
non-contributory. Father died at 80, mother alive/well at 88.
Physical Exam:
T 98.3 HR 64 BP 153/86 RR 18 SpO2 100%RA
PERRL, EOMI, good dentition, MMM, no JVD
(+)transmitted murmur to carotids b/l
RRR, (+)[**4-5**] holosystolic ejection murmur
CTA b/l
Abdomen soft, NT/ND
ext warm, 2+ femoral pulses b/l
CN II-XII grossly intact
Pertinent Results:
[**2190-2-28**] 05:50AM BLOOD WBC-6.6 RBC-4.80 Hgb-14.3 Hct-39.6*
MCV-83 MCH-29.9 MCHC-36.1* RDW-14.5 Plt Ct-125*
[**2190-2-28**] 05:50AM BLOOD PT-12.3 PTT-25.9 INR(PT)-1.1
[**2190-2-28**] 05:50AM BLOOD Plt Ct-125*
[**2190-2-28**] 05:50AM BLOOD Glucose-113* UreaN-14 Creat-1.0 Na-142
K-4.7 Cl-104 HCO3-29 AnGap-14
[**2190-2-28**] 05:50AM BLOOD ALT-65* AST-68* AlkPhos-53 TotBili-0.7
[**2190-2-28**] 05:50AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-1.9
[**2190-2-28**] 05:50AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
[**2190-2-27**] 11:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2190-2-27**] 11:58PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
Brief Hospital Course:
The patient was admitted to the hospital for pre-operative
work-up prior to surgery. A carotid ultrasound was obtained,
which showed less than 40% stenosis bilaterally. An
echocardiogram was obtained, and showed moderate thickening of
the aortic valve leaflets with severe aortic valve stenosis and
mild (1+) aortic regurgitation. The mitral valve leaflets were
also mildly thickened without evidence of regurgitation. The
decision was made to take the patient to the operting room on
[**2190-3-2**], where a CABG x2 (SVG->OM, SVG->RCA) was performed,
along with the placement of a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial tissue arotic valve. Please see operative note for
full details. The patient tolerated this procedure well.
Post-operatively, the patient was taken to the Cardiac Surgery
Recovery Unit. There, the patient did well. He was extubated on
post-op day #1. The PA catheter and chest tubes were removed on
post-op day #2. One unit of red blood cells was transfused for a
hematocrit of 25. The patient was transferred to the floor. On
post-op day #3, the patient's pacing wires were removed, and the
lopressor was increased. The patient was able to ambulate well,
and was discharged home with services on post-op day #5 in
stable condition.
Medications on Admission:
isosorbide 20mg PO QID
Atenolol 100mg PO QD
Aspirin 325mg PO QD
Multivitamin
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. 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*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 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 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
AS
s/p CABG/AVR
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incision with mild soap and
water
do not apply lotions, creams, ointments or powders to your
incisons
do not swim or take a bath for 1 month
do not drive for 1 month
do not lift anything heavier than 10 pounds for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 17234**] in [**2-1**] weeks
follow up with Dr. [**Last Name (STitle) 3659**] in [**2-1**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**4-3**] weeks
|
[
"V26.52",
"424.1",
"414.01",
"401.9",
"794.31",
"285.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.12",
"34.04",
"99.07",
"99.04",
"89.64",
"39.61",
"38.91",
"99.05",
"39.64",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
4320, 4369
|
2098, 3382
|
400, 457
|
4453, 4459
|
1342, 2075
|
4765, 4968
|
988, 1051
|
3509, 4297
|
4390, 4432
|
3408, 3486
|
4483, 4742
|
1066, 1323
|
281, 362
|
485, 846
|
868, 904
|
920, 972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,576
| 118,596
|
31282
|
Discharge summary
|
report
|
Admission Date: [**2162-5-4**] Discharge Date: [**2162-5-8**]
Date of Birth: [**2085-3-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
77M transferred from [**Hospital3 3583**] with choledocholithiasis,
elevated LFTs, RUQ pain.
Major Surgical or Invasive Procedure:
[**5-4**] - ERCP
[**2162-5-4**] - ERCP
[**2162-5-6**] - Lap cholectomy
History of Present Illness:
77M w/ CAD s/p [**Hospital **] transferred from [**Hospital3 3583**] with
choledocholithiasis, elevated LFTs, RUQ pain. Pain started 2
days prior to admission in RUQ after a pizza meal. Pain was
constant across the upper abdomen. Pt then had 4 episodes non
bilious no bloody emesis along with some chills, decreased
appetite.
Past Medical History:
Coronary Artery Disease, History of IMI, Cardiac Arrest in [**2139**]
s/p AVR [**2160**]
Ventricular Tachycardia
Hypercholesterolemia
Prostate Cancer - s/p Prostatectomy [**2144**]
Hernia Repair [**2150**]
Bleeding Ulcer [**2132**]
s/p IVC filter [**2159**]
DVT / PE
Social History:
Lives with wife, retired [**Name2 (NI) **]
20+ pack year history of tobacco but denies current use. He
denies ETOH.
Family History:
Mother and father died of heart attacks
Physical Exam:
On admission
T 97.9 HR 73 BP 108/48 RR 18 99% RA
Gen: alert, oriented x 3, scleral icterus
Pulm: b/l rales at bases
Card: RRR no M/R/G
Abd: mild distention, normal BS, soft, non tender
Pertinent Results:
[**2162-5-4**] 01:38PM BLOOD WBC-16.6* RBC-3.80* Hgb-10.9* Hct-33.6*
MCV-89 MCH-28.8 MCHC-32.6 RDW-14.1 Plt Ct-202
[**2162-5-4**] 02:00AM BLOOD WBC-20.6*# RBC-3.91*# Hgb-11.6*#
Hct-34.7*# MCV-89 MCH-29.7 MCHC-33.5 RDW-14.4 Plt Ct-197
[**2162-5-4**] 02:00AM BLOOD PT-15.9* PTT-28.5 INR(PT)-1.4*
[**2162-5-4**] 01:38PM BLOOD Glucose-84 UreaN-32* Creat-1.3* Na-141
K-4.1 Cl-108 HCO3-25 AnGap-12
[**2162-5-4**] 02:00AM BLOOD Glucose-122* UreaN-36* Creat-1.7* Na-140
K-4.4 Cl-105 HCO3-24 AnGap-15
[**2162-5-4**] 02:00AM BLOOD ALT-169* AST-126* AlkPhos-235*
TotBili-5.5*
[**2162-5-4**] 01:38PM BLOOD ALT-125* AST-86* AlkPhos-199* Amylase-37
TotBili-3.8*
ERCP [**2162-5-4**]
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire. Sphincteroplasty
was done with a CRE balloon to 13.5 mm to extend the
sphincterotomy opening. Frank pus was seen to flow out freely
from the ampulla.
6 large stones were extracted successfully using a balloon.
Spiral basket was used to sweep and clear the duct.
Impression: The major papilla looked normal. Purulent bile was
seen to flow out of the papilla.
Cholangiogram revealed a grossly dilated bile duct measuring at
least 2 cm with multiple large filling defects.
Wire guided sphincterotomy and balloon sphincteroplasty (13.5
mm) was performed.
Bile duct sweeped with a balloon and a spiral basket.
6 large stones were extracted successfully using a balloon.
Clear duct after removing stones.
Brief Hospital Course:
The patient was admitted to the ICU from the ED for intense
monitoring. He was made NPO, IVF for hydration, foley catheter
inserted, and started on IV unasyn. An ERCP was performed and
the results listed above. He tolerated the procedure well and
was transferred back to the ICU for further monitoring. He
remained NPO, IVF for hydration, continued on unasyn.
[**5-5**]: transferred to the floor, diet advanced as tolerated
[**5-6**]: The patient underwent a laparoscopic cholecystectomy. He
tolerated the procedure well and was transferred to 12Reisman
for continued monitoring. His diet was started at clears, IVF
for hydration, continued on IV unasyn.
[**Date range (1) 73789**]: The patient remained hemodynamically stable and
improved post-operatively until his pain had almost completely
dissipated, and he was at this baseline functional status, at
which time he was discharged from the hospital in a stable
condition.
Medications on Admission:
colace prn
ASA 81mg po qd
Metoprolol 25mg PO BID
Zocor 10mg PO qd
Norvasc 5mg qd
Lisinopril 5mg PO qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: Take with
food.
Disp:*35 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: Take with Percocet.
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days: Take with food.
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceed 4000mg in 24
hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cholangitis
Cholelithasis
Bacteremia
.
Secondary:
CAD s/p CABG x4, AVR [**2160**], prostate Ca s/p prostatectomy [**2144**],
hyperchol, hernia repair [**2150**], VT, IVC filter [**2159**], DVT/PE(was
on warfarin tills topped 6mos. ago)
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or 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.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) 1924**] to make a follow up
appointment in [**12-27**] weeks [**Telephone/Fax (1) 7508**]
.
Please call the office of Dr. [**Last Name (STitle) 23388**] to make a follow up
appointment in 1 week and as needed.
|
[
"412",
"V10.46",
"584.9",
"576.1",
"V43.3",
"401.9",
"V45.81",
"414.00",
"574.80",
"V12.51",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.23",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
5012, 5018
|
3047, 3983
|
405, 479
|
5307, 5385
|
1541, 3024
|
6601, 6866
|
1277, 1318
|
4135, 4989
|
5039, 5286
|
4009, 4112
|
5409, 6240
|
6255, 6578
|
1333, 1522
|
273, 367
|
507, 837
|
859, 1127
|
1143, 1261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,704
| 179,297
|
52076+52077
|
Discharge summary
|
report+report
|
Admission Date: [**2165-7-26**] Discharge Date:
Date of Birth: [**2097-1-31**] Sex: M
Service: C-MEDICINE
CHIEF COMPLAINT: Transferred for cardiac catheterization.
HISTORY OF PRESENT ILLNESS: This is a 68 year old man with
coronary artery disease, status post coronary artery bypass
graft, hypertension, hyperlipidemia, diabetes mellitus, who
presented to [**Hospital3 36606**] Hospital for sharp [**11-15**] back
pain between scapulae. No radiation of pain or shortness of
breath or palpitations associated. He had a similar episode
of back pain prior to his coronary artery bypass graft
approximately twenty years ago. He has not had a recurrence
of the back pain until approximately one to two months ago
when he started developing back pain with exertion. This
pain was relieved with rest. It has never been associated
with shortness of breath, palpitations, diaphoresis, nausea
or vomiting. On the day of admission, he had one episode of
the [**11-15**] back pain which occurred while at rest.
At the outside hospital, a CT angiogram was performed which
was negative for dissection. He was found to have evolving
Electrocardiographic changes with T wave inversions initially
in V1 through V3 which then developed within ten hours to
include V1 through V6 as well as I and aVL. He was started
on Nitroglycerin, Lovenox and given one dose of Lasix and
sent to [**Hospital1 69**] for
catheterization.
On presentation to [**Hospital1 69**], he
was pain free for the last few hours. He had one episode of
[**2-15**] back pain which occurred during transient which was
relieved with one sublingual Nitroglycerin. He currently is
pain free.
REVIEW OF SYSTEMS: He does complain of bilateral lower
extremity edema over the last weeks to months. He has had no
recent change in weight. No change in bowel or bladder
function. No bright red blood per rectum or melena. No
fever, chills, nausea, vomiting, no recent cough or trauma to
the back.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft approximately twenty years ago. Anatomy is
unknown. Report of exercise treadmill test in [**2162**], showing
ischemic electrocardiographic changes lateral apex and
posterior wall, however, this could not be confirmed with a
report.
2. Diabetes mellitus.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Status post cholecystectomy.
6. Hyperlipidemia.
7. Status post left rotator cuff repair.
8. Carotid ultrasound [**2165-1-6**], showing no hemodynamic
limiting stenoses.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (On transfer and home
medications):
1. Diltiazem XT 360 mg p.o. once daily.
2. Dipyridamole 50 mg p.o. three times a day.
3. Zestril 60 mg p.o. once daily.
4. Hydralazine 50 mg p.o. three times a day.
5. Aspirin 325 mg p.o. once daily.
6. Atenolol 100 mg p.o. once daily.
7. Protonix 40 mg p.o. once daily.
8. Hydrochlorothiazide 25 mg p.o. once daily which is new
since [**2164**], and held at outside hospital.
9. Lipitor 20 mg p.o. once daily.
10. NPH 24 units q.a.m. and 27 units q.h.s.
11. Humalog 5 units q.a.m. and 6 units q.p.m.
12. Glucophage 1000 mg p.o. twice a day on hold.
SOCIAL HISTORY: The patient denies any significant tobacco
use although did smoke occasional cigar multiple years ago.
No alcohol use. He did have a son die suddenly at age 39
years. He has multiple children in the area and they are
very supportive family.
PHYSICAL EXAMINATION: On presentation, vital signs revealed
temperature 98.6, blood pressure 112/47, heart rate 47,
oxygen saturation 94% in room air, respiratory rate 18. In
general, the patient is in no apparent distress. He is
comfortable, breathing in room air, well developed, well
nourished. On head, eyes, ears, nose and throat examination,
mucous membranes are moist. The oropharynx is clear. The
patient is normocephalic and atraumatic. Sclera were
anicteric. Neck was supple without lymphadenopathy. Jugular
venous distention approximately eight centimeters above
sternal notch. Chest - The lungs were clear to auscultation
bilaterally. Cardiovascular - regular rate, II/VI systolic
murmur present at the left sternal border. No S3 or S4 were
noted. The abdomen was obese, soft, nontender, nondistended,
normoactive bowel sounds, no hepatosplenomegaly was noted.
The extremities demonstrated 1 to 2+ bilateral lower
extremity pitting edema. Back examination demonstrated no
costovertebral angle or paraspinal tenderness to palpation.
No reproducible back pain. On neurologic examination, he is
alert and oriented times three, grossly intact.
LABORATORY DATA: On admission, white blood cell count was
10.0, hemoglobin 12.7, hematocrit 38.4, platelet count
238,000, MCV 88. INR 1.1. Sodium 137, potassium 4.4,
chloride 102, bicarbonate 24, blood urea nitrogen 28,
creatinine 1.1, glucose 218,000.
Electrocardiogram on admission to [**Hospital1 190**] showed normal sinus rhythm with a rate of 46
beats per minute, T wave inversion in V1 through V6, I and
aVL consistent with electrocardiogram performed at outside
hospital approximately 19 hours before. Right bundle branch
block was noted which on reviewing previous notes has been
present in the past.
IMPRESSION: This is a 68 year old man with coronary artery
disease, status post coronary artery bypass graft
approximately twenty years ago, diabetes mellitus,
hypertension, hyperlipidemia, who presents with anginal
equivalent of back pain, starting approximately one to two
months ago associated with exertion. Now with one episode of
back pain at rest and electrocardiographic changes consistent
with unstable angina.
HOSPITAL COURSE:
1. Cardiovascular disease - coronary artery disease - The
patient was transferred from outside hospital for unstable
angina with anterolateral electrocardiographic changes. On
arrival, he was pain free with his anginal equivalent being
back pain. He was continued on his intravenous Heparin and
Nitroglycerin without incident. Cardiac enzymes were
continued to be cycled and he was noted to have an increase
in his CK from 89 at outside hospital to as high as 145. His
troponin, however, bumped from less than 0.4 initially to
13.3 on arrival at [**Hospital1 69**].
This, however, trended down.
He had one episode of back pain [**4-15**] in intensity on hospital
day number two which was relieved after approximately five
minutes with an increase in his Nitroglycerin. Although he
states that the pain is in a similar location, it was felt
that it was most likely musculoskeletal in origin given that
it was not as intense, relieved with very little
intervention, and no electrocardiographic changes were
present simultaneously. Nevertheless, cardiac enzymes
continued to be cycled and were pending at the time of this
dictation.
Given that he remained relatively pain free throughout the
first two hospital days, it was planned for a cardiac
catheterization on Monday, [**2165-7-29**]. Should he become
unstable in the interim, an emergent cardiac catheterization
and/or addition of Integrilin to his medication regimen will
be considered.
He was continued on Aspirin and Lipitor, however, his
Dipyridamole was held secondary to possible inducible
ischemia from the medication. As well, his Diltiazem was
held given his acute coronary syndrome.
Lopressor was administered infrequently given his relative
bradycardia with heart rate in the 40s.
Congestive heart failure - He was diuresed at outside
hospital prior to transfer for mild congestive heart failure
with lower extremity edema and mild decrease in oxygen
saturation. Chest x-ray was performed which showed no
evidence of cardiomegaly without any evidence of acute
congestive heart failure. He was continued on Zestril,
Hydralazine and Hydrochlorothiazide. Of note, his oxygen
saturation remained in the mid 90s during the first two days
of hospitalization.
Cardiac rhythm - He did have sinus bradycardia which appears
to be chronic per his OMR notes. He was relatively
bradycardic even from his baseline with heart rate in the 40s
on presentation. This improved slightly and his Lopressor
was given as tolerated for heart rate greater than 55.
2. Endocrinology - His Glucophage was held secondary to
planned cardiac catheterization. He was continued on home
insulin regimen and Humalog insulin sliding scale.
3. Renal - His creatinine was 1.1, however, given his
unknown baseline, he will be given two doses of Mucomyst
prior to cardiac catheterization as well as prehydrated.
The remainder of hospital course including cardiac
catheterization results will be dictated in discharge summary
addendum which will include discharge diagnoses and
medications.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2165-7-27**] 14:38
T: [**2165-7-27**] 14:58
JOB#: [**Job Number 72066**]
Admission Date: [**2165-7-26**] Discharge Date: [**2165-8-4**]
Date of Birth: [**2097-1-31**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 68-year-old
gentleman who had a history of hypertension,
insulin-dependent diabetes, elevated lipids, and coronary
artery disease, status post CABG about 20 years ago. He
presented to the hospital earlier on [**2165-7-26**] for the
complaint of sharp chest pain. There was no shortness of
breath, no palpitations. This chest pain is similar to his
prior symptoms of MI. On workup in the Emergency Room at the
outside hospital, chest CT angiogram was negative for
dissection and found to have elevated EKG changes for which
he was started on nitroglycerin, Lovenox, and Lasix and sent
to [**Hospital6 256**] for catheterization
study.
PAST MEDICAL HISTORY: As indicated above.
PAST SURGICAL HISTORY: Status post CABG [**82**] years ago.
ALLERGIES: The patient has no known drug allergies.
AT-HOME MEDICATIONS:
1. Cartia XL 360.
2. Persantine 50 t.i.d.
3. Zestril 60 q.d.
4. Hydralazine 50 three times a day.
5. Aspirin 325 once a day.
6. Atenolol 100 once a day.
7. Protonix 40 once a day.
8. Hydrochlorothiazide 25 once a day.
9. Lipitor 20 a day.
10. NPH 24, Humalog 5 units in the morning, NPH 27 in the
evening, Humalog 6 units in the evening.
11. Glucophage 1,000 b.i.d.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Medical Service for workup of symptoms of acute myocardial
infarction. On workup, he received an echocardiogram which
showed an EF of 70% and he was taken to the catheterization
laboratory which showed severe three vessel disease. He was
then taken to the Operating Room on [**2165-7-30**] for an
emergent coronary artery bypass operation. This was a three
vessel CABG redo with vein graft to LAD, ramus, and PDA. The
pump time was 73 minutes and cross clamp time was 62 minutes
and he tolerated the procedure well. He was transferred to
the CSRU in stable condition, intubated.
In the CSRU, he did well and essentially started to be
diuresed and was put on Lopressor for blood pressure control.
He was successfully transferred to the floor on [**2165-8-2**]. His recovery course was essentially unremarkable. The
blood pressure was well controlled. His blood sugar was also
well controlled.
He was seen by Physical Therapy who cleared him for level V
activity and he is discharged to home on [**2165-8-4**].
DISCHARGE MEDICATIONS: The patient was instructed to restart
his home medication except Persantine and Plavix. The blood
pressure control has been effective with his home
medications, antihypertensive medication regimen, and Lasix
40 t.i.d. and a prescription for Lasix and potassium was
given to him at the time of discharge and also Dilaudid for
pain medication, and Colace for constipation as needed.
DISCHARGE INSTRUCTIONS: The patient is instructed to call
his cardiologist for follow-up within the next two weeks for
antihypertensive medication adjustment and he was also
instructed to call Dr.[**Name (NI) 3502**] office for surgical
postoperative follow-up.
DISPOSITION: The patient was discharged to home in stable
condition.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft re-do.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 6276**]
MEDQUIST36
D: [**2165-8-4**] 11:02
T: [**2165-8-4**] 11:28
JOB#: [**Job Number 107789**]
|
[
"593.9",
"414.02",
"414.01",
"410.71",
"428.0",
"401.9",
"272.0",
"414.04",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.13",
"37.22",
"39.61",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
11527, 11910
|
12268, 12606
|
2625, 3221
|
10440, 11503
|
11935, 12246
|
9933, 10028
|
10046, 10422
|
3505, 5689
|
1695, 1979
|
144, 186
|
215, 1675
|
9888, 9909
|
3238, 3482
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,842
| 153,603
|
33384
|
Discharge summary
|
report
|
Admission Date: [**2138-4-7**] Discharge Date: [**2138-4-16**]
Date of Birth: [**2080-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache past ten days
Major Surgical or Invasive Procedure:
Image guided right craniotomy for tumor resection
History of Present Illness:
Mr. [**Known lastname **] [**Known lastname **] is a 57 y/o male who was in good health until
10 days ago, when he began having gradually worsening headaches.
These were right-sided and throbbing and initially controlled
with over the counter analgesics, but are now refractory to
these. He has had no visual changes in association, no N/V or
drowsiness. He does not appreciate worsening with cough/strain
or
sneezing. The patient denies other difficulties, such as
weakness, numbness/tingling, visual loss or diplopia, speech
abnormalities, gait difficulties, vertigo, dysarthria or
dysphagia. He was taken to an outside hospital today, where head
CT revealed an intracranial mass lesion. He was given decadron
and sent to [**Hospital1 18**] ER.
Past Medical History:
renal cell carcinoma s/p L nephrectomy in [**2129**], no xrt/chemo
Social History:
lives with his daughter. Infrequent EtOH use. Quit smoking
25yrs ago. No IVDU
Family History:
negative for past malignancies
Physical Exam:
VS 97.9 60 150/100 12 97%
Gen Awake, cooperative, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO EXAM
MS Awake, alert and oriented x 3. Speech fluent, with normal
naming, [**Location (un) 1131**], comprehension and repetition. Able to follow
both midline and appendicular commands. No apraxia. No
dysarthria.
CN I: not tested
CN II: Visual fields were full to confrontation, but with
extinction on the left to double simultaneous stimulation.
Pupils
4->2 b/l.
CN III, IV, VI: EOMI no nystagmus or diplopia
CN V: intact to LT throughout;
CN VII: slight L NLF flattening and asymmetry
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**4-28**] and symmetric
CN XII: tongue midline and agile
Motor
Normal bulk and tone. No pronator drift
D B T WE FE FF IP Q H DF PF TE
L 5 5 5 5 5- 5 5 5 5 5 5 5
Sensory intact to light touch, pinprick, joint position sense,
vibration throughout. No extinction to double simultaneous
stimulation.
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2 2 2 2 1 down
R 2 2 2 2 1 down
Coordination Fine finger movements, rapid alternating movements,
finger-to-nose, and heel-to-shin were all normal
Pertinent Results:
[**2138-4-7**] 04:30PM PT-12.6 PTT-26.8 INR(PT)-1.1
[**2138-4-7**] 04:30PM PLT COUNT-156
[**2138-4-7**] 04:30PM NEUTS-87.7* LYMPHS-10.9* MONOS-1.0* EOS-0.3
BASOS-0.1
[**2138-4-7**] 04:30PM WBC-6.7 RBC-5.41 HGB-15.8 HCT-47.0 MCV-87
MCH-29.2 MCHC-33.7 RDW-13.2
[**2138-4-7**] 04:30PM estGFR-Using this
[**2138-4-7**] 04:30PM GLUCOSE-107* UREA N-19 CREAT-1.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
MR HEAD W & W/O CONTRAST [**2138-4-8**] 5:37 AM
MR HEAD W & W/O CONTRAST
Reason: evaluate lesion
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with intracranial mass lesion
REASON FOR THIS EXAMINATION:
evaluate lesion
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 57-year-old mid patient, with endocranial mass
lesion, to evaluate lesion.
PRIOR STUDIES: CT of the head done on [**2138-4-7**].
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the head
was performed without and with IV contrast.
FINDINGS:
There is a large heterogeneous mass lesion, in the right
temporoparietal lobes, with areas of hemorrhage, cystic change,
necrosis and large solid enhancing component. The solid
competent measures 5.0 x 4.3 cm. There is entrapment of the
right temporal [**Doctor Last Name 534**]. There is surrounding significant vasogenic
edema, with a leftward shift of subfalcine herniation; measuring
approximately 1 cm is unchanged, allowing for technical
differences, compared to the prior CT. Mass effect on the right
lateral ventricle, is unchanged. There is a 1.7 x 1.6 cm round
focus of increased signal on the FLAIR, with enhancement on the
post-contrast images in the left parapharyngeal space, which
corresponds to an abnormally enlarged lymph node, on correlation
with the CT angiogram performed on the same day (series 9, image
1), however, this is not completely included on our present
study.
IMPRESSION:
1. Large heterogeneous mass lesion in the right parietal and
temporal lobes, with cystic, necrotic, hemorrhagic and solid
components, the solid competent measuring 5.0 cm, with
significant surrounding edema, mass effect and subfalcine
herniation, and entrapment of the right temporal [**Doctor Last Name 534**] without
significant change since the CT head done the day before.
2. 1.7-cm enhancing focus in the left parapharyngeal region,
representing an abnormally enlarged lymph node, representing
metastatic involvement. However, this is not completely included
on our present study.
MR HEAD W & W/O CONTRAST [**2138-4-13**] 2:41 PM
MR HEAD W & W/O CONTRAST
Reason: residual mass?
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with parietal mass s/p resection
REASON FOR THIS EXAMINATION:
residual mass?
CONTRAINDICATIONS for IV CONTRAST: None.
GADOLINIUM-ENHANCED MR SCAN OF THE BRAIN
HISTORY: Status post resection of right parietal mass. Assess
for residual tumor.
TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was
obtained pre- and post-gadolinium administration.
COMPARISON STUDY: MR scan of the brain from [**2138-4-8**].
FINDINGS: There is a lace-like pattern of enhancement along the
anteromedial aspect of the right temporal lobe, apparently
surrounding the right temporal [**Doctor Last Name 534**] body. There is persistent
mild dilatation of the right temporal [**Doctor Last Name 534**] tip, but
substantially reduced in extent compared to the prior
preoperative study. Additionally, there is presumed hemorrhage
along the operative tract, more peripherally situated within the
posterior aspect of the right temporal lobe.
The extensive edema surrounding the formerly very large tumor
appears unaltered in extent. However, overall, there is somewhat
less mass effect, though there is still leftward subfalcine
herniation present. Numerous tiny areas of elevated T2 signal
are seen within the white matter of both cerebral hemispheres,
presumably representing chronic small vessel infarctions or
post- inflammatory residua.
There is soft tissue swelling, subgaleal in locale at the
craniotomy site and there is a possible fluid collection or
surgical material within the crescent- shaped space between the
dura spanning the craniotomy flap and the inner table of the
flap itself.
There is redemonstration of the well- defined, rounded 21 mm
area of contrast enhancement in the left parapharyngeal fat
area. Its sharp margination seems most consistent with a benign
neoplastic process (question neurogenic tumor). This location
would be very unusual for a lymph node or metastatic disease, as
was suggested on the previous report.
CONCLUSION: Findings suggest that there is residual tumor in the
region of the right temporal lobe surrounding the right temporal
[**Doctor Last Name 534**], with mild residual entrapment of this portion of the right
lateral ventricle, as described above.
Pathology pending at time of discharge
Brief Hospital Course:
The patient was admitted to the neurosurgery service with an
intraventricular mass in the ICU for close monitoring. He was
started on Decadron and dilantin. An [**Doctor Last Name 4338**] was obtained to further
characterize the lesion. A staging CT of the torso was obtained
which showed metastasis to the lungs, left hilum, and spine. He
was hydrated with bicarb fluids and given Mucomyst for renal
protection prior to the CT scans. On HD#2 he was transferred to
the neuro step down unit. A WAND study was obtained for image
guidance of the resection. He was taken to the OR for resection
of the brain mass on HD#5. He tolerated the procedure well and
initially recovered in the PACU. He was extubated in the PACU
without difficulty. He was then transferred to the neurosurgery
step down unit. On POD#1 a repeat [**Doctor Last Name 4338**] was obtained which showed
no bleeding. He was then transferred to the floor. On POD#2 his
diet was advanced, his Foley was removed and he was seen by
PT/OT. His Decadron was weaned to 2 mg TID. He was seen by
oncology and radiation oncology who recommended follow up in the
brain tumor clinic and the biologics clinic. These appointments
were set up for the patient. His antibiotics were stopped on
POD#4. On POD#5 he was tolerating a regular diet, he had had a
bowel movement, he was voiding without difficulty and he was
cleared by PT for home. He was discharged home with follow up
instructions.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid ().
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Brain tumor
Discharge Condition:
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
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**5-3**] DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES CALL [**Telephone/Fax (1) **] to schedule an appointment
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
Additional appointments:
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-5-2**] 2:35
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2138-5-5**] 4:00
[**Hospital 29684**] Clinic on [**2138-4-23**] at 3PM. They will send you a letter
with instructions
|
[
"198.3",
"V10.52",
"348.4",
"198.5",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
9914, 9920
|
7861, 9311
|
341, 392
|
9975, 9983
|
2952, 3507
|
11369, 12001
|
1373, 1406
|
9366, 9891
|
5590, 5639
|
9941, 9954
|
9337, 9343
|
10007, 11346
|
1421, 2933
|
278, 303
|
5668, 7838
|
420, 1171
|
1193, 1262
|
1278, 1357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
808
| 125,152
|
3777
|
Discharge summary
|
report
|
Admission Date: [**2181-5-30**] Discharge Date: [**2181-6-6**]
Date of Birth: [**2126-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
Pericardiocentesis
Balloom Pericardiotomy
IVC Filter Placement
History of Present Illness:
54 F wiht h/o HTN, asthma, recent admission to CCU for
pericardial/pleural effusion and tamponade presents from home
after episode of syncope this morning. Patient was walking to
the bathroom and felt dizzy, then found on the floor by her
husband. She does not know if she hit her head but reports right
buttock pain from the fall. Since her discharge she has been
feeling "tired" and has had a poor appetite but denies any chest
pain or shortness of breath. She has been getting around her
apartment easily. She endorses "tightness" with deep
inspiration. Otherwise no fever, chills, GI, or GU complaints.
.
Patient initially presented with DOE and right flank pain and
was evaluated by her PCP found to have cardiomegaly on CXR.
Subsequent [**First Name3 (LF) 113**] showed a large pericardial effusion with
tamponade physiology. She was admitted to the CCU from [**5-11**] to
[**5-16**] s/p periocardiocentesis. Patient also underwent right sided
thoracentesis. Both sources are showing evidence of a highly
differentiated adenocarcinoma. Patient was discharged with PCP
follow up and ongoing workup. CT of the abd/pelvis did not
reveal a source but did reveal some bony lytic lesions in the
right ischium and bilateral ilia concerning for metastatic
disease. Of note, she also is known to have a large common
femoral DVT.
.
In the ED, VS 97.5 113 86/68-->106/59 94% RA-->98% NRB. Bedside
[**Month/Day (4) 113**] showing large pericardial effusion. Given 1L NS and taken
to cath lab for urgent pericardiocentesis.
Past Medical History:
- Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in
[**2162**].
- GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age
50, normal pap's per patient
- Hypertension.
- History of mild asthma, inhalers not used for several years.
- normal mammogram less than one year ago.
- normal colonoscopy 2/[**2178**].
- recent pericardial effusion/tamponade
- right pleural effusion
- adenocarcinoma of unclear primary
Social History:
She works as a nursing assistant. Lives with her husband, who
keeps very early hours, working at the [**Location (un) **] food market.
Children are 18 and 19.
Family History:
Her father died of stomach cancer at age 72. Mother died of
colon cancer at age 63. She is the 10th of 13 children. She has
lost 3 siblings to motor vehicle accidents.
Physical Exam:
VS: T:98.0 BP: 117/75 HR: 112 RR: 23 O2: 98%RA
Gen: NAD, lying flat in bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, JVP to jaw lying flat
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. ?rub with one component, pericardial drain in
place
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA anteriorly.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: Dry, no stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
EKG [**5-30**]: sinus tachy at 118 bpm, nl axis, nl intervals, no ST-T
changes, normal voltage. Unchanged compared to [**2181-5-11**]
.
Admission Labs:
K:4.3
PT: 12.4 PTT: 23.9 INR: 1.1
135 104 8
-------------< 128
4.3 25 0.8
CK: 102 MB: 1 Trop-T: <0.01
LDH 805
TProt: 6.9
.
14.1
7.4 >----< 278
43
N:74 Band:0 L:20 M:5 E:1 Bas:0
.
PERICARDIAL FLUID
Other Body Fluid Chemistry:
TotProt: 5.9
Glucose: 42
LD(LDH): 1566
Amylase: 13
Albumin: 3.1
.
PERICARDIAL FLUID
Other Body Fluid Hematology:
WBC: 2488
RBC: [**Numeric Identifier 16981**]
Polys: 75
Lymphs: 13
Monos: 9
Eos: 1
Macro: 2
Negative for malignant cells.
.
AP PELVIS: No fracture or dislocation is identified within the
single view. No pubic symphysis or SI joint diastasis is
detected.
.
CXR [**5-30**]:
Single AP chest radiograph demonstrate hazy opacity within the
right lung base likely representing atelectasis vs air space
disease. Small right pleural effusion is present. Compared to
prior radiograph from [**2181-5-15**], there is moderate cardiac
enlargement, concerning for pericardial effusion.
IMPRESSION:
1. Opacity in right lung base concerning for atelectasis vs
airspace
disease. Small right pleural effusion.
2. Compared to prior radiograph from [**2181-5-15**], there is
moderate increase in cardiac size, concerning for pericardial
effusion.
.
Urgent [**Year (4 digits) **] [**5-30**]:
Large pericardial effusion. Effusion circumferential. Stranding
is visualized within the pericardial space c/w organization. RV
diastolic collapse, c/w impaired fillling/tamponade physiology.
GENERAL COMMENTS: Emergency study performed by the cardiology
fellow on call
.
post procedure [**Month/Year (2) **] [**5-31**]: Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
.
Repeat [**Month/Year (2) **] [**6-4**]:Compared with the prior study (images reviewed)
of [**2181-6-2**], there is probably no signficant change. A
loculated pericardial effusion with constriction should be
considered.
.
Endoscopy [**6-4**]:Gastro esophageal junction mucosal biopsy:
Gastric type mucosa with chronic active inflammation.
Very focal intestinal metaplasia consistent with Barrett's
esophagus in the appropriate clinical setting.
No dysplasia.
Squamous mucosa with focal active inflammation
.
Colonoscopy [**6-5**]: No masses or polyps seen. External
hemorrhoids.
Brief Hospital Course:
Pt is a 54 y/o woman here with recurrent malignant pericardial
effusion. Hospital course by problem:
.
# Malignant Effusion. s/p pericardiocentesis and balloon
pericardiotomy with removal of 520 cc of bloody fluid. Patient
with known highly differentiated adenocarcinoma of unknown
primary. Fluid analysis suggested exudative fluid and cytology
again pending. An [**Month/Year (2) 113**] on [**6-1**] showed partial resolution of
part of the pericardial effusion, but persistance of a loculated
effusion. It was felt that the drain should be pulled and an
[**Month/Year (2) 113**] repeated on [**6-2**] showed no progression. [**Month/Year (2) **] on [**6-4**] showed
stable loculated pericardial effusion.
.
# Mucinous adenoca unknown primary: The heme/onc team was
consulted during admission and workup to determine source was
undertaken. Endoscopy and colonoscopy were performed without
evidence of malignancy.
.
# DVT - large VTE in common femoral artery extending to IVC
found on CT scan. On discharge from recent hospitalization she
was briefly anticoagulated. This was stopped however given
concerns for recurrence of pericardial effusion. We reviewed
recent CT scan and decided to place an IVC filter on day of
admission to help prevent spread of DVT into the pulm
vasculator. The risks/benefits of anticoagulation were
considered and we opted to start heparin gtt with close
monitoring of her hemodynamics and pericardial output. Shortly
after the IVC filter placement, she experience right sided
pleuritic chest pain. This was thought to be a PE. Her oxygen
requirement did not increase but she remained mildly
tachycardic. She was continued on heparin. The heparin was held
for 24 hours after the drain was pulled. The patient was
restarted on SubQ Heparin and instructed on the use of Levonox
to continue on discharge.
.
# Right buttock pain: patient with lytic lesions found on CT
scan thought likely malignant. AP pelvis negative for fracture.
.
# Syncope - likely due to large pericardial effusion and
tamponade physiology
.
# CAD: no known CAD
.
# HTN: Held meds given tamponade, remained normotensive
throughout admission.
.
# Code: changed to DNR DNI after discussion between patient and
PCP shortly after admission.
Medications on Admission:
ALLERGIES: NKDA
.
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-12**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
Disp:*1 Spray* Refills:*0*
4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 syringe* Refills:*2*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Please apply one patch to site of pain daily,
leave on for 12 hours and then remove for 12hrs.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Mucinous Adenocarcinoma of unknown primary
Malignant pericardial effusion
Cardiac Tamponade
Venous Thromboembolism of common femoral artery and inferior
vena cava
Discharge Condition:
Stable, with normalized cardiac and respiratory function.
Discharge Instructions:
You have been treated for malignant pericardial effusion and
tamponde with a pericardiocentesis and balloon pericadiotomy.
The effusion was the result of an adenocarcinoma of unknown
etiology. Further studies were performed to evaluate for the
source of malignancy. On evaluation it was found that you have a
DVT and you were started on Lovenox.
.
For you chest pain you were stared on a LIdocaine patch. You may
also take Tylenol (up to 4g daily). We also prescribed you
Percocet as needed. Please watch out for constipation when
taking the Percocet.
.
Please do not take your blood pressure medication until
otherwise instructed by your cardiologist.
.
Please return to the hospital or see you primary care physician
if you experience any fevers, chills, shortness of breath,
lightheadedness or if you have any other concerns.
Followup Instructions:
The following appointments have been arranged for you:
Please follow-up with Dr. [**Last Name (STitle) **] on Monday [**2181-6-11**] at 10AM
on the [**Location (un) **] of the [**Hospital Unit Name 723**]. Please call
1-[**Telephone/Fax (1) 6568**] if you have any questions.
You have follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 16982**] on
[**2181-6-12**] at 10:30am. Phone:[**Telephone/Fax (1) 22**]
.
You also have the following appointments:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2181-7-25**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2181-9-18**] 9:40
|
[
"493.90",
"198.5",
"197.2",
"E878.8",
"453.2",
"415.11",
"530.85",
"401.9",
"420.90",
"453.41",
"199.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.7",
"37.12",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
9523, 9529
|
5991, 6065
|
322, 409
|
9736, 9796
|
3439, 3575
|
10674, 11472
|
2629, 2798
|
8678, 9500
|
9550, 9715
|
8267, 8655
|
9820, 10651
|
2813, 3420
|
275, 284
|
6093, 8241
|
437, 1956
|
3591, 5968
|
1978, 2436
|
2452, 2613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,457
| 169,960
|
8790
|
Discharge summary
|
report
|
Admission Date: [**2153-1-6**] Discharge Date: [**2153-2-14**]
Date of Birth: [**2106-5-1**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins / Haldol / Cellcept / Vancomycin /
Amitriptyline / Iron / Reglan / Amikacin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Bacteremia
Major Surgical or Invasive Procedure:
RIJ portacath removed, RIJ TPL placed
History of Present Illness:
46 year-old male c ESRD s.p renal tpl x 4, HCV, HTN, aortic
stenosis who is transferred from NH with bacteremia. Port was
placed at [**Hospital3 68**] on [**12-16**] for ARF from dehydration
from nausea and vomiting. On [**1-2**] he spiked a fever of 101.9;
blood cultures were positive for MRSA on [**1-2**] and group D
enterococcus. Initial urine cx with group D enterococcus;
subsequent was negative. He was started on daptomycin. His
anti-hypertensive regimen was increased. With IVF his Cr went
from 3.3 to 2.6 on transfer. He was transfused 2 units pRBCs on
[**12-18**].
.
Of note, pt had a recent hospitalization [**2152-11-24**] -> [**2152-12-3**]. He
was transferred to [**Hospital1 18**] from an OSH for worsening renal failure
and hypotension, felt to be possibly due to orthostasis. Here,
he was found to have MRSA in his urine which was treated with
linezolid (last dose planned for [**12-15**]). He was in renal failure
at the OSH and required HD. Here his peak Cr was 4.0 (felt to be
due to bactrim, which was initially used to treat his MRSA) and
it was felt that he had a prerenal azotemia in addition to drug
toxicity. His cyclosporine levels were elevated as well, which
may have contributed to his renal failure. His Cr at discharge
was 3.3. He remained on cyclosporine for his renal transplant,
along with azathioprine and prednisone. For his hypotension,
autonomic testing confirmed orthostatic hypotension. Multiple
etiologies were entertained, including cervical cord compression
(MRI showed C5-6 disc herniation and moderate spinal stenosis),
hypovolemia, medication effects (he was on labetalol and
prazosin at the time), and neuropathy. He was educated in
various dietary changes and advised to keep upright posture as
much as possible. He was scheduled to f/u in the outpatient
neurology clinic. At the OSH, he had had a hypercarbic
respiratory failure but he was extubated without incident and
had no other respiratory issues as an inpatient at [**Hospital1 18**]. He was
maintained on his outpatient inhaler regimen. For his seizure
disorder, he was transitioned from dilantin to keppra. For his
hypertension, his medications were changed to amlodipine and
metoprolol, with higher thresholds given his newly diagnosed
orthostatic hypotension.
.
On arrival he complains of bilateral arm and leg pain ([**8-26**]).
He denies fever, chills, cough, dysuria, graft pain, rash. He
reports diarrhea up until last week, which has since resolved.
Past Medical History:
1. End-stage renal disease.
2. Alport's syndrome.
3. Kidney transplant times four.
4. Hepatitis C.
5. Seizure disorder.
6. Right lower extremity phlebitis.
7. Right eye blindness.
8. Right ear hearing loss.
9. Peripheral vascular disease.
10. Small-bowel obstruction.
11. Osteoporosis.
12. Hypertension.
13. Gastrointestinal bleed in [**2147-4-17**].
14. Aortic stenosis.
15. Endocarditis
16. DVT [**2148**]
17. Gout
18. h/o abnormal chest x-ray with multiple lung nodules last
year
.
PAST SURGICAL HISTORY:
1. Hernia repair.
2. Kidney transplant times four in [**2145-1-16**] and [**Month (only) 956**]
of [**2144**] with last transplant in [**2147-7-17**].
3. Open cholecystectomy in [**2145-3-17**].
4. Right shoulder replacement.
5. Eye surgery.
6. AV graft.
7. Right ankle surgery in [**2148-3-16**].
8. Subtotal gastrectomy.
Social History:
Lives w/ parents in [**Location (un) 1456**]. single, no kids. Occasional ethanol
use. One pack per day of tobacco >20packyear smoking hx. Past
cocaine abuse (none since fall, [**2151**]).
Family History:
Father had prostate cancer.
Physical Exam:
T 97.5 BP 145/90 HR 63 RR 20 O2 sat 97% RA Wt 76.2 kg
Gen - appears older than stated age, NAD.
HEENT - R corneal clouding, left PERRL. OP with very dry MM.
Neck - no cervical LAD
CV - 3/6 SEM best at RUSB, radiating to b/t carotids
Chest - port to R anterior chest wall, non-tender, no erythema
or fluctuance.
Lungs - wheezes to right base posteriorly, fine crackles to left
base.
Abd - soft, multiple well-healed scars. normoactive BS. graft
in LLQ with tenderness with deep palpation.
Ext - Bilaterally assymetric in LE/UE; RUE larger proximally
due to 'infiltration'; RLE larger diameter proximally/distally
with large scar down medial border c/w with saphenous vein
anatomy; 1+ edema in RLE
Neuro - A& O x 2. 4/5 strength to UE/LE. minimal usage of
right arm (despite reporting right-handedness) but will use when
instructed
Skin - chronic venous stasis changes to b/t LE, R>L. no rash.
no bruising; multiple well healed scars on abdomen
Pertinent Results:
LABORATORY VALUES:
DISCHARGE LABS:
WBC 3.6 HCT 23.1 PLT 232
PT 34.4 INR 3.6
Na 140 K 4.5 Cl 103 HCO3 28 BUn 30 Cr 2.5 Gluc 82 (at HD)
LFTs: [**2153-2-12**]
ALT 10 AST 12 LDH 169 AP 205 Bili 0.3
HEMATOLOGIC
Iron Binding Capacity, Total 155* ug/dL 260 - 470
Ferritin 188 ng/mL 30 - 400
Transferrin 119* mg/dL 200 - 360
THYROID
Parathyroid Hormone 318* pg/mL 15 - 65
HEP C AB : POSITIVE
TEE:
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. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. Aortic valve gradient was not
assessed in this study. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
ULTRASOUND OF LOWER EXTREMITIES [**2154-1-7**]
1. Acute/subacute nonocclusive thrombus within the right common
femoral vein extending into the greater saphenous vein and
proximal superficial femoral vein.
U/S OF TRANSPLANTED KIDNEY [**2154-1-8**] : WNL
MRI CERVICAL SPINE [**2153-1-17**]
1. Large right central disc extrusion at the C5/6 level as
before, which is severely compressing the right ventral cord and
causing cord edema.
2. New diffuse edema of the visualized subcutaneous fat as well
as new minimal amount of prevertebral edema/fluid. The lack of
IV gadolinium limits the evaluation for infectious process.
However, given the generalized nature of the edema, the
prevertebral findings likely represent changes of generalized
edema as opposed to prevertebral cellulitis from an infectious
process.
3. Minimal amount of T2 hyperintensity of the anterior disc at
the C5/6 and C6/7 levels, which is a nonspecific finding. There
are no adjacent destructive changes to suggest spondylodiscitis.
If there is strong concern for an infectious process, consider
reevaluation with gadolinium.
MRI C SPINE [**2153-1-19**] W/WO CONTRAST
1. Study significantly limited due to patient motion.
2. No obvious enhancement in the intervertebral discs at C5-6
and C6-7 levels. No evidence of discitis at these levels.
3. Unchanged appearance of the small amount of prevertebral
edema/fluid in the cervical spine; mild increase in the
posterior spinal soft tissue increased signal from
edema/inflammation. No obvious abscess is noted, within the
limitations of this study from patient motion artifacts.
4. No evidence of cord compression in the thoracic spine.
5. Severe cord compression in the cervical spine, from large
right paracentral disc extrusion at C5-6, unchanged.
6. Large bilateral pleural effusions.
MRI, HEAD [**2153-1-19**]
1. No evidence of meningitis or acute intracranial process.
2. Bilateral increased signal in both mastoid sinuses is
suggestive of mastoiditis.
RUQ U/S [**2153-1-18**]
No gallbladder, post-cholecystectomy [**2148**]. Intrahepatic biliary
dilatation has increased since [**2148-11-16**]. The common bile
duct tapers from a maximum of approximately 8 mm to 6 mm in the
region of the pancreatic head which is incompletely visualized
due to overlying bowel gas. Common duct stone cannot be
excluded. If clinically feasible, consider MRCP for further
evaluation.
.
MICROBIOLOGY
BLOOD CULTURES
MRSA from outside hospital.
Enterococcus faecalis: [**Last Name (un) 36**] to amp, vanc [**2153-1-9**]
[**Female First Name (un) 564**] albicans
Subsequent surveillance cultures negative.
[**2153-1-13**] 5:51 pm CATHETER TIP-IV Source: right IJ.
ENTEROBACTER CLOACAE. <15 colonies
URINE CULTURE ([**2153-1-29**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
AZTREONAM RESISTANT
.
Bilateral hip XR:
FINDINGS: Frontal view of the pelvis and cone down views of each
hip demonstrate some rounded peripheral calcifications that are
presumed to be in the soft tissues measuring 3.3 cm on the right
and 1.2 cm on the left with dense vascular calcifications.
Scattered clips overlie the lower abdomen. Alignment is normal.
No fracture is identified.
.
Bilateral knee XR:
On the right, there are mixed lucent and sclerotic irregular
moderately well defined geographic lesions in the distal femur
and proximal tibia most likely representing bone infarcts. Some
increased density deep to the medial femoral condyle may also
reflect a subchondral bone infarct. Doubt joint effusion. Dense
vascular calcification noted. Probable diffuse osteopenia.
On the left, increased density in the distal medial femoral
condyle and vaguer densities in the proximal tibia, also likely
represent bone infarcts. A small bone island is seen in the
proximal medial tibia. Of note, there is a focal multilobulated
lucent lesion extending to the articular surface of the lateral
femoral condyle, with a thin sclerotic rim measuring
approximately 2.0 x 3.2 cm. There is background osteopenia.
Possible small joint effusion.
No acute fracture identified. Multifocal bone infarcts including
probable subchondral bone infarcts noted.
2. Focal lucent lesion in the left lateral femoral condyle.
There appears relatively extensive to represent a subchondral
cyst or interosseous ganglion. Differential diagnosis includes a
chondroid lesion or possibly a brown tumor. Further evaluation
with MRI or CT scan is recommended. Of note, on the lateral
view, the cortex over this is thinned and if not present
already, the possibility of a pathologic fracture in this
location should be considered.
.
EKG:
Sinus, probably normal tracing, T waves are less prominent.
Brief Hospital Course:
46 y.o. male admitted for MRSA, Enterococcus, Candidal
bacteremia, s/p renal transplants x4 for Alports, most recently
[**2145**].
.
# ID - POLYMICROBIAL BACTEREMIA, LINE SOURCE, ?GI source:
MRSA, Enterococcus, [**Female First Name (un) 564**] from [**1-2**] blood cx and OSH blood
cx, likely from R chest portacath that was removed soon after
admission. He was hemodynamically stable on heavy
anti-hypertensives, afebrile. He had a RIJ TPL placed on [**1-11**].
He was placed on Daptomycin and Fluconazole IV, and on PO
linezolid and PO fluconazole and PO voriconazole when he lost IV
access for one day.
His blood cultures started to become negative on [**1-9**]. TTE
showed possible vegetations, but TEE showed no vegetations, no
abscess, no endocarditis. ID and renal consults followed this
patient throughout admission. Optho assessed the patient for
candidal retinitis, found none, no intravitreous abx needed, but
the patient has ocular Alport's findings and is blind in his R
eye.
The right IJ line was pulled on [**1-14**] and a new right IJ
dialysis line was placed on [**1-22**].
On [**1-14**], a CT abdomen incidentally showed effusions and a CXR
was done. It showed cavitary lesions in LUL. Given his lung
pathology, his antibiotics were changed. Fluconazole was
continued for + Blood Cultures, daptomycin continued for MRSA as
indicated for bacteremia, and Linezolid was started for possible
abscess in lungs.
His blood cultures began to grow GNR so aztreonam was started.
The reason Vanco was not started initially was because pt had a
question of an allergy to it (thus needed coverage with
aztreonam and linezolid as above). However, since questionable
allergy, his linezolid and daptomycin were stopped and
vancomycin was started. Aztreonam was stopped and ciprofloxacin
was started after sensitivites returned. He was called out to
the floor and contiuned these courses of antibiotics. The
patient completed his course of cipro.
He again become febrile. He was empirically treated with flagyl
for CDiff, but toxin testing was negative. He was also
empirically restarted on cipro to cover a positive UA.
Pseudomonas grew from the urine and he was switched to aztreonam
because of his penicillin allergy to cover the pseudomonas. The
pseudomas was resistent and one of the only choices left that he
was not allergic to was amikacin. He completed a 10 day course
of amikacin. Briefly he was transitioned back from linezolid to
vancomycin but he was switched back because of leukopenia that
developed from the vancomycin.
His fluconazole and linezolid courses will be complete on
[**2153-2-24**]. He does not need follow-up with ID here at [**Hospital1 18**].
Of note, the constilation of organisms that grew from the
patient's blood made a GI source concerning. He also
intermittently had abdominal pain and an elevated alk phos. GI
was consulted and because of a previously seen dilated common
bile duct they recommended a MRCP. The patient refused the
MRCP. GI also recommended a colonoscopy. The patient refused
both the prep for the colonoscopy and a virtual colonoscopy.
His last colonoscopy was in [**4-23**] and a polyp that was not
malignant was removed. It was recommended that he have a follow
up colonoscopy in 1 year.
.
# ACUTE RENAL FAILURE, KNOWN CHRONIC KIDNEY DISEASE, ALPORTS,
S/P TRANSPLANT
: Most recent transplant in [**2145**]. Has chronic renal
insufficiency (discharged with Cr of 2.4) from Alport's
syndrome. Renal function was worsening and pt was initiated on
dialysis on [**1-14**]. Unclear etiology for renal failure, possibly
[**2-17**] antibiotics, bacteremia, or prerenal. Renal U/S not
complete as pt uncooperative but no hydronephrosis. The
patient's graft continued to function poorly during the
admission. Regular dialysis was restarted and it is likely that
he will remain dialysis dependent.
He was kept on cyclosporin and prednisone; his azathioprine was
stopped. Cyclosporin levels were checked daily and the dose was
beginning to be tapered because of his non functioning graft. He
was kept on calcitriol and epogen with iron at dialysis.
.
IV ACCESS
IV access was extremely difficult in this patient. After his
portacath was removed, it was attempted to keep him free from IV
lines for 24 hours, and he had a peripheral line placed that was
pulled out by the patient by accident after 12 hours. A RIJ TPL
was placed the next day by IR under fluoroscopy. He has 2
nonfunctional fistulas in each arm, and one graft in each leg.
His right leg graft was last accessed in fall [**2152**], and his left
leg graft was thought to be nonfunctional. After the patient's
infections were under control, the temporary dialysis line was
changed for a tunneled line.
.
#SPINAL CORD COMPRESSION
Seen on MRI at C5/C6 level. The patient does not have focal
neurological deficits. He was followed in house by ortho spine
service. They did not see an indication for emergent surgery
and wanted him medically optimized before eventually performing
surgery in the future. It will also be necessary to keep the
patient off of anticoagulation for 5 days after the procedure
which will be difficult while treating his DVT. At rehab his
movement restriction will be placement of [**Location (un) **]-J collar.
Surgery will be planned after treatment and completion of his
antibiotic courses.
He has a f/u appointment at [**Hospital1 18**] with Dr. [**Last Name (STitle) 548**] on Wednesday
[**3-7**] at 11am. [**Hospital Unit Name **], [**Location (un) 470**], [**Hospital Unit Name **] ([**Telephone/Fax (1) 18865**] .
.
# RLE DVT:
The patient was noted to have R>L edema in his legs. US showed
new partially occlusive thrombus in distal SFV. He was
maintained on a heparin drip until the tunneled dialysis line
was placed. At that time, he was without IV access and heparin
could not be continued. He was bridged with lovenox until his
coumadin levels were therapeutic.
On day of discharge, his INR was 3.6 and should be held tonight.
The duration of his anticoagulation is at least six months, if
not longer given that he has had a prior clot in the past. His
anticoagulation around time of spine surgery will have to be
discussed with surgeons.
# HTN:
His HTN was difficult to control at his nursing home, but
baseline BPs during admission were elevated in the ICU. There
was no evidence of renal artery stenosis on US from [**11-23**]. He
was initially kept on clonidine, labetalol, and amlodipine until
his SBP dropped into 90's. All anti-hypertensives were held.
His BPs started to increase and his BP meds were added back on
as needed. On the floor, his blood pressures again decreased in
the setting of a more active infection necessitating holding his
BP meds. As his pressures increased, the meds were added back
on.
.
# Depression:
He was seen by psych at his nursing home, and he was kept on
duloxetine. Abilify was stopped during this hospitalization as
it was not a necessary medication.
.
Anemia -
Patient was noted to below baseline and was guaiac positive. He
refused both a virtual and traditional colonoscopy. As
discussed above his last colonoscopy was in [**4-23**] and he will
need a repeat study within 1 year. Hemolysis labs were also
negative. His HCT was monitored and he was given iron and
epogen at dialysis
# Hypercarbic respiratory failure:
Patient was initially transfered to the unit for respiratory
failure. Thought to be due to combination of reglan and
abilify. Heavy sedating medications were avoided in this
patient. Care should be taken in future when ever sedating
medications are given to this patient.
.
# COPD:
He was kept on advair and albuterol during admission.
Medications on Admission:
-daptomycin 450 mg IV Q48H
-labetatolol 300 mg Q6H
-furosemide 40 mg PO Qday
-clonidine 0.6mg TID
-aripiprazole 5 mg PO BID
-Na HCO3 650 mg PO Q8H
-duloxetine 20 mg [**Hospital1 **]
-quetiapine 25 mg Q4H prn
-fluticasone/salmeterol 250-50mcg/dose disk [**Hospital1 **]
-amlodipine 10mg PO daily
-azathioprine 25mg PO Q96H
-dulcolax 10mg PO daily prn
-colace 100mg PO BID
-ferrous sulfate 325mg PO BID
-pantoprazole 40mg PO Q daily
-prednisone 5mg PO daily
-tamsulosin 0.4mg PO QHS
-calcitriol 0.25mcg PO Q daily
-darbopoetin 40 mcg SQ QWeek
-levetiracetam 500mg PO 6x per week
-hydrocortisone 0.5% ointment TP QID prn
-cyclosporine 100mg PO Q12
-albuterol 90mcg IH QID prn
-lorazepam 0.5mg PO Q8 prn
-odansetron 4 mg IV Q4H prn
-prochloperazine 25 mg PR Q8H prn
-acetaminophen 650 mg Q6H prn
.
ALL:
codeine -> n/v
PCN -> unknown
haldol -> unknown
cellcept -> unknown
vancomycin -> unknown
amitryptyline -> unknown
IV iron -> anaphylaxis (?)
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: Last dose on [**2153-2-24**].
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days: Last dose on [**2153-2-24**].
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16): ** TO BE RESTARTED on [**2153-2-15**] **.
4. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
5. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed: Hold for RR <12, oversedation.
6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Hold for SBP <110, HR <55.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP <110.
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection QHD.
10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO MON WED
FRI ().
11. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO SUN,
TUES, THURS ().
12. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
15. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**First Name9 (NamePattern2) **] [**Hospital1 **]
Discharge Diagnosis:
Primary diagnosis:
Polymicrobial sepsis w/ [**Female First Name (un) **], enterobacter, and MRSA
DVT of RLE
Pseudomonas UTI
Renal failure
C5-6 cord compression
Secondary diagnoses:
Alport's syndrome s/p kidney transplant x4, still on
immunosuprresion
ESRD on HD
Hepatitis C
Seizure disorder
R eye blindness
R ear hearing loss
PVD
h/o SBO
Osteoporosis
HTN
h/o GIB
Aortic stenosis
h/o endocarditis
h/o RLE DVT in [**2148**]
h/o gout
Discharge Condition:
Stable. Afebrile. INR of 3.6.
Discharge Instructions:
You were admitted with sepsis felt to be due to an infected
port-a-cath. The port-a-cath was removed and you had central
lines placed. You were monitored in the ICU initially because of
the severity of your infection. You likely suffered septic
emboli to your lungs and your pulmonary status should be
monitored regularly given that you have known cavitary lesions
in your lung. You were transferred to the floor once you were
more stable. We were unable to determine why you developed this
line infection, but you are currently being treated successfully
with linezolid and fluconazole. Please complete the course of
these antibiotics (last dose on [**2153-2-24**]). You also had a UTI
while you were here and were treated with amikacin at dialysis.
You completed the course of this antibiotic while you were still
an inpatient.
You also developed worsening renal failure and were started on
hemodialysis. You had a permanent tunneled line placed for HD
and you are currently on a M-W-F hemodialysis schedule. You were
last dialyzed on [**2153-2-14**]. Your cyclosporine is being tapered
down and we are no longer checking cyclosporine levels. You
should continue taking both prednisone and cyclosporine at your
current doses until further notice from Dr. [**Last Name (STitle) **].
You were found to have a DVT of your RLE while you were
hospitalized. You were initially treated with heparin and then
lovenox until you became therapeutic on coumadin. Please have
your PT/INR checked at each dialysis session to insure that your
levels remain therapeutic. YOU SHOULD NOT TAKE COUMADIN on [**2-14**]
AS YOUR INR TODAY IS 3.6. Please start taking 2mg of coumadin on
[**2153-2-15**] and have your INR drawn at HD on Friday [**2153-2-16**]. Please
have the doctors at rehab adjust your dose of coumadin based on
your INR.
Your neurologic exam remained stable throughout your
hospitalization. You were monitored by ortho-spine who felt that
you could undergo decompression in the future, either once you
begin to develop symptoms or once you complete your course of
anticoagulation. It was recommended that you use a [**Location (un) 2848**] J
collar as a precaution with transportation and movement until
you follow up in clinic. Please continue to use this as
instructed.
You need a repeat colonoscopy because you have blood in your
stool, but you refused to have this done as an inpatient. We
recommend that you follow-up with your PCP to schedule this as
an outpatient, given that you have a history of colonic polyps
in the past.
Please continue taking all your medications as prescribed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**] on Wednesday [**3-7**] at
11am. [**Hospital Unit Name **], [**Location (un) 470**], [**Hospital Unit Name **]. Please call his
office at ([**Telephone/Fax (1) 88**] if you have any questions about this
appointment.
Please follow up with Dr. [**Last Name (STitle) **] on Monday, [**3-12**], at
4pm. Please call her office at ([**Telephone/Fax (1) 3618**] if you have any
questions about this appointment. Her office is located at LMOB
[**Location (un) 436**] [**Last Name (NamePattern1) 439**].
Please follow up with your PCP upon discharge from rehab. You
can make this appointment by calling [**Telephone/Fax (1) 10508**].
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
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26,097
| 126,042
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44364+44365
|
Discharge summary
|
report+report
|
Admission Date: [**2122-1-28**] Discharge Date: [**2122-2-7**]
Date of Birth: [**2078-8-17**] Sex: F
Service: MICU
CHIEF COMPLAINT: Fever, shortness of breath, hypoxia.
HISTORY OF PRESENT ILLNESS: This is a 43-year-old female
with a past medical history significant only for
hypertension, who presents with 3-4 days of fever, malaise,
stiff neck, nonproductive cough. In the Emergency
Department, the patient had a fever of 103.0 F, complained of
pleuritic chest pain, nausea, headache, diarrhea. According
to her husband, she decompensated over the 24 hours leading
up to her presentation to the Emergency Room.
In the Emergency Department, the patient was placed on 100%
nonrebreather, but came up to only 90% oxygen saturation.
She also started to drop her systolic blood pressure with a
low systolic of 75/45. She was placed on Levophed in order
to support her pressure. She also received 3 liters of
normal saline in the Emergency Department. The patient was
empirically given 2 grams of ceftriaxone and 500 mg of
levofloxacin. She was also started on Vancomycin, and
treated as if she had bacterial meningitis. Patient was
intubated. Of note, the patient has no significant past
medical history other than her hypertension. There is no
travel history.
In the MICU, the patient was continued on aggressive volume
resuscitation with three more liters of normal saline. An
A-line was placed. Patient met criteria for SIRS/sepsis. In
addition, she had end-organ dysfunction in the form of
hypotension. For this reason, she met criteria to be placed
on Xigris. A Swan-Ganz catheter was floated to optimize the
patient's fluid status.
PAST MEDICAL HISTORY: Hypertension.
OUTPATIENT MEDICATIONS:
1. Hydrochlorothiazide.
2. Zoloft.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco or alcohol use. The patient is
married and lives with her husband.
PHYSICAL EXAMINATION: Vitals: Temperature 101.0, pulse 90,
respiratory rate 24, blood pressure 87/40, and 80% on
nonrebreather. General: The patient is lethargic. HEENT:
Mucous membranes moist, no neck stiffness or photophobia
noted. Lungs have coarse rhonchi on expiration, decreased
breath sounds in the left lower lobe. Cardiovascular:
Regular, rate, and rhythm, no murmurs, rubs, or gallops.
Abdomen is soft, nontender, nondistended. Extremities: No
clubbing, cyanosis, or edema, slightly cool extremities.
Neurologic: Sedated in preparation for intubation.
LABORATORIES: White count 14.0 with 36% neutrophils, 56%
bands, 1% lymphocyte, hematocrit 40.7, platelets 236. Sodium
135, potassium 3.4, chloride 97, bicarb 24, BUN 15,
creatinine 0.7, glucose 131, calcium 8.8, magnesium 1.3,
phosphorus 3.4.
ARTERIAL BLOOD GAS: After intubation on vent setting of AC
with tidal volume of 600, respiratory rate of 20, FIO2 of
100%, and PEEP of 15, was pH 7.31, pCO2 33, pAO2 73, bicarb
17.
CHEST X-RAY: Significant for left lower lobe pneumonia.
HOSPITAL COURSE: In short, this is a 43-year-old female with
a past medical history significant for only hypertension, who
presents with three days of fever, shortness of breath,
headache, neck stiffness. Presented with hypoxia,
hypotension in the setting of left lower lobe pneumonia, and
meeting criteria for SIRS/sepsis.
1. ID: Patient presented with a community acquired
pneumonia. Given her rapid decompensation, she likely
developed Strep pneumonia. Patient has no known history of
any immunosuppression that have made her more vulnerable to
this infection. Patient also presented with headache and
complaint of neck stiffness. A lumbar puncture was not done
because the patient was too far out on her antibiotics.
Therefore, she was treated as if she had bacterial meningitis
with a 14 day course of Vancomycin and ceftriaxone. The
patient was also placed empirically on levofloxacin for
community acquired pneumonia.
[**Hospital **] hospital course was significant in that she
continued to spike despite being on this trial of
antibiotics. In addition, her white count continued to go up
and her bandemia was not resolving. Patient received a chest
CT scan on [**2122-2-1**] which showed bilateral pulmonary
parenchymal air space opacification throughout the posterior
aspects of the lower lobes, left greater than right, findings
consistent with diffuse pneumonic consolidation. There was
no definite evidence of empyema, however, the study was
limited by the lack of IV contrast. CT scan was also
significant for bilateral pleural effusions and a small
pericardial effusion.
Patient also received a sinus CT scan. This showed mucosal
thickening and air fluid levels throughout the maxillary,
ethmoid, and sphenoid sinuses bilaterally, but could be also
counted by the fact that the patient was intubated. The
patient continued to spike. She was tested multiple times
for Clostridium difficile toxin all of which were negative.
The patient had a small volume diarrhea. Patient was started
empirically on po Flagyl on [**2-3**]. In addition, the
patient's right IJ was switched to a left IJ on [**2-4**]. The
catheter tips were negative. After [**2-5**], patient remained
afebrile, and her white count came down. All the patient's
blood culture data was negative.
2. Pulmonary: Initially patient was placed on AC mode.
Esophageal balloon tracings determined that the patient
required high PEEPs secondary to high intrathoracic pressure.
Initially, the patient met criteria for ARDS, although, her
pAO2/FIO2 fraction quickly improved. Patient was tried
multiple times on pressure support, however, failed secondary
to episodes of hypoxia. These appeared to be related to poor
sedation or moving, but sometimes occurred in the absence of
any kind of stimulation.
Patient had a CT angiogram on [**2122-2-6**] to evaluate for
possible PE despite prophylaxis. This showed a limited CT
angiogram of the chest due to low rate of injection. No
pulmonary embolus was noted in the central large pulmonary
arteries. However, it also showed multilobar dense
consolidation and atelectatic changes with bilateral pleural
effusions. Thus, the patient had no interval improvement in
her chest CT scan from [**2-1**]. Bilateral lower extremity
noninvasive ultrasounds were negative for any deep venous
thrombosis.
At this time, we believe that the patient still has a large
shunt secondary to her multilobar pneumonia which appears to
be resolving quite slowly. Also, because of her large volume
overload for the course of the hospitalization, the patient
easily goes into pulmonary edema even if it is not picked up
on chest x-ray. At this time, we will continue AC
ventilation until further more aggressive diuresis is
attained.
3. Sepsis: The patient initially met criteria for SIRS, in
addition to having hypotension. She received 72 hours of
Xigris, which was stopped secondary to bleeding from a
central line site. She received aggressive fluid
resuscitation and became 20 liters positive for her
admission. Patient quickly came off of pressors.
4. FEN: As already noted, the patient is 20 liters positive
for admission. IV Lasix alone was not getting her negative.
Patient was started on a Lasix drip on [**2-5**] with excellent
diuresis. However, because of this drip, she became
hypernatremic with a contraction alkalosis. The patient was
given free water boluses for her hypernatremia which adheres
to control it. She was also checked q6h for her potassium
level and was aggressively repleted.
5. Heme: The patient's hematocrit initially was dropping,
largely dilutional. However, she kept on having a slow drop.
This was thought to be secondary to aggressive phlebotomy.
Hemolysis laboratories were negative. No transfusions were
indicated.
6. Acid base: Initially, the patient had a metabolic
acidosis, nongap, likely from diarrhea, and dilutional
component. This resolved. Currently, the patient has a
metabolic alkalosis likely from aggressive diuresis. Patient
was started on Diamox for bicarb wasting.
7. Renal: Patient had a decrease in urine output on [**1-30**].
She was found to have ATN on the basis of multiple
muddy-brown casts in her urine. We believe this ATN was
secondary to hypotension. Patient began to autodiurese, and
her creatinine came down.
8. Endocrine: Patient's initial random cortisol was 50, so
patient was not started on hydrocortisone. However, she had
a random cortisol level on [**2-3**] which was only 15. She was
started on a seven day course of hydrocortisone 50 mg IV q8h.
My dictation stops at this point. Further course will follow
in a subsequent dictation.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2122-2-7**] 12:53
T: [**2122-2-10**] 06:00
JOB#: [**Job Number 95124**]
Admission Date: [**2122-1-28**] Discharge Date: [**2122-2-14**]
Date of Birth: [**2078-8-17**] Sex: F
Service:
ADDENDUM: The patient was successfully extubated and weaned
off of pressors, transferred to the floor where she underwent
spontaneous diuresis.
With the exception of metronidazole, all antibiotics were
discontinued. This final medication will be continued until
[**2122-2-15**]. The patient was successfully weaned off
supplemental oxygen after undergoing spontaneous diuresis.
He hematocrit remained above 27. She remained afebrile.
DISCHARGE DIAGNOSES:
1. Adult respiratory distress syndrome secondary to
multilobar pneumonia.
2. All discharge diagnoses from previous dictation will
remain the same.
DISPOSITION: The patient was transferred to pulmonary
rehabilitation.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 40 mg by mouth daily.
2. Sertraline 50 mg by mouth daily.
3. Metronidazole 500 mg p.o. t.i.d. until [**2122-2-15**].
4. Acetaminophen 325-650 mg by mouth every four to six hours
as needed.
5. Heparin 5,000 units subcutaneously every eight hours until
the patient is ambulating.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AEB
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2122-2-13**] 13:15
T: [**2122-2-13**] 13:47
JOB#: [**Job Number 95125**]
|
[
"276.2",
"401.9",
"481",
"276.1",
"320.9",
"584.5",
"423.9",
"276.3",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"96.04",
"00.11",
"38.93",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9449, 9669
|
9692, 10211
|
2982, 9428
|
1733, 1807
|
1927, 2964
|
150, 188
|
217, 1671
|
1694, 1709
|
1824, 1904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,219
| 121,070
|
1281
|
Discharge summary
|
report
|
Admission Date: [**2153-6-6**] Discharge Date: [**2153-6-19**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
increased swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 year old man with hx of CAD, prior MI, [**Last Name (un) 3843**] [**Doctor Last Name **]
AVR, NIDDM c/b CRI, Left CEA, admitted to the [**Hospital1 **] with CHF
(EF 50%) today now transferred to [**Hospital1 18**] for further managment.
He describes that over the last month he has had slowly
increasing edema and dyspnea on exertion. He reports being
compliant with his medications and diet though he drinks around
8 16oz glasses of water a day.
He denies any preceeding symptoms to this exacerbation including
any recent chest pain, dietary indiscretion. In fact he just
notes that he has had a slow increase in his weight that he
thought was due to increasing caloric intake. He approximates
that he has gained 13-15 lbs.
.
He was given 100 mg lasix prior to transfer and had 400 cc urine
output on arrival. He had echo done prior to transfer. Per Dr.
[**Last Name (STitle) **] EF was 50%, with 4+ TR and AVR gradient 30mmHG.
Past Medical History:
CARDIAC
CAD:
[**2140**] Inferior wall MI- RCA stented at [**Hospital1 2025**], requiring IABP.
[**2147-2-2**]- (bioprosthetic) AVR for AS.
[**2150-8-20**] cath: 40-50% LM stenosis, LCx with minimal disease. LAD
with a 70-80% lesion at the level of the D1. Moderate disease in
the ostium of the D2. RCA widely patent in the site of the prior
stenting. PA pressure 60/17, wedge 21 mmHg. Started on Plavix
with plans to return to lab for PCI.
[**2150-8-27**]: direct stenting of the mid LAD with a 3.5 x 18 mm
Cypher DES. Other vessels: 50% LMCA, Cx with mild luminal
irregularities, RCA not engaged.
VALVULAR:
Aortic valve replacement for aortic stenosis in [**2146**] ([**Last Name (un) 3843**]
[**Doctor Last Name **])
Rhythm:
Atrial fibrillation on coumadin s/p cardioversion in [**2146**], [**2151**]
HTN
hyperlipidemia
Thyroid disorder
Non insulin dependent diabetes c/b CRI
[**2142**]: Left carotid endarterectomy
[**7-23**]: Lap Chole
Appendectomy
Chronic renal insufficiency
[**Last Name (un) **]
BPH
Shingles (started 4 mo ago)
Hypertension
Social History:
Social history is significant for the absence of current tobacco
use (though has 60 pack year history). There is no alcohol abuse
but has history of "drinking a lot".
Patient is married with 4 children. He is a retired recreation
manager. He is the primary care taker for his wife who had
a CVA about 5 years ago. Quit smoking 40-50 years ago. Rare
EtOH, no recreational drug use.
Family History:
(+) Family history of [**Name (NI) 7957**] sisters and a brother died from
vascular complications in their 40's-50's
Physical Exam:
VS - T 95.6 HR 70 rr 18 02 98% RA BP 154/71
Gen: Elderly slightly obese male. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of > 14cm (~4cm above clavicle when
sitting at 90 degrees).
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg irreg, with high pitched honking murmur heard best at RUSB
but radiates throughout precordium. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, obese with edema of lower abdominal skin. Has slight
erythema of LQ. Unable to assess for organomegaly given obesity.
No abdominial bruits.
Ext: [**12-23**]+ edema of LE to knee
Skin: with stasis dermatitis, with small left ulcers (reported
to be draining last week) no xanthomas.
Guaiac + stool
.
Pulses:
Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2153-6-6**] WBC-9.9 RBC-3.53* Hgb-10.1* Hct-30.3* MCV-86 MCH-28.8
MCHC-33.5 RDW-18.4* Plt Ct-143* PT-17.9* PTT-32.8 INR(PT)-1.7*
[**2153-6-7**] 04:26AM PT-19.1* PTT-108.3* INR(PT)-1.8*
[**2153-6-6**] 07:30PM Glucose-70 UreaN-51* Creat-2.8* Na-138 K-3.5
Cl-95* HCO3-33* AnGap-14
[**2153-6-6**] 07:30PM CK(CPK)-218* CK-MB-5 cTropnT-0.05*
proBNP-[**Numeric Identifier 7959**]*
[**2153-6-7**] 04:26AM CK-MB-5 cTropnT-0.06*
[**2153-6-6**] Calcium-8.7 Phos-3.8 Mg-1.6
CXR:
Admission
FINDINGS: There is status post sternotomy and the metallic
components of porcine aortic valve prosthesis are identified in
place. The heart is moderately enlarged with a clear prominence
of the left ventricular contour to the left and posteriorly. The
lateral view also demonstrates a prominence of the left atrium
in posterior direction. The thoracic aorta is elongated and
demonstrates extensive wall calcifications both in the aortic
root, ascending portion and descending aorta. There is no
evidence of any local aortic contour abnormality. The pulmonary
vasculature demonstrates an upper zone redistribution pattern
and some perivascular haze exists in the lower pulmonary
vascular portions but there is no evidence for significant
interstitial or alveolar edema. Also, the lateral pleural
sinuses are free but very mild blunting of the posterior pleural
sinuses is recognized on the lateral view. Acute parenchymal
infiltrates are not present.
Available for comparison is a previous PA and lateral chest
examination of [**2153-2-1**]. The heart size was significantly
enlarged already on the previous study and findings concerning
cardiac configuration and aortic valve prosthesis are unchanged.
Direct comparison of the frontal views suggests that the
previously observed degree of interstitial edema resulting in
perivascular haze has decreased slightly. As on the previous
examination, there was no evidence of any acute infiltrate nor
is there any pneumothorax or significant pleural effusion.
IMPRESSION: Status post aortic valve replacement (porcine type)
with cardiac enlargement and mild degree of chronic CHF. No
significant progression during latest four-month examination
interval.
CXR: 7/22IMPRESSION: No evidence of pneumonia. No significant
change definite.
[**6-16**] ECHO:LA is mildly dilated. RA is moderately dilated. LV
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. RV chamber size is
increased with free wall hypokinesis. A bioprosthetic AV
prosthesis is present with thin/mobile leaflets. The transaortic
gradient is higher than expected for this type of prosthesis.
Trace aortic regurgitation is seen. MV leaflets are mildly
thickened. Mild (1+) MR is seen. There is moderate PA systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal global biventricular systolic function. Well
seated aortic bioprosthesis with mobile leaflets but increased
gradient. Moderate PA systolic hypertension. RV cavity
enlargement with free wall hypokinesis. Mild MR.
[**6-15**] Right Heart Catheterization:
1. Coronary angiography was deferred due to elevated creatinine.
2. Resting hemodynamics revealed elevated right and elevated
left sided
filling pressures with RVEDP of 21 mmHg and PCW of 25 mmHg.
There was
severe pulmonary arterial systolic hypertension with PASP of 78
mmHg.
3. Left ventriculography was not performed due to elevated
creatinine.
FINAL DIAGNOSIS:
1. Elevated left sided filling pressures.
2. Severe pulmonary hypertension.
3. Succesful Swan Ganz catheter placement.on
[**6-15**] Renal US: No hydronephrosis and no new mass is identified
bilaterally. Arterial flow identified in both kidneys but unable
to obtain a full Doppler study due to patient's condition.
[**6-16**] CXR:Interval development of a retrocardiac density which
may be secondary to atelectasis or pneumonia.
Brief Hospital Course:
On the floor, diuresesis was attempted with lasix, metolazone,
then nesiritide, without good results, and he was transitioned
from coumadin to heparin, to lovenox (with a notable cr of 3.4,
INR 2.2) to the cath lab for Swan placement for tailored
inotropic therapy for his severe right heart failure. Initial PA
pressures were RA 24, RV 76/16 PCWP 25 PA 78/24. On presentation
to ICU, was CO was 2.43, started on 5mg of dobutamine and CO
went to 2.57 with some PVC ectopy, no increased urine output and
was changed to lasix drip. ECHO consistent with systolic
dysfunction with EF>55%. Diruesed effectivly with a lasix drip
and d/c weight was 96 kilograms (down form admit weight of
101kg). Ischemia not felt to be cause of exacerbation. Also had
a febrile episode and was treated with a 7 day course for
hospital acquired vs. aspiration pneumonia. He was afebrile on
transfer from the unit.
Currently in atrial fibrillation s/p unsuccessful cardioversion
x 2. Continued on B-Blocker with good rate control. d/c on
lovenox bridge to restarting coumadin after invastive
procedures.
Valves: has history of AVR ([**Last Name (un) **] [**Doctor Last Name **] bioprosthetic).
Currently on anticoagulation and heparin while subtherapeutic.
Evaluated by echo prior to transfer. ECHO on [**6-16**] shows trace
AR, mod TR, 1+MR.
He had acute renal failure but with improved forward flow
following diuresis his Cr improved to approx 2.9. His baseline
is ~2.5.
He was discharged to rehab with Dr. [**Last Name (STitle) **] follow up.
Medications on Admission:
Synthroid 25 mcg daily
Colchicine 0.6 mg [**Hospital1 **]
Allopurinol 100mg [**Hospital1 **]
Tylenol 650 mg QID prn
Hydrocodone/apap 7.5/750 prn pain
amaryl 2 mg [**Hospital1 **]
coumadin 2.5 mg daily (has not taken in 1 week as
supratherapeutic)
crestor 10 mg daily
ecotrin 81 mg daily
flomax 0.4 mg daily
potassium 40 mg [**Hospital1 **]
lasix 80 mg daily
lopressor 50 mg daily
neurontin 300 mg TID
niferex 150 mg daily
nexium 40 mg daily
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Polysaccharide Iron Complex 150 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).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
9. Epoetin Alfa 2,000 unit/mL Solution Sig: [**2145**] ([**2145**]) UNITS
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
15. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed.
16. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight
(8) UNITS Subcutaneous at bedtime: to be given at bedtime.
18. Insulin Regular Human 100 unit/mL Solution Sig: 2-12 UNITS
Injection four times a day: Use As Directed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Right Heart Failure
.
CAD
Atrial fibrillation on coumadin s/p cardioversions
Hypertension
Hyperlipidemia
Thyroid disorder
Non insulin dependent diabetes
Chronic renal insufficiency (basline Cre 2.0)
Gout
BPH
Shingles
s/p left carotid endarterectomy ([**2142**])
s/p laproscopic ccy ([**2148**])
s/p appendectomy
Discharge Condition:
Ambulating with assistance, deconditioned.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1200 cc/ day
.
You were admitted to the hospital with right heart failure. You
had a cardiac cath and were placed in the intensive care unit
for close monitoring. FLuid was removed and you were discharged
to rehab.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks post discharge.
HIS number is [**Telephone/Fax (1) 7960**]
|
[
"585.9",
"274.9",
"V45.82",
"272.4",
"V58.67",
"584.9",
"507.0",
"427.31",
"V58.61",
"600.00",
"V42.2",
"403.90",
"250.00",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
11578, 11643
|
7885, 9413
|
237, 243
|
11999, 12044
|
3896, 7411
|
12426, 12591
|
2697, 2815
|
9905, 11555
|
11664, 11978
|
9439, 9882
|
7428, 7860
|
12068, 12403
|
2830, 3877
|
179, 199
|
271, 1205
|
1227, 2280
|
2296, 2681
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,080
| 166,322
|
23377+57349
|
Discharge summary
|
report+addendum
|
Unit No: [**Numeric Identifier 59990**]
Admission Date: [**2177-3-14**]
Discharge Date: [**2177-5-7**]
Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Pelvic abscess.
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
with Sjogren syndrome and history of temporal arteritis on
steroids who was recently discharged to a rehabilitation
facility after a prolonged stay after a lower GI bleed from
diverticulosis. She presented to the surgery service where
she was admitted and treated with percutaneous drainage and
IV antibiotics. She was also treated for her adrenal
insufficiency and ultimately required transfer in a prolonged
SICU stay.
PAST MEDICAL HISTORY: Acute renal failure with current right
internal jugular tunneled hemodialysis catheter.
Right lower extremity deep venous thrombosis.
Gastrointestinal bleed.
Diverticulosis.
Sjogren syndrome.
Question of vasculitis.
Bilateral pleural effusions, pericardial effusion.
Raynaud's.
Cryoglobulinemia.
Papillary neoplasm.
Renal cyst.
Hypertension.
Hyperlipidemia.
Anemia.
History of congestive heart failure and volume overload.
Hyponatremia.
Hypoalbuminemia.
Peripheral neuropathy.
Paget disease.
Secondary hyperparathyroidism.
Thrombocytopenia.
Hematuria.
PAST SURGICAL HISTORY: Exploratory laparotomy [**2177-1-1**].
ALLERGIES: Penicillin.
MEDICATIONS ON ADMISSION:
1. Folate.
2. Neurontin.
3. Dilantin.
4. Isosorbide dinitrate 40 q.i.d.
5. Bactrim.
6. Zantac.
7. Coumadin.
8. Lasix 80 b.i.d.
9. Lopressor 75 b.i.d.
10. Clonidine 0.2 b.i.d.
11. Lasix 80 b.i.d.
12. Diltiazem SR 360 daily.
13. Lansoprazole 30 daily.
14. Heparin 5,000 units subcutaneously t.i.d.
15. Prednisone 20 mg per G tube daily.
16. Lactulose 30 daily.
17. Regular insulin-sliding scale.
SOCIAL HISTORY: Patient lives at home with an 83-year-old
sister, but on this past admission and from prior has been
admitted to a rehabilitation facility. No current smoking or
alcohol use.
FAMILY HISTORY: Noncontributory.
INITIAL PHYSICAL [**Year (4 digits) **]: Patient was well-appearing in no
apparent distress. Chest was clear to auscultation anteriorly
bilaterally. Heart: Regular rate and rhythm. Abdomen was
soft, benign, no hepatosplenomegaly. Extremities: Warm,
slight edema. Neurologically: Equal strength bilaterally.
BRIEF HOSPITAL COURSE BY SYSTEM: Neurologically: The patient
did have some altered mental status. This was thought
secondary to possible IC psychosis and at the time of
discharge, is relatively clear, although is still ventilator
dependent.
Cardiovascular: Given her history of hypertension, she was
maintained on labetalol and Norvasc. Her labetalol dose was
slowly cut back to allow for greater overall perfusion, which
she tolerated well. She remained hemodynamically stable
through most of her hospital course.
Respiratory: Due to her grave illnesses and pelvic abscesses,
she did require transfer to the ICU mostly for hemoptysis.
Bronchoscopy was performed, and she had bilateral chest tubes
placed for pneumothoraces. These, however, drained a
significant amount between a liter and 1500 cc of fluid per
day. She was then followed serially by the thoracic surgery
service who performed talc pleurodesis. This seemed to hold
and at the time of this dictation, has no pneumothorax on her
chest, but does have some bibasilar atelectasis.
GI: Of note, the patient's LFTs had complete rise. More
specifically, her alkaline phosphatase. On several
examinations, this was actually coming down. Her right upper
quadrant ultrasound performed showed no significant
abnormalities.
GU: Of note, the patient did experience some hyponatremia and
hyperkalemia during her hospitalization. Renal consult was
called, and recommendations were made for electrolyte
adjustment. She did have hyponatremia associated with her
hyperkalemia and had been diuresed after that point most
recently with only small doses of Lasix given appearance of
CHF on recent chest x-rays. However, there was thought that
she was somewhat hypovolemic and did require some fluid
boluses of normal saline and close monitoring of her
electrolytes.
FEN: Her tube feeds were advanced after she was out of the
acute phase and because of her electrolyte abnormalities, was
maintained on [**3-6**] strength Nepro with a goal of 45 cc or
should she be able to advance to full strength, then her rate
would be 60 cc per hour. Of note, the patient was on TPN for
sometime and developed cholestasis with an elevated alkaline
phosphatase of around 1,100. She was started on Actigall with
significant improvement in her alkaline phosphatase.
Remainder of her LFTs were within normal limits and her right
upper quadrant ultrasound did not show cholecystitis or
choledocholithiasis. We continued to follow this level
closely. She was maintained on Prevacid and Carafate for anti-
ulcer prophylaxis.
Fluid, electrolytes, and nutrition: As forementioned, the
patient was kept on tube feeds. She did have some electrolyte
abnormalities approximately 72 hours before her transfer.
However, these serial checks were normalizing and she was
asymptomatic.
ID: She was on multiple antibiotics given her pelvic
abscesses. However, she eventually developed Clostridium
difficile infection. This was treated with oral Flagyl and
quarantine precautions. Her treatment was transitioned to
oral vancomycin for the time course while she was on
antibiotics and this was eventually tapered on a daily, then
every other day schedule to off. However, of note in the week
before her transfer to rehab, she did have significant
increase in her white blood cell count and pancultures were
sent.
Her stool at that point had cleared her Clostridium difficile
infection. However, she grew Serratia marcescens from her
urine which was resistant to the fluoroquinolones, which she
had been treated with. She was then switched to cefepime,
which she tolerated without incident.
Endocrine: She initially required a stress-dose steroid and
was on IV hydrocortisone. However, her being able to tolerate
orals and be hemodynamically stable, she was then transferred
to oral prednisone at a dose of 20 mg via her G tube daily,
which is her maintenance dose.
Heme: She had a significant anemia. She did require some
transfusion and was started on erythropoietin with reasonable
success.
Tubes, lines, and drains: The patient had a right internal
jugular Quinton catheter and a central venous line. She also
had chest tubes that had been removed the week prior by
thoracic surgery.
Respiratory: As the patient at about 2 or 3 weeks prior to
transfer to rehab, had actually done quite well off
ventilator support. However, after about 20 hours, she did
require ventilator support and subsequent to that has
tolerated only 1-2 hour increments on tracheostomy collar.
However, the goal is to eventually wean her completely.
DISCHARGE STATUS: The patient will be discharged to [**Hospital **]
Rehabilitation Facility for further vent weaning. Her
nutritional status was quite compromised and at the time of
this dictation, a transferrin level was pending.
DISCHARGE INSTRUCTIONS: Tube feeds to consist of [**3-6**]
strength Nepro at 45 cc per hour. The patient's feeding
weight is 60 kg, which would translate to a full-strength
tube feeding rate of 60 cc per hour. She is to receive local
wound care to a sacral and back decubitus ulcer. She is also
to receive standard tracheostomy care. The patient is to
followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] in approximately 2 weeks
after discharge from rehabilitation facility. The patient
should have weekly nutrition labs checked including
prealbumin and transferrin.
DISCHARGE MEDICATIONS:
1. Epogen 8,000 units subcutaneously every Monday, Wednesday,
Friday.
2. Labetalol 400 mg by G tube t.i.d.
3. Atrovent 2 puffs q.i.d.
4. Prednisone 20 mg via G tube daily.
5. Actigall 300 mg via G tube twice daily.
6. Vitamin C liquid 500 mg via G tube daily.
7. Diltiazem 30 mg via G tube 4x a day.
8. Heparin 5,000 units subcutaneously 2x a day.
9. Prevacid suspension 30 mg via G tube twice daily.
10. Sodium chloride nasal spray 4 sprays to each nostril
4x per day.
11. Carafate 1 gram via G tube 4x per day.
12. Sodium chloride solution 100 cc via G tube q.8h.
13. Regular insulin-sliding scale.
14. Cefepime 2 grams IV q.12h. for 5 days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2177-5-7**] 03:00:00
T: [**2177-5-7**] 04:48:48
Job#: [**Job Number 59991**]
Name: [**Known lastname 10990**],[**Known firstname **] Unit No: [**Numeric Identifier 10991**]
Admission Date: [**2177-3-14**] Discharge Date: [**2177-5-12**]
Date of Birth: [**2094-8-7**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2674**]
Addendum:
Since the discharge summary dictated [**2177-5-7**], following events
are noted:
Despite being on Cefepime, patient continued to have elevated
WBC due to UTI with ESBL Serratia. IV Antibiotics were changed
to Meropenem. Patient is to finish a total 7 day course of
Meropenem, to finish with last dose on [**5-13**].
In addition, patient had RECURRENT C DIFF COLITIS, on stool
cultures from [**5-8**]. Given its recurrence, patient was started on
PO Linezolid and PO Vancomycin. Patient is to finish a 7 day
course of Linezolid with last dose on [**5-14**]. Patient is to finish
a 14 day course of po Vancomycin with last dose on [**5-21**].
Patient's abdomen was mildly distended but non-tender, with no
evidence of dilated colon on KUB the day prior to discharge.
Patient was tolerating TF on discharge.
Pertinent Results:
[**2177-5-12**] 03:55AM BLOOD WBC-19.8* RBC-3.05* Hgb-8.7* Hct-26.7*
MCV-88 MCH-28.6 MCHC-32.6 RDW-16.9* Plt Ct-291
[**2177-5-11**] 03:00AM BLOOD PT-13.3 PTT-35.6* INR(PT)-1.1
[**2177-5-12**] 03:55AM BLOOD Glucose-109* UreaN-67* Creat-0.8 Na-138
K-3.5 Cl-107 HCO3-28 AnGap-7*
[**2177-5-11**] 03:00AM BLOOD ALT-29 AST-30 AlkPhos-429* TotBili-0.3
[**2177-5-12**] 03:55AM BLOOD Albumin-2.1* Calcium-8.7 Phos-2.2* Mg-1.8
Iron-PND
[**2177-5-7**] 02:30AM BLOOD calTIBC-143* TRF-110*
[**2177-5-8**] 9:00 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2177-5-8**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2177-5-8**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 400**] @ 3:30 PM ON [**2177-5-8**].
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).
[**2177-5-8**] 6:01 pm CATHETER TIP-IV Source: PICC.
**FINAL REPORT [**2177-5-11**]**
WOUND CULTURE (Final [**2177-5-11**]): No significant growth.
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: Four (4) Spray
Nasal QID (4 times a day).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-2**]
Drops Ophthalmic PRN (as needed).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: Please do
sliding scale Injection ASDIR (AS DIRECTED).
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5,000
units
units Injection [**Hospital1 **] (2 times a day).
7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Ascorbic Acid 100 mg/mL Drops Sig: Five Hundred (500) mg via
NGT PO DAILY (Daily). mg via NGT
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4-6H (every 4 to 6 hours) as needed.
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
14. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 units
Injection QMOWEFR (Monday -Wednesday-Friday). units
16. Hydralazine HCl 20 mg/mL Solution Sig: Twenty (20) mg
Injection Q6H (every 6 hours) as needed for SBP>160.
17. Linezolid 100 mg/5 mL Suspension for Reconstitution Sig: Six
Hundred (600) mg PO twice a day for 2 days: for VRE in blood.
7day course.
18. Meropenem 1 g Recon Soln Sig: 1000 (1000) mg Recon Solns
Intravenous Q8H (every 8 hours) for 1 days: One more day to
complete 7day course.
19. Vancomycin HCl 10 g Recon Soln Sig: Two [**Age over 90 2238**]y (250)
mg Recon Soln Intravenous Q6H (every 6 hours) for 9 days:
complete 14 day course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
pelvic abscess s/p CT drainage of abscess
adrenal insufficiency
Clostridium difficile colitis, recurrent
hemoptysis
bilateral pleural effusions
bilateral pneumothoraces s/p bilateral chest tubes
hyperkalemia
acute renal failure
Sjogrens disease
hypertension
congestive heart failure
anemia
urinary tract infection - ESBL Serratia
Discharge Condition:
stable
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) 10225**]>101, sustained increasing
ventilator requirements, highly abnormal sodiums, high
potassiums, or other laboratory abnormalities
Please check electrolytes, especially potassium, frequently.
Please check CBC once every week while on Linezolid.
Patient is currently tolerating trach mask. She may
intermittently need vent resp overnight. (PEEP=4, PSupp=5, and
40% FiO2)
Please continue tube feeds as directed and keep patient NPO
until follow up.
Please do physical therapy to work on stretching, range of
motion, and dependent ADLs.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in one to two weeks. Call
[**Telephone/Fax (1) 7554**] for an appointment.
Please follow-up with your primary care physician,
[**Name10 (NameIs) 10992**],[**Name11 (NameIs) 10993**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10994**].
[**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 2675**] MD [**MD Number(1) 2676**]
Completed by:[**2177-5-12**]
|
[
"255.4",
"784.7",
"V58.65",
"998.59",
"567.2",
"512.1",
"446.5",
"710.2",
"518.84",
"599.0",
"707.03",
"576.8",
"284.8",
"V45.1",
"276.7",
"786.3",
"276.1",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"54.91",
"99.04",
"99.15",
"34.04",
"34.91",
"99.05",
"33.24",
"21.03",
"34.92",
"31.1",
"96.05",
"96.6",
"38.93",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
13150, 13231
|
13605, 13613
|
9877, 11147
|
14271, 14730
|
2024, 2357
|
11170, 13127
|
13252, 13584
|
1378, 1814
|
13637, 14248
|
2385, 7135
|
1287, 1352
|
168, 185
|
214, 666
|
689, 1263
|
1831, 2007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,363
| 107,556
|
4861+4862
|
Discharge summary
|
report+report
|
Admission Date: [**2120-5-30**] Discharge Date: [**2120-6-13**]
Date of Birth: [**2074-6-19**] Sex: M
Service: MED
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
type 1 diabetic male with known coronary artery disease,
status post stenting who presents with chest pain which began
at 11 A.M. The patient reports he climbed a flight of stairs
and experienced dyspnea although he has had one month of
dyspnea on exertion, then ten minutes after while at rest
developed substernal epigastric pain radiating to the left
arm and back. Patient reports chest pain was 7 to 8 out of
10 and slowly reported to 3 or 4 out of 10 with morphine. He
denies any nausea or vomiting, diaphoresis or shortness of
breath at rest. Describes the pain as a pressure. When he
had a stent in [**2118**] he complained of dyspnea on exertion as
well. He has never had an myocardial infarction. Patient
reports similar episode of chest pressure in [**9-20**] where he
had a stress test that was "fine" and required no further
follow up. Patient originally moved here from [**Location (un) 20309**],
[**State 15946**], has no medical care in [**Location (un) 86**]. Patient's
cardiologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] in [**Location (un) 20309**], took care of patient
during last stenting procedure. Patient denies any
paroxysmal nocturnal dyspnea, no orthopnea. He does report
dyspnea on exertion and fatigue. In the emergency department
the pain responded pretty much to morphine. Patient received
aspirin, beta blocker, Mucomyst and gastrointestinal
cocktail. Electrocardiogram was sinus at 100 with normal
intervals, normal axis, poor R wave progression, T wave
inversion in lead 3, no ST changes noted.
PREVIOUS MEDICAL HISTORY: Diabetes type 1, end stage renal
disease, status post kidney transplant in [**2100**], blindness
with two prosthetic eyes. Coronary artery disease, status
post stents of the RCA. Neck: Pituitary infarcts.
Gastroesophageal reflux disease. Chronic rectal pain which
patient has had since age of 13.
MEDICATIONS AT HOME: Include Humalog insulin pump, Lescol,
BuSpar, methadone 10 B.I.D for chronic rectal pain which
patient has had since the age of 13. Clonazepam 1.5 q.d.,
prednisone 5 q.d., azathioprine, atenolol 25 q.d., Lasix 20
B.I.D, Aldactone B.I.D, aspirin 81, vitamin E and Paxil.
Patient reports he is allergic to erythromycin.
SOCIAL HISTORY: Denies any tobacco use, no alcohol use. Is
married. Wife is very involved with his medical care.
PHYSICAL EXAMINATION: On admission heart rate 98, blood
pressure 110/56, patient was afebrile, in no acute distress.
Head, eyes, ears, nose and throat: Prosthetic eyes. Mucous
membranes mucoid. Jugular venous pressure approximately 9
cm. Chest clear to auscultation bilaterally, no wheezes,
rubs, crackles. Cardiovascular: Regular rate and rhythm,
S1, S2, no murmurs, rubs or gallops. Abdominal examination:
Mildly distended, normal bowel sounds, no hepatosplenomegaly
noted. An area over transplanted kidney is nontender,
nonerythematous. Skin: No rashes. Extremities: Decreased
pulses bilaterally. Neurologic: Alert and oriented times
three, [**5-22**] upper and lower extremity strength.
Patient's hematocrit 44.9 with admission white count 8.8,
creatinine 1.2. Patient's first set of cardiac enzymes - CK
135, MB 2, troponin less than 0.01.
HOSPITAL COURSE: This is a 44 year old man with type 1
diabetes, coronary artery disease, status post stents done in
[**State 15946**] presenting with substernal chest pressure that
started with exertion and only relieved by morphine.
According to the history this pain ever since this stent was
placed, reports that it is the same pain he has had for six
months and he has been recently hospitalized for in the past.
Patient also reports a recent hospitalization in [**State 15946**] for
pneumonia. Patient's last admission for this chest pain on
further history on hospital day that he was told it was
gastroesophageal reflux disease but never relieve this. No
gastroesophageal reflux disease symptoms recently. Patient
reports that it usually goes away after a few days.
Nitroglycerine never helps but it only gives him a headache.
Patient reports he has been on chronic pain since the age of
13 for rectal spasm and he needs higher doses of spasm. In
the past Dr. [**First Name (STitle) **] at [**Hospital **] Clinic has been patient's
primary care prior to his move to [**State 15946**] many years ago.
Patient's cardiologist, Dr. [**Last Name (STitle) 3748**], [**Name (NI) 653**] in [**State 15946**] who
reports patient had a MIBI in [**2118**] which demonstrated small
inferior wall defect. In [**2118-8-18**] patient had a distal
right stent placed as well as a mid circumflex stent placed.
Patient underwent a stress PMIBI in [**2119**] which was a negative
study and demonstrated an ejection fraction of 61 percent.
Dr. [**Last Name (STitle) 3748**] also reports patient had a MRSA positive groin
abscess complicating his last hospitalization. CT on [**5-31**]
demonstrated no aortic dissection aneurysm, intramural
hematoma. It did demonstrate mediastinal lipomatosis which
was known by patient prior to this CT and two 2 mm
noncalcified pulmonary nodules in the right upper lobe and
right lower lobe, incompletely imaged transplanted kidney
with suggestion of dilated collecting system and parapelvic
cysts. Patient was ruled out for myocardial infarction by
enzymes times three. Persantine MIBI demonstrated mild
perfusion defect of the inferior wall. Resting perfusion
images showed resolution of this defect. Patient had mild
chest pain throughout this test. Ejection fraction was
calculated at 59 percent. Patient complained of persistent
pain. Cardiology consult was obtained and patient was taken
for catheterization on [**6-3**]. At that time coronary
angiography of his right dominant circulation revealed single
vessel coronary artery disease. The left main coronary
artery had no obstructions. Left anterior descending
coronary artery had mild luminal irregularities without
limiting lesions. The left circumflex had widely patent
stents. The right coronary artery had an 80 percent in stent
restenosis in the distal vessel. Stenting of the right
coronary artery was performed with a 2.5 x 18 mm Cipher
stent. Final angiography demonstrated no residual stenosis,
no dissection and TIMI3 flow. Integrelin was stopped at the
end of the case due to the patient's viral syndrome and
severe cough. Patient returned to the floor.
In the evening following catheterization patient underwent an
post catheterization examination at 10 P.M. at which point he
was in good spirits and his baseline mental status. However,
he had little urine output post catheterization so a Foley
catheter was placed and 1400 cc came out. Night float
resident returned to re-evaluate patient's urine output at
midnight and found that he was having increased difficulty
getting words out. He seemed to have an acute mental status
change. Neurology team was called. The team believed this
may have been a stroke. Head CT was done which was negative
for a bleed. MRI was not obtained as the patient had a new
metal stent that was less than 24 hours old and this a
contraindication to MRI. Patient's family was notified and
attending physician was notified. According to his wife
patient has a had prior history of word finding trouble in
the past when he had hypoglycemia and was overdosing on
narcotics. Patient was started on a heparin drip and felt to
have question of an acute stroke versus a new metabolic
stress causing Broca 's' aphasia. Patient was continued on
his aspirin and Plavix and underwent careful follow up.
Patient's blood pressure was allowed to autoregulate per
neuro recommendation. Patient's mental status waxed and
waned over the next 24 hours. Repeat CT demonstrated no
acute bleed, no brain edema or midline shift. The plan was
obtain a transesophageal echocardiogram as well as carotid
study. Carotid study was negative. Transesophageal
ultrasound was delayed as patient had a history of dysphagia.
He underwent an esophagogastroduodenoscopy which was notable
for small hiatal hernia as well as a widely patent Schatzki
ring in the lower esophagus. The web was not dilated.
Patient to return for further gastrointestinal follow up
after his acute issues have resolved.
Overnight from [**6-4**] to [**6-5**] patient developed increasing
hypoxia with some evidence of aspiration pneumonia and a
worsening lung examination. The hypoxia cleared the day
after patient's esophagogastroduodenoscopy evaluation. It
was felt that patient likely had a new aspiration pneumonia.
At 1 A.M. on the morning of [**6-5**] the patient's room air
saturations were 88 percent. Patient deteriorated over the
course of the night and required a face mask. Arterial blood
gas was 7.43, 41, 50, lactate of 1.2. Repeat CT of the head
negative for bleed. At this time the patient spiked a
temperature to 102 and had worsened aphasia, hypoxia and a
worsening mental status. The patient no longer recognized
his wife and was unable to answer any questions. Medical
Intensive Care Unit evaluation was requested at that time and
care was transferred to the Intensive Care team.
Other issues evaluated during [**Hospital 228**] hospital course from
[**5-31**] to [**6-5**]:
1. Renal transplant: A renal transplantation team was
consulted and followed patient throughout this portion of
his hospital course. He was maintained on his anti
rejection medication. He was treated with Mucomyst prior
to contrast administration and given intravenous fluids
based on renal transplantation team recommendations.
1. Endocrine: Patient had a normal TSH and T4 but in light
of his history of immunosuppression and pituitary infarct
he was given stress dose steroids prior to his cardiac
catheterization.
1. Lung nodules: The patient had lung nodules noted on his
CT and will need follow up CT in a few months. A PPD was
placed and read as negative.
1. Diabetes: Patient initially was on his home insulin pump.
However, the battery and pump ran out prior to patient's
cardiac catheterization. Patient was transitioned to an
insulin drip after his development of Broca's aphasia as
he was no longer able to manage his insulin pump and
become unsafe.
1. Rectal pain: Patient has persistent chronic rectal pain.
His methadone maintenance was increased over the first few
days of his hospitalization in an attempt to help control
his chronic chest pain which was unrelieved by
catheterization. However, it was noted patient had a
worsened mental status with increased dose of methadone.
The methadone dose was decreased back to patient's
baseline dosing with good effect.
This completes the dictation for the portion of [**Hospital 228**]
hospital course from [**5-31**] to [**6-5**] when his care was
transferred to the Medical Intensive Care Unit Team.
DR.[**First Name (STitle) **],[**First Name3 (LF) 2515**] 12-927
Dictated By:[**Last Name (NamePattern1) 6709**]
MEDQUIST36
D: [**2120-6-13**] 16:01:14
T: [**2120-6-13**] 17:55:37
Job#: [**Job Number 20310**]
Admission Date: [**2120-5-30**] Discharge Date: [**2120-6-13**]
Date of Birth: [**2074-6-19**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient presented with a
chief complaint of chest pain. The patient is a 45-year-old
man with a history of type 1 diabetes status post renal
transplant 20 years ago, with a history of known CAD with two
stents in the right coronary artery and the left circumflex
artery done in [**2119**], who presented on the day of admission
with exertional chest pain that began at 11 a.m. the day of
admission. The patient had climbed a flight of stairs with
noted increased dyspnea on exertion, although he also
reported a one month history of dyspnea on exertion prior to
admission as well.
Approximately 10 minutes after the patient climbed the
stairs, he developed substernal and epigastric chest pain
that radiated to the left arm and back. The patient
complained of back pain that was [**2126-7-25**], which decreased to
[**3-27**] after Morphine was given to the patient in the Emergency
Room. The patient denied any nausea, vomiting, or
diaphoresis, or shortness of breath at rest. The patient
described the pain as a pressure that was constant and which
felt heavy.
Upon further questioning by the initial primary medical team,
it was described that the patient had a report of this
similar type of chest pain ever since his stents had been
placed in [**2119**] and had recurrent pain of this sort every six
months. The patient had been told in the past that it was
due to GERD, but stated that he did not believe this
diagnosis. The patient also noted that nitroglycerin never
helped, and only gave him a headache. The patient reported
that since he had been on methadone for chronic pain in the
past and on admission, that he needed increased and very high
amounts of Morphine to treat this pain.
The patient noted that he had just recently moved from
[**State 15946**], but had not experienced any colds or flus, no
vomiting, no nausea, no diarrhea, no constipation.
PAST MEDICAL HISTORY: Diabetes type 1.
End-stage renal disease status post renal transplant in [**2100**]
here at [**Hospital1 **].
Bilateral legal blindness.
Coronary artery disease status post stents to the RCA and the
left circ in [**2119**].
Pituitary apoplexy.
GERD.
MEDICATIONS ON ADMISSION:
1. Insulin pump, which the patient and the patient's wife,
who managed at home.
2. Lescol 40 mg p.o. q.h.s.
3. BuSpar 15 mg q.a.m., 30 mg q.p.m.
4. Methadone 10 mg p.o. b.i.d.
5. Clonazepam 1.5 mg p.o. q.d.
6. Prednisone 5 mg p.o. q.d. The patient stated the
prednisone was for his history of rheumatoid arthritis.
7. Azathioprine 50 mg p.o. q.a.m. and 100 mg p.o. q.h.s.
8. Atenolol 25 mg p.o. q.d.
9. Lasix 20 mg p.o. b.i.d.
10. Aldactone 20 mg p.o. b.i.d.
11. Aspirin 81 mg p.o. q.d.
12. Vitamin E 400 units p.o. q.d.
13. Paxil 37.5 mg p.o. q.d.
ALLERGIES: The patient is allergic to erythromycin.
SOCIAL HISTORY: The patient denies any tobacco use, alcohol
use, or intravenous drug use. The patient's social history
also includes that he just recently moved from [**State 15946**] with
his wife. The patient's wife works as a technician at the
[**Name (NI) **] [**Hospital 982**] Clinic. The patient has one son.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Heart rate 98, blood
pressure of 116/50 or 86. In the left arm, the blood
pressure is 119/73. In the right arm, it was 124/81. The
patient's temperature was 98.4, respiratory rate was 16, and
he was saturating 96 percent on room air. His exam showed
that he was in no apparent distress. His HEENT exam showed
that he has no reactive pupils. Sclerae were anicteric. His
neck showed jugular venous distention at 8 cm. His chest was
clear to auscultation bilaterally, no wheezes were noted.
His heart exam showed regular, rate, and rhythm, normal S1,
S2, no murmurs, rubs, or gallops. His abdominal exam was
mildly distended, normoactive bowel sounds, no
hepatosplenomegaly was noted. His skin exam showed no
rashes. His neurologic exam showed that he was alert and
oriented times three. He has [**5-22**] motor strength in his upper
and lower extremities, and his sensory examination was
grossly intact. His extremities showed [**1-19**] dorsalis pedis
pulses.
LABORATORIES ON ADMISSION: White count of 8.8, hematocrit of
44.9, platelets of 358. His sodium is 136, potassium was
6.1. This was hemolyzed and redrawn, and the repeat
potassium was 3.5, bicarb of 24, BUN of 20, and a creatinine
of 1.2. Patient's glucose was 122. His initial set of
cardiac enzymes showed a CK of 135, MB of 2, and troponin
less than 0.01.
The patient's EKG on admission showed sinus rhythm with a
heart rate at 95, normal intervals, normal axis, poor R-wave
progression, Q in lead III, and otherwise no acute ST-T
changes.
The patient's chest x-ray showed a widen mediastinum. The
patient then received chest and abdominal CT scan, which
showed a normal thoracic aorta, no mediastinal or hilar
lymphadenopathy, and an abdominal aorta within normal limits.
The transplanted kidney was incompletely imaged, however,
there were no significant abnormalities, according to the
Radiology [**Location (un) 1131**]. It was also noted in the chest CT that
there were these 2 mm noncalcified pulmonary nodules in the
right upper lobe and right lower lobe. Of note, the patient
reported that he had "fatty nodules" in his lungs that have
been noted and have remained stable since his renal
transplant 20 years prior to admission.
According to the patient's physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3748**] in [**State 15946**],
the patient had received P-MIBI in the year [**2118**], which
showed a small inferior wall defect and underwent a cardiac
catheterization with a distal right stent and a mid circ
stent on [**2118-8-31**]. Several months later the patient
then had another P-MIBI, which showed a negative study, an EF
of over 60 percent. Patient was also noted to have a history
of MRSA from a groin abscess in the past.
HOSPITAL COURSE: In the Emergency Room, the patient had been
given IV Morphine with relief of the patient's chest pain.
The patient was then admitted first to the Medicine service.
While in the Medicine service, patient underwent a P-MIBI on
[**5-31**], which was positive for inferior reversible defect.
On [**6-3**], the patient underwent a cardiac catheterization,
where he was found a right coronary artery restent thrombosis
and stenosis. The patient had this restented with a Cypher
stent.
On [**6-3**] after the catheterization had been completed, the
patient was noted to have a new expressive aphasia, and there
is a concern for a new embolic stroke as a result. The
Neurology consult service was notified and recommended
carotid studies and head CT. The patient underwent two
negative head CT scans, and carotid studies that showed
normal flow. The patient was started on a Heparin drip as
per Neurology recommendations. It was recommended by the
Neurology team that the patient undergo a transesophageal
echocardiogram, however, since the patient complained of
dysphagia, the patient first underwent an EGD on [**6-4**].
The EGD showed that the patient was noted to have a
Schatski's ring, and although this was widely patent.
On [**6-5**], the patient was noted to have an acute event
consisting of temperature spike to 102 degrees, worsening
mental status, and continued aphasia, hypoxia with an ABG on
face mask of 7.43/41/51, and the patient was then transferred
to the ICU on the opposite campus. The patient was never
intubated and his hypoxia resolved on his first day in the
ICU. The patient was noted to have a multilobar pneumonia as
shown on a chest x-ray that was done on [**6-5**], and patient
was started on IV antibiotics including IV vancomycin and IV
Zosyn. The patient also had sputum cultures that were drawn,
which showed gram-negative rods and gram-positive cocci in
pairs and clusters. These eventually returned with as
speciosities that showed that the patient did have MRSA in
his sputum. By the time the sensitivities returned, the
patient had already completed seven days of IV Zosyn and this
was discontinued. The patient was continued, however, on his
IV vancomycin as he did have MRSA in his sputum that grew
out.
While in the Intensive Care Unit, the patient was noted to
have resolving symptoms of his expressive aphasia and by his
second day in the ICU, the patient's mental status had
returned to baseline. The patient did undergo a
transesophageal echocardiogram on [**6-7**], which showed a
small atrial septal defect with no thrombus noted.
The Cardiology service initially recommended anticoagulation
and the patient was started on a Heparin drip and later on
Coumadin. The Cardiology service did note that the patient
was not in ASD closure candidate given all of his multiple
comorbidities. The Neurology team was then re consulted with
the question of whether or not anticoagulation should be
continued in this patient given his ASD with left-to-right
flow.
The Neurology attending, after extensive discussion between
the Medical team and the Neurology attending, it was decided
that the patient did not require anticoagulation as the
patient's changes in his neurological status were more likely
consistent with a renewal of his old stroke. The patient's
head CT scans had shown evidence of an old stroke in the
past, and the Neurology attending felt that the patient's
transient expressive aphasia was most likely consistent with
a renewal of the patient's old stroke symptoms given his
acute medical stressors at the time.
The Neurology attending felt that the patient could be
discontinued on the anticoagulation, however, should be
continued on the aspirin and Plavix. The Neurology attending
also felt the patient should follow up in the
Neuro/Cardiology Clinic 1-2 weeks after discharge from the
skilled-nursing facility for further workup as an outpatient
of hypercoagulability state. The patient was also told to
followup with the Neuro/Cardiology Clinic by the Cardiology
service as well.
The patient's other problems included: 1. [**Name2 (NI) 1194**]: The patient
had a history of chronic rectal pain for which he had been
placed on standing methadone b.i.d. The patient continued to
have episodes of recurrent chest pain after he was
transferred from the Intensive Care Unit once he was stable
to the Medical floor. Multiple EKGs were done in the several
days prior to the patient's discharge, and all of them showed
no changes in the patient's EKG from his baseline. The
patient was then again ruled out for myocardial infarction
for a second time three days prior to his discharge from the
hospital.
The patient continued to report that he had a chronic level
of chest pain at all times, however, when he became anxious,
the chest pain would become more intense. The patient had
described the chest pain as starting from his neck either the
right or the left, and occasionally migrating to his
substernal or left substernal area. The patient also
reported that only Morphine relieved the pain, and the
patient did not receive nitroglycerin when the chest pain
rose since he had a RCA stent that was placed.
In light of the patient's chest pain that did not show any
evidence of changes on EKG or any evidence of myocardial
infarction as shown by his cardiac enzymes, the patient also
had his clonazepam dose increased from 0.5 t.i.d. prn
eventually to 1 mg p.o. t.i.d. The patient was also given
prn doses of subQ Morphine every 4-6 hours 1-2 mg each time.
The patient also continued to report a headache, although
this was relieved by starting Ultram for the patient. The
patient was also reported having low back pain at the site of
his lumbar punctures that were done by the Neurology service
after the patient had an expressive aphasia. Although the LP
results were negative, the patient continued to report pain
at the site of the LP.
The patient underwent imaging studies for the low back pain,
which did not show any acute defect, compression, or
fracture. The patient's lumbar puncture site was also noted
never to be edematous, have a fluid collection, to be
erythematous, or to be warm. The patient was started on
Tylenol 1 gram q.6h. for the patient's low back pain.
According to the patient, these combination of medications
did relieve his pain in his low back area, his headache, his
chest pain, and his rectal pain. At the time of discharge,
the patient was on the combination of Tylenol 1 gram q.6h.,
Ultram prn, methadone 10 mg p.o. b.i.d., and subQ Morphine
every six hours 1 mg each time. The patient was told that he
would be eventually transitioned to p.o. pain medication if
he required additional pain management control.
1. Dysphagia: The patient reported a history of dysphagia
and underwent an EGD, which showed a Schatski's ring that
was widely patent. The patient also underwent a speech
and swallow study with a video oropharyngeal study portion
done showing functional or pharyngeal swallowing mechanism
without evidence of dysphagia or aspiration. The patient
was placed on a regular consistency p.o. diet, with thin
liquids, as recommended by speech and swallow. The
patient was also told that he should have an outpatient
gastric emptying study performed at some point as an
outpatient.
1. Renal transplant: The patient was status post renal
transplant 20 years ago by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15473**] at [**Hospital1 20311**]. The patient is currently on
azathioprine and prednisone for the patient's status post
transplant condition. The patient was followed by the
renal transplant fellow while in-house. The patient's
creatinine decreased from 1.2 on admission and on
discharge it was 0.8, and the patient's creatinine
remained stable throughout the majority of his hospital
stay. From the Renal Transplant team perspective, the
patient's never had any acute renal problems or issues.
1. Diabetes: The patient has a history of type 1 diabetes
and is on an insulin pump that is managed by the patient
and the patient's wife at home. The patient was noted to
have labile sugars while in the ICU that necessitated
insulin drip. The patient was eventually weaned off the
insulin drip, and was followed by the [**Hospital **] Clinic while
in-house. The patient was placed on a Glargine and
Humalog sliding scale by the [**Last Name (un) **] clinicians. On
discharge, the patient was on Glargine 28 units at
breakfast and an insulin-sliding scale.
According to the [**Last Name (un) **] attending on discharge, the patient
should resume his insulin pump once at the skilled-nursing
facility and/or rehab. The patient should also continue
using the insulin pump once he returns to home.
1. Heme: The patient had a decrease in his hematocrit from
30 to 26 during his hospital stay and he received 2 units
of packed red blood cells with an appropriate increase in
his hematocrit from 26 to 33. The patient was guaiac
negative during his hospital stay and showed no evidence
of bleeding at any point. The patient's hematocrit
remains stable in the low 30s after the blood transfusion.
1. Lung nodules: The patient was noted to have incidental
calcified lung nodules on his CT on admission. It was
recommended by the team that the patient have a followup
CT in a few months for his noncalcified lung nodules.
Patient had a PPD that was placed during hospital stay
that was negative.
1. GI: The patient initially presented with constipation and
was placed on a bowel medication regimen. During the last
four days of his hospital stay, the patient had
intermittent episodes of diarrhea. The patient did have
three Clostridium difficile tests sent. The first two of
three Clostridium difficile cultures were negative. The
patient also had stool cultures sent, and these were also
pending at the time of discharge.
1. Psychiatric issues: The patient has a history of
depression and anxiety, and is on BuSpar, clonazepam, and
Paxil at home. The patient had these medications
temporarily stopped while in the ICU. These were
restarted once the patient was again transferred back to
the Medicine floor. As the patient experienced multiple
episodes of anxiety throughout his hospital stay
manifesting with chest pain at times, the patient had his
clonazepam increased from 0.5 mg t.i.d. to 1 mg t.i.d.
1. Coronary artery disease: As mentioned previously, the
patient received a cardiac catheterization during his
hospital stay, where he was found to have a instent
restenosis of his right coronary artery and had a new
Cypher stent placed. Given his coronary artery disease,
the patient was started on simvastatin 10 mg p.o. q.d.
The patient was also started on an ACE inhibitor and on
discharge, the patient was on captopril 12.5 mg p.o.
t.i.d. The patient had his atenolol or metoprolol dose
increased to 25 mg p.o. b.i.d. during his hospital stay,
and also was sent to rehab on aspirin and Plavix.
1. Access: The patient had a right subclavian central line
placed on [**6-5**], which was discontinued prior to
discharge. Given that the patient required IV vancomycin
antibiotics for seven days after discharge, the patient
had a PICC placed by Interventional Radiology on the day
prior to discharge.
1. FEN: The patient was placed on the cardiac, diabetic diet
regular consistency with thin liquids. The patient had
electrolytes repleted as necessary.
1. Prophylaxis: The patient was placed on a proton-pump
inhibitor and a bowel regimen. The patient was initially
on a Heparin drip, however, after the Neurology attending
and Cardiology felt that this was no longer necessary,
this was discontinued. The patient was then seen by
Physical Therapy and the patient ambulated daily.
DISCHARGE STATUS: To the [**Hospital3 2558**] Skilled Nursing
Facility.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES: Coronary artery disease status post
stents to the right coronary artery and left circumflex
artery with restenosis of his right coronary artery
necessitating cardiac catheterization on [**6-3**].
Atrial septal defect as noted on a transesophageal
echocardiogram on [**2120-6-7**]: After discussion with the
Neurology and Cardiology teams, it was decided the patient
did not require anticoagulation for this as no thrombus was
noted.
Transient exacerbation of the patient's old stroke: The
patient had transient expressive aphasia and was found by the
Neurology service not to have had suffered an acute stroke.
It was recommended by the Neurology service to have the
patient sent out on aspirin and Plavix, and follow up with
the Neuro/Cardiology Clinic.
Diabetes type 1: The patient is being sent out on his
insulin pump that he manages at home with his wife.
End-stage renal disease status post kidney transplant 20
years ago.
Blindness.
Pituitary apoplexia/infarct.
Chronic rectal pain.
Anxiety.
Depression.
Dysphagia with a normal video oropharyngeal study without any
evidence of oropharyngeal dysphagia or aspiration.
Incidental noncalcified lung nodules: Follow-up CT in a few
months.
Diarrhea, with negative Clostridium difficile results on
discharge.
Multilobar pneumonia for which the patient requires seven
more days of intravenous vancomycin, as methicillin-resistant
Staphylococcus aureus was found in the patient's sputum.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Paroxetine 30 mg p.o. q.d.
4. Clonazepam 1 mg p.o. t.i.d.
5. Methadone 10 mg p.o. b.i.d.
6. Prednisone 5 mg p.o. q.d.
7. Buspirone 10 mg, three tablets p.o. q.a.m.
8. Buspirone 30 mg p.o. q.p.m.
9. Azathioprine 50 mg p.o. q.o.d. alternate with 100 mg p.o.
q.o.d.
10. Azathioprine 100 mg p.o. q.o.d. alternate with 50 mg
p.o. q.o.d.
11. Plavix 75 mg p.o. q.d.
12. Bisacodyl 10 mg p.o. q.d. prn.
13. Maalox 15-30 mL p.o. q.i.d. prn.
14. Lactulose 30 mg p.o. q.8h. prn.
15. Albuterol nebulizer one nebulizer q.3-4h. prn.
16. Ipratropium nebulizer one nebulizer q.3-4h. prn.
17. Ambien 5-10 mg p.o. q.h.s. prn.
18. Vitamin D 400 units p.o. q.d.
19. Benzonatate 100 mg p.o. t.i.d. prn.
20. Vancomycin 1000 mg IV q.12h. for seven more days
after [**2120-6-13**].
21. Simvastatin 10 mg p.o. q.d.
22. Pantoprazole 40 mg p.o. q.12h.
23. Senna one tablet p.o. b.i.d.
24. Docusate sodium 100 mg p.o. b.i.d. prn.
25. Acetaminophen 1000 mg p.o. q.6h.
26. Captopril 12.5 mg p.o. t.i.d.
27. Tramadol 50 mg p.o. q.6h. prn.
28. The patient was told to restart his insulin pump
once he arrived at the skilled-nursing facility.
29. Insulin-sliding scale as needed until the insulin
pump is initiated. The patient was on 28 units of
Glargine at breakfast while in the hospital, and also on
an insulin-sliding scale as needed.
The patient is told to followup with Neuro/Cardiology Clinic
at [**Hospital1 69**]. The patient is told
to followup with these appointments:
1. New primary care physician appointment at the [**Hospital 191**] Clinic
at [**Hospital1 69**]. Please call to
schedule your appointment for 7-10 days after discharge
from the skilled-nursing facility. The phone number is
[**Telephone/Fax (1) 250**].
2. [**Last Name (un) **] followup: You are scheduled to followup with a new
[**Last Name (un) **] physician on [**2120-6-26**]. They will also contact
you regarding a reminder for this followup clinic
appointment. They will have a teaching nurse appointment
for you once you leave the skilled-nursing facility.
3. Neuro/Cardiology appointment. Please call Dr.[**Name (NI) 20312**]
office's office for a follow-up appointment with
Interventional Cardiology. His phone number is [**Telephone/Fax (1) 20313**].
4. [**Hospital 878**] Clinic followup. Please call to schedule
followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Her office clinic phone
number is [**Telephone/Fax (1) 2574**]. The follow-up appointments for
Cardiology and Neurology should be made within 1-2 weeks
after discharge from the skilled-nursing facility as well.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 20314**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2120-6-13**] 13:53:46
T: [**2120-6-13**] 15:14:47
Job#: [**Job Number **]
cc:[**Hospital3 20315**]
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12,737
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50641
|
Discharge summary
|
report
|
Admission Date: [**2170-12-2**] Discharge Date: [**2170-12-14**]
Date of Birth: [**2090-3-5**] Sex: M
Service: MEDICINE
Allergies:
Ceftazidime
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Increased respiratory secretions and inability to swallow meds.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
80 y.o. man with P.D., s/p 2 admissions over last month for
falls. Pt was just discharged to rehab yesterday, but is now
returning with inability to take PO meds, requiring frequent
suctioning. When pt was here last he was admitted after a
witness fall and injured his left elbow. On that admit, he was
witness to aspirate with meds, food, and liquids but family was
refusing NGT or PEG tube. Therefore, pt was discharged with
rehab with understanding that he could take food and meds but
was at high risk of aspiration and ensuing complications. This
morning at [**Hospital 599**] rehab in [**Location (un) **], pt was noted to have
increased resp secretion requiring q30min suctioning. He also
could not swallow his medications.
Though pt did pass swallow study at [**Hospital1 5595**] about 2 weeks ago, he
was clearly witnessed to aspirate over last 2 days while here.
..
Currently, pt denies pain, SOB, CP, cough. He understands why
he is here.
Past Medical History:
1. CAD s/p CABG [**2165**]-3VD--CABG by [**Last Name (un) 2230**]
-[**2146**] IMI (Rx'd with SK), CATH with 75% mid RCA.
-Noted to have VEA and ?PAF, Rx'd with quinidine and later
digoxin.
[**11/2153**] normal ETT, [**2158**] 10" ETT/neg EKG/neg Sx.
- [**10/2160**] admitted for eval palpitations, MI R/O, HOLTER with VEA,
quinidine/dig stopped, atenolol begun.
2. hypercholesterolemia
3. HTN
4. parkinson's
5. colon cancer
-S/P RESECTION [**2158**] WITH CLEAR MARGINS (R-colon), f/u
colonoscopies negative [**12/2160**], [**6-/2161**]; [**6-/2163**]; [**6-/2165**]- two small
(4mm) sessile adenomatous polyps were identified and removed
6. anemia
7. hx hip fracture w/right total hip replacement
8. actinic keratoses, SCC on forehead, s/p MOHS excision
9. h/o PAF
Social History:
SH: Has been at [**Hospital 599**] rehab in [**Location (un) **] x2 days since last
admission. Son and family live nearby. Son heavily involved in
pt's care and is healthcare proxy. Former [**Name2 (NI) 1818**] (+20 pack year
h/o), quit 25 years ago. Seldom EtOH, no drugs. No longer able
to ambulate secondary to frequent falls and rigidity from
Parkinson's. He passed a speech and swallow eval at [**Hospital 100**]
Rehab ~1 month; he was taking his Parkinson's Meds at that time.
Family History:
FH - CAD, HTN
Physical Exam:
97.8---91---102/72---17---95%RA
Gen: cogwheeling tremor, pt in no resp distress.
HEENT: Pupils min reactive to light. Anicteric. OP clear with
dry MM.
Neck: supple
Lungs: b/l rhonchi and occ insp and exp wheezing.
CV: irreg irreg rhythm, nml S1S2, no m/r/g
Abd: soft, NT, ND, na BS
Ext: no edema, Left elbow wrapped but nontender.
Neuro: A&Ox2 (not date), cogwheelng tremor of left hand
mostly. Gait not tested.
Pertinent Results:
[**2170-12-1**] 07:20AM WBC-5.8 RBC-3.50* HGB-11.2* HCT-32.9* MCV-94
MCH-32.1* MCHC-34.1 RDW-14.2
[**2170-12-1**] 07:20AM NEUTS-78.8* LYMPHS-18.1 MONOS-1.3* EOS-1.4
BASOS-0.4
[**2170-12-1**] 07:20AM PLT COUNT-195
[**2170-12-1**] 07:20AM GLUCOSE-102 UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2170-12-1**] 07:20AM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2170-12-1**] 01:42AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2170-12-1**] 01:42AM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
CXR: no acute infiltrate.
EKG: poor baseline, irregular, likely AF with nml vent
response, Qs inf (old), no ST changes.
Brief Hospital Course:
80 y.o. man with Parkinson disease, h/o recent aspiration
presenting with increasing resp secretions and now worsening
dysphagia.
.
# MRSA aspiration pna:
Patient developed respiratory failure in the MICU from MRSA
aspiration pna. He was maintained on Levo, Vanco, and Flagyl.
He initially was afebrile, with normal WBC and clear CXR.
Inability to swallow and take his PD regimen is the likely
reason that his dysphagia worsened. Over the hospital stay, the
patient developed aspiration pna. PD sublingual meds were
attempted, but were not successful. Patient had an NGT placed
for administration of his meds, but placement attempts failed
because of anatomical variant in his pharynx. Pulmonary and GI
both attempted to place the NGT without success.
.
Patient was frequently suctioned, underwent chest PT, and had
nebs. Oxygen saturation were in the high 90s on nc until the
last two days before passing. The patient's son was called to
patient's bedside for desaturation to 80s for the first time,
and code status was changed from full to DNR/DNI, consitent with
the patient's previously expressed wishes. With the focus of
care on patient [**Last Name (LF) **], [**First Name3 (LF) **] infusion of morphine was used to
provide relief of pain and airhunger. The patient passed away
in the MICU, with the patient's son by his bedside. [**Name (NI) **]
son [**Name (NI) 382**] did not wish to have an autopsy.
.
# C diff diarrhea:
Patient was being treated for C diff with IV flagyl.
.
# AFIB with RVR:
Patient was rate controlled on digoxin, and was anticoagulated
on heparin gtt.
.
# CAD with CABG:
Hct was maintained at > 30, on digoxin, well controlled.
.
# Parkinson disease:
Continued on sinemet and mirapex.
Medications on Admission:
1. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qid ().
2. Carbidopa-Levodopa 25-100 mg One Tablet PO TID.
3. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY
7. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO tid ().
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2171-2-18**]
|
[
"V10.05",
"276.51",
"V15.88",
"401.9",
"518.81",
"787.2",
"038.9",
"V45.81",
"008.45",
"482.41",
"427.31",
"507.0",
"332.0",
"995.92",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.22",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6299, 6314
|
3873, 5600
|
336, 343
|
6366, 6376
|
3112, 3850
|
6433, 6598
|
2638, 2653
|
6129, 6276
|
6335, 6345
|
5626, 6106
|
6400, 6410
|
2668, 3093
|
233, 298
|
371, 1329
|
1351, 2117
|
2133, 2622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,770
| 186,731
|
34044+57888
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-5-20**] Discharge Date: [**2130-6-21**]
Date of Birth: [**2103-7-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
[**2130-6-16**] Redo-Sternotomy and Bentall procedure with a 29-mm St.
[**Male First Name (un) 923**] mechanical composite valve graft and coronary button
reimplantation.
History of Present Illness:
Mr. [**Known lastname **] is a 25 yo M w/hx VSD s/p patch and aortic
coarctation s/p repair (repaired 10 years ago) who presents with
fevers to 103 at home, chills, nausea and NBNB emesis, abdominal
cramping and shortness of breath over the past 10 days. He took
Tylenol at home without much effect and over the course of the
last four days, developed difficulty walking as well [**2-11**]
cramping leg pain bilaterally, from ankles to knees, worse in
the calf. He denies back pain, and presented today to an OSH ED.
He notes travel to [**Country 4194**] in [**10/2129**], and had a dental procedure
at the time. He took prophylactic antibiotics (amoxicillin) at
the time. Since then, he has noted tooth pain as well as oozing
of black pus from around his tooth several weeks ago, none
recently. He denies any history of recent injection drug use,
last injected heroin 3 years prior. Cardiac review of systems is
notable for absence of chest pain, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope. He
does note SOB at rest and with exertion. At baseline, he is
unable to run, but is able to walk "forever" without development
of dyspnea. He denies headache, vision changes, neck stiffness,
cough, hemoptysis, chest pain, abdominal pain, dysuria,
numbness, weakness.
Past Medical History:
History of VSD/Aortic Coarctation - s/p repair as a teenager
Hepatitis C
History of IVDA/Heroin Abuse
Social History:
He works as an English teacher. Denies alcohol use. Has a remote
history of heroin injection and heavy alcohol use three years
prior. He denies any recent travel, last traveled to [**Country 4194**] in
10/[**2129**]. Denies pets at home. Lives at home with his wife.
Family History:
Mother with alcoholism. No hx heart defects in other siblings.
Physical Exam:
PREOP EXAM
VS: T 103.1, BP 101/55, HR 113, RR 19, O2 94% on 4L NC
Gen: Diaphoretic, anxious appearing male in NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. +Gingivitis and
tooth pain at molar on right side. No cervical LAD.
Neck: Supple with JVP of 8 cm.
CV: Tachycardic. No thrill. II/IV diastolic descrescendo murmur
at RUSB. Hyperdynamic PMI at 5th ICS. No rubs or gallops.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations labored. Inspiratory crackles at bases. No wheezes
or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. + [**Last Name (un) 5813**]. + Splinter
hemorrhages. -Osler nodes.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2130-5-19**] WBC-10.9 RBC-3.77* HGB-10.9* HCT-31.9*
[**2130-5-19**] PLT COUNT-340
[**2130-5-19**] PT-14.5* PTT-26.4 INR(PT)-1.3*
[**2130-5-19**] GLUCOSE-105 UREA N-6 CREAT-0.7 SODIUM-138 POTASSIUM-3.4
CHLORIDE-102 TOTAL CO2-29 ANION GAP-10 CALCIUM-8.1*
PHOSPHATE-2.8 MAGNESIUM-1.8
[**2130-5-19**] LACTATE-1.9
[**2130-5-19**] CK(CPK)-47
[**2130-5-19**] cTropnT-0.20*
[**2130-5-19**] CK-MB-NotDone
[**2130-5-20**] CK(CPK)-51
[**2130-5-20**] CK-MB-NotDone cTropnT-<0.01
[**2130-5-19**] ETHANOL-NEG tricyclic-NEG
[**2130-5-20**] URINE barbitrt-NEG cocaine-NEG amphetmn-NEG
mthdone-NEG
[**2130-5-19**] URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2130-5-19**] BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2130-5-20**] Chest/Abd CT Scan:
1. Bilateral lower lobe opacities may represent atelectasis,
aspiration, or pneumonia. Bilateral small pleural effusions.
2. Cardiac enlargement and dilation of the aortic root with
narrowing of the aortic arch, consistent with the patient's
history of coarctation status post repair.
3. Small wedge-shaped region of relative hypoperfusion in the
right kidney in otherwise normal-appearing kidneys, most
consistent with small focal infarct; differential includes focal
pyelonephritis.
4. Small amount of ascites distributed throughout the abdomen
and pelvis, nonspecific.
5. Mediastinal lymph nodes measuring up to 9.5 mm, nonspecific.
[**2130-5-20**] Transthoracic Echocardiogram:
Moderately dilated left ventricle with overall preserved
systolic function. There is a vegetation on the non-coronary
cusp of the aortic valve. This appears echo-bright suggesting
some degree of chronicity. Severe aortic regurgitation. Dilated
aortic sinus. No vegetation seen on mitral valve. Normal LV
systolic function. Mild pulmonary hypertension, borderline RV
systolic function.
[**2130-5-21**] MRI Spine:
No spondylodiscitis or abscess of the cervical, thoracic, or
lumbar spine.
[**2130-5-24**] Renal Ultrasound:
The right kidney measures 12.7 cm and the left kidney measures
12.7 cm. Both kidneys demonstrate diffusely increased cortical
echogenicity, without cortical thinning, hydronephrosis, focal
cortical abnormality or calculi. Blood flow is seen throughout
both kidneys. The urinary bladder appears unremarkable. There is
a small amount of free pelvic fluid.
IMPRESSION: Findings compatible with medical renal disease.
[**2130-6-14**] Coronary CTA:
The ascending aorta at the level of the main pulmonary artery is
46 x 48 mm in diameter and mildly dilated. The aortic root shows
a tricuspid valve; however, the valve is considerably thickened
with what would appear to be vegetations along the entire
leaflets. In addition, there is one vegetation that measures 7.3
x 9.4 mm in diameter that appears to arise from the left
anterior cusp and extends over to the right cusp below the
origin of the right coronary artery. In addition there is a
smaller area of vegetation on the left anterior valve leaflet
near the orifice of the left main coronary artery. The coronary
arteries arise from their expected locations. The circulation is
left dominant with a prominent left anterior descending that
extends to the apex with the D1. In addition there is a
prominent left circumflex which gives off an OM1 or ramus
branch. The left circumflex supplies the PDA and PDL.
[**2130-6-16**] Intraop TEE:
PRE-BYPASS:
1. The left atrium and right atrium are normal in cavity size.
2. The right upper pulmonary vein may be entering at the SVC/RA
junction.
3. A left-to-right shunt across the interatrial septum is seen
at rest. A small secundum atrial septal defect is present.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is low l (LVEF40%).
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is moderately dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
moderately dilated. There are simple atheroma in the descending
thoracic aorta.
7. The aortic valve is bicuspid. A mass is present on the aortic
valve. Severe (4+) aortic regurgitation is seen. There is an
area degeneration along the length of the aortic valve from the
annulus extending to the sinus that appears to be consistent
with a former perivalvular abscess, measuring 1cm x 2cm; there
is flow demonstrated in this area.
8.The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
9. Moderate [2+] tricuspid regurgitation is seen.
10. There is a trivial/physiologic pericardial effusion.
11. There is a small left pleural effusion.
POST-BYPASS:
1. There is a mechanical valve in the aortic position, with
normal leaflet motion and no aortic regurgitation. Mean gradient
across the valve is 14mmHg with a cardiac output of 7.56L/min.
The area previous mentioned at the level of the aortic valve
extending from the annulus to the sinus has been surgically
repaired and there is no evidence of flow.
2. Degree of mitral regurgitation remains unchanged and is mild
(1+) mitral regurgitation.
3. Degree of tricuspid is unchanged.
4. The replaced ascending aorta measures 3.7cm.
5. Aortic contours are intact post decannulation.
Brief Hospital Course:
PREOPERATIVE COURSE: Mr. [**Known lastname **] is a 26 year old male who
presented with culture negative aortic valve endocarditis, with
hospital course complicated by acute renal failure secondary to
acute tubular necrosis, likely medication-induced (gentamicin,
NSAIDs, contrast).
1)Aortic Valve Endocarditis: Mr [**Known lastname **] came to us from an
outside hospital; both here and there, cultures have been
negative, but Mr [**Known lastname **] did apparently receive antibiotics
before cultures. A TEE was performed which showed a vegetation
on his aortic valve as well as 4+AR and 3+TR. There was no
indication of aortic root involvement; PR intervals were
lengthened on arrival but stayed at ~0.22 through his admission.
Vancomycin and Gentamicin were started on [**2130-5-20**] with a plan
for at least a six-week course for vancomycin. Mr [**Known lastname **]
developed acute renal failure (see below), Gentamicin was
stopped and the Vancomycin dosing schedule was changed.
Ciprofloxacin was eventually started on [**2130-5-22**] to cover
possible HACEK organisms. He eventually went on to develop rash
and fevers,associated with eosinophilia and worsening
pancytopenia which was attributed to Vancomycin. Given his renal
insufficiency, Vancomycin was switched to Daptomycin
2)Infectious Disease: Mr [**Known lastname **] had extensive testing for
possible causative or associated pathogens, which was mostly
negative. Among the tests was one for Hepatitis C; he had
antibody to Hepatitis C but a negative viral load, perhaps
suggesting clearance. This should be followed up as an
outpatient. Additionally he tested HIV-negative. RPR, fungal
cultures, and IgM for Bartonella, Coxiella and mycoplasma were
all negative; he did have IgG positive for mycoplasma. Brucella
was found on cultures and awaiting PCR results. ID service will
follow up with him at rehab.
3) Acute Renal failure - On [**5-23**] (hospital day 4), Mr
[**Known lastname 78572**] creatinine climbed to 2.7 from 0.7 approximately 36
hours earlier. We suspected that this was secondary to CT
contrast, gentamicin, and NSAIDs, and that this was ATN. The
renal service was consulted and confirmed the presence of ATN by
microscopy of urine sediment. Gentamicin was held. His
creatinine peaked at 4.1 on the [**5-25**], after which it
began a slow steady decline, reaching 2.0 by [**2130-6-5**]. Continued
to improve prior to going to the operating room.
POSTOPERATIVE COURSE:
On [**6-16**] he was brought to the operating room and underwent
bentall procedure, see operative report for further details. He
continued on cipro and daptomycin treatment per infectious
disease recommendations. He was started on amiodarone for
atrial fibrillation in the operating room. In the first 24
hours post operative he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
He was weaned from vasoactive medications and was transferred to
the floor on POD 2. His chest tubes and pacing wires were
removed, and he was started on anticoagulation for his
mechanical valve. Psychiatry was consulted for management of
anxiety and his medications were adjusted with improvement in
symptoms. It was recommended that he follow-up with a
neurologist as an outpatient for evaluation of possible
Tourette's Syndrome. He continued to improve and was ready on
POD 5 to be discharged to rehab for continued antibiotic
therapy. Plan for infectious disease to follow up with rehab
when PCR results are returned.
Medications on Admission:
None
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
2. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg)
Intravenous Q24H (every 24 hours) for 2 weeks: [**Date range (1) 78573**].
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks: [**Date range (1) 78574**].
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 packets* Refills:*0*
14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H
(every 6 hours) as needed.
Disp:*30 elixir* Refills:*0*
16. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses: titrate for an INR goal of 2.5-3 for his mechanical
AVR.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Hospital1 **]
Discharge Diagnosis:
Aortic Valve Endocarditis
Biscupsid Aortic Valve, Aneurysm of Ascending Aorta and Aortic
Root
Acute Renal Insufficiency
Hepatitis C, History of IVDA/Herion Abuse
History of VSD/Aortic Coarctation - s/p repair as a teenager
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks, call for appt
Cardiologist Dr. [**Last Name (STitle) **] after discharge from rehab
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4844**] after discharge from rehab [**Telephone/Fax (1) 250**]
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2130-7-12**]
10:30
Please have patient follow-up with a neurologist to evaluate for
Tourette's Syndrome.
Completed by:[**2130-6-21**] Name: [**Known lastname 6000**],[**Known firstname **] Unit No: [**Numeric Identifier 12649**]
Admission Date: [**2130-5-20**] Discharge Date: [**2130-6-21**]
Date of Birth: [**2103-7-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 1543**]
Addendum:
d/c meds changed.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
2. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg)
Intravenous Q24H (every 24 hours) for 2 weeks: [**Date range (1) 12650**].
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks: [**Date range (1) 12650**].
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 packets* Refills:*0*
14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H
(every 6 hours) as needed.
Disp:*30 elixir* Refills:*0*
16. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses: titrate for an INR goal of 2.5-3 for his mechanical
AVR.
Disp:*30 Tablet(s)* Refills:*0*
17. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
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. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 12651**] House of [**Hospital1 **]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2130-6-21**]
|
[
"729.82",
"E930.8",
"305.50",
"427.31",
"300.00",
"284.1",
"693.0",
"447.8",
"423.1",
"421.0",
"307.23",
"V15.1",
"584.5",
"424.1",
"070.70",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"88.72",
"38.45",
"35.22",
"39.59"
] |
icd9pcs
|
[
[
[]
]
] |
17855, 18093
|
8616, 12130
|
283, 456
|
14273, 14280
|
3285, 8593
|
14615, 15500
|
2219, 2283
|
15523, 17832
|
14027, 14252
|
12156, 12162
|
14304, 14592
|
2298, 3266
|
237, 245
|
484, 1792
|
1814, 1918
|
1934, 2203
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,557
| 138,883
|
27355
|
Discharge summary
|
report
|
Admission Date: [**2130-8-27**] Discharge Date: [**2130-9-27**]
Date of Birth: [**2058-11-17**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Percocet / Zosyn / Amiodarone
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Hypercarbic resp failure, hypotension, altered mental status
Major Surgical or Invasive Procedure:
Bronchoscopy
Tracheostomy change
PICC placement
History of Present Illness:
This patient is transferred here primarily for hypotension from
[**Hospital **] Rehab. Prior to transfer here, she was hypercapneic and
required ventilation to reduce her pCO2.
.
The patient has had extensive recent hospitalizations. She had
Influenza A in [**4-10**] complicated by ARDS eventually leading to
intubation, ventilatory support, and tracheostomy. Complicated
by tracheocutaneous fistula. Returned for hypercarbic
respiratory failure -> ventilation through ET tube. She was
found to have a LLL PNA, paroxysmal rapid AFib (hr 180s) and
pneumomediastinum,
upper esophageal dilatation, and UTI. She underwent bronchoscopy
which was apparently unremarkable. Her course had been
complicated by hypotension requiring levophed and rapid AFib for
which chemical cardioversion was attempted unsuccessfully with
ibutilide. Cultures revealed MRSA PNA/bacteremia, and
pseudomonas UTI, and treatment was initiated with vancomycin and
zosyn.
.
She was then admitted to [**Hospital1 18**] [**5-30**] after short stay at OSH for
workup of pneumomediastinum. Bronch at OSH revealed no defects
in the tracheal wall, and an esophageal gastrograffin study was
negative as well. Multiple imaging studies did not reveal any
pneumomediastinum. Repeat EGD/Rigid bronchoscopy did not show
any TE fistula, but the evidence for pneumomediastinum is that
respiratory symptoms (hypercarbic failure) and AF with RVR
became worse when ET tube was in higher position, and resolved
when ET tube was repositioned lower, presumably below the site
of a fistula. Her tracheostomy was revised and she had no
recurrence of afib with RVR. The may many attempts for pressure
support wean unsuccessfully so PEG was placed and she was
discharged to a chronic vent facility.
.
She was then recently admitted (discharged on [**8-2**]) for
psedomonas pneumonia and sepsis. She was treated with a 14 day
course of Aztreonam. This Pseudomonas was found to be
intermediate in sensitivity, but the regimen was completed
because of clinical improvement on the medication. She was
thought to have a cuff leak on this occasion despite elevated
cuff pressures. She had a L PICC removed prior to discharge and
a new R PICC line placed. She also had in a R subclavian during
this admission.
.
At [**Hospital1 **], she was maintained on her trach mask and was found
to have Pseudomonas in her sputum. Per their sensitivities she
was treated with Amikaicin and Ertopenem. But, 7 days past, she
had some changes in her mental status hence, ertopenem was
discontinued. This did not ameliorate her symptoms and 3 days
prior, her amikaicin was stopped. The morning of admission, per
report, she was SOB though with good sats, good PIPs, but
copious sputum and diffuse fibronodular disease (no
pneumopthorax or atelectasis) on CXR at [**Hospital1 **]. Later, she
became more lethargic; her BP was in the 90s (Normally in the
150s), her temperature was 96 and she was gassed and had a pCO2
of 130 (with pO2 >100). She was ventilated and her ABG was
7.3/77/110 when she was transferred here. Her last vent settings
were AC 22x450 FiO2 of 0.45 and 5 of PEEP.
Past Medical History:
1. Influenza A in [**4-10**] complicated by ARDS eventually leading to
intubation, ventilatory support, and tracheostomy.
2. Remote history of pneumonia.
3. Status post left eye cataract surgery.
4. Anxiety
5. DMII
Social History:
no significant tobacco or alcohol use.
Family History:
non-contributory.
Physical Exam:
T: 97.8 BP:98/45 P: 70 (AFib) RR: 23 O2 sats: 98%
Gen: Cachexic elderly female with tracheostomy and intention
tremors.
HEENT: OP with whitish exudate on tongue
CV: +s1+s2 irregular No Murmurs
Resp: Coarse air movement anteriorly.
Abd: Tender over umbilicus and to the right of the umbilicus.
There is some guarding/rigidity. No rebound tenderness.
Back: Scoliotic
Ext: 1+ pretibial/pedal edema
Neuro: ? to assess orientation because of trach
- patient with intention tremors. ? resting tremors as patient
constantly holding onto fixed objects.
Pertinent Results:
[**2130-8-27**] 06:07PM BLOOD WBC-6.4 RBC-3.25* Hgb-9.7* Hct-30.1*
MCV-93 MCH-29.8 MCHC-32.2 RDW-15.7* Plt Ct-179
[**2130-9-6**] 05:27AM BLOOD WBC-10.1 RBC-2.66* Hgb-7.9* Hct-23.9*
MCV-90 MCH-29.8 MCHC-33.1 RDW-16.9* Plt Ct-249
[**2130-9-20**] 05:10AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-89 MCH-30.1 MCHC-34.0 RDW-16.0* Plt Ct-259
[**2130-9-25**] 05:50AM BLOOD WBC-6.4 RBC-2.80* Hgb-8.5* Hct-25.1*
MCV-90 MCH-30.4 MCHC-33.9 RDW-15.8* Plt Ct-199
[**2130-9-26**] 06:16AM BLOOD WBC-6.2 RBC-2.98* Hgb-8.9* Hct-26.8*
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.8* Plt Ct-189
.
.
[**2130-8-27**] 06:07PM BLOOD PT-21.0* PTT-150* INR(PT)-2.0*
[**2130-9-1**] 02:02AM BLOOD Plt Ct-133*
[**2130-9-7**] 03:53AM BLOOD Plt Ct-266
[**2130-9-17**] 06:10AM BLOOD Plt Ct-252
[**2130-9-23**] 05:19AM BLOOD Plt Ct-284
[**2130-9-26**] 06:16AM BLOOD PT-24.0* PTT-29.6 INR(PT)-2.4*
.
.
[**2130-8-27**] 06:07PM BLOOD Glucose-94 UreaN-116* Creat-1.2* Na-146*
K-5.9* Cl-102 HCO3-41* AnGap-9
[**2130-9-5**] 04:21AM BLOOD Glucose-122* UreaN-71* Creat-1.6* Na-142
K-4.1 Cl-106 HCO3-28 AnGap-12
[**2130-9-19**] 06:00AM BLOOD Glucose-114* UreaN-89* Creat-1.1 Na-150*
K-3.5 Cl-100 HCO3-47* AnGap-7*
[**2130-9-26**] 06:16AM BLOOD Glucose-105 UreaN-71* Creat-1.1 Na-138
K-3.9 Cl-87* HCO3-48* AnGap-7*
.
.
[**2130-9-16**] 05:28AM BLOOD calTIBC-138* Hapto-128 Ferritn-870*
TRF-106*
.
.
[**2130-9-8**]: Successful placement of a double-lumen 37 long PICC
line via the left basilic vein with the tip terminating in the
lower SVC. The line is ready for use.
.
.
[**2130-8-28**]: CT of the chest: Overall, unchanged appearance of the
chest with scattered bilateral airspace consolidation and ground
glass opacities as well as bronchiectasis and bilateral pleural
effusions, these findings may represent chronic changes,
however, superimposed pulmonary edema/infection cannot be
excluded.
CT abdomen/pelvis: CT evidence of anemia as seen on prior exam.
Cholelithiasis without evidence of cholecystitis. No evidence of
bowel obstruction with free passage of oral contrast. Thickened
left adrenal gland without evidence of focal lesion, which is
unchanged since [**6-10**].
Brief Hospital Course:
71f with chronic respiratory failure secondary to
influenza/ARDS, reccurent pseudomonal pneumonias, afib,
bronchiectasis admitted with sepsis and acute on chronic
respiratory failure.
.
# Resp failure: Felt to be a combination of chronic psudomonas
PNA, bronchiectasis, fibrosis, pleural effusions, mucus
plugging. Dead space calculated to be around 80%. Was on AC
during the initial portion of this hospitalization but was able
to wean to pressure support which she tolerated quite well, even
down to as low as [**11-9**] for over a week prior to discharge. On
[**11-9**] with 40% fio2 she appeared comfortable, had good O2 sats
(mid-90's), and had a minute ventilation of around [**9-13**]
(300-400cc tidal volumes). She had a trach change for trach
leak but continued to have trach leak even with new trach. In
terms of dealing with the underlying etiologies, she was treated
first with meropenem for three weeks, then switched on to
colistin nebs for a two weeks on, two weeks off course (her
first two weeks ended [**9-25**] and should be restarted [**10-9**]). She
was also put on scheduled albuterol and ipratropium MDI's and an
empiric taper of prednisone (she was discharged on 60mg daily
with plans to taper to 40mg daily on [**9-29**]; further taper per Dr.
[**Last Name (STitle) **], as below). She is also being diuresed with furosemide
120mg IV daily to minimize any pulmonary edema, though this has
not been a significant problem. She has a follow-up appointment
schedule with Dr. [**Last Name (STitle) **], a pulmonologist at [**Hospital1 18**], for [**10-12**],
where he will make any changes in this treatment course.
.
# Pseudomonal PNA: She has history of resistant Pseudomonas,
most recently Ertopenem, Amikacin. Has been on Aztreonam in the
past but likely resistant. Her sputum again grew Pseudomonas
this admission. Intially, she was tried on Ceftazidime
(intermedicate sensitivity) and Azreonam (intermediate
sensitivity); ID was consulted who recommended Meropenem, with a
21 day course completed on [**2130-9-14**]. Colistin nebs at 100mg [**Hospital1 **]
were also started as above, for two weeks on, two weeks off
course. She seemed to respond well to this with improvements in
fever, wbc, and sputum production.
.
# Anemia: HCT 30 on admission, Guaiac negative, trended down
gradually. Was started on epogen, as lab studies indicated
anemia of inflammation. She was transfused 5 units pRBCs in
total, the last being two units on [**2130-9-16**], with a stable hct
and no transfusion requirement since then.
.
# Peripheral edema: Felt mainly to be due hypoalbuminemia
(1.9-2.6) and initialy resuscitative IV fluids, she was
gradually diuresed with furosemide 120mg IV daily, which was
continued on discharge pending improved edema.
.
# ARF: She has a baseline of 0.5, was elevated during this
admission to 1.6, likely prerenal from dehydration and
infection. IV fluids improved her Cr, with new baseline of 1.1.
.
# CDiff colitis: C. diff positive stools, with abdominal
tenderness, white count normal but w/ 2% bands, low grade fever.
She finished a course of oral vancomycin with good result.
.
# Altered Mental Status: Intially though to be from hypercarbia,
azotemia, and dehydration, on top of underlying Parkinsonism. CT
head showed no acute process or bleed. Then pt developed
delirium and psychosis with hallucinations. This eventually
cleared with clearing infection and improving respiratory
status.
.
# A Fib: was rate controlled. Intially came in on Sotalol and
diltiazem which were continued. Coumadin was adjusted with
monitoring of INR; she eventually had a stable INR in the 2's on
warfarin 4mg daily. INR should be checked at rehab q 304 days.
.
# FEN: continued on G-tube feeds. S&S evaluated pt and
recommended complete NPO. They also performed FEES and found
partial vocal cord paralysis. ENT then saw patient and
recommended further w/u as an outpatient.
.
# Electrolytes: for the last week, the patient's sodium has
remained within normal limits. Electrolytes should be checked
every 2-3 days and the amount of free H2O flushes with the tube
freeds shoudl be adjusted to regulate the patient's sodium. The
patient has not required potassium repletion.
.
# Code status: She remained full code throughout
Medications on Admission:
- bacitracin TP
- diltiazem: 60mg QID
- colace
- atrovent 4 puffs Q6
- lansoprazole: 30mg [**Hospital1 **]
- zoloft: 50mg daily
- sotalol: 40mg [**Hospital1 **]
- warfarin: 1mg daily
- albuterol: 1 NEB Q6
- tylenol: PRN
- dulcolax PRN
- lactulose: PRN
- ativan: 0.5mg Q8:PRN
- zofran: 4mg IV Q8: PRN
- simethicone: 80 TID:PRN
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Insulin Lispro (Human) 100 unit/mL Solution Sig: Sliding
scale scale Subcutaneous ASDIR (AS DIRECTED).
5. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours).
8. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
9. Hydralazine 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
10. Epoetin Alfa 2,000 unit/mL Solution Sig: 1000 (1000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): As part of taper, decrease to 40mg daily on [**9-29**], then
keep on this dose until she sees Dr. [**Last Name (STitle) **].
15. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
16. Furosemide 10 mg/mL Solution Sig: One [**Age over 90 **]y (120)
mg Injection DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Sepsis
Acute on chronic hypercarbic respiratory failure
Pseudomonal pneumonia
Atrial fibrillation with rapid ventricular response
Hypernatremia
Acute renal failure
Altered mental status
C. difficile colitis
Secondary:
1. Chronic respiratory failure: Influenza A in [**4-10**] complicated
by ARDS eventually leading to intubation, ventilatory support,
and tracheostomy. Complicated by tracheocutaneous fistula.
2. Remote history of pneumonia.
3. Status post left eye cataract surgery.
4. Anxiety
5. DMII
6. Hypertension
Discharge Condition:
Fair: alert, asymptomatic, stable vitals, on CPAP+PS setting of
a ventilator.
Discharge Instructions:
You were admitted for a pseodmonal pneumonia and subsequent
respiratory failure, recieved antibiotics both intravenous and
inhaled, and have had your ventilator ssupport steadily
decreased.
.
Please follow-up as below.
.
Please check Chem 7 panel at rehab every 2-3 days. Adjust free
water flushes as needed to regulate sodium
.
Please check patient's INR q 4-5 days. Adjust coumadin as
necessary per protocol.
Followup Instructions:
You have a follow-up appointment with Dr. [**Last Name (STitle) **], a
pulmonologist, on Thursday [**10-12**] at noon in the [**Hospital Ward Name 23**]
building on the seventh floor. Your rehab facility will need to
arrange transportation; please call ([**Telephone/Fax (1) 513**] if this
appointment cannot be made or for any questions you may
have.Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2130-10-12**] 12:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2130-10-12**] 12:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2130-10-12**] 12:10
Completed by:[**2130-9-27**]
|
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icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.6",
"99.04",
"00.17",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
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12757, 12832
|
6621, 9767
|
364, 414
|
13395, 13475
|
4464, 6598
|
13936, 14761
|
3864, 3883
|
11268, 12734
|
12853, 13374
|
10917, 11245
|
13499, 13913
|
3898, 4445
|
264, 326
|
442, 3553
|
9782, 10891
|
3575, 3791
|
3807, 3848
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,300
| 126,566
|
52257
|
Discharge summary
|
report
|
Admission Date: [**2194-4-3**] Discharge Date: [**2194-4-21**]
Date of Birth: [**2145-5-1**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
woman with a past medical history of HIV and hepatitis C who
is having problems with nausea and vomiting. Workup included
a head CT which showed three aneurysms. The patient was
admitted for coiling of these aneurysms.
PHYSICAL EXAMINATION: On physical exam, this is a pleasant
woman in no acute distress. HEENT: Pupils are equal, round,
and reactive to light. EOMs are full. Chest was clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm. Abdomen is soft, nontender, nondistended, positive
bowel sounds. Extremities: No cyanosis, clubbing, or edema.
Neurologic: Awake, alert, and oriented times three. Cranial
nerves II through XII: Intact. Strength is [**6-19**] in all
muscle groups. Sensation is intact to light touch.
Reflexes: Two plus throughout.
PAST SURGICAL HISTORY: Back surgery times five.
Ankle surgery times two.
Lymph node biopsy.
ALLERGIES: Penicillin and Augmentin.
MEDICATIONS ON ADMISSION:
1. Zantac 150 two times a day.
2. Celexa 60 every day.
3. Albuterol inhaler.
4. Zofran as needed.
HOSPITAL COURSE: The patient was admitted and preop'd for
diagnostic angio for possible aneurysm coiling. The patient
was found to have three right-sided aneurysms not all
optimal for coiling. Post angio, the patient was awake,
alert, and oriented times three with no drift. Groin site
was clean, dry, and intact. There was no hematoma and
positive pedal pulses.
It was decided that the patient would go for surgery for
clipping of these aneurysms. The patient was
preop'd and in so doing, was found to have a low platelet
count. Hematology was consulted, and the patient was found
to have potentially related to Zantac and a mild case of ITP.
The patient was therefore placed on prednisone 60 mg by mouth
every day. Further discussions between team members led to
recommendation of endovascular rather than open surgical
treatment given her co-morbidities.
On [**2194-4-10**], the patient was taken back to Angio and had
coiling embolization of the anterior temporal artery
aneurysm, and of the anterior choroidal artery aneurysm. The
patient was taken to the SICU postoperatively with sheath in
place and on IV Heparin and integrilin low-dose because of the
appearance of a small filling defect on one of the coil loops
that was close to the lumen of the M1 segment of the right MCA.
The patient remained neurologically stable. The integrilin was
discontinued on post procedure day number one
and a sheath was discontinued. Her groin site was clean,
dry, and intact. She had no hematoma and positive pedal
pulses.
She continued to be followed by Hematology/Oncology, and her
platelet count remained above 100 on 60 mg of prednisone
every day. She was started on Plavix and aspirin on
[**2194-4-12**]. She was transferred to the regular floor on
[**2194-4-13**], remained neurologically stable, and remained on
aspirin and Plavix and prednisone for her platelet count.
On [**2194-4-15**], she was taken back to Angio and had a repeat
diagnostic angio, which showed stable appearance of the
coiled aneurysms with no distal branch occlusions, and she was
post angio stable awake, alert, and oriented times three,
neurologically intact. Groin site was clean, dry, and intact.
Pulses were positive. She was transferred back to the regular
floor post procedure.
On [**4-16**], she developed a severe rash, and Dermatology was
consulted. They felt it could be related to aspirin and
Plavix, although she had a rash on admission to Augmentin
that she was being treated for an ear infection. She was
treated with triamcinolone 0.1 percent lotion and Sarna
lotion. They continued to follow her closely, the rash did
improve, and she was kept on the aspirin and Plavix. Her
prednisone was weaned to off, and she was discharged in
stable condition on [**2194-4-21**] with follow up with Dr. [**Last Name (STitle) 1132**]
in two weeks.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg by mouth every day.
2. Fioricet 1-2 tablets by mouth every four hours as needed.
3. Plavix 75 by mouth every day.
4. Prednisone 5 mg by mouth every day for one dose and then
discontinue.
5. Hydromorphone 2 mg 1-2 tablets by mouth every four hours
as needed.
CONDITION AT DISCHARGE: The patient's condition was stable
at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2194-4-21**] 11:10:08
T: [**2194-4-21**] 11:41:39
Job#: [**Job Number 108070**]
|
[
"287.3",
"782.1",
"070.70",
"V08",
"305.1",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
4124, 4417
|
1148, 1248
|
1266, 4098
|
1011, 1122
|
437, 987
|
4432, 4746
|
163, 414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,984
| 151,108
|
42569
|
Discharge summary
|
report
|
Admission Date: [**2142-12-24**] Discharge Date: [**2143-1-4**]
Date of Birth: [**2089-5-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Trauma: fall
Major Surgical or Invasive Procedure:
[**2142-12-24**]
1. Fasciotomy left leg medial and lateral compartments
without debridement.
2. Closed treatment proximal tibia fracture with
manipulation.
3. Application uniplanar external fixator.
4. Application vac sponges left leg.
[**2142-12-25**]
Anterior exposure for L3, L4, L5, S1 fusion
[**2142-12-25**]
1. Vertebrectomy of L4.
2. Fusion L4 to S1.
3. Anterior spacers times corpectomy device at L3 at L4
spanning from L3-L5 and a separate device at L5-S1.
4. Anterior instrumentation.
5 Autograft.
[**2142-12-29**]
1. Irrigation and debridement, left medial and lateral
compartments.
2. Application of negative pressure wound sponge, left leg.
[**2142-12-29**]
1. Total laminectomy of L3, L4 and L5.
2. Fusion L3-S1.
3. Instrumentation L3-S1.
4. Autograft.
5. Epidural catheter placement.
[**2142-12-29**]
1. Revision anterior fusion from L3-L5.
2. Removal of previous instrumentation.
3. Application of new instrumentation.
4. Autograft and allograft.
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 53 year old male who complains of S/P
FALL. Pt on [**Location (un) 470**] patio smoking, locked himself out, and
tried to climb down to the [**Location (un) 1773**] patio in order to
get back in. Inadverentently fell about 25 feet to ground
landing on feet [**Street Address(1) 92115**] rash on both wrists. Main
complaints were leg and back pain. Seen at OSH where was
found to have L4 burst fracture as well as pelvic rami
fracture. Was hemodynamically stable en route.
Timing: Sudden Onset
Quality: Fall,
Severity: Moderate
Duration: few, Hours
Location: pelvis and lumbar spine
Context/Circumstances: patient was trying to get
down to [**Location (un) **] patio when
he fell down to the ground
landing on his feet
Associated Signs/Symptoms: L knee pain and swelling;
small laceration L hand
Past Medical History:
Past Medical History: schizophrenia, HTN, Psychiatric
Social History:
Social History: did not drink Etoh tonight
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission:
Temp: 96.2 HR: 81 BP: 117/83 Resp: 16 O(2)Sat: 96 Normal
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact; TMs clear
bilaterally; no spetal hematoma; midface stable; no
significant bony TTP
Oropharynx within normal limits; c-spine collar on
Chest: Clear to auscultation; no chest wall TTP
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Pelvic: Pelvis stable and non-tender
Extr/Back: L knee grossly edematous with decreased ROM and
diffuse TTP; pedal pulses palpable; left calf is tense and
tender on palpation, pedal pulses are palpable
Neuro: Speech fluent; motor [**5-17**] R=L in UE and LE; sensation
to light touch grossly intact
Physical examination upon discharge:
vital signs: t=97, bp=130/82, hr=88, resp. rate 18, oxygen
sat=98% room air
General: NAD
CV: Pacemaker left upper shoulder, ns2, s2, -s3, s-4
Lungs: Clear, diminshed bases
Abdomen: steri-strips to mid-abdomen, mild bulging to left of
incision, soft, non-tender
Mentation: disorient to place, oriented to time, person,
follows commnads
Ext: + dp/pt left foot, ext. fix. left, dsd to suture line,
right leg splint, toes warm, +CSM, abrasion right elbow,
superficial abrasions left upper arm, posterior aspect.
Pertinent Results:
[**2143-1-4**] 05:12AM BLOOD WBC-12.4* RBC-3.57* Hgb-10.5* Hct-31.3*
MCV-88 MCH-29.5 MCHC-33.7 RDW-16.0* Plt Ct-288
[**2143-1-3**] 05:53AM BLOOD WBC-14.7* RBC-3.68*# Hgb-10.9* Hct-32.0*
MCV-87 MCH-29.5 MCHC-34.0 RDW-16.3* Plt Ct-306
[**2143-1-1**] 04:46PM BLOOD WBC-17.2* RBC-3.06* Hgb-9.3* Hct-26.9*
MCV-88 MCH-30.2 MCHC-34.4 RDW-15.4 Plt Ct-250
[**2142-12-23**] 11:33PM BLOOD WBC-15.5* RBC-3.79* Hgb-11.6* Hct-34.7*
MCV-92 MCH-30.4 MCHC-33.2 RDW-13.6 Plt Ct-238
[**2143-1-1**] 02:43AM BLOOD Neuts-86.3* Lymphs-6.7* Monos-4.5 Eos-2.4
Baso-0.1
[**2143-1-4**] 05:12AM BLOOD Plt Ct-288
[**2142-12-30**] 01:18AM BLOOD PT-12.9* PTT-26.5 INR(PT)-1.2*
[**2142-12-25**] 12:56PM BLOOD Fibrino-155*
[**2143-1-4**] 05:12AM BLOOD Glucose-100 UreaN-12 Creat-0.7 Na-135
K-3.4 Cl-101 HCO3-27 AnGap-10
[**2143-1-3**] 05:53AM BLOOD Glucose-97 UreaN-13 Creat-0.7 Na-133
K-3.5 Cl-100 HCO3-26 AnGap-11
[**2142-12-27**] 01:24AM BLOOD ALT-35 AST-44* AlkPhos-41 TotBili-1.0
[**2142-12-26**] 12:59PM BLOOD ALT-50* AST-55* AlkPhos-43 TotBili-0.9
[**2142-12-27**] 01:24AM BLOOD cTropnT-<0.01
[**2142-12-26**] 05:47PM BLOOD cTropnT-<0.01
[**2143-1-4**] 05:12AM BLOOD Calcium-7.3* Phos-3.1 Mg-1.7
[**2143-1-3**] 05:53AM BLOOD Calcium-7.4* Phos-3.0 Mg-1.8
[**2142-12-29**] 06:14PM BLOOD Glucose-120* Lactate-1.6
[**2142-12-29**] 03:09PM BLOOD Hgb-10.0* calcHCT-30
[**2142-12-23**]: foot x-rays:
IMPRESSION: Right comminuted calcaneal fracture, and
redemonstration of left tibial plateau and proximal fibular
fractures.
[**2142-12-23**]: tib/fib x-ray:
IMPRESSION: Right comminuted calcaneal fracture, and
redemonstration of left
tibial plateau and proximal fibular fractures.
Attending review:
Right knee: tricompartmental osteoarthritis. No fracture -
agree.
Right ankle and foot: Agree. Depressed, comminuted calcaneal
fracture.
Suspect talar, navicular and cuboid fractures as well - better
evaluatedby
CT. Left foot: soft tissue swelling at medial aspect of foot,
query nondisplaced navicular fracture.
[**2142-12-23**]: Bilateral knee x-rays:
IMPRESSION: Left lipohemarthrosis of the knee with impacted
tibial
plateau/fibular fractures.
[**2142-12-23**]: bil. femur x-ray:
IMPRESSION: Left lipohemarthrosis of the knee with impacted
tibial
plateau/fibular fractures.
[**2142-12-24**]: cat scan of the head:
HEAD CT
1. No acute intracranial injury.
2. Sequela of prior lacunar infarction on the left.
3. Right frontal scalp swelling.
CERVICAL SPINE CT
No evidence of fracture or subluxation.
Degenerative disk disease with canal narrowing.
The study ends at mid C7, and the C7-T1 level is not included.
[**2142-12-24**]: cat scan of the c-spine:
No acute fracture or subluxation of the cervical spine.
2. Osteophytes at C5-6 result in moderate canal narrowing. If
there is
concern for cord injury, MRI is more sensitive for this.
[**2142-12-24**]: lower ext. fluro:
Interval changes of an external fixation with orthopedic
hardware in place and intact. Please refer to operative report
for further details.
[**2142-12-25**]: L spine:
There is again seen a compression deformity of L4, which is
better appreciated on the prior CT scan. Subsequent images show
placement of a cage device within L4. There is then placement of
screws within the L5-S1 disc space.
Please refer to the operative note for additional details.
q12/14/11: Echo:
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe regional left ventricular systolic dysfunction with
septal and anterior akinesis. There is an anteroapical left
ventricular aneurysm. Doppler parameters are indeterminate for
left ventricular diastolic function. 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. Physiologic mitral regurgitation
is seen (within normal limits). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Severe focal LV hypokinesis with septal and anterior
akinesis. The anterior apex is aneurysmal. No evidence of LV
thrombus. No significant valvular abnormality seen.
[**2142-12-29**]: chest x-ray:
The pacemaker tip is in unchanged position, presumably in the
right ventricle.
Cardiomediastinal silhouette is stable. Interval development of
mild edema is seen associated with bibasilar atelectasis. Small
amount of left pleural effusion cannot be excluded. No evidence
of pneumothorax is seen.
[**2142-12-30**]: left elbow:
There is no evidence of fracture, dislocation, osteoblastic or
osteolytic
osseous lesions, or soft tissue calcifications.
[**2142-12-31**]: EKG:
Sinus rhythm. Low QRS amplitude in the limb leads. Delayed R
wave transition in the precordial leads. Modest intraventricular
conduction delay of the left bundle-branch block type. Compared
to the previous tracing of [**2142-12-23**] the QRS axis is no longer
leftward.
[**2142-12-31**]: fluro:
FINDINGS: Multiple fluoroscopic images from the operating room
demonstrate interval placement of a large fracture plate and
associated cortical screws fixating a complex fracture involving
the left proximal tibial metaphysis.
There is good anatomic alignment, and no signs of
hardware-related
complications. There is also a fracture seen of the left
proximal fibular
neck.
[**2143-1-1**]: chest x-ray:
IMPRESSION: Minimal bibasilar atelectasis. No pulmonary edema or
pleural
effusion
[**2143-1-1**]: x-ray of the abdomen:
IMPRESSION: Ileus.
Brief Hospital Course:
53 year old gentleman admitted to the acute care service after a
20 foot fall landing on on his feet. Upon admission, he was
made NPO, given intravenous fluids, and underwent radiographic
imaging. He was reported to have an L4 burst fracture, left
tibial plateau fracture, right calcaneal fracture, a pelvic rami
fracture. Orthopedics was consulted becausue of his lower
extremity injuries. Compartment readings of his lower extremity
were taken because he was noted to have increased swelling and
pain. He was reported to have left compartment syndrome of his
left leg. On HD #1 he was taken to the operating room for a
facitotomy left leg with an ex-fix placed into the left tibial
plateau fracture. His operative course was stable with a 400cc
blood loss. He required brief infusion of neosynephrine during
the case. He was extubated after the procedure and monitored in
the recovery. He returned to the surgical floor.
On POD #2, he returned to the operating room for repair of his
L4 burst fracture. He underwent an anterior L1-S3 lumbar fusion.
During this procedure he had a 12,000cc EBL and required 11 u
PRBC, 8uFFP, and 2 bags platelets. After the procedure he was
admitted to the intensive care unit for hemodynamic monitoring.
He returned to the operating room on HD #7 for irrigation and
debridement of the left medial and lateral compartments and
application of negative pressure wound sponge to his left leg.
At this time, he also had a IVC filter placed because of his
prolonged immobility. The operative course was notable for a
1700cc blood loss. He did require neosynephrine for blood
pressure support. After the procedure, he was transported
intubated to the intensive care unit for monitoring and
pulmonary toilet. On HD #9, he returned to the operating room
for irrigation and debridement of fasciotomy wounds and an open
reduction internal fixation complex proximal tibial fracture
with bone grafting and lateral plating and delayed fasciotomy
closures of both medial and lateral wounds. The operative
course was stable with a 200 cc blood loss. He was extubated
after the procedure and returned to the intensive care unit for
monitoring. He was gradually re-introduced to sips with
advancement to clear liquids. Serial hematocrits were monitored
and he required additional PRBC on [**1-1**] for a hematocrit of 24.
He was still maintained on bedrest until arrival of TLSO brace.
His home medications were resumed except for his plavix which
can be resumed on [**1-11**]. He was evauluated by physical therapy
and because of his NWB status will need rehabilation to progress
transfers with a slide board. He was also evaulated by social
services who provided additonal support.
He was transferred to the surgical floor on [**1-2**]. He has been
transitioned to oral analgesia for management of his injuries.
He is tolerating a regular diet, but was reported to have mild
distension of his abdomen. He underwent an x-ry of his abdomen
which showed dilated loops of bowel suggestive of an ileus. He
has moved his bowels. His current hematocrit has stablized at
31.0 with a white blood cell count of 12.0. His vital signs
are stable and he is afebrile. He is voiding without diffculty,
altough does experience urinary incontinence. He is preparing
for discharge to a rehabilitation facility where he can further
regain his strength and mobility. He will follow up wiht ACS,
orthopedics, and ortho-spine and with his cardiologist.
Medications on Admission:
[**Last Name (un) 1724**]: Cogentin 1mg HS; Thiothixine 10mg qAM/2mg HS; Imipramine
50mg x2tab qHS; Valium 10mg qHS; Benadryl 50mg qHS; Pravachol
80mg'; Coreg 6.25mg''; Amiodarone 200mg', Plavix 75mg',
Lisinopril 10mg', EC ASA 325mg
OP Psych: [**Last Name (un) 92116**] [**Last Name (un) 78601**], [**Location (un) 92117**], [**Location (un) 7661**], [**Telephone/Fax (1) 92118**], [**Telephone/Fax (1) 92119**]
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
4. thiothixene 5 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
5. thiothixene 5 mg Capsule Sig: Four (4) Capsule PO QHS (once a
day (at bedtime)).
6. benztropine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO BID (2 times a day).
10. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): please hold for increased sedation, resp. rate <12.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm PO DAILY (Daily).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stools.
17. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain: hold for increased sedation, resp.
rate <12.
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE RESUME on [**1-11**], monitor for bleeding.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p [**2143**]0 feet; polytrauma
Injuries:
Left inferior pubic ramus fracture
Left tibial plateau fracture
Left Lower Extremity compartment syndrome
Right calcaneal fracture
L4 burst fracture with retropulsion
Blood loss anemia
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:
You were admitted to the hospital after suffering a fall. You
sustained multiple injuries including a fracture in your pelvis,
fractures in your left leg and a fracture in your right heel.
You also had an unstable fracture in one of the vertebrae of
your spine. You were taken to the operating room to have your
injuries fixed and bones stabilized. You lost blood during the
surgeries and required blood transfusions during and after your
surgeries. You are now preparing for discharge to an extended
care facility where you can further regain your strength and
mobility.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2143-1-15**] at 12:20 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: TUESDAY [**2143-1-15**] at 12:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2143-1-22**] at 3:15 PM
With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], MD
Department of Orthopedics
[**Location (un) 830**], [**Hospital Ward Name 23**] 2
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 11061**]
When: [**1-21**] at 10:30am
Please follow-up with your Psychiatrist:
OP Psych: [**Last Name (un) 92116**] [**Last Name (un) 78601**], [**Location (un) 92117**], [**Location (un) 7661**], [**Telephone/Fax (1) 92118**], [**Telephone/Fax (1) 92119**]
Please follow up with your Cardiologist, Dr. [**Last Name (STitle) **]. You have
an appointment scheduled on [**2143-1-31**] at 1:30 pm. The telephone
number is [**Telephone/Fax (1) 34574**]. The office is at [**Hospital **] Medical
center, [**Location (un) **], [**Hospital1 487**], Mass.
Completed by:[**2143-1-4**]
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83,278
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39016
|
Discharge summary
|
report
|
Admission Date: [**2104-7-14**] Discharge Date: [**2104-7-20**]
Date of Birth: [**2054-5-22**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Keppra
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Lethargy, headache, and emesis.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 50-year-old woman with known left glioblastoma
followed closely by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]. She is status post left
posterior parietal occipital glioblastoma status post left
parietal craniotomy then chemoradiation therapy. She woke up
morning of admission day with increasing headaches followed by
nausea, vomiting and right sided weakness. Patient was seen at
[**Hospital3 3583**] where a Head CT showed gross left cerebral edema
with 1.2 cm midline shift. Subsequently, patient was intubated
for airway protection and given 10 mg of dexamethasone and 50
gram of mannitol and transferred to [**Hospital1 18**].
On arrival to the ED, patient was lightly sedated and moving all
extremities. Additionally, patient's mannitol was held given
her good examination per ED. Neurosurgery consulted for further
management.
Past Medical History:
Oncologic History:
She is status post
1. Gross total resection on [**2103-4-18**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) **] at [**Hospital 2586**].
2. Study drug ZD6474 started on [**2103-5-9**].
3. Radiation plus Temodar started on [**2103-5-14**].
Her neurological history began in [**Month (only) 958**] of this year with
fatigue, malaise, and headache. It progressed to difficulty
doing her usual tasks. She was involved in two minor car
accidents. She then started having nausea and vomiting. A head
CT was done in [**Last Name (LF) **], [**First Name3 (LF) 5864**] she was living and showed a large
left occipitoparietal mass with brain edema. She came back to
[**Location (un) 86**] where her parents live for surgery. This was done by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (STitle) **] and most of her symptoms improved.
PAST MEDICAL HISTORY: Tonsillectomy as a child.
Social History:
She is single. She is a masters' graduate and is a landscape
architect. She does not have any children. She has been living
out in [**State 5864**] for several years and was skiing during the
[**Doctor Last Name 6165**].
Family History:
Her parents are alive and well with a history of coronary artery
disease and melanoma. She has two brothers, one who has
diverticulitis that required a colectomy. She has one sister
with asthma and skin lupus.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.0 F, blood pressure 114/77, pulse
63, respiration 23, oxygen saturation 100% on 100% FIO2 with
PEEP.
GENERAL: Intubated/sedated on propofol, well nourished and well
developed.
HEENT: Radiation alopecia, eyes are 2mm and reactive to 1mm,
EARS: Hearing intact, nods to question Pupils: [**1-29**], EOMs
restricted
NECK: Supple.
LUNGS: Clear to auscultation bilaterally, no wheezes or rales.
CARDIOVASCULAR: Regular rate and rhythm. S1/S2.
ABDOMEN: Soft, non-tender, and with positive bowel sounds.
EXTREMITIES: Warm and well-perfused.
NEUROLOGICAL EXAMINATION:
Mental status: intubates/sedated, after propofol stopped pt nods
to questions and follows commands
Orientation: nods to name
follows commands in all extremities, noticeable right
hemiparesis
UE>LE, left side full, + gag, + corneals
Toes are upgoing on the right, left is mute
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS: T 97.1, Tmax 97.5, BP 104/62 (90-112/54-76), HR 70
(56-70), RR 13, O2Sat 97% RA
GENERAL: Comfortable, not in distress, pleasant
HEENT: PERRLA, EOMI, visual field defect in her temporal half
of right visual field. No OP lesion. MMM.
NECK: No JVD, No LN's
CARDIOVASCULAR: RRR, NS1 S2, no added sounds,murmurs,rub or
gallop
CHEST: Clear air entry bilaterally, no wheezes or rales. Right
Port-A-Cath
ABDOMEN: Soft, nontender,nondistended, +BS, no organomegaly
EXTREMITIES: No edema or cyanosis or clubbing, pulses palpable
peripherally bilaterally +2.
NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is
60. She is awake, alert, and able to follow commands. Her
language is fluent with good comprehension. Her recent recall
is good. Cranial Nerve Examination: Her pupils are equal and
reactive to light, 4 mm to 2 mm bilaterally. Extraocular
movements are full; there is no nystagmus. Visual field
examination is notable for a right field cut, with OD denser
than OS. Her face is symmetric. Facial sensation is intact
bilaterally. Her hearing is intact bilaterally. Her tongue is
midline. Palate goes up in the midline. Sternocleidomastoids
and upper trapezius are strong. Motor Examination: She does
not have a drift. Her muscle strengths are [**5-1**] at all muscle
groups. Her muscle tone is normal. Her reflexes are 2- and
symmetric bilaterally. Her ankle jerks are absent. Her right
toe is equivocal while her left is down going. Sensory
examination is intact to touch and proprioception. Coordination
examination does not reveal
dysmetria. Her gait is somewhat unsteady but with minimal
assist.
Pertinent Results:
ADMISSION LABS:
[**2104-7-14**] BLOOD WBC-7.0 RBC-3.40* Hgb-13.0 Hct-34.3* MCV-101*
MCH-38.2* MCHC-37.9* RDW-14.8 Plt Ct-413
[**2104-7-14**] BLOOD Glucose-97 UreaN-13 Creat-0.7 Na-129* K-4.4 Cl-96
HCO3-26 AnGap-11
[**2104-7-15**] BLOOD ALT-19 AST-18 LD(LDH)-207 AlkPhos-85 TotBili-0.4
[**2104-7-14**] BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
[**2104-7-15**] BLOOD Osmolal-293
[**2104-7-14**] BLOOD Lactate-1.4
[**2104-7-14**] URINE ANALYSIS WNL
DISCHARGE LABS:
[**2104-7-16**] 04:19AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
[**2104-7-17**] 06:00AM BLOOD Glucose-85 UreaN-15 Creat-0.7 Na-141
K-4.0 Cl-105 HCO3-28 AnGap-12
[**2104-7-17**] 06:00AM BLOOD WBC-5.5 RBC-3.29* Hgb-11.8* Hct-33.4*
MCV-101* MCH-35.8* MCHC-35.3* RDW-13.7 Plt Ct-343
RADIOLOGY:
CHEST (PORTABLE AP) Study Date of [**2104-7-14**]
IMPRESSION:
1. Endotracheal tube ends 2.5 cm above the carina.
2. Nasogastric tube side port is at the GE junction and could be
advanced.
MR HEAD W & W/O CONTRAST Study Date of [**2104-7-14**]
Impression:
1. Enlarging complex enhancing hemorrhagic mass involving the
left occipital, posterior temporal and parietal regions with
associated vasogenic edema. There is worsening mass effect over
the left lateral ventricle and worsening midline shift to the
right now measuring 1.3 cm.
Brief Hospital Course:
[**Known firstname 2127**] [**Last Name (NamePattern1) 86522**] is a 50-year-old woman, with glioblastoma, s/p
resection, temozolomide chemo-irradiation, who presented to
[**Hospital1 18**] with nausea, vomiting, and headache. She was found to
have a hemorrhagic intracerebral mass with associated edema,
mass effect, and midline shift. She was admitted from the ED of
[**Hospital1 18**] to SICU for further care. Upon improvement, she was
transferred to Medical Oncology floor and received irinotecan on
[**2104-7-16**].
(1) Glioblastoma: She was intubated for airway protection and
was admitted to the SICU on [**2104-7-14**]. Her MRI scan showed left
occipital lesion compatible with regrowth of her prior known
glioblastoma. It was a hemorrhagic intracerebral mass with
associated edema, mass effect, and midline shift. She was
treated with dexamethasone and mannitol but was deemed to not be
a surgical candidate. She remained stable on the ventilator
overnight and on the morning of [**2104-7-15**] was extubated. She was
transferred to medical oncology floor in a stable condition on
[**2104-7-16**]. On the floor, neurologically she was alert,
interactive and oriented to time place and person, with power of
[**4-1**] in her right upper and lower extremities. She could say the
weekdays back and forth. She could not say the months of the
year backwards but could easily say them forward. She needed
guidance when testing for cerebellar functions as it seems it
was difficult for her to comprehend complex tasks. She received
chemotherapy (irinotecan) on [**2104-7-16**]. She was evaluated by
PT/OT and was felt to benefit from rehabilitation. Her home
dexamethasone dose was increased to 4 mg every 6 hours, and she
was started on phenytoin 100 mg three times daily (for seizure
prophylaxis) and famotidine 20 mg twice daily. She will
continue these medications until instructed otherwise by Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]. She is scheduled for her next administration of
chemotherapy on [**2104-7-24**].
(2) Hyponatremia: She was hyponatremic on admission and
received fludrocortisone and hypertonic saline, which led to
normalization of her hyponatermia. Fludrocortisone was
discontinued.
Medications on Admission:
DEXAMETHASONE - 1 mg Tablet - 2 Tablet(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - 1 (One) Tablet(s) by mouth one
hour before chemo and PRN, SEND with Temodar
TEMOZOLOMIDE [TEMODAR] - 140 mg Capsule - 1 Capsule(s) by mouth
HS for 5 nights total daily dose 390 mgs
TEMOZOLOMIDE [TEMODAR] - 250 mg Capsule - 1 Capsule(s) by mouth
HS for 5 nights, DX: 191.8 Needs for [**2104-5-11**].
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Disp:*30 Tablet(s)* Refills:*0*
2. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours). Disp:*120 Tablet(s)* Refills:*0*
3. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO every eight (8) hours. Disp:*30 Tablet,
Chewable(s)* Refills:*2*
Discharge Disposition:
Home with Service
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
Left occipital glioblastoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 86523**],
It was a pleasure caring for you. You were admitted with a
headache, nausea, and vomiting, and were found to have a lesion
in your brain. This was treated with medications and
chemotherapy.
We made the following changes to your medications:
- INCREASE dexamethasone from 2mg daily to 4mg every 6 hours
(four times daily), to be taken until directed otherwise by Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]
- START dilantin (phenytoin) 100mg by mouth every 8 hours
- START famotidine 20mg twice daily, to be taken while you are
taking phenytoin.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY (Chemotherapy)
When: THURSDAY [**2104-7-24**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3281**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2104-7-24**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], 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 1935**] CENTER
When: TUESDAY [**2104-9-30**] at 11:00 AM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
|
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"342.81",
"348.4",
"191.4",
"348.5",
"431",
"V16.8",
"780.79",
"784.0",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
9703, 9777
|
6601, 8896
|
314, 321
|
9850, 9850
|
5304, 5304
|
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|
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|
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|
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10000, 10250
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|
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|
10279, 10645
|
243, 276
|
349, 1260
|
5320, 5743
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9865, 9976
|
2182, 2209
|
2225, 2450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,917
| 110,182
|
5968
|
Discharge summary
|
report
|
Admission Date: [**2102-5-29**] Discharge Date: [**2102-6-5**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
left sided numbess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 46 year old man with h/o alcohol abuse, hcv and
dilated alcoholic cardiomyopathy (EF25%) who was brought into
the ED by a friend after drinking large amounts of alcohol. He
reports last drink about 12 hours prior to presentation. He was
just discharged from [**Hospital1 18**] three weeks ago on [**2102-5-9**] for alcohol
withdrawal requiring ICU monitoring and large valium taper.
.
He also complains of left sided numbness and tingling of his
entire body from head to toe, which came on around the same time
as his last drink 12 hours ago. He denies deficits in strength
and sensation, and reports never having had this problem in the
past. Denies trouble with speech or vision.
.
In the ED, his vitals were: 98.3, 102, 211/128, 16, 96%-2LNC.
He got a head CT to r/o bleed and stroke. He had no EKG changes
and first set of enzymes were negative. Alcohol level was 354.
Tox screen was also positive for cocaine. He was given valium
for alcohol withdrawal, dose unknown. He was admitted to
Medicine for further care.
Past Medical History:
- EtOH abuse
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy
- cocaine abuse
- hypothyroidism
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated Aspergillous
fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]
- h/o C. diff colitis
- h/o IVDA per OSH records (pt denies)
- HCV (no serologies in OMR)
Social History:
Recently cut down to 5-6 cigs/day, prior to that he smoked 1 ppd
x30 years. Heavy EtOH use; drinks 1 shot of Vodka every 3 hours
(~1 pint per day). Sober x10 years, started drinking again 1.5
yrs ago. +Cocaine abuse. He denies IVDA although history
questionable. Sexually active with his girlfriend. Reports
negative HIV test 2 yrs ago.
Family History:
Mother - CAD. Sister - h/o CVA.
Physical Exam:
VITALS: 97.1, 150/102, 86, 18, 99RA
GEN: A+Ox3, NAD, Calm, speech not pressured, no tremors
HEENT: OP clear, MMM
NECK: no LAD, no JVD
CV: RRR, no m/g/r
PULM: CTAB, no w/r/r
ABD: Soft, NT, ND, +BS
EXT: no c/e/c
Pertinent Results:
145 107 6
-------------< 81
4.1 25 0.7
CK: 118 MB: 3 Trop-T: <0.01
Serum EtOH 354
Serum [**Year (4 digits) 2238**] Pos
Serum ASA, Acetmnphn, [**Year (4 digits) **], Tricyc Negative
99
6.8 > 13.4 < 288
38.2
N:42.2 L:48.5 M:4.6 E:4.0 Bas:0.6
PT: 11.9 PTT: 27.1 INR: 1.0
HEAD CT: Unremarkable head CT.
CXR:
1. No acute cardiopulmonary process.
2. Emphysema and biapical pleural scarring, which is
discontinuous with the pleural surface at the left apex.
Followup radiographs recommended in [**3-7**] months to determine
stability of this finding.
Brief Hospital Course:
Mr. [**Known lastname 4223**] is a 46 year old man with alchohol abuse and
anxiety originally admitted to MICU for alcohol withdrawal and
subsequently transferred back to the floor.
.
# ALCOHOL WITHDRAWAL: On original admission to the floor, the
patient was requiring large doses of valium and was admitted to
the ICU management of alcohol withdrawal. In the ICU, the
patient was noted to be very anxious, but with few objective
signs of withdrawal. There, he initially required large doses of
valium and then was placed on the following taper outlined by
Psychiatry:
- Valium 20mg po q3h standing [**6-1**]
- Valium 15mg po q3h standing [**6-2**]
- Valium 10mg po q3h standing [**6-3**]
- Valium 5mg po q3h standing [**6-4**]
- The patient was monitored closely and did not require any PRN
benzodiazepines while on the valium taper. He was discharged to
home for follow up with a sobriety program. While hospitalized,
he spent a significant portion of time talking with our social
worker, [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**], to help arrange appropriate follow up for
alcohol abuse treatment.
- We continued the patient's thiamine, folate, and multivitamin.
- He was NOT discharged with any benzodiazepines.
.
# Anxiety: There appeared to be a large component of anxiety
prompting treatment of positive CIWA scale values while in the
ICU. This did not occur on the floor. At the recommendation of
Psychiatry, the patient was treated with zyprexa [**Hospital1 **] prn; he was
discharged home with a two-week supply of zyprexa with
instructions to follow up with his primary care doctor for
further management of anxiety.
.
# HTN: The patient has hypertension at baseline, and prior to
admission, he was being treated with clonidine, lisinopril, and
carvedilol. He was initially hypertensive due to withdrawal. We
placed the patient on his home lisinopril as well as HCTZ. We
discontinued his carvedilol given his cocaine use.
- BPs were well controlled at discharge.
- He was restarted on digoxin at discharge.
- Of note, the patient had bottles of pills with him which were
last filled in [**2102-2-2**]. These pill bottles (digoxin,
clonidine, carvedilol) were [**2-4**] full.
.
# H/O Etoh dilated CHF: Currently stable and euvolemic.
Continued digoxin as above. Discontinued carvedilol due to
cocaine use.
.
# Hypothyroidism: We continued his levothyroxine.
.
# FEN: He tolerated a low sodium cardiac diet. Repleted lytes as
necessary.
.
# PPX: The patient was ambulatory, tolerating a regular diet on
the floor. He used nicotine patches for tobacco abuse.
.
# CODE: full
.
# Patient was instructed to follow up with sobriety program.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Quetiapine 25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for anxiety for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for anxiety.
Disp:*80 Tablet(s)* Refills:*0*
8. Nicotine 21-14-7 mg/24 hr Patch Daily, Sequential Sig: One
(1) patch Transdermal once a day.
Disp:*1 box* Refills:*0*
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication with subsequent withdrawal
Cocaine abuse
Secondary:
Dilated cardiomyopathy
Hypothyroidism
History of head/neck cancer status post resection and radiation
History of C. diff colitis
History of bilateral cavitary lung lesions
Discharge Condition:
Afebrile, normotensive, comfortable on room air
Discharge Instructions:
You have been evaluated for alcohol intoxication and alcohol
withdrawal. CONTINUING TO DRINK ALCOHOL WILL JEOPARDIZE YOUR
HEALTH. We recommend treatment at a Sober House. It is your
responsibility to establish yourself at this facility.
You should not take your carvedilol or clonidine any more.
Taking this medication in conjunction with using cocaine is
dangerous.
Call your doctor or return to the emergency room should you
develop any of the following symptoms: fever > 101, chills,
seizure, passing out, nausea or vomiting with inability to take
liquids or medications, or any other concerns.
Followup Instructions:
You should follow up at the [**Hospital **] Community Health Center within
one week.
A program which will help you remain sober should be a priority.
You should also follow up at the [**Hospital **] Community Health Center.
Please call [**Telephone/Fax (1) 23520**] for an appointment.
Completed by:[**2102-6-6**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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332, 339
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2,732
| 195,124
|
679
|
Discharge summary
|
report
|
Admission Date: [**2101-9-7**] Discharge Date: [**2101-9-13**]
Date of Birth: [**2034-11-19**] Sex: F
Service: [**Company 191**]
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old
woman who has a past medical history dominated by severe
chronic obstructive pulmonary disease with OSA, as well as
CAD, and CHF. The patient was brought to the emergency
department this AM by her son, after she awakened with severe
shortness of breath. She was discharged from [**Hospital1 1501**] ([**Hospital1 2670**]
in [**Location (un) 5089**]). Two weeks ago, doing well overall, with
increased activity level and no chest pain or resting
dyspnea. She denied recent fever of chills. She has a cough
at baseline.
She was last hospitalized in late [**Month (only) 216**] with fatigue and
later chest pain; she underwent catheterization and stenting
of 90% lesions of RCA and left circumflex. She went to the
[**Hospital1 1501**] for rehabilitation as above. She was doing well and
continued to do well at home. She denies nausea, vomiting,
or chest pain with present illness. She was found to be
febrile in the emergency department with striking
leukocytosis and new right lower lobe infiltrate on the chest
x-ray.
Chest x-ray also was consistent with mild CHF. The tachypnea
and desaturation had responded to repeated medications and
increased oxygen. In the emergency department, she was
initially treated with nebulizers with some mild improvement,
however, she acutely worsened with increasing shortness of
breath, increased systolic blood pressure to the 200s and
heart rate to the 130s sinus tachycardia.
EKG showed ST segment depression in the lateral leads. She
was given aspirin, IV Lopressor, nitropaste, morphine, and 40
IV Lasix with good response. The ST segment depression
resolved.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease with 100 plus pack
year smoking history, resulting in multiple hospitalizations.
2. OSA. The patient has documented sleep apnea. The
patient is on home oxygen and CPAP. The patient reports not
using the CPAP due to relative intolerance.
3. She has both restrictive and obstruction defects on PFTs
and she has been dependent on oral steroids.
4. Diabetes mellitus. She has a history of diabetes
mellitus requiring treatment in the early [**2088**]. She is
maintained on insulin b.i.d. with a sliding scale.
5. Glucose control has been fair at best over time.
6. Coronary artery disease. Noteworthy for myocardial
infarction and PTCA in [**2089**]. She had echocardiogram in the
mid [**2088**] showing good function, but with worsening
exertional chest pain in [**2094**]. She underwent endotracheal
MIBI with an anterior defect as identified on catheterization
to have 100% LAD lesions for which PTCA was performed. She
ultimately redeveloped a restenosis of the stent placement
complicated by Dfib. ETT MIBI on [**10/2098**] showed a good EF
and equivocal EKG changes with anginal symptoms. She
underwent catheterization and angioplasty of two vessels, RCA
and proximal LAD in [**2099-8-23**]. She developed unstable
coronary syndrome in [**2100-9-23**]. She underwent repeat
catheterization and another PTCA of the right (PDA). Latest
dobutamine MIBI showed inferior ischemia. Most recent
cardiac intervention as described above.
7. Osteoporosis with recurrent back pain and dorsal
compression fractures. She has had bilateral hip fractures
and THRs, hospitalized twice for rehabilitation at [**Hospital3 5090**] in [**2098**] and earlier this year times two, last at
[**Hospital1 2670**].
8. Chronic pain. She is on Percocet for chronic pain.
9. Anxiety disorder.
10. Depression.
11. Longstanding chronic abdominal pain.
12. Chronic constipation.
13. Hypercholesterolemia, status post bilateral cataract
surgery with limited vision in one eye.
ALLERGIES: The patient is allergic to PENICILLIN, IODINE,
SULFA DRUGS AND A QUESTIONABLE ALLERGY TO CEPHALOSPORIN.
FAMILY HISTORY: Significant for coronary artery disease and
stroke.
SOCIAL HISTORY: The patient lives alone with VNA support and
close attention by her son. She had been resistant to
nursing home placement despite frequent hospitalizations
after decompensation at home. She has 100% pack per year
history of cigarettes. No recent tobacco or ethanol use.
MEDICATIONS ON ADMISSION:
1. Albuterol inhaler four puffs four times a day.
2. Aspirin 81 mg a day.
3. Atorvastatin 20 mg a day.
4. Atrovent two puffs three times a day for shortness of
breath.
5. Clonazepam 500 mcg three times a day.
6. Lasix 40 mg b.i.d.
7. NPH Insulin 70 units in the morning, 15 units in the
evening. Regular insulin 6 units in the morning, 4 units in
the evening.
8. Atrovent four puffs four times a day.
9. Isosorbide mononitrate 30 mg three tablets by mouth every
day.
10. Lactulose 30 cc, 3 tablespoons at bedtime, as needed for
constipation.
11. Reglan 10 mg before meals and at bedtime.
12. Nitroglycerin 400 mcg p.r.n.
13. Prednisone 10 mg a day.
14. Prevacid 30 mg a day.
15. ....................10 mg every six hours as needed for
nausea.
16. Regular insulin sliding scale, sliding scale as directed
four times a day.
17. Risperdal 1 mg, take one by mouth at bedtime.
18. Salsalate 500 mg one by mouth three times a day with
food as needed.
19. Zoloft 100 mg b.i.d.
20. Vicodin 5/500 one to two tablets by mouth up to four
times a day, limit six per day.
22. Vitamin D, one tablet q.week.
PHYSICAL EXAMINATION: Examination revealed the following:
The patient is an obese Cushingoid woman lying semiupright in
bed at rest. VITAL SIGNS: Pulse 108, blood pressure 174/74,
temperature 101.6, oxygen saturation 91% on three liters.
SKIN: Scattered abdominal striae and few resolving
ecchymoses. HEENT: No overt sinus tenderness. EOMI:
conjugates and grossly full. Conjunctivae are clear. Mild
nasal congestion. Oropharynx: There is normal, but,
however, dry mucosa. NECK: Supple, slightly reduced range
of motion. CHEST: Dorsal kyphosis with very faint breath
sounds throughout; coarse scattered wheezes and rhonchi
especially anteriorly; reduced breath sounds in the right
round ligament with no obvious consolidation, but harsh
crackles extreme base, no egophony. HEART: Regular, normal
S1 and S2. No obvious gallops. 2/6 systolic ejection murmur
at the upper lobe and upper right sternal border. PMI
slightly laterally displaced. Hyperdynamic. ABDOMEN: Soft,
obese, diffuse minimal tenderness less than baseline, loud
bowel sounds, no overt masses are appreciated. EXTREMITIES:
Striking distal wasting, no edema. No acute joint
inflammation. NEUROLOGICAL: The patient is dozing, but
arousable and responsive.
LABORATORY DATA: Laboratory data showed a white count of
216.5, hematocrit 30.9, platelet count 497,000. Sodium 142,
potassium 4.1, chloride 99, bicarbonate 25, BUN 15,
creatinine 0.8, glucose 100. ABG on three liters was 7.5,
38, 60. CK was 94. Troponin I less than 0.3. Urinalysis
negative for nitrite, negative for leukocyte esterase, 3 to 5
white blood cells, no red blood cells, many bacteria, 6 to 10
squamous cells. Chest x-ray disclosed new right basilar
consolidation, no overt CHF, small pleural effusion.
EKG showed sinus tachycardia at a 120 beats per minute, left
axis deviation, which was old. A second EKG disclosed sinus
tachycardia at 125 beats per minute, new 1 mm ST segment
depressions in V4 through V6. A third EKG showed that the ST
depressions now resolved and the heart rate had decreased to
110.
HOSPITAL COURSE: The patient was noted to have acute onset
of dyspnea with fever and evidence on examination and chest
x-ray of likely new right lower lobe pneumonia against the
backdrop of severe COPD/OSA and CHF. The patient showed
initial improvement in the emergency department, but worsened
this afternoon, suggestive of pulmonary edema superimposed on
pneumonia. She was also noted to have lateral EKG changes.
The patient was admitted to the MICU for stabilization and
further evaluation.
HOSPITAL COURSE: by systems.
PULMONARY: The patient was noted to have an acute
decompensation secondary to a combination of right lower lobe
pneumonia, chronic obstructive pulmonary disease flare, and
CHF. She was treated for COPD exacerbation with steroids and
nebulizer treatments. She was treated for a presumed
community-acquired pneumonia with Levofloxacin. PE was
thought to be unlikely due to the patient's wheezing and
evidence of pneumonia on chest x-ray.
On [**9-9**], the patient was changed to PO steroids. She
was administered CPAP as tolerated. She remained in the MICU
until [**9-8**], when she was then transferred to the
floor. Chest x-ray done on [**9-13**], the day of
discharge, revealed an interval improvement in the
collapse/consolidation in the lung bases and improvement in
her heart failure.
CARDIAC:
A. Ischemia. The patient was initially noted to have ST
segment depressions, 1 mm V4 through V6. The EKG changes
resolved. Cardiac enzymes were cycled times three and she
ruled out for myocardial infarction. The patient was
continued on aspirin and statins.
B. Pump. The patient was aggressively diuresed in the ICU.
She continued on her ACE inhibitor. She was then put on her
outpatient Lasix dose of 40 mg PO b.i.d. On [**9-9**],
the patient had undergone blood transfusion with two units of
packed red blood cells. She developed mild CHF following the
transfusion, administered 80 mg IV Lasix. As noted above,
chest x-ray done on [**9-13**], the day of discharge, noted
improvement in the patient's CHF.
INFECTIOUS DISEASE: The patient initially had a low-grade
temperature with a leukocytosis and evidence of right lower
lobe consolidation. She was administered Levofloxacin for
treatment of a community-acquired pneumonia. She will
complete a 14-day course of Levofloxacin. She was also
initially administered Vancomycin for right lower extremity
cellulitis. The Vancomycin was discontinued on [**9-8**].
Since the right lower extremity skin changes were attributed
to steroids, rather than infection, blood, urine, and sputum
cultures were sent. All cultures were no growth to date.
Sputum was contaminated with polymicrobial growth.
GI: The patient has a history of constipation and chronic
abdominal pain. She was treated with Protonix, Reglan, and
the bowel regimen, which consisted of Colace, Senna, and
Lactulose. The patient continued to be constipated during
her hospitalization and this issue should be addressed in the
rehabilitation facility. Administration of narcotics should
be limited.
ENDOCRINE: The patient has diabetes mellitus. She continued
on her outpatient insulin regimen. She was given 70 units
NPH in the morning, 10 units at night, and she was placed on
a sliding scale.
PSYCHIATRIC: The patient has history of anxiety and
depression. She continued on her Zoloft, Risperdal, and
Klonopin.
PAIN CONTROL: The patient has a history of chronic abdominal
pain and chronic narcotic use. She has history of bilateral
hip fractures and total hip replacement. Pain control was
with Percocet.
FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
initially given clears, diet, but then advanced to diabetic
diet. The nutrition service followed the patient during her
hospitalization.
HEMATOLOGY: The patient was administered 5000 units
subcutaneous heparin b.i.d. for DVT prophylaxis. On [**9-9**], she was noted to have a hematocrit of 27.2. She was
transfused two units of packed red blood cells. The
hematocrit should be maintained over 30 due to her history of
coronary artery disease.
On [**9-13**], the day of discharge, the hematocrit was
37.2.
PT: The patient was seen by the Physical Therapy Department
during her hospitalization. She should continue to work with
physical therapy while at rehabilitation.
The patient is full code.
DISPOSITION: The patient will followup with her internist,
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]. Telephone #: [**Telephone/Fax (1) 250**].
Pulmonologist is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2146**]. Telephone #: [**Telephone/Fax (1) 5091**].
Appointment should be made for followup when the patient is
ready for discharge.
CONDITION: Stable.
DIAGNOSIS:
1. Community-acquired pneumonia.
2. Chronic obstructive pulmonary disease exacerbation.
3. Pulmonary edema.
4. Anemia.
MEDICATIONS:
1. Levofloxacin 500 mg PO q.d. times 7 days.
2. NPH 70 q.a.m.; 10 q.p.m.
3. Regular insulin sliding scale.
4. Lipitor 20 mg PO q.d.
5. Heparin 5000 subcutaneously b.i.d.
6. Protonix 40 mg PO q.d.
7. Albuterol, Atrovent nebs q.4h.
8. Reglan 10 mg at meals and q.h.s.
9. Nystatin q.i.d. swish and swallow.
10. Dulcolax 10 mg PO/pr/p.r.n.
11. Maalox 10 cc b.i.d.p.r.n.
12. Percocet one to two tablets q.6h.p.r.n.
13. Lactulose 30 cc t.i.d.p.r.n.
14. Prednisone taper 60 mg PO q.d. times two days; then 40 mg
PO q.d. times four days; then 30 mg PO q.d. times four days;
then 20 mg PO q.d. times six days; then 10 mg PO q.d.
15. Lisinopril 5 mg PO q.d.
16. Aspirin 81 mg PO q.d.
17. Klonopin 0.5 mg PO t.i.d.
18. Risperidone 0.5 mg q.a.m.; 10 mg q.p.m.
19. Zoloft 100 mg PO q.h.s.
20. Colace 100 mg PO b.i.d.
21. Senna two tablets PO q.h.s.
22. Lasix 40 mg PO b.i.d.
23. .................... 30 mg PO p.r.n.
24. Compazine 5 mg t.i.d.p.r.n.
25. Albuterol inhaler four puffs q.i.d.
26. Atrovent inhaler one puff t.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2101-9-13**] 10:32
T: [**2101-9-13**] 11:54
JOB#: [**Job Number 5093**]
|
[
"491.21",
"250.00",
"V45.82",
"428.0",
"300.00",
"780.57",
"486",
"272.0",
"255.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4040, 4093
|
4410, 5526
|
8123, 13810
|
5549, 7604
|
168, 1870
|
1892, 4023
|
4110, 4384
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,030
| 132,107
|
49180
|
Discharge summary
|
report
|
Admission Date: [**2117-1-9**] Discharge Date: [**2117-1-15**]
Date of Birth: [**2078-4-17**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
admitted from dialysis unit with fever and MS changes
Major Surgical or Invasive Procedure:
1. Right groin dialysis catheter removal
2. Right subclavian central line placement
3. Left EJ dialysis catheter placement
History of Present Illness:
38 yr old female with h/o DM type I complicated by ESRD s/p
failed renal tx in [**2104**], now on HD MWF, h/o CVA in [**2113**] and
[**2116-5-7**] with VP shunt initially that was removed [**3-9**]
infection, h/o MRSA and VRE who was admitted [**2117-1-9**] from
dialysis with septic picture and Gram negative rod bacteremia.
Patient had fever to 105, rigors in HD. Vancomycin 1g iv given.
On arrival to [**Hospital1 18**] ED temp 102.8, tachy to 120s, BP 160s/80s,
RR 33, O2 95%2L. Progressively more hypotensive in ED to SBP 90
-> put on levophed. Given zosyn 3g, tylenol, NS 1L total, 2 mg
ativan x 2 for right subclavian central line placement. Patient
was confused, unable to give hx or ROS but responsive.
She was transferred to the MICU under the sepsis protocol. She
was hypotensive and was aggressively fluid resuscitated and
given one unit of blood with appropriate HCT bump, but also
required Levophed to keep sbp >90. She came off pressors
[**2117-1-11**] in early am. Lisinopril and metoprolol were held. She
was on an insulin gtt for tight glycemic control. Blood
cultures from [**1-10**] initially grew out pan sensitive GNR ([**7-12**]
bottles), and the patient was placed on Zosyn in addition to the
Ceftriaxone that had been started in the ED. A TTE was done to
r/o vegetations and was negative. She improved clinically and
was transferred to the general medicine floor the evening of
[**1-11**]. She remained afebrile, her white count trended down, and
her surveillance blood cultures remained negative.
Past Medical History:
1. ESRD due secondary to diabetes, on hemodialysis three times
weekly. She had a failed renal transplant ([**2104**])
2. Diabetes mellitus type I with retinopathy, nephropathy and
peripheral vascular disease, diagnosed as a child, brittle
3. CVA ([**2113**], [**2116**]) with hydrocephalus status post VP shunt
(removed in [**12-10**] as CSF grew out coag negative staph), right
basal ganglia hemorrhage
4. Hypercholesterolemia
5. Hypertension
6. Unclear history of grand mal seizure during dialysis
7. MRSA line tip infection with right atrial thrombus (line tip
pulled [**2116-6-16**])
8. Diffuse lymphadenopathy of unknown etiology.
9. Chronically elevated alkaline phophatase
10. History of naphthelene induced coma from inhaling moth balls
11. Recently admitted with fever of unknown origin - culture
grew VRE bacteremia (completed linezolid in 11/[**2116**]).
Past Surgical history
1. Status post failed renal transplant in [**2104**]
2. Status post parathyroidectomy
3. Status post multiple amputations (right BKA, left digit, left
metatarsal)
4. Exploratory laparotomy and appendectomy for appendicitis in
[**2116-3-8**]
5. Prior history of tracheostomy
Social History:
Ms [**Known lastname **] usually lives in JP with her daughter and
granddaughter, although she came from rehab. Her sister-in-law,
[**Name (NI) 1060**], helps her with management of her multiple medications.
No tobacco or alcohol use. Her baseline is such that she can
feed herself, knows when to take medicines and when to go to
dialysis.
Family History:
Family history of diabetes mellitus in children.
Physical Exam:
Temp: 96.6 BP 139/76 HR:97 RR:22 100%O2 sat
General: confused, pleasant, oriented x 2(person and place)
but not time (thought it was "[**2114**]" and did not know month),
able to follow one-step commands, ill-appearing
HEENT: NC, well healed scar in left frontal lobe, PERLLA, MMM,
OP clear, no lesions, no pharyngeal edema, exudate
Neck: non-tender, shoddy LAD, no thyromegaly, no JVD, surgical
scar at neck
Chest: right subclavian line w/o signs of infeciton
Heart: regular, normal S1 and S2, no m/r/g
Lung: CTA bilaterally
Abd: + BS, soft, multiple scars, non-tender, distended, tender
right groin LAD
Sacrum: grade [**3-10**] sacral decub, no discharge, non-tender, clean
base, granulation tissue
Extr: Left MT amputation, right BKA, no edema
Neuro: Alert and oriented to person and place, but not time.
Appropriate. No focal neurological deficits appreciated.
Pertinent Results:
Admission:
[**2117-1-9**] 07:20PM BLOOD WBC-36.4*# RBC-3.53* Hgb-9.7* Hct-33.0*
MCV-93 MCH-27.5 MCHC-29.5* RDW-16.5* Plt Ct-687*
[**2117-1-9**] 07:20PM BLOOD Neuts-89* Bands-5 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2117-1-9**] 07:20PM BLOOD Glucose-197* UreaN-20 Creat-4.4*# Na-135
K-4.3 Cl-94* HCO3-25 AnGap-20
[**2117-1-9**] 07:20PM BLOOD CK-MB-NotDone cTropnT-0.94*
[**2117-1-10**] 03:41AM BLOOD CK-MB-NotDone cTropnT-0.84*
[**2117-1-9**] 07:20PM BLOOD ALT-15 AST-28 CK(CPK)-21* Amylase-74
TotBili-0.5
[**2117-1-10**] 03:41AM BLOOD CK(CPK)-70
[**2117-1-9**] 10:12PM BLOOD LD(LDH)-211
[**2117-1-9**] 07:20PM BLOOD Calcium-9.7 Mg-1.5*
[**2117-1-9**] 07:15PM BLOOD Lactate-3.8*
[**2117-1-10**] 03:41AM BLOOD Vanco-6.7*
[**2117-1-9**] 10:12PM BLOOD Cortsol-25.5*
[**2117-1-10**] 01:00AM BLOOD Cortsol-34.8*
Micro data:
Blood cultures: [**2117-1-9**] 6/6 bottles citrobacter koseri
resistant to piperacillin
[**2117-1-10**] Neg
[**2117-1-11**] Neg
[**2117-1-12**] Neg
[**2117-1-13**] Neg
Perma cath culture: [**2117-1-10**] >15 colonies citrobacter koseri R
to piperacillin
C diff: [**2117-1-10**] negative
CXR [**2117-1-9**]: No acute pulmonary disease.
Echo [**2117-1-11**]:
1. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
2. The aortic valve leaflets are mildly thickened.
3. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
4. No evidence of endocarditis seen.
5. Compared with the findings of the prior study of [**2116-11-18**],
there has been
no significant change.
Left subclavian tunnelled line placement ([**2117-1-13**]), revised
([**2117-1-14**]).
IMPRESSION:
Successful exchange of existing triple-lumen catheter for a
dual-lumen dialysis catheter with tip in the high right atrium.
The catheter tip-to-cuff length measures 23 cm. Catheter is
ready for immediate use.
Brief Hospital Course:
38F with multiple medical problems including DM I, ESRD s/p
failed renal tx, now on HD, h/o CVAs and hydrocephalus presented
with line sepsis from right groin hemodialysis line.
1. ID
Sepsis: The patient was admitted with fevers (to 105) and change
in mental status. The sepsis protocol was initiated and the
patient was transferred to the MICU, she was placed on
antibiotics, aggressively fluid hydrated and briefly on
levophed; she was given a unit of PRBCs with an appropriate HCT
bump. The source was thought to be her right groin dialysis
line and this was removed and sent for culture. Her blood
cultures and catheter tip from admission initially grew out pan
sensitive gram negative rods, that were then further speciated
into citrobacter koseri resistant to piperacillin. Initially
she had been given a dose of vanco at hemodialysis, then started
on Ceftriaxone in the ED; Zosyn was added with initial Cx data
for broader coverage; finally she was switched to levofloxacin,
renally dosed to complete a 14 day course. Her surveillance
cultures were negative after antibiotics were initiated. She
did not spike >101 for the remainder of her stay.
The patient also had a chronic decubitus ulcer which did not
appear necrotic. A wound care consult was obtained and
recommended duoderm dressings and a special mattress. During
her hospitalization, two areas of skin breakdown were noted in
her right groin at the site of her previous dialysis catheter.
There was no fluctulance, and these were kept clean and dry.
Additionally, the patient has abdominal fluid collections from
her VP shunt that cannot be fully drained and have grown coag
negative staph in the past.
2. Neuro
The patient has a history of CVAs and briefly had a VP shunt for
hydrocephalus (it was removed [**3-9**] infection in [**Month (only) **]); she
presented with mental status changes from her baseline likely in
context of her sepsis. This was clearing slowly as her
infection was treated and as she re-initiated hemodialysis.
While hospitalized her ambien was held, but her oxycodone was
continued as she required it for pain.
3. GI
The patient began to have diarrhea during her hospitalization.
Her outpatient reglan was held. C. difficile was checked x2 and
was negative. She was then started on immodium. The patient
was continued on her protonix. She has CSF collections in her
abdomen at baseline [**3-9**] VP shunt (see previous dc summary for
additional details).
4. Renal
The patient has long standing end stage renal disease secondary
to her diabetes and is anuric at baseline on hemodialysis MWF.
She had a right groin tunnelled line on admission that was
discontinued and likely the cause of her sepsis. Once she had
been afebrile and on antibiotics, with negative surveillance cx,
another tunnelled line was placed in the left subclavian by IR;
this line had to be changed (same site) as it was not large
enough for HD. She was able to undergo hemodialysis on [**2117-1-14**].
She was continued on her renagel and her electrolytes were
monitored as below. Renal followed her throughout her course.
5. Endo
The patient had a long standing history of type I DM starting at
age 4 complicated by retinopathy, nephropathy, and neuropathy
requiring UE and LE amputations. At home she is on lantus 12
units. She was placed on an insulin gtt while in the MICU for
tight glycemic control and was transitioned to a RISS and lantus
12 units qhs (outpatient dose) on transfer to the floor. A
[**Last Name (un) **] consult was obtained for BG >300 on the floor. Her
lantus was titrated up to 20 qhs and she became somewhat
hypoglycemic the following day (low FS 38). She was given a
total of 2 amps D50 and started on D5 1/2NS at 50/hr. Her
lantus was decreased to 15 units qhs, then to 13 units qhs and
her fingersticks were adequately controlled thereafter. She was
discharged to rehab on her usual outpatient dose of lantus and a
regular insulin sliding scale.
6. Heme
The patient has a history of anemia with baseline HCTs in the
mid-high 20s. On admission her HCT was 33 and fell to 27.5 and
she was transfused 1 unit PRBCs with HCT bump to 31. Her
hematocrit was stable throughout the rest of her course. She had
some bleeding around her new hemodialysis catheter site which
was controlled with a pressure dressing and did not require
ddAVP.
On admission the patient had an INR of 3.1 and PTT 150. Her
platelets, LDH, and total bili were normal, and her coagulopathy
resolved with treatment of the sepsis.
7. CV
Ischemia: Initially the patient had a mild troponin leak (peak
0.94) likely in setting of sepsis, CKs <100. No EKG changes.
Pump: The patient is hypertensive at baseline on lisinopril and
metoprolol, but became hypotensive in the setting of sepsis,
requiring levophed and IVF hydration. Her antihypertensive
medications were initially held and lisinopril was added back
once she was on the floor, followed by metoprolol. She was
discharged on her regular outpatient doses.
Rate/rhythm: The patient was initially tachycardic, and once she
was volume repleted and treated for sepsis, returned to NSR
without ectopy.
8. FEN: After transfer out of the MICU, she was maintained on a
renal/diabetic diet and B complex/vitamin C/zinc. She required
kayexalate while she was waiting for HD for an elevated
potassium.
9. Proph: The patient was maintained on Hep SQ and was
tolerating a renal/diabetic diet while on the floor, she had
freq turns given her decubitus ulcer and was seen by wound care
consult, she was kept on her oxycodone 5-10mg q4-6 hrs per
outpatient regimen, her bowel regimen was held given the
diarrhea and once her c diff came back negative x2 she was
started on immodium.
10. The patient was full code.
11. Communication: The patient's HCP is [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 103163**]. She was aware of the patient's hospitalization
and course.
12. Access: The patient initially had a right subclavian triple
lumen; this was removed and a new tunnelled catheter was placed
in her left subclavian on [**2117-1-14**] for hemodialysis.
14. Precautions: VRE and MRSA
15. The patient was discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Medications on Admission:
1. Lisinopril 20 mg po qd
2. Fluoxetene HCl 10 mg po bid
3. Vit C 500 mg tid
4. B-complex with Vit C
5. Zinc Sulfate 220 mg po qd
6. Amlodipine Besylate 10 mg po qd
7. Reglan
8. Lantus 12 units qhs
9. Metoprolol 100mg daily
10. Oxycodone 5-10mg q4-6 hrs prn
11. SubQ heparin 5000 units TID
12. Renagel 600mg TID
13. Pantoprazole
14. Ambien 5mg qhs
15. Aspirin 81mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for DM I.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 10 days.
13. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
14. Insulin Regular Human 300 unit/3 mL Syringe Sig: per insulin
sliding scale Subcutaneous four times a day: QID fingerstick.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day: hold for HR < 60, SBP < 100.
16. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed.
17. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: hold for sedation, confusion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis
1. Gram negative rod sepsis (citrobacter koseri) secondary to
infected dialysis catheter
Secondary diagnoses
2. End stage renal disease on hemodialysis MWF
3. Diabetes Mellitus type I complicated by retinopathy,
nephropathy, and peripheral neuropathy s/p multiple amputations
4. Multiple CVAs h/o VP shunt placement, removed [**3-9**] infection
5. MRSA and VRE
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as prescribed. Call your
doctor or return to the emergency department if you notice
fevers, chills, night sweats, worsening confusion, nausea,
vomiting, chest pain, difficultly breathing, or any other
symptoms concerning to you, your caretakers, or your family.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 805**] in [**2-7**] weeks after discharge.
Please continue to get your dialysis Mondays, Wednesdays and
Fridays.
|
[
"038.3",
"707.03",
"285.21",
"996.81",
"996.62",
"403.91",
"286.9",
"250.41",
"995.92",
"785.52",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.17",
"38.95",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14931, 15004
|
6611, 12855
|
329, 454
|
15428, 15436
|
4533, 6588
|
15780, 15946
|
3574, 3624
|
13278, 14908
|
15025, 15407
|
12881, 13255
|
15460, 15757
|
3639, 4514
|
236, 291
|
482, 2015
|
2037, 3201
|
3217, 3558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,910
| 190,411
|
36400
|
Discharge summary
|
report
|
Admission Date: [**2110-3-12**] Discharge Date: [**2110-3-26**]
Date of Birth: [**2033-4-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
transfer from OSH for severe MR / SOB
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2110-3-13**]
[**2110-3-17**] MV repair ( 26mm [**Company 1543**] 3D Profile ring)/ cabg x1 (
SVG to RCA)
History of Present Illness:
76 yo F with h/o COPD, PVD and HTN presented to OSH on [**3-10**] with
SOB, thought to be PNA vs. COPD exac. Pt reports being in her
usual state of health (active, without O2 requirement or
dyspnea) until developing acute onset shortness of breath
worsening over several minutes after walking her dog on [**3-10**]. She
describes difficulty catching her breath and diaphoresis,
without any associated pain, nausea. Based on initial workup was
thought to be due to pneumonia, COPD exacerbation and CHF and
thus was treated with abx, steroids, diuresis. Was then noted to
have severe MR murmur, with associated elevated BNP (663). ECHO
revealed 4+ MR and could not rule out flail leaflet. She had EF
75% without WMA. ECG and CE also without evidence of ischemia.
Hospital course also significant for lack of fever, but
leukocytosis to 24 in setting of steroids. Creatinine also
increased to 1.6 on diuresis.
Vital Signs on transfer: afebrile, 104/43, 80 SR, 20, 95% on
2liters
On review of systems completely negative other than mentioned in
HPI including history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors, exertional buttock or
calf pain.
Cardiac cath done [**3-13**] which showed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) **] chordae
and 70-80% RCA lesion. Referred for surgery.
Past Medical History:
hypertension
Chronic obstructive pulmonary disease - no oxygen at home
Peripheral vascular disease s/p aorto-bifemoral bypass
glaucoma
hyperlipidemia
panic attacks
stomach ulcer
Social History:
Lives in E [**Doctor Last Name 40750**] with son and [**Name2 (NI) 7337**]. 1 of 11 kids, has 4
kids, 9 [**Name2 (NI) 7337**], 3 great [**Name2 (NI) 7337**].
-Tobacco history: Former heavy smoker -1ppd X 60 years, quit 3
years ago.
-ETOH: None
-Illicit drugs: None
Very active at baseline->gardens, vacuums, takes dog for walk
6X/day
Family History:
Extensive heart disease including MI in father in 40s, sudden
death in brother, murmur in brother, "arteries cleaned" in
sister, sons with CAD
Physical Exam:
61" 111#
VS: afeb, 93, 140/79, 21, 97% on 2L
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. No xanthalesma.
NECK: Supple with JVP to earlobe.
CARDIAC: prominent PMI irregularly irregular, normal S1, soft
S2. LOUD systolic high pitched murmur at apex radiating to
axilla. soft diastolic murmur at apex
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi anteriorly. Unable to assess
posteriorly because has to lay flat post-cath.
ABDOMEN: Soft, NTND. No tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Strong distal pulses
Pertinent Results:
OSH LABS/RADIOLOGY:
INR-1.1
BUN 41
CR 1.60 (was 1.02)
Lytes otherwise wnl
WBC 24.4 from 8.7 on [**3-11**]
hct 42.3
plt 181
Myoglobins: 92-->100-->193 ([**2110-3-11**])
Troponin I: 0.02, 0.02, 0.035 ([**2110-3-8**])
Urine: 25 leuks, 5-10WBC
ABG: 7.44/31/62
BNP: 663
Cardiac cath [**2110-3-12**]
Right dominant
LMCA diffuse w/ ostial 30%
LAD 40% after D1
LCx mild diffuse
RCA diffuse disease w/ serial 70-80% stenosis throughout
Moderately elevated L sided pressures w/ giant v wave c/w MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
RVEDP 7
PCW mean 32
PA mean 34
LVEDP 17
CT CHEST [**2110-3-14**]:
5mm incidental lung nodule. Recommend f/u CT scan in a few
months. Final read pending.
Conclusions
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
partial mitral leaflet flail. An eccentric, anteriorly directed
jet of Severe (4+) mitral regurgitation is seen. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**2110-3-17**]
at 1430.
Post Bypass
Patient is AV paced and receiving an infusion of phenylephrine,
epinephrine and milrinone.
LVEF is globally reduced to 35%
Annuloplasty ring seen in the mitral position. Appears well
seated and there is mild mitral regurgitation. Mean gradient
across the mitral valve is 4 mm Hg. There is no systolic
anterior motion.
Aorta appears intact post decannulation. Mild aortic
insufficiency persists.
The tricuspid regurgitation is now mild to moderate
Dr [**Last Name (STitle) **] aware of post bypass findings.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2110-3-19**] 11:15
Brief Hospital Course:
# SOB: This was thought likely due to severe acute MR leading to
pulmonary edema. Had been getting moxifloxacin at OSH but post
diuresis CXR showed no evidence of infection. CXR showed no
infiltrate. Antibiotics were discontinued. Steroids were
discontinued as well. Patient remained afebrile and euvolemic
prior to surgery.
# Mitral Regurgitation: Possible etiologies include 1. ischemia
although never had CP has significant RFs inc. HTN, HL, family
history, and with RCA at 70-80% stenosis could have infarcted
posterior leaflet 2. Infection but denies recent sick symptoms
inc. fevers and no signs endocarditis on exam, 3. Trauma but
patient denies history of trauma. CT surgery was consulted and
recommended MVr vs MVR. Patient had pre-op carotid studies
showing 40-59% stenosis bilaterally as well as chest CT and CXR
that showed a pulmonary nodule that will need to be follow up as
an outpatient in a few months.
# CAD: No h/o CAD, no h/o CP per patient. Had cardiac cath (via
radial artery as has bilateral LE bypasses) to assess severity
of valve disease and CAD for potential bypass in conjunction
with MVR if necessary. cath with mild LCX and LAD disease and
tight RCA disease not intervened upon. Has RCA with significant
stenosis by numbers (no pressure or IVUS done). Plan to have 1
vessel CABG during MV surgery. Continued asa, statin.
After cath done, pre-op workup completed. Underwent surgery with
Dr. [**Last Name (STitle) **] on [**3-17**]. Transferred to the CVICU in stable
condition on epinephrine, milrinone, and propofol
drips.Extubated the next day but developed acute renal
failure.Had rapid A Fib and was treated with amidoarone drip and
subsequent oral dosing. EP was consulted for management.
Creatinine continued to decline and she was transferred to the
floor on POD #5 to begin increasing her activity level. Coumadin
was started for A Fib. ACE-I added for tighter BP control. EF
noted to be approx 35% post-CPB in OR.
Chest tubes and pacing wires removed per protocol. Cleared for
discharge to rehab on POD #9. Target INR is 2.0-2.5 for A Fib.
Medications on Admission:
MEDICATIONS AT HOME:
-Albuterol nebs q4H
-Alprazolam 0.75mg qhs
-Carvedilol 3.125mg [**Hospital1 **]
-Lisinopril 20mg [**Hospital1 **]
-Pantoprazole 40mg daily
-Simvastatin 20mg daily
-ASA 325mg daily
MEDICATIONS ON TRANSFER:
Moxifloxacin 400mg daily
Advair 100/50 [**Hospital1 **]
Spiriva 18mcg
Albuberol nebs
Solumedrol 40mg IV Q6H
Bumex 1mg IV BID
Lisinopril 40mg daily
Simvastatin 40mg daily
Carvedilol 3.125mg [**Hospital1 **]
ASA 325mg daily
Alprazolam 0.25MG daily
Pantoprazole 40mg daily
Tylenol prn
Discharge Medications:
1. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): for one month.
3. Simvastatin 40 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO DAILY (Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Alprazolam 0.25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day) as needed.
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb soln 0.083% Inhalation Q4H (every
4 hours) as needed.
11. Acetaminophen 325 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO Q4H
(every 4 hours) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Warfarin 1 mg [**Hospital1 8426**] Sig: [**Name6 (MD) **] daily MD [**First Name (Titles) **] [**Last Name (Titles) 8426**] PO Once
Daily at 4 PM: daily dosing per HCP- target INR 2.0-2.5.
15. Amiodarone 200 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO DAILY
(Daily) for 7 days: 400 mg daily for 7 days until [**3-31**]; then 200
mg daily ongoing.
16. Lisinopril 5 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY (Daily).
17. Metoprolol Tartrate 25 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID
(2 times a day).
18. Furosemide 20 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2 times
a day).
19. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34165**] of [**Location (un) 2498**]
Discharge Diagnosis:
mitral regurgitation s/p MV repair/cabg x1 [**2110-3-17**]
coronary artery disease
postop atrial fibrillation
hypertension
hyperlipidemia
peripheral vascular disease s/p aorto-bifem bypass graft
chronic obstructive pulmonary disease
glaucoma
panic attacks
stomach ulcer
Discharge Condition:
deconditioned
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 any incision
No driving for one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
call and schedule the following appointments;
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-6**] weeks
Cardiologist Dr. [**Last Name (STitle) 8098**] in [**1-7**] weeks
**** will need chest CT in future to follow-up on pulmonary
nodule as outpatient with PCP
Completed by:[**2110-3-26**]
|
[
"424.0",
"E878.2",
"440.8",
"584.9",
"997.1",
"443.9",
"496",
"276.2",
"512.1",
"433.00",
"285.9",
"V58.61",
"433.10",
"427.31",
"518.89",
"414.01",
"424.2",
"287.4",
"272.4",
"440.0",
"511.9",
"997.5",
"300.01",
"416.8",
"365.9",
"531.90",
"428.0",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.56",
"37.23",
"88.53",
"39.61",
"34.04",
"35.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10835, 10915
|
5800, 7883
|
350, 483
|
11229, 11245
|
3348, 5777
|
11745, 12130
|
2549, 2693
|
8445, 10812
|
10936, 11208
|
7909, 7909
|
11269, 11722
|
7930, 8111
|
2708, 3329
|
273, 312
|
511, 1978
|
8136, 8422
|
2000, 2181
|
2197, 2533
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,407
| 164,059
|
54751
|
Discharge summary
|
report
|
Admission Date: [**2192-4-30**] Discharge Date: [**2192-5-3**]
Date of Birth: [**2156-3-8**] Sex: F
Service: MEDICINE
Allergies:
Suboxone
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
tylenol overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 36 year old female who presented to OSH with abdominal
pain, nausea/vomiting after ingesting large amounts of Tylenol,
now transferred to [**Hospital1 18**] for further management. Pt states she
took 1.5gm q5hours for the last 2 days for her menstrual pains.
Denies any suicidal intention. States last dose was yesterday
evening at 5pm but since then, has been having nausea/vomiting
and abdominal pain mostly in the epigastric region. Pt states
she had multiple episodes of emesis, some blood tinged last
night, +emesis today without any evidence of bleeding. Pt has
also been drinking large amount of EtOH during this past week,
is unable to quantify the exact amount, last drink was yesterday
at 4 PM. States she has been having problems with her mother
which drove her to drinking. She has been drinking every night
from 6 pm to 3 am, incl beers, whiskey, shots. Denies
fevers/chills, chest pain, shortness of breath.
.
At OSH, pt was found to have tylenol level of 33 with AST 9346
and ALT 4577. INR was 1.5 and Cr was 1.0. Pt was started on NAC
and then transferred to [**Hospital1 18**] for further management. In the ED
here, initial VS were 98.0 68 146/96 20 97%. Labs here were
remarkable for Tylenol level of 22, ALT of 3821, AST of 6169, AP
of 182 and Tbili of 1.2. INR was 2.0 and lactate was wnl at
1.9. Pt rec'd 2L NS. Toxicology was consulted. Pt was given
40mg oral pantoprazole and continued on IV NAC (given 2nd dose).
On transfer, VS were 86, 16, 133/75, 98% RA.
.
On arrival to the MICU, pt is comfortable, has no major
complaints. States her abd pain is about [**4-19**]. Endorses mild
nausea, last emesis was this am, none since. Endorses chronic
diarrhea x 2years, being worked up as outpt, with plans for
[**Last Name (un) **].
.
Past Medical History:
DM
GERD
"elevated liver levels"
hematuria
s/p cholecystectomy in [**2175**]
s/p c-section
R knee mensical tear
"frequent kidney infections"
Social History:
+ tobacco - 1ppd x 25 years
+ etoh - states had a recent binge x 1 week, last drink last
night at 7pm. Pt states she does not drink regularly, usually
[**4-15**] drinks per setting, once in [**1-13**] months. no hx of withdrawal
or DTs.
+ hx of heroin abuse, stopped 1 year ago
Family History:
mother with SLE, COPD, "heart valve problem", does not know her
father, maternal grandfather with CHF, siblings are healthy
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tender in epigastric are, non-distended,
bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
Discharge exam:
T 98.1 BP 140/96 P 74 RR 18 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear, no fetor hepaticus
Neck: supple, JVP not assessed no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft,mildly tender in epigastrum and RUQ,+ bowel
sounds, no rebound tenderness or guarding, no caput medusae
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact, No asterxis,
Skin: No rash, no palmar erythema, spider angioma
Pertinent Results:
admission labs
[**2192-4-30**] 02:54PM BLOOD WBC-13.2* RBC-4.70 Hgb-14.8 Hct-44.1
MCV-94 MCH-31.5 MCHC-33.5 RDW-13.4 Plt Ct-262
[**2192-4-30**] 02:54PM BLOOD Neuts-88.1* Lymphs-9.8* Monos-0.9*
Eos-0.8 Baso-0.4
[**2192-4-30**] 02:54PM BLOOD PT-20.7* PTT-26.2 INR(PT)-2.0*
[**2192-4-30**] 02:54PM BLOOD Glucose-151* UreaN-16 Creat-1.0 Na-142
K-4.3 Cl-105 HCO3-27 AnGap-14
[**2192-4-30**] 02:54PM BLOOD ALT-3821* AST-6169* AlkPhos-182*
TotBili-1.2
[**2192-4-30**] 09:30PM BLOOD Calcium-8.5 Phos-2.3* Mg-1.8
[**2192-4-30**] 02:54PM BLOOD Albumin-3.5
[**2192-4-30**] 02:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-22
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-4-30**] 05:20PM BLOOD Type-[**Last Name (un) **] pO2-68* pCO2-45 pH-7.34*
calTCO2-25 Base XS--1
[**2192-4-30**] 05:20PM BLOOD Lactate-4.7*
INR trend:
[**2192-4-30**] 02:54PM BLOOD PT-20.7* PTT-26.2 INR(PT)-2.0*
[**2192-4-30**] 09:30PM BLOOD PT-22.4* PTT-27.1 INR(PT)-2.1*
[**2192-5-1**] 04:22AM BLOOD PT-20.7* PTT-28.1 INR(PT)-2.0*
[**2192-5-1**] 04:04PM BLOOD PT-18.3* INR(PT)-1.7*
[**2192-5-2**] 06:45AM BLOOD PT-13.2* INR(PT)-1.2*
[**2192-5-3**] 05:30AM BLOOD PT-11.1 INR(PT)-1.0
LFT trend
[**2192-4-30**] 02:54PM BLOOD ALT-3821* AST-6169* AlkPhos-182*
TotBili-1.2
[**2192-4-30**] 09:30PM BLOOD ALT-3016* AST-3967* AlkPhos-173*
TotBili-1.4
[**2192-5-1**] 04:22AM BLOOD ALT-2379* AST-2457* AlkPhos-162*
TotBili-1.3
[**2192-5-1**] 04:04PM BLOOD ALT-[**2186**]* AST-1345* LD(LDH)-259*
AlkPhos-171* TotBili-1.5
[**2192-5-2**] 06:45AM BLOOD ALT-1546* AST-671* AlkPhos-141*
TotBili-1.5
[**2192-5-3**] 05:30AM BLOOD ALT-991* AST-259* AlkPhos-115*
TotBili-1.1
Acetaminophen level trend:
[**2192-4-30**] 02:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-22
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-5-1**] 04:22AM BLOOD Acetmnp-6*
[**2192-5-1**] 04:04PM BLOOD Acetmnp-NEG
Hepatitis serologies:
[**2192-5-1**] 04:22AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2192-5-1**] 04:22AM BLOOD HCV Ab-POSITIVE*
Hep C genotype:
Test Result Reference
Range/Units
HCV GENOTYPE, LIPA 1
Hep C viral load: 836 IU/mL.
RUQ ultrasound:
IMPRESSION:
1. Echogenic liver consistent with fatty deposition. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Normal liver Doppler examination.
Brief Hospital Course:
This is a 36 year old female now here with Tylenol overdose.
.
# Tylenol Overdose: appears to be accidental, not intentional.
Patient denied suicidal intent. Likely from a combintation of
Tylenol and binge alcohol use. No indication for transplant at
this time (based on [**First Name4 (NamePattern1) 3728**] [**Last Name (NamePattern1) 1688**] Criteria - inr >6, crt 3.4,
stage III/IV hepatic encephalopathy or a ph < 7.3 after
resusication). She was admitted to the hepatology service.
Patient was continued on NAC (full dosing as follows: 1st dose -
150mg/kg/hr; 2nd dose - 50mg/kg over 4 hours or 12.5mg/kg/hr x 4
hrs; 3rd dose - 100mg/kg over 16 hours or 6.25mg/kg/hr x 16 hr).
After that protocol, she was continued on 500mg/hr until her INR
was less than 2 and her acetaminophen level was negative. She
had every 2 hour neurology checks without signs of
encephalopathy. She had a headache c/w her chronic headaches,
but no other signs of brain edema. At time of discharge, her
acetaminophen level was negative, INR normalized, and LFTs
significantly downtrending. A RUQ ultrasound showed fatty
infiltration of the liver. A hepatitis panel showed immunization
to hepatitis B and infection with hepatitis C
.
# Hepatitis C: Pt with positive Hep C antibody. Viral load of
836 IU/mL. Genotyping was performed revealing HCV genotype 1.
# EtOH abuse: does not appear to have dependence and therefore
was at low risk for EtOH withdrawal. Social work was consulted.
.
# DM: supposed to be on insulin, but not compliant per her
report. Hemoglobin A1c only 6.8%, suggesting that she may be
managed with oral medications alone. She was managed with an
insulin sliding scale while inpatient with minimal insulin
requirements. Thus, she was discharged with a prescription for
a glucometer and given a follow up appointment at [**Last Name (un) **].
.
# GERD: continued 40mg Omeprazole, which she was not taken due
to cost of medication.
Transitional:
Follow up with liver service for tylenol toxicity and hepatitis
C
Follow up with [**Last Name (un) **] for diabetes
Counseling for ethanol abuse
Medications on Admission:
none except Tylenol recently. Supposed to be on insulin but
hasn't been for about 2 years now as well as 40mg Omeprazole.
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Glucometer
Glucose-meter please dispense one with 90 glucose test strips.
Please dispense glucometer that is compatible with patient's
insurance for monitoring of Type 2 DM
Discharge Disposition:
Home
Discharge Diagnosis:
Tylenol overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure participating in your care. You were
transferred to [**Hospital1 18**] for an accidental tylenol overdose. You
were treated with a medication to help eliminate the tylenol
from your body. Your liver function tests were initially very
elevated but have been progressively declining. We did an
ultrasound that indicated that you may have some chronic changes
in your liver from alcohol, fat, or other cause. We checked for
hepatitis C which showed you have been exposed to the hepatitis
c virus. A test is still pending to establish if you're actively
infected. You have follow-up scheduled with the liver center to
follow-up on this issue. Please abstain from drinking alcohol.
Your liver has not returned to [**Location 213**] function and drinking
alcohol could damage it.
You also have diabetes which you have not been treating for
the past two years. Your blood sugar was mildly elevated while
you have been hospitalized. We have prescribed you a glucometer
so you can continue to monitor this at home. Please monitor your
blood sugars at home and bring the values with you to your
[**Last Name (un) **] appointment.
Please START the following medications:
Omeprazole 40mg daily
Followup Instructions:
Department: LIVER CENTER
When: [**Last Name (un) **] [**2192-5-14**] at 9:10 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 **] Garag
Endocrinology Appointment: [**Last Name (LF) 766**], [**5-14**] at 3pm
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location:[**Last Name (un) **] Diabetes Center, One [**Last Name (un) **] Place
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
PCP [**Name Initial (PRE) **]: Pending
With:[**Name6 (MD) **] [**Last Name (NamePattern4) 111942**], MD
Address: [**State **], [**Location (un) **],[**Numeric Identifier 72762**]
Phone: [**Telephone/Fax (1) 79219**]
** Your PCP office is closed until Tuesday, [**5-8**]. A message has
been put in your PCPs answering service that you need a
discharge follow up appoinmtnet early next week. Please call the
number above next Tuesday to secure this appointment.
Completed by:[**2192-5-10**]
|
[
"E850.4",
"965.4",
"305.02",
"305.1",
"250.00",
"573.3",
"276.8",
"530.81",
"V15.81",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9006, 9012
|
6366, 8464
|
285, 292
|
9073, 9073
|
3947, 6343
|
10488, 11583
|
2580, 2706
|
8638, 8983
|
9033, 9052
|
8490, 8615
|
9224, 10465
|
2721, 3286
|
3302, 3928
|
229, 247
|
320, 2103
|
9088, 9200
|
2125, 2267
|
2283, 2564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,910
| 111,498
|
12689
|
Discharge summary
|
report
|
Admission Date: [**2116-11-17**] Discharge Date: [**2116-11-23**]
Date of Birth: [**2041-7-21**] Sex: M
Service: SURGERY
Allergies:
Flomax / Ace Inhibitors / Ativan
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Diverticulitis
Major Surgical or Invasive Procedure:
s/p Colectomy, colostomy closure, repair of
parastomal hernia
History of Present Illness:
This gentleman had perforated diverticulitis
with sepsis and required a colostomy with a colostomy
revision. He has finally recovered and wishes to have this
repaired. He also has a peristomal hernia which needs to be
repaired at the same time. Workup has shown that the patient
had some residual diverticula and a Hartmann closure which
really incorporates a portion of the lower sigmoid. There are
also a few diverticula seen in the descending colon on
colonoscopy. He presents now for reanastomosis and repair of
his hernia.
Past Medical History:
CAD w/ stent, Diverticulits, Hartmann's, Resp failure, Trach,
Afib, MRSA, DMII
Tracheal stenosis by bronch ([**2116-5-27**]),
Perforated sigmoid colon diverticulitis with peritonitis s/p
colostomty([**2116-3-8**])
Coronary Artery Disease
Paroxysmal atrial fibrillation
Transient Complete Heart Block
Diabetes Mellitus typeII
Peripheral Vascular disease
Hypertension
Hypothyroidism
Gout, DVT ([**3-7**])
Anxiety
Acalculous cholecystitis
MRSA Pneumonia
Social History:
Married lives with wife.
Family History:
non-contributory
Physical Exam:
Vitals T 97.6, P 53, R 16, Sat 98% RA, BP 141/56
Gen NAD
Lungs: CTA
Card: RRR 2/6 SEM
Abd: NT ND ostomy on L
Ext: no edema
Pertinent Results:
[**2116-11-18**] 05:15AM BLOOD WBC-11.7* RBC-4.59* Hgb-12.3* Hct-37.0*
MCV-81* MCH-26.9* MCHC-33.3 RDW-16.4* Plt Ct-227
[**2116-11-20**] 05:45AM BLOOD WBC-13.2* RBC-4.57* Hgb-12.3* Hct-36.9*
MCV-81* MCH-27.0 MCHC-33.4 RDW-16.4* Plt Ct-239
[**2116-11-23**] 06:25AM BLOOD WBC-7.2 RBC-4.01* Hgb-10.7* Hct-33.0*
MCV-82 MCH-26.7* MCHC-32.5 RDW-17.2* Plt Ct-335
[**2116-11-23**] 06:25AM BLOOD PT-13.8* PTT-25.9 INR(PT)-1.2*
[**2116-11-19**] 05:39PM BLOOD CK(CPK)-471*
[**2116-11-20**] 05:45AM BLOOD CK(CPK)-401*
[**2116-11-20**] 05:45AM BLOOD CK-MB-7 cTropnT-<0.01
[**11-22**]: CXR Fluid overload. Pericardial abnormality as previously
described.
[**11-19**]: Although top normal heart size is unchanged, there is new
engorgement of hilar upper lobe pulmonary and mediastinal
vasculature suggesting volume overload, though there is no
pulmonary edema. Small left pleural effusion is new. No
pneumothorax.
Brief Hospital Course:
The patient was admitted for a colectomy, colostomy closure, and
repair of peristomal hernia; for details, please see operative
note.
The patient was extubated, and taken to the PACU for initial
recovery.
Neuro: The patient was initially put on a dilaudid PCA for pain
control; he was transitioned to PO pain medications when
appropriate. On [**11-19**], the patient complained of hallucinations
with Benadryl which resolved.
CV: The patient was stable until [**11-19**], when he developed new
onset rapid response atrial fibrillation. The patient was put
on telemetry, labs were drawn, and the patient received
diltiazem with good initialy response. The patient was ruled
out for a myocardial infarction. The patient's home
cardiologist was consulted regarding this apparently new onse
atrial fibrillation; the patient has a history of paroxysmal
atrial fibrillation, which had been managed with coumadin as the
patient was usually in sinus rhythm. The cardiology recommended
cardioversion to sinus rhythm, and that his coumadin be
restarted.
On [**11-21**], the patient was chemically cardioverted with
amiodarone; he converted back into sinus rhythm, and was able to
be transferred to the floor. On the floor he was noted to be in
and out of atrial fibrillation but his rate was controlled. He
was kept on PO amiodorone on discharge 800 [**Hospital1 **] in consultation
with cardiology here. He had no received the full 10 g load.
He will follow up with his cardiologist within 1-2 weeks for
management of his PAF
Pulm: good pulmonary toilet was encouraged. Pulmonology was
consulted , and recommended chest PT for secretions, as there
were no other active airway issues. Please see results section
for chest x-ray details
GI: The patient was initially made NPO with IVF. His diet was
advanced when appropriate.
GU: The patient's urinary output was routinely followed, and his
IVF were adjusted accordingly. Post operatively, the patient had
a rise in his creatinine level; the team discussed the issue
with Nephrology, who felt that it was likely diabetic
nephropathy. The patient's baseline creatinine was 1.5-2.0 per
the patient's PCP. [**Name10 (NameIs) 39181**] was stopped given the patient's
renal dysfunction.
Endo: The patient was put on a sliding scale of insuling
Heme: The patient's hematocrit was routinely followed.
ID: The patient was cultured, and his fever curves were closely
followed.
Proph: The patient received GI and DVT prophylaxis throughout
his stay.
Medications on Admission:
Coumadin, Allopurinol, Diovan 80', Lopressor 50", Folic acid,
Biotin, Levoxyl 25', Lipitor 20
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks: please follow up with your cardiologist
regarding continuing this medication.
Disp:*56 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Colectomy, colostomy closure, repair of
parastomal hernia
Post operative paroxysmal atrial fibrillation
Chronic renal insufficiency
Discharge Condition:
stable
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-3**] weeks; call ([**Telephone/Fax (1) 8818**] to schedule an appointment.
Please follow up with Dr. [**Last Name (STitle) **] in [**12-3**] weeks; call ([**Telephone/Fax (1) 8818**] to schedule an appointment.
Please follow up with your cardiologist about your atrial
fibrillation.
Please have an INR level drawn and faxed to your PCP for
coumadin management
Please follow up with your pulmonologist in [**2-2**] weeks as needed
|
[
"997.3",
"427.31",
"244.9",
"E878.2",
"562.10",
"518.0",
"274.9",
"E849.7",
"V55.3",
"569.69",
"414.01",
"511.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.75",
"46.42",
"46.52"
] |
icd9pcs
|
[
[
[]
]
] |
5999, 6005
|
2565, 5067
|
309, 373
|
6184, 6193
|
1641, 2542
|
7535, 8029
|
1465, 1483
|
5212, 5976
|
6026, 6163
|
5093, 5189
|
6217, 6217
|
6233, 7512
|
1498, 1622
|
255, 271
|
401, 931
|
953, 1406
|
1422, 1449
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,547
| 145,856
|
43414
|
Discharge summary
|
report
|
Admission Date: [**2115-9-15**] Discharge Date: [**2115-9-23**]
Date of Birth: [**2047-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Rofecoxib
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion, Fatigue
Major Surgical or Invasive Procedure:
[**2115-9-19**] Redo sternotomy/Full left and right-sided Maze procedure
with resection of left atrial appendage using combination of
Atricure
bipolar RF system and the cryo cath.
[**2115-9-17**] Cardiac Catheterization
History of Present Illness:
68 year old gentleman with past medical history of AVR, MVR and
septomyomectomy in [**2112**] who now has atrial fibrillation/flutter
which is extremely symptomatic and has been very difficult to
control. He underwent 2 cardoversions in [**Month (only) 956**] and feels
quite well when in normal sinus rhythm however reverts back to
atrial tachycardia after a few days. Despite aggressive medical
therapy
and cardioversions, Mr. [**Known lastname 62250**] continues to suffer from atrial
tachycardia. His symptoms are significant dyspnea with minimal
activity and fatigue. He presents for admission today for
cardiac catheterization, intravenous heparin to bridge from
coumadin, and preoperative workup for MAZE.
Past Medical History:
Past Medical History
Hypertrophic cardiomyopathy with significant LVOT gradient.
Complete heart block s/p dual chamber pacemaker ([**Company 1543**])
Hypertension
Diastolic Heart Failure
Atrial tachycardia
Obesity
Aortic Insufficiency
Gout
AF s/p Successful electrical cardioversion of atrial
fibrillation
to sinus rhythm. [**2115-5-17**]
Depression
Foot Cellulitis treated with antibiotics in [**Month (only) 116**]
Past Surgical History
Several ethanol ablations
Permanent pacemaker [**2099**] - [**Company **]
Aortic valve replacement with a [**Street Address(2) 11688**]. [**Hospital 923**] Medical
mechanical
valve.
Mitral valve replacement with a [**Street Address(2) 11599**]. [**Hospital 923**] Medical
mechanical valve.
Septomyectomy([**2112**])
bilateral knee arthroscopies
Social History:
-Pt is widowed, lives with daughter in [**Name (NI) 7661**].
Currently on disability, previous occupation-mechanic.
-Quit TOB 15 years ago, smoked 1.5 PPD x30years
-Social ETOH use 1 drink per week. Denies any other drug use.
Family History:
Family History: no premature heart disease
-F: deceased at 87 from Alzheimer's disease
-M: alive, [**Age over 90 **] years of age, no known CAD
Physical Exam:
Physical Exam
Pulse: 61 Resp: 22
B/P Right: 110/65
Height: 5'6" Weight: 280lb
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [x] Edema trace ankle
edema, early venous stasis changes
Varicosities None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit no bruits appreciated
Pertinent Results:
Admission:
[**2115-9-15**] 05:10PM PT-25.5* PTT-32.4 INR(PT)-2.5*
[**2115-9-15**] 05:10PM PLT COUNT-168
[**2115-9-15**] 05:10PM WBC-7.6 RBC-4.71 HGB-13.9* HCT-41.6 MCV-88
MCH-29.5 MCHC-33.4 RDW-15.2
[**2115-9-15**] 05:10PM TSH-0.64
[**2115-9-15**] 05:10PM %HbA1c-5.5 eAG-111
[**2115-9-15**] 05:10PM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-4.6*#
MAGNESIUM-2.4
[**2115-9-15**] 05:10PM CK-MB-4 cTropnT-<0.01
[**2115-9-15**] 05:10PM LIPASE-70*
[**2115-9-15**] 05:10PM ALT(SGPT)-28 AST(SGOT)-30 LD(LDH)-328*
CK(CPK)-90 ALK PHOS-131* AMYLASE-80 TOT BILI-0.7
[**2115-9-15**] 05:10PM GLUCOSE-85 UREA N-27* CREAT-1.4* SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2115-9-15**] 06:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
Discharge:
[**2115-9-22**] 04:55PM BLOOD WBC-11.3* RBC-3.33* Hgb-10.1* Hct-29.0*
MCV-87 MCH-30.4 MCHC-34.9 RDW-15.5 Plt Ct-118*
[**2115-9-23**] 06:16AM BLOOD PT-29.0* INR(PT)-2.9*
[**2115-9-22**] 04:55PM BLOOD Plt Ct-118*
[**2115-9-22**] 04:55PM BLOOD Glucose-99 UreaN-22* Creat-1.0 Na-137
K-4.4 Cl-97 HCO3-28 AnGap-16
[**2115-9-20**] 06:29PM BLOOD ALT-23 AST-84* LD(LDH)-397* AlkPhos-59
TotBili-1.0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *7.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.8 cm <= 5.2 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Mitral Valve - MVA (P [**2-9**] T): 2.7 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Marked LA enlargement. Moderate to severe
spontaneous echo contrast in the body of the LA. No spontaneous
echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection
velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR
leaflets move normally. No AR.
MITRAL VALVE: Mechanical mitral valve prosthesis (MVR). Normal
MVR leaflets. Mild mitral annular calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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. The rhythm appears to be atrial fibrillation.
patient.
Conclusions
PREBYPASS:
The patient is V-paced at a rate of 80 bpm.
The left atrium is markedly dilated. Moderate to severe
spontaneous echo contrast is seen in the body of the left
atrium. No spontaneous echo contrast is seen in the left atrial
appendage.
It is difficult to evaluate the left ventricle due to
reverberation artifact from the mechanical mitral valve and
suboptimal transgastric views but function appears to be within
normal limits.
Right ventricular systolic function appears normal with normal
free wall contractility.
There are simple atheroma in the descending thoracic aorta.
A mechanical aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. No aortic
regurgitation is seen.
A mechanical mitral valve prosthesis is present. The prosthetic
mitral leaflets appear normal.
POSTBYPASS:
The patient is on an infusion of phenylephrine and is still
V-paced at a rate of 80 bpm.
The left atrial appendage has been ligated. A small pouch (at
most several millimeters deep) remains without evidence of flow
on color Doppler.
Left ventricular function appears to be unchanged although the
views of the left ventricle are limited.
The mechanical mitral and aortic valves continue to appear
normal without regurgitation.
Aortic contours are normal.
Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) 5209**], MD,
Radiology Report CHEST (PORTABLE AP) Study Date of [**2115-9-22**] 2:35
PM
[**Hospital 93**] MEDICAL CONDITION: 68 year old man s/p MAZE
REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest
tube removal
Final Report
REASON FOR EXAMINATION: Followup of the patient after maze
procedure.
Portable AP chest radiograph was compared to [**2115-9-21**].
The right internal jugular line tip is at the level of low SVC.
There is
unchanged appearance of the cardiomediastinal silhouette,
bibasal atelectasis and bilateral pleural effusions. Note is
made that the current study was obtained with suboptimal
technique and repeat radiograph for precise evaluation of the
chest is recommended.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
68yoM admitted to [**Hospital1 18**] for heparin bridge prior to cardiac
catheterization followed by redo sternotomy and full Maze
procedure.
On [**9-16**] he had a repeat cardiac echo, on [**9-17**] he had cardiac
catheterization.
On [**9-19**] he was brought to the operating room for: Redo
sternotomy. Full left and right-sided Maze procedure with
resection of left atrial appendage using combination of Atricure
bipolar RF system and the cryo cath. His CARDIOPULMONARY BYPASS
TIME was 127 minutes, with a CROSSCLAMP TIME of 80 minutes. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
He remained hemodynamically stable in the immediate post-op
period, woke neurologically intact and was extubated. All tubes,
lines and drains were removed according to cardiac surgery
protocol. He was ready to transfer to the stepdown floor on POD1
however there were no beds available and he therefore stayed in
the ICU until POD3. Once on the floor he worked with the
physical therapist to increase his activity level, generally the
remainder of his stay was uneventful.
On POD4 he was discharged to rehabilitation at [**Location (un) 582**] of
[**Location (un) 7658**]. He is to f/u with Dr [**Last Name (STitle) 914**] in one month.
Medications on Admission:
amiodarone 400mg daily
lisinopril 2.5mg daily
Toprol-XL 100mg daily
simvastatin 20mg daily
Aldactone 25 mg daily
Coumadin 2.5 mg monday thru saturday (last dose 8/6)
furosemide 80 mg twice a day
Colace 100 mg daily
Multivitamin
Aspirin 81 mg daily
Trazadone 50 mg at bedtime
Colchicine 0.6 for gout flare up (1-2 doses a week)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous Q AC&HS.
7. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Target INR 2.5-3.0 for aortic and mitral mechanical
valves.
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Before surgery patient took 2.5mg QD on Mon-Sat. none on Sunday.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
18. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO every twelve (12)
hours as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
S/P Redo sternotomy/Full left and right-sided Maze procedure
with resection of left atrial appendage using combination of
Atricure
bipolar RF system and the cryo cath.
Past Medical History
Hypertrophic cardiomyopathy with significant LVOT gradient.
Complete heart block s/p dual chamber pacemaker ([**Company 1543**])
Hypertension
Diastolic Heart Failure
Atrial tachycardia
Obesity
Aortic Insufficiency
Gout
AF s/p Successful electrical cardioversion of atrial
fibrillation
to sinus rhythm. [**2115-5-17**]
Depression
Foot Cellulitis treated with antibiotics in [**Month (only) 116**]
Past Surgical History
Several ethanol ablations
Permanent pacemaker [**2099**] - [**Company **]
Aortic valve replacement with a [**Street Address(2) 11688**]. [**Hospital 923**] Medical
mechanical
valve.
Mitral valve replacement with a [**Street Address(2) 11599**]. [**Hospital 923**] Medical
mechanical valve.
Septomyectomy
bilateral knee arthroscopies
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions: Sternal - healing well, no erythema or drainage
Edema- chronic bilat edema with venous stasis changes
Discharge Instructions:
Discharge Instructions
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments:
Surgeon: Dr [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 1504**]on [**10-22**] @1:45PM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name8 (NamePattern2) 93423**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 16777**]) in [**2-9**]
weeks
Cardiologist Dr [**First Name (STitle) 437**], [**First Name3 (LF) 449**] in [**2-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2115-9-23**]
|
[
"V43.3",
"425.1",
"V45.01",
"427.31",
"427.32",
"428.0",
"278.01",
"426.0",
"458.29",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"37.36",
"39.61",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11648, 11725
|
8278, 9581
|
304, 527
|
12732, 12935
|
3179, 7561
|
13796, 14461
|
2355, 2484
|
9958, 11625
|
7598, 7623
|
11746, 12690
|
9607, 9935
|
12959, 13773
|
2499, 3160
|
236, 266
|
7652, 8255
|
555, 1270
|
1292, 2079
|
2095, 2323
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,522
| 114,279
|
17488
|
Discharge summary
|
report
|
Admission Date: [**2142-4-7**] Discharge Date: [**2142-4-11**]
Date of Birth: [**2090-7-12**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 51-year-old
male with no significant past medical history who presented
earlier this evening to [**Hospital3 **] Medical Center
complaining of substernal chest pain associated with dyspnea
and diaphoresis times 30 minutes. EKG disclosed ST segment
elevation in II, III, aVF, ST segment depression in I, aVL,
V1 through V4. The vital signs at the outside hospital
included a blood pressure of 98/palpable, heart rate 84,
respiratory rate 20, 02 saturation 98% on room air. The
patient was given Retavase times two. The patient still
complained of chest pain and was transferred by helicopter to
[**Hospital1 18**]. While in the helicopter, the patient became
pain-free.
At [**Hospital1 18**], the patient was immediately taken to the
Catheterization Laboratory. He was found to have occlusion
of the distal RCA. He underwent Angiojet thrombectomy times
one and removal of the thrombus. Two stents were placed in
the RCA. Final residual was 0% stenosis with normal flow.
The patient was transferred to the CCU overnight.
PAST MEDICAL HISTORY: None.
ADMISSION MEDICATIONS: None. The patient takes aspirin
"once a week" for shoulder pain/neck pain.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: The patient's father died in his 50s of a
heart attack. His mother had lung cancer and thyroid
problems.
SOCIAL HISTORY: The patient is a former smoker. He quit
approximately three weeks ago. He smoked a half a pack per
day times ten years. He lives with his wife. [**Name (NI) **] has one
daughter. [**Name (NI) **] is employed as a salesman. He drinks
approximately a six-pack per week. He denied the use of
drugs.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
an obese male, lying in bed, in no apparent distress. Vital
signs: Temperature 98.9, blood pressure 130/90, heart rate
90, respiratory rate 16, saturations 96% on 2 liters. HEENT:
Normocephalic, atraumatic. Pupils equal, round, and reactive
to light. Extraocular movements intact. The membranes were
moist. The oropharynx was clear. Neck: JVP at ear. Heart:
Regular rate and rhythm. Normal S1, S2, no murmurs, rubs, or
gallops. No S3. Lungs: Clear to auscultation anteriorly.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds. Extremities: No clubbing, cyanosis or edema.
LABORATORY DATA FROM THE OUTSIDE HOSPITAL: White count 13,
hematocrit 43.8, platelet count 297,000. Chemistries:
Sodium 132, potassium 3.3, chloride 105, bicarbonate 24, BUN
11, creatinine 1.2, glucose 113. Troponin I less than 0.1.
Myoglobin 26.9.
EKG revealed a normal sinus rhythm, 100 beats per minute,
normal intervals, normal axis, ST segment elevation 6 mm in
II, 7 mm in III, 7 mm in aVF, T wave inversions in I, aVL, V1
through V4.
EKG post catheterization revealed a normal sinus rhythm, 93
beats per minute, normal intervals, normal axis, ST segment
elevation in lead II, 3 mm in lead III, 4 mm in lead aVF, 3
mm ST segment depression in I, aVL, V1 through V2.
IMPRESSION: The patient is a 51-year-old male with a
positive family history of coronary artery disease and
history of smoking, status post thrombolysis with Retavase,
now status post catheterization with RCA stent placement.
The patient was noted to have elevated right and left-sided
filling pressures in the Cath Lab. The patient was
transferred to the CCU for management overnight.
HOSPITAL COURSE: The patient was administered aspirin,
Plavix, and statin as his blood pressure tolerated. He was
started on a beta blocker and low-dose ACE inhibitor. His
cardiac enzymes were followed and were noted to peak at 2,200
on [**2142-4-7**]. The patient remained chest pain-free
during the hospital stay.
The patient was noted to have episodes of NSVT. He also
remained tachycardiac and there was concern for alcohol
withdrawal. The patient was monitored on the CIWA scale and
was given empiric benzodiazepines. His level on CIWA scale
was never greater than 10.
On [**2142-4-8**], the patient was noted to spike a
temperature to 101.7. Blood cultures and urine cultures were
obtained and were negative. Chest x-ray did not disclose
evidence of infiltrate or pleural effusion.
Echocardiogram on [**2142-4-9**] disclosed an EF of 50%. The
left atrium was mildly dilated. A symmetric LVH resting
regional wall motion abnormalities included inferior and
basal inferior septal akinesis. The RV cavity was mildly
dilated. The aortic valve leaflets appeared structurally
normal. The mitral valve leaflets were mildly thickened with
1+ MR. There was borderline pulmonary artery systolic
hypotension. There was no pericardial effusion.
The patient remained tachycardiac and his Lopressor was
titrated up to 150 mg t.i.d.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Home.
FOLLOW-UP: The patient will follow-up with his primary care
physician in one to two weeks. He will also follow-up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] at [**Telephone/Fax (1) 3183**].
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d. times nine months.
2. Folic acid 1 mg p.o. q.d.
3. Lopressor 150 mg p.o. t.i.d.
4. Zestril 5 mg p.o. q.d.
5. Lipitor 40 mg p.o. q.d.
6. Aspirin 325 mg p.o. q.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
3. Acute inferior ST elevation myocardial infarction treated
with rescue PCA post failed lytic therapy.
4. Revascularization of the right coronary artery with good
results.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2142-4-11**] 01:04
T: [**2142-4-13**] 09:31
JOB#: [**Job Number 48839**]
|
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icd9cm
|
[
[
[]
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[
"36.01",
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icd9pcs
|
[
[
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4929, 5191
|
1406, 1513
|
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|
3580, 4907
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1258, 1389
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1870, 3562
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1227, 1234
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1530, 1855
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,961
| 150,566
|
8226
|
Discharge summary
|
report
|
Admission Date: [**2120-7-2**] Discharge Date: [**2120-7-24**]
Date of Birth: [**2081-2-11**] Sex: F
Service: SURGERY
Allergies:
Dilaudid / Shellfish Derived
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Hepatopulmonary Syndrome, admitted for liver transplant
Major Surgical or Invasive Procedure:
[**2120-7-2**] ABO Incompatible Liver transplant
[**2120-7-3**] Ex-Lap, choledochocholedochostomy
[**2120-7-4**] - [**2120-7-15**] Plasmapheresis (12 times total)
[**2120-7-22**] U/S guided Liver Biopsy
History of Present Illness:
39F admitted [**2120-7-2**] when she was called for ABO incompatibile
liver transplant. Has been followed extensively for autoimmune
hepatitis and following complications (see PMhedhx) and reports
over the last few weeks that she has beens table with no medical
issues. She denies any fever or pain, but does have some mild
nausea and one episode of emesis before arrival to hospital
which she attributes to anxiousness/nervousness for her upcoming
surgery.
Past Medical History:
- autoimmune hepatitis dx [**2095**], [**Doctor First Name **] -, SMA +, liver biopsy
[**1-17**]: mild to moderate periportal inflammation including plasma
cells, portal fibrosis and possible stage 3 fibrosis
- DM 2
- portal hypertension
- splenomegaly
- hepatopulmonary syndrome (dx [**1-/2119**] based on platypnea,
orthodeoxya and Aa gradient; she had a ? PFO vs. AVM on TEE w/
some echos showing incr. PAP vs. not)
- hx of hepatic encephalopathy
- migraine headaches
- depression
- Cholecystectomy in [**2112**]
- Endometrial ablation [**2114**] (but pt unsure)
- Cesarian sections
Social History:
She curretly lives at rehab. She does not smoke, use alcohol, or
illicit drugs. She is currently unemployed but worked as a bus
driver previously.
Family History:
No h/o autoimmune illnesses or liver disease. Father with CAD,
mother had a CVA. Her children are healthy although two of them
have asthma. Maternal uncle with esophageal cancer.
Physical Exam:
VS: T 99.6 BP 146/66 P 81 RR 20 99% on non-rebreather
Gen: A&Ox3, Appears stated age, laying comforably in bed with
NAD, obese caucasian female
HEENT: EOMI, non-rebreather mask in place
CV: RRR, no m/r/g
Pulm: CTAB
Abd: obese, non-distended, no organomegaly, tender to deep
palpation in epigastrum, LUQ, RLQ
Ext: Warm, well perfused, Distal pulses intact
Pertinent Results:
On Admission: [**2120-7-2**]
WBC-2.7* RBC-3.99* Hgb-11.7* Hct-33.1* MCV-83 MCH-29.2
MCHC-35.2* RDW-15.7* Plt Ct-120*
PT-14.5* PTT-26.4 INR(PT)-1.3*
Glucose-190* UreaN-14 Creat-0.7 Na-136 K-3.4 Cl-103 HCO3-27
AnGap-9
ALT-20 AST-29 AlkPhos-124* TotBili-0.7
Albumin-3.4* Calcium-9.1 Phos-3.8# Mg-1.6
[**2120-7-24**] calTIBC-195* Ferritn-653* TRF-150* Iron-19*
[**2120-7-2**] TSH-5.0*
On Discharge: [**2120-7-24**]
[**2120-7-24**] 04:50AM BLOOD WBC-16.7* RBC-2.97* Hgb-8.4* Hct-25.6*
MCV-86 MCH-28.4 MCHC-33.0 RDW-15.6* Plt Ct-807*
PT-14.2* PTT-22.5 INR(PT)-1.2*
Glucose-53* UreaN-30* Creat-1.1 Na-137 K-5.1 Cl-97 HCO3-27
AnGap-18
ALT-44* AST-24 AlkPhos-171* TotBili-0.3
Albumin-3.9 Calcium-9.9 Phos-5.4* Mg-1.9
tacroFK-10.9
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname **] is a 39F with past medical history significant
for Auto Immune Hepatitis, portal hypertension, splenomegaly,
and hepatopulmonary syndrome requiring home O2. She was admitted
[**2120-7-2**] for a liver transplant, and subsequently underwent
surgery where she received an ABO incompatible liver, and had a
splenectomy. On POD#1 it was noted that she had biliary drainage
from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain and there was concern for bile duct [**Last Name (LF) 3564**], [**First Name3 (LF) **]
the patient was taken back to the OR for an ex-lap,
choledochocholedochostomy. She tolerated the procedure well and
was monitored in the SICU until she was stable for transfer on
[**2120-7-11**]. In regards to her immunosuppression, the patient
received MMF, methylprednisolone to prednisone taper,
Tacrolimus, and ATG per ABO incompatible liver transplant
protocol. Tacrolimus levels were monitored daily and adequate
suppression was achieved (most recent tacro levels ranging
[**9-21**]). Initially the patient was checked for Anti-A and Anti-B
titers. Throughout her hospital course patient was pheresed a
total of 12 times for elevated titers, which was continued when
the patient was transferred to the floor. Due to the history of
hepatopulmonary syndrome, the patient has continued to require
oxygen by face mask. Throughout her course she has been able to
maintain good sats on face mask, but decompensates into the 80's
upon ambulation. This was consistent with her initial baseline,
and she will require supplemental oxygen upon discharge. While
on the floor, her blood sugars were monitored and patient was
managed on an ISS with the help of [**Hospital **] [**Hospital 982**] Clinic.
Through her course serial liver enzymes were monitored, and
AST/ALT levels remained stable. Recently on [**2120-7-20**] there was a
bump in the Alk Phos 121 up to 171 on [**2120-7-24**]. A Liver US was
performed which demonstrated a patent portal vein and branches,
and good flow on the Hepatic artery. An U/S guided liver biopsy
was also performed on [**2120-7-22**] to check for signs of rejection,
the pathology report was negative for signs of acute rejection
or ductal proliferation. Patient remained stable and was set up
for discharge to a rehab facility ([**Hospital1 **] [**Location (un) 701**]).
Medications on Admission:
Alendronate 70 weekly, Aripiprazole 2.5 mg QOD, Azathioprine
50', clotrimazole 10''''', Fluoxetine 60', folate', Furosemide
80', Gabapentin 200''', humalog, Lactulose 30', omeprazole 20'',
oxycodone 5''', prednisone 10', Rifaximin 550'', Spironolactone
200', Bactrim 400mg-80mg 1 tab MWF, Trazadone 150mg QHS, NPH
Insulin (patient says she rarely uses with sliding scale)
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
3. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
Two (42) units in AM Subcutaneous once a day: 8 units PM, please
follow insulin scale provided.
11. insulin lispro 100 unit/mL Solution Sig: Per Sliding Scale
Subcutaneous four times a day: Please follow sliding scale
provided.
12. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Anxiety.
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: Not to exceed 2 grams total
daily.
17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
19. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
20. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
Please follow transplant clinic taper.
21. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
ABO Incompatible Liver Transplant with Splenectomy
Autoimmune Hepatitis
Hepatopulmonary Syndrome
Diabetes Mellitus (Type II)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (pt has
desaturation upon ambulation).
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, worsening
respiratory status (patient has desaturations with
movement/ambulation), inability to tolerate food, fluids or
medications, increased abdominal pain, yellowing of skin or
eyes, increased lower extremity edema, or any other concerning
symptoms
Monitor incision for redness, drainage or bleeding
Patient may shower, pat incision dry and leave open to air,
staples will be removed in clinic
No heavy lifting
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2120-7-31**]
2:00, [**Last Name (NamePattern1) **], [**Hospital Unit Name **] [**Location (un) **], [**Location (un) 86**], MA
TRANSPLANT SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2120-7-31**]
2:40 [**Last Name (NamePattern1) **], [**Hospital Unit Name **] [**Location (un) **], [**Location (un) 86**], MA
Completed by:[**2120-7-24**]
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7964, 8036
|
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342, 547
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8204, 8204
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974
| 132,333
|
14920
|
Discharge summary
|
report
|
Admission Date: [**2200-5-5**] Discharge Date: [**2200-5-8**]
Date of Birth: [**2160-7-22**] Sex: M
Service: Medical Intensive Care Unit/[**Hospital1 139**]
CHIEF COMPLAINT: Chest pain, depression, with suicidal
ideation.
HISTORY OF PRESENT ILLNESS: This is a 39-year-old male with
a history of cocaine-induced myocardial infarction times two
(with a clean cardiac catheterization), and extensive
polysubstance abuse, and a history of depression who
presented complaining of suicidal ideation.
The patient reports having been checked out of a treatment
program at High [**Last Name (un) **] for his polysubstance abuse on the day
of admission. He was hitching a ride to [**Location (un) 86**] and found
someone with cocaine and had a cocaine binge, and he came in
complaining of suicidal ideation and depression.
While in the Emergency Department, he developed chest pain
two to four hours after his crack cocaine use.
Electrocardiogram in the Emergency Department showed ST
elevations diffusely in leads V3 to V6. He was initially
started on a ACE inhibitor and a heparin drip; both of which
were discontinued after receiving the cardiac catheterization
report from [**Hospital6 1129**] showing clean
coronary arteries. The patient was started on diltiazem and
morphine sulfate with relief of pain. Creatine kinase was
4348, but MB index and troponin levels were negative.
The patient was thought to have pericarditis and was treated
with ibuprofen, and the patient was thought to have an
elevated creatine kinase secondary to cocaine-induced
rhabdomyolysis.
He was admitted to the Coronary Care Unit for observation.
The Coronary Care Unit course was also significant for
abdominal pain which resolved. He was worked up and seen by
Surgery. An abdominal computed tomography scan was obtained
which showed no pathology. The patient remained stable
medically with decreasing creatine kinase levels and was then
transferred to the [**Hospital1 139**] Service for further observation.
On transfer to the [**Hospital1 139**] Service, the patient complained of
continued intermittent chest pain with cough, and depression.
He denied any active suicidal ideation at that time. He
denied any shortness of breath, sore throat, dysuria,
abdominal pain, nausea, vomiting, or diarrhea. He denied any
diaphoresis or palpitations.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus; diagnosed in [**2188**].
Contracted from intravenous drug abuse.
2. Hepatitis C.
3. Bilateral neuropathy (on Neurontin).
4. Cocaine-induced myocardial infarction times two with
clean coronary arteries on cardiac catheterization at
[**Hospital6 1129**] in [**2199-8-22**].
5. Antisocial personality disorder.
6. History of suicidal ideation and attempts.
7. Polysubstance abuse including alcohol, crack cocaine, and
heroin.
8. Multiple psychiatric admissions for depression and
substance abuse.
9. Recently diagnosed with bipolar disorder.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (Medications at High [**Last Name (un) **] were)
1. Dapsone 100 mg p.o. once per day.
2. Neurontin 600 mg p.o. three times per day.
3. Epivir 150 mg p.o. twice per day.
4. Zerit 40 mg p.o. twice per day.
5. Protonix 40 mg p.o. once per day.
6. Lithium 300 mg p.o. three times per day.
7. Wellbutrin 100 mg p.o. twice per day.
8. Depakote 250 mg p.o. three times per day.
9. Sustiva 600 mg p.o. q.h.s.
MEDICATIONS ON TRANSFER: (From the Coronary Care Unit)
1. Ibuprofen 400 mg p.o. q.8h.
2. Colace.
3. Ambien.
4. Tylenol.
5. Valium.
6. Zerit 40 mg p.o. twice per day.
7. Sustiva 600 mg p.o. q.h.s.
8. Epivir 150 mg p.o. twice per day.
9. Protonix 40 mg p.o. once per day.
10. Neurontin 600 mg p.o. three times per day.
11. Dapsone 100 mg p.o. once per day.
12. Aspirin 325 mg p.o. every day.
13. Subcutaneous heparin 5000 units subcutaneously twice per
day.
SOCIAL HISTORY: Multiple jail time. Crack cocaine, heroin,
and alcohol abuse. Homeless. He lives with a friend.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 98, blood pressure was 120/62, heart
rate was 72, respiratory rate was 16, oxygen saturation was
94% on room air. In general, in no acute distress. A
well-nourished young male who was eating in bed. Mucous
membranes were moist. No jugular venous distention. The
chest was clear to auscultation bilaterally. Heart
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. Positive third heart
sound. No murmurs. The abdomen was soft and nontender.
Normal active bowel sounds. Neurologically, he was alert and
oriented times three with a depressed affect.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
studies revealed white blood cell count was 4.9, hematocrit
was 36.6, and platelets were 194. INR was 1.1 and partial
thromboplastin time was 26.5. Sodium was 137, potassium was
3.9, chloride was 102, bicarbonate was 28, blood urea
nitrogen was 9, creatinine was 0.7, and blood glucose was
124. Calcium was 9, phosphate was 2.8, and magnesium was 2.
CD4 count was 521. Vitamin B12 level was 570 and folate was
16.8. Urinalysis was negative. Lipase was 29. Creatine
kinase trended down to 400 by [**5-7**]. CK/MB was negative.
Troponin I was negative. Urine culture was negative.
Thyroid-stimulating hormone was 7.5 (elevated), but T4 was
normal at 6.4. Lithium level was 0.4. Urine toxicology
screen was positive for cocaine.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen was negative.
A chest x-ray was negative.
Electrocardiogram showed diffuse ST elevations in leads V3 to
V6.
HOSPITAL COURSE: During the hospital course, the patient
remained stable. The patient was treated with ibuprofen for
his pericarditis.
He was evaluated by the Psychiatry Service who recommended
holding all of his psychiatric medications while trying to
clarify his diagnosis. The patient denied suicidal ideation
for the remainder of his hospital course. He was contracted
for safety. He was continued on his antiretroviral therapy
for his human immunodeficiency virus and Dapsone for
prophylaxis.
He was thought to have sick euthyroid syndrome with a normal
T4 and an elevated thyroid-stimulating hormone. He was
screened for a diagnosis program to treat substance abuse as
well as his depression.
CONDITION AT DISCHARGE: The patient was discharged in good
condition.
DISCHARGE DIAGNOSES:
1. Pericarditis.
2. Rhabdomyolysis (induced by cocaine).
MEDICATIONS ON DISCHARGE:
1. Dapsone 100 mg p.o. once per day.
2. Neurontin 600 mg p.o. three times per day.
3. Epivir 150 mg p.o. twice per day.
4. Zerit 40 mg p.o. twice per day.
5. Protonix 40 mg p.o. once per day.
6. Sustiva 600 mg p.o. q.h.s.
7. Ibuprofen 600 mg p.o. q.4-6h. with meals as needed (for
chest pain).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with the Psychiatry Service.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 43719**]
MEDQUIST36
D: [**2200-5-7**] 15:02
T: [**2200-5-7**] 17:31
JOB#: [**Job Number 43720**]
|
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"423.9",
"311",
"728.89",
"412",
"070.54",
"296.7",
"V08",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6503, 6563
|
6589, 6891
|
3027, 3438
|
5720, 6420
|
6926, 7238
|
6435, 6482
|
196, 245
|
274, 2358
|
3464, 3918
|
2380, 3000
|
3935, 5701
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,379
| 161,174
|
45961
|
Discharge summary
|
report
|
Admission Date: [**2104-9-20**] Discharge Date: [**2104-9-29**]
Date of Birth: [**2040-7-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
lumbar wound infection
Major Surgical or Invasive Procedure:
[**2104-9-21**] lumbar wound washout
[**2104-9-24**] PICC line placement
History of Present Illness:
History of the Present Illness: Ms. [**Known lastname **] is a 63 year old woman
who underwent an elective L3-L5 laminectomy and fusion as well
as
L5-S1 microdiscectomy on [**9-1**] with Dr. [**Last Name (STitle) 739**]. On [**9-3**] she
was evaluated and her dressing was removed from her surgical
site. The area had staples and had some mild serosanguinous
drainage and a new dressing was placed. At this time her
Hemovac
drain was also removed. On [**9-4**] she was discharged to rehab.
The patient reports that she had not been feeling well over the
past two days. Recently, she was noted to have a UTI and was
given a course of Cipro. Today, patient spiked to 103 and it was
noted that there was copious serosnginous and purulent drainage
from wound. Patient was given vancomycin and rocephin and was
transferred from [**Hospital3 417**] hospital to [**Hospital1 18**].
Past Medical History:
dyslipidemia, hypertension, bronchitis, PNA, gout, hiatal hernia
Social History:
denies tobacco, EOTh, or recreational drug use
Family History:
noncontributory
Physical Exam:
Temp: 100.4 HR: 78 BP:116/66 Resp:18 O(2)Sat: 94 RA
HEENT:
Chest: CTA b/l
Cardiovascular: Regular Rate and Rhythm
Normal first and second heart sounds
Abdominal: Soft, Nontender
Extr/Back: There is extensive serosanginous drainage from the
wound site with occasional frank purulent drainage.
NEURO:
Mental Status: Alert and fully oriented. Fluent and prosodic.
Naming and repetition intact. + 3 step commands.
Cranial nerves: PEERL, VFF. EOM full. V1-V3 intact to PP, LT and
temp. Face symmetric Tongue and palate midline. No dysarthria or
dysphonia.
Motor examination: No cogwheeling or tremor. Finger and toe
tapping symmetric. No pronator drift.
Delt Bic Tric Grasp APB Quad Ham TA Gastroc DF PF
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Coordination: FNF and HTS without dysmetria. No checking or
dysdiadokinesia.
Sensation intact in legs to LT, JPS, Vib, temp, PP. There is no
sensory level.
Reflexes: 2+ and symmetric with toes downgoing bilaterally
Gait: Deferred
Pertinent Results:
CT L-SPINE W/ CONTRAST Study Date of [**2104-9-20**] 11:45 PM
Final Report
HISTORY: Status post L3-L5 laminectomy and fusion on [**9-4**]
presenting with
fever and purulent discharge.
CT L-SPINE: Helical imaging was performed through the lumbar
spine after
uneventful administration of IV contrast. Sagittal and coronal
reformats were
prepared.
COMPARISON: L-spine radiograph [**2104-9-3**].
FINDINGS: Patient is status post laminectomy from L3 to L5 with
posterior
fusion hardware. The appearance of the posterior fusion hardware
including
morselized bone graft material appears intact. Evaluation of the
region
posterior to the laminectomy is limited by streak artifact.
Posterior to the L1-L2 spinous process is a 1.7 x 1.3 cm fluid
collection with peripheral rim enhancement. There is stable
grade 1 anterolisthesis of L4 on L5.
Limited views of the abdomen and pelvis appear grossly normal.
IMPRESSION:
1. Status post laminectomy from L3 to L5 with posterior fusion.
Hardware
appears intact.
2. Evaluation limited by streak artifact and fluid collection at
the site of laminectomy cannot be excluded. Intrathecal detail
is markedly limited.
3. Small fluid collection posterior to the spinous process of L1
and L2.
Final Attending Comment:
Also noted is an illdefined hypodensity in the right psoas
muscle which may represent a fluid collection or evolving
hematoma. Consider MRI for further evaluation.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Age over 90 97858**] F 64 [**2040-7-5**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2104-9-21**] 8:04
PM
[**2104-9-21**] 8:04 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 97859**]
Final Report
REASON FOR EXAMINATION: Re-intubation, evaluation of ET tube
placement.
Portable AP chest radiograph was compared to prior study
obtained on [**2104-7-21**].
The ET tube tip is 5.3 cm above the carina. The NG tube tip is
in the
stomach. Cardiomediastinal silhouette is stable. There is no
evidence of
interval increase in pleural effusion or pneumothorax. Bibasal
opacities are most likely consistent with areas of atelectasis.
The patient is after lumbar surgery.
CT CHEST
1. Bilateral segmental and subsegmental atelectasis
predominantly basal,
without bronchial obstruction.
2. Right upper lobe infarct or abscess. Presuming there is no
indication of active venous thrombosis or pulmonary embolus,
evaluation would be to obtain concurrent routine radiographs
including oblique views to see if a baseline can be established
for followup study in four weeks.
3. 4.5-mm right upper lobe lung nodule warrants repeat chest CT
in six months if the patient is a smoker, 12 months if there is
no particular risk of bronchogenic carcinoma.
CXR [**2104-9-29**] done / final report pending
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97860**]TTE (Complete) Done
[**2104-9-29**] at 10:06:43 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 742**]
[**Hospital1 18**]-Division of Neurosurgery
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2040-7-5**]
Age (years): 64 F Hgt (in): 62
BP (mm Hg): 124/66 Wgt (lb): 230
HR (bpm): 84 BSA (m2): 2.03 m2
Indication: Endocarditis. Staph bacteremia
ICD-9 Codes: 424.90
Test Information
Date/Time: [**2104-9-29**] at 10:06 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2010W054-0:00 Machine: Vivid [**8-7**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.37 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 8 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.1 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.73
Mitral Valve - E Wave deceleration time: 160 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: ?# aortic valve leaflets.
MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification.
TRICUSPID VALVE: Tricuspid valve not well visualized.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality as the patient was difficult to position.
Suboptimal image quality - body habitus.
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The diameters of aorta at the sinus, ascending and arch levels
are normal. The number of aortic valve leaflets cannot be
determined. The mitral valve leaflets are structurally normal.
IMPRESSION: Suboptimal image quality.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
Brief Hospital Course:
Patient presented to [**Hospital3 417**] hospital on [**9-20**] for fever
and drainage from her surgical incision and was subsequently
transferred to [**Hospital1 18**] for further treatment. She was evalauted
in the emergency room and was admitted to the neurosurgery
service. Upon exam her incision from her L3-5 laminectomy and
L5-S1 microdiscectomy had copious amounts of drainage. A CT of
the lumbar spine was obtained to evalaute for abcess as well as
the extent of the fluid collection which showed a small fluid
collection posterior to the spinous process of L1 and L2. Blood
wound and urine cultures were also obtained upon admission.
Blood and wound cultures grew coagulase positive staph aureus
and Infectious disease consult was obtained to assist in
selecting the appropriate antibiotic regimen for her bacteremia.
They recommended treating her with vancomycin and meropenem and
these recommendations were initiated and treatment begun.
On [**9-21**] she went to the operating room for washout of her lumbar
incision. A hemovac drain was placed in the operating room to
assist with drainage of the wound. She was extubated in the OR
however required reintubation in the PACU for hypoxia and
obstruction versus bronchospasm. She was transferred to the SICU
from the PACU where she remained stable overnight.
On [**9-22**] she remained intubated in the SICU with a good exam.
she was following all commands off of sedation and had good
motor strength which was limited by pain and effort. The SICU
attempted to wean her from the vent but they were unsuccessful
as she had no cuff leak. She remained stable and intubated
overnight on [**9-22**] into [**9-23**] and they again performed an SBT
which was unsuccessful. They began to sit her up while wearing
her TLSO with hopes that this would improve her respiratory
status. She was given lasix as well.
In the morning of [**9-24**] her motor exam was improved and she
continued with following commands appropriately while off
sedation. On the afternoon of [**9-24**] her hemovac drain was pulled
from her lumbar incision and she was extubated. She remained
stable in the SICU after extubation overnight on [**9-24**] into [**9-25**].
She recieved two units of packed cell for a Hct of 22.
On [**9-28**], patient's exam remains unchanged. Her incision had
minimal drainaged. She was encouraged to work with physical
therapy. An echo to r/o vegitation and a baseline cxr was
obtained for ? of abscess vs infarct / she will have a follow up
cxr in 4 weeks as well as a follow up CT of the chest in one
year.
She is tolerating po intake, voiding freeling and stooling. She
agrees with plan for d.c to rehab. She will follow up with ID
and neurosurgery in 2 weeks.
Medications on Admission:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
Disp:*20 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for Itching.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
12. Ondansetron 4 mg IV Q8H:PRN Nausea
13. Prochlorperazine 10 mg IV Q6H:PRN n/v
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
9. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Four (4) Puff Inhalation Q4H (every 4 hours).
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain
16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
17. Pantoprazole 40 mg IV Q24H
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
19. 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.
20. Vancomycin 500 mg Recon Soln Sig: 1250 MG Recon Solns
Intravenous Q 12H (Every 12 Hours): WILL NEED [**7-8**] WEEK COURSE
PER INFECTIOUS DISEASE / HOLD IF VANCO LEVEL >20.
Disp:*0 Recon Soln(s)* Refills:*0*
21. Alteplase 1mg/2mL ( Clearance ie. PICC, tunneled access line
) 1 mg IV ONCE piccline clot clearance Duration: 1 Doses
to be instilled in line for PICCLINE clot clearance- by IV RN
only per protocol-
NOT for systemic use
22. Outpatient Lab Work
Q MONDAY
CBC WITH DIFFERENTIAL / BUN / CR/ ESR /CRP /VANCO TROUGH
PLEASE FAX RESULTS TO DR [**Last Name (STitle) **] / [**Hospital **] CLINIC [**Hospital1 18**] AT [**Telephone/Fax (1) **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
Lumbar wound infection
Bronchospasm requiring intubation
MRSA in lumbar wound
Bacteremia
POST OP ANEMIA REQUIRING TRANSFUSION
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:
Lumbar (Low Back) Spine Surgery
******PLEASE CONTINUE TO WEAR TLSO BRACE WHEN OUT OF BED********
Diet:
?????? You may resume your normal diet.
?????? You can help avoid constipation by eating a balanced diet
including: fruits, vegetables, and
whole grains (like multi-grain bread, cereals, and bran
muffins).
?????? You may also take fiber supplements and over-the-counter stool
softeners or laxatives such as Colace or Dulcolax
Activity:
?????? Walk at least three times a day and gradually increase your
distance and light activities each day.
?????? Do not exercise other than walking until after your first
6-week office visit.
?????? Do not sit longer than one hour at a time for the first two
weeks ?????? get up and move around.
?????? You will be more comfortable reclining in an easy chair or on
pillows in bed than sitting upright.
?????? Avoid twisting, turning, stopping, bending or reaching over
your head for six weeks.
?????? Do not return to the gym, play golf, swim, run, mow grass
until 3 months after surgery.
?????? Avoid exercises like aerobics, heavy house cleaning and
lifting over [**6-9**] pounds (a gallon of milk weighs 8.5 pounds).
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you are
awake.
?????? Do not drive if you are taking pain medications, muscle
relaxants, or if you are in pain.
?????? You may resume sexual activity when this is comfortable for
you.
?????? You can return to work when you feel ready. However, you must
stay within the [**6-9**] pound weight lifting restriction ?????? half
days might be better at first.
Lumbar Spine patients:
?????? Do not drive 1-2 weeks after surgery.
?????? Do not ride in the car longer than one hour at a time ?????? get
out to stretch your back each
hour.
Wound Care:
?????? You may shower after [**Month/Year (2) 2729**] have been removed. Prior to that
time frame, you may take a sponge bath, or shower such that the
water does not directly run over your incision. You [**Month (only) **] NOT soak
the incision in a bathtub or pool for 4 weeks. If your wound
gets wet, gently [**Last Name (LF) **], [**First Name3 (LF) **] NOT RUB the wound dry.
?????? Your incision was closed with staples or stitches.
?????? You may remove the dressing after 2 days after surgery. If
there is still a small amount of bloody drainage, you can place
a new sterile gauze dressing, otherwise you can leave the wound
open to air
Pain:
?????? The second day after surgery will be the most painful due to
swelling and the anesthetic wearing off, and increased muscle
spasms as the lower back muscles begin to heal.
?????? You may also experience some back pain from muscle spasm as
you increase your daily activity, this is to be expected and
will improve with time.
?????? Around the fifth week after surgery, you may experience
discomfort for a few days due to scar tissue forming.
?????? You may also have some pain, numbness and tingling in the legs
and feet for the first 6-8 weeks as normal nerve function
returns.
?????? Some pain is normal as you resume your daily activities. You
may tire more easily for several months after surgery.
Medications:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and be comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
?????? Narcotic pain medication such as Dilaudid, Percocet or Vicodin
?????? Muscle relaxant such as Robaxin, Flexeril or Valium. Take
these as needed for muscle spasm. They will make you sleepy, so
do not drive while taking these medications
?????? You may be prescribed an anti-inflammatory medication such as
Indomethacin or Ibuprofen.
?????? Take these as prescribed on a regular basis to reduce
inflammation and pain
?????? An over the counter stool softener for constipation (try
Dulcolax, Milk of Magnesia or
?????? Correctal at first and Magnesium Citrate or Fleets enema if
needed).
Miscellaneous:
?????? If you have had a fusion, do not use non-steroidal
anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen,
Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months
after surgery. NSAIDs may cause bleeding and interfere with bone
healing.
?????? Do not smoke. Smoking delays healing by increasing the risk of
complications (e.g., infection) and inhibits the bones' ability
to fuse.
WHEN TO CALL THE DOCTOR
?????? Call the doctor at ([**Telephone/Fax (1) 88**] if you have:
?????? A temperature of 101??????F or above
?????? Increased redness, soreness, swelling or foul-smelling
drainage from the incision
?????? Clear drainage from the incision
?????? Inadequate pain relief
?????? Nausea or vomiting
?????? Shortness of breath
?????? Pain in your calf
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Follow-Up Appointment Instructions
Please return to the office in [**8-9**] days (from your date of
surgery) for removal of your staples/[**Date Range 2729**] and a wound check.
Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or
staples. Be sure to point out any incisions, which may be
covered by clothing
Followup Instructions:
1> PLEASE FOLLOW-UP WITH YOUR PCP REGARDING THE RESULTS OF THE
CT OF THE CHEST THAT WAS OBTAINED WHILE YOU WERE ADMITTED
******YOU WILL NEED A CT SCAN OF THE CHEST IN 12 MONTHS -
PLEASE MARK YOUR CALENDAR WHEN YOU GET HOME. YOU WILL ALSO NEED
TO FOLLOW UP WITH YOUR PRIMARY CARE REGARDING THE RESULTS OF
YOUR CHEST XRAY.
2> Please Follow-Up with Dr. [**Last Name (STitle) 739**] in 2 weeks / WITH
XRAYS.
[**Location (un) 830**] / [**Hospital Ward Name **] / [**Location (un) **]
[**Telephone/Fax (1) 3736**] Date/Time:[**2104-10-16**] to follow your xray
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2104-10-16**] 10:45 am
Your [**Month/Day/Year 2729**] will stay in until you're follow-up appointment.
3> You will need a CXR [**10-30**] / Please go to the [**Location (un) **] [**Location (un) **] RADIOLOGY AS A WALK IN. THE ADDRESS
IS '[**Hospital1 **]'. CONTACT YOUR PRIMARY CARE FOR THESE
RESULTS.
4> YOU NEED TO FOLLOW UP IN THE [**Hospital **] CLINIC IN TWO WEEKS
AN APPOINTMENT HAS BEEN SET FOR YOU ON [**2104-10-21**] AT
4:00 PM
WITH DR. [**Last Name (STitle) **] / DR. [**Last Name (STitle) **]. THE OFFICE IN ON THE GROUND FLOOR
/ BASEMENT OF THE [**Hospital Unit Name **] / [**Doctor First Name **].
[**Telephone/Fax (1) **]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2104-9-29**]
|
[
"401.9",
"041.11",
"519.11",
"790.7",
"278.00",
"998.59",
"272.4",
"V45.4",
"V12.04",
"518.81",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.59",
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15270, 15372
|
8929, 11664
|
298, 373
|
15542, 15544
|
2549, 8906
|
21687, 23108
|
1449, 1466
|
12880, 15247
|
15393, 15521
|
11690, 12857
|
15720, 17532
|
1481, 1782
|
236, 260
|
17544, 21664
|
401, 1280
|
1910, 2530
|
15559, 15696
|
1302, 1368
|
1384, 1433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,064
| 159,239
|
38376
|
Discharge summary
|
report
|
Admission Date: [**2109-11-15**] Discharge Date: [**2109-11-21**]
Date of Birth: [**2039-12-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
ICD infection
Major Surgical or Invasive Procedure:
ICD removal, ICD lead removal
History of Present Illness:
Mr. [**Known lastname 85460**] is a 69M with h/o CABG, HTN, HL, ischemic
cardiomyopathy, PAF, bioprosthetic AVR, s/p ICD in [**2105**] changed
to BiV in [**2107**] presenting with worsening ICD infection. He notes
that he has had chronic swelling/hematoma and occasional redness
over the past 4 years but does not recall being treated for any
infection in the past. Dr. [**Last Name (STitle) 1911**] evacuated the hematoma
on [**2109-10-11**]; culture of the pocket grew coag negative staph and
the patient was placed on Keflex TID x 6 wks per ID recs. Over
the past 1.5-2 wks the patient notes that the swelling over his
ICD has worsened and has become more erythematous and tender
despite taking his Keflex regularly. He denies any recorded
fevers, but notes he has been feeling 'warm' at home
occasionally over the past [**3-13**] wks. He also notes a sharp [**3-20**]
pain that radiates down from his ICD site along the left side of
his chest on occasion during the same time period. This pain is
not exertional and is not associated with SOB or diaphoresis; he
notes that it is not like the angina he has had in the past. He
was admitted from home per Dr. [**Last Name (STitle) 1911**] for IV abx
management and closer monitoring.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent documented fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: paroxysmal afib, CAD s/p NSTEMI,
infarct-related cardiomyopathy, lateral hypokinesis (LVEF 43%)
-CABG: w/bioAVR in [**2104**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: [**2105**] w/ upgrade in [**2107**] [**3-12**] lead fracture and
recurrent shocks.
3. OTHER PAST MEDICAL HISTORY:
- CVA in [**2104**] without residual deficits.
- PAD: CT angio in [**2106**] R internal iliac artery occlusion and
80% left internal iliac artery stenosis that was stented and 95%
L superficial femoral artery treated with atherecotomy.
- chronic lower back pain
- OSA
- emphysema
- Restless leg syndrome
Social History:
-Tobacco history: 60 yrs x 1ppd, quit [**7-16**] wks ago
-ETOH: social
-Illicit drugs: occ marijuana
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: Tm 99.3, Tc 97.7, HR 63 (57-69), BP 111/54 (107-124/54-71),
RR 18, SaO2 94% RA
I/O: 440/ NR (500), BM x 1
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple neck, no bruits, difficult to assess JVP 2/2 body
habitus
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS/CHEST: Prior ICD site minimally tender, serosang drainage,
penrose drain in place, incision c/d/i. Evidence of prior
sternotomy, no scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. Minimal end expiratory wheezes
bilaterally, no crackles, rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. 1+ edema on LE bilaterally.
SKIN: Hemostatic changes in LE bilaterally.
PULSES:
Right: Carotid 1+ Radial 1+ DP 1+ PT 1+
Left: Carotid 1+ Radial 1+ DP 1+ PT 1+
.
Telemetry: SB/SR 50s-60s, 1st degree AVB, BBB, rare PVCs, v
couplets, v trigeminy
Pertinent Results:
[**2109-11-21**] CXR: As compared to the previous radiograph, the left
pacemaker has been removed. The leads have also been removed.
.
Newly placed PICC line over the right upper extremity. The tip
of the line
projects over the mid SVC. There is no evidence of complication,
notably no pneumothorax. Unchanged minimal retrocardiac
atelectasis. No evidence of focal parenchymal opacity suggesting
pneumonia. Normal size of the cardiac silhouette. Moderate
tortuosity of the thoracic aorta.
Brief Hospital Course:
69M with h/o CABG, HTN, HL, ischemic cardiomyopathy, PAF,
bioprosthetic AVR, s/p ICD in [**2105**] changed to BiV in [**2107**]
presenting with worsening ICD infection s/p ICD and lead
extraction on [**11-19**].
.
# ICD infection: Longstanding ICD infection after placement in
[**2105**]; s/p hematoma evacuation 5 wks ago, pocket tissue noted to
be friable. Swelling and erythema worsened over the past 2 weeks
prior to presentation, evidence of cellulitis. s/p ICD and lead
extraction on [**2109-11-19**], pt has remained hemodynamically stable,
afebrile, no signs of systemic infection. Will treat with
vancomycin 1000mg q12H, ciprofloxacin 500mg [**Hospital1 **], Flagyl 500mg
TID for a total of 2 wks per ID (day 1 = [**2109-11-20**]. Of note,
patient developed red man syndrome after 1st dose of vancomycin;
please administer at 1/2 rate (100mg/hr) and administer
diphenhydramine and Zofran as needed. Has been tolerating vanc
at reduced rate without issues after 1st dose. No evidence of
valvular vegetations on TEE prior to surgery. Unfortunately, no
deep tissue cultures taken at time of ICD removal, will be
treating empirically for GNR found on tissue swab 5 weeks ago.
PICC line placement confirmed by CXR: RUE, tip of line over the
mid SVC. Penrose drain placed during surgery was pulled prior to
discharge; stitches will be removed in 1 wk during cardiology
follow-up.
.
# CORONARIES: Known CAD, s/p NSTEMI, CABG. Denied CP, SOB
throughout entire admission. Patient was bradycardic and
hypotensive s/p ICD removal, which was expected as the patient
was pacer dependent prior to the ICD extraction. Continue ASA
81mg daily, continue reduced doses of Toprol XL 25mg [**Hospital1 **].
.
# PUMP: LVEF of 30-35% on recent ECHO and mild aortic stenosis.
Evidence of minimal fluid overload on exam. Continue home
regimen at reduced doses as pt relatively bradycardic and
hypotensive s/p ICD and lead removal. Cont spironolactone
12.5mg, metoprolol 25mg [**Hospital1 **], lisinopril 10mg daily. Continue
home lasix 20mg [**Hospital1 **].
.
# RHYTHM: History of PAF, s/p BiV ICD placement and ICD
extraction [**3-12**] ICD pocket infection. Pt in sinus rhythm on day
of discharge, rates in 50s-60s with first degree AVB and BBB,
rare PVCs. Continue digoxin 0.125mg daily. Continue to hold
anti-coagulation as pt is not in a-fib, will re-eval for need
for anticoagulation at follow-up cards appt.
.
# HTN: BP 111/54 on AM of discharge. Cont home regimen at
reduced doses as stated above (lisinopril, spironolactone,
toprol XL).
.
# Acute renal insufficiency: Cr 1.3 on day of discharge, 1.1 on
admission. Likely [**3-12**] poor PO fluid intake, recent NPO status
for surgery; will have obtain follow-up blood work to monitor.
We encouraged increasing PO fluid intake on day of discharge.
.
#Shoulder Pain: Resolving, likely [**3-12**] vaccination given in L
deltoid; ROM has improved, minimal concern for ICD infection
spreading to joint.
.
# HL: Recent lipid panel [**2109-9-26**] - chol 165, TG 158, HDL 42, LDL
91. Continued atorvastatin.
.
# COPD: Pt notes that breathing has improved since quitting
smoking. Continued Singulair, Advair and albuterol prn.
.
# Chronic back pain: continue home regimen lexapro, gabapentin.
Meloxican held during admission.
.
# Restless leg syndrome: Continued pramipexole.
.
# OSA: Please continue patient on CPAP (home machine to be
brought to ECF, please use home setting of 25cm H2)
Medications on Admission:
Metoprolol Succ 200mg daily
Warfarin 2.5-7mg daily
Lipitor 40mg daily
Lisinopril 10mg daily
spirinolactone 12.5mg daily
Lasix 40mg [**Hospital1 **] (*not currently taking)
Meloxican 15mg daily
pramipexole 25mg daily
lexapro 20mg daily
digoxin 125mcg daily
zonasamide 100mg qhs
gabapentin 300mg qhs
singulair 10mg daily
Discharge Medications:
1. vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
twice a day for 2 weeks: Please give at 100cc/hr, administer
diphenhydramine, zofran prn.
Disp:*qs 2 wks* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Toprol XL 50 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*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. zonisamide 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
12. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
13. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
17. Antihistamine 25 mg Capsule Sig: One (1) Capsule PO twice a
day as needed for itching for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
18. Zofran 4 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for nausea for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
19. Outpatient Lab Work
Please have your chem 10 panel checked on Monday, [**11-25**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
Primary diagnosis: ICD infection
.
Secondary diagnosis: Dyslipidemia, Hypertension, paroxysmal
afib, CAD s/p NSTEMI, infarct-related cardiomyopathy, emphysema,
Restless leg syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your admission to
the cardiology service. You were found to have a worsening ICD
infection, and your ICD and leads were removed on [**2109-11-19**]
without complications.
.
Please make the following changes with your medications:
-CHANGE Metoprolol Succinate to 50mg daily
-CHANGE Lasix to 20mg twice daily
.
-START vancomycin 1g IV twice daily
-START ciprofloxacin 500mg by mouth twice daily
-START Flagyl 500mg by mouth three times daily
.
-STOP coumadin
.
Please continue all other medications as prescribed.
.
Please follow-up with Dr. [**Last Name (STitle) 1911**] within 1 week; you will
have your staples removed at that time. You will be called by
Dr.[**Name (NI) 1912**] office with an appointment time. Also, please
have your blood drawn on Monday, [**11-25**] to monitor your
electrolytes and kidney function.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**Name8 (MD) **], MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Monday, [**12-2**] at 3:15PM
**We are working on a follow up appointment with Dr.
[**Last Name (STitle) 1911**] in [**5-16**] days. You will be called at home with the
appointment. If you have not heard from the office or have
questions, please call [**Telephone/Fax (1) 62**].**
|
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10,847
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46921+58960
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Discharge summary
|
report+addendum
|
Admission Date: [**2194-8-3**] Discharge Date: [**2194-8-9**]
Date of Birth: [**2120-7-3**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
woman with coronary artery disease, inferior myocardial
infarction, status post 4-vessel coronary artery bypass graft
in [**2182**], hypercholesterolemia, non-insulin-dependent diabetes
status post appendectomy, and bleeding diverticulosis who
presented to an outside hospital with substernal chest pain.
The patient says the pressure-like chest pain began last
night with radiation to the right shoulder. She had one
episode of nausea. No shortness of breath. She did have
diaphoresis. The patient says the pain was not relieved by
it a [**6-23**] in severity. In the morning, her visiting nurse
called the Emergency Medical Service. The patient was taken
to an outside hospital.
The patient says at the outside hospital the pain went away,
but around dinner time when she began eating at around 4:30
it returned. At the outside hospital an electrocardiogram
showed T wave inversions in leads V1 through V6 and in lead
III, and Q waves in III and aVF. The patient was put on a
nitroglycerin drip and heparin. Her enzymes were significant
for equivocal possibly positive troponin I. The patient was
hypotensive and was given a bolus of fluid. She was started
on a bolus of heparin and was mistakenly given 25,000 units
initially causing her PTT to become greater than 150.
She was then sent to [**Hospital1 69**] for
transfer to the Coronary Care Unit for control of hypotension
in the setting of a myocardial infarction.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Inferior myocardial infarction.
2. Coronary artery bypass graft.
3. Diabetes mellitus.
4. Hypercholesterolemia.
5. Cellulitis.
6. Bilateral edema since she was young.
7. A ruptured appendix in [**2194-5-14**]; status post
appendectomy with drain placement.
8. Bright red blood per rectum two weeks ago.
9. Diverticulosis.
10. Hernia repair.
MEDICATIONS ON ADMISSION: Outpatient medications included
Lasix, Flagyl, glipizide, penicillin, captopril (doses
unknown).
ALLERGIES: Allergies include TYLENOL WITH CODEINE which
caused her to be very sleepy. DEMEROL and MORPHINE which
caused delirium.
SOCIAL HISTORY: She is a positive smoker. She has smoked
half a pack to one pack per day for the last 45 years. No
alcohol use. She is widowed. She lives alone. She has a
visiting nurse and home health aide. She has four children.
REVIEW OF SYSTEMS: On review of systems, the patient has
had diarrhea two weeks ago. She has had occasional
heartburn. No ulcers in the past. She does have the edema
in both legs. No orthopnea. No paroxysmal nocturnal
dyspnea. She does complain of nocturia for the past four
years (she says).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed a temperature of 98.2, blood pressure
was 110/38, pulse was 75, respiratory rate was 15, pulse
oximetry was 100% on 4 liters. She is an obese middle-aged
woman lying comfortably in bed, in no acute distress. She
had dry mucous membranes. No jugular venous distention. No
carotid bruits. Distant heart sounds. No murmurs, rubs or
gallops were appreciated. Bibasilar crackles about one-third
of the way up; left greater than right. Her abdomen was
soft, positive bowel sounds. She had two wounds on the right
upper quadrant that were draining bloody discharge. Her
extremities showed extreme lymphedema in both legs
bilaterally. On the left shin, she had healing cellulitis,
was warm and nontender. Neurologic examination was grossly
intact.
PERTINENT LABORATORY DATA ON PRESENTATION: At the outside
hospital her white blood cell count was 8.1, [**Year (4 digits) 14256**]
was 41.5, platelets were 185. On admission to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 14256**] had fallen to 37.5. Her chemistry
at [**Hospital1 **] [**First Name (Titles) 7837**] [**Last Name (Titles) **] was 145, potassium
was 4.1, chloride was 108, bicarbonate was 26, blood urea
nitrogen was 27, creatinine was 1.2, and a blood glucose
was 141. Her coagulations on admission were a PT of 18.2,
INR was 2.3, and PTT was 150. Her initial creatine
phosphokinase (the first one at the outside hospital at 7:15
p.m.) was a creatine phosphokinase of 24, troponin I of 0.91.
On admission, her second creatine phosphokinase at 10 p.m.
was a creatine phosphokinase of 26, troponin I of 2.5.
HOSPITAL COURSE: The hospital course will be described
systematically.
1. CARDIOVASCULAR: The next day the patient was taken to
the catheterization laboratory for questionable unstable
angina. Hemodynamics showed a cardiac output of 3.75, a
cardiac index of 2.03, right atrial mean pressure of 19, a
pulmonary artery pressure of 70/27 with a mean of 42, and
right ventricular pressure of 70/26. A wedge pressure was
unable to be obtained.
The findings were left main coronary artery with small
diffuse disease of 40%, left anterior descending artery with
an 80% stenosis proximal to the anastomosis but only through
a small diagonal graft. The left circumflex had a 50%
middle, right coronary artery had a total middle. The
saphenous vein graft to posterior descending artery graft was
widely patent with tapering 40% stenosis at the anastomosis,
and an 80% stenosis was present proximal to the origin of the
posterior descending artery which only compromised a right
ventricular branch. The left internal mammary artery to left
anterior descending artery was widely patent with 30%
subclavian stenosis present proximal to the internal mammary
artery takeoff. There was no gradient on pullback from the
subclavian to the central aorta.
Assessment was severe biventricular heart failure with
decreased output and severe pulmonary hypertension.
An echocardiogram done the next day showed an ejection
fraction of 60%, an E to A ratio of 0.67, a TR gradient
of 37, left atrial and right atrial dilation, and mild left
ventricular hypertrophy with normal cavity size and systolic
function. The right ventricular free wall had hypokinesis.
There was abnormal diastolic septal motion consistent with a
right ventricular volume overload. She had mild-to-moderate
aortic stenosis and mild-to-moderate pulmonary artery
hypertension.
Her findings were consistent with diastolic heart failure.
The patient was diuresed with Lasix with some improvement in
her oxygen saturation. The patient persisted to have chest
pain during the hospital course. Electrocardiograms were
performed and showed no significant changes. The pain was
not relieved with nitroglycerin; however, it was relieved
with Vicodin. It was found that the patient also had a spot
on her midsternum that, when pressed, caused severe pain. In
light of the fact that the pain was somewhat reproducible,
and she described it varying on position, it was thought that
it was more related musculoskeletal pain that a cardiac
etiology.
During the course of her admission, the patient had one
episode of a 9-beat run of nonsustained ventricular
tachycardia; however, no other ectopy was noted during her
hospital course.
The patient was at times found to be hypotensive with her
systolic blood pressure falling to the 80s. However, the
patient remained asymptomatic during these episodes with
normal mentation.
2. PULMONARY: Catheterization showed elevated pulmonary
artery pressures; a wedge pressure was unable to be done. It
was possible that the patient had some compliment of
pulmonary hypertension. At times, her pulse oximetry was
noted to fall into the 80s. The patient remained
asymptomatic during these times and did not complain of
shortness of breath. The patient may have some component of
obstructive sleep apnea, but she was also evaluated for
possible chronic thromboembolic disease.
A lower extremity Duplex was done and showed no signs of deep
venous thrombosis. CT angiogram confirmed multiple defects
consistent with chronic recurrent pulmonary emboli. She was
restarted on IV heparin with plan for long-term
anticoaqgulationi with coumadin.
3. RENAL: Throughout the hospital course, her blood urea
nitrogen and creatinine remained stable. Her electrolytes
were checked and were repleted when necessary.
4. HEMATOLOGY: The patient came in with a PTT of 150;
having received a large bolus of heparin. Given her history
of recent gastrointestinal bleeds and the fact that she had
oozing from recent drains being pulled for her appendectomy,
she was followed for possible bleeding risks. However, her
[**Last Name (Titles) 14256**] remained stable; falling from 37.5 to 35.8.
However, her [**Last Name (Titles) 14256**] remained stable within a range of 33
to 35. She showed no signs of oozing. Guaiacs of her stool
only showed trace blood. No large tarry stools were seen.
No melena was noted.
5. INFECTIOUS DISEASE: The patient came in taking a regimen
of Flagyl which she said she was supposed to take for 30 days
for an abdominal abscess. The patient was continued on her
Flagyl regimen. She also said she takes penicillin for
cellulitis, and she was also continued on that regimen.
During her hospital course, the patient had episodes of
frequent bowel movements. She was tested for possible
Clostridium difficile, but toxins were negative.
NOTE: The rest of the Discharge Summary will be completed as
an Addendum.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Name8 (MD) 43155**]
MEDQUIST36
D: [**2194-8-7**] 18:02
T: [**2194-8-7**] 18:51
JOB#: [**Job Number **]
cc:[**Numeric Identifier 99524**]
Name: [**Known lastname 15945**], [**Known firstname 15946**] Unit No: [**Numeric Identifier 15947**]
Admission Date: [**2194-8-3**] Discharge Date: [**2194-8-10**]
Date of Birth: [**2120-7-3**] Sex: F
Service: .
ADDENDUM:
PULMONARY: Due to the patient's persistent hypoxia, lower
extremity Duplexes were done which were negative for deep
vein thrombosis. She was sent for a CT angiography of her
chest, which were positive for pulmonary emboli.
The patient was started on heparin and Coumadin. For
discharge, she was switched over to Lovenox 80 mg twice a day
and continued on a daily dose of Coumadin 5 mg q. day. On
the day of discharge, her INR was still sub-therapeutic at
1.2.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will go to a rehabilitation
facility.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post catheterization
without intervention.
2. Pulmonary embolus.
3. Diabetes mellitus.
4. Diverticulosis.
5. Cellulitis.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Lasix 40 mg p.o. q. day.
3. Lopressor 50 mg p.o. twice a day.
4. Flagyl 250 mg three times a day until she has finished
the course she had been taking prior to admission.
5. Penicillin 250 mg twice a day.
6. Lovenox 80 mg twice a day.
7. Coumadin 5 mg q. h.s.
8. Insulin sliding scale.
9. Glipizide 5 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed to follow-up with her primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15948**].
2. She was to follow-up with a Cardiologist of his
reference.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1095**]
Dictated By:[**Doctor Last Name 15949**]
MEDQUIST36
D: [**2194-8-10**] 12:13
T: [**2194-8-10**] 17:47
JOB#: [**Job Number 15950**]
|
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|
10529, 10609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,727
| 154,386
|
35920
|
Discharge summary
|
report
|
Admission Date: [**2158-12-13**] Discharge Date: [**2158-12-20**]
Date of Birth: [**2098-1-13**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Percodan / Propoxyphene
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
PICC line placement [**12-14**]
History of Present Illness:
60 year old woman with immunodeficiency on IVIG, COPD,
dyslipidemia, possible history of CVA, tobacco abuse and DM2 was
found unresponsive in bed on the morning of admission. History
was obtained from medical records and from son. The pt was not
answering phonecalls from her friend and on the morning of
admission and was found to be unresponsive in her bed. The pt's
last known contact with her was the previous day but the son was
unclear about the time. The pt was found to be slightly confused
during the 5 days prior to admission according to her friend.
She was unable to write her checks and had asked for the
friend's help with writing them. No known complaints by the
patient. She had visited her doctor approximately 10 days prior
to admission after a fall and was told that she might have had a
stroke and her physician advised her to get more tests. On the
day of admission the pt was taken to [**Hospital 8641**] Hospital where her
temp was 102.1. She had a CT of the head which revealed a
possibe left frontal abscess. She was intubated for airway
proctection and a central line was placed. She was given
vancomycin 1 gram IV, zosyn 3.375 IV, flagyl 500 IV, sedated,
and given paralytics prior to intubation. She was also treated
for hyperkalemia. At [**Hospital 8641**] Hospital the pt also received 1 L of
NS. She was transfered to [**Hospital1 18**] for further workup of the
possible frontal brain abscess.
In [**Hospital1 18**] ED the pt's vitals were T 99.1 BP 115/59 HR 95 RR 27
95% intubated AC TV 500 FIO2 50% PEEP 5. Patient received 2
grams of IV ceftriaxone.
.
On arrival to MICU her vitals were T 98 HR 78 BP 118/92 RR 15
100% on AC TV 500 PEEP 5 FiO2 60%. Neurology was consulted who
felt that her CT head changes were secondary to prior surgery,
which after discussion with the pt's family turned out to be
true as the pt had had prior intracranial surgery for removal of
a granuloma related histiocytosis X.
Past Medical History:
Hystiocytosis X
Common Variable Immunodeficiency
Tobacco abuse
COPD
Hyperlipidemia
Hypothyroid
Psoriatic arthropathy
Osteoporosis
Tremor - ? early Parkinsons
Type 2 DM
Depression
Chronic Low back pain
Lung nodule
? h/o cerebral infarct
Social History:
Patient lives by herself. Independent ADL. Able to drive without
difficulty at baseline. Heavy smoker with approx 2-3pk per day
for years per son. [**Name (NI) **] known heavy ETOH use. No known street drug
use.
Family History:
Unable to obtain any significant history.
Physical Exam:
Vitals: On arrival to MICU her vitals were T 98 HR 78 BP 118/92
RR 15 100% on AC TV 500 PEEP 5 FiO2 60%
Gen: Intubated. In no apparent distress. Has some purposeful
movements. Withdraws to pain. Do not respond to verbal stimuli.
HEENT: PERRL, MMM, unable to assess JVP due to difficult neck
anatomy.
Heart: S1S2 RRR, no MRG
Lungs: CTAB in anterior lung fields
Abdomen: midline surgical scars, obese, nontender, nondistended.
No appreciable organomegaly.
Ext: WWP, no edema, DP 2+ b/l
Neuro: Limited by mental status. Normal muscle tone. Plantars
down going.
Pertinent Results:
[**2158-12-13**] 05:45PM URINE MUCOUS-MANY
[**2158-12-13**] 05:45PM URINE GRANULAR-[**3-8**]* HYALINE-[**6-13**]*
[**2158-12-13**] 05:45PM URINE RBC-[**3-8**]* WBC-[**6-13**]* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2158-12-13**] 05:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2158-12-13**] 05:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2158-12-13**] 05:45PM PT-16.3* PTT-27.2 INR(PT)-1.5*
[**2158-12-13**] 05:45PM PLT COUNT-306
[**2158-12-13**] 05:45PM NEUTS-91.1* LYMPHS-6.7* MONOS-2.0 EOS-0.1
BASOS-0.1
[**2158-12-13**] 05:45PM WBC-15.1* RBC-3.69* HGB-11.4* HCT-34.2*
MCV-93 MCH-30.9 MCHC-33.4 RDW-14.2
[**2158-12-13**] 05:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-12-13**] 05:45PM PHENYTOIN-<0.6*
[**2158-12-13**] 05:45PM ALBUMIN-3.2*
[**2158-12-13**] 05:45PM ALT(SGPT)-460* AST(SGOT)-799* LD(LDH)-1462*
CK(CPK)-[**Numeric Identifier **]* ALK PHOS-103 TOT BILI-0.3
[**2158-12-13**] 05:45PM estGFR-Using this
[**2158-12-13**] 05:45PM GLUCOSE-227* UREA N-36* CREAT-2.1* SODIUM-142
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
[**2158-12-13**] 06:08PM LACTATE-3.3*
[**2158-12-13**] 06:20PM TYPE-ART PO2-69* PCO2-41 PH-7.46* TOTAL
CO2-30 BASE XS-4 INTUBATED-INTUBATED
[**2158-12-13**] 10:15PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-460*
POLYS-22 LYMPHS-69 MONOS-0 MACROPHAG-9
[**2158-12-13**] 10:15PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-68*
POLYS-4 LYMPHS-80 MONOS-0 MACROPHAG-16
[**2158-12-13**] 10:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-31
GLUCOSE-115
.
Echo: TTE The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild symmetric LVH with normal regional and global
biventricular systolic function. No pathologic valvular
abnormality seen.
.
MRA MRI brain IMPRESSION:
1. Bilateral T2 hyperintense cerebellar lesions and
corresponding abnormal
signal intensity in the diffusion-weighted images with mild low
signal in the
ADC map. These findings likely represent subacute infarction.
The pattern
suggest embolic infarction.
2. Questionable narrowing involving both PICA's.
3. Sinus disease as described above.
.
US abd: Normal scan and Doppler examination of the hepatic and
portal veins and main
hepatic artery.
.
TEE: The left atrium is normal in size. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
Overall left ventricular systolic function and size are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are extensive complex (>4mm) atheroma in the
aortic arch and descending aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. No masses or vegetations are seen on the
aortic, pulmonary, tricuspid, or mitral valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
IMPRESSION: No intracardiac thrombus. No valvular vegetations.
Brief Hospital Course:
60 year old woman with immunodeficiency on IVIG, COPD,
dyslipidemia, tobacco abuse and diabetes who was admitted after
being found unresponsive.
.
During this admission the following issues were addressed:
.
# Altered Mental status: The pt was intubated at an outside
hospital for airway protection. Her chest xray was not
suspicous for intrapulmonary process. On the morning following
admission the pt's mental status improved and she was extubated
without diffculty. The patient was originially thought to have
bilateral cerebellar [**Doctor Last Name 6056**]. However, per the neurology
consultation service, it would be unusual to have simultaneous
bilateral cerebellar strokes causing loss of consciousness. It
is more likely that the findings seen on MR of the brain are old
cerebellar strokes. The pt was found to have a UTI on
urinanalysis and her altered mental status was presumed to be
due to delirium secondary to dehydration in the setting of
diminished oral intake and a UTI. With treatment of the pt's UTI
the pt's mental status improved to baseline. As an outpatient
the pt is also on a number of sedating medications including
several medications for her chronic low back pain, and these
medications may have also contributed to the pt's diminished
mental status on presentation. The pt also had a 7-day course of
acyclovir for potential HSV encephalitis and acyclovir was
discontinued when the pt's HSV PCR returned negative.
.
# Rhabdomyolysis: The pt's creatinine kinase elevation was
likely due to a fall, or the prolonged period that she was
unresponsive before she was found by her family members. The
pt's CK, LFT's and LDH returned to [**Location 213**] during this
hospitalization initially with intravenous hydration, and then
with regular diet.
.
# Urinary tract infection: During this admission the pt was
treated empirically with broad-spectrum antibiotics prior to
obtaining and urine culture, so the urine culture failed to grow
and organism, but urinalysis on admission did show a likely UTI.
The pt received a 7-day course of ceftriaxone for her UTI, and
did not complain of any urinary symptoms on discharge.
.
# COPD: The pt was continued on her home COPD medications
(Spiriva, Fluticasone-Salmeterol and Montelukast) during this
admission and did not report any increased difficulty with
breathing on room air following extubation.
.
# Parkinsons: The pt was continued on her home
Carbidopa-Levodopa during this admission.
.
# Hypothyroidism: The pt was continued on her home levothyroxine
during this admission.
.
# Depression: The pt was continued on her home Paroxetine,
Clonazepam and Trazodone during this admission.
.
Medications on Admission:
Sulfasalazine 500mg Q6h
Tiotropium 1 cap INH daily
Fluticasone/salmeterol 500-50 [**Hospital1 **]
Albuterol INH PRN
Trazodone 100mg QHS
Meloxicam 7.5mg ? freq
Montelukast 10mg daily
Lovsatstain 40mg daily
Lunesta 2 mg daily
Buspar 5mg [**Hospital1 **]
Levothyroxine 25mcg daily
Folate 1mg daily
reglan 10mg q6h
Klonopin 1mg [**Hospital1 **]
Paroxetine 40mg daily
Levodopa 100mg PO TID
Omegprazole 20mg daily
Phernergan 25mg Q6h PRN
Dilaudid 2mg PO @6h PRN
Flexeril 1mg PO Q8h PRN
Fentanyl Patch ? 75mcg q72h
IVIg PRN-
Sinemet 25-100mg 1 tab TID
Discharge Medications:
1. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Azulfidine 500 mg Tablet Sig: One (1) Tablet PO four times a
day.
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
6. Mobic 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Levodopa (Bulk) Powder Sig: One (1) powder Miscellaneous
once a day.
8. Mevacor 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
10. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
15. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Primary diagnosis: Rhabdomyolysis, urinary tract infection
.
Secondary diagnosis: Histiocytosis X, CVA
Discharge Condition:
Stable, able to breathe comfortably on room air, able to
ambulate with a walker.
Discharge Instructions:
You were admitted to the hospital for altered mental status. You
were found to have lab abnormalities that suggested that you had
experienced some muscle breakdown during the period that you
were unresponsive. You also had a urine analysis that showed
that you had a urinary tract infection. You were treated with
antibiotics for the urinary tract infection.
.
Your unresponsiveness on admission was also concerning given the
multiple sedating medications that you take. The following
medications have been discontinued due to their sedating
effects:
Reglan
Phernergan
Dilaudid
Flexeril
Fentanyl Patch
.
Below are your medications. Please continue to take your
medications as directed.
.
During this admission you were evaluated by the neurology
service and you had a brain MRI that showed changes in your
brain that are likely small strokes. For these findings you will
continue on aspirin and follow up with your outpatient
neurologist.
.
Below are your follow up appointments. Please make sure to
attend your follow up appointments as they are very important to
your long term care.
.
Please call your primary care doctor or go to the nearest
emergency room if you develop headaches, nausea, vomiting,
weakness or numbness, are unable to tolerate food or liquids,
fever > 100.4, chills, shortness of breath, chest pain, or any
other concerning
symptoms.
Followup Instructions:
Primary care follow up:
Your primary care doctor Dr. [**Last Name (STitle) 81603**] is out of the office on a
family emergency at this time. You will follow up with her nurse
practitioner [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4068**] on Monday, [**2158-12-25**] at 9:45am.
.
Neurology follow up:
You have an EMG scheduled for Monday, [**2158-12-25**] at 3:00pm
with Dr. [**Last Name (STitle) 66221**] at Dr.[**Name (NI) 81604**] office.
.
You also have a neurology follow up appointment with Dr. [**Last Name (STitle) **]
on Wednesday, [**2159-1-10**] at 2:30pm.
|
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icd9cm
|
[
[
[]
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,512
| 121,716
|
48644
|
Discharge summary
|
report
|
Admission Date: [**2144-1-28**] Discharge Date: [**2144-2-4**]
Date of Birth: [**2089-3-1**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Nitroglycerin / Furosemide / Heparin Agents
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
ARF
Major Surgical or Invasive Procedure:
Right femoral catheter placement
History of Present Illness:
54y/o M w/ CAD, ESRD, HCV, HTN, and spinal stenosis admitted
with renal failure for initiation of hemodialysis with line
placement. He was recently seen at the [**Hospital1 18**] liver clinic
([**2144-1-20**]) where he was starting a w/u for HCV when he was found
to be anemic to 24 and referred to NEBH for furhter evaluation.
There, he complained of recent fatigue, SOB, CP, and
palpatations. He was admitted and treated with transfusion of 3u
PRBC with appropriate Hct elevation to 31. As his EKG was at
baseline and symptoms improved with transfusion, he was d/c home
with close follow-up. During this hospitalization hemodialysis
was again broached with the patient and he agreed to return to
NEBH for catheter placement and initiation of HD.
.
On [**2144-1-27**], he presented to NEBH for catheter placement and
underwent this procedure in his R subclavian. However, on [**1-28**]
when they attempted to use the line for HD, no flow was obtained
and the line was d/c. He had significant bleeding from this site
requiring >1hr of pressure and sandbags but hemostasis was
eventually achieved. His Hct was found to be 25.4 and he was
transfused 1u PRBC w/out incident and sent to [**Hospital1 18**] for furhter
management. On transfer, his creatinine was elevated from his
baseline (~7.5->9.3) but stable since [**1-20**] (9.7).
.
Here, the patient notes continued fatigue but denied any SOB,
CP, N/V, palpatations, abdominal pain, diarrhea, weakness, or
paresthesias. He has had no problems with his medications and is
eager to start HD.
.
Past Medical History:
1. ESRD thought to be [**1-24**] chronic HTN
2. CAD s/p RCA taxus stent in [**6-26**]
3. Hepatitis C positive
4. HTN
5. RAS s/p stent [**9-21**]
6. PVD s/p aortobifemoral bypass [**2138**]
7. Osteoarthritis
8. Cervical disc disease w/ chronic LBP
9. Anemia
10. Gout
11. Hemorrhoidectomy
12. Tonsillectomy
Social History:
Lives w/ his son w/ developmental delay. Divorced. On disability
for spinal stenosis. Per patient quit tobacco several months ago
and no EtOH for >15yrs
Family History:
His family history is significant for father who died at 55 from
coronary heart disease issues.
Physical Exam:
PE: 98.0, 160/80, 82, 20, 98%RA
Gen: WNWD [**Male First Name (un) 4746**] lying in bed sleeping, arousable to voice and light
touch
HEENT: MMM, O/P clear, neck w/ pressure dressing and dried
blood, no active bleeding
CV: RRR, 2/6 SEM at the LUSB w/out radiation
Lungs: CTA bilaterally
Abd: S/NT/ND, +BS, -HSM
Ext: No C/C/E
Neuro: Answered questions appropriately, fell asleep during
interview, moving spontaneously
Skin: No obvious rashes
Pertinent Results:
Cath [**6-26**]: 1 vessel disease s/p Taxus stent to RCA
.
femoral us: IMPRESSION: No evidence of fistula or
pseudoaneurysm. 1.2 x 1.0 cm right groin hypoechogenic focus
could representing a small hematoma vs a native thrombosed
vessel.
.
MR chest: IMPRESSION:
1. Patent appearance of right subclavian and brachiocephalic
veins, as well as the superior vena cava.
2. Nonvisualization of the internal jugular veins, presumably
occluded.
3. While the left brachiocephalic vein and distal aspects of the
left subclavian and axillary veins appear patent, the proximal
aspects of the left subclavian vein is suspicious for some
degree of narrowing, although further interrogation of this
vessel could not be performed due to the patient's inability to
continue further imaging
.
[**1-29**]: IMPRESSION: Successful placement of right femoral tunneled
hemodialysis catheter with tip in the IVC/right atrial junction.
The port is ready for use.
.
venous mapping:
LEFT ARM: The cephalic vein measures 18 mm superiorly at the
level of the shoulder and 19 mm at the level of the distal
forearm. Its smallest diameter is 13 mm at the level of the
elbow.
The left basilic vein measures 33 mm at the level of the mid arm
and 10 mm at the level of the mid forearm. Its largest diameter
is 37 mm just below the left elbow.
Incidental note was made of duplicated brachial arteries
bilaterally, with monophasic brachial arterial flow bilaterally.
IMPRESSION: Patent basilic and cephalic veins as above.
Duplicated brachial arteries bilaterally with monophasic
waveforms.
Brief Hospital Course:
Brief ICU course: As above, this is a 54 yo man w/ MMP including
[**Hospital 102311**] transferred from OSH to [**Hospital1 18**] on [**2144-1-28**] for placement of
HD catheter. The IR service placed a tunneled right femoral HD
catheter, and the pt then successfully completed his first HD
session. After HD, the pt rose from bed and ambulated as he was
not aware of the contraindication for walking with the femoral
line in place. At 21:00 on [**2144-1-29**], the pt noted blood oozing
from the femoral line exit site. The oozing continued despite
holding direct pressure for more than an hour, prompting
transfer to the MICU for further treatment and monitoring of
right groin. By the time he arrived in MICU, the bleeding had
compltely resolved and he was hemodynamically stable. He denied
any chest pain, palpitations, dyspnea, dizziness,
lightheadedness, or weakness. He received upper ext U/S to
assess for possible fistula/graft sites; however, none were
acceptable. He was monitored and remained completely stable and
was subsequently called out to medical floor.
Floor course:
.
1. HD catheter placement: Once the patient was transferred to
the floor his groin bleeding was resolved and he remained
hemodynamically stable. He did not require transfusions. His
groin hematoma and hematocrit were followed and per US he did
not have a fistula or pseudoaneurysm, and his hematocrit
remained stable. The patient was then seen by transplant
surgery to prepare for placement of a subclavian tunneled
catheter. IR saw the patient as well, and felt that his right
femoral line was sufficient for dialysis and did not feel he
needed other access. While preparing the patient for outpatient
dialysis, the patient decided to leave AMA. He was warned that
he needed dialysis set up, and without proper outpatient set up
he could bleed again or die if he was not dialyzed as needed.
The patient said he fully understood these risks and said he
would follow-up with renal on his own, and despite multiple
warnings refused to stay and signed out AMA
.
2. ESRD: The patient has ESRD likely from poorly controlled HTN.
He has been symptomatic with lethargy and pruritis over the past
few months. After access was obtained in the hospital, dialysis
was performed on the patient. Renal followed the patient
closely and made adjustments to his regimen including the
addition of sevelmer and epogen at dialysis. With nephrocaps,
sevelmer, renal diet, hemodialysis and renal following him, the
patient did well, and while setting up outpatient care for his
renal needs, as above the patient refused to stay and signed out
AMA. The patient was admitted with a creatinine of 9.4, and at
discharge after dialysis was improved to 5.9. The patient was
feeling well and lacked any signs of uremia when he left.
.
3. Thrombocytopenia: The patient was admitted with platelets of
91, and per records his platelets have declined over past few
weeks, with unclear time course. There may be some contribution
form platelet consumption in large right shoulder ecchymosis
(from the line placed at NEBH) and subsequent PRBC transfusions
received at the outside hospital. During his course his work-up
included a HIT antibody which was negative and he had no
evidence of consumptive coagulopathy at present. His platelets
were followed closely and improved slowly over his course. This
should continue to be followed as an outpatient.
.
4. HCV: The patient has a history of hepatitis C genotype 2,
viral load from [**2143-6-22**] was 472,000 copies per mL. A repeat
HCV VIRAL LOAD on [**2144-2-4**] was 3,300,000 IU/mL. He had no signs
of decompensated liver disease during his course and his LFT's
were stable. His hepatitis core antibody in [**Month (only) **] was positive
and on follow-up here, his HBsAg, HBsAb and IgM HBc were
negative while his HBcAb remained positive. Based on these
results hepatology was consulted, but the patient left AMA
before they saw the patient. The patient should have his
hepatitis followed closely as an outpatient.
.
5. CAD: The patient has a history of CAD and had stent placement
to RCA with subsequent in-stent restenosis 6 months ago. He
remained chest pain free during his course with no signs of
active ischemia. He was continued on all appropriate
medications including ASA, plavix, BB, nitrate and a low dose
statin (given his hepatitis). His LFT's should closely be
followed given his need for a statin and hepatitis status.
.
6. HTN: The patient's hypertension was well controlled with
hydralazine, metoprolol, and isosorbide. He should continue all
these medications as an outpatient.
.
7. Anemia of ESRD: The patient has a baseline HCT of 24-28, and
this remained stable during his course and was treated with
epogen at dialysis.
.
8. Disposition: As above the patient left against medical
advise. He was warned repeatedly of the dangers of leaving
before his dialysis was set up, including infection, bleeding,
death, and organ failure. He fully understood and said he would
follow-up as needed on his own, but was not willing to wait in
the hospital for us to set it up for him. He needs dialysis as
an outpatient, and close follow-up with nephrology, hepatology
and his primary care doctor. The patient was aware of all of
this when he left.
Medications on Admission:
Meds:
Isordil 30mg [**Hospital1 **]
Bumex 2mg [**Hospital1 **]
Metoprolol 50mg [**Hospital1 **]
Plavix 75mg
ASA 325mg
Hydralazine 25mg qid
PhosLo 666mg tid
Niacin 500mg
Procrit 6000u tiw
Nephrocaps 1 tab
Discharge Medications:
1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
2. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
End stage renal disease
Access for dialysis
Reinitiation of dialysis
Secondary diagnosis:
HTN
thrombocytopenia
Hepatitis C
Discharge Condition:
LEAVING AGAINST MEDICAL ADVICE. No dialysis spot or permanent
access set up.
Discharge Instructions:
You signed out against medical advice. You do not have a
dialysis spot set up yet.
We have made some medication changes (these assume you will
continue to get dialysis). You are no longer taking bumex. Your
metoprolol was increased to 100 mg tiwce a day (from 50 mg twice
a day). You will take sevelamer instead of phoslo. You should
get epogen at dialysis.
We have given you a months worth of prescriptions.
You need to follow up with your PCP and cardiologist this week.
You also must follow up with your nephrologist.
You have a femoral catheter in place. it is imperative that you
have it looked at this week. If you have any bleeding, chest
pain, pain in the groin, problems ambulating, tingling/numbness
in leg, or any other health concern go to ED
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2144-4-15**] 1:00
You are leaving against medical advice. You must follow up with
your nephrologist, cardiologist, and PCP.
|
[
"070.54",
"724.02",
"274.9",
"585.6",
"414.01",
"998.11",
"E879.1",
"403.91",
"285.21",
"287.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11029, 11035
|
4592, 9890
|
316, 352
|
11222, 11301
|
3014, 4569
|
12107, 12337
|
2441, 2539
|
10145, 11006
|
11056, 11056
|
9916, 10122
|
11325, 12084
|
2554, 2995
|
273, 278
|
380, 1926
|
11166, 11201
|
11075, 11145
|
1948, 2255
|
2271, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,600
| 112,314
|
5595
|
Discharge summary
|
report
|
Admission Date: [**2111-8-25**] Discharge Date: [**2111-8-31**]
Service: MEDICINE
Allergies:
Epinephrine / Adhesive Tape
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
hypotension and retroperitoneal bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an 84 y.o male with h.o HTN, s/p CABG, PM/ICD, CMP with EF
35%, PAF, MDS/anemia, hypothyroidism, h.o prostate ca, DVT, with
recently diagnosed metastatic adenoca with unknown primary who
presented to the ED with symptoms suggestive of presyncope.
.
Pt had been seen by rad onc for ciber knife eval. Had large dye
load for CT scan (then diuresed ~1500cc) and likely became
orthostatic. Pt then fell at NH, hit his back, and presented to
the ED hypotensive. Pt underwent a FAST exam that looked
"positive", underwent CT torso showing large RP bleed. Pt given
blood and fluid with good effect. SBP now 120's. U.O good
50-100cc/hr. Pt mentating.
.
Upon conversation with pt's son with Dr. [**Name (NI) 496**], pt is
DNR/DNI and does not want CVL.
.
Past Medical History:
1. Dyslipidemia.
2. Hypertension.
3. CABG in [**2103**]
4. Pacemaker/ICD due to AV block and tachybrady syndrome
5. Cardiomyopathy with LVEF = 35% in [**10-6**].
6. PAF
7. TIA in [**2103**].
8. Macrocytic anemia, attributed to MDS with bone marrow biopsy
in [**State 531**].
9. Spinal stenosis.
10. Hypothyroidism.
11. H/o gastric ulcer; GERD.
12. OSA on nocturnal CPAP.
13. Prostate cancer s/p XRT.
14. Adenocarcinoma of unknown primary metastatic to the left
occipitoparietal region s/p resection in [**7-7**]
15. DVT/PE s/p IVC filter on Lovenox [**Hospital1 **]
Social History:
He lives with his wife in a senior center and is independent in
his ADLs. He quit smoking in [**2060**] after 3 ppd for many years. He
does not drink EtoOH.
Family History:
Father died of lung cancer at age 50. Mother had an MI and died
at age 86. A brother also had lung cancer. He has two children
that are healthy.
Physical Exam:
Vitals: T 95.4, BP 102/52, HR 73, RR 23, sat 100% on RA
General: Alert, oriented, no acute distress, pale.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
chest: [**Doctor Last Name **] chest with pacer/no erythema.
Abdomen: soft, TTP R.periumbilical/R.flank. +bs, no guarding/no
rebound.
Ext: warm, 2+pulses, 1+ pitting edema, +multiple areas of
ecchymoses.
Pertinent Results:
LABS ON ADMISSION:
HCT 19
lactate 3.4,
WBC 16.1
LABS ON TRANSFER FROM ICU:
135 / 101 / 36
===============< 134
4.0 / 25 / 0.9
CBC 18.9 > 11.0 / 31.3 < 94
Ca: 7.2 Mg: 2.3 P: 2.7
LABS ON DISCHARGE:
EKG: Vpaced @70, STD I, AVF, unchanged from prior on [**2111-8-7**]
CXR [**8-26**]: The pacemaker leads terminate in right atrium and
right ventricle, unchanged. There is interval decrease in the
left pleural effusion with still present area of left basal
atelectasis. The left upper lung and the right lung are
unremarkable. Cardiomediastinal silhouette is stable. Overall,
the lung volumes are lower than on the prior radiograph that
might be explained by suboptimal inspiratory effort.
CT Torso [**8-25**]: Large right-sided retroperitoneal hematoma,
stable bilateral pleural effusions, left greater than right,
patient appears anemic and may be hypovolemic as indicated by a
spleen, which is smaller than on prior study, and a narrowed
IVC. IVC filter in unusual position with the distal aspect at
the level of the iliac vein bifurcation. Extensive stool within
the colon and fluid within the stomach, but no evidence for
bowel obstruction. Stable pulmonary nodule. Stable spine
degenerative changes and compression fractures and chronic right
posterior rib fracture.
CT Head. [**2111-8-25**]. IMPRESSION: Status post left parietooccipital
craniotomy with small hyperdense focus at the margin of the
resection bed, corresponding to the enhancing focus on the most
recent study, which may represent residual tumor, as suggested
previously. Otherwise, there is no hemorrhage or other acute
process.
Brief Hospital Course:
1. Retroperitoneal bleed: Patient was initially hypotensive upon
arrival to the hospital shortly after falling at his nursing
home and was found on CT to have a large retroperitoneal bleed.
Hematocrit on admission was 19.3 and hit a nadir of 18.6 shortly
after admission. Patient has MDS with baseline HCT of 30. He was
trasnfused a total of 9 units PRBCs in the MICU. He did not
require a procedure to stop the bleed. His lovenox and
antihypertensives were held.
2. Leukocytosis: He had an elevated WBC reaching 23.0 on the day
of admission, likely related to a stress response and ?UTI in
the setting of chronic steroid use and malignancy. Initial UA
showed > 50 WBCs and positive leukocytes and nitrites. Notably,
the patient had been on a suppressive macrodantin which had been
stopped a few weeks prior to admission. He had no other clear
source of infection. Blood cultures were negative. He was
treated with 2 days of Levaquin which was stopped when his urine
culture grew out yeast.
3. Acute Renal Failure: Patient was in acute renal failure when
admitted with a creatinine at 1.7 from baseline of 1.0. This was
most likely due to his pre-renal etiology in the setting of an
acute bleed. His creatinine resolved with resolution of his
bleed and correction of his volume status. His creatinine on
discharge was 0.9.
4. Recent History of DVT: The patient was recently admitted for
a DVT and has had an IVC filter placed. In addition he was on
Lovenox, which was held on the current admissions. Given his
severe risk of internal bleeding, it was decided to permanently
discontinue his Lovenox on discharge.
5. Positive U/A: On admission patient was found to have a
positive UA showed > 50 WBCs and positive leukocytes and
nitrites. Patient was asymptomatic and notably has lived with an
indwelling catheter for several months. He was treated with 2
days of Levaquin which was stopped when his urine culture grew
out yeast.
5. PICC Line: A PICC line was placed for access and proper
placement was confirmed on CXR.
6. Brain Metastesis: Patient known to have a brain metastesis of
adenocarcinoma of unknown origin. Patient was undergoing
cyberknife evaluation the day he was admitted. During his
admission he was continued on dexamethasone and gabapentin
7. CHF and AF: Patient has a history of CHF with EF of 40-45% in
[**2108**] and PAF. Patient is s/p AICD. During this admission this
patient was monitored for arrythmias, and transufused blood to
maintain a goal hematocrit above 30. Patient remained in NSR
across his admission. He is currently controlled on amiodarone.
8. HTN: Patient was admitted on daily doses of Carvedilol and
Lasix, both of which were initially held in the setting of acute
bleed. The carvedilol was initially restarted at half his home
dose, with good effect, and then resumed to his normal dose.
Lasix was restarted. The patient was discharged on all of his
home cardiac medications.
9. Code Status: Per discussions with patient's family, this
patient was considered DNR but not DNI. His wishes are only to
be intubated only if it is considered likely that his would make
a relatively rapid recovery.
10. MRSA Status: MRSA screen on admission was positive. Patient
was placed on contact precautions. Specific MRSA treatment was
not initiated at this time.
11. Wound Care: Wound care recommendations from this patient's
previous admission were followed. No new complications
developed.
Medications on Admission:
1. IV access: PICC, heparin dependent Location: Right, Date
inserted: [**2111-8-27**] Order date: [**8-28**] @ 1300 11. Levothyroxine
Sodium 75 mcg PO DAILY Order date: [**8-28**] @ 1300
2. IV access: Peripheral line Order date: [**8-28**] @ 1300 12.
Lidocaine 5% Patch 1 PTCH TD DAILY Order date: [**8-28**] @ 1300
3. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever Order date:
[**8-28**] @ 1300 13. Omeprazole 40 mg PO DAILY Order date: [**8-28**] @
1300
4. Amiodarone 200 mg PO DAILY Order date: [**8-28**] @ 1300 14.
Ondansetron 4 mg IV Q8H:PRN nausea Order date: [**8-28**] @ 1300
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date:
[**8-28**] @ 1300 15. Oxycodone-Acetaminophen 1 TAB PO Q6H severe
pain
pls hold for SBP <100, sedation Order date: [**8-28**] @ 1300
6. Carvedilol 12.5 mg PO BID
Hold for HR less than 60 or SBP less than 100mmHg Order date:
[**8-28**] @ 1703 16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN
pain
hold for sedation, RR <10 Order date: [**8-28**] @ 1300
7. Dexamethasone 4 mg PO Q12H Order date: [**8-28**] @ 1300 17.
Polyethylene Glycol 17 g PO DAILY:PRN constip Order date: [**8-28**]
@ 1300
8. Docusate Sodium 100 mg PO BID Order date: [**8-28**] @ 1300 18.
Senna 1 TAB PO BID:PRN Constipation Order date: [**8-28**] @ 1300
9. Gabapentin 400 mg PO HS Order date: [**8-28**] @ 1300 19.
Simvastatin 10 mg PO DAILY Order date: [**8-28**] @ 1300
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. Order date: [**8-28**] @
1300 20. 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.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for severe pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constip.
16. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
PRIMARY:
1. Retroperitoneal hemorrhage
2. Brain metasteses of unknown primary adenocarcinoma
3. Recent history of DVT
SECONDARY:
1. Hypertension
Discharge Condition:
stable, afebrile
Discharge Instructions:
It was a pleasure to help care for you during your stay at [**Hospital1 1535**].
You were admitted to the hospital with low blood pressure. In
our emergency department you were found to have an internal
bleed.
While you were here you were treated with intravenous fluids and
given 9 units of blood. We also continued most of your home
medications.
You should continue to refraine from taking your Lovenox when
you leave the hospital. We have decided to stop this medication.
We did not stop any of your other medications while you were
here. Please take all of your other medications exactly as
prescribed.
Please call your physician or return to the emergency department
if you experience any of the following: worsening shortness of
breath, chest pain, nausea or vomiting, any fevers above 100.4,
dizziness or light-headedness, headache, worsening pain, loss of
consciousness, or any other concerning signs or symtoms.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2111-9-10**]
10:20
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-9-28**]
1:55
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2111-9-28**]
4:00
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"428.0",
"E888.9",
"V45.02",
"425.4",
"238.75",
"276.2",
"244.9",
"199.1",
"428.22",
"V45.81",
"584.9",
"285.1",
"276.52",
"868.04",
"112.2",
"276.7",
"427.31",
"V10.46",
"401.9",
"198.3",
"V12.51",
"041.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10845, 10961
|
4204, 7509
|
273, 279
|
11151, 11170
|
2572, 2577
|
12144, 12662
|
1841, 1987
|
9396, 10822
|
10982, 11130
|
7661, 9373
|
11194, 12121
|
2002, 2553
|
196, 235
|
2775, 4181
|
7521, 7635
|
307, 1059
|
2592, 2755
|
1081, 1650
|
1666, 1825
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,685
| 134,313
|
35253
|
Discharge summary
|
report
|
Admission Date: [**2179-8-11**] Discharge Date: [**2179-8-17**]
Date of Birth: [**2096-5-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
obstructing colon mass
Major Surgical or Invasive Procedure:
Exploratory laparotomy; high volume ascites removal of 10 L;
partial omentectomy; Tru-Cut liver biopsy.
History of Present Illness:
83F with obstructing R colonic mass 6.5 x 5 x 5 cm on CT and
diffuse ascites (CT also showed atrophic R kidney, small R
adrenal mass (incidental), R pleural effusion. Had been scanned
for increasing abdominal girth, + for adenoCa for c-scope bx.
Past Medical History:
Afib (rate controlled), CRI ([**Name8 (MD) 4222**] Crt 1.4), HTN, DM II
PSgH: B/L TKR's, appy (dates unknown)
Social History:
Russaian speaking. Daughter, [**Name (NI) **] involved with care.
she was a dentist in [**Country 532**] & has lived here about 6 years. She
was accepted as a US Citizen & is scheduled to be sworn in on
[**9-2**]. Pt
describes the strong support from her family. She indicates she
was living alone & was healthy until recently.
Physical Exam:
98.2 83 110/70 16 98%RA
NAD alert (russian speaking)
CTAB
[**Last Name (un) 3526**] [**Last Name (un) 3526**]
protuberant, istended, tympanitic, soft, drainage from
paracentesis wound
no c/c/e
Pertinent Results:
[**2179-8-11**] 08:27PM BLOOD WBC-9.9 RBC-3.84* Hgb-11.0* Hct-32.4*
MCV-84 MCH-28.6 MCHC-33.9 RDW-15.6* Plt Ct-244
[**2179-8-15**] 05:10AM BLOOD WBC-10.4 RBC-3.57* Hgb-10.1* Hct-31.4*
MCV-88 MCH-28.4 MCHC-32.3 RDW-15.1 Plt Ct-243
[**2179-8-15**] 05:10AM BLOOD Glucose-132* UreaN-16 Creat-1.1 Na-135
K-4.6 Cl-108 HCO3-20* AnGap-12
[**2179-8-11**] 08:27PM BLOOD ALT-11 AST-25 LD(LDH)-256* AlkPhos-56
Amylase-182* TotBili-0.5
[**2179-8-11**] 08:27PM BLOOD Lipase-181*
[**2179-8-12**] 05:01PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2179-8-15**] 05:10AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.8
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. 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. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal global biventricular systolic function. Mild
pulmonary hypertension.
.
Radiology Report RENAL U.S. Study Date of [**2179-8-12**] 1:07 PM
IMPRESSION: No evidence of hydronephrosis. Difficult study,
limiting
evaluation, however, right kidney appears possibly small, with
likely
cyst at lower pole.
.
Brief Hospital Course:
This is a 83 year old female with an obstructing R colonic
mass, ascites, rapid afib/rvr. She went to the OR on [**2179-8-12**] and
found carcinomatosis, removal of ascites, partial omentectomy,
liver bx ([**8-12**]).
He was brought back to SICU, extubated. She had decreased urine
output/BP and received 500c bolus NS for post-op hypovolemia.
Her BP improved, urine output remained marginal.
CV: She was weaned off dilt gtt, started on PO dilt. Currently
alternating between afib and aflutter. Remains well rate
controlled, HD stable on dilt PO and metoprolol.
EP/Cards: No indication for cardioversion; rate control and not
a candidate for anticoagulation.
Carcinomatosis: She was seen by Palliative care re: her new
diagnosis. The patient and family agreed to Hospice care.
Abd: Her abdomen was distended with ascites. She denies pain at
this time.
FEN: She was tolerating a full liquid diet at time of discharge.
Medications on Admission:
simvastatin 20', citalopram 40', lisinopril 10', ambien,
omeprazole 20', lopressor 50", glyburide 2.5", lovenox 40 [**Hospital1 **],
asa 81', clonazepam 0.5'
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
6. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous ASDIR (AS DIRECTED).
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia (home med).
8. Haloperidol Lactate 5 mg/mL Solution Sig: 0.5 mg Injection HS
(at bedtime) as needed for confusion/agitation.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
12. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO
Q3-4 HRS PRN () as needed for palliative care.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Right colon mass; carcinomatosis with significant ascites.
Discharge Condition:
Fair
Discharge Instructions:
You were found to have a Right colon mass, and carcinomatosis
with significant ascites.
You are being discharged with Hospice.
Followup Instructions:
Hospice care
Completed by:[**2179-8-17**]
|
[
"427.31",
"427.32",
"560.9",
"153.6",
"789.51",
"511.9",
"V43.65",
"585.9",
"197.6",
"403.90",
"250.00",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"54.4"
] |
icd9pcs
|
[
[
[]
]
] |
5327, 5391
|
3034, 3958
|
338, 444
|
5494, 5501
|
1430, 3011
|
5677, 5721
|
4166, 5304
|
5412, 5473
|
3984, 4143
|
5525, 5654
|
1215, 1411
|
275, 300
|
472, 720
|
742, 854
|
870, 1200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,726
| 183,578
|
27471
|
Discharge summary
|
report
|
Admission Date: [**2187-12-17**] Discharge Date: [**2187-12-19**]
Date of Birth: [**2116-10-30**] Sex: F
Service: MEDICINE
Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Transfer [**Hospital1 100**] MACU for hemodialysis line replacement for
poorly functioning catheter
Major Surgical or Invasive Procedure:
s/p R subclavian tunnelled line removal
s/p a new tunnelled hemodialysis line placement
History of Present Illness:
71yo F with ESRD on HD, respiratory failure s/p trach on vent,
s/p PEG, COPD, recurrent aspiration PNA, and C.diff colitis is
transferred from [**Hospital 100**] Rehab MACU for poorly functioning HD
catheter and thus HD catheter change. She tolerated HD today
well at [**Hospital 100**] rehab and removed 1.7kg. She has multiple medical
problems as above, but all has been stable.
.
For respiratory failure, she is on pressure support and has had
30 minutes trial of trach mask this past weekend which was
stopped due to hypoxia. Rehab has been slowing weaning her from
the vent. Pt is on PS 4/5/50%.
.
For PVD, pt has necrotic, dry gangrene that is auto-amputating.
Getting pain meds/prn and lidoderm patch.
.
For AF, pt is on digoxin. Last level checked on [**12-12**] was 0.8. Pt
is not anticoagulated.
Past Medical History:
#. ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN. Outpatient nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
#. Respiratory failure s/p trach in [**2-11**], on vent dependent
chronically on PS at rehab with currently underogoing trach
collar trials.
#. COPD
#. Recurrent aspiration PNA
#. PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toew bilaterally and autoamputating
#. HTN
#. Hypothyroidism
#. h/o GI bleeding
#. CHF no previous echo here, so unclear [**Name2 (NI) **]
#. h/o Cholesterol emboli syndrome
#. Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# Dementia
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
# h/o MRSA colonization
# h/o VRE infection
# C.diff colitis
Social History:
Per rehab d/c summary, she has been bouncing around various long
term care facilities since her tracheostomy and vent dependency.
She is divorced. She is a former smoker 3 packs per day x 13
years. Occasionally used alcohol. Has 3 adult children. Her son
[**Name (NI) **] is her health care proxy and is very involved in her
care.
Family History:
Per rehab d/c summary, her parents lived until old age. One
brother died of an MI in his 60s. Another brother with
schizophrenia. Son with hypothyroidism
Physical Exam:
VS: 98.7, 84, 110/50, 28, 95% on PS 5/5, 50%, Tv 525
GEN: Awake, opens eyes spontaneously. Does not follow commands.
HEENT: PERRL, cloudy cornea, Mouth open with dry tongue. no
obvious OP lesions
NECK: trached with collar
CV: RRR, nl S1 and S2, no m/r/g
PULM: CTA bilaterally, no wheezes/rhonchi/crackles.
ABD: Soft, grimaces on palpation, mildly distended, active bowel
sounds. No hepatosplenomegaly
EXT: warm, no edema of LEs, no rashes, lidoderm patch on feet
bilaterally, dry gangrenous toes bilaterally and auto-amputated
toes on L. R great toe looks dry and auto-amputating. No signs
of infection in any toes, however.
NEURO: awake, alert and opens eyes spontaneously, but does not
follow any commands.
Pertinent Results:
Admission labs:
PT: 13.3 PTT: 35.7 INR: 1.2
140 100 29
---------------< 90
3.8 28 2.5
Ca: 9.2 Mg: 2.4 P: 3.4 D
WBC: 7.3
Hct 33.6
Plt 284
.
PT: 13.7 PTT: 137.3 INR: 1.2
.
Hct: 33 - 34 - 31 - 32 - 31
.
IR REPORT:
RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 9441**] and
[**Name5 (PTitle) 2492**], the attending radiologist who was present and
supervising throughout.
PROCEDURE AND FINDINGS: After informed consent was obtained, the
patient was placed supine on the angiography table and the right
neck and chest were prepped and draped in the standard sterile
fashion. After using approximately 10 cc of 1% lidocaine along
the subcutaneous tract of the previously placed hemodialysis
catheter, blunt dissection was performed until the cuff of the
catheter was completely exposed. Then two super stiff glide
wires were advanced through each one of the two lumens of the
previously placed catheter into the inferior vena cava and right
atrium under fluoroscopic guidance. The previously placed
catheter was then removed and a new double-lumen hemodialysis
catheter was advanced over both wires and the tip was positioned
into the right atrium under fluoroscopic guidance. The wires
were removed, the entry site on the skin was sutured with Vicryl
suture, and the catheter was secured to the skin with 2-0 silk
sutures. Catheter was then flushed, hep locked and a sterile
dressing was applied. The patient tolerated the procedure well
without immediate complications.
Moderate sedation was provided by administering divided doses of
75 mcg of fentanyl and 1 mg of versed throughout the total intra
service time of 55 minutes during which the patient's
hemodynamic parameters were continuously monitored.
IMPRESSION: Successful replacement of a double-lumen
hemodialysis catheter. Final fluoroscopic image of the chest
demonstrates the tip of the catheter to be located in the right
atrium approximately 2.0 cm below the tip of the previously
placed catheter. The line is ready for use.
Brief Hospital Course:
71yo F with multiple chronic medical problems but stable
admitted for a new HD catheter placement. Brief hospital
course:
.
# ESRD: Pt was admitted in a very stable condition. She
underwent HD with 1.7kg fluid removal at rehab prior to arrival
to MICU. Her 'lytes were all wnl. She was continued on her
tums. She was also given mucomyst per son's (HCP) request to
preserve any remaining renal function she has. She was also
written for prn dilaudid for feet pain she has during HD after
fluid/electrolytes shift. The malfuncting RSC tunnelled line
was removed and a new tunnelled line was placed by IR on
[**2187-12-18**]. She received 1h HD on [**12-18**] to confirm that it is
functioning. She then received a more complete round of HD on
[**12-19**] prior to transfer back to MACU.
.
# Anemia: hct was 33.3 at admission which is stable. Epogen can
be continued during HD. She had hematoma and bleeding at site
of HD line after the procedure. Pressure was applied and it
stabilized. Her HCT was followed serially and remained stable.
She was hemodynamically stable.
.
# Respiratory failure s/p trach: Pt is being followed closely by
Dr. [**Last Name (STitle) **]. Vent satting at [**Hospital **] rehab is PS 4/5/50%, rr25-30,
Vt350-402 satting 93-95%. Pt was placed on PS 5/5/50% and O2 sat
was in 93-95%. Trach collar trial can be restarted at the
rehab. Her COPD inhalers were continued.
- Continue pressure support
- trach collar trial as tolerated
- continue nebs for COPD
.
# C.diff colitis: continued PO vanc but [**Hospital1 18**] does not have
lactobacillus, so it was not given. Lactobacillus can be
continued at rehab.
.
# Hypothyroidism: Continued synthroid
.
# Atrial Fibrillation: Pt was in sinus rhythm. We continued
digoxin every other day, recent digoxin level was 0.8 at the
rehab. Pt was not started on anticoagulation as she was not on
it as outpatient.
.
# PVD: Followed by vascular surgery at rehab. dry gangrene of
toes and auto-amputating. Continued wound care with betadine
and dry dressing and lidoderm patch on the feet and
oxycodone/prn for pain control.
.
# Decub ulcer: Followed by wound care team at rehab. Frequent
turns and [**Doctor First Name **] air bed.
.
# Pruritis: [**3-9**] previous fentanyl. Continued benadryl/prn
.
# FEN: Continued g-tube feeding with Nepro at 35cc/hr with [**Hospital1 **]
Prostat.
.
# PPX: Pt did receive a flu vaccine at rehab. PPI. No bowel
regimen given c.diff diarrhea.
.
# DNR per rehab d/c summary, confirmed with Dr. [**Last Name (STitle) 67217**]/HCP at
rehab
.
# Dispo: back to MACU
Medications on Admission:
1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today
([**2187-12-17**]) at the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
2. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q6H (every 6
hours) as needed for pain.
3. Digoxin 50 mcg/mL Solution Sig: 0.125 mcg PO EVERY OTHER DAY
(Every Other Day): last dose given on [**2187-12-17**].
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Six Hundred
Fifty (650) mg PO QID (4 times a day).
5. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: Two (2) PO
BID/PRN () as needed for pruritis.
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H
(every 6 hours) as needed.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Six (6) puffs
Inhalation four times a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed.
12. Hydromorphone 1 mg/mL Liquid Sig: 0.75 PO Q2H as needed for
pain: only during hemodialysis.
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY (): to feet
bilaterally .
14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1)
Miscellaneous TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary diagnosis:
-End-stage renal disease
-Malfunctioning hemodialysis line s/p removal and a new
tunnelled hemodialysis placement
-Hematoma: HCT stable, hematoma resolved
Secondary diagnoses:
Respiratory failure s/p tracheotomy on ventilation
C. difficile colitis
Chronic obstructive pulmonary disease
Hypothyroidism
Paroxysmal atrial fibrillation
Peripheral vascular disease
Discharge Condition:
stable on ventilator
Discharge Instructions:
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] if you develop
bleeding or redness around hemodialysis catheter, fever, chills,
nausea, vomiting, or any other concerning symptoms.
.
Take your medications as prescribed. We did not make any
changes in your medications. You may continue all your
medications you were taking at the [**Last Name (Titles) **].
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1366**] if needed.
|
[
"996.1",
"403.91",
"998.12",
"008.45",
"427.31",
"V44.1",
"V44.0",
"707.03",
"244.9",
"496",
"285.21",
"V10.05",
"585.6",
"440.24",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
"38.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10175, 10260
|
5479, 8053
|
440, 530
|
10684, 10707
|
3438, 3438
|
11142, 11212
|
2537, 2692
|
8773, 10152
|
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|
8079, 8750
|
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|
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|
10477, 10663
|
301, 402
|
558, 1366
|
3454, 5456
|
10300, 10456
|
1388, 2173
|
2189, 2521
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,097
| 174,801
|
30473
|
Discharge summary
|
report
|
Admission Date: [**2191-3-5**] Discharge Date: [**2191-3-24**]
Date of Birth: [**2111-9-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
SOB, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 72408**] is a 79 yo female with COPD,CHF, dementia who was
transferred from [**Hospital 100**] Rehab due to increasing SOB and
abdominal pain. Per PCP note, pt has had increasing "moans",
SOB, and abd pain/distension over past week, which is a change
from baseline. She was seen by psychiatry at NH, who questioned
psychotic depression and started Seroquel and Paxil. Pt also had
non-contrast Abd CT at [**Hospital1 882**] on [**3-1**], which reportedly showed
"no acute process." She had CXR on [**3-1**] which showed "interval
improvement" of bilateral opacities. Per the pt's daughter, pt
had pneumonia in [**1-9**] and has had gradually decreasing function
since then. The daughter also reports pt's mental status has
decreased significantly over the past week. She has had frequent
"panic attacks." R arm contracture has also occurred over the
past several weeks, however the daughter is unsure of the cause.
In the [**Name (NI) **], pt was found to have a PNA on CXR and was started on
BiPAP for hypercarbic resp failure. Her BP initially was up to
206/88, but this decreased without antihypertensive therapy.
Temp was up to 100.6, with O2 sat 92% on 4L NC (increased to
100% on BiPAP). Her code status was reportedly reversed from
DNR/DNI to only DNR (but intubatable). She was given Solumedrol
125mg IV, 2L NS, Levofloxacin 500mg IV, and Morphine 2mg IV.
She currently is not able to converse due to resp distress,
agitation, and BiPAP machine, however she nods "yes" to almost
every question.
Past Medical History:
1)Primary intermedullary ependymoma/astrocytoma, spinal cord
tumor (in the process of being worked up per daughter, s/p XRT
and steroid taper at [**Hospital1 2025**], oncologist Dr. [**Last Name (STitle) **]
2)Remote hx of brain tumor s/p VP shunt placement
3)h/o thoracic aneurysm
4)s/p recent PNA
5)COPD
6)CHF (unknown EF)
7)MVR (bioprosthetic MV)
8)Atrial fibrillation (on coumadin)
9)dementia
10)h/o urinary retention (had foley cath at rehab)
Social History:
Lives at [**Hospital 100**] Rehab. Pt needs total care with ADL's. Other
social hx not obtained.
Family History:
Fam hx of depression.
Physical Exam:
Vitals: T 99.5 BP 147/110 HR 87 RR 17 O2sat 100% on BiPAP
10/4/40%
Gen: pt in resp distress, using accessory muscles, on BiPAP,
awake, alert, moaning
HEENT: OP slightly dry, but not fully examined due to BiPAP
machine
Neck: Supple. JVD approximately to earlobe
Cardio: irregularly irregular, 2/6 SEM @ apex
Resp: diffuse exp wheezes bilaterally (although difficult to
discern from pt making "squeeking" noises while exhaling)
Abd: soft, nt, mildly distended, +BS, no rebound/guarding
Ext: trace BL LE edema. LUE ecchymoses
Neuro: awake, alert, R arm with contracture. Knows she is in
"hospital", but unable to speak further due to agitation and
BiPAP machine. Asked her to squeeze my fingers, and she nodded
"no".
Pertinent Results:
Laboratory Results:
[**2191-3-4**] 06:00PM BLOOD WBC-10.6 RBC-3.89* Hgb-12.5 Hct-36.6
MCV-94 MCH-32.0 MCHC-34.0 RDW-15.9* Plt Ct-506*
[**2191-3-13**] 06:10AM BLOOD WBC-12.7* RBC-3.08* Hgb-10.1* Hct-31.2*
MCV-101* MCH-32.8* MCHC-32.4 RDW-15.8* Plt Ct-411
[**2191-3-20**] 05:27AM BLOOD WBC-8.1 RBC-2.89* Hgb-9.2* Hct-28.1*
MCV-97 MCH-31.8 MCHC-32.7 RDW-16.1* Plt Ct-398
[**2191-3-5**] 03:25AM BLOOD PT-25.9* PTT-24.2 INR(PT)-2.6*
[**2191-3-20**] 05:27AM BLOOD PT-20.4* PTT-27.2 INR(PT)-2.0*
[**2191-3-4**] 06:00PM BLOOD Glucose-121* UreaN-19 Creat-0.7 Na-135
K-4.6 Cl-92* HCO3-31 AnGap-17
[**2191-3-4**] 06:00PM BLOOD ALT-21 AST-39 LD(LDH)-536* CK(CPK)-128
AlkPhos-70 Amylase-68 TotBili-0.4
[**2191-3-13**] 06:10AM BLOOD ALT-41* AST-26 LD(LDH)-373* AlkPhos-51
TotBili-0.4
[**2191-3-4**] 06:00PM BLOOD CK-MB-4 cTropnT-0.09*
[**2191-3-15**] 11:29AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2191-3-16**] 06:19AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2191-3-17**] 06:00AM BLOOD proBNP-1752*
[**2191-3-5**] 01:00AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
[**2191-3-14**] 04:40AM BLOOD VitB12-1446* Folate-14.8
[**2191-3-5**] 03:12PM BLOOD Lactate-1.2
Relevant Imaging:
1)Cxray ([**3-4**]): Retrocardiac opacity, possibly representing
atelectasis versus focal consolidation. Likely small bilateral
pleural effusions.
2)CT abdomen/pelvis ([**3-4**]): 1. No evidence of pulmonary embolism.
2. Bibasilar consolidation, likely atelectasis, although
evolving infection cannot be entirely excluded. Moderate right
and small left pleural effusion. 3. Coronary artery
calcifications. 4. Multiple hepatic cysts. 5. Sigmoid
diverticula without evidence of diverticulitis
3)CT Head ([**3-6**]): Limited study due to motion. No acute
intracranial hemorrhage. No mass effect. No evidence of
dilatation of the ventricles.
4)Abdomen xray ([**3-10**]): No evidence of obstruction.
5)ECHO ([**3-17**]): Symmetric LVH with preserved global and regional
biventricular systolic function. Minimal aortic stenosis with
mild regurgitation. Normally-functioning mitral bioprosthesis.
Moderate tricuspid regurgitation. EF 70-80%.
.
6) CT abdomen/pelvis [**3-17**]:
IMPRESSION:
1. Airspace opacity of the dependent bilateral lower lobes is
thought more likely to represent atelectasis; however,
underlying infection cannot be definitively excluded.
2. Small right pleural effusion and minimal left pleural
effusion.
3. Multiple well-defined hypodense foci scattered throughout the
liver, the larger of which are consistent with cysts. Several
smaller lesions are too small to definitively characterize.
4. Numerous sigmoid diverticula without evidence of acute
diverticulitis.
.
7) CXR [**3-16**]:
Feeding tube present, with distal tip directed cephalad in the
fundus. Right PICC line remains in place in the superior vena
cava. Cardiac and mediastinal contours are widened but without
change from the prior radiograph. Previously reported pulmonary
edema has slightly progressed with increased perihilar haziness.
Bilateral pleural effusions are present, best visualized on the
lateral view, small in size.
.
Discharge labs:
[**2191-3-23**] 08:21AM BLOOD WBC-8.4 RBC-2.89* Hgb-9.2* Hct-28.2*
MCV-98 MCH-31.9 MCHC-32.7 RDW-15.9* Plt Ct-377
[**2191-3-24**] 05:28AM BLOOD PT-16.0* PTT-29.5 INR(PT)-1.5*
[**2191-3-23**] 08:21AM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-141
K-3.7 Cl-104 HCO3-33* AnGap-8
Brief Hospital Course:
Ms. [**Known lastname 72408**] is a 79 yo female with COPD, dementia, here with PNA,
hypercarbic respiratory failure, abd pain, and abnormal EKG.
1) Respiratory failure: Patient presented with respiratory
acidosis and was admitted to the MICU for closer monitoring.
Respiratory decompensation likely occurred in the setting of
pneumonia seen on cxray, COPD, and CHF exacerbation. She was
placed on Levaquin, then vancomycin and zosyn. Zosyn and
Levaquin were stopped and she was continued on Vancomycin for 2
weeks since sputum cultures grew MRSA. Her oxygen saturations
improved with antibiotics and agressive diuresis. She also
completed a short Prednisone taper for her COPD. Per daughter,
she requires at least 2L at baseline at rehab. She was continued
on 2L NC with O2 sats in high 90s. She was continued on lasix
PO and this was progressively decreased to 20mg daily.
2)Abdominal pain: Patient presented with several week history of
diffuse abdominal pain. All imaging studies, including CT scan
abdomen/pelvis, were negative for acute pathology that could
explain her symptoms. It was thought that she was constipated.
She did have bowel movements that were extremely loose in
nature. Lactate was normal and guiac negative suggestive of
mesenteric ischemia being unlikely. GI was consulted and they
recommended a repeat CT abdomen/pelvis which was unchanged. She
was started on oxycodone standing and narcotics were tapered due
to effects on her bowels. Her bowel regimen was optimized with
Colace, senna, and Miralax. Her abdominal pain and distention
improved following bowel movements. She was decreased to
oxycodone 2.5mg q8hr prn pain.
3)Elevated troponins/EKG changes: Patient presented with mildly
elevated troponins and diffuse ST depressions in the
anterolateral leads. Likely demand ischemia given respiratory
distress and underlying infection. Given patient's persistent
abdominal pain, it was thought that this may be an anginal
equivalent. Cardiology was consulted and agreed with agressive
diuresis as well as change from CCB to b-blocker. There were no
new wall motion abnormalities on both ECHOs. She did have
significant LVH with hyperdynamic EF~70-80's. No further imaging
or studies were recommended.
4)Atrial fibrillation: Patient remained in afib throughout her
hospital stay. Her digoxin was d/c'ed in the MICU. She was
continued on Verapamil for rate control. Verapamil was changed
to Metoprolol, per cardiology recommendation, as a result of
increasing abdominal pain and distention. She was continued on
Coumadin with close monitoring of her INR. Her INR became
supratherapeutic to >6 at which point her coumadin was held for
one dose and she was given vitamin K. Her INR then became
subtherapeutic and her coumadin was continued. Her INR on the
day of discharge was 1.5
5)Hypertension: Patient presented with SBP in 200's on admission
but quickly returned to baseline. She was continued on
outpatient regimen of Verapamil, but this was changed to
Metoprolol during her hospital stay.
6) Delirium/Dementia/agitation: Per patient's daughter, she has
had an acute decline in her mental status over past several
weeks. The daughter and PCP denied any history of dementia. She
was initially started on Quetiapine and Lorazepam but given the
increased sedative effects of the quetiapine this medication was
stopped. She was continued on Ativan prn and her mental status
contineud to wax and wane throughout her hospital stay likely
from her comorbidities. She remained oriented to self but not
to time or place. The etiology of her delirium was thought to
be multifactorial with a prolonged hospital stay and significant
comorbitities contributing. She remained afebrile with a stable
WBC count so infection was thought not to be contributing. Her
electrolytes were wnl and her B12 and folate were also normal.
She was started on depakote for mood stabilization at 250mg [**Hospital1 **].
She was also started on paxil 30mg daily for her depression. She
was evaluated by psychiatry given her delirium and history of
depression and they recommended seroquel 12.5 mg tid prn for
anxiety/agitation. They also recommended decreasing her paxil
to 20mg daily. On the day of discharge the patient was more
alert and appropriate following these medication adjustments.
7) h/o brain/spinal tumors: Patient being followed closely at
[**Hospital1 2025**]. She received XRT in [**Month (only) 404**] and was supposed to undergo a
repeat MRI of her C-spine. This was attempted during this
admission but given her agitation this could not be done.
Further work-up will be deferred to as an outpatient. She will
likely need MRI c-spine as an outpatient at [**Hospital1 2025**].
.
8) FEN: NGT was initially placed since patient had poor mental
status. When her mental status improved the NGT was removed and
she tolerated PO intake appropriately. She was evalauted by
speech and swallow who determined that she could tolerate a
regular diet without signs of aspiration. She requires
significant encouragement to take PO.
.
9) Sacral decubitus ulcer: patient was evaluated by wound care
nurse who recommended dressing changes every 2-3 days with
following protocol: clean with commercial cleanser, pat dry,
apply protective barrier wipe to periwound tissue, apply duoderm
gel, cover with Allevyn Foam adhesive 5x5". This should be
continued at rehab. She also requires repositioning every 2
hours. There was no sign of infection at the site.
Medications on Admission:
coumadin 3.5 mg qd
flovent 110mcg 1 puff [**Hospital1 **]
gabapentin 300mg qhs
MOM 30ml qd prn
Verapamil 120mg qd
Amoxicillin 2g prn dental procedures
Klonopin 0.25mg [**Hospital1 **]
Doxycycline 100mg [**Hospital1 **] (started [**3-2**] to be completed [**3-9**])
Levaquin (started [**2-26**], finished [**3-1**])
Digoxin 0.125mg qd
Morphine (Roxanol) 2mg q2h prn
Morphine (Roxanol) 4mg q12h
Seroquel 25mg [**Hospital1 **]
Maalox 15ml q6h prn
Atrovent nebs q4h prn
Albuterol nebs q4h prn
Lasix 40mg qd
Sorbitol 15ml qd
Colace 250mg qd
Senna 2 tabs qhs
Paxil 20mg [**Hospital1 **]
Dulcolax 10mg qhs
Dexamethasone 0.125mg q12h (started [**3-2**])
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
4. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
5. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
7. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO every eight (8)
hours as needed for pain.
8. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation every four (4) hours as needed.
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Paroxetine HCl 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
12. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO every six
(6) hours.
13. Maalox 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: Five (5) ml PO
three times a day.
14. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Polyethylene Glycol 3350 17 g (100%) Powder in Packet [**Last Name (STitle) **]:
One (1) Powder in Packet PO DAILY (Daily).
16. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day) as needed for anxiety/agitation.
17. Divalproex 125 mg Capsule, Sprinkle [**Last Name (STitle) **]: Two (2) Capsule,
Sprinkle PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
MRSA pneumonia
COPD
Atrial fibrillation
Constipation
Sacral decubitus ulcer
CHF
Dementia/delirium
Discharge Condition:
Afebrile. Respiratory status stable. Tolerating PO. Moving
bowels.
Discharge Instructions:
Please take all of your medications as directed
.
If you experience difficulty breathing, chest pain, inability to
eat, high fevers or other concerning symptoms, please call your
doctor or come to the emergency room.
Followup Instructions:
|
[
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"788.20",
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"428.0",
"276.1",
"401.9",
"780.09",
"413.9",
"V46.2",
"276.4",
"564.00",
"V45.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14712, 14777
|
6653, 12131
|
333, 339
|
14919, 14991
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3269, 4403
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15259, 15259
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12828, 14689
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6355, 6630
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2534, 3250
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4421, 6339
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367, 1895
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|
2382, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,484
| 148,869
|
49469
|
Discharge summary
|
report
|
Admission Date: [**2166-11-15**] Discharge Date: [**2166-11-22**]
Date of Birth: [**2090-4-4**] Sex: M
Service: MEDICINE
Allergies:
Darvocet-N 100
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Increased secretions and work of breathing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 y/o M with PMH progressive MS s/p trach and G-tube placement
for recurrent aspirations, recent ESBL E. coli PNA transferred
from an OSH with hypoxia and hypotension.
The patient presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on the day prior to admission
after his trach tube had fallen out. His trach was replaced in
the ED, and he was subsequently discharged. He returned to the
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with increased work of breathing, increased secretions
from his trach, hypoxia (74% unclear O2 delivery), and BP 69/59.
Per report, his trach was suctioned aggressively. A L femoral
central line was placed, and after 4L IVF his BP improved to
110/65 and HR improved to 100. At the time of transfer, he was
satting 98% on 12L humidified air via trach mask. CXR
demonstrated R-sided infiltrate/pneumonitis and his UA was
positive. Initial troponin was 0.2 and lactate 9.3. He was given
vancomycin, ceftazadime (h/o pseudomonas sensitive) and
gentamycin.
History of E. coli in urine ([**2160**]) resistent to bactrim and
flouroquinolones. Patient admitted in [**7-/2166**] with hypoxic
respiratory failure and RLL aspiration PNA. Due to
deterioration of MS in the acute setting as well as difficulty
extubation [**1-8**] recurrent aspiration, PEG and trach were placed.
Sputum culture grew Enterobacter resistent to ceftriaxone and
ceftazidime. Treated initially with Vanc/Zosyn, then narrowed
to PO cipro. In [**10/2166**], admitted to OSH with LLL PNA, ESBL E.
coli and treated with Ertapenem.
In the ED inital vitals were, 98 116 90/60 20 100% 15L. Lactate
3.1. He was given 1L NS, then transferred to the ICU.
On arrival to the ICU, VS: 96.2; 126; 110/84; 22; 95% trach mask
15L; 40%. Patient has diminished mental status though unclear
whether this is close to his baseline. Patient is unable to
describe any further symtpoms, including chest pain and
shortness of breath.
Review of systems:
(+) Per HPI, son added chronic b/l LE weakness and right facial
droop
(-) Per son, HCP, denies fever, chills, cough, chest pain.
Past Medical History:
- Multiple sclerosis with [**Year (4 digits) 103518**] elements (followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 **])
- Anemia [**1-8**], h/o guaiac + stools, but no colonoscopy or known
source of GIB
- Coronary artery disease status post multiple PCI.
- cath [**6-13**] showed progression of diffuse disease: Mid LAD: 40
%, 1st Diagonal: focal 80 %, 2nd diagonal: 95% proximal,
Proximal Circumflex: focal 100 % in distal third, 2nd Marginal:
focal 70 % in proximal third, Ramus: Occluded at site of prior
stenting, Mid RCA: long and irregular 30 % stenosis, PDA:
irregular 80 % mid-vessel stenosis, overall no intervention
- Heart failure with EF 40-45%
- Hyperlipidemia.
- Hypertension.
- Chemosis with left eyelid swelling, followed at MEEI.
- Osteoarthritis, right knee.
- s/p total knee replacement R [**9-13**]
- History of UTI.
- neurogenic bladder
Social History:
Unable to obtain
Family History:
Unable to obtain
Physical Exam:
Admission exam:
VS: 96.2; 126; 110/84; 22; 95% trach mask 15L; 40%.
General: Alert, awake, follows command, can nod yes to questions
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated
Lungs: Trach in place, tachypneic, rhonchorous transmitted upper
airway sounds throughout
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: PEG tube in place, soft, non-tender, non-distended,
bowel sounds present
GU: Foley in place, draining clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
WBC-5.9 RBC-3.09* Hgb-9.5* Hct-29.1* MCV-94 MCH-30.7 MCHC-32.6
RDW-13.9 Plt Ct-242
Neuts-30* Bands-51* Lymphs-15* Monos-0 Eos-0 Baso-0 Atyps-0
Metas-4* Myelos-0
Glucose-94 UreaN-43* Creat-1.1 Na-146* K-4.2 Cl-114* HCO3-23
AnGap-13
ALT-17 AST-22 LD(LDH)-162 CK(CPK)-115 AlkPhos-40 TotBili-0.3
CK-MB-4 cTropnT-0.03*
Albumin-2.5* Calcium-7.7* Phos-2.9 Mg-1.8
Lactate-3.7*
.
Imaging:
CXR [**2166-11-15**]- Large scale consolidation in the right lower lung,
predominantly lower lobe, was new earlier today compared to
[**11-1**]. It has grown slightly more radiodense over the past
eight hours, probably active pneumonia. Small right pleural
effusion is presumed and should be monitored in order to detect
any development of empyema. Left lung is clear.
Cardiomediastinal silhouette is normal. The patient has a
tracheostomy tube in standard placement. No pneumothorax.
.
CXR [**2166-11-16**] (following PICC placement)- Right PIC line has been
repositioned, tip is approximately 2 cm below the estimated
location of the superior cavoatrial junction.
Extensive consolidation right mid and lower lung zone stable
since [**11-15**], increased at the left base since [**11-15**]
consistent with worsening pneumonia. There is no pulmonary
edema. Heart size is normal. Tracheostomy tube in standard
placement.
.
Microbiology: .
**FINAL REPORT [**2166-11-19**]**
URINE CULTURE (Final [**2166-11-19**]):
IDENTIFICATION AND SENSITIVITY TESTING REQUESTED BY DR
[**First Name (STitle) **] #[**Numeric Identifier 103519**].
ENTEROCOCCUS SP.. ~3000/ML.
ESCHERICHIA COLI. ~1000/ML.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LINEZOLID------------- 2 S
MEROPENEM------------- <=0.25 S
NITROFURANTOIN-------- 128 R <=16 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ =>32 R
.
**FINAL REPORT [**2166-11-21**]**
.
GRAM STAIN (Final [**2166-11-16**]):
<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 [**2166-11-21**]):
MODERATE GROWTH Commensal Respiratory Flora.
WORK UP ALL PATHOGENS PER DR. [**First Name (STitle) **] [**2166-11-19**].
ESCHERICHIA COLI. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
.
SENSITIVITIES: MIC expressed in
MCG/ML
.
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S 8 S
CEFTAZIDIME----------- 16 R 16 I
CEFTRIAXONE----------- 2 I
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
HOSPITAL COURSE
76 y/o M with PMH progressive multiple sclerosis s/p trach and
G-tube placement for recurrent aspiration PNA, recent
Enterobacter and [**Hospital 40097**] [**Hospital 11091**] transferred from an OSH with hypoxia,
hypotension and focal consolidation on CXR. He was treated for a
pneumonia with IV antibiotics and transferred to an LTAC for
further care. His hospital course was complicated by tachycardia
and volume overload.
.
ACTIVE ISSUES
# Septic Shock: At outside hospital, patient met SIRS criteria
with tachycardia, bandemia and tachypnea. He was afebrile, but
hypotensive and not responsive to fluid boluses, and had a
lactate of >9. CXR at outside hospital, and confirmed at [**Hospital1 18**]
showed new right lower lobe opacity. In addition, he had a
positive urinalysis. Patient was started on broad spectrum
antibiotics with vancomycin, levofloxacin and meropenem to cover
hospital acquired pneumonia and urinary tract infection, with
history of ESBL e.coli UTIs. Lactate trended down, was 3 on
arrival to [**Hospital1 18**], and was normal by HD1. Patient required a
total of 6L NS in fluids, and then was placed on phenylephrine
for blood pressure support. Pressors were weaned on HD1.
Patient had a PICC line placed on HD1 for antibiotic
administration, with plan to continue broad spectrum antibiotics
for 14 days, day 1= [**2166-11-15**]. At the time of discharge, urine
culture was positive for both enterococcus and ecoli, which were
speciated to VRE however < 3000 colonies so therfore not
treated. Sputum cultures were contaminated but speciated to
pseudomonas and ecoli. Blood cultures were still pending or
negative at the time of transfer. At the time of transfer he was
day [**7-20**] of meropenem for esbl pneumonia. He completed 7 days
of vancomycin which was discontinued prior to transfer given
absence of culture driven data.
- Continue IV Meropenem for 6 additional days to complete 14 day
course
.
# Hypoxic respiratory distress: Thought to be due to recurrent
pneumonia, likely aspiration despite tube feeds through PEG. On
arrival to ICU, sat's were in the 90s on tach mask at FiO2 35%.
ABG 7.44/34/87. Patient was treated with broad spectrum
antibiotics as above, with plan to treat for 14 days. Patient
was at his baseline at the time of discharge. Interventional
pulmonology saw patient while in-house and were concerned about
recurrent aspirations and recommended that G-tube be changed to
J-tube. Head of bed was elevated to prevent aspirations in
addition to frequent suctioning of oral secretions. He was
diuresed prior to transfer given total fluid balance during his
hospital stay was over 10 liters. He was placed on a lasix drip
prior to transfer in an effort to achieve relative [**Name (NI) 52753**].
- [**Name2 (NI) **] should be continued on bolus lasix 20 IV for [**Name2 (NI) **] net
negative 1 liter per day.
- At the time of discharge he was 7 liters up total length of
stay.
.
# Tachycardia: Documented initially as sinus, with rates in the
120s. He went into atrial fibrillation with short bursts into
the 190s that were felt to be supraventricular. As blood
pressure was stable, home metoprolol was restarted on the
evening of admission and was titrated up for improved heart rate
control. Tachycardia coincided with aggressive diuresis. He
flipped back into sinus rhythm and his metoprolol was ultimately
down-titrated to tid dosing.
- Increase metoprolol to 12.5 mg tid
.
Chronic issues:
# CAD s/p stent- Unknown when stents were placed, but at higher
risk of cardiac event in the setting of sepsis, hypoperfusion,
and tachycardia. Aspirin and [**Name2 (NI) 4532**] were continued. Cardiac
enzymes were flat.
.
# Anemia- patient with chronic anemia and history of guaiac
positive stools. No signs of bleeding from recent EGD prior to
PEG placement in 08/[**2165**]. No colonoscopy records. Baseline Hct
26-29. Was 29 on arrival. Noted to have coffee grounds in oral
suction. He was started on IV protonix for [**3-12**] week course.
- Start IV protonix for [**3-12**] week course.
.
# HTN - Continued home metoprolol as above.
.
# sCHF - EF in [**7-/2166**] 40-45% with focal WMA.
.
# DM - Started on humalog insulin sliding scale while an
inpatient.
.
# MS - History of progressive MS, also recently developed
[**Year (4 digits) 103518**] symptoms and started on carbidopa-levodopa.
Continued all home medications includeing baclofen and sinement.
.
# Transitional issues:
- blood cultures pending
- code status: full (Discussed at length with patient and health
care proxy while hospitalized. Patient was able to express
understanding regarding discussion and wish for continued full
code status)
Medications on Admission:
#. heparin (porcine) 5,000 unit/mL One (1) Injection TID
#. Carbidopa-Levodopa 25-100 mg, 1 tab TID
#. bisacodyl 5 mg Two (2) Tablet PO DAILY (Daily) prn
constipation
#. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID
#. senna 8.6 mg Tablet One (1) Tablet PO BID prn constipation.
#. albuterol sulfate 2.5 mg /3 mL (0.083 %) One (1) Inhalation
Q6H
#. ipratropium bromide 0.02 % Solution One (1) Inhalation Q6H
#. aspirin 81 mg One (1) Tablet, Chewable PO DAILY (Daily).
#. baclofen 10 mg One (1) Tablet PO TID (3 times a day).
#. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
#. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
#. metoprolol tartrate 25 mg 0.5 Tablet PO BID (2 times a day).
#. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
6. folic acid 1 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. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-8**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
14. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
15. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO at bedtime as needed for constipation.
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
18. meropenem 500 mg Recon Soln Sig: One (1) injection
Intravenous every six (6) hours for 6 days.
19. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
20. furosemide 10 mg/mL Solution Sig: [**12-8**] mL Injection twice a
day as needed for volume overload: titrated as directed by
supervising MD [**First Name (Titles) **] [**Last Name (Titles) **] urine output .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Pneumonia, Paroxysmal Atrial Fibrillation
2. Multiple Sclerosis status post tracheostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for increased oxygen requirement, low blood
pressure and increased respiratory secretions that were
secondary to a pneumonia. You were treated with strong
antibiotics initially to cover for urinary and respiratory
sources. Ultimately, bacteria was isolated from your
respiratory secretions and you will require a total of fourteen
days of antibiotic therapy.
Your hospitalization was complicated by a fast heart rate which
was treated with increased doses of your metoprolol. You also
developed volume overload, which was treated with a diuretic,
furosemide. Lastly you were noted to have blood in your stomach
so you were started on 6 weeks of anti-acid medication.
The following changes were made to your medication list:
1. CONTINUE Lasix (furosmide): 10mg-20mg IV for [**Hospital6 **] urine out
put 1 liter per day for several days
2. CONTINUE Meropenem 500 mg IV every 6 hours for 6 more days
3. INCREASE Metoprolol to 12.5mg three times a day
4. START Pantoprazole 40mg IV twice a day for four additional
weeks
Followup Instructions:
Please follow-up with the providers at your long term acute care
facility.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"428.0",
"401.9",
"427.0",
"428.22",
"596.54",
"V44.0",
"038.9",
"427.31",
"250.00",
"518.82",
"285.9",
"507.0",
"340",
"V44.1",
"414.01",
"715.96",
"995.91",
"V45.82",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15790, 15856
|
8222, 11687
|
327, 333
|
15992, 15992
|
4027, 4027
|
17176, 17390
|
3421, 3439
|
13749, 15767
|
15877, 15971
|
12949, 13726
|
16110, 17153
|
3454, 4008
|
2348, 2479
|
244, 289
|
361, 2329
|
4043, 8199
|
16007, 16086
|
12696, 12923
|
11703, 12673
|
2501, 3371
|
3387, 3405
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,049
| 196,556
|
52480+52481
|
Discharge summary
|
report+report
|
Admission Date: [**2135-7-3**] Discharge Date: [**2135-7-7**]
Service: MEDICINE
Allergies:
Levofloxacin / Penicillins
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **] yo man with PMHx sig. for HTN, DM2, and HL who
was brought in by EMS, reports having difficulty walking. Per
patient, this is not a new phenomenon. He reports falling in
the past but cannot remember when. He is also complaining of
thirst. Patient lives with his wife, both of whom cannot give
adequate histories. Per ED, the wife called the EMS for the
patient. When the ED called the wife, the wife did not recall
that he went to the hospital today.
In the ED, initial VS were: 98.6 56 101/41 16 96. Labs were
notable for WBC 12.3, Cr 3.1 (bl 1.6), trop 0.03. U/A is
pending. CXR is normal. Pt is receiving 1 L NS.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, vision
problems, dysarthria. Denies chest pain or tightness,
palpitations. Denies acute productive cough, shortness of
breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, BRBPR, or abdominal pain. No dysuria, urinary
frequency. No numbness/tingling or muscle weakness in
extremities.
Past Medical History:
1. Pacemaker placed [**2110**] for CHB
2. HTN
3. DM2
4. Hypothyroidism
5. Hyperlipidemia
6. s/p TURP
Social History:
Retired postal office worker. Originally from [**Location (un) 3156**], formarly
Poland. Lives with wife of >50 years in [**Location (un) **]. No children.
He has VNA. Lifetime non smoker but occasional cigars many
years ago. No ETOH.
Family History:
Both parents had DM.
Physical Exam:
VS: 97.1, 90/D, 60, 16, 93RA
Gen: NAD, AOX3, loquacious, easily redirectable and will answer
questions appropriately
HEENT: PERRLA, EOMI, MM extremely dry, sclera anicteric, not
injected
Neck: no LAD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: normoactive bowel sounds, soft, non-tender, non distended
Extremities: No edema, 2+ DP pulses
Neurological: CN II-XII intact except hard of hearing, normal
attention, sensation normal, speech fluent, DTR's 2+ patellar,
achilles, biceps, brachioradialis bilaterally, babinski
down-going bilaterally
Integument: Extremely dry, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Pertinent Results:
SINGLE SEMI-UPRIGHT AP VIEW OF THE CHEST: Right-sided pacemaker
is noted with single lead terminating in the right ventricle.
The heart remains mildly enlarged. The aorta is unfolded, and
the mediastinal and hilar contours are stable. Prominence of the
right paratrachial stripe is also unchanged and likely
attributable to tortuous vascular structures. Lungs are clear
without focal consolidation. Pulmonary vascularity is normal. No
pleural effusion or pneumothorax is appreciated. No acute
osseous abnormality is seen.
IMPRESSION: No acute cardiopulmonary process.
EKG: Sinus brady at 55 bpm. No acute ischemic changesc ompared
to prior.
[**2135-7-4**] 06:45AM BLOOD WBC-9.9 RBC-2.93* Hgb-9.8* Hct-29.2*
MCV-100* MCH-33.4* MCHC-33.5 RDW-14.4 Plt Ct-172
[**2135-7-3**] 04:15PM BLOOD WBC-12.3*# RBC-3.09* Hgb-10.2* Hct-31.2*
MCV-101* MCH-32.9* MCHC-32.5 RDW-14.4 Plt Ct-179
[**2135-7-3**] 04:15PM BLOOD Neuts-90.1* Lymphs-6.4* Monos-3.3 Eos-0.1
Baso-0.1
[**2135-7-3**] 04:15PM BLOOD PT-16.2* PTT-29.5 INR(PT)-1.4*
[**2135-7-6**] 06:15AM BLOOD Glucose-61* UreaN-63* Creat-1.8* Na-139
K-4.6 Cl-109* HCO3-21* AnGap-14
[**2135-7-3**] 04:15PM BLOOD Glucose-158* UreaN-87* Creat-3.1*# Na-137
K-5.0 Cl-106 HCO3-22 AnGap-14
[**2135-7-4**] 05:42PM BLOOD CK(CPK)-314
[**2135-7-4**] 06:45AM BLOOD CK(CPK)-360*
[**2135-7-4**] 05:42PM BLOOD CK-MB-3 cTropnT-0.02*
[**2135-7-4**] 06:45AM BLOOD CK-MB-2 cTropnT-0.02*
[**2135-7-5**] 07:05AM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.9
[**2135-7-5**] 07:05AM BLOOD TSH-6.1*
[**2135-7-4**] 1:13 am URINE Source: Catheter.
**FINAL REPORT [**2135-7-5**]**
URINE CULTURE (Final [**2135-7-5**]): NO GROWTH.
[**2135-7-3**] 4:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
Patient is a [**Age over 90 **] yo man with PMHx sig. for HTN, DM2, and HL who
was brought in by EMS, reports having difficulty walking and
thirsty, found to have acute renal failure.
FAILURE TO THRIVE: the patient has been declining at home, has a
decreased appetite and presented malnourished and dehydrated
with acute on chronic renal failure. He was rehydrated and seen
by physical therapy who recommended rehab. The patient refused
rehab understanding the risks and preferred instead returning
home to his wife and to have home health aide 24 hours per day/
7 days per week. He will pay out of pocket for this. He will be
met at home by the the home health aide on the day of discharge
and agreed to the plan.
HTN: BP was stable on a low dose of metoprolol and with
lisinopril discontinued.
DM: glyburide was held, he was on a low dose. He had borderline
low blood glucoses and this should be discontinued altogether.
Medications on Admission:
PER ED notes, require VERIFICATION as patient is not aware of
any meds:
Glyburide 1.25 mg daily
Lisinopril 5 mg daily
Metoprolol 200 mg daily
Simvastatin 10 mg daily
Synthroid 100 mcg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
9. Toprol XL 25 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Acute renal failure
Dehydration
Malnutrition
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You were admitted with an inability to care for yourself and
decreased eating and drinking. You were given IV fluids and
were set up with a home care assistant to help you with
mobility, feeding and encouraging fluids.
MEDICATION CHANGES:
please STOP taking your GLYBURIDE
please STOP taking LISINOPRIL
please CHANGE your metoprolol dose to TOPROL XL 25mg daily
please START taking mirtazipine
Followup Instructions:
Please follow up with your primary care physician
[**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 133**] within 2 weeks of your
discharge from the hospital.
Admission Date: [**2135-7-8**] Discharge Date: [**2135-7-14**]
Service: MEDICINE
Allergies:
Levofloxacin / Penicillins
Attending:[**Doctor First Name 2080**]
Chief Complaint:
nausea / vomiting / anorexia
Major Surgical or Invasive Procedure:
Expired
History of Present Illness:
Patient is a [**Age over 90 **] yo man with PMHx sig. for HTN, DM2, and systolic
CHF EF 30-35% presents with nausea/vomiting and anorexia. He
has no dysphagia, odynophagia, or any abdominal discomfort. He
has no lightheadedness or syncope. He was discharged the day
prior to his presentation but returned given inability to keep
down POs.
In addition the patient was discharged with a plan to have a 24
hour home health aide, he refused this care when he had arrived
at home (he would only want home health aide during the daytime)
Past Medical History:
1. Pacemaker placed [**2110**] for CHB
2. HTN
3. DM2
4. Hypothyroidism
5. Hyperlipidemia
6. s/p TURP
Social History:
Retired postal office worker. Originally from [**Location (un) 3156**], formarly
Poland. Lives with wife of >50 years in [**Location (un) **]. No children.
He has VNA. Lifetime non smoker but occasional cigars many
years ago. No ETOH.
Family History:
Both parents had DM.
Physical Exam:
VS: T 97.6 BP 148/85 HR 90 RR 12 O2 98% on RA
GEN: NAD, AOX3
CARD: RRR, no m/r/g
PULM: CTAB, poor inspiratory effort
ABD: soft, NT, ND, no masses or organomegaly, BS+
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Pertinent Results:
[**2135-7-8**] 12:50PM BLOOD WBC-10.8 RBC-3.68*# Hgb-12.1* Hct-37.7*#
MCV-103* MCH-32.8* MCHC-32.0 RDW-14.6 Plt Ct-210
[**2135-7-8**] 12:50PM BLOOD Neuts-95.3* Lymphs-3.4* Monos-1.2* Eos-0
Baso-0.1
[**2135-7-8**] 12:50PM BLOOD Glucose-188* UreaN-59* Creat-2.4* Na-138
K-4.7 Cl-106 HCO3-17* AnGap-20
[**2135-7-8**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2135-7-8**] 03:00PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-15 Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG
[**2135-7-8**] 03:00PM URINE RBC-21-50* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
CXR [**2135-7-8**]:
PA AND LATERAL VIEWS OF THE CHEST: Cardiac, mediastinal and
hilar contours
are all stable. There is no pleural effusion or pneumothorax.
Note is made
of left basilar subsegmental atelectasis. A single-lead cardiac
pacing device is unchanged.
.
CT ABD:
IMPRESSION:
1. Innumerable hypodense hepatic lesions, consistent with
metastatic disease.
2. Multiple bilateral tiny pulmonary nodules, the largest of
which is 4 x 4
mm in the right lower lobe new from [**2130**] and also concerning for
metastases
3. Small bilateral pleural effusions.
4. Prostatic enlargement.
5. Fat-containing right inguinal hernia.
6. Atherosclerotic disease.
[**2135-7-13**] 11:12PM BLOOD WBC-6.6 Hct-16.0*# Plt Ct-62*#
[**2135-7-13**] 11:12PM BLOOD Neuts-87* Bands-7* Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2135-7-13**] 11:12PM BLOOD Glucose-78 UreaN-49* Creat-2.4* Na-141
K-5.3* Cl-113* HCO3-9* AnGap-24*
[**2135-7-9**] 07:50AM BLOOD Calcium-7.4* Phos-4.4 Mg-2.4
[**2135-7-10**] 05:33AM BLOOD CEA-2862* PSA-10.9* AFP-1.9
Brief Hospital Course:
FAILURE TO THRIVE: Continued decline at home, related to PO
intolerance. Alk phos elevated which prompted a RUQ ultrasound
which revealed multiple liver lesions concerning for metastatic
disease, unknown primary. CT of the torso revealed diffuse
metastatic disease to both the liver and lungs. CEA very
elevated so colon cancer was suspected but not confirmed. The
patient requested no further diagnostic procedures be performed.
Palliative care, social work, and geriatrics teams were
consulted for assistance in comfort and dischage planning. He
remained comfortable during the course of his admission. Plans
were being arranged for either home with 24hr care vs ALF
placement. Because he was the primary caregiver for his wife, a
plan had to be in place for the both of them. It was determined
that he did have capacity to make decisions. Prior to the
events below, we were arranging for ALF placement. His
non-necessary medications were taken away. He was comfortable
both physically and mentally, not wanting aggressive care and
aware about the prospects of his mortality.
HTN: Continued metoprolol.
DM: given poor PO intake home glyburide was held and BG remained
well controlled without medication.
----------------
[**Hospital Unit Name 153**] Course: Transferred to the [**Hospital Unit Name 153**] from the hospitalist
service for shock and hypoxia in the setting of aFib with RVR
and lactate of 11.
# Shock: Prior to transfer patient's medicine attending spoke to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 96052**] who asked us to give fluids and pressors but no
electrical cardioversion, CPR or intubation. Etiology of the
shock was presumed to be cardiogenic vs. sepsis vs. both and the
patient was managed accordingly. Was cardioverted with
Amiodarone 150mg x 2, the first bolus on the floor and the
second in the [**Hospital Unit Name 153**] followed by Amiodarine GTT. Broad spectrum
coverage with Vanc/Cef/Flagyl was started. The patient was
refractory to 4L boluses of NS; SBP remained < 90 and bladder
scan showed < 50cc of urine. Patient's condition continued to
decline despite these measures and dopamine was started. His HCP
was [**Name (NI) 653**] again and she asked that antibiotics and pressors
be stopped in keeping with the patient's wishes. This was done
and the patient expired shortly after. An autopsy was declined
by his HCP and his HCP asked that his wife not be notified
overnight.
# Lactic acidosis / Tachypnea: Tachypnea with CO2 of 18 on
transfer to [**Hospital Unit Name 153**] was consistent with repiratory alkalosis in the
setting of metabolic gap acidosis. Likely multifactorial with
underlying etiology being progressive metastatic cancer.
# Hypoxia: Likely due to lung infilitrate and potentially
worsening bilateral effusions; exam was also suggestive of a
possible aspiration.
# Acute on chronic kidney injury: Likely pre-renal in etiology
given the setting of FTT and poor PO intake, and in the acute
setting, exacerbated by shock, complicating the picture with
potential ATN.
# Hypothyroid: Levothyroxine held.
.
# HTN: Toprol held.
.
# DM2/Hyperlipidemia: Medications held.
Medications on Admission:
Colace 100mg po bid
Aspirin 81 mg po daily
Vitamin D3 800unit po daily
Calcium Carbonate 500 mg po tid
Multivitamin po daily
Simvastatin 10 mg po daily
Levothyroxine 100 mcg po daily
Mirtazapine 7.5mg po daily
Toprol XL 25 mg po daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Cancer, unknown primary
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"V45.01",
"V85.0",
"403.10",
"585.2",
"272.4",
"584.9",
"244.9",
"276.51",
"250.00",
"263.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13889, 13898
|
10405, 13572
|
7507, 7517
|
13996, 14006
|
8754, 10382
|
14062, 14073
|
8478, 8500
|
13857, 13866
|
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|
13598, 13834
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14030, 14039
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8515, 8735
|
4283, 4283
|
967, 1338
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6864, 7022
|
7439, 7469
|
7545, 8082
|
13938, 13975
|
8104, 8207
|
8223, 8462
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
728
| 167,721
|
23685
|
Discharge summary
|
report
|
Admission Date: [**2154-3-24**] Discharge Date: [**2154-3-30**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Sternal Drainage
Major Surgical or Invasive Procedure:
s/p Sternal rewiring
History of Present Illness:
83 y/o male s/p Coronray Artery Bypass Graft x 4 on [**2154-3-15**]
without post-op complications who present to ED with sternal
drainage after coughing spell. Upom exam, pt was found to have
an unstable sternum and cxr revealed displacement and rotation
of sternotomy wires, consistent with sternal dehiscence.
Past Medical History:
Coronary Artery Disease s/p Coronray Artery Bypass Graft x 4 on
[**2154-3-15**]
Hyperlipidemia
s/p Appendectomy in [**2090**]
Social History:
He lives in [**Location 620**] with his wife. [**Name (NI) **] retired 1 year ago from
sales. He drives. He uses no assistive devices. He is very
active. He quit smoking in [**2116**]. He has a 40-pack-year history.
He has 3 alcoholic drinks per year.
Family History:
His father died of a MI at the age of 87.
Pertinent Results:
CXR [**2154-3-24**]: Interval increase in moderate left pleural
effusion. Displacement and rotation of sternotomy wires,
consistent with sternal dehiscence.
[**2154-3-24**] 06:07AM BLOOD WBC-12.3* RBC-3.74* Hgb-10.8* Hct-32.9*
MCV-88 MCH-28.8 MCHC-32.7 RDW-14.4 Plt Ct-371#
[**2154-3-29**] 05:55AM BLOOD WBC-10.9 RBC-3.03* Hgb-8.7* Hct-26.8*
MCV-88 MCH-28.7 MCHC-32.5 RDW-14.1 Plt Ct-433
[**2154-3-24**] 08:15AM BLOOD PT-13.3 PTT-26.4 INR(PT)-1.1
[**2154-3-24**] 06:07AM BLOOD Glucose-93 UreaN-26* Creat-1.1 Na-139
K-4.4 Cl-102 HCO3-27 AnGap-14
[**2154-3-28**] 05:35AM BLOOD Glucose-107* UreaN-32* Creat-1.3* Na-134
K-4.0 Cl-98 HCO3-26 AnGap-14
[**2154-3-29**] 05:55AM BLOOD UreaN-29* Creat-1.2 K-4.8
[**2154-3-24**] 06:07AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1
[**2154-3-28**] 05:35AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.1
[**2154-3-24**] 12:13PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2154-3-24**] 12:13PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
Pt. was admitted on [**3-24**] with sternal dehiscence. IV ABX were
started and pt was kept NPO for preparation to OR the next day.
On HD #2 he was brought to the operating room and underwent
sternal rewiring. Please see op note. Pt. tolerated the
procedure well, was extubated in the OR and was transferred to
the CSRU in stable condition. POD #1 pt was recovering well
after rewiring. He was not receiving any gtts and pre-op meds
were started. Pt. cont. to need aggressive chest pt, nebs and O2
to remain adequate O2 stats. He therefore remained in the CSRU
until POD #2. On this day he was transferred to the telemetry
floor. His chest tubes were removed and ABX were cont. His
pre-op culture (urine) was negative and the chest swab performed
in the OR was negative as well. From POD #[**2-2**] pt slowly
improved. He cont. to need O2 via NC which was slowly weaned
with aggressive pt, IS and nebs. Vanco was continued until day
of discharge where it was stopped. Exam on POD #5 was
unremarkable. Chest was stable, without clicks or drainage. Pt
was discharged home with the appropriate follow-up.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Sterile sternal dehiscence after CABG
Coronary Artery Disease s/p Coronray Artery Bypass Graft x 4 on
[**2154-3-15**]
Hyperlipidemia
s/p Appendectomy in [**2090**]
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 3142**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 70**] for 6 weeks.
Completed by:[**2154-5-3**]
|
[
"511.9",
"998.31",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"34.79"
] |
icd9pcs
|
[
[
[]
]
] |
3328, 3377
|
2202, 3305
|
286, 308
|
3584, 3590
|
1145, 2179
|
3833, 4006
|
1083, 1126
|
3398, 3563
|
3614, 3810
|
230, 248
|
336, 649
|
671, 798
|
814, 1067
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,244
| 183,858
|
3358
|
Discharge summary
|
report
|
Admission Date: [**2142-7-21**] Discharge Date: [**2142-7-27**]
Date of Birth: [**2069-2-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ambien / Trazodone
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
fever and altered mental status
Major Surgical or Invasive Procedure:
transesophageal echocardiogram on [**2142-7-25**].
IMPRESSION: Pacing wires present with shaggy echodensities that
could represent presence of clot / fibrin / vegetations. No
valvular vegetations seen. Severely depressed left ventricular
function. Moderate mitral regurgitation.
PICC placement
History of Present Illness:
73 year old male with CAD, CHF (EF 20%), v-tach s/p ICD
placement, AFib on warfarin, s/p whipple, chronic dyspnea with
2.5L NC at baseline, presenting with fever (100.2 at home),
rigors, and altered mental status. Patient has a history of
aspiration pneumonia, with admission in [**2142-4-22**] requiring an
ICU stay and ventilation.
Patient relates that symptoms began yesterday with fevers,
shaking chills and overall malaise. He did have a cough prior
to admission, which was not productive of sputum, but usually
brought up undigested food. Due to constipation, the patient
took extra Colace and Senna yesterday, and he had [**3-27**] bowel
movements. After straining during one bowel movement, he felt
short of breath and dizzy. He denies having any chest pain
yesterday, although history in the ED had noted some chest pain
prior to admission. At his baseline, the patient sometimes has
dyspnea on exertion (walking around his home) and sleeps on 2
pillows at night. He denies any leg swelling. He denies any
nausea, vomiting, abdominal pain, diarrhea, hematochezia,
melena, dysuria or hematuria.
In the ED, initial vs were: 99.2 74 95/64 16 99%. He was alert
and oriented x2, pale, diaphoretic, and hypotensive to SBP 75.
Of note, from recent previous OMR records, baseline BP is
105/68. RIJ placed, with CVP 13 and MAP ~60. After <500 cc of
fluids and abx, pt with improved MS though still not oriented to
time. Vanc + levoflox given. CXR showed bilateral opacities
c/w atelectasis vs. infection. Total IVF given ~750cc with
resolving pressures to BP 91/51. Given no meningismus, HA, or
neck pain, LP was deferred. Vitals on transfer: 101.8, 75,
91/51, 17, 97% 2L NC and CVP 13.
In the ICU, the patient was comfortable, oriented x3 and
conversant. He knew that he was in the [**Hospital1 18**] ICU, but not in
the "nice" ICU that is in the clinical center. He was breathing
comfortably on supplemental oxygen by nasal cannula. He was
able to provide details of his history.
Past Medical History:
1. Coronary artery disease
- status post anterior wall myocardialinfarction in [**2126**]
- MI c/b large apical aneurysm and VT/VF s/p ablation [**2126**]
- s/p biventricular pacer implantation [**2135**] (replaced previous
dual chamber ICD) for complete heart block
- pacemaker interrogated [**7-12**]
2. Systolic heart failure
- ejection fraction 20% on TTE in [**2141-11-22**]
3. Atrial fibrillation, status post cardioversion [**2141-5-23**], on
anticoagulation, managed by Dr.[**Name (NI) 1912**] office.
4. Hypertension.
5. Hypothyroidism.
6. Anemia.
7. Irritable bowel syndrome.
8. Constipation.
9. Obesity.
10. Hearing loss, requiring bilateral hearing aids.
11. Squamous cell carcinoma of the left lower eyelid [**2138**].
12. Vitamin D deficiency.
13. Cerebral infarction [**2132**].
14. Gait disorder with history of falls.
15. Compression fractures.
16. Bile duct dysplasia s/p ERCP/stent/sphincterotomy [**4-/2139**]
and Whipple operation c/b E. coli and Klebsiella bacteremia (at
[**Hospital1 2025**]). Apparently, the source of the bacteremia was his teeth.
He is s/p removal of all of his teeth.
17. Abdominal hernia secondary to a local procedure.
18. Syncope.
19. Hemorrhoids.
20. VRE infection
Past Surgical History (per OMR):
1. Replacement of pacemaker and ICD implantation with
revisions.
2. Knee surgery.
3. Squamous cell removal of the left lower eyelid.
4. Whipple procedure.
5. Right eye cataract surgery
Social History:
The patient lives with his significant other,
[**Name (NI) **] [**Name (NI) **]. He is divorced, and has two grown daughters. [**Name (NI) **]
taught British and American History at [**Last Name (un) **] and [**Last Name (un) 15565**].
- Tobacco: Previous smoker. Began smoking cigarettes in high
school and continued until age 60. Also, smoked a pipe until
age 60.
- Alcohol: [**12-24**] glasses of wine per day.
- Illicits: None ever.
Family History:
Father died of stroke age 59. Mother died of MI at age 70.
Brother with MI in his 50s, deceased. Second brother deceased
with pancreatic cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.2 (37.3) BP: 92/56 P: 75 RR: 16 SpO2: 96% NC
General: Alert, oriented x3, conversant, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, adentulous
Neck: supple, JVP not appreciated, no LAD
Lungs: Crackles at the bases bilaterally, no wheezes
CV: Paced, regular rate and rhythm. Holosystolic murmur,
loudest at LLSB with radiation to the apex. No carotid bruits.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
small midline ventral hernia.
GU: + foley
Ext: Warm, well-perfused, 2+ pulses, fingernails mostly white
with thin reddish line at tip (c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15569**] nails), no edema
Discharge Physical Exam:
VS: T 100.8 HR 75 BP 93/49 RR 21 95%/2L O2xNC
Gen: NAD, comfortable, scab/thickened skin on forehead
Cardiac: RRR, holosystolic murmur loudest at LLSB
Abd: soft, nt, pos bs, ventral hernia, very mildly distended
abdomen
Ext: warm, perfused
Pertinent Results:
[**2142-7-21**] 05:50PM WBC-8.5# RBC-3.36* HGB-11.5* HCT-33.5*
MCV-100* MCH-34.3* MCHC-34.4 RDW-15.1
[**2142-7-21**] 05:50PM NEUTS-90.8* LYMPHS-5.2* MONOS-2.0 EOS-1.6
BASOS-0.5
[**2142-7-21**] 05:50PM GLUCOSE-114* UREA N-34* CREAT-1.3* SODIUM-133
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-24 ANION GAP-16
[**2142-7-21**] 10:51PM PT-29.9* PTT-34.0 INR(PT)-2.9*
[**2142-7-21**] 05:50PM cTropnT-<0.01 proBNP-3062*
[**2142-7-21**] 06:07PM LACTATE-1.6
[**2142-7-21**] 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Micro:
[**7-22**] MRS [**Last Name (STitle) 15570**] pending
[**7-21**] BCx x2 pending
[**7-21**] UCx pending
Imaging:
CXR [**7-21**]: Left-sided pacemaker device is noted with
leads terminating in the right atrium, right ventricle, and
coronary sinus. Abandoned leads are also noted. There are low
lung volumes. The heart size is moderately enlarged. The aortic
knob is calcified, and there is mild tortuosity of the thoracic
aorta. There is mild pulmonary vascular
congestion. No focal consolidation, pleural effusion or
pneumothorax is
present. Streaky opacities in the lung bases may reflect
atelectasis, though infection is not excluded. There are no
acute osseous abnormalities.
IMPRESSION: Mild pulmonary vascular congestion. Low lung volumes
with streaky opacities in the lung bases, possibly atelectasis,
although infection is not excluded. Repeat films with improved
inspiration may be helpful for further evaluation.
[**2142-7-21**] 6:05 pm BLOOD CULTURE (2 bottles)
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2142-7-22**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) 15571**] [**Last Name (NamePattern1) 15572**] [**2142-7-22**]
12:12PM.
Anaerobic Bottle Gram Stain (Final [**2142-7-22**]): GRAM
NEGATIVE ROD(S).
[**2142-7-25**] TEE:
Pacing wires present with shaggy echodensities that could
represent presence of clot / fibrin / vegetations. No valvular
vegetations seen. Severely depressed left ventricular function.
Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2141-3-14**],
there appears to be more material associated with the wires,
although less views of the wires were taken previously.
Brief Hospital Course:
73 M with extensive cardiovascular history including CHF
secondary to ischemic cardiomyopathy with EF 20%, implanted
biventricular pacer and atrial fibrillation on warfarin, as well
as recent hospital admission for aspiration pneumonia, who was
admitted to the hospital for aspiration pneumonitis and
Klebsiella oxytoca bacteremia. Pt was initialy admitted to the
ICU and then transfered to the medical floor.
Active Diagnoses:
# GNR Bacteremia/Hypotension. Pt initial febrile, hypotensive
(low 80s) and found to have klebsiella oxytoca bacteremia.
Unclear source of infection as CT abd and Pelvis unrevealing for
GI source and urine neg for source. TEE showed no signs of
endocarditis but there were ?fibrinous material on the leads
suspicious for fibrin clot versus vegetations. He was intialy
given vanco/levoflox/flagyl for empiric coverage and then
transitioned to cefepime for a few days followed by ceftriaxone.
He will go home with 2 weeks of ceftriaxone (though [**8-8**])
followed by Cefpodaxime 200mg [**Hospital1 **] PO therafter. BP remained
primarily in the 90-110 range.
#Aspiration pneumonitis. Patient's history of difficulty
swallowing and presentation with fever, hypotension, clear CXR,
and quick resolution of elevated WBC was suggestive of
aspiration pneumonitis rather than aspiration PNA. Maintained on
regular diet with thickened liquids and aspiration precautions.
# Systolic CHF: Baseline low EF with evidence of pulmonary
congestion in CXR, although exam not consistent with volume
overload. Continued home furosemide, beta blocker, and ASA. Held
lisinopril given acute kidney injury. Repeat TTE showed EF
15-20 %. Severely hypokinetic,dilated right ventricle. Apical
left ventricular aneurysm without clot seen. Moderate pulmonary
artery systolic hypertension. Similar to that on 12/[**2140**].
# AMS: Cleared quickly. Thought to be secondary to cerebral
hypoperfusion due to baseline decreased systolic function that
was exacerbated by SIRS from infection. Pt A+O x3 at time of
discharge.
# [**Last Name (un) **]: Creatinine peaked to 1.3 (from baseline 1.1), with BUN
34. Likely prerenal azotemia from baseline poor systolic
function, with decreased preload secondary to SIRS, and cardiac
inability to increase stroke volume. Cr improved with some
gentle IVF. His Cr at baseline was 0.8-1.0.
# Anemia: Macrocytic, chronic. Stable at discharge Hct (29).
#A fib: Pt with paroxysmal A fib years ago. He was last in A fib
2 yrs ago. He was continued on coumadin with goal INR [**1-25**]. INR
at discharge was 2.5.
PENDING:
-blood cx from [**7-22**], [**7-23**], [**7-24**], [**7-25**], [**7-26**]
TRANSITIONAL ISSUES:
- has recurrent gram neg rod bacteremia. Unclear primary source.
Possibly GI although CT abd and pevlis unremarkable. He will
follow up with his [**Hospital1 2025**] GI doctors.
- TEE showed some thick fibrinous material on the leads. Unclear
if this is infected. Will be treated for 2 weeks IV antibiotics
followed by PO antibiotics.
- Recurrent aspiration events. S&S saw pt in house and made
reccomendations:
1. PO diet: thin liquids, soft solids.
2. Small pills whole, large pills crushed with puree.
3. Take small sips of liquid.
4. Alternate bites and sips.
5. [**Hospital1 **] oral care.
6. Assistance with meals as needed.
- MRSA positive in nares
-TEE: Pacing wires present with shaggy echodensities that could
represent presence of clot / fibrin / vegetations. No valvular
vegetations seen. Severely depressed left ventricular function.
Moderate mitral regurgitation.
Medications on Admission:
AMIODARONE 200 mg daily
BUPROPION HCL 150 mg daily
FUROSEMIDE 60 mg daily
LEVOTHYROXINE 100 mcg Tablet daily\
LIPASE-PROTEASE-AMYLASE [CREON] - unknown dose
LISINOPRIL 2.5 mg daily
METOPROLOL TARTRATE 12.5mg [**Hospital1 **]
OXYGEN 2.5L via nasal cannula daily upon exertion
PRAMIPEXOLE 0.125 mg QHS PRN restless legs
RANITIDINE HCL 75 mg [**Hospital1 **]
WARFARIN 1-4 mg daily
ASPIRIN 81mg daily
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit daily
DOCUSATE SODIUM [COLACE] 100 mg Capsule TID PRN
FERROUS SULFATE 325 mg (65 mg iron) daily (MWF)
GUAR GUM [BENEFIBER (GUAR GUM)] packet daily
SENNOSIDES [SENOKOT] 8.6 mg [**Hospital1 **] PRN
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
3. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qHS PRN ()
as needed for restless leg syndrome.
9. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
([**Doctor First Name **],MO,TU,WE,TH,SA).
11. warfarin 2 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. ceftriaxone 2 gram Recon Soln Sig: One (1) Intravenous once
a day for 20 days: Take through [**2142-8-8**].
Disp:*20 days* Refills:*0*
18. Oxygen 2.5L NC Sig: as directed as directed: Uses 2- 2.5L
NC at all times.
19. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a
day: *START: [**2142-8-8**]. Continue until infectious disease doctor
says.
20. Lab Draw Sig: One (1) once a week: CBC with diff, chem 7,
INR/PTT, LFTs. Fax results to: ATTN Dr. [**Last Name (STitle) 3197**] [**Telephone/Fax (1) 1419**].
21. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
22. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Gram Negative Rod Bacteremia
Congstive Heart Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]! You were admitted with a fever and confusion.
You were found to have gram negative rod bacteria in your blood
culture, and you were treated with antibiotics. You were found
by laboratory testing and physical exam not to have other causes
of fever such as pneumonia, meningitis, encephalitis, colitis,
gastroenteritis, or pulmonary embolism. Your mental status
improved throughout hospitalization. We will send you home on
ceftriaxone, an IV antibiotic for 2 weeks. The last day of your
IV antibiotics will be [**8-8**]. You have an appointment with Dr.
[**Last Name (STitle) 5461**] scheduled for [**8-8**] at 1pm. Dr. [**Last Name (STitle) 5461**] will be
able to further direct your management.
MEDICATION CHANGES:
START:
ceftriaxone 2gm IV
Continue taking your regular medications as prescribed
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up this hospitalization with the following
appointments:
Please make sure you arrange an appointment with your GI doctor
from [**Hospital1 2025**] in the next 2 weeks.
Department: GERONTOLOGY
When: THURSDAY [**2142-8-2**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2142-8-8**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2142-8-8**] at 1 PM
With: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DERMATOLOGY AND LASER
When: MONDAY [**2142-8-13**] at 1:15 PM
With: [**Doctor Last Name **],KATHEEN [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on
Site\nDepartment: CARDIAC SERVICES
When: THURSDAY [**2142-8-23**] at 3:00 PM
With: [**Name6 (MD) 1918**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2142-8-1**]
|
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,763
| 104,058
|
47963
|
Discharge summary
|
report
|
Admission Date: [**2111-6-12**] Discharge Date: [**2111-6-29**]
Date of Birth: [**2029-11-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Unstable neck fracture
Major Surgical or Invasive Procedure:
Occipito cervical fusion O to C4 fusion
History of Present Illness:
81M with PMHx of primary speech apraxia, DM2, COPD, asbestosis,
and recent fall for which he was admitted and placed in a
[**Location (un) 2848**]-J collar (noted to have an old C1-C2 fracture) who
presents from rehab with concern for ill-fitting collar and
possible mental status changes. Patient was discharged to rehab
yesterday to rehab, and was reportedly complaining of nausea,
anorexia, dizziness, and headache. There was a question of
worsening of his apraxia. He required a 1:1 sitter last night
for agitation and was sent to the ED from his rehab for further
evaluation.
In the ED, initial VS were 98 90 157/70 15 95%. Labs were
significant for stable hyponatremia & anemia. Preliminary read
of non-contrast head CT showed no acute process. U/A was
negative. Patient did not receive any medications or fluids in
the ED; they did note that the patient fell asleep twice during
interview. Patient was seen by neurosurgery who felt that his
mental status was at baseline. They determined that there was no
acute neurosurgical issues and that his C-collar was
appropriately fit. Patient reportedly denied weakness or gait
abnormalities. Patient was admitted to medicine for placement,
as his rehab facility refused to take him back. Vital signs on
transfer were 98.5 ??????F (36.9 ??????C), Pulse: 99, RR: 16, BP: 139/70,
O2Sat: 94%RA.
On arrival to the floor, patient appears calm and comfortable.
Communication is difficult [**1-29**] apraxia, but pt able to answer
yes/no. He correctly circled (on a piece of paper) that he is at
the hospital and said "no" when asked if he was in pain.
Past Medical History:
Copd, Asbestosis, Diabetes, primary speech apraxia
Social History:
Widowed, Remote ETOH and Smoking history, lives in
[**Hospital3 **] in [**Location 7182**] : [**Street Address(2) 101207**].
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O:
T: 98 BP: 157/70 HR:90 R 15 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
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.
Language: at baseline dysarthria. Primarily communicates by
writing
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-2**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right: + + + + +
Left + + + + +
PHYSICAL EXAMINATION ON DISCHARGE:
same
Pertinent Results:
[**2111-6-12**] Head CT:
IMPRESSION: No evidence of acute intracranial process.
[**2111-6-12**] CXR:
IMPRESSION: Extensive bilateral calcified pleural plaque, likely
reflecting prior asbestos exposure. No signs of superimposed
pneumonia.
[**2111-6-12**] 07:56PM URINE HOURS-RANDOM
[**2111-6-12**] 07:56PM URINE GR HOLD-HOLD
[**2111-6-12**] 07:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2111-6-11**] 07:02AM GLUCOSE-101* UREA N-10 CREAT-0.5 SODIUM-126*
POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-29 ANION GAP-13
[**2111-6-11**] 07:02AM WBC-8.0 RBC-4.18* HGB-12.8* HCT-38.7* MCV-93
MCH-30.7 MCHC-33.1 RDW-13.6
[**2111-6-11**] 07:02AM PLT COUNT-266
Brief Hospital Course:
Initially, the patient was admitted to the medical service. An
extensive conversation with the HCP was had, who felt the
patient was at his baseline. He was noted to be hypovolemic, no
worse than previous admission, and this was felt to be secondary
to hypovolemia, so he was managed with gentle IV hydration. He
was transferred to the neurosurgery service for work-up of his
cervical spine fracture.
On [**6-14**], after discussion with the HCP, it was determined that
the patient would be electively intubated on [**6-15**] and placed in
traction prior to undergoing occipital-cranial fusion. He
remained hyponatremic with a sodium of 125. On [**6-16**], patient
remained intubated. He was taken out of traction in CT scanner
for a CT c-spine which showed stable c1/c2 fracture with good
reduction. On exam, MAE and squeezes hand. He was pre-oped for
OR on [**6-17**]. On [**6-17**] he was stable in the ICU, intubated, and on
cervical traction while awaiting OR for occipital to C2 fusion.
C0-C4 fusion was performed on [**6-17**] without any intraoperative
complications.On [**6-18**] patient remained stable, intubated in the
ICU. He was leethargic, but opened his eyes, squeezes hands and
moves toes bilaterally on command. Bronchoscopy showed airway
edema necesitating General Surgery consult for tracheostomy.
Traheostomy was performed on [**6-20**], he remained in the ICU until
[**6-23**] when he was transferred to floor. He was evaluated by
Speech Therapy prior to his transfer, on [**6-22**] and was seen again
once he was on the floor. On [**6-24**] he failed the speech and
swallow study and poorly tolerated his PMV. At that time PEG was
suggested but both patient and his HCP/nephew declined the PEG
citing limited evidence that it would improve his survival.
After further discussion on [**6-25**] the patient changed his mind
and agreed to have the PEG placed. PEG was placed on [**6-26**], tube
feeds were started on [**6-27**] and stopped. Tube feeds restarted on
[**6-28**] and found to be at goal per GI. Staples removed from
incisional wound on [**6-29**].
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH TID copd
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID Patient may refuse. Hold if
patient has loose stools.
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH TID copd
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Quinapril 10 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
14. Tamsulosin 0.4 mg PO HS
15. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Vitamin D 800 UNIT PO DAILY
2. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *Ultram 50 mg 1 Tablet(s) by mouth Q6H:PRN Disp #*100 Tablet
Refills:*0
3. Tamsulosin 0.4 mg PO HS
4. Simvastatin 20 mg PO DAILY
5. Senna 1 TAB PO BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Quinapril 10 mg PO DAILY
Hold for SBP < 100
8. Multivitamins 1 TAB PO DAILY
9. Heparin 5000 UNIT SC TID
10. FoLIC Acid 1 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
12. Bisacodyl 10 mg PO/PR DAILY
13. Ipratropium Bromide Neb 1 NEB IH Q6H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Odontoid type 2 fracture unstable.
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any medications such as Aspirin unless directed by
your doctor.
?????? Unless you had a fusion, you should take Advil/Ibuprofen
400mg three times daily
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? 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:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Physical Therapy:
activity as tolerated.
Brace to be worn out of bed while ambulating. No need of brace
in bed or in chair.
Treatments Frequency:
see discharge instructions.
Keep incisions dry
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**7-7**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Physician Assistant or [**Name9 (PRE) **]
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 2 weeks.
??????You will need x-rays/CT-scan prior to your appointment.
Completed by:[**2111-6-29**]
|
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icd9cm
|
[
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icd9pcs
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,952
| 129,189
|
37789
|
Discharge summary
|
report
|
Admission Date: [**2189-8-29**] Discharge Date: [**2189-9-21**]
Date of Birth: [**2151-3-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Neck pain; weakness/numbness in arms and legs.
Major Surgical or Invasive Procedure:
[**2189-8-31**]: posterior cervical spine decompression for bilateral
lower extremity paralysis with C3-C7 laminectomies and C3-T1
instrumented fusion.
History of Present Illness:
38 year-old morbidly obese male with Crohn's disease,
transferred on [**8-29**] from [**Hospital 3844**] Hospital for evaluation
of neck pain, weakness, and numbness. The patient reports the
sudden onset of posterior neck pain on [**8-26**]. When
he nodded his head, it felt like an "electric current" was
running from his head to his feet. On [**8-27**] he noticed that his
legs felt numb and heavy, from the level of his umbilicus to his
feet. On [**8-27**] He was seen at an outside ED, where CT of the
neck showed narrowing of the spinal canal according to the
patient. He was discharged home from the ED on pain medications
but then developed numbness of the left 4th and 5th digits as
well as the right 3rd, 4th, and 5th digits. Also, he noticed his
grip was weaker on the right, and his walking felt off balance.
His back pain was significantly worse with sitting
and walking. He took one dose of Flexeril and oxycodone for the
pain, but then returned to the ED the following day on [**8-28**] for
further evaluation. He stated the outside hospital wanted to get
an MRI of his spine but due to his large body habitus, he was
unable to fit in the scanner; thus, he was transferred to [**Hospital1 18**]
on [**8-29**] for further imaging and management, initially on
neurology service.
ROS: Pain, weakness, and numbness as per HPI. Denies headache,
dizziness, vision changes, hearing changes, swallowing
difficulties, chest pain, nausea, vomiting, diarrhea,
constipation, and urinary difficulties.
Past Medical History:
-Crohn's disease (Dx [**2180**], last Tx w/ Remicade >5 yrs ago)
Stopped Remicade d/t lack of health insurance, Crohn's has been
quiescent despite no treatment
-obesity (Weighs 360 lb per ED)
-degenerative joint disease
Social History:
Smokes 1 ppd. Occasional alcohol use, socially.
Denies IV drug use.
Family History:
An uncle has epilepsy. There is no family
history of multiple sclerosis or other neurologic disorders.
Physical Exam:
T 98.1, HR 70, BP 147/73, RR 18, O2 sat 98%RA
Gen: Obese male, awake, alert, not in distress when lying in
bed
but appears to be in pain when sitting or standing.
Skin: No rash
Heent: Normocephalic, no conjunctival injection, mucous
membranes
moist, oropharynx clear. No tenderness over temporal,
occipital,
neck area.
Neck: Complains of pain with strength testing, but supple
without
rigidity.
Resp: Clear to auscultation bilaterally
CV: Regular rate, normal S1/S2, no murmurs, rubs, or gallops
Abd: Obese, non-tender.
Extrem: Warm and well-perfused.
Neuro:
MS - Awake, alert, interactive. Oriented to person, place, and
date. Speech is fluent. Attention is appropriate.
Cranial Nerves ?????? Pupils equal and reactive (3 to 2mm); EOM
smooth
and full, no diplopia; no nystagmus, intact facial sensation,
face symmetric with full strength of facial muscles, hearing
intact to finger rub bilaterally, palate elevation is symmetric,
and tongue protrusion is symmetric and full movement.
Sternocleidomastoid and trapezius are strong and normal volume.
Strength -
Delt [**Hospital1 **] Tri WrEx FEx FFlx IO [**Location (un) **] / IP Quad Ham Gastr TA [**First Name9 (NamePattern2) **]
[**Last Name (un) 938**] ToeFlex
R 5 5 5 5 5 5 5 5 4 4- 4- 5 5 5
L 5 5 5 5 5 5 5 5 4 4- 4- 5 5 5
Reflexes -
Biceps Triceps Brachioradialis Patellar Ankle
R 2+ 2+ 2+ 2+ 2+
L 2+ 2+ 2+ 2+ 2+
Plantar responses downgoing bilaterally
Sensation - There is decreased sensation to vibration a stocking
pattern in the feet bilaterally. Proprioception is intact in
the
fingers but not in the toes. There is decreased sensation to
sharp touch in the lower leg, from the feet to [**1-13**] of the way up
the shin. Temperature sensation is normal. Romberg negative.
Coordination - No dysmetria and smooth finger to nose.
Gait - Able to walk but appears unsure of foot placement, with a
steppage-type gait.
Pertinent Results:
[**2189-8-29**] 12:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2189-8-29**] 12:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2189-8-29**] 07:16AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2189-8-29**] 01:03PM BLOOD WBC-11.0 RBC-5.29 Hgb-14.1 Hct-43.1
MCV-82 MCH-26.8* MCHC-32.8 RDW-14.6 Plt Ct-416
[**2189-8-31**] 01:12PM BLOOD Neuts-83.8* Lymphs-9.7* Monos-3.3 Eos-2.6
Baso-0.6
[**2189-8-29**] 01:03PM BLOOD PT-13.6* PTT-22.1 INR(PT)-1.2*
[**2189-8-31**] 02:17PM BLOOD PT-13.3 PTT-22.0 INR(PT)-1.1
[**2189-8-29**] 01:03PM BLOOD Glucose-149* UreaN-13 Creat-0.8 Na-139
K-4.5 Cl-100 HCO3-27 AnGap-17
[**2189-8-29**] 01:03PM BLOOD ALT-49* AST-29 CK(CPK)-119 AlkPhos-72
TotBili-0.5
[**2189-8-31**] 02:17PM BLOOD CK(CPK)-458*
[**2189-8-31**] 02:17PM BLOOD CK-MB-4 cTropnT-<0.01
[**2189-8-29**] 01:03PM BLOOD Calcium-10.2 Phos-3.1 Mg-2.2
[**2189-8-29**] 01:03PM BLOOD %HbA1c-5.9
[**2189-8-29**] 01:03PM BLOOD TSH-0.45
[**2189-8-29**] 01:03PM BLOOD CRP-9.8*
[**2189-8-29**] 01:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-9-19**] 03:12PM BLOOD WBC-6.5 RBC-3.85* Hgb-10.2* Hct-32.7*
MCV-85 MCH-26.5* MCHC-31.2 RDW-14.7 Plt Ct-322
[**2189-9-19**] 03:12PM BLOOD Neuts-82.0* Lymphs-10.3* Monos-4.1
Eos-3.1 Baso-0.5
[**2189-9-19**] 03:12PM BLOOD Plt Ct-322
[**2189-9-19**] 03:12PM BLOOD Glucose-115* UreaN-14 Creat-0.5 Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
[**2189-9-10**] 05:09AM BLOOD ALT-73* AST-85* CK(CPK)-2315* AlkPhos-54
TotBili-0.4
[**2189-9-19**] 03:12PM BLOOD Calcium-8.9 Phos-5.1* Mg-1.9
[**2189-9-10**] 05:09AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
[**2189-9-10**]: MRI spine
No evidence of infection or abscess formation.
2. Multilevel degenerative changes, unchanged when compared to
prior exam.
[**2189-8-29**]:MR cervical spine w/o contrast
IMPRESSION: Limited study with sagittal T1- and T2-weighted
somewhat motion- limited images obtained. There appears to be
severe spinal stenosis by disc herniation and bulging at C5-6
level. This can be better evaluated with a focused cervical
spine MRI study. Degenerative changes are seen on scout images
in the thoracic and lumbar regions. There appears to be epidural
lipomatosis in the thoracic region.
[**8-31**]-C-SPINE non trauma- [**1-13**] views in OR
On view #1, C1 through lower portion C4 is demonstrated and a
surgical marker
overlies the spinous process of the C4 vertebral body. Multiple
support
devices are in place.
On the AP view, bilateral pedicle screws are in place from C4
through T1.
On the unlabelled lateral view, the pedicle screws are seen
posteriorly,
nominal in position, with evidence of laminectomy.
Correlation with real- time findings and when appropriate,
conventional
radiographs are recommended for full assessment.
[**2189-8-31**]: MRI spine w/wo contrast
IMPRESSION: Multilevel disc degenerative changes throughout the
thoracic
spine with enlargement of the anterior-posterior diameter of the
thoracic
vertebral bodies, more significant from T4 through T11 and also
intervertebral
disc Schmorl's nodes, raising the possibility of sequelae of
osteochondritis,
mild epidural lipomatosis is also identified. Multilevel disc
degenerative
changes, more significant at T1/T2, T2/T3 and T8/T9 levels.
There is no
evidence of abnormal enhancement in the thoracic spinal canal,
the signal
intensity throughout the thoracic spinal cord is normal.
In the lumbar spine, there is evidence of multilevel disc
degenerative
changes, more significant at T12/L1, L2/L3, L3/L4 and L4/L5
levels.
[**2189-9-13**]: CXR
Interval increase in mediastinal and pulmonary vascular caliber
suggests
cardiac decompensation and volume overload. Edema would account
for
thickening of the minor fissure and a mild generalized increase
in
opacification of the left lower lung. Pleural effusion, if any,
is minimal. I doubt that there is pneumonia.
Brief Hospital Course:
Mr. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] was initially admitted to [**Hospital1 18**] Neurology
service upon transfer from a hospital in [**Location (un) 3844**] for
further evaluation of neck pain and bilateral upper and lower
extremity altered sensation and weakness. patient was initially
in too much pain to tolerate an MRI scan. he had general
anesthesia for an MRI on [**8-31**]. this showed multi-level cervical
stenosis and he had progressive motor weakness with BLE
paralysis (some preserved sensation) and worsening BUE weakness
(most pronounced distally). ortho spine was urgently consulted
and patient was taken to the OR that afternoon for the above
decompression and fusion. patient tolerated the procedure well
and was transferred to the ICU intubated for airway
protection/edema. self-extubated on [**9-1**]. transferred to floor
on [**9-2**]. continued with fevers on [**9-25**]. pan-cultures done
along with xrays. vanco and zosyn started empirically. he had
received several doses of clinda periop for possible aspiration
PNA. he otherwise had ancef for 3 doses postop. he continued
with BLE paralysis postop and PT/OT worked with him.
1. FEVERS OF UNKNOWN ORIGIN- Initially, he was on the neurology
service; MRI of cervical/thoracic/lumbar spine was attempted but
unable to conduct due to patient's claustrophobia and anxiety
despite anxiolytics so he was intubated by anesthesia with video
assisted laryngoscopy on [**8-31**]. MRI revealed degenerative disc
disease with bulging of thecal sac at C4/C5 (see full report in
Imaging section). He developed worsening symptoms and due to
concern for cord compression, he was evaluated by Ortho-Spine
and taken emergently to the OR for decompression and laminectomy
of C3-T1 on [**8-31**]. He did well post-operatively and
self-extubated on POD 1. However, on POD 2 he started spiking
low-grade fevers to 99s-100s. He started a course of Vanc/Zosyn
on [**9-4**]. Blood and urine cultures were negative at the time. On
[**9-6**], he was reported to have a fever of 105.7, but did not
realize his fever was so high. He was swabbed for influenza and
this returned negative. On [**9-7**], he was transferred to the
general medical service (from ortho-spine) to further evaluate
his fevers of unknown origin. Each time he spiked a fever, he
was pan-cultured. Several chest X-rays were done to rule out
pneumonia. His surgical wound was carefully evaluated to rule
out possible infectious source. Neurology was initially
consulted, but refused to see the patient as they had no further
recs regarding his bilateral lower extremity paralysis.
Infectious Disease was consulted regarding his fevers of unknown
origin and they suggested discontinuing the Vancomycin and Zosyn
as no source of infection could be identified to date. Viral
serologies for possible transverse myelitis were sent and
patient was Lyme negative, EBV IgG positive but IgM negative,
indicating an EBV infection at some point in the past, but not
currently. Wound care was consulted and followed the patient
closely. OrthoSpine service (Dr. [**Last Name (STitle) 1007**] evaluated the patient's
surgical incision and it was clean, dry, intact and not
infected. Vanc and Zosyn were both discontinued as blood and
urine cultures have bene negative to date, and it seemed
patient's fever subsequently resolved as he was afebrile for the
remainder of his hospital course.
2. NECK/SHOULDER PAIN- Post-operatively, Mr. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] was
initially on Dilaudid, but he wished to discontinue this
medication due to hallucinations at night. A number of pain
regimens were tried without much effect, so a pain consult was
called on [**9-8**]. Drs. [**First Name (STitle) 84601**] [**Name (STitle) **] and [**Name5 (PTitle) **] [**Doctor Last Name **] recommended a
pain regimen of MS Contin, Morphine IR, Amitryptaline,
Gabapentin and lidoderm patches was initiated, with good
symptomatic relief. This pain regimen was monitored throughout
his course and tramadol four times daily was added on [**9-15**]. The
patient reported that after this regimen was initiated it was
the best he had ever felt in the hospital.
3. DECUBITUS ULCERS- Patient developed pressure ulcers on his
Left heel and around his buttocks. Skin breakdown was present
along the intergluteal cleft bilaterally. His wounds were
A daily plan of q2h turning and wound management was initiated
as well as daily tap water enemas to remove stool that could
potentially contaminate his sacral decubitus site. He remained
afebrile with no signs of infection from these ulcers. Wound
care ([**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 11198**], [**First Name8 (NamePattern2) 501**] [**Last Name (NamePattern1) **] and M. Gunning) carefully
followed the patient and left specific recommendations on [**8-17**], [**9-14**] and [**9-16**] to minimize risk of infection.
He is being discharged to the [**Hospital 27021**] Rehab [**Hospital 67742**] Medical
Center tel: [**Telephone/Fax (1) 84602**] in [**Location (un) **] [**Location (un) 3844**], with plan for
follow up with his orthopedic surgeon Dr [**Last Name (STitle) 79**] within 2 weeks.
Medications on Admission:
1. oxycodone 10-20mg q4h pain
2. dilaudid 1-3mg q2h PRN breakthrough pain
3. Vancomycin 1250mg IV q8h started [**9-7**]
4. Zosyn 4.5g IV q8h started [**9-7**]
5. Nystatin 500,000 u PO q8h
6. gabapentin 300mg PO q8h
7. bisacodyl 10mg PO/PR daily: PRN
8. famotidine 20mg PO q12h
9. docusate 100mg PO BID
10. senna 1 tab PO bid
11. diazepam 10mg PO q6h: PRN muscle spasms
12. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for if
no bowel movement.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*240 Tablet(s)* Refills:*0*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
7. Nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for thrush.
Disp:*90 Tablet(s)* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for back spasms.
Disp:*240 Tablet(s)* Refills:*0*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3PRN () as
needed for pain.
Disp:*240 Tablet(s)* Refills:*0*
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
Disp:*10 Suppository(s)* Refills:*2*
12. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
15. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 67742**] Medical Center Rehabilitation - [**Location (un) **], NH
Discharge Diagnosis:
multi-level cervical spinal stenosis with spinal cord injury.
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were admitted [**8-29**] with neck pain and lower extremity
weakness. Due to concern for cord compression, you underwent the
following operation: Posterior Cervical Decompression and Fusion
on [**8-31**].
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks.
- Rehabilitation/ Physical Therapy:
-continue intensive rehab.
-- Wound Care: Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Call the office at that time.Staples can
be taken out in 1 week.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. . Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
The following medications have been ADDED:
1. hydromorphone 4mg tab q3H PRN pain
2. fentanyl 75mcq 72hr patch.
3.lorazepam 0.5mg TID PRN back spasm
4. lidocaine 5%-700mg/patch
5. Morphine 15mg p.o q3h PRN pain
6 Amitryptyline 50mg p.o HS bedtime
7. Tramadol 80mg p.o QID
8. Gabapentin 800mg T.I.D
Followup Instructions:
Please set up an appointment to follow up with your orthopedic
surgeon, Dr [**Last Name (STitle) 79**] within 2 weeks.
|
[
"707.22",
"707.05",
"344.09",
"555.9",
"341.20",
"599.71",
"707.03",
"780.62",
"305.1",
"728.88",
"722.71",
"575.10",
"278.01",
"707.20",
"300.29",
"338.18",
"707.07",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
16199, 16303
|
8596, 13838
|
362, 516
|
16409, 16428
|
4578, 8573
|
18266, 18388
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2402, 2508
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14310, 16176
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16324, 16388
|
13864, 14287
|
16452, 16661
|
2523, 4559
|
16804, 16834
|
17598, 18243
|
16694, 16786
|
276, 324
|
16847, 17586
|
544, 2056
|
2078, 2299
|
2315, 2386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,325
| 128,829
|
29597
|
Discharge summary
|
report
|
Admission Date: [**2179-1-5**] Discharge Date: [**2179-1-20**]
Date of Birth: [**2123-5-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hypotension, hypoxia
Major Surgical or Invasive Procedure:
Insertion of peripherally inserted central catheter
Insertion and subsequent removal of internal jugular central
venous catheter
History of Present Illness:
Ms. [**Known lastname **] is a 55 yo woman with Down's syndrome living at an
[**Hospital3 **] facility who was sent in for hypotension. By
report from staff at her facility, she has appeared more
lethargic over the past week. Again by report, she has had
baseline sbp on order of 90's. She was referred initially to
[**Hospital 882**] hospital where she was found to have sbp in 70's. She
was was given IVF, stress dose steroids (solumedrol 100mg), and
empiric zosyn (3.375mg). EKG was NSR at 67bpm with nl axis,
intervals with no diagnostic ST/Twave findings. No prior for
comparison. Trop I was 0.04 (ref range < 0.10). WBC 8.9. Hct
35.1. Plt 347. ABG (unspecified O2) was 7.39/46/101/27. Urine
and blood cultures were sent.
.
In our ED, initial vitals were 97.0, 72, 74/25, 18, 98% 4L nc
(sats in 88% on RA). A R. IJ catheter was placed under sterile
conditions. She had very low CVP readings (reportedly 0 to -3),
which responded to IVF boluses. She was also started on
Dopamine. Her pressures increased to low 100's sbp after these
interventions. BP increased to 113/84 after 4L NS in total and
starting Dopamine gtt to 7.5mcg/kg/hr. The etiology of her
hypotension was unclear, but considered likely from hypovolemia.
Otherwise she did not meet SIRS criteria. She did have an
elevated WBC at 14.7, but did not have fever, tachycardia,
tachypnea. UA was normal from outside hospital.
.
In the MICU, her dopamine was quickly weaned off. [**Last Name (un) **] stim was
negative. All Cx were negative. BP was ten points higher by a
line. She was called out several days ago, but has not gotten a
bed. Her BPs have been consistently 90s-110. She had some mild
hypoxia, attributed to sleep apnea which was treated with oxygen
via nasal cannula at night. She has been sad and not taking
POs--conversation was had with her brother, who is her guardian
and he does not want PEG.
Past Medical History:
1. Down's syndrome
2. GERD
3. h/o adrenal insufficiency
4. Bipolar
5. hypothyroidism
6. h/o urosepsis
7. on aspiration precautions
Social History:
Lives at an [**Hospital3 **] facility. Her brother live in
[**Name (NI) 108**]. She was previously cared for by her mother who is now
ill and living in [**Name (NI) 108**].
Family History:
Not obtained
Physical Exam:
96.9 90/51 75 14 95%RA
NAD, sleepy
MMM&clear
CTAB
Nl S1/S2
Soft, nt, nd, +BS
WWP X 4
Pertinent Results:
Labs on admission:
WBC 14.7 (90% neutrophils, 6% bands), Hct 36.9, Plt 423,000
INR 1.3
Retic count 1.5%
creatinine 1.1
glucose 206
LFTs within normal limits
iron 34,
albumin 2.8
vitamin B12 759, folate 19.8
TSH 4
cortisol 11.9 --> 26.4
negative urine eosinophils
.
Imaging:
CTA chest ([**1-5**]): There is no evidence of main or segmental
pulmonary embolism. Evaluation of the subsegmental pulmonary
arteries is slightly limited by respiratory motion and
atelectasis; however, no secondary signs of distal pulmonary
emboli are identified. There is no CT evidence of right heart
strain. Prominent mediastinal lymph nodes measuring upwards of 1
cm are seen. No pathologically enlarged hilar or axillary
lymphadenopathy is identified. The esophagus appears slightly
patulous with fluid level noted. There is evidence of right neck
hematoma, incompletely evaluated on this study, possibly
secondary to right-sided central venous line placement. Also
noted is an aberrant right subclavian artery.
.
ECHO ([**1-6**]): The left atrium is normal in size. The estimated
right atrial pressure is 5-10 mmHg. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular systolic function is normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and regional left ventricular systolic
function. Mild mitral regurgitation.
.
CT Chest ([**1-11**]): The overall findings are most consistent with
hydrostatic pulmonary edema, with septal thickening, ground
glass and bilateral pleural effusions. Hydrostatic pulmonary
edema could potentially obscure a viral or PCP [**Name Initial (PRE) 2**].
.
CT neck ([**1-11**]): The previously noted soft tissue fluid has
resolved. There is no evidence of a soft tissue hematoma on
today's exam. No fluid collections are identified. There are
bilateral pleural effusions present. Please refer to the CT of
the chest from the concurrent day.
Aberrant left subclavian artery. Enlarged temporal horns of the
lateral ventricles as well as enlarged fourth ventricle could be
consistent with communicating hydrocephalus. Please correlate
the patient's history on prior examinations.
.
Renal ultrasound ([**1-18**]): 1) Normal Greyscale appearance of the
kidneys. No hydronephrosis. 2) Asymmetric decreased vascularity
of the right kidney of unclear etiology and significance; if
warranted this could be further evaluated by dedicated MRA on a
non-emergent basis.
.
Microbiology:
Blood culture ([**1-5**]): negative
Blood culture ([**1-10**]): ANAEROBIC BOTTLE (Final [**2179-1-13**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 70954**] -CC7- @ 14:05
[**2179-1-11**].
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
Blood culture ([**1-11**], [**1-12**], [**1-13**]): negative
stool negative for C diff X 3 ([**1-13**], 15, 16)
Urine culture ([**1-6**], 11, 12, 14): negative
.
Labs at discharge:
WBC 4.4, Hct 26.4, Plt 378
creatinine 1.3
INR 1.2
Vancomycin level 18.6
Brief Hospital Course:
Ms. [**Known lastname **] is a 55 year old female with Down's syndrome and
recent hospitalizations for hypoxia/hypotension here with same
now called out of the MICU and found to have MRSA sepsis.
.
# Hypotension/fever: On arrival from the MICU, the etiology of
the patient's hypotension was unknown. Potentially, her
presentation could be due to dehydration/volume depletion. Her
blood pressures improved with fluid boluses. On the floor, the
patient again had low blood pressures into the 70s systolic and
was febrile. Originally, we thought she had aspiration pneumonia
and she received levofloxacin/flagyl. Another possibility was
seeding of neck hematoma (secondary to line insertion) but neck
CT demonstrated resolution of the hematoma. She was persistently
febrile so vancomycin was added to her antibiotic regimen.
Subsequently, blood cultures demonstrated MRSA growing from [**1-31**]
blood cultures from [**1-10**]; there was no sign of aspiration
pneumonia. When these cultures returned, we discontinued the
levo/flagyl. It is thought that this bacteremia resulted from
her central line placed in the ICU. Her blood pressures improved
on treatment; as her PO intake has been poor, she intermittently
required normal saline boluses. Later, she developed diarrhea
but was C diff negative.
- No sign of adrenal insufficiency by labs.
- She will need one more dose of vancomycin on [**1-22**] to complete
a 2-week course of antibiotics for bacteremia.
- She has a right-sided PICC line for antibiotics.
- At times, she is found to be hypotensive while sleeping. When
this occurs, it is usually in conjunction with slight hypoxia
which we believe is secondary to sleep apnea. When this occurs,
the patient should be roused as necessary (cool towels to face,
talking with her). Her blood pressure repeats when this happens
return to baseline which is 90s-100s.
.
# ARF: The patient's creatinine was 1.1 on arrival and peaked at
1.4. It is 1.3 at the time of discharge. The patient was
evaluated by the Renal team here. We believe that her
hypotension caused an element of ATN (FeNA was 3.9%). Renal
ultrasound demonstrated decreased blood flow to the right kidney
but this is of uncertain significance. She received fluid
boluses as above to keep blood pressures ~ 90. She had no
evidence of urine eosinophils.
.
# Hypoxia - The patient's intermittent hypoxia is probably
secondary to baseline sleep apnea in this patient with Down's
syndrome. Since arrival on the floor, she has been comfortable
on room air. She does intermittently dip her sats during sleep.
- She should have a Sleep study as an outpatient to further
evaluate this.
.
# Diarrhea: The patient developed diarrhea after one week of
antibiotic therapy. Her C diff screens were negative X 3 and a
stool culture was also negative. This could be a side effect of
antibiotic therapy. This is improved at the time of discharge.
.
# Hypothyroidism: On levothyroxine. TSH normal.
.
# Anemia: The patient, after hydration in the MICU, had stable
but low hematocrit ranging from 24-27. Her ferritin was 89, iron
34 with TIBC 160 (> 17%). Her B12 and folate were WNL. She
should have this followed as an outpatient. Colonoscopy could be
considered by her PCP; however, this would be an invasive
procedure and it is unclear if she has had this further
evaluated in the past.
.
# Increased INR: Her INR was slightly elevated during her stay
and is 1.2 on discharge. She did receive PO vitamin K X 3 doses.
This could be secondary to poor nutrition as her albumin was 2.8
on admission.
.
# FEN - The patient tolerated a thin liquid diet with pureed
solids. She enjoys Boost pudding. She should have 1:1
supervision with meals. When her PO intake was poor, we
discussed with [**First Name8 (NamePattern2) **] [**Known lastname **] (the patient's brother) in FL the
possibility of PEG placement. He feels that this would be too
invasive for a long term intervention. He thought that she would
do better in a more familiar environment. She received IVF as
necessary for poor PO intake and when her diarrhea was profuse.
.
# Code: Full for now, the patient's brother expresses wish for
short-term reversible problems to be addressed but recognizes
that long-term quality of life is larger issue.
.
# Access : Has right-sided PICC line as above for antibiotics.
.
# Dispo: To extended care facility that can manage her PICC
line. She should continue PT/OT as appropriate.
.
# Comm- [**Name (NI) **] [**Name (NI) **], brother, in [**Name2 (NI) **] [**Telephone/Fax (1) 70955**] (cell),
([**Telephone/Fax (1) 70956**]; [**Telephone/Fax (1) 70957**] (home); her case manager at her
group home is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Telephone/Fax (1) 70958**].
Medications on Admission:
celexa 20 daily
asa 81 mg daily
lipitor 40 mg daily
gabapentin 300 TID
depakote 250 mg TID
synthroid 50 mg daily
Levaquin X 4 days
evista 50 mg daily
vitamins
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. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
6. 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.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
9. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous ONCE for 1 doses: Please give one dose on [**2179-1-22**].
Thanks.
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Methicillin-resistant staph aureus sepsis with resultant
hypotension
Hypoxia, resolved
Down's syndrome
Gastroesophageal reflux
Hypothyroidism
History of bipolar disorder
History of urosepsis
History of adrenal insufficiency
Discharge Condition:
Afebrile, normotensive, comfortable on room air
Discharge Instructions:
Please take your medications as prescribed. Please call your
physician or return to the emergency room should you develop any
of the following symptoms: fever > 101, chills, nausea or
vomiting with inability to keep down liquids or medications,
diarrhea, low oxygen saturations, low blood pressure, dizziness,
passing out, decreased mental status, or any other concerns.
.
You have been evaluated for your low blood pressure and your low
oxygen saturation. You were found to have a blood infection
which is being treated with antibiotics. Your oxygen is low at
times while sleeping. You will need an outpatient sleep study.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
within 1-2 weeks. Call [**Telephone/Fax (1) 70959**] for an appointment.
Completed by:[**2179-1-20**]
|
[
"244.9",
"327.23",
"758.0",
"458.9",
"038.11",
"995.91",
"V09.0",
"799.02",
"787.91",
"584.5",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12995, 13036
|
6972, 11721
|
334, 465
|
13304, 13354
|
2867, 2872
|
14026, 14242
|
2732, 2746
|
11930, 12972
|
13057, 13283
|
11747, 11907
|
13378, 14003
|
2761, 2848
|
274, 296
|
6876, 6949
|
493, 2371
|
2886, 6857
|
2393, 2526
|
2542, 2716
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,010
| 185,722
|
7525
|
Discharge summary
|
report
|
Admission Date: [**2126-6-16**] Discharge Date: [**2126-6-23**]
Date of Birth: [**2054-8-5**] Sex: M
Service: Medicine, [**Hospital1 **] Firm
HISTORY OF PRESENT ILLNESS: This is 71-year-old male with a
past medical history of chronic abdominal pain (status post
esophagogastroduodenoscopy on [**2126-6-11**] showing
gastritis), depression, hypothyroidism, and hypertension who
presented with abdominal pain to the Emergency Department on
[**2126-6-15**] associated with nausea, vomiting, decreased oral
intake, and decreased urine output.
Laboratories at the time of Emergency Department presentation
were notable for a lipase of greater than 6000, amylase
of 1321, elevated white blood cell count at 14.9 (with 7%
bands). Blood glucose was 136. LDH of 1156 and AST of 866.
Vital signs on presentation were temperature of 99.9, heart
rate of 125, blood pressure of 145/98, respirations of 18,
pulse oximetry of 95% on room air. A CT scan of the abdomen
showed moderate peripancreatic and perigallbladder fat
stranding, and a small amount of gas in the gallbladder. The
patient was admitted to the Surgical Intensive Care Unit
after receiving ceftriaxone 2 g, Flagyl 500 mg, and
levofloxacin 500 mg, as well as Demerol and intravenous
morphine for pain control in the Emergency Department. The
patient also received fluid resuscitation with 5 liters of
normal saline.
The patient was presumed to have gallstones pancreatitis, and
an endoscopic retrograde cholangiopancreatography was
performed on [**6-16**] showing frank pus at the major papilla,
cholangitis, successful extraction of sludge and stone
fragments, and a sphincterotomy was performed.
Following endoscopic retrograde cholangiopancreatography, the
plan was to take the patient for laparoscopic
cholecystectomy, but surgery was delayed secondary to
congestive heart failure treated with Lasix, and rapid atrial
fibrillation (treated with a diltiazem drip). Status post
endoscopic retrograde cholangiopancreatography, the patient
developed respiratory distress and a new oxygen requirement
which was considered to be pulmonary edema but was also noted
to have an elevated creatinine.
Cardiology was consulted on [**6-18**] and recommended continuing
with Lopressor and Lasix. An echocardiogram showed an
ejection fraction of greater than 55%. As part of the
congestive heart failure evaluation, a Swan-Ganz catheter was
placed on [**6-18**] showing a central venous pressure of 16, a
pulmonary capillary wedge pressure of 28, and a cardiac
output of 6.6.
Because of the elevated creatinine and difficulty diuresing
the patient, the Renal Service was consulted on [**6-18**] as
well for management of fluid overload. Recommendations from
the Renal Service were to continue Lasix with electrolyte
repletion, renal dosing of medications, and to add D-5 water
for hypernatremia. A renal ultrasound showed no renal artery
stenosis or hydronephrosis.
Between [**6-16**] and [**6-20**], the patient was treated with
ampicillin, levofloxacin, and metronidazole. On [**6-20**], the
patient was transferred to the Surgery floor at which time
the antibiotics were discontinued, and the patient began
tolerating a clear liquid diet. On [**6-21**], the patient was
transferred to the Medicine Service for management of medical
issues.
PAST MEDICAL HISTORY:
1. Depression, status post admission to Psychiatry in [**2125-6-15**]; status post electroconvulsive therapy, followed by
Dr. [**Last Name (STitle) 2109**].
2. Chronic abdominal pain, status post
esophagogastroduodenoscopy on [**2126-6-11**] showing gastritis.
3. Hypothyroidism.
4. Hypertension.
5. Benign prostatic hypertrophy.
6. Status post kidney donation to son; now deceased.
7. B12 deficiency.
MEDICATIONS ON TRANSFER: Medications on transfer from the
Surgical Service included Flomax 0.4 mg p.o. q.d.,
Levoxyl 50 mcg p.o. q.d., Protonix 40 mg p.o. q.d.,
metoprolol 75 mg p.o. b.i.d., subcutaneous heparin 5000 units
b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married, and his wife has
[**Name (NI) 2481**] disease. He has a total of three children; one
of whom is deceased. He denies tobacco or alcohol use. He
is a retired custodian.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 98.3, blood pressure of 156/80, heart rate
of 80, respirations of 20, pulse oximetry of 92% on room air.
Generally, a pleasant and somewhat anxious-appearing male who
was otherwise comfortable, in no apparent distress. Head,
eyes, ears, nose, and throat revealed pupils were equal,
round, and reactive to light. No scleral icterus. Mucous
membranes were moist and without lesions. Neck was supple
without adenopathy or elevated jugular venous distention.
Heart had a regular rate and rhythm. First heart sound and
second heart sound were present. Positive fourth heart
sound. No third heart sound or murmur. There was a left
internal jugular catheter which was intact. Lungs were clear
to auscultation bilaterally. The abdomen revealed bowel
sounds were present, soft, nontender, and nondistended. No
masses. Extremities revealed trace lower extremity edema.
Foley was in place. Skin was warm and dry. No jaundice.
Neurologically, alert and oriented times three. No gross
deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
transfer revealed white blood cell count of 13.3, hematocrit
of 38.2, platelets of 224. Potassium of 3.5, blood urea
nitrogen of 24, creatinine of 1.5, glucose of 81. ALT of 77,
AST of 55, alkaline phosphatase of 162, amylase of 29, lipase
of 49, and total bilirubin of 0.9. Calcium of 8.2, magnesium
of 1.8, phosphorous of 3.7. Thyroid-stimulating hormone
of 7.8.
RADIOLOGY/IMAGING: A chest x-ray on [**6-20**] revealed left
internal jugular catheter placement, decreased right upper
lobe atelectasis, consolidation versus atelectasis in the
left retrocardiac space.
HOSPITAL COURSE BY SYSTEM: The bulk of the hospital course
occurred on the Surgical Service, and is per the summary in
the History of Present Illness.
1. CARDIOVASCULAR: The patient had converted to sinus
rhythm on the Surgical Service after being rated controlled
for atrial fibrillation with diltiazem. He was transiently
placed on a beta blocker for blood pressure and rate control.
In terms of volume status, the patient was felt to be
clinically euvolemic when transferred to the Medicine
Service, and further diuresis was held.
2. PULMONARY: On transfer to the Medicine Service, the
patient had stable oxygen saturations on room air and was
noted to have atelectasis by chest x-ray. The patient
remained on room air throughout the hospitalization without
further pulmonary complications.
3. RENAL: At the time of transfer, the patient's creatinine
had returned to its baseline of approximately 1.5. Further
diuresis was held. The patient continued to make adequate
urine output.
4. INFECTIOUS DISEASE: The patient was afebrile on transfer
and was noted to have a slightly evaluated white blood cell
count to 13.3 which had decreased to 9.8 by the time of
discharge. Culture data showed no growth to date from blood
cultures drawn on [**6-18**] or [**6-23**]. Urine cultures from
[**6-21**] showed no growth. After the left internal jugular
catheter was discontinued on [**6-21**], the culture of the
catheter tip showed no growth.
At the time of discharge, the patient was sent home with a
10-day course of ciprofloxacin 500 mg p.o. b.i.d. and
instructed to call his primary care physician should he
develop fevers, recurrent abdominal pain, or vomiting.
5. GASTROINTESTINAL: At the time of transfer, the patient
was noted to have resolving pancreatitis and cholangitis with
normalizing laboratory values. He was tolerating a clear
diet which was advanced until the time of discharge to a
soft-solid diet without further nausea, vomiting, or
abdominal pain.
As mentioned above, the patient was to continue on a course
of ciprofloxacin at home for 10 days.
6. ENDOCRINE: As part of the patient's workup for atrial
fibrillation, a thyroid-stimulating hormone was checked which
was found to be elevated at 7.8. Consideration may be given
as an outpatient to increasing the patient's Levoxyl dose.
7. NEUROLOGY/PSYCHIATRY: The patient was noted to be on
multiple psychiatric medications; the doses of which were
unknown at the time of this admission. He was to follow up
with regular psychiatric care at discharge and to resume his
outpatient psychiatric medications.
DISCHARGE DISPOSITION: The patient was evaluated by Physical
Therapy and found to be safe for discharge to home without
further services.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: To home.
DISCHARGE ACTIVITY: Discharge activity as tolerated.
DISCHARGE DIET: A cardiac/soft diet; advance slowly as
tolerated.
DISCHARGE DIAGNOSES:
1. Gallstones pancreatitis.
2. Cholangitis.
3. Atrial fibrillation with rapid ventricular response.
4. Congestive heart failure.
5. Chronic renal insufficiency.
6. Depression.
7. Hypothyroidism.
8. Hypertension.
9. Benign prostatic hypertrophy.
10. Status post kidney donation.
11. Chronic abdominal pain.
12. B12 deficiency.
DISCHARGE INSTRUCTIONS:
1. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within one week.
2. Follow up with Dr. [**Last Name (STitle) 468**] (telephone number
[**Telephone/Fax (1) 476**]) of Surgery within two weeks.
3. Call Dr. [**Last Name (STitle) **] with any recurrent abdominal pain,
vomiting, or fever.
4. The patient to follow up with Dr. [**Last Name (STitle) 2109**] for
continued psychiatric care.
MEDICATIONS ON DISCHARGE: Protonix 40 mg p.o. q.d. and
ciprofloxacin 500 mg p.o. b.i.d. (times 10 days). The
remainder of medications unchanged from admission.
[**Name6 (MD) **] [**Name8 (MD) 21809**], M.D. [**MD Number(1) 21812**]
Dictated By:[**Last Name (NamePattern1) 737**]
MEDQUIST36
D: [**2126-6-23**] 23:32
T: [**2126-6-26**] 07:59
JOB#: [**Job Number **]
|
[
"276.0",
"401.9",
"427.31",
"428.0",
"577.0",
"576.1",
"574.20",
"584.5",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"38.93",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
8572, 8698
|
8923, 9270
|
9750, 10128
|
9294, 9723
|
5971, 8548
|
8713, 8901
|
188, 3319
|
3777, 4021
|
3341, 3751
|
4038, 5943
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,569
| 114,532
|
8171
|
Discharge summary
|
report
|
Admission Date: [**2176-1-10**] Discharge Date: [**2176-1-16**]
Date of Birth: [**2116-12-12**] Sex: M
Service: SURGERY
Allergies:
Tylenol / Potassium
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
progressively increased swelling of his graft site since surgery
Major Surgical or Invasive Procedure:
[**2176-1-11**] Ultrasound-guided access for vascular imaging,
aortic catheterization with abdominal aortogram and pelvic
runoff, right common iliac artery stent, right external iliac
artery stent, right to left femoral to femoral bypass,
removal of axillary to femoral bypass graft.
History of Present Illness:
59M Hispanic male s/p left axillofemoral bypass on [**2175-4-3**] with PTF Propaten graft. He has a long history of severe
symptomatic left aorto-iliac disease thigh and calf claudication
with ambuation, L>R. He has had significant improvement in his
claudication symptoms since his surgery, however he has had
progressively increased swelling of his graft site since
surgery.
He was recently discharged for increased swelling of the graft
site for concern of graft site infection v. seroma v. allergic
reaction, and was on IV anti-biotics. Since then, he has
continued to have further expansion of the graft site with
tightness.
Past Medical History:
-Coronary artery disease
-myocardial infarction in [**2166**], status post percutaneous
coronary intervention, vessel intervene unknown.
-systolic congestive heart failure recurrent with ejection
fraction of 20%.
- diabetes,controlled.
- hypertension, controlled
- bilateral renal artery stenosis status post renal artery
stenting bilaterally.
- hypercholesteremia
- subarachnoid hemorrhage secondary to cerebral aneurysm s/p
aneurysm clipping in [**2163**].
Social History:
Non contributory
Family History:
Non contributory
Physical Exam:
VS T 99.9 P3 BP 142/72 RR 20 O2 sat 97% on RA
Gen: AAOx3, NAD
Heart: RRR, no murmur
Lungs: clear by auscuktatiob bilaterally
Abd: soft, non-tender, non-distended
Skin: incision dry and intact
Ext: well perfused no edema
Pulses: Fem [**Doctor Last Name **] DP PT
[**Name (NI) 167**] palp dop palp palp
Left palp dop palp palp
Pertinent Results:
[**2176-1-15**] 04:41AM BLOOD WBC-9.4 RBC-3.02* Hgb-9.9* Hct-27.5*
MCV-91 MCH-33.0* MCHC-36.2* RDW-14.2 Plt Ct-188
[**2176-1-15**] 04:41AM BLOOD Plt Ct-188
[**2176-1-15**] 04:41AM BLOOD Glucose-116* UreaN-24* Creat-2.1* Na-136
K-4.4 Cl-106 HCO3-25 AnGap-9
[**2176-1-14**] 07:11PM BLOOD CK(CPK)-106
[**2176-1-14**] 07:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2176-1-15**] 04:41AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.5
[**2176-1-12**] 10:54AM BLOOD Glucose-94
[**2176-1-11**] 08:41PM BLOOD Glucose-83 Lactate-1.2 Na-137 K-3.5
Cl-110 calHCO3-21
Cardiology Report
ECG Study Date of [**2176-1-10**] 9:16:54 PM
Sinus rhythm with ventricular premature beats. Left ventricular
hypertrophy with ST-T wave changes. Compared to the previous
tracing of [**2175-9-19**] the ventricular premature beat is new and
the ventricular rate is slightly faster.
TTE (Complete) Done [**2176-1-11**] at 8:46:47 AM
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe global left ventricular hypokinesis with akinesis of
the inferior and inferolateral walls. (LVEF = 20-25 %). A left
ventricular mass/thrombus cannot be excluded. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] 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 but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPERSSION: Severe global hypokinesis with akinesis of the
inferior and inferolateral walls. Diastolic dysfunction. At
least moderate mitral regurgitation with an eccentric jet due to
tethering of the posterior mitral valve leaflet by the infarcted
infero-lateral wall.
ECG Study Date of [**2176-1-11**] 4:15:34 PM
Sinus rhythm. Baseline artifact. T wave inversions in the
lateral leads.
Early R wave transition. Possible right ventricular hypertrophy.
Possible
left ventricular hypertrophy. The ST-T wave changes may be
related to
left ventricular hypertrophy. Compared to the previous tracing
of [**2176-1-10**]
there is no significant change.
ECG Study Date of [**2176-1-12**] 12:50:16 PM
Sinus rhythm with premature atrial contractions. Possible
biventricular
hypertrophy with extensive ST-T wave changes secondary to left
ventricular
hypertrophy. Compared to the previous tracing of [**2176-1-11**] there
is no
significant change.
Radiology Report
CHEST (PRE-OP PA & LAT) Study Date of [**2176-1-10**] 8:28 PM
Final Report COMPARISON: [**2175-9-19**].
FINDINGS: There is a tortuous thoracic aorta. Heart size is
within normal
limits. No radiographic evidence of pneumonia present. Pulmonary
vascularity appears within normal limits. No effusion or
pneumothorax.
IMPRESSION: No acute cardiopulmonary process identified.
CHEST (PORTABLE AP) Study Date of [**2176-1-12**] 9:07 AM
Final Report
REASON FOR EXAMINATION: Evaluation of Swan-Ganz position.
Portable AP chest radiograph was compared to [**2176-1-11**].
The patient was extubated. The Swan-Ganz catheter tip is at the
right main
pulmonary artery. The cardiomediastinal silhouette is unchanged.
Bibasilar
atelectasis are unchanged. No edema or pneumothorax is present.
Brief Hospital Course:
[**2176-1-10**] Patient admitted for increased swelling of Axillary to
femoral bypass graft,
seroma versus infection, claudication. Routine nursing, labs,
NPO post MN and IVF and Bicarb drip start at MN. Pre-op
EKG-Sinus rhythm with ventricular premature beats. Left
ventricular hypertrophy with ST-T wave changes. Compared to the
previous tracing of [**2175-9-19**] the ventricular premature beat is
new and the ventricular rate is slightly faster. Pre-op CXR-No
acute cardiopulmonary process identified. Pre-op and consented
for abdominal aortogram and pelvic runoff, right common iliac
artery stent, right external iliac artery stent, right to left
femoral to femoral bypass and removal of axillary to femoral
bypass graft.
[**2176-1-11**] TTE ECHO-that showed severe global hypokinesis with
akinesis of the inferior and inferolateral walls. Diastolic
dysfunction. At least moderate mitral regurgitation with an
eccentric jet due to tethering of the posterior mitral valve
leaflet by the infarcted infero-lateral wall. Taken to OR and
underwent Ultrasound-guided access for vascular imaging,aortic
catheterization with abdominal aortogram and pelvic runoff,
right common iliac artery stent, right external iliac
artery stent, right to left femoral to femoral bypass,removal of
axillary to femoral bypass graft. A-line, PA line, foley
catheter and JP drains were placed intra-op. Cultures sent in
OR. Patient tolerated procedure. Transferred to CVICU post-op
for recovery and further monitoring. Patient was hypotensive
post-op, placed on pressors, transfused with 1 unit PRBC, sedate
and intubated. Started ABX vanco/Cipro and Flagyl. Pulses stable
pulse signals. DVT prophylaxis. Pain control.
[**2176-1-12**] Patient was extubated in CVICU, remains on ABX
Vanco/Cipro/Flagyl. T maxed 101.7. Pulse status stable. Pressors
weaned off, vitals stable. Started diet. Tranferred to VICU [**Hospital Ward Name 121**]
5 w/ telemetry for further monitoring. Pain managed w/ prn.
[**2176-1-13**] Patient remains febrile T maxed 101.4 pan cultured, the
rest of his vitals stable. PA line changed to tripple lumen
line-placement confirmed by CXR- also showed no evidence of
pulmonary vascular congestion and no signs of new parenchymal
infiltrates. JP remain in place. Pulse status stable. Physical
therapy consult- started out of bed to chair activity. Cultures
from the OR came back negative. [**2176-1-14**] Patient c/o vertigo-
became intermittent, remains febrile T maxed 101.2. Remains on
ABX (Vanco/Cipro/Flagyl). Patient c/o chest pressure with a 9
beat run for V-tach, EKG done and cardiac enzymes sent. All came
back negative and R/O for MI. Electrolytes repleted. No further
episodes of V-tach. Cultures from [**2176-1-11**] came back negative.
A-line d/c'd.
[**2176-1-15**] Patient's fever is now coming down, T maxed 99.9.
Remains to have intermittent dizziness, w/ VSS. Made floor
status w/ telemetry. Foley d/c'd and voiding. Remains on ABX.
Cultures from [**1-13**] remain pending. Rehab screening.
[**2176-1-16**] Vitals stable overnight, patient is feeling better he
wants to go home instead of rehab. All cultures came back
preliminary negative. Patient discharged to home in good
condition, tolerating diet, ambulating, and voiding adequately,
will FU with Dr. [**Last Name (STitle) 1391**] in 2 weeks.
Medications on Admission:
plavix 75 mg po qd
ASA 81 mg po qd
carvedilol 12.5 mg [**Hospital1 **]
felodipine 5 mg po qd
lisinopril 20 mg po qd
digoxin 0.25 mg po qd
lasix 40 mg po qd
zocor 40 mg po qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
10. 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*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for temperature.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Axillary to femoral bypass graft seroma vs infection,
claudication.
history of Coronary artery disease, s/p MI [**2166**], status post PCI
vessel intervention unknown
history of chronic systolic congestive failure with ejection
fraction of 20% compensated
history of type 2 diabetes controlled with diet
history of hypertension
history of bilateral renal artery stenosis status post renal
artery stenting bilaterally
history of hypercholesteremia on statin
history of subarachnoid hemorrhage secondary to cerebral
aneurysm with aneurysm clipping and second aneurysm embolization
in [**2163**].
Discharge Condition:
Good
Discharge Instructions:
walk essential distances only until FU
ace wrap left lower extremity from foot to knee when walking
elevate lower extremities when sitting
no driving till seen in FU with Dr. [**Last Name (STitle) 1391**]
may shower, no tub baths
continue stool softener while on pain medications
continue current medications as directed
keep FU appointments
call Dr.[**Name (NI) 1392**] office for FU appointment ([**Telephone/Fax (1) 4852**]
call if you have a fever of more than 101.5, pain swelling, and
draining of your incisions
Followup Instructions:
Call Dr. [**Last Name (STitle) 1391**] for FU appointment in 2 weeks Phone: ([**Telephone/Fax (1) 29063**]
Completed by:[**2176-1-16**]
|
[
"276.2",
"428.42",
"272.0",
"250.00",
"E947.8",
"428.0",
"585.9",
"427.69",
"440.1",
"584.5",
"E878.2",
"427.1",
"403.90",
"440.21",
"V12.54",
"414.01",
"412",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"88.49",
"39.29",
"88.42",
"39.90",
"00.47",
"39.50",
"38.93",
"00.41",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10752, 10758
|
5795, 9114
|
345, 631
|
11396, 11403
|
2211, 5772
|
11970, 12108
|
1825, 1843
|
9338, 10729
|
10779, 11375
|
9140, 9315
|
11427, 11947
|
1858, 2192
|
241, 307
|
659, 1291
|
1313, 1775
|
1791, 1809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,091
| 178,213
|
35291
|
Discharge summary
|
report
|
Admission Date: [**2141-3-10**] Discharge Date: [**2141-3-14**]
Date of Birth: [**2086-12-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
hypoxia/resp failure
Major Surgical or Invasive Procedure:
ICU monitoring, endotracheal intubation, flexible bronchoscopy,
arterial catheter, IJ CVC, donor nephrectomy in OR
History of Present Illness:
This is a 54 yo M with a history of IPF, currently undergoing
lung transplant evaluation who was sent in to the ED with
hypoxia and worsening dyspnea.
.
The patient has been at [**Hospital **] rehab with baseline sats there
on 6L of high 80s to low 90s. Over the last 24 hours, he was
found to be having increasing work of breathing and decreased
sats to low 80s. Per his family, he was having difficulty even
completing sentences due to dyspnea. Additionally he spiked a
temperature to around 103. He was subsequently sent to an OSH
for evaluation. Per report, he was in respiratory distress and
was intubated. CXR there showed pulmonary fibrosis, unclear if
there was superimposed infiltrate. He was not given any
medications (?ertapenem) but rec'd 2 L of NS. As his care is
primarily here (he is followed by [**Doctor Last Name **]), he was sent here.
.
Patient was recently admitted from [**Date range (1) 80477**] with progressive DOE
without any new source. It was thought to be secondary to
worsening IPF. He intermittently required increased oxygen up
to 6L NC but did not require BiPAP or intubation. His work up
for lung transplant was continued during that time.
.
In the ED, initial VS 103.2 120 73/49 39 100% on vent, unclear
settings. Once propofol was weaned, BPs increase to 120s.
However, patient became agitated and was given versed which also
made him hypotensive. He was given 1 gram of tylenol,
Vanc/Levoflox for presumed pna and 3 additional L of IVF. Also
had dirty appearing urine. UA contaminated. He was sent to the
floor for further management.
.
On arrival to the floor, patient was satting in the low 80s on
PEEP of 5 which was increased to 10. O2 sats increased to the
mid-90s. He required versed for sedation as he became
dyssynchronous with the vent when agitated and more awake.
.
Review of sytems: Unable to obtain secondary to
intubation/sedation
Past Medical History:
Born w/ pectus excavatum
IPF undergoing transplant evaluation
HTN
AVNRT s/p ablation in [**1-30**]
Social History:
Currently works as a painter, but previously has worked with
sandblasting for 4 yrs during the [**2111**] (wore respirator but
beard prevented tight seal). Occasionally travels overseas to
[**Country 2045**] and [**Country 14635**] but states not a/w Sx. No known asbestos
exposure. Smoked for 19 yrs but quit 19yrs ago.
Family History:
Brother died of rare, agressive form of pulmonary fibrosis at
VA in CT. Brother did work with him briefly as a painter.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2141-3-10**] 06:10AM BLOOD WBC-22.1*# RBC-4.41* Hgb-12.3* Hct-37.9*
MCV-86 MCH-27.8 MCHC-32.4 RDW-13.2 Plt Ct-375
[**2141-3-10**] 06:10AM BLOOD Neuts-89* Bands-1 Lymphs-3* Monos-6 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2141-3-10**] 06:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2141-3-10**] 06:10AM BLOOD PT-17.1* PTT-25.0 INR(PT)-1.5*
[**2141-3-10**] 06:10AM BLOOD Glucose-108* UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-100 HCO3-29 AnGap-12
[**2141-3-10**] 06:10AM BLOOD ALT-34 AST-42* CK(CPK)-142 AlkPhos-152*
TotBili-0.5
[**2141-3-10**] 06:10AM BLOOD Lipase-21
[**2141-3-10**] 06:10AM BLOOD CK-MB-7
[**2141-3-10**] 06:10AM BLOOD Albumin-2.6* Calcium-8.3* Phos-4.1 Mg-2.0
[**2141-3-10**] 01:45PM BLOOD Cortsol-12.1
[**2141-3-10**] 09:45AM BLOOD Type-ART pO2-175* pCO2-76* pH-7.20*
calTCO2-31* Base XS-0
[**2141-3-10**] 06:30AM BLOOD Glucose-109* Lactate-1.1 Na-136 K-3.9
Cl-98* calHCO3-29
[**2141-3-10**] 07:26PM BLOOD O2 Sat-98
[**2141-3-10**] 07:26PM BLOOD freeCa-1.16
[**2141-3-14**] 03:21AM BLOOD WBC-15.8* RBC-2.85* Hgb-8.2* Hct-25.1*
MCV-88 MCH-28.6 MCHC-32.5 RDW-13.7 Plt Ct-369
[**2141-3-14**] 03:21AM BLOOD PT-18.0* PTT-30.1 INR(PT)-1.6*
[**2141-3-14**] 03:21AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-136
K-3.9 Cl-97 HCO3-35* AnGap-8
[**2141-3-10**] 06:10AM BLOOD cTropnT-0.16*
[**2141-3-10**] 01:44PM BLOOD CK-MB-15* MB Indx-6.3* cTropnT-0.14*
[**2141-3-10**] 10:10PM BLOOD CK-MB-11* MB Indx-8.9* cTropnT-0.11*
[**2141-3-11**] 02:10AM BLOOD CK-MB-9 cTropnT-0.11*
[**2141-3-12**] 02:17AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2141-3-14**] 03:21AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2141-3-14**] 03:21AM BLOOD Vanco-13.1
[**2141-3-14**] 01:20PM BLOOD Type-ART Temp-36.4 Rates-35/0 Tidal V-448
PEEP-8 FiO2-70 pO2-130* pCO2-67* pH-7.36 calTCO2-39* Base XS-9
-ASSIST/CON Intubat-INTUBATED
[**2141-3-14**] 01:20PM BLOOD Lactate-1.3
[**2141-3-13**] 04:50PM BLOOD O2 Sat-78
.
Radiology
.
[**3-10**] TTE: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal for the patient's body size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. An eccentric,
posteriorly directed jet of Mild (1+) 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 [**2140-12-26**], the RV
appears (more) dilated with evidence of pressure overload. The
estimated PA pressure has increased.
.
[**3-10**] CXR: Findings: There has been interval worsening of
opacification of the upper lung fields. A linear lucent line is
noted within the medial border of the left lung which most
likely represents pneumothorax. The endotracheal tube projects
approximately 6.7 cm above the carina. The NG tube distal tip
projects in the pylorus. IMPRESSION: 1. Interval increase in
opacification of upper lung zones. 2. New left pneumothorax.
.
[**3-13**] TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular free wall
is hypertrophied. The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
IMPRESSION: Severely dilated and moderately hypokinetic right
ventricle with at least moderate pulmonary artery systolic
hypertension. Moderate tricuspid regurgitation. Normal left
ventricular regional and global function. Small pericardial
effusion without evidence of tamponade.
Compared with the prior study (images reviewed) of [**2141-3-10**],
the findings are similar. The prior report mentions that the
right ventricle is mildly hypokinetic and moderately dilated
however on review, it was severely dilated and moderately
hypokinetic then.
.
[**3-14**] CXR: FINDINGS: In comparison with the study of [**3-13**], there
is little interval change. Support and monitoring devices remain
in place. Widespread bilateral pulmonary opacifications persist.
Enlargement of the trachea is again noted, unchanged from the
previous study.
.
Brief Hospital Course:
Respiratory failure: The patient's acute decompensation was
likely due to superimposed pneumonia on a patient with no
pulmonary reserve due to severe idiopathic pulmonary fibrosis.
According to prior OMR discharge summaries, he has been
experiencing worsening dyspnea with increased O2 requirement for
the last several weeks. He was treated with N-acetylcysteine,
vancomycin, meropenem, and ciprofloxacine during this admission.
Dr. [**Last Name (STitle) **] was in contact with [**Hospital6 1708**]
regarding the patient's transplant status. A repeat
Echocardiogram was obtained on [**3-13**], which showed severely
dilated and hypokinetic RV. This unfortunately meant that the
patient was no longer a candidate for transplant. A family
meeting was held on [**3-14**], and the patient was made CMO. The
patient was made eligible for kidney and spleen donation and
NEOB coordinated transfer of patient to the OR for nephrectomies
and splenectomy post-mortem.
Medications on Admission:
Acetylcysteine 20% 20 mg PO BID
Zolpidem Tartrate 5 mg PO HS:PRN
Sodium Chloride Nasal [**12-23**] SPRY NU [**Hospital1 **]:PRN
Lactulose 30 mL PO BID:PRN
Guaifenesin-CODEINE Phosphate [**4-30**] mL PO Q6H:PRN
Cosamin DS *NF* 500-400 mg Oral [**Hospital1 **]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Acetaminophen 325-650 mg PO Q6H:PRN
Vitamin D 400 UNIT PO DAILY
Senna 1 TAB PO BID:PRN
Omeprazole 20 mg PO DAILY
Multivitamins 1 TAB PO DAILY
Docusate Sodium 100 mg PO BID
Calcium Carbonate 500 mg PO QID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN
Benzonatate 100 mg PO QID
Aspirin 325 mg PO DAILY
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute exascerbation of IPF in setting of PNA
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2141-3-14**]
|
[
"518.81",
"486",
"785.51",
"E879.8",
"786.3",
"410.91",
"285.9",
"428.0",
"401.9",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"96.72",
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10488, 10497
|
8856, 9817
|
293, 409
|
10585, 10594
|
3425, 8833
|
10646, 10680
|
2814, 2937
|
10459, 10465
|
10518, 10564
|
9843, 10436
|
10618, 10623
|
2952, 3406
|
233, 255
|
2287, 2338
|
437, 2269
|
2360, 2460
|
2476, 2798
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,873
| 164,473
|
38447
|
Discharge summary
|
report
|
Admission Date: [**2170-1-19**] Discharge Date: [**2170-1-23**]
Date of Birth: [**2106-1-18**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
Upper EGD
History of Present Illness:
Ms. [**Known firstname **] is a 64 year old woman with history of autoimmune
hepatitis, hypertension, hyperlipidemia, and GERD who presents
with melena x 3 and crampy generalized abdominal pain. She
notes that symptoms started with nausea on [**1-16**] evening a
couple of hours after eating dinner, resulting in emesis of
blood-streaked mucus. The next morning she had one medium-sized
melenotic stool, followed by two more in the last two days. She
was seen first at her PCP's office [**1-18**] who did a CBC showing
Hct 30 (baseline Hct ~39) who sent her to the ED for upper
endoscopy. She notes having one large gritty black stool per
day for last three days. She reports no prior episodes of
melena, denies any lightheadedness or presyncopal symptoms. She
denies diarrhea or bright red blood per rectum. She did take
aspirin and Advil for joint pain this week, but no more than
usual, usually takes one per day. She has no history of
cirrhosis, ulcers, or varices.
.
EGD was done in [**6-/2169**] at outside site and showed no evidence of
varices. ERCP here did show some subtle beading in the
intra-hepatic biliary tree which raised the remote possibility
of PSC, which was felt to be unlikely. She was diagnosed in
[**6-/2169**] with autoimmune hepatitis with positive smooth muscle
antibody, significantly elevated IgG; she also had liver biopsy
confirmation of severe autoimmune hepatitis. She is followed by
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of Gastroenterology at [**Hospital1 18**], last seen in
11/[**2169**].
.
In the ED, initial vitals were as follows: T 98.1 HR 88 BP
155/65 RR 18 O2sat 100%RA. NG lavage was positive with pink
liquid, and rectal exam revealed melena. Two 16g peripheral IVs
were placed. Patient was started on a pantoprazole bolus + drip
in the ED. GI team is aware of patient's admission. Vitals in
ED prior to MICU transfer are as follows: T 98.6 HR 85 BP
148/60 RR 16 O2sat 100%RA.
.
On the floor, she feels well, reports no lightheadedness or
dizziness, but she does report generalized fatigue in the last
two days, though not significant enough to affect her activity
level. She has had no further bowel movements since
presentation to the ED.
.
Review of systems:
(+) Per HPI. Reports recent sore throat in last week which has
resolved. Has also had sinus headaches recently. She reports
elbow and knee bilateral joint pains since [**Month (only) 359**], worsened
with activity throughout day and denies morning stiffness of
joints. Reports increased neck stiffness as well. She does
report leg edema bilaterally R>L for several months, since
starting prednisone, improved since weaning prednisone though
still persists.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies rhinorrhea or congestion. Denies cough, shortness
of breath, or wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation or changes in bowel habits.
Denies dysuria, frequency, or urgency. Denies myalgias. Denies
rashes or skin changes.
Past Medical History:
- Acute Autoimmune Hepatitis - with signs of fulminant hepatitis
with coagulopathy, jaundice, and hypoalbuminemia. No cirrhosis
on liver biopsy.
- Responded to therapy with high-dose corticosteroids and
transition to azathioprine, per gastroenterologist
- Macular rash secondary to azathioprine and mild
leukopenia/thrombocytopenia secondary to azathioprine - topical
creams for rash and azathioprine dose reduced from 150 to 75 mg
daily in [**11/2169**]
- Pneumonia in [**7-/2169**] secondary to immunosuppression requiring
hospitalization (treated with cefpodoxime and doxycycline
therapy)
- HTN
- GERD
- hyperlipidemia
- osteopenia
- Raynaud's
- hiatal hernia
- urinary incontinence
- s/p appendectomy
- scoliosis and DJD of spine, s/p spine surgery
- renal cysts
Social History:
Ms. [**Known lastname **] teaches at [**Location (un) **]for 25 years, working
with disabled adults to teach preschool children. She lives
with her husband in [**Name (NI) 745**] and has 2 grown daughters and a
grandson. She denies any history of tobacco, used to drink an
occasionl glass of beer or wine but denies any alcoholic
beverage since [**11/2168**], and does not take any illicits, though
admits to an occasional marijuana joint in college.
Family History:
Father died of Parkinson's in [**2139**], mother died of
complications of CHF, had dementia and survived breast CA.
Uncle with ?exposure-related cirrhosis, another uncle with
pancreatic CA
and alcoholism. Brother also has [**Name (NI) 25670**].
Physical Exam:
Admission Physical exam:
Vitals: T: BP:118/64 P:83 R:12 O2:100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear with no tonsils;
mild maxillary sinus tenderness on medial right
Neck: supple, JVP not elevated but bounding carotid pulse
Lungs: Clear to auscultation bilaterally but with decreased air
movement at left base; no wheezes/crackles/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
appreciated
Abdomen: soft, non-tender, non-distended, mildly hyperactive
bowel sounds, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, trace DP pulses; 1+ edema bilateral
lower extremities
Pertinent Results:
LABS:
[**2170-1-19**] 08:30PM WBC-5.5 RBC-3.50* HGB-11.4* HCT-32.2* MCV-92
MCH-32.5* MCHC-35.4* RDW-17.4*
[**2170-1-19**] 08:30PM PLT COUNT-94*
[**2170-1-19**] 05:02AM GLUCOSE-102* UREA N-18 CREAT-0.6 SODIUM-139
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-26 ANION GAP-7*
[**2170-1-19**] 05:02AM CALCIUM-8.0* PHOSPHATE-4.0 MAGNESIUM-1.6
[**2170-1-19**] 01:20AM ALT(SGPT)-18 AST(SGOT)-26 ALK PHOS-65 TOT
BILI-1.0
[**2170-1-19**] 01:20AM LIPASE-74*
[**2170-1-19**] 01:20AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-4.2
MAGNESIUM-1.7
[**2170-1-19**] 01:20AM PT-14.0* PTT-27.7 INR(PT)-1.2*
IMAGING:
[**2170-1-19**] RUQ U/S
1. echogenic/coarse liver, denoting fatty infiltration,
cirrhosis, or
fibrosis.
2. No focal hepatic lesions seen.
3. Gallbladder polyp and cholelithiasis, with no evidence of
cholecystitis.
4. Patent flow within the portal and hepatic veins, with
appropriate waveforms
and flow directions.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 64 year old woman with severe autoimmune
hepatitis, treated with azathioprine, hiatal hernia,
hypertension, osteopenia, Raynaud's who presented with melena x
3 for two days and Hct drop from baseline, found to have likely
esophageal variceal bleed.
# Upper variceal bleed/Anemia: EGD showed grade 2 varices with
red wheel sign indicating likely site of bleed. 3 bands were
placed in the area of the lower [**1-22**] esophagus and lower
esophageal sphincter. A sliding hiatal hernia was also found.
She was started on a PPI drip x48 hours then transitioned to PO.
She was transfused 2 units of PRBCS, after which time her
hematocrit remained stable. She received 2 days of IV
ceftriaxone, then transitioned to po ciprofloxacin for SBP
prophylaxis.
.
# Autoimmune Hepatitis: RUQ US showed increase in the size of
her spleen and suggestion of cirrhotic changes of the liver.
With presence of varices and splenic enlargement, it is inferred
that she now has likely Stage IV disease. This is in contrast
to liver biopsy in [**6-/2169**] which did not show evidence of
fibrosis. Therefore she has likely had a rapid progression to
cirrhosis. Her liver enzymes have normalized on azathioprine
and her MELD is now 6, indicating a favorable response to
immunosuppression, although may require transplant in the future
should her MELD increase >15. She was continued on azathioprine
75mg daily. She will follow with Dr. [**Last Name (STitle) **] and her
rheumatologist. She has a repeat EGD for further banding
scheduled in 2 weeks.
.
# Hypertension: She was started on propranolol to help decrease
her esophageal varices and also treat her hypertension.
.
# Osteopenia: Her fosamax was discontinued due to the
possibility that it was a precipitant of esophageal varices
irritation and subsequent bleeding. She was continued on
Vitamin D and calcium.
.
# History of allergy to antibiotics: She developed a rash during
prior admission likely secondary to an antibiotic. We referred
her to see allergy for testing to elucidate which antibiotics
she might be allergic to.
.
She was FULL CODE for this admission.
Medications on Admission:
Azathioprine 75 mg daily
atenolol 50 mg daily
calcium
vitamin D
Fosamax (alendronate) 70mg weekly
omeprazole 20mg daily
Discharge Medications:
1. azathioprine 75 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Calcium 500 With D 500-125 mg-unit Tablet Oral
4. propranolol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. 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:*2*
6. Outpatient Lab Work
AST, ALT, Alkaline phosphatase, Total Bilirubin, albumin, WBC,
Hb, HCT, Plt, Na, K, Cl, HCO3, BUN, Cr, Glucose, PT, INR
7. sucralfate 100 mg/mL Suspension Sig: Ten (10) PO four times
a day.
Disp:*300 mL* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal varices (lower [**1-22**] of esophagus and at
gastroesophageal juntion) s/p banding of 3 varices
Upper GI bleed causing anemia- secondary to varices
Autoimmune hepatitis - with developement of stage IV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You came to the hospital because of blood in your stool. You had
an endoscopy which showed that you have esophageal varices
(distended veins) that bled. The esophageal varices were banded
in order to prevent re-bleeding. The varices are likely
secondary to your autoimmune hepatitis and underlying liver
disease. You required blood transfusions earlier in your
hospital stay, but since then your anemia has improved.
We have made the following changes to your medications:
- STOP atenolol
- STOP fosamax
- START ciprofloxacin 500mg by mouth twice daily for 3 days
(please take as soon as you wake up and right before bedtime) -
Ideally we want this medication to be spaced apart from
sucralafate
- START sucralafate 1gm by mouth four times daily, please take
apart from ciprofloxacin (try to wait 2 hours after cipro before
taking this medication)
- INCREASE omeprazole to 40mg once daily
- START propranolol 40mg twice daily
Please follow up with your physicians. You will need to have
laboratory tests drawn on [**2169-1-30**] (1 day prior to your visit
with Dr. [**Last Name (STitle) **], please go to [**Company 191**] to have this completed.
It was a pleasure caring for you. We wish you a speedy
recovery.
Followup Instructions:
[**2170-1-30**]: Please have laboratory tests drawn for your appointment
with Dr. [**Last Name (STitle) **]. The order is already in the computer.
Endoscopy with banding: [**2170-2-6**] at 9am with an 8am arrival time.
Location is the [**Hospital Ward Name 1950**] Building on the [**Location (un) 470**].
Liver center: [**Telephone/Fax (1) 2422**]
Department: LIVER CENTER
When: WEDNESDAY [**2170-1-31**] at 1:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (un) 85580**], [**Name8 (MD) 85581**], NP.
Location: [**Location (un) 2274**] [**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 70959**]
When: [**Last Name (LF) 2974**], [**2170-2-2**]:30
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82506**], MD
Specialty: Allergy and Inflammation
Address: [**Hospital1 **], [**Location (un) **]
Phone: [**Telephone/Fax (1) 72622**]
When: [**2-26**] at 12:50pm
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2170-1-23**]
|
[
"443.0",
"456.8",
"537.89",
"788.30",
"733.90",
"456.20",
"571.42",
"553.3",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
9644, 9650
|
6528, 8693
|
274, 285
|
9917, 9917
|
5591, 6505
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11347, 12693
|
4644, 4891
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8863, 9621
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9671, 9896
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10578, 11324
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2564, 3360
|
230, 236
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313, 2545
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9932, 10044
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3382, 4158
|
4174, 4628
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,644
| 143,093
|
40907
|
Discharge summary
|
report
|
Admission Date: [**2169-6-27**] Discharge Date: [**2169-6-28**]
Date of Birth: [**2133-9-29**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
right internal jugular central venous catheterization
left femoral arterial catheterization
History of Present Illness:
38 yo M with history of HCV and heroin abuse, who collapsed
after snorting heroin. His friends, who were also using drugs,
hit him in an attempt to awaken him. They called EMS, who
reportedly arrived after 5 minutes. He was reportedly initially
not in a shockable rhythm and received 20 minutes of CPR. During
CPR, he received epinephrine 4 mg, narcan 4 mg, and 40 units of
vasopression. He was intubated by EMS.
.
He was initially brought to [**Hospital 4199**] Hospital, where he was found
to be in Vfib and regained spontaneous circulation with 1 shock.
He was transferred to [**Hospital1 18**] for further management. Urine tox
was positive for benzos, opioids, ethanol, marijuana.
.
In the ED at [**Hospital1 18**], initial vital signs were T 32C HR 69 BP
127/66 RR 20 Sat 99%. He had no gag reflex, no reponse to
painful stimuli, pupils fixed 6 mm. GCS 3. He did overbreath the
vent. He was taken for CT, which showed extensive cerebral edema
with herniation, consistent with global hypoxic injury. After
CT, he became hypertensive to 230s/140s, and there was concern
for further herniation, but this was later felt to be secondary
to asynchrony. The patient was given vecuronium and propofol and
started on a propofol gtt, with normalization of his blood
pressure. The patient was also given mannitol 25 gm IV x 2. A
right IJ CVL was placed in the ED. A left femoral A-line was
placed due to difficulty placing a radial A-line. The patient
was noted to have copious urine and stool output.
.
Neurosurgery was consulted in the ED, and communicated that due
to the patient's extemely poor prognosis, there was no
indication for intracranial pressure monitoring.
.
Vitals at the time of transfer to were HR 105 SBP 140s. On
arrival to the MICU, the patient was unresponsive and unable to
give a history.
.
ROS: unobtainable
Past Medical History:
Past Medical History ([**First Name8 (NamePattern2) **] [**Hospital 4199**] Hospital ED records):
hepatitis C
h/o shoulder separation
adjustment reaction with anxiety and depression
.
Past Surgical History ([**First Name8 (NamePattern2) **] [**Hospital 4199**] Hospital ED records)
hernia repair
laproscopic cholecystectomy
Social History:
Notable for drug use. Parents are deceased. No children. Never
married. Has a half-brother [**Name (NI) **] [**Name (NI) 89325**], who lives in [**Name (NI) 1468**],
an a half-sister [**Name (NI) **] [**Name (NI) 89325**].
Family History:
non-contributory
Physical Exam:
VS: HR 111 BP 124/78 Sat 95%
GEN: Unresponsive. Intubated.
HEENT: Pupils 6 mm and fixed. Bruising around eye.
NECK: No JVD. Right IJ in place.
RESP: CTA b/l
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
copious stool output
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Unresponsive to voice, sternal rub, or painful stimuli.
No spontaneous movement. Pupils 6 mm and non-reactive. Corneal
reflexes absent. No oculocephalic reflex. Face symmetric.
Pertinent Results:
[**2169-6-27**] 05:00PM BLOOD WBC-23.0* RBC-4.37* Hgb-13.8* Hct-42.0
MCV-96 MCH-31.5 MCHC-32.8 RDW-12.9 Plt Ct-186
[**2169-6-27**] 07:17PM BLOOD PT-14.3* PTT-45.4* INR(PT)-1.2*
[**2169-6-28**] 12:44AM BLOOD Glucose-43* UreaN-25* Creat-1.5* Na-142
K-4.2 Cl-123* HCO3-11* AnGap-12
[**2169-6-27**] 09:51PM BLOOD Glucose-96 UreaN-22* Creat-1.3* Na-139
K-6.4* Cl-116* HCO3-13* AnGap-16
[**2169-6-27**] 05:00PM BLOOD ALT-379* AST-453*
[**2169-6-27**] 05:00PM BLOOD Lipase-85*
[**2169-6-27**] 05:00PM BLOOD cTropnT-<0.01
[**2169-6-27**] 05:00PM BLOOD CK-MB-5
[**2169-6-27**] 05:00PM BLOOD Calcium-7.1* Phos-8.9* Mg-2.5
[**2169-6-27**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Micro:
[**2169-6-27**] 5:00 pm BLOOD CULTURE (resulted reported as positive
after patient's death)
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2169-6-28**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
Imaging:
.
CT head w/o contrast [**2169-6-27**]:
1. Global cerebral edema and effacement of sulci consistent with
global anoxic injury.
2. Early downward transtentorial herniation secondary to
cerebral edema.
Findings discussed with the emergency room and the ICU team.
.
CXR (portable AP) [**2169-6-27**]: Limited study as above. Question
possible infiltrate at the right lung base versus atelectasis.
Endotracheal tube and nasogastric tube both in satisfactory
position.
Brief Hospital Course:
38 yo M admitted to MICU s/p cardiac arrest in setting of drug
abuse, with head CT indicating anoxic brain injury and cerebral
edema, with signs of early hearniation.
.
# Anoxic brain injury: Head CT showed anoxic brain injury with
cerebral edema and early herniation. Neurosurgery was consulted
in the emergency department and stated that the prognosis was
very poor, with recovery highly unlikely. For this reason,
neurosurgery recommended against any neurosurgical intervention.
This prognosis was discussed with the patient's half brother and
half sister by the MICU team.
.
# s/p cardiac arrest: The patient was started on an Arctic Sun
cooling protocol. However, after a family meeting in the MICU,
during which the patient's very poor neurologic prognosis was
explained, the family decided that it would be most consistent
with goals of care for the patient to be made comfort measures
only. At this point, the cooling protocol was stopped.
.
# Hypotension: The patient developed hypotension which was
treated with phenylephrine and IV fluids.
.
# Hyperkalemia: The patient had hyperkalemia to 6.4, which was
treated with calcium, insulin, and dextrose, with improvement in
the patient's potassium to 4.2.
.
# Heroin overdose: Narcan given prior to admission.
.
# Goals of care: The MICU team met with the patient's half
brother [**Name (NI) **] [**Name (NI) 89325**], as well as [**Name (NI) 15000**] wife. The MICU team
also spoke with the paient's half sister [**Name (NI) **] [**Name (NI) 89325**] via
telephone. [**Doctor Last Name **] and [**Doctor First Name **] explained that the patient's parents
were deceased and that the patient had no children, was never
married, had no other siblings or half siblings, and had no
other relatives. They also explained that the patient had never
selected a healthcare proxy. Therefore, [**Name2 (NI) **] and [**Doctor First Name **] were
determined to be the patient's next of [**Doctor First Name **]. During extensive
conversations, during which the patient's prognosis was
discussed, [**Doctor Last Name **] and [**Doctor First Name **] explained that the patient would not
want to be kept alive on life support unless there were a
reasonably good chance that he would have the ability to
function and live independently. The MICU team explained that
given the patient's anoxic injury and cerebral edema, such a
recovery was extremely unlikely. [**Doctor Last Name **] and [**Doctor First Name **] decided that it
would be most consistent with the patient's wishes to be made
comfort measures only, without any further life-sustaining
therapy. The patient's vasopressors were stopped, and he was
subsequently extubated. He died peacefully and was pronounced
dead at 3:04 a.m. on [**2169-6-28**]. The medical examiner was
[**Name (NI) 653**], and given the circumstances of the patient's cardiac
arrest, the case was accepted for review.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. heroin overdose
2. cardiac arrest
3. hyperkalemia
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
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icd9cm
|
[
[
[]
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] |
[
"99.62",
"38.93",
"38.91",
"96.71"
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icd9pcs
|
[
[
[]
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] |
7932, 7941
|
4939, 7845
|
312, 405
|
8046, 8055
|
3426, 4240
|
8107, 8113
|
2866, 2884
|
7903, 7909
|
7962, 8025
|
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8079, 8084
|
2899, 3407
|
4284, 4916
|
254, 274
|
433, 2262
|
2284, 2610
|
2626, 2850
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,825
| 125,810
|
46653
|
Discharge summary
|
report
|
Admission Date: [**2118-4-10**] Discharge Date: [**2118-4-16**]
Service: MEDICINE
Allergies:
Percocet / lisinopril / Zetia / [**Month/Day/Year **] / Lovastatin / Doxepin /
Boniva / Gleevec / Ciprofloxacin
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88F with hx of CAD, AF on coumadin, CML, CRI, s/p mechanical
fall from standing prior to being in the shower today. She was
attempting to hang something on the shower rod when she fell and
hit her elbow. She denies any dizziness, CP, increased SOB (has
SOB at baseline from COPD), heart palpitations, loss of vision,
weakness, numbness, tingling anywhere, N/V/F/C. Patient has a
"life necklace" that she pushed and then EMS came and brought
her to the ED.
.
Of note, patient reports that she has fallen 3 times (including
this one) over the last 2 months. The fall prior to this one
was 1 month ago, as she was getting out of bed. She reports no
CP, SOB, dizziness, weakness or any other associated sx with
this fall. She again pushed her "life necklace", but because
she didn't hit anything, they did not take her to the ED. In
addition, she had another fall 2 months prior that was as she
was getting her trash ready to take to the dumpster and she then
fell and landed on the floor. Again, she didn't hurt anything,
so there was no ED visit.
.
Also of note, pt reports a 3 week hx of new urinary
incontinence. She is not aware that she has to urinate "but
then I'm just going", so she doesn't make it to the bathroom
"because I don't know I need to go". She also notes fatigue over
the last 3 weeks.
.
In [**Name (NI) **], pt complained of left elbow pain without numbness or
tinlging. initial VS were 98.3, 90, 116/69, 18, 99 % on RA. Of
note, while in the ED patient got up to go to the BR and BP
dropped transiently to 70 with recheck in 80's, not symptomatic,
responded to 250 cc bolus of NS, re-eval without new symptoms.
States BP usually 100/58, and she checks her BP daily. BP
returned to 90's on re-evaluation. Labs significant for WBC
10.6, Hct 34.3, Platelets 161, INR 2.6. creatinine 2.0 (from
baseline 2.2), UA and UCx was sent.
CXR showed mild intravascular engorgement with mild bibasilar
atelecatasis. Pelvis x-ray showed no definite fx but showed DJD
in both hips. Elbow x-ray showed mildly displaced comminuted
lateral epicondyle fracture with 6 mm osseous fragment within
the joint space. CT head was negative. Splint in place. Ortho
saw pt in the ED and will follow, no surgery at this time. EKG
showed no change from prior.She was given Morphine 4mg, Zofran
2mg, Vicodin 5mg X 2 and got 1 L NS.
.
Upon transfer to the floor, patient was BP 90/47, HR 80, 16,
95% on 2L (was previously 91-92 on RA in ED). Has 1 single PIV
18G. She was c/o L arm pain and "feeling lousy" overall. Other
than arm pain, no specific complaints.
.
ROS: Patient reports worsened SOB when lying flat x 2-3 years,
with very mild recent worsening over the last 2-3 weeks. Denies
fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, above baseline
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Hypertension / CAD / CHF EF 35%, [**2094**] IWMI cardiogenic
shock. Cath: LVEF 0.40, INFERIOR AKINESIS, 1+ MR, LMCA, LAD AND
LCX -- NO SIGNIFICANT DISEASE, RCA -- 100% PROX. [**2110-1-6**] ETT
modified [**Doctor Last Name 4001**], 3.5 min, 55% age pred max heart rate, MIBI
LVEF 48%, large inf fixed defect. Echocard [**5-/2113**]: mild sym
LVH, EF only 30%, 2+ MR. s/p mi [**2094**], cath [**2103**] one vessel dz
RCA, LVEF 40%; [**4-13**] ETT fixed defect inf/lat and apical EF 42%,
[**12-17**] new septal moderate, parially reversible defect
2. Type 2 diabetes, diet controlled.
3. Atrial fib / flutter and wide complex tachycardia, rx
pacemaker / defibrillator [**2108**], anticoag.
4. CML, stable on Gleevec despite side effects incl eye
discomfort and occasional gassiness, dry heaves
5. Hyperlipidemia, discontinued pravachol due to myalgias which
then promptly resolved. Had liver problems on [**Name2 (NI) 17339**], zocor so
intolerant to multiple statins.
6. COPD, FEV1 1.13 [**2112**]. Stopped smoking in [**2094**], pulmonary
eval [**2112**]: deconditioning and wt is contributing to dyspnea.
7. Depression,
8. Eczema / psoriasis, pruritis improved with Sarna.
9. GERD, ? asymptomatic.
10. Gout, treated.
11. Hypothyroidism.
12. Mesenteric ischemia, without abdominal sx after eating.
Positive angiogram
13. Osteporosis. stopped Fosamax due to heartburn.
14. Renal insufficiency, creat 1.4.
Social History:
Uses a walker at baseline to get around outside of her apt, she
says she "gets by" without it at home. She lives in an apt in
senior housing in Revers, she has a VNA that comes 1x per week
and another person who comes "to draw my labs to check my
coumadin level", which her PCP [**Name Initial (PRE) **]. She is a widower with 2
children, both of whom are happy. Smoked for 60 years 2ppd,
quit in [**2094**], denies alcohol or illicits.
Family History:
mom died of a stroke at age 70, dad died of colon ca in his
70's.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.3F, BP 90/47, HR 80, R 16, O2-sat 95% on 2L
GENERAL - elderly female lying in bed with L arm splint in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MM mmildly dry, OP
clear
NECK - supple, no thyromegaly, JVP elevated to mandible while
laying flat, no carotid bruits
LUNGS - CTA bilat anteriorly
HEART - irregularly, irregular, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - bruises on both shins L>R
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-17**] throughout except did not test LUE given it is in a sling,
sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
.
[**2118-4-10**] 01:00PM BLOOD WBC-10.6 RBC-3.31* Hgb-11.6* Hct-34.4*
MCV-104* MCH-35.0* MCHC-33.6 RDW-15.6* Plt Ct-161
[**2118-4-10**] 01:00PM BLOOD Neuts-76.7* Lymphs-10.6* Monos-4.9
Eos-6.7* Baso-1.0
[**2118-4-10**] 01:00PM BLOOD PT-27.0* PTT-29.8 INR(PT)-2.6*
[**2118-4-10**] 01:00PM BLOOD Glucose-116* UreaN-51* Creat-2.0* Na-141
K-3.9 Cl-107 HCO3-23 AnGap-15
[**2118-4-10**] 01:00PM BLOOD CK-MB-5 cTropnT-0.02*
[**2118-4-10**] 11:33PM BLOOD CK-MB-4 cTropnT-0.01
[**2118-4-11**] 06:10AM BLOOD CK-MB-4 cTropnT-0.02*
.
IMAGING:
CT HEAD W/OUT CONTRAST [**2118-4-10**]: IMPRESSION:
No acute intracranial process.
.
ELBOW X-RAY [**2118-4-10**]: IMPRESSION: Mildly displaced comminuted
lateral epicondyle fracture with 6 mm osseous fragment within
the joint space.
.
PELVIC X-RAY [**2118-4-10**]: IMPRESSION: No definite fracture or
dislocation. If there is continuedconcern for a hip fracture,
dedicated radiographs of the hip are recommended for further
evaluation.
.
CXR [**2118-4-10**]: IMPRESSION: Mild pulmonary vascular engorgement and
bibasilar atelectasis.
.
Echocardiogram (TTE) [**2118-4-12**]: The left atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is moderate regional left
ventricular systolic dysfunction with inferior and
inferolateral. The remaining segments contract normally (LVEF =
35%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Moderate mitral regurgitation. Moderate to
severe tricuspid regurgitation. Severe pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2117-3-25**],
tricuspid regurgitation is more prominent and pulmonary
pressures are higher. Left ventricular function and the other
findings are similar
Brief Hospital Course:
Ms. [**Known lastname 1617**] is a 88F with hx of CAD, AF on coumadin, CML, CRI who
presented s/p fall and found to have UTI complicated by
hypotension. She subsequently developed pneumonia, complicated
by sepsis, Afib with rapid ventricular response, and heart
failure exacerbation. After several days of worsening
respiratory distress, she and her family decided to focus her
care on comfort. She died on [**2118-4-17**].
.
# Urinary tract infection, complicate by sepsis: The patient's
admission urine culture grew E. coli. She was initially treated
ceftriaxone, with was broadened to cefepime and vancomycin on
[**4-11**] in the setting of hypotension and concern for sepsis.
Antibiotics were briefly narrowed to just ceftriaxone on [**4-13**]
when the sensitivities of the E. coli became available, but were
broadened to cefepime, vancomycin, and azithromycin the same
day, as the patient's clinical condition worsened and it became
clear that she also had pneumomia.
.
# Pneumonia: On [**4-13**], the patient developed increased respiratory
distress. CXR showed a right perihilar opacity that was
concerning for pneumonia. Antibiotics were broadened to
vancomycin, cefepime, and azithromycin.
.
# Sepsis/Hypotension: On [**4-11**], the patient became hypotensive to
the 60s. She was treated with a total of 3 liters of IV fluids
and her antibiotics were empirically broadened to
vancomycin/cefepime. As explained above, antibiotics were
subsequently narrowed to just ceftriaxone, but then broadened to
vancomycin, cefepime, and azithromycin in the setting of
pneumonia. On [**4-13**] and [**4-14**], the patient developed worsening heart
failure, treated with Lasix and morphine. She subsequently
developed hypotension to the 70s, which responded to a 250-cc
normal saline boluses. Blood pressures stabilized without need
for pressors.
.
# Hypoxemic respiratory failure: The patient developed
increasing respiratory distress, which was initially attributed
to heart failure in the setting of fluid resuscitation for
hypotension. She was treated with IV Lasix, with partial
improvement in her respiratory status. On [**4-13**], the patient's
dyspnea worsened, and it became clear that she also had
pneumonia. Antibiotics were broadened as above. The patient
developed worsening hypoxia, requiring high-flow masks and
eventually non-invasive positive pressure ventillation. The
patient went on and off of non-invasive positive pressure
ventillation, but by [**4-14**], she found this too uncomfortable, and
it was stopped according to her request. She received some
additional doses of Lasix without significant improvement in her
respiratory status. The medical team explained to the patient
and her family that the patient would likely not survive without
intubation. The patient and her family decided against
intubation. As the patient's hypoxemia and dyspnea worsening,
the patient and her family decided to focus her care on comfort.
On [**2118-4-17**], the patient's daughter arrived. With her family at
her bedside, the patient transitioned to comfort care. She died
on [**2118-4-17**].
.
# Acute on chronic systolic heart failure: The patient was
initially treated with IV fluids for sepsis. She subsequently
developed increased work of breathing, which was multifactorial,
related to pneumonia and CHF. She was diuresed with IV Lasix as
she endorsed being 10 pounds over her dry weight. (Gleevac can
also cause some edema). She was also given IV morphine and
intermittently required BiPAP. Eventually, on [**4-14**], the patient
declined any more BiPap. On [**4-17**], she decided to focus her care
on comfort, with no further treatment for her worsening
respiratory failure.
.
# Wide complex tachycardia: On [**4-13**], the patient a wide-complex
tachycardia, which was likely due to Afib with aberrency. She
was treated with amiodarone 150 mg IV and then subsequently dig
loaded.
.
# Atrial fibrillation with rapid ventricular response: On [**4-13**],
the patient developed Afib, with RVR. This was initially
wide-complex, but then became narrow-complex. She was initially
treated with amiodarone, then with metoprolol, with improvement
in her heart rate from 130-140 to 100-110. She was loaded with
digoxin and started on oral doses w/ improvement in her
HR90-100s. The patient was supratherapeutic on her coumadin,
which was held during the initial part of her hospitalization
and gradually restarted.
.
# Acute on chronic kidney injury: She has known CKD with
baseline creatintine of 2.0. Her creatinine increased to as
high as high as 2.6. Her acute kidney injury was likely
pre-renal and improved with IV fluids.
.
# s/p fall: Patient reports this was a mechanical fall without
associated LOC or syncope although hypotension may have
constributed. Her elbow is immobilized by splint but she has
maintained good hand grip and strength. Her pain was treated
with Tylenol. Ortho aware and opted for non-operative managment.
PT consult re: home safety. The patient had a new cast placed on
[**4-14**].
.
# Coronary artery disease: Most recent echo showed EF of 35%, pt
s/p PM and ICD placement, most recent cath in [**2103**] showed
sizable inferior wall akinesis and RCA occlusion. Metoprolol
was initially held for hypotension. Aspirin was continued.
.
# COPD: Continued albuterol and ipratropium nebs PRN
.
# CML: Continued Gleevec.
.
# Hypothyroidism: Stable, last TSH in [**3-/2118**] was 0.6. Continued
synthroid 100mcg QD.
.
# Anemia: Her baseline hct is 35, and she is currently 30, with
MCV of 106 (baseline in the 100's). Her chronic anemia is
likely [**12-15**] CML and treatment. Monitored hct daily.
.
# Goals of care: The patient stated that she wished to be
DNR/DNI. As the patient's respiratory status worsened, goals of
care were again discussed, and the patient and her family again
affirmed that the patient would not want to be intubated or
resuscitated, even though she would likely die without
intubation. The patient was closely monitored in the intensive
care unit and treated with broad spectrum antibiotics, diuresis,
non-invasive positive pressure ventillation, and other
non-invasive measures. On [**4-14**], she decided that did not want
non-invasive ventillation either. As her respiratory status
worsened, she decided to focus her care on comfort. She wanted
to see her daughter first, and once her daughter arrived on
[**2118-4-17**], she changed her code status to comfort measures only.
Cardiology was consulted and recommended placing a magnet over
the patient's ICD. She died peacefully with her son and daughter
at her bedside on [**2118-4-17**].
Medications on Admission:
Avapro 75 mg QD
Gleevec 200 mg QD
Aspirin EC 81 mg QD
allopurinol 100 mg QD
Tylenol Extra Strength 1000 mg QID PRN pain
Furosemide 40 mg Tab QD or increase to 60mg if weight incr.
>3lbs
amiodarone 100 mg Tab QD
Klor-Con M20 20 mEq QD
Nitroglycerin 0.4 mg SL PRN angina
zolpidem 2.5-5mg QHS PRN insomnia(pt reports she rarely takes
this)
fluocinonide 0.05 % Topical Cream [**Hospital1 **] to itchy rash
levothyroxine 100 mcg QD
Warfarin 2 mg on M, W, Fr, Sat, and 4mg on Tues, Thurs, Sun
Metoprolol Succinate ER 50 mg QD
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
urinary tract infection, complicated by sepsis
pneumonia
acute on chronic systolic heart failure
hypoxemic respiratory failure
atrial fibrillation with rapid ventricular response
elbow fracture
.
Secondary:
chronic kidney disease
Discharge Condition:
died
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
|
[
"V15.88",
"285.22",
"585.3",
"250.00",
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"599.0",
"276.2",
"451.82"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.54"
] |
icd9pcs
|
[
[
[]
]
] |
15708, 15717
|
8501, 15110
|
324, 330
|
15999, 16005
|
6034, 6034
|
16057, 16155
|
5224, 5291
|
15680, 15685
|
15738, 15978
|
15136, 15657
|
16029, 16034
|
5331, 6015
|
280, 286
|
358, 3305
|
6050, 8478
|
3327, 4751
|
4767, 5208
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,667
| 183,191
|
735
|
Discharge summary
|
report
|
Admission Date: [**2123-6-12**] Discharge Date: [**2123-6-18**]
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
Bright red blood per rectum x 2
Major Surgical or Invasive Procedure:
Colonoscopy on [**2123-6-14**]
History of Present Illness:
86 yo woman with h/o diverticulosis and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear/PUD
on PPI, [**Last Name (NamePattern4) 5390**]/MDS presents with BRBPR. Pt was in her usual
health until 3am today when she woke up to have a BM. While
having BM, noted "blood pouring out," filling the entire toilet.
She went back to bed and then had the urge to have another BM
and had more bloody stools and came to the ED. Pt denies passing
bloody clots, abdominal pain, n/v, f/c, chest pain, SOB. She
does report feeling dizzy and weak. Denies dysuria, frequency,
bladder, fullness, or urgency. Since in emergency room, has not
had any more bloody stools.
.
In ED, VS BP 193/100-->135/80, HR 90s. Received 1.35L of NS. GI
made aware. Received Protonix and Ciprofloxacin 500mg x i. No NG
lavage in ED.
Past Medical History:
1. UGIB from gastric ulcer/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear on EGD [**4-15**] on
Protonix.
2. Diverticulosis-last colonoscopy [**2121**] showing diverticulosis
in entire colon.
3. Hypertension.
4. Myeloproliferative disorder/[**First Name9 (NamePattern2) 5388**] [**Doctor First Name **]. Baseline
includes white blood cell count of 15 to 20, hematocrit in the
mid forties, platelets close to one million. The patient did
not tolerate hydrea. She is on aspirin.
5. Status post cholecystectomy.
6. Status post resection for bowel strangulation.
7. Hypothyroidism.
8. Hemorrhoids
Social History:
Lives alone, no alcohol/tob/drugs, distant tobacco use about 20
years abck
Family History:
The patient's mother died of peritonitis.
The patient's father had an unknown cancer. No history of
gastrointestinal bleeding in the family
Physical Exam:
PE: VS 96.7, 135/70, 14, 92% on RA
GEN: NAD, pleasant, lying in bed
SKIN: Face with pink
HEENT: Perrla, EOMI, anicteric sclerae, mmm
NECK: supple
LUNGS: crackles up to 1/2 up bilaterally, otherwise clear. No
wheezing or rhonchi
HEART: S1S2 normal, RRR, no m/r/g
ABD: soft, nt, nd, +BS, per ED note, guaiac +, dark brown
stools. + external hemorrhoids-not overtly bleeding.
EXT: no e/c/c, DP 2+ bilat
NEURO: AOX 3. CN 2-12 intact, moving extremities.
Pertinent Results:
ECG: NSR at 74, LAD, nl axis, poor R wave progression, no ST/T
wave changes. No changes from previous ECG.
.
Imaging: There is mild stable cardiomegaly and a tortuous
calcified thoracic aorta. The pulmonary vasculature is normal.
The lungs are clear without evidence of focal consolidation or
pneumothorax. There is persistent elevation of the left
hemidiaphragm.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
A/P: 86yo F with h/o gastritis/[**Doctor First Name 329**] [**Doctor Last Name **] tear,
diverticulosis presenting with hematochezia.
.
# Acute blood loss anemia/diverticular bleed: Given multiple
diverticulosis found on c-scope in [**2121**] and painless abdomen,
thought to be most likely secondary to diverticular bleeds. Hct
remained on the floor for two day, and pt underwent a bowel prep
with Golytely and noted to have a small blood passing with prep,
but hct/hemodynamics remained stable. Pt underwent colonoscopy
on [**2123-6-14**] and noted to have large amount of bleeds from
left-sided colon and severe diverticulosis and a three point hct
drop from 35 to 32 but stayed hemodynamically stable. Pt was
transferred to [**Hospital Unit Name 153**] for closer monitoring and IR was made aware
for possible embolization in case pt continued to bleed. Pt
stopped bleeding in [**Hospital Unit Name 153**] and was tranfused with 1 unit of PRBC.
The following day, she was transferred back to the floor as
active bleeding stopped and hemodynamics stabilized. On the
floor, pt received 1 more unit of PRBC for hct <32 but did not
further have BRBPR. Surgery was consulted to explain risks of
possible colectomy emergently as well as for elective procedure
for prophylaxis for any furture diverticular bleeds. Pt decided
to consider emergent surgery if needed but deferred elective
surgery. After one unit of PRBC, pt's hct bumped appropriately
and remained stable. After ~48 hours of stable hct, pt was
discharged home.
.
# Myeloproliferative disorder/[**Last Name (NamePattern4) **]: Pt was treated with ASA
and therapeutic phlebotomy as outpatient. Held aspirin in the
setting of GIB.
.
# Hypothyroidism: Previous TSH checked in [**4-15**] elevated but free
T4
normal and no outpatient f/u check. Continued levoxyl 88mcg and
recheck TSH, free T4 as outpatient.
.
# HTN: Pt was hypertensive in the ED and restarted amlodipine on
the floor. On transfer to [**Hospital Unit Name 153**], amlodipine was discontinued for
relatively low blood pressure. Restarted amlodipine on the day
of discharge as BP was noted to be elevated.
.
# Gastritis/recent [**Doctor First Name 329**] [**Doctor Last Name **] tear- PPI [**Hospital1 **]
.
# UTI: Although pt was asymptomatic, she was treated with three
days of ciprofloxacin. Ucx was consistent with contamination.
.
# FEN: NPO with IVF and started clears and advanced diet to
cardiac diet once hct stabilized.
.
# PPX: Pneumoboots, PPI.
.
# CODE: DNR/DNI
Medications on Admission:
1. Amlodipine 5 mg Tablet Qday
2. Levothyroxine 88 mcg Qday
3. Pantoprazole 40 mg Daily
4. Aspirin 81 mg PO once a day
Discharge Medications:
1. Levothyroxine 88 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 once a day.
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnoses:
Blood loss anemia
Diverticular bleeds
.
Secondary diagnoses:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Hypertension
Discharge Condition:
Stable, no active bleeding from rectum
Discharge Instructions:
Return to emergency department if you develop bright red bloody
stools, chest pain, shortness of breath, lightheadedness,
weakness, or any other worrisome symptoms. Keep your follow-up
appointments and take medications as instructed. Do not take
aspirin until you see Dr. [**First Name (STitle) **]. Please, call Dr. [**First Name (STitle) **] for
appointment next week. He would like to see you next week but
his schedule is full next week and he will arrange an
appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2123-6-22**] 11:00
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2123-12-14**] 2:20
|
[
"562.12",
"238.7",
"244.9",
"401.9",
"285.1",
"238.4",
"455.3",
"799.02",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5986, 6044
|
2946, 5458
|
249, 282
|
6244, 6285
|
2507, 2923
|
6811, 7090
|
1879, 2021
|
5628, 5963
|
6065, 6124
|
5484, 5605
|
6309, 6788
|
2036, 2488
|
6145, 6223
|
178, 211
|
310, 1130
|
1152, 1770
|
1786, 1863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,132
| 106,508
|
18262
|
Discharge summary
|
report
|
Admission Date: [**2177-11-5**] Discharge Date: [**2177-11-15**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Malignant, bilateral, pleural effusion
Major Surgical or Invasive Procedure:
Right thoracoscopy & evacuation of pleural effusion
PleurX catheter placement on right
Left video assisted thoracoscopy
Pericardial window
Talcolm poudrage
Pleural biopsy
Endotracheal tube placement
Foley catheter placement
History of Present Illness:
Patient is an 81 year-old female who has a significant history
of metastatic breast cancer treated with a number of hormone
therapies, and over the last few years with Taxol and perhaps
over the last year and a half, Xeloda on which she has slowly
progressed. She has a known malignant right pleural effusion
which has been tapped a total of three times over the last year
and a half. She is having more shortness of breath, which began
shortly after the summer and more limitations on exercise. A CT
scan of her chest and torso in late [**Month (only) **] did show
progression of disease with a few more liver lesions, a new
small left pleural effusion and what was described as a small
pericardial effusion. She also has extensive bone disease for
which she has been on Zometa, as well as medical therapy.
Past Medical History:
Breast cancer
Right total mastectomy with axillary dissection
Hypothyroidism
Angina
Questionable CAD/MI (~10ya)
Left hip replacement
Left ankle pinning
Social History:
No tobacco, social Alcohol use, no IDU
Family History:
No history of cancer, Father had CAD and has passed-on
Brief Hospital Course:
Mrs. [**Known lastname 50390**] was admitted to Dr.[**Name (NI) 1816**] [**Name (STitle) 4869**] at [**Hospital1 18**] on
[**2177-11-5**] for surgical management of her bilateral malignant
pleural effusion and possible intervention of her pericardial
effusion. She underwent a right thoracoscopy, evacuation of
pleural effusion and PleurX catheter placement on the right on
[**2177-11-6**]. The following day, she underwent a left video
assisted thoracoscopy, pericardial window, talc poudrage and
pleural biopsy. For details of the procedures, see operative
dictations.
Post-operatively, Mrs. [**Known lastname 50390**] required ongoing ventilatory
support with increasing decline in her respiratory status. The
family believed that the patient's prognosis was very poor given
the rapid progression of her cancer and respiratory failure.
Furthermore, they felt that quality of life was important to the
patient and that she would not wish to be on ventilatory
support. After discussion with the ICU team, the family decided
to withdraw support and make the patient as comfortable as
possible on [**2177-11-15**]. She then passed-on comfortably
shortly therafter.
Medications on Admission:
Atenolol 25mg PO QDaily
Cardizem CD 240mg PO QDaily
Aspirin 81mg PO QDaily
Synthroid 50mg PO QDaily
Zocor 20mg PO QDaily
Digoxin 0.25mg PO QDaily
Iron Sulfate
Vitamin C
Zometa QMonthly
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cadiopulmonary collapse
Respiratory failure
Metastatic breast cancer
Discharge Condition:
Expired
|
[
"512.1",
"V10.3",
"E849.8",
"427.31",
"197.2",
"458.29",
"V46.11",
"413.9",
"E878.8",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.71",
"34.92",
"37.12",
"38.93",
"34.21",
"96.04",
"34.24",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
3098, 3107
|
1663, 2834
|
273, 498
|
3219, 3229
|
1584, 1640
|
3069, 3075
|
3128, 3198
|
2860, 3046
|
195, 235
|
526, 1336
|
1358, 1512
|
1528, 1568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,928
| 182,018
|
30801
|
Discharge summary
|
report
|
Admission Date: [**2118-2-17**] Discharge Date: [**2118-2-28**]
Service: SURGERY
Allergies:
Codeine / Epinephrine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
duodenal adenoma
Major Surgical or Invasive Procedure:
1. Pylorus preserving Whipple pancreaticoduodenectomy (with
pancreaticogastrostomy reconstruction).
2. Umbilical hernia repair.
3. J-tube placement.
History of Present Illness:
Ms. [**Known lastname **] is an 86-year-old woman who has recently been found to
have an incidentally identified duodenal adenoma. This was a
sessile lesion directly around the ampulla of Vater and involved
three fourths of the circumference of the duodenum. There had
been biliary dilatation behind it but no pancreatic duct
dilation. It was thought that this lesion was at least a
high-grade
premalignant condition, if not an invasive cancer. She was not
pleased with the idea of further observation and wished to
proceed with a Whipple resection.
Past Medical History:
Paroxysmal atrial fibrillation
Type 2 DM
benign hypertension
hyperlipidemia
essential tremor
Hemmorhoids
Anemia
PSH: VATS Wedge for Right benign nodule (post-op AFib),
Cholecystectomy, Hysterectomy, benign breast lumpectomy,
Social History:
Lives at home alone in a retirement community. Her son and
daughter-in-law live nearby. She drinks one drink nightly (1.5
oz liquor or [**4-6**] oz wine).
Family History:
Father: CAD
Mother: Lymphoma, [**Name (NI) 72915**]
Sister: [**Name (NI) **] [**Name (NI) 3730**] at 50
Physical Exam:
Upon Discharge:
VS:
GEN:
HEENT:
CV:
PULM:
ABD:
EXT:
Pertinent Results:
CXR [**2-17**]: FINDINGS: In comparison with the study of [**2-9**], there
has been placement of a right IJ catheter that extends to the
lower portion of the SVC. No evidence of pneumothorax.
CT Head [**2-18**]:
1. No intracranial hemorrhage. If there is concern for
cerebellar infarct
MRI with diffusion-weighted images would be recommended for
further
evaluation. This was discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2118-2-18**].
2. Sinus disease as described with small fluid levels in the
sphenoid sinus and possibly right maxillary sinus.
MRI/MRA Brain [**2-19**]:
CONCLUSION: Limited study due to motion artifact. No evidence of
infarction or hemorrhage. No vascular abnormality is detected.
CXR [**2-20**]:
FINDINGS: Cardiac silhouette is upper limits of normal in size,
and there is new mild vascular engorgement and perihilar
haziness attributed to edema from CHF or fluid overload. New
left retrocardiac atelectasis, and slight increase in the left
pleural effusion as well as a new small right pleural effusion.
EKG [**2-22**]:
Sinus bradycardia
Short QT interval
Leftward axis
Anteroseptal T wave changes are nonspecific
Low lead voltage
Since previous tracing of [**2118-2-19**], atrial fibrillation resolved,
and anterior T
wave abnormalities more marked
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 168 90 400/400 74 -23 27
Abdominal XRay [**2-23**]:
MPRESSION: No evidence of bowel obstruction or ileus.
Abdominal Xray [**2-25**]:
No evidence of bowel obstruction or ileus
[**2118-2-17**] 04:10PM BLOOD WBC-19.6*# RBC-3.50* Hgb-10.5* Hct-30.2*
MCV-86 MCH-29.9 MCHC-34.7 RDW-13.1 Plt Ct-320
[**2118-2-18**] 04:28AM BLOOD WBC-13.8* RBC-3.19* Hgb-9.5* Hct-27.6*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.5 Plt Ct-275
[**2118-2-19**] 06:54AM BLOOD WBC-15.4* RBC-3.01* Hgb-9.0* Hct-26.5*
MCV-88 MCH-29.8 MCHC-33.8 RDW-13.4 Plt Ct-246
[**2118-2-19**] 05:30PM BLOOD WBC-13.8* RBC-3.07* Hgb-9.1* Hct-27.1*
MCV-88 MCH-29.8 MCHC-33.7 RDW-13.6 Plt Ct-268
[**2118-2-20**] 01:41AM BLOOD WBC-12.3* RBC-2.81* Hgb-8.4* Hct-24.6*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.6 Plt Ct-242
[**2118-2-21**] 01:35AM BLOOD WBC-8.7 RBC-2.92* Hgb-8.8* Hct-25.2*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.7 Plt Ct-280
[**2118-2-22**] 04:26AM BLOOD WBC-7.1 RBC-3.10* Hgb-9.3* Hct-27.2*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.4 Plt Ct-331
[**2118-2-23**] 05:30AM BLOOD WBC-7.7 RBC-3.24* Hgb-9.7* Hct-28.6*
MCV-88 MCH-29.9 MCHC-33.9 RDW-13.5 Plt Ct-373
[**2118-2-25**] 09:10AM BLOOD WBC-12.2*# RBC-3.41* Hgb-10.1* Hct-29.5*
MCV-86 MCH-29.6 MCHC-34.3 RDW-13.7 Plt Ct-556*
[**2118-2-26**] 06:00AM BLOOD WBC-10.8 RBC-3.19* Hgb-9.4* Hct-27.3*
MCV-86 MCH-29.4 MCHC-34.3 RDW-13.9 Plt Ct-536*
[**2118-2-19**] 05:30PM BLOOD Neuts-89.3* Lymphs-7.6* Monos-2.8 Eos-0.1
Baso-0.1
[**2118-2-17**] 04:10PM BLOOD PT-14.5* INR(PT)-1.3*
[**2118-2-17**] 04:10PM BLOOD Plt Ct-320
[**2118-2-19**] 05:30PM BLOOD PT-14.2* PTT-31.0 INR(PT)-1.2*
[**2118-2-22**] 04:26AM BLOOD PT-12.5 INR(PT)-1.1
[**2118-2-17**] 04:10PM BLOOD Glucose-186* UreaN-17 Creat-0.9 Na-136
K-3.5 Cl-99 HCO3-28 AnGap-13
[**2118-2-18**] 04:28AM BLOOD Glucose-141* UreaN-18 Creat-0.9 Na-138
K-4.7 Cl-104 HCO3-31 AnGap-8
[**2118-2-19**] 06:54AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-135
K-4.3 Cl-101 HCO3-29 AnGap-9
[**2118-2-19**] 05:30PM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-134
K-4.3 Cl-100 HCO3-28 AnGap-10
[**2118-2-20**] 01:41AM BLOOD Glucose-165* UreaN-17 Creat-0.8 Na-134
K-4.4 Cl-101 HCO3-30 AnGap-7*
[**2118-2-21**] 01:35AM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-33* AnGap-6*
[**2118-2-21**] 12:01PM BLOOD K-4.2
[**2118-2-22**] 04:26AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-137
K-4.3 Cl-99 HCO3-32 AnGap-10
[**2118-2-23**] 05:30AM BLOOD Glucose-134* UreaN-12 Creat-0.8 Na-134
K-5.2* Cl-96 HCO3-29 AnGap-14
[**2118-2-25**] 09:10AM BLOOD Glucose-177* UreaN-15 Creat-0.8 Na-131*
K-4.6 Cl-94* HCO3-31 AnGap-11
[**2118-2-26**] 06:00AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-133
K-3.5 Cl-94* HCO3-31 AnGap-12
[**2118-2-19**] 05:30PM BLOOD CK(CPK)-245*
[**2118-2-20**] 01:41AM BLOOD CK(CPK)-200*
[**2118-2-20**] 08:28AM BLOOD CK(CPK)-198*
[**2118-2-25**] 05:40AM BLOOD ALT-17 AST-25 LD(LDH)-187 AlkPhos-62
TotBili-0.2
[**2118-2-19**] 05:30PM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-2-20**] 01:41AM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-2-20**] 08:28AM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-2-17**] 04:10PM BLOOD Calcium-8.0* Phos-3.8 Mg-1.5*
[**2118-2-18**] 04:28AM BLOOD Calcium-7.4* Phos-3.9 Mg-2.6
[**2118-2-19**] 05:30PM BLOOD Calcium-7.7* Phos-2.5* Mg-2.0
[**2118-2-20**] 01:41AM BLOOD Calcium-7.6* Phos-2.0* Mg-2.0
[**2118-2-21**] 01:35AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8
[**2118-2-21**] 12:01PM BLOOD Calcium-7.5* Phos-2.4* Mg-2.2
[**2118-2-22**] 04:26AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0
[**2118-2-23**] 05:30AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.5
[**2118-2-25**] 05:40AM BLOOD Albumin-2.5*
[**2118-2-25**] 09:10AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2118-2-26**] 06:00AM BLOOD Calcium-7.6* Phos-2.2* Mg-1.9
[**2118-2-19**] 05:30PM BLOOD TSH-0.66
Brief Hospital Course:
Mrs. [**Known lastname **] arrived at the [**Hospital1 18**] on [**2118-2-17**] for her scheduled
Whipple Procedure. She was taken to the OR and she tolerated the
procedure well. An NGT, a foley catheter, a CVL, and a JP drain
were placed intraoperatively. She recovered in the PACU without
acute events, and she was transferred to the floor on POD 0.
Vertigo/Diplopia: During the night of POD 0/POD 1, she had
several episodes of dizziness and diplopia. She was evaluated by
the geriatric service for these symptoms, who subsequently
advised a neurology consult. After being evaluated by the neuro
service, it was recommended that a CT and then MRI/MRA of her
brain be performed to rule out organic causes of her symptoms.
All studies were negative for acute pathology. Incidentally, her
symptoms resolved spontaneously on POD 2.
Pain control: Her pain was treated at first with a morphine PCA.
When she began eating clear liquids, she was transitioned to PO
pain meds and her pain was well controlled.
Post-op A-Fib:
On POD 2 she became tachycardic in the 130s and was found to be
in atrial fibrillation. She was also hypotensive in the 70s/40s
and was immediately transferred to a surgical ICU, where she was
converted back into NSR with amiodarone. She remained on
amiodarone for 3 days, but it was stopped after her nausea
worsened. She remained on her metoprolol as ordered. She
remained in sinus rhythm during the remainder of her hospital
course.
GI/Diet: She remained NPO until POD 4 where she began tolerating
sips. She was advanced to clear liquids on POD 5. However, she
became nauseous and vomited x 1 and was reverted back to NPO
stats. A KUB showed a non-obstructive pattern. She was started
on TFs via her Jtube for nutritional supplementation. However,
this exacerbated her nausea and they were held. As her nausea
resolved, she baegan tolerating a diet again. She tolerated full
liquids on POD 8 and regular food on POD 9.
Her NGT was removed on POD 4. Her foley catheter was removed on
POD 4. However, she had very low urine output and the foley
catheter was replaced on POD 5. It was again removed on POD 6,
and was again replaced for failure to void appropriately. A JP
amylase was checked after she ate a full liquid diet, and was
10. Thus, the JP drain was removed on POD 9.
UTI:
On POD 8, she was noted to have a UA consistent with a UTI. She
wast treated with a 3 day course of Cipro.
She was discharged to rehab on [**2118-2-28**]. Her staples were removed
prior to discharge.
Medications on Admission:
Ambien CR 12.5', Lipitor 10', Wellbutrin 150", HCTZ 25',
Lisinopril 5', Omeprazole, Propanolol XL 120', ASA 81, Folic
Acid
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection every eight (8) hours as needed for nausea.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. Duodenal adenoma with high-grade dysplasia.
2. Umbilical hernia.
3. Atrial Fibrillation
4. UTI
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* 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.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2118-3-18**] 9:30
Completed by:[**2118-2-28**]
|
[
"599.0",
"401.9",
"780.4",
"788.20",
"458.29",
"553.1",
"997.5",
"427.31",
"368.2",
"250.00",
"211.6",
"285.9",
"272.4",
"211.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"96.6",
"52.7",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
10254, 10339
|
6674, 9186
|
244, 399
|
10481, 10490
|
1608, 6651
|
12021, 12264
|
1416, 1521
|
9359, 10231
|
10360, 10460
|
9212, 9336
|
10514, 11661
|
11676, 11998
|
1536, 1536
|
188, 206
|
1552, 1589
|
427, 978
|
1000, 1227
|
1243, 1400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,308
| 180,741
|
39254
|
Discharge summary
|
report
|
Admission Date: [**2117-10-10**] Discharge Date: [**2117-10-15**]
Date of Birth: [**2062-7-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 55 yo M with h/o ESRD on HD, IDDM, and h/o
femoral fracture at rehab since [**2117-2-6**] who presented to
his rehab MD [**First Name (Titles) 151**] [**Last Name (Titles) **] and was found to be hypoxemic with
oxygen 85%. He did not improve with nebs and empiric levaquin
and was transferred to ED. [**Name8 (MD) **] RN at rehab, he denied complaints
other than [**Name8 (MD) **] and at baseline is alert and oriented. On
arrival to the ED, he had sats in low 80s and multifocal PNA on
CXR. He was intubated and antibiotics broadened to vanc/zosyn
and transferred to ICU.
Past Medical History:
ESRD on HD qTTS (on HD since [**1-13**])
DM2
HTN
History of C. diff infection
Hepatitic C
Cognitive deficit
s/p hip fracture & ORIF; s/p fight
Pleural effusions and lymphadenopathy documented on prior
imaging studies
Social History:
Smokes, many years
ETOH - used to be heavier, then cut back
Drugs - in the past, cocaine & marajuana, denies IVDU
Lives with brother & brother's wife
Uses [**Name2 (NI) **]
Family History:
none relevant to this hospitalization
Physical Exam:
General: Intubated, sedated
HEENT: Sclera anicteric
Neck: supple, JVP not elevated, no LAD
Lungs: ronchi 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
GU: foley draining clear urine
.
Pertinent Results:
[**2117-10-10**] 09:40PM BLOOD WBC-15.8* RBC-4.08* Hgb-13.2* Hct-38.3*
MCV-94 MCH-32.3* MCHC-34.5 RDW-14.2 Plt Ct-348
[**2117-10-11**] 03:20AM BLOOD WBC-17.2* RBC-3.42* Hgb-10.8* Hct-31.7*
MCV-93 MCH-31.7 MCHC-34.1 RDW-14.1 Plt Ct-271
[**2117-10-14**] 03:28AM BLOOD WBC-13.9* RBC-3.39* Hgb-10.4* Hct-32.2*
MCV-95 MCH-30.8 MCHC-32.5 RDW-14.6 Plt Ct-281
[**2117-10-11**] 03:20AM BLOOD Neuts-93* Bands-1 Lymphs-3* Monos-2 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2117-10-12**] 02:08AM BLOOD Neuts-86* Bands-3 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2117-10-14**] 03:28AM BLOOD Plt Ct-281
[**2117-10-13**] 03:33AM BLOOD Plt Ct-257
[**2117-10-10**] 09:40PM BLOOD Plt Ct-348
[**2117-10-10**] 09:40PM BLOOD Fibrino-428*
[**2117-10-11**] 03:20AM BLOOD Glucose-238* UreaN-34* Creat-4.1* Na-134
K-4.1 Cl-98 HCO3-20* AnGap-20
[**2117-10-12**] 02:08AM BLOOD Glucose-160* UreaN-44* Creat-4.8* Na-135
K-4.6 Cl-100 HCO3-18* AnGap-22*
[**2117-10-13**] 03:33AM BLOOD Glucose-68* UreaN-29* Creat-3.4*# Na-138
K-3.7 Cl-98 HCO3-24 AnGap-20
[**2117-10-11**] 03:20AM BLOOD ALT-24 AST-32 LD(LDH)-177 AlkPhos-172*
TotBili-0.5
[**2117-10-14**] 10:19AM BLOOD CK-MB-3 cTropnT-0.32*
[**2117-10-11**] 03:20AM BLOOD Albumin-2.7* Calcium-7.5* Phos-6.3*
Mg-1.8
[**2117-10-14**] 08:35AM BLOOD Type-ART Temp-37.3 Rates-0/24 Tidal V-493
PEEP-10 FiO2-50 pO2-92 pCO2-36 pH-7.25* calTCO2-17* Base XS--10
Intubat-INTUBATED Vent-SPONTANEOU
[**2117-10-10**] 09:46PM BLOOD pH-7.26* Comment-GREEN TOP
.
CXR:
IMPRESSION:
1. Left greater than right pulmonary opacification could reflect
diffuse
pneumonia, massive aspiration or, less likely, hemorrhage.
2. Bilateral small pleural effusions.
.
CT CHEST:
IMPRESSION:
1. Multifocal peribronchovascular airspace tree-and-[**Male First Name (un) 239**]
opacities with
bronchiolar wall thickening, and possibly tiny foci of
cavitation. The
differential diagnosis includes atypical infection and/or
vasculitis.
2. Dense consolidation of the lung bases might be atelectasis
though
aspiration/infection is not excluded.
Brief Hospital Course:
55 yo M with h/o ESRD on HD presenting from rehab with sepsis
and hypoxemic respiratory failure secondary to pneumonia.
.
#Hypoxic respiratory failure: The patient was found to have
pneumonia on chest imaging. He was started intubated, started on
broad spectrum antibiotics (vanc/zosyn/levo) and admitted to the
ICU. He underwent bronchoscopy on [**2117-10-14**]. After discussion with
the brother, who is the HCP, the decision was made to focus care
on comfort and extubate the patient. He expired soon after.
.
# ESRD: He was continued on hemodialysis and followed by the
renal consult service during the hospitalization.
.
Medications on Admission:
gabapentin 300 tid
hep subcut 5000 tid
hydralazine 50 qid
senna 8.6 qhs
lantus 5units qpm
metoprolol 75mg [**Hospital1 **]
clonidine 0.3 qhs and 0.2 qam
amlodipine 10mg daily
lisinopril 40mg daily
docusate 100mg [**Hospital1 **]
renagel 3tabs tid with meals
humalog 5units tid with meals and ss
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"250.40",
"070.54",
"585.6",
"276.2",
"285.9",
"511.9",
"294.9",
"V66.7",
"518.81",
"038.9",
"305.1",
"V58.67",
"403.91",
"V49.86",
"995.91",
"486",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.72",
"96.6",
"33.24",
"39.95",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
4882, 4891
|
3874, 4503
|
324, 330
|
4943, 4953
|
1811, 3851
|
5010, 5021
|
1398, 1437
|
4849, 4859
|
4912, 4922
|
4529, 4826
|
4977, 4987
|
1452, 1792
|
265, 286
|
358, 950
|
972, 1191
|
1207, 1382
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,407
| 167,617
|
7604
|
Discharge summary
|
report
|
Admission Date: [**2170-1-19**] Discharge Date: [**2170-2-1**]
Date of Birth: [**2108-5-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
left shoulder wash out and debridement- [**1-19**] and [**1-22**]
right sternoclavicular joint excision- [**1-19**] and [**1-22**]
Vac placement to sternal wound- [**1-22**]
Bronchoscopy- [**1-22**]
TEE- [**1-22**]
chest tube for pneumothorax- [**1-19**]- [**1-29**]
lumbar puncture- [**2170-1-23**]
intubation for airway protection- [**Date range (1) 27746**]
femoral central line for intravenous access
PICC line placement for long term antibiotic therapy- [**2170-1-26**]
History of Present Illness:
61 yo with hx of htn, etoh abuse presents with 2 months of
fevers to 104, weight loss and left shoulder pain.
Has had 1-2 weeks of drenching night sweats.
Had 30# wt loss over last year- thinks most wt loss came after
he quit drinking [**2169-12-19**]. No ha/visual changes/GU-GI
sx/cough/voice changes/dysphagia/odynophagia. No
travel/stds/rash.
Tagged WBC scan [**1-17**] showed increased uptake in left shoulder,
right sternoclavicular joint and thoracic vert. The scan was
obtained as outpt as part of workup of patient's fevers (up to
104 at home) nightsweats and 30# weight loss over past 2 months.
Previously all studies obtained, including TTE were negative
except for ESR noted to be 130.
In ED rec'd unasyn 3gm, 1 gm tylenol and shoulder was tapped.
Past Medical History:
PMH:
htn
etoh abuse quit [**2169-12-19**]
hypercholesterolemia
pancreatitis [**2165**]
depression
epistaxis with recent cauterization [**2170-1-2**]
Social History:
sh: employed, no smoking, etoh abuse-quit one mo ago, no hx of
DTs, no IVDU, married 11 years, monogamous, denies hiv risk
factors, 28 yo son
Family History:
fH: mother died 92 from emphysema; father died of "old age" 82
Physical Exam:
PE on admission:
vs 99.7 107-125 133/86 24 95% RA nl wt 172 now 145
gen a&ox 3, pleasant nad
perrla, eomi, o/p clear, + temporal wasting
neck supple from right sternal mass no tracheal deviation
cv tachy rr without mrg
lungs ctab
abd scaphoid no splenomegaly
no occipital,axillary, auricular, epitrochlear lad
shoulder erythema, hot, indurated, pain with active/passive
mvmt, decreased rom
ext atrophic, fine resting tremor no c/c/e
Pertinent Results:
[**2170-1-18**] 07:00PM RET AUT-2.8
[**2170-1-18**] 07:00PM SED RATE-130*
[**2170-1-18**] 07:00PM PT-13.4 PTT-29.5 INR(PT)-1.1
[**2170-1-18**] 07:00PM PLT COUNT-360#
[**2170-1-18**] 07:00PM NEUTS-76.1* LYMPHS-17.6* MONOS-5.6 EOS-0.5
BASOS-0.3
[**2170-1-18**] 07:00PM WBC-8.8# RBC-3.51* HGB-10.5* HCT-32.3*
MCV-92# MCH-29.9# MCHC-32.4 RDW-17.0*
[**2170-1-18**] 07:00PM CRP-12.56*
[**2170-1-18**] 07:00PM TSH-3.0
[**2170-1-18**] 07:00PM calTIBC-259* VIT B12-410 FOLATE-16.2
FERRITIN-179 TRF-199*
[**2170-1-18**] 07:00PM ALBUMIN-2.9* URIC ACID-2.9* IRON-18*
[**2170-1-18**] 07:00PM ALT(SGPT)-36 AST(SGOT)-70* LD(LDH)-219 ALK
PHOS-148* AMYLASE-15 TOT BILI-0.6
[**2170-1-18**] 07:00PM GLUCOSE-95 UREA N-15 CREAT-0.6 SODIUM-133
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13
[**2170-1-18**] 07:06PM LACTATE-1.1
[**2170-1-18**] 10:22PM JOINT FLUID WBC-[**Numeric Identifier 27747**]* RBC-[**Numeric Identifier 27748**]* POLYS-97*
LYMPHS-0 MONOS-0 MACROPHAG-3
[**2170-1-24**] 03:13PM BLOOD ESR-115*
[**2170-1-23**] 04:00AM BLOOD Hapto-298*
[**2170-1-24**] 03:45AM BLOOD CRP-6.50*
lt shoulder joint tap: wbc 130,500 97% polys
MRI CHEST/MEDIASTINUM W/O & W/CONTRAST [**2170-1-19**] 8:29 AM
IMPRESSION:
In the absence of a clinical history, these findings could be
seen in the setting of rheumatoid inflammatory polyarthropathy.
Given the laboratory results from recent left shoulder
aspiration, the findings are consistent with an infectious
process.
Changes involving the right sternoclavicular joint are accute
and represent an active inflammatory arthropathy. Considerations
again include rhematoid and infection. The changes anterior to
the right sternoclavicular joint appear chronic given the
presence of a tiny calcification within the subcutaneous tissue
(seen on CT) and these may be due to an old trauma or chronic
infection.
The study and the report were reviewed by the staff radiologist.
ABD CT 150CC NONIONIC CONTRAST [**2170-1-20**] 5:51 PM
IMPRESSION:
1) Postoperative changes...
2) Fluid identified external to the left glenohumeral joint.
3) Small-to-moderate bilateral pleural effusions, right greater
than left, with associated atelectatic changes.
4) Tiny right basilar pneumothorax.
5) No evidence of disseminated infection.
The study and the report were reviewed by the staff radiologist.
MRA BRAIN W/O CONTRAST [**2170-1-22**] 5:37 AM
IMPRESSION: Normal MR angiography of the circle of [**Location (un) 431**]. The
study addresses major vessels in that medium and small vessels
where you expect vasculitis to be found.
The study and the report were reviewed by the staff radiologist.
TEE [**1-22**]:
Conclusions:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. There aortic
valve leaflets (3) are thin/mobile. No masses or vegetations
are seen on the aortic valve. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally
normal. No mass or vegetation is seen on the mitral valve. No
mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: Trace aortic regurgitation with normal valve
morphology. No 2D echo evidence of endocarditis
[**1-22**] MRI Spine
1.Degenerative disc disease of the cervical, thoracic and lumbar
spine, as
described, most notably at L4-5, where there is fairly severe
canal stenosis.
2. Abnormality at T7-8 attributable to discitis and
osteomyelitis with
epidural involvement. No clear evidence of an epidural abscess.
Note is made of bilateral pleural effusions and multiple renal
lesions, most likely representing cysts.
CXR [**1-29**]:
IMPRESSION: Small residual right apical pneumothorax post-chest
tube removal.
Otherwise, unchanged appearance of right-greater-than-left
effusion and lower lobe atelectasis.
Brief Hospital Course:
Assessment: 61 yo male with PMH ETOH, pancreatitis,
hypercholesterolemia who presented with fevers/NS/weight loss
and left shoulder pain/sternal mass and found to have a left
septic shoulder, Manubrium/Rt sternoclavicular joint
osteomyelitis, T7-8 thoracic spine diskitis/osteo. Of note,
patient has had multiple negative blood cultures, negative TEE,
& negative LP.
Hospital Course:
Patient was admitted to medicine. Shoulder joint aspiration
revealed > 100,000 WBC/97% polys, no microorganisms. He was
initially started on unasyn and taken to OR [**1-19**] for debridement
by orthopeadics (Dr. [**Last Name (STitle) 2719**]. Thoracics (Dr. [**Last Name (STitle) **] became
involved when pre-op MRI demonstrated infectious collection
around R sternoclavicular joint. Manubrium and right 1st rib
were removed and vac device was placed. Post- op complicated by
a right pneumothorax requiring chest tube placement which was
removed on [**1-29**]. He also had a persistent right pleural effusion
s/p surgery which remained stable. Post-op course was also
complicated by significant delirium accompanied by
hallucinations, elevated BPs, and agitation. In light of his
ETOH abuse, he was diagnosed with delirium tremens and
transferred to the MICU for 2 days and started on benzos. He
was electively intubation for airway protection. He returned to
OR on [**1-22**] for repeat debridement of both shoulder and sternum
for continued fevers. His sternal debridement from [**1-19**] grew
coag neg staph and group B strep and he was started on Vanco,
Gent and ampicillin for presumed endocarditis. His [**1-19**] left
shoulder culture was initially negative. Gent was d/ced on [**1-23**]
and ampicillin was changed to PCN (-cidal) on [**1-26**]. From then,
he was continue on vanco (for coag neg staph) and IV penicillin
(for GBS).
The sensitivities from the [**1-19**] sternal debridment revealed the
coag neg staph was resistant to erythromycin & PCN and sensitive
to oxacillin, levo and gent. The GBS was sensitive to both PCN
and erythromycin. He also had a coag negative staph species seen
from [**1-22**] culture of left shoulder which was ox/PCN resistant and
sensitive to vanco. This however was thought to be a
contaminent and not the causative organism. ID following looked
for endocarditis as source- TTE and TEE done here both negative
for vegetations. Also looked for other areas of infection due to
fevers: MRA-brain negative, LP negative, bronchoscopy negative,
abdominal CT scan also done, no other abcesses, lesions in
kidneys thought to be cysts. MRI spine demonstrated diskitis and
osteomyelitis in thoracic spine (T7/T8)- orthospine consulted
and recommended prolonged antibiotic treamtent. No epidural
abscess was seen. Patient improved on IV antibiotics. ESR and
CRP greatly diminished prior to discharge. (ESR from 125 peak on
[**1-26**], down to 42 on [**1-31**] and CRP peak [**7-/2160**] on [**1-26**], down to 1.8
on [**1-31**]). He did have a fever on [**1-30**], but blood and urine
cultures were negative. Stage 1 decub ulcer stable. Urine/serum
eos negative (r/o drug fever). He was clinically improved and
afebrile x 48 hours by time of discharge.
Of note, DAY 1 of ANTIBIOTIC treatment = POD 1 = [**2170-1-20**].
He was changed to IV oxacillin 2 gm Q4 hours (from IV vanco/IV
PCN) on day of discharge. Baseline LFTs were ALT 26, AST 50, Alk
Phos 117, TB 0.2. Weekly LFTs, CBC, BUN/Cr should be faxed to
Dr. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) **] (fax [**Telephone/Fax (1) 27749**]; phone [**Telephone/Fax (1) 693**]). He
will follow up with all surgeons/consults (Ortho- Dr. [**Last Name (STitle) 2719**],
Thoracics- Dr. [**Last Name (STitle) **], and spine ortho- Dr. [**First Name (STitle) 1022**] and follow up
in [**Hospital **] clinic with Dr. [**First Name (STitle) **] on [**2-16**]. He should continue IV
antibiotics for AT LEAST 6 weeks (6 weeks= [**3-3**]) and ID
will decide if a longer course is required. He will need repeat
MRI of the spine in about 2 months (first week of [**2170-3-18**]) and
will see Dr. [**First Name (STitle) 1022**] for follow up appointment.
The source of his multiple infections was not found, but
hematogenous spread is clearly the case. His TEE was negative
and interestingly multiple blood cultures were negative as well.
2. delerium/DTs- Initally, he was placed on CIWA scale with prn
ativan. As noted above, post-op patient much more confused,
visual hallucinations, concerning for DTs and was transferred to
MICU for intubation/sedation in order to obtain MRI brain/spine
and LP. To recap, the brain MRI was negative, spine with osteo
as above, LP without meningitis. He was still delerious until
[**1-29**] and were holding benzos and narcotics due to mental status;
Neuro consulted by micu team [**1-25**] for further evaluation,
however, mental status markedly clear on [**1-29**], and was likely
thought to be to benzos/sedating meds in MICU.
3. PTX.- apical right sided s/p chest tube placement. Also had
RIJ injury intraop. RUE performed and negative for damage to
vascular structures. CT removed [**1-29**]. Pulmonary function
stable.
5. htn- no meds as outpatient or currently. Hypertension on
floor was c/w likely DTs.
6. hyperlipidemia- holding pravachol
7. anemia- Consistent with anemia of chronic disease (Fe 18,
TIBC 259, ferritin 179, B12 410 and folate 16). Had recent
colonscopy in [**2168**] which was essentially negative. Guiac
negative.
8. Renal- Cr did increase to 1.2 on day of discharge from
0.4-0.5 on admission. His baseline is closer to (0.7-0.9). FeNa
was < 1% and he was hydrated with 1 liter IVF. He was taking
good POs by day of discharge. Urine eos negative. Sediment
bland. Renal function will need to followed at rehab.
9. Depression- celexa was held during stay. Would recommended
restarting it on discharge at 1/2 dose- 20 mg qd and increasing
to 40 mg qd in one week.
10. code- full
11. communication- with wife
12. Access- he currently has PICC line in right anticub which is
Day 7 today.
13. Dispo- He was discharged to [**Hospital3 **] on [**2-1**]. Phone:
[**0-0-**].
Medications on Admission:
Pravachol 20 qd
humabid prn
celexa 40 qd
MVI
Cipro 250 mg [**Hospital1 **]
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Oxacillin Sodium 2 g Recon Soln Sig: One (1) injection
Intravenous every four (4) hours.
10. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left septic shoulder
Osteomyelitis of right sternoclavicular joint and manubrium
Thoracic osteomyelitis/diskitis- T7/T8
Right pleural effusion (post-op)
Right apical pneumothorax s/p chest tube
ETOH withdrawal/Delerium Tremens
Anemia of chronic disease
Hyperlipidemia
Discharge Condition:
Fair. He is medically stable for discharge to rehab facility.
Discharge Instructions:
1. Please remove sutures in left shoulder on [**2170-2-5**].
2. Please check weekly ESR/CRP, CBC with differential, BUN/Cr,
LFTs starting [**2170-2-5**]. These tests can also be done more
frequently if clinically indicated. Please fax results to Dr.
[**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) **] (fax [**Telephone/Fax (1) 27749**]; phone [**Telephone/Fax (1) 693**]).
3. If patient spikes, please obtain blood cultures x2, urine
culture, and repeat CXR.
4. VAC dressing needs to be changed on Mondays and Thursdays.
5. Please continue oxacillin for at least 6 weeks. Infectious
disease physician will determine if longer treatment is
necessary.
Followup Instructions:
Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] ORTHOPEDICS
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2170-2-5**] 2:00
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTISPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2170-2-8**] 10:30
Provider: [**First Name8 (NamePattern2) 7805**] [**Name11 (NameIs) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-2-16**] 9:30
Dr. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) **], your primary care physician, [**Name10 (NameIs) **] contact
you to arrange a follow up visit.
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**]- [**Telephone/Fax (1) 27750**]- [**2-20**] at 11 am at [**Street Address(2) 27751**]. Will need repeat MRI of the spine the first week
of [**Month (only) 116**] (2 month follow up).
|
[
"711.01",
"291.0",
"292.81",
"722.92",
"997.3",
"730.28",
"272.4",
"285.29",
"998.2",
"511.9",
"512.1",
"727.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31",
"39.32",
"80.99",
"96.04",
"96.71",
"33.24",
"38.93",
"80.89",
"93.59",
"80.81",
"96.59",
"80.21",
"96.6",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
13947, 14017
|
6841, 7209
|
320, 798
|
14329, 14392
|
2480, 6818
|
15112, 16062
|
1941, 2005
|
13103, 13924
|
14038, 14308
|
13004, 13080
|
7226, 12978
|
14416, 15089
|
2020, 2023
|
274, 282
|
826, 1592
|
2037, 2461
|
1614, 1765
|
1781, 1925
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,889
| 102,867
|
32360
|
Discharge summary
|
report
|
Admission Date: [**2194-11-26**] Discharge Date: [**2194-11-28**]
Date of Birth: [**2129-7-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Cerebral Artery Stenosis
Major Surgical or Invasive Procedure:
Bilateral carotid artery stenting
History of Present Illness:
65 year old F with history of s/p left middle cerebral artery
infarct secondary to occlusive tandem stenotic lesions of the
left internal carotid artery in [**10/2194**] who is in the hospital
right now after stenting of her carotid lesions.
Neurology consult was called today for the management of her
neurological problems and [**Name2 (NI) **] pressure.
Her symptoms of right sided weakness have significantly improved
in rehabilitation after the stroke. Her speech has returned to
[**Location 213**]. She only reports difficulty writing with the right hand
and slight decrease in dexterity of the right hand. She also
indicates that her right knee tends to buckle every now and
then.
Review of symptoms and systems is otherwise all negative. She
denies any history of left-sided transient monocular blindness
or TIA/stroke prior to her recent symptoms. She denies neck
pain or headaches at the time of stroke onset.
Past Medical History:
non-insulin-dependent diabetes diagnosed approximately 10 years
ago and hyperlipidemia. She was recently diagnosed with acute
renal failure in [**Month (only) **], which was attributed to "bilateral renal
stones." She underwent bilateral renal artery stent placement.
Social History:
She lived alone until her recent stroke. She worked as a
part-time sales woman at a card store. She has three children.
She does not smoke nor consume alcohol.
Family History:
Her family history is noted for a father who had a stroke,
coronary artery disease, and diabetes.
Physical Exam:
Exam on Admission:
T- 98.0 BP- 140/84 HR- 67 RR- 18 O2Sat 100
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. No right left confusion. No evidence of apraxia or
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, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout except in lower extremities
bilaterally
where vibration and pinprick is decreased.
No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin not
checked.
Gait: not checked as patient is s/p post angio
Romberg: not checked.
Exam on Discharge:
Pertinent Results:
[**2194-11-26**] 12:18PM TYPE-ART PO2-224* PCO2-33* PH-7.57* TOTAL
CO2-31* BASE XS-8
[**2194-11-26**] 12:18PM GLUCOSE-273* LACTATE-2.8* NA+-136 K+-2.6*
CL--97*
[**2194-11-26**] 12:18PM HGB-8.3* calcHCT-25
[**2194-11-26**] 12:18PM freeCa-0.96*
[**2194-11-26**] 09:00AM UREA N-28* CREAT-1.4*
[**2194-11-27**] 02:55AM [**Month/Day/Year 3143**] WBC-6.3 RBC-2.50*# Hgb-7.2*# Hct-21.0*#
MCV-84 MCH-28.8 MCHC-34.3 RDW-15.2 Plt Ct-181
[**2194-11-27**] 02:55AM [**Month/Day/Year 3143**] Neuts-64.0 Lymphs-31.5 Monos-3.0 Eos-1.4
Baso-0.1
Brief Hospital Course:
65 year old female presenting with cerebral artery stenosis. The
patient underwent bilateral carotid stenting on [**11-26**]. Her
intraoperative [**Month/Year (2) **] loss was approximately 200cc, she was
admitted to the SICU post operatively to watch her after her
acute [**Month/Year (2) **] loss. Her hematocrit on POD 1 was 21.0, down from
her preop hematocrit of 35. She was transfused 2 units of packed
red [**Month/Year (2) **] cells while in the SICU. Her hematocrit post
transfusion improved, and her [**Month/Year (2) **] pressure was liberalized, as
well as her diet was advanced, and PT was consulted. She has
tolerated diet well, and PT recommended d/c home without
services. She is voiding without any difficulties, and she will
follow up with dr. [**Last Name (STitle) **] in one month with a carotid duplex, as
well as follow up with her PCP and Nephrologist. Pt was
discharged directly from SICU since there were no regular floor
beds available. Patient and familiy are aware and comfortable
with the plan.
Medications on Admission:
Aggrenox twice daily,
folic acid 1 mg once daily,
metoprolol 50 mg twice daily,
Prilosec 20 mg once daily,
Lantus 20 units at bedtime,
Lipitor 80 mg once daily,
ciprofloxacin 250 mg once daily for a recent urinary tract
infection.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): TAKE FOR SIX MONTHS DAILY.
Disp:*30 Tablet(s)* Refills:*5*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*10*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): PLEASE USE WITH PAIN MEDICINE, IF DIARRHEA, STOP
THE MEDICINE.
Disp:*60 Capsule(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety: PLEASE DISCUSS WITH YOUR PRIMARY
CARE PHYSICIAN THE USE OF LORAZEPAM FOR LONGER THAN 10 DAYS. DO
NOT DRIVE WHILE USING LORAZEPAM.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
all care vna of [**Location (un) **]
Discharge Diagnosis:
Left cerebral artery stenosis
Discharge Condition:
Good
Discharge Instructions:
?????? Have a family member monitor your mental status and headaches
if occur
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? If you use pain medicine, ncrease 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.
?????? 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
Followup Instructions:
YOU WILL NEED A CAROTID DUPLEX PRIOR TO YOUR APPOINTMENT, PLEASE
CALL [**Telephone/Fax (1) 657**] TO HAVE IT SCHEDULED.
PLEASE FOLLOW UP WITH YOUR NEPHROLOGIST AND PRIMARY CARE
PHYSICIAN AS AN OUTPATIENT
YOU HAVE AN APPOINTMENT WITH DR. [**First Name (STitle) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 657**] Date/Time:[**2194-12-23**] 3:30
Completed by:[**2194-11-28**]
|
[
"790.01",
"728.87",
"V13.01",
"433.10",
"272.4",
"250.00",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"99.07",
"88.41",
"99.04",
"00.46",
"00.63",
"00.61"
] |
icd9pcs
|
[
[
[]
]
] |
6839, 6906
|
4316, 5341
|
301, 336
|
6980, 6987
|
3753, 4293
|
8049, 8473
|
1783, 1883
|
5623, 6816
|
6927, 6959
|
5367, 5600
|
7011, 8026
|
1898, 1903
|
237, 263
|
364, 1293
|
2664, 3713
|
3734, 3734
|
1917, 2267
|
2306, 2648
|
2291, 2291
|
1315, 1587
|
1603, 1767
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,830
| 137,856
|
11026
|
Discharge summary
|
report
|
Admission Date: [**2150-12-29**] Discharge Date: [**2151-1-23**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic with Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2150-12-30**] Endovascular Stenting of Ascending and Aortic Arch w/
Debranching and Re-anastomosis of Right Innominate and Left
Carotid Arteries
History of Present Illness:
85 y/o male s/p thoracoabdominal aneurysm repair in [**2144**]. He was
followed over the years with serial CT scans for known
infrarenal AAA and dilated Asc. Aorta. Recent CT scan revealed
an increasing aneurysm from 6.7 to 7.8 involving the distal
ascending and aortic arch.
Past Medical History:
- Hypertension
- Aortic pathology - aneurysm ascending aorta, infrarenal AAA
(3.9 X 4.5 cm), s/p thoracoabdominal aneurysm repair ([**8-/2144**])
- CRI : recent left ureteral stone with mild hydronephrosis
- Prostate CA s/p radiation
- Diverticulosis
- Amputation R toe: several months ago secondary to infection
- Bilateral Knee Replacement
Social History:
The patient currently lives alone as his wife is in Rehab. He
will be moving shortly to live closer to his children. He does
not smoke or drink. He is a retired sales representative.
Family History:
Denies any premature CAD
Physical Exam:
VS: 55 12 R155/70 L161/70 6'1" 99.8kg
General: Well-appearing man in NAD
Skin: W/D and unremarkable
HEENT: EOMI, PERRL, OP Benign
Neck: Supple, FROM, -JVD, -Bruits
Chest: CTAB -w/r/r
Heart: RRR +3/6 systolic murmur
Abd: Soft, Non-distended, Non-tender, +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses
throughout
Neuro: Non-focal, MAE, A&O x 3
Pertinent Results:
[**2151-1-4**] Chest MRI/MRA: 1. Markedly suboptimal examination due
to patient and technical factors. 2. Markedly attenuated and
thinned right braciocephalic vein. 3. Patent left
brachiocephalic vein. 4. Occluded left internal jugular vein.
[**2151-1-4**] CXR: Endotracheal tube is 7 cm above carina. Left
cordis catheter is in left jugular vein. Tip of NG tube is in
fundus of stomach. Thoracic aortic endograft in situ. There is
cardiomegaly with LV predominance and tortuosity of the thoracic
aorta. There is widening of the superior mediastinum, unchanged
since the prior film of [**2151-1-3**]. There is opacity at the
left base medially obscuring the left hemidiaphragm likely due
to atelectasis/consolidation in the left lower lobe and there is
a probable small left pleural effusion. Surgical clips are
present in the left upper quadrant. No pneumothorax.
[**2150-12-31**] Head CT: There are bilateral hypodensities in the
cerebellar hemispheres and bilaterally in the occipital lobes.
These all to be of similar age, and are most suggestive of
severe posterior circulation ischemia with infarction. The
cerebellar infarcts demonstrate minimal mass effect at this
time, but should be followed for later swelling and posterior
fossa mass effect. There is a mass along the left optic nerve
that appears focally expanded at the orbital apex. There may be
a continuation of this mass in the left cavernous sinus. These
findings are most suggestive of a meningioma, but other lesions,
such as lymphoma, sarcoid, and optic nerve glioma, should be
considered. This will be better evaluated by adding an orbital
study to the brain MR. This is almost certainly a chronic
finding, and need not be evaluated emergently. There is left
posterior parietal and right anterior parietal and temporal
scalp swelling.
[**2150-12-30**] Echo: PRE-BYPASS: The left atrium is mildly dilated.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is moderately dilated to 4.2 cm. The aortic arch is
markedly dilated with a maximum diameter of 6.2 cm.. The
descending thoracic aorta had a uniform size and texture
consistent with previous descending thoracoabdominal repair by a
graft. The aortic valve leaflets (3) are mildly thickened with
an immobile non-coronary cusp. There is aortic sclerosis with an
aortic valve area of 1.8cm2 and Mild (1+) aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Post-Bypass: Preserved biventricular systolic function. Mild MR.
Mild AI and TR. Immedialtely post bypass, there is a mobile
echodensity seen in the ascending aorta and arch giving an
impression of double barrel aorta with flows in both lumens.
This is consistent with retrograde filling of aneurysm sac from
left subclavian artery or an endoleak. The mobile echodensity
represents the arch endograft placed during the surgery. At the
end of the surgery, following additional stent placement, this
filling resolved completely with no residual endoleak
visualized. Ascending and Arch are difficult to visualize
completely, but grafts appear grossly well seated. Descending
Thoracic Aorta is unchanged.
[**2150-12-29**] Abd/Pelvis/LE MRA: 1. Small infrarenal AAA measuring
4.2 x 3.8 cm as described above. No evidence of critical
stenosis in the aorta or iliac arteries. 2. Widely patent right
superficial femoral to posterior tibial artery bypass. Single
vessel runoff to the foot through the right posterior tibial
artery which supplies a widely patent DP through a collateral
and diminuitive plantar arteries. 3. Widely patent flow on the
left to the level of the knee, where arthroplasty susceptibility
obscures the popliteal artery; stenosis can not be excluded at
that level. Two vessel runoff with a PT and peroneal with mild
irregularity; medial plantar is widely patent as is the dorsalis
pedis, which is supplied from a peroneal collateral.
[**2150-12-29**] 01:20PM BLOOD WBC-7.1 RBC-3.99* Hgb-11.5* Hct-34.6*
MCV-87 MCH-28.8 MCHC-33.3 RDW-15.9* Plt Ct-248
[**2151-1-1**] 03:13AM BLOOD WBC-8.7 RBC-3.58* Hgb-10.6* Hct-30.5*
MCV-85 MCH-29.6 MCHC-34.9 RDW-16.1* Plt Ct-143*
[**2151-1-5**] 01:55AM BLOOD WBC-8.0 RBC-3.23* Hgb-10.1* Hct-28.3*
MCV-87 MCH-31.2 MCHC-35.7* RDW-15.5 Plt Ct-197
[**2150-12-29**] 01:20PM BLOOD PT-12.4 PTT-31.7 INR(PT)-1.1
[**2151-1-5**] 01:55AM BLOOD PT-14.1* PTT-29.6 INR(PT)-1.2*
[**2150-12-29**] 01:20PM BLOOD Glucose-95 UreaN-31* Creat-1.8* Na-140
K-4.2 Cl-103 HCO3-27 AnGap-14
[**2151-1-1**] 09:34PM BLOOD Glucose-136* UreaN-42* Creat-2.5* Na-139
K-4.5 Cl-106 HCO3-21* AnGap-17
[**2151-1-5**] 01:55AM BLOOD Glucose-175* UreaN-108* Creat-5.6* Na-134
K-5.5* Cl-102 HCO3-17* AnGap-21*
[**2151-1-5**] 01:55AM BLOOD ALT-49* AST-54* LD(LDH)-294* AlkPhos-254*
Amylase-59 TotBili-1.0
[**2151-1-5**] 01:55AM BLOOD Albumin-2.3* Calcium-7.7* Phos-8.3*#
Mg-3.2*
[**2151-1-3**] 11:30AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2151-1-3**] 11:30AM URINE RBC-106* WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
Brief Hospital Course:
Mr. [**Known lastname 35694**] was admitted a day prior to his surgery for MRA of
his abd/pelvis and routine blood work. On the following day he
was brought to the operating room where he underwent
Endovascular Stenting of Ascending and Aortic Arch w/
Debranching and Re-anastomosis of Right Innominate and Left
Carotid Arteries. Please see operative report for surgical
details. Following the surgery he was transferred to the CSRU
for invasive monitoring in stable but serious condition.
Sedation was weaned off by post-op day one but patient did not
wake up and had very poor response to stimuli. Head CT was
immediately performed and Neurology was consulted. CT revealed a
severe posterior circulation infarction. The consulting
neurologist believed that there was a very low likelyhood of
recovery of any significant neurologic function. The family
initially chose to continue with aggressive treatment over the
next few weeks. He has remianed in an unresponsive state, on
hemodialysis, on the ventilator, and on tube feedings. Due to
the poor prognosis, and lack of improvement in neurologic
function, the family requested that he be made a DNR, and that
dialysis be stopped on [**2151-1-22**]. The following day,
[**2151-1-23**], the patient's daughter and daughter-in-law both
requested for him to be extubated and made comfort measures
only. A morphine drip was started for tachypnea at the time of
extubation. He expired on [**2151-1-23**] at 1840.
Medications on Admission:
Aspirin 81mg qd, Norvasc 10mg qd, Doxazosin, MVI
Discharge Disposition:
Expired
Discharge Diagnosis:
aortic aneurysm
CVA
Discharge Condition:
expired
Completed by:[**2151-1-23**]
|
[
"486",
"V43.65",
"V15.3",
"997.02",
"434.11",
"518.5",
"V10.46",
"585.9",
"441.2",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.73",
"39.95",
"39.59",
"38.93",
"96.72",
"96.6",
"39.61",
"38.45",
"38.95",
"88.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8609, 8618
|
7044, 8510
|
303, 452
|
8681, 8719
|
1757, 2639
|
1338, 1364
|
8639, 8660
|
8536, 8586
|
1379, 1738
|
230, 265
|
480, 757
|
2648, 7021
|
779, 1122
|
1138, 1322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,339
| 183,742
|
50564
|
Discharge summary
|
report
|
Admission Date: [**2137-7-4**] Discharge Date: [**2137-7-11**]
Date of Birth: [**2071-3-16**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Percocet
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fever and increasing secretions
Major Surgical or Invasive Procedure:
Mechanical ventilation
History of Present Illness:
66 year old female with tracheal stenosis s/p trach/PEG
presenting with hypoxia and increased sputum production and
transferred to the MICU for significant nursing requirements.
Her baseline O2 sats are in the low 90s and tends to desaturate
with mucus plugging or agitation. Also, she has only mild
secretions at baseline. On the morning of admission she had an
oxygen saturation in the 60s and was cyanotic. She was seen at
an OSH ED where she was bagged & suctioned and clinically
improved immediately. She remained hemodynamically stable with
BP 90s/40s and asymptomatic. She had an abnormal but stable CXR
and BNP was 251. Her temperature was 100.6 and WBC count was 13K
with 10% bands. She was started on ertapenem and vancomycin for
healthcare associated pneumonia then transferred to [**Hospital1 18**].
.
At [**Hospital1 18**], she continued to have profuse tracheal secretions. She
ultimately required suctioning every hour leading to
desataturations to the 60s with suctioning. Her secretions are
described as deep tan, thick and intermittently frothy. Her ABG
was: 7.47/38/53 on 70% trach collar and she was placed on 100%
trach collar. CXR demonstated an LLL infiltrate (preliminary).
She required intense nursing and respiratory therapy attention
and was then transferred to the MICU for further care and
monitoring.
Past Medical History:
-Coronary artery disease s/p CABG in [**2118**] and "recent" PCI
-Left total hip replacement-[**1-27**], elective. Complicated
postoperative course with post-operative atrial fibrillation
wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE
UT, and prolonged intubation leading to trach/PEG. Discharged to
chronic wean facility but unable to decannulate. Bronchoscopy
revealed tracheomalacia of subglottic region.
-Supraglottic edema from GERD
-Bipolar disorder
-Depression
-chronic atrial fibrillation, developed postop from THR, not
anticoagulated
-Chronic constipation
-HIT during Fragmin therapy
Social History:
Married. Very supportive husband. When she is not
hospitalized/in rehab, she lives with him. No ETOH or
Family History:
non-contributory
Physical Exam:
Vitals: 99.9, 93/40, 105, 21, 97% 60% trach collar
Gen: well appearing female, found asleep, easily arousable,
interactive with mouthing words, appropriate
HEENT: EOMI. OP clear
Neck: supple. trach collar in place. no surrounding erythema. no
JVP seen
Chest: coarse rhonchi bilat. good air entry. no crackles
CV: RRR no m/r/g
Abd: soft, NT, ND. g-tube in place and site dressing c/d/i and
nontender
Ext: vein harvest scar. no edema. 2+ DP pulses. no clubbing or
cyanosis. Pneumoboots in place
Neuro: preserved strength and sensation to light touch
Pertinent Results:
Outside hospital/Pre-admission labs:
CBC: 13.3>42<469 86%pmn 11.5%band
Na 139 K 4 Cl 97 CO2 30 BUN 36 Cr 1.7 Gluc 208
UA: 1.030 cloudy pH 6, 3+prot, trace ketone, +bili, 3+blood,
+nitr, small leuk est, WBC 40/hpf, RBC >100/hpf, gran cast 5,
epi 12, amorph moderate, bacteria large
BNP 251 (<100 is normal)
CXR: diffuse interstitial infiltrates, tracheostomy and prior
sternotomy. little change infiltrates from [**2137-6-3**]. per my read
has increased opacity at left base.
.
[**Hospital1 18**] Admission labs:
[**2137-7-5**] 12:45AM BLOOD WBC-7.5 RBC-3.70* Hgb-11.6* Hct-31.9*
MCV-86 MCH-31.2 MCHC-36.2* RDW-17.0* Plt Ct-322
[**2137-7-5**] 12:45AM BLOOD Neuts-83.9* Bands-0 Lymphs-9.2* Monos-3.7
Eos-2.6 Baso-0.6
[**2137-7-5**] 12:45AM BLOOD Glucose-128* UreaN-26* Creat-1.3* Na-139
K-3.9 Cl-103 HCO3-29 AnGap-11
[**2137-7-5**] 03:30AM BLOOD Type-ART pO2-53* pCO2-39 pH-7.47*
calTCO2-29 Base XS-4
[**2137-7-5**] 03:30AM BLOOD Glucose-123* Lactate-1.2
.
Other Relevant & Discharge Labs:
[**2137-7-10**] 06:21AM BLOOD GAS Type-ART Temp-37.8 Rates-/29 Tidal
V-430 PEEP-10 FiO2-50 pO2-65* pCO2-43 pH-7.45 calTCO2-31* Base
XS-4 Intubat-INTUBATED
.
[**2137-7-8**] 06:56AM BLOOD Cortsol-23.2* Pre-Cosyntropin
[**2137-7-8**] 12:01PM BLOOD Cortsol-31.0* 30-min post-Cosyntropin
[**2137-7-8**] 12:38PM BLOOD Cortsol-37.2* 30-min post-Cosyntropin
[**2137-7-9**] 08:58AM BLOOD proBNP-1286*
[**2137-7-10**] 04:33AM BLOOD Glucose-119* UreaN-13 Creat-0.7 Na-138
K-3.7 Cl-104 HCO3-29 AnGap-9
[**2137-7-10**] 04:33AM BLOOD WBC-6.3 RBC-3.31* Hgb-9.9* Hct-28.0*
MCV-84 MCH-29.9 MCHC-35.4* RDW-16.6* Plt Ct-312
Brief Hospital Course:
The patient is a 66 year old woman with history of respiratory
failure & tracheostomy following hip replacement surgery,
diastolic CHF, CAD, admitted for respiratory distress and
hypoxia, transferred to the MICU for management of her copious
secretions.
.
# Respiratory failure: Pt has chronic hypoxia with a 40 to 50%
trach collar requirement to keep sats in low 90s. Pt had acute
worsening hypoxia due to healthcare associated pneumonia (and
associated copious sputum production). Pt initially treated
with zosyn/vanc until cultures came back positive for
Pseudomonas. The pseudomonal sensitivities are as follows:
CEFEPIME (sensitive), CEFTAZIDIME (sensitive), CIPROFLOXACIN
(sensitive), GENTAMICIN (sensitive), IMIPENEM (resistant),
MEROPENEM (sensitive), PIPERACILLIN/TAZO (sensitive), TOBRAMYCIN
(sensitive). She was treated with meropenem & ciprofloxacin for
double coverage. She is to complete total of 14 days of
antibiotcs (start day = [**2137-7-7**], stop day [**2137-7-20**]).
She was also treated with atrovent and albuterol nebs as she had
occasional of episodes wheezing. The pt underwent bronchoscopy
on [**2137-7-7**] which showed some thick secretions. Her mucosa was
normal and no lesions were seen.
During her hospital stay, pt required mechanical ventilation via
trach as she became developed more severe hypoxia. She
underwent CTA chest, which was negative for PE, but did show
evidence of pulmonary edema. Her BNP was elevated at ~1300.
These findings along with her fluid balance of positive 4L for
her length of stay suggested that she was likely volume
overloaded. Pt was diuresed w/ IV lasix. She may need further
diuresis once at rehab; dosing of lasix should be done at the
discretion of the rehab physician.
[**Name10 (NameIs) **] discharge, the pt required frequent suctioning for her thick
tracheal secretions. She was tolerating periods of trach mask
(up to six hours on the day before discharge) followed by time
on the vent. It is believed that as pt recovers from her
pneumonia and pulmonary edema resolves she should again tolerate
full time trach mask. Until then, may need the vent for short
periods of time.
.
# Airway stenosis: Patient found to have severe supraglottic
edema from likely GERD as well as subglottic
stenosis/?tracheomalacia. She has been followed by Dr.
[**Name (NI) **], who recently referred the pt to otolaryngologist
Dr. [**First Name (STitle) **] (# [**Telephone/Fax (1) 31733**]). The pt was seen by ENT during her
stay. The recommended optimizing her PPI therapy given evidence
of severe GERD. Her PPI was changed to twice daily dosing.
They also recommended follow-up with Dr. [**First Name (STitle) **] (scheduled for
[**2137-7-19**] at 1pm). In the future, she will likely need rigid
bronchoscopy.
.
# Atrial fibrillation: not currently on rate controlling
medications as her rate is well controlled w/o meds (70-80 bpm).
Not on anticoagulation (reason unclear). Pt was in sinus for
the duration of her hospital stay.
.
# Depression/Anxiety: Pt needs frequent re-assurance regarding
her care and clinical status. She was treated with prn
lorazepam, which she required frequently, and standing klonopin.
.
# Acute Renal Failure: baseline creatinine of 0.7 to 1.0. Was
1.7 on admission. Due to pre-renal etiology. It improved with
IVF. Discharge crt 0.7.
.
# Anemia: likely anemia of chronic disease given significant
medical issues over the last few months. Iron studies done last
month revealed elevated ferritin, normal iron and normal TIBC.
.
# Yeast in urine: pt had U/A on [**7-7**] w/ [**3-25**] WBC. Yeast grew in
culture. Because of this pt had her foley changed on [**2137-7-10**].
.
# FEN: PEG tube feeds given with supplemental protein powder
(Probalance at 45cc/hr; 1296 kcals)
# Prophylaxis: PPI, pneumoboots. NO HEPARIN as history of HIT.
# Access: pt had PICC line placed on [**2137-7-9**]
# Code: FULL
# Contact: [**Name (NI) **] [**Name (NI) 16471**] (husband) [**Telephone/Fax (1) 105264**]; [**Name (NI) **] [**Name (NI) **]
(son) [**Telephone/Fax (1) 105265**]
Medications on Admission:
*Aspirin 81 mg PO DAILY
*Olanzapine 5 mg PO BID
*Paroxetine HCl Suspension Ten (10) mg PO DAILY
*Therapeutic Multivitamin 1 Cap PO DAILY
*Docusate Sodium 100 mg PO BID (2 times a day).
*Lactulose 30 ML PO BID
*Furosemide 40 mg PO BID
*Klonopin 0.5 mg [**Hospital1 **]
*Lorazepam 1 mg PO Q4H prn
*Zolpidem 10 mg Tablet PO HS
*Spironolactone 25 mg 1 [**Hospital1 **]
*Pyridium 100 mg TID x3 days
*Zegerid 40 mg [**Hospital1 **]
*protein powder 1 scoop TID
*senna 8.6 mg 2 tabs HS
*KCl 20 mEq daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ciprofloxacin 250 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H
(every 24 hours): Stop day [**2137-7-20**].
5. Clonazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
6. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: Two (2) ml PO BID (2
times a day).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: 4-6 Puffs
Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Lactulose 10 g/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO BID (2
times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
10. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q3H PRN () as
needed for anxiety.
11. Meropenem 500 mg IV Q8H
day 1 = [**2137-7-7**]
12. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical QID
(4 times a day) as needed.
13. Therapeutic Multivitamin Liquid [**Month/Day/Year **]: Five (5) ML PO
DAILY (Daily).
14. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day/Year **]: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed.
15. Olanzapine 2.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times
a day).
16. Paroxetine HCl 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
17. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. Spironolactone 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
20. Zolpidem 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO at bedtime as
needed for insomnia.
21. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2
times a day).
22. Furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
-Pseudomonal pneumonia
-Volume overload/diastolic heart failure
-Supraglottic edema and subglottic stenosis
-Chronic respiratory failure with tracheostomy
.
Secondary:
-History of
-Anxiety/Depression
-Coronary artery disease
-Atrial fibrillation
-status post total left hip replacement ([**1-27**])
Discharge Condition:
Awake, alert, tolerating trach mask with 50% Fi02. SBP 90's to
120's.
Discharge Instructions:
Please suction as needed. Pt may need time on the vent if she
tires.
.
Please continue PPI twice a day--this is a change for pt.
.
Please follow-up with scheduled appointments
.
Please avoid heparin products as pt has been HIT positive in
recent past.
-Pt has contact precautions
Followup Instructions:
You have a follow-up appointment scheduled with Dr. [**First Name (STitle) **] of ENT
on [**2137-7-19**] at 1pm. Phone: [**Telephone/Fax (1) 31733**].
.
A phone message was left with Dr.[**Doctor Last Name 56347**] office
(interventional pulmonary) to schedule a follow-up appointment
in the next month. They may call pt's home # to schedule.
|
[
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"519.19",
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"427.31",
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"V44.0",
"V44.1",
"285.29",
"482.1",
"112.2",
"300.4",
"V45.81",
"458.9",
"414.00",
"428.30",
"478.6",
"518.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.56",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11549, 11624
|
4696, 8771
|
317, 341
|
11977, 12050
|
3078, 3099
|
12379, 12727
|
2476, 2494
|
9318, 11526
|
11645, 11956
|
8797, 9295
|
12074, 12356
|
4067, 4673
|
2509, 3059
|
246, 279
|
369, 1702
|
3591, 4051
|
1724, 2336
|
2352, 2460
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,502
| 183,617
|
8674
|
Discharge summary
|
report
|
Admission Date: [**2199-2-20**] Discharge Date: [**2199-3-11**]
Date of Birth: [**2140-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
Arterial line placement
Central venous line placement
History of Present Illness:
Patient is a 58 y/o M with unknown PMH who was brought in by EMS
for increased SOB and palpitations. Patient now refusing to
answer questions, responding "i don't know" to most questions.
He does report that his breathing has been worse for many weeks.
He gives a h/o asthma and COPD and uses "an inhaler". He also
complains of non-productive cough that is chronic. He denies CP.
He also reports that he has had LE swelling for some time. The
patient also endorses a significant h/o EtOH use over the last
40 years and states that he has been drinking [**11-28**] a [**Month/Day (2) **] of
vodka daily. He currently denies CP, palpitations, nausea,
vomiting, abdominal pain, melena or hematochezia. he reports
that he doesn't take any medications because he doesn't see the
need.
.
ED course: Patient was found to be in afib with RVR. patient was
given 2l NS, valium 60mg IV, diliazem 20mg IV, dilt 40mg [**Last Name (LF) **], [**First Name3 (LF) **]
325 and banana bag. He was admitted to MICU for further care.
Past Medical History:
asthma
COPD
Pancreatitis
EtOH abuse
Social History:
Lives alone in [**Location (un) **] square. No family for friends. Drinks [**11-28**]
[**Name2 (NI) **] of vodka daily. + tobacco use, cannot say how much.
Family History:
Unknown
Physical Exam:
VS: T 97.4 BP 113/86 HR 140 RR 25 O2 sat 100% NRB
Gen: agitated, uncooperative with portions of exam
HEENT: EOMI, PERRL, OP clear, MM dry
NECK: supple, no JVD
Heart: tachy, irregularly, irregular, no m/r/g
Lungs: [**Month (only) **]. BS at bases, diffuse exp. wheezes
Abdomen: soft, +epigastric tenderness, ND, +BS
Ext: 2+ pitting edema to knees on R, 1+ pitting edema on L
Neuro: oriented to person and hospital, answered [**2197**] for year
Pertinent Results:
Labs on admission:
[**2199-2-20**] 04:45PM BLOOD WBC-3.9* RBC-2.45*# Hgb-8.4*# Hct-24.7*#
MCV-101*# MCH-34.1* MCHC-33.8 RDW-15.3 Plt Ct-84*#
[**2199-2-20**] 04:45PM BLOOD Neuts-68.1 Lymphs-22.9 Monos-5.6 Eos-2.9
Baso-0.5
[**2199-2-20**] 04:45PM BLOOD PT-13.8* PTT-28.9 INR(PT)-1.2*
[**2199-2-20**] 04:45PM BLOOD Glucose-90 UreaN-30* Creat-1.3* Na-134
K-4.2 Cl-97 HCO3-22 AnGap-19
[**2199-2-20**] 04:45PM BLOOD ALT-23 AST-50* CK(CPK)-402* AlkPhos-122*
TotBili-0.7
[**2199-2-20**] 04:45PM BLOOD Lipase-641*
[**2199-2-20**] 04:45PM BLOOD CK-MB-13* MB Indx-3.2 proBNP-2958*
[**2199-2-20**] 04:45PM BLOOD cTropnT-0.14*
[**2199-2-20**] 04:45PM BLOOD calTIBC-330 VitB12-1044* Folate-8.9
Ferritn-84 TRF-254
[**2199-2-20**] 04:45PM BLOOD Triglyc-98 HDL-41 CHOL/HD-3.2 LDLcalc-70
[**2199-2-20**] 04:45PM BLOOD TSH-2.1
[**2199-2-22**] 05:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
[**2199-2-20**] 04:45PM BLOOD [**Month/Day/Year **]-NEG Ethanol-20* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-2-22**] 05:10AM BLOOD HCV Ab-POSITIVE
.
Studies:
CT head [**2-20**]: There is no evidence of intracranial hemorrhage,
mass effect, shift of midline structures, hydrocephalus, or
acute major vascular territorial infarct. [**Doctor Last Name **]- white matter
differentiation appears well preserved. There is moderate
atrophy which appears disproportionate to age with ex vacuo
dilatation of the ventricular system. Atherosclerotic
calcifications are noted within the anterior and posterior
circulations. Soft tissues and globes appear unremarkable. No
osseous abnormalities are noted. There are large probable mucus
retention cysts noted within the left frontal sinuses and right
maxillary sinus with mucosal thickening noted within the left
maxillary sinus and ethmoid air cells.
.
CXR [**2-20**]: Bibasilar atelectasis with bilateral pleural
effusions, appearing loculated on the right side. Cardiomegaly.
.
TTE [**2-21**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. The supporting
structures of the tricuspid valve are thickened/fibrotic. There
is no pericardial effusion.
.
ABI [**3-5**]: Normal arterial study of the lower extremity arterial
system at rest.
.
MRI brain [**3-5**]:
1. No evidence of hemorrhage or definite diffusion-weighted
abnormality to suggest ischemia.
2. MR angiography through the circle of [**Location (un) 431**] shows
irregularity of the distal branches of the middle cerebral
arteries bilaterally, which may represent atherosclerotic
disease, although vasculitis is also a diagnostic consideration.
3. Multiple foci of increased T2 and FLAIR signal abnormality in
the periventricular white matter along with age-inappropriate
brain atrophy may reflect marked small vessel ischemic changes.
4. Marked sinus disease most prominent in the left frontal,
bilateral sphenoid and right greater than left maxillary sinuses
may represent acute sinusitis. Clinical correlation is
recommended.
Swallow Evaluation [**3-4**]:
SUMMARY / IMPRESSION:
Signs of aspiration were noted with thin liquid, and the patient
had significant retention of solid consistencies in his pharynx.
He appears safest on nectar-thick liquids and puree consistency
solids, with supervision. He appears at risk to choke on solids
due to his impulsiveness, and his diet probably cannot be
advanced unless his mental status improves.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild-moderate dysphagia.
RECOMMENDATIONS:
1. PO diet of nectar-thick liquids and puree consistency solids.
2. Pills can be given whole with nectar-thick liquid or in
puree.
3. Strict 1:1 supervision with all POs. Pt appears at choking
risk and aspiration risk due to his mental status.
4. Please check mouth after giving pills and POs to ensure pt is
not pocketing solids, and suction if needed.
5. Aspiration precautions, including seating pt as upright as
possible, before and for 30 minutes following meals.
6. We will follow up later this week to advance the pt's diet if
appropriate.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2199-2-24**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2199-2-24**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN G---------- S
Brief Hospital Course:
# EtOH abuse/withdrawl: Patient with significant history of
alcohol abuse, last drink one day prior to admission, [**2-20**].
Reported history of DTs. On admission, receieved
thiamine/folate/banana bag. Required increasing high levels of
vallium, ultimatly requrining intubation. Pt now extubated since
[**3-2**]. No active signs of withdrawl and patient at mental status
baseline. Patient uncooperative with social work consult to
address addiciton/homlessness issues, should be reattempted. No
longer on CIWA scale. Patient with aggitiation requiring
[**Hospital1 **]:PRN haldol. Continuing dialy thiamine/folate.
.
#. Resp failure: The combination of a depressed MS with
increasing valium requirment coupled with increased secretions
with possible mucus plug, patient required intubation on [**2-23**].
Noted to have a sputum PCN sensitive strep pneumonia, and was
treated with PCN and levo. With worsened CXR and worsened O2
requirement, patient began treatment on [**3-2**] for VAP with
vanc/zosyn, sputum Cx came back positive for MRSA. Patient
afebrile and relativly normal WBC. Zosyn was discontinued, and
patinet completed 8 day course of vanc treatment for MRSA VAP
completed [**3-9**]. Some component of respiratory difficutlies
likely secondary to fluid overload with acute systolic heart
failure, as patinet 10L positive over admission. Patient had
been responding to diuresis of 40mg IV lasix [**Hospital1 **], with removal
of fluid. Now on maintence lasix dose.
.
# Hypernatremia: Patient was hypernatremic, with sodium level of
150. Likely free water deficit with no PO intake following
extubation with concurrent diuresis. Patient was given 3L D5,
and is now corrected.
.
#. C.Diff: Patient with diahrea that was c.diff positive. Not
currently febrile, without abdominal pain, and no elevation of
WBC. Patient will need to complete a two week course of flagyl
after completing course of vanc, now day [**1-10**] on day of
transfer.
#. Sinusitis: Significant sinus disease noted on head imaging.
No sinus tenderness, afebrile, and no elevation of WBC. Patient
was given a 3 day course of afran.
.
#. L sided Weakness: Left sided weakness first noticed [**3-2**] after
extubation, using R side to move L side. Anisocoria also noted.
Has head CT had a question of hypodensity in left ventral pons,
neuro was consulted. Concerning
for Horner's syndrome and would localize anywhere along the
cervical sympathetic pathway, hypothalamus, posterolateral
brainstem, cervical cord, spinal root at T1 (Pancoast, cervical
rib), neck trauma (no ipsa lateral neck lines per team), carotid
artery and unlikely to involve the orbit or cavernous sinus due
to no other CN involvement. MRI and MRA obtained, showing no
[**Known lastname **] pathology, only noting small vessel ischemic disease.
Neurology singed off. Patients left-sided weakness resolved.
Continuing aspirin.
.
# CHF: Patient volume overloaded by exam and CXR, has bilateral
LE edema, bilateral effusions, and a BNP elevated >[**2190**]. TTE
showing EF of 30% with global LV hypokensis. Picture consistent
with alcohol-induced cardiomyopathy vs. HTN cardiomyopathy vs
tachycardia induced cardiomyopathy. Pt is being diuresed, was
rate controlled with metop titrated to 100mg TID-tolerated well,
now written for Toprol XL. 10L positive since admission, now
diuressed off, and now on maintenence lasix dose which may need
to be adjusted. Patinet was started on ACE and titrated up.
.
# Afib: Unknown whether patient has h/o afib or this is new.
Rate uncontrolled in setting of withdrawl, anxiety, heart
failure. TSH wnl. Reasonably well controlled with PO
metoprolol. Poor candidate for anticoagulation.
.
# Pancytopenia: All cell lines depressed on presentation, c/w
alcohol-induced myelosuppression. Guaiac neg. in ED. Transfused
[**2-28**], no GIB or any signs of bleeding. Anemia studies all within
normal limits. Hct has been stable at 23, at 21.7 on day of
transfer, likely just from over phlebotomy, but should be
followed.
.
# ARF: unknown baseline. Pre-renal in setting of poor PO intake,
excessive etoh intake, also may have poor forward flow in
setting of afib with RVR. Resolved, with stable Cr at 1.0-1.2.
.
#. DM: FS stable at NPH 15U [**Hospital1 **] + ISS. [**Month (only) 116**] need to readjusted
if PO intake increases.
.
# Asthma/COPD: Has exp. wheezing on exam could be [**12-29**]
bronchospasm or pulm. edema as well as COPD. Written for
albuterol/atrovent nebs and is actively being diuresed.
.
# FEN: Failed my bedswide evaluation, now on thickened liquids
requiring 1:1 during feedings. Full report listed above.
Medications on Admission:
Albuterol INH
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks: day 1 [**3-10**].
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) Subcutaneous twice a day.
11. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous QACHS.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
18. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for aggitation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Atrial Fibrillation with Rapid Ventricular Response
Ethanol Withdrawl
Respiratory Failure
Ventillatory acquired MRSA pneumonia
Anemia
Acute systolic heart failure
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after an admission
for shortness of breath and palpitations. You were found to
have atrial fibrillation with rapid ventricular response. In
order to withdraw you from ethanol, you required such high doses
of medication that you required intubation. You developed a
pneumonia from this intubation, and have now been treated with
antibiotics. You also developed an infectious diahreal illness
known as c.diff and will need to compelete a 14 day course of
flagyl. You had become significantly deconditioned from this
illness, and will require physical therapy for rehabilitation.
You are now being transfered for futher care.
Followup Instructions:
None
|
[
"285.9",
"482.41",
"473.9",
"038.2",
"729.89",
"379.41",
"284.1",
"250.90",
"427.31",
"303.91",
"263.0",
"999.9",
"428.0",
"577.0",
"V09.0",
"584.9",
"428.21",
"070.54",
"785.52",
"008.45",
"425.5",
"995.92",
"276.0",
"518.81",
"291.0",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"96.04",
"94.62",
"96.72",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14092, 14107
|
7811, 12440
|
319, 385
|
14333, 14342
|
2165, 2170
|
15061, 15068
|
1677, 1686
|
12504, 14069
|
14128, 14128
|
12466, 12481
|
14366, 15038
|
1701, 2146
|
276, 281
|
413, 1428
|
14147, 14312
|
2185, 7788
|
1450, 1488
|
1504, 1661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,374
| 115,690
|
34287
|
Discharge summary
|
report
|
Admission Date: [**2168-9-22**] Discharge Date: [**2168-9-26**]
Date of Birth: [**2112-9-20**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Intraoperative blood loss.
I&D right hip THA
Major Surgical or Invasive Procedure:
Intubation; Attempted Total hip replacement
History of Present Illness:
This 56 year male unilingual russian speaker w/ a hx of hep B/C,
cirrhosis, hypersplenism and pancytopenia was taken to the OR
today for complex revision total right hip replacement because
of debilitating right hip pain. The surgery was intended to be
exploratory to see if there were any loose parts from previous
surgeries that might be causing pain and could be removed. The
patient's hip was opened and no such loose parts were found.
Orthopedics feels the patient is not a candidate for any further
surgical intervention. The procedure could not be completed due
to heavy bleeding from the surgical site in the context of
platlets of 34 and an INR 1.6. He lost an estimated 4L of blood,
but got most of this back as cell [**Doctor Last Name 10105**]. He was also transfused
3 units PRBC, 6 units FFP and 5 units of platlets. He remained
hemodynamically stable throughout the OR and never became
hypoxic. Vanc and ancef were given intra-op and a drain was
placed in the operative site before closing the hip.
Post-op, he is admitted to [**Hospital Unit Name 153**] for resuscitation and monitoring
in the context of heavy bleeding intra-op.
.
On the floor, he is intubated and sedated w/ pressure wrappings
over his right hip and a drain in place. He remained stable in
the [**Hospital Unit Name 153**] and was tranferred to the general orthopedic floor.
Remainder of his hospital stay was unremarkable. He progressed
with PT and was discharged to home with services in stable
condition.
Past Medical History:
-Motor vehicle accident: failed ORIF acetabulum in [**2160**]
requiring complex right total hip replacement in [**2160**].
-Hep B serology pos, DNA neg
-Hep C presumed [**1-5**] transfusion after MVA in [**2160**]. s/p 6mo
Interferon and Ribavirin tx, but hep C recurred
-Liver cirrhosis: followed by GI. no focal lesions on U/S in
[**2168-6-2**]
-Cholelithiasis, no acute cholecystitis
-hypersplenism
-pancytopenia: felt to be secondary to marrow suppression from
HCV and hypersplenism, not considered a candidate for epo tx per
report
-s/p appendectomy
-s/p right hand surgery
-s/p left shoulder surgery
Social History:
Originally from [**Country 532**].
- Tobacco: None per anesthesia report
- Alcohol: None per anesthesia report
- Illicits: None per anesthesia report
Family History:
Unknown
Physical Exam:
On arrival to ICU,
Vitals: stable
General: Intubated and sedated
HEENT: Sclera anicteric. Right eye with cataract. Left pupil 1mm
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended, bowel sounds present
GU: foley draining clear fluid
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Skin over feet is darker brown bilaterally. incision
C/D/I
Skin: diffuse macular papular [**Country **] over shoulder, neck legs and
abdomen. Chest is spared.
Brief Hospital Course:
56 year male with hep B/C, cirrhosis, hypersplenism and
pancytopenia s/p unsuccessful complex revision total right hip
replacement today, now admitted to [**Hospital Unit Name 153**] for resuscitation in the
context of extensive intraoperative blood loss.
# Hemorrhage: Patient had bleeding secondary to surgery with
high intraop blood loss in context of thrombocytopenia and
cirrhosis with elevated INR. He was transfused a total of 4
units PRBCs, 5U of platelets, and 5U FFP, and was bolused with
IVF to maintain hemodynamic stability. He remained intubated
overnight after surgery while he was being bolused and
transfused repeatedly but was extubated to 2L NC the following
morning on [**9-23**] without difficulty. DIC labs were wnl, and
platelets were 40-70s.
.
# Post-op attemtpted total hip replacement: He received 2 g
ancef Q8H x 48H for infection ppx. As above, he intitially
remained intubated overnight due to fluid shifts and was kept on
ARDSnet ventilation as pt at risk for TRALI. Pain was treated
with dilaudid PCA when extubated. He spiked a fever to 100.7 on
[**9-23**] and was pan cultured but has been afebrile since
.
# [**Name (NI) **] - Unclear etiology but resolved by following day. [**Month (only) 116**]
have been secondary to transfusion or anesthesia as he continued
on abx without further reaction.
.
# Cirrhosis - Stable. Management as above. Gastroenterologist
is Dr. [**First Name (STitle) 679**] if questions arise.
He progressed well with PT while on the general orthopedic floor
and was stable for discharge to home with physical therapy.
Medications on Admission:
Oxycodone-acetaminophen 5/325 mg 1 tab up to TID prn pain
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*80 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
painful R THA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool
softener (such as colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
10. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment.
Physical Therapy:
wbat rle
post hip precautions
Treatments Frequency:
daily dressing changes as needed
ice as tolerated
wbat
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-10-21**] 10:00
Completed by:[**2168-9-26**]
|
[
"070.30",
"782.1",
"571.5",
"998.11",
"284.1",
"E849.8",
"E849.7",
"070.70",
"285.1",
"727.89",
"V43.65",
"289.4",
"287.5",
"719.45",
"574.20",
"996.77",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.65",
"81.53",
"80.75"
] |
icd9pcs
|
[
[
[]
]
] |
5341, 5427
|
3392, 4975
|
362, 407
|
5485, 5485
|
8152, 8385
|
2748, 2757
|
5083, 5318
|
5448, 5464
|
5001, 5060
|
5668, 7269
|
2772, 3369
|
8021, 8051
|
8073, 8129
|
278, 324
|
7281, 8003
|
435, 1933
|
5500, 5644
|
1955, 2562
|
2578, 2732
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,829
| 157,262
|
45209
|
Discharge summary
|
report
|
Admission Date: [**2121-12-1**] Discharge Date: [**2121-12-10**]
Date of Birth: [**2061-11-17**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Lightheadedness, dark stools
Major Surgical or Invasive Procedure:
EGD
Colonscopy
History of Present Illness:
HPI: This 60 year old gentleman with hepatitis C cirrhosis with
known gastric varices, CAD s/p DES to LAD in [**2118**], presented
with lightheadedness & dark stools since saturday. This was
associated with dyspnea on exertion, but no CP. Not vomiting any
blood.
SBP 120 with P 60-80 in ED. Guaiac (+). Hct noted to be 18.9
from baseline 33. Typed and cross for 6 units and 2 large bore
IV placed. Started on octreotide and protonix drip on
consultation with the liver service. SBP did decline, at one
point, to 100--this was responsive to fluids with SBP to 120. He
also received ciprofloxacin for possible variceal bleed and also
5 mg SC vitamin K. Pt had brief episode of CP while in ED which
resolved spontaneously. CP associated with non specific EKG
changes (T wave flattening) Admitted to ICU where the patient
denied any complaints. Underwent upper endoscopy which
visualized minimal oozing and no blood.
Past Medical History:
1. Hepatitis C: diagnosed 6 years ago, received 7 months IFN
treatment, but was not responsive.
2. Cirrhosis: secondary to Hepatitis C, patient also has
history of long time alcohol use. History of esophageal varices
seen on EGD ([**2115**]), though most recent EGD ([**1-29**]) showed
gastropathy and duodenitis, no varices. Patient reports that
biopsy showed fibrosis/cirrhosis.
3. Coronary Artery Disease - s/p stent 1-2 years ago.
4. Hypertension: sub-optimally controlled, not currently on any
medications.
4. Substance use - 20 year heroin use history, maintained on
methadone now.
5. Iron Deficiency Anemia ; most likely from GI source.
Social History:
Patient lives by himself in [**Location (un) **]. He works as a gardener.
He has a long history of alcohol use, stopped 15 years ago. He
has a 30 year smoking history, quit several months ago. He has
20 year history of heroin use, has been maintained on methadone
for many years now.
Family History:
Mother died from jaw cancer at very young age, father died from
lung cancer. He has five siblings: one sister died from sudden
cardiac death, the other sister and three brothers are well.
Physical Exam:
T: 98.1 BP: 136/74 P: 62 RR: 20 O2: 95% on 2L HEENT Exam:
Gen: Pleasant male Caucasian. Obese, NAD.
Mouth: MM somewhat dry.
Chest: Clear to auscultation bilaterally. Distant breath sounds
bilaterally, particularly on right base. No crackles, wheezes
or rhonchi throughout. Gynecomastia.
Cor: RR, normal S1/S2, no murmurs/rubs/gallops.
Abd: Protuberant and soft. Non tender, no palpable masses, no
hepatosplenomegaly, no guarding or rebound. No fluid wave.
Minimal bowel sounds.
Ext: Warm, well-perfused. No clubbing, cyanosis, edema.
2+ dorsalis pedis pulses bilaterally. No asterixis.
Neurol: Alert and oriented x3. CN II-XII intact to direct
testing. Preserved sensation and motor throughout.
Pertinent Results:
Na 137 Cl 106 BUN 19 Glu 126 AGap=10
K 3.6 HCO3 21 Cr 0.7
estGFR: >75
CK: 46 MB: Notdone Trop-T: <0.01
Ca: 7.5 Mg: 1.7 P: 2.4
ALT: 36 AP: 116 Tbili: 0.6 Alb: 3.0
AST: 47 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 47
.
WBC 4.1 N:72.5 L:21.3 M:4.3 E:1.6 Bas:0.3
Hgb 6.0. Hct 18.9
Plts 80
.
EGD: [**2121-12-2**]
Impression: Varices at the fundus
Otherwise normal EGD to second part of the duodenum
Recommendations:
1) Continue octreotide and antibiotics
2) Prep for colonoscopy tomorrow
3) If no bleeding source on colonoscopy, may need TIPS
.
Colonoscopy [**2121-12-3**]
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
.
CT abd [**2121-12-8**]
CONCLUSION:
1. Aberrant venous anatomy as described.
2. Probable thrombosis of subsegmental branches of the
posterior branch of
the right portal vein.
3. Apparent interval development of mediastinal
lymphadenopathy.Formal Chest
CT recommended
4. Extensive cirrhosis, portal hypertension.
.
ECHO
.
RUQ doppler [**12-4**]
IMPRESSION: Echogenic liver without focal lesion. Patent
portal and splenic veins. Small ascites.
Brief Hospital Course:
Assessment: Pt is a 58 year old man with history of Hep C/ETOH
cirrhosis with known gastric varices and CAD who admitted to the
MICU and subsequently transferred to the floor after being
resuscitated for GI bleed.
Hospital Course by Problem:
GI Bleed: Pt was admitted to the MICU with a hct of 18, and was
transfused a total of 3 units PRBCs. He was started on IV PPI
[**Hospital1 **], and octreotide drip, which was continued for 3 days. He had
2 large bore IVs. In the MICU, he had EGD not showing any acute
bleeding, but did show known gastric varices. The anemia is
likely secondary to slow oozing from gastric varices. He was
transferred to the floor with a stable Hct. His HCt was
initially checked TID, then [**Hospital1 **], and eventually daily. The Hct
continued to be stable for the rest of the hospitalization. The
patient was transferred to the floor for further work up prior
to TIPS. Given the has gastric but not esophageal varices, and
has had 3 episodes of anemia secondary to acute blood loss from
gastric varices, banding is not an option, and the next step for
him is TIPS. He had a colonoscopy to rule out any colonic
sources of bleed. He then had a tips attempt on [**12-5**] day, which
was unsuccessful due to the patients aberrant anatomy. The
patient the patient was discharged with plans on having an EUS
the day after discharge to rule out mass causing the varices,
and if negative, a TIPS procedure the next week.
CAD: No active issues. patient was ruled out for ACS on
admission. ASA held, restarted on discharge. No beta blocker
secondary to bradycardia. continue lipitor
h/o substance abuse: off heroin on methadone, continued
methadone 60mg every morning, 6am.
Medications on Admission:
1. Methadone 60 mg PO daily.
2. Ferrous Sulfate 325 daily
3. Aspirin EC 81 mg Tablet PO once a day.
4. Omeprazole 20 mg PO twice a day.
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN
7. Lipitor 40 mg PO once a day.
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Six (6) Tablet PO Q6AM ().
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute anemia from blood loss
hep c/ETOH cirrhosis
Esophageal varicies
Secondary:
Narcotics abuse
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital with anemia. You recieved a blood
transfusion. You had an upper endoscopy and a colonscopy, and
the most likely cause of the repeat episodes of anemia are the
varicies around your esophagus.
.
Please call your doctor or return to the hospital if you have
bright red or black stools, vomit blood, or feel dizzy or
lightheaded.
Followup Instructions:
1. You are scheduled for an outpatient endoscopic ultrasound
with Dr. [**Last Name (STitle) **] for [**2121-12-11**] at 11:30 AM. It will be in the
[**Hospital Ward Name 1950**] building [**Location (un) 453**], on the [**Hospital Ward Name 516**]. If you have
questions, his office phone number is [**Telephone/Fax (1) 96609**]. They will
call you to verify today.
Based on these results, we will plan for the TIPS procedure.
.
2. Please make an appointment to see your liver physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], for next week. His office number is: [**Telephone/Fax (1) 24157**].
3. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 250**].
4. Please f/u with the pulmonary phsyicial, Dr. [**Last Name (STitle) 575**],
regarding enlarged carinal lymph nodes on abdominal CT. [**1-13**],
tuesday, at 930, and 10:00. [**Location (un) 436**] of [**Hospital Ward Name 23**] building
Completed by:[**2121-12-29**]
|
[
"578.9",
"786.59",
"785.6",
"571.5",
"280.0",
"305.03",
"304.01",
"414.01",
"V45.82",
"305.1",
"070.54",
"V15.84",
"411.1",
"V10.11",
"456.8",
"284.1",
"562.10",
"572.3",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"38.93",
"88.64"
] |
icd9pcs
|
[
[
[]
]
] |
6916, 6922
|
4305, 4520
|
300, 316
|
7073, 7082
|
3180, 4282
|
7481, 8552
|
2258, 2448
|
6311, 6893
|
6943, 7052
|
6032, 6288
|
7106, 7458
|
2463, 3161
|
232, 262
|
4549, 6006
|
344, 1259
|
1281, 1936
|
1952, 2242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,701
| 149,780
|
21047
|
Discharge summary
|
report
|
Admission Date: [**2178-1-17**] Discharge Date: [**2178-1-23**]
Date of Birth: [**2109-6-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
leg swelling
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
.
History was obtained via interpreter and medical reports.
.
HPI: This is a 69yo [**Location 7972**] male with a history of ITP on
prednisone 80mg, HTN who presents with left leg swelling and
shortness of breath. The patient reports that over the past 1
week he has had worsening left leg pain and swelling. He stated
it was associated with some mild shortness of breath,
palpitations and fatigue. He denied any chest pain, hemoptysis
or trauma to his leg. He presented to his PCP office today and
VS were significant for O2 saturation of 94% on room air, heart
rate 108 and blood pressure 100/74. He was also noted to have
some swelling of his left leg. Mr. [**Known lastname 55897**] was sent to the [**Hospital1 18**]
ED for further evaluation.
.
In the ED, 98.7 109 102/70 16 99%RA. He underwent LENI that
showed extensive DVT of the left lower extremity that involved
the femoral, superficial femoral and popliteal veins. He then
underwent CTA of his chest that revealed b/l pulmonary embolus
including right and left pulmonary arteries and middle & infeior
branches. There was also some concern for bowing of the
intraventricular septum that could indicate right heart strain.
The patient CE negative x1. He was started on a heparin gtt
(weight based) with a 5400U bolus and 1200U/hr infusion. He was
guaiac negative. The patient's glucose was also noted to be 515
and was given 6U humalog and FS improved to 227. VS upon
transfer from the ED to the [**Hospital Unit Name 153**] were 98.1 98 107/82 16 100% RA.
He was sent to the ICU for closer hemodynamic monitoring given
concern for right heart strain on CT-scan.
.
In the ICU he denied SOB, pain or other complaints.
.
Of note, the patient was seen in the ED on [**12-24**] and found to
have platelets of 17K and started on 80mg prednisone daily per
Hem/Onc. He was supposed to follow-up, but did not show for his
follow-up appointment. His platelets in the ED were 165.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
Hypertension
ITP
Anemia
H. pylori s/p triple therapy
GERD
Chronic right foot and ankle pain, peroneal tendonitis
Hearing loss
Allergic rhinitis
Erectile dysfunction
Mild cataracts
Social History:
He is retired and lives with his wife. [**Name (NI) **] has two supportive
daughters. [**Name (NI) **] denies cigarette, EtOH, or illicit drug use.
Family History:
There is no family history of bleeding or coagulation disorders.
No history of clots
Physical Exam:
On Admission:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/ 1+ edema in the lower ext
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
On Admission:
[**2178-1-17**] 11:00AM WBC-9.8 RBC-4.14* HGB-13.0* HCT-37.5* MCV-91
MCH-31.3 MCHC-34.6 RDW-13.5
[**2178-1-17**] 11:00AM PLT COUNT-165
[**2178-1-17**] 11:00AM NEUTS-73.7* LYMPHS-21.8 MONOS-3.0 EOS-0.9
BASOS-0.5
[**2178-1-17**] 11:00AM GLUCOSE-515* UREA N-17 CREAT-1.2 SODIUM-133
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-27 ANION GAP-17
[**2178-1-17**] 11:00AM cTropnT-<0.01
[**2178-1-17**] 10:56PM CK-MB-2 cTropnT-<0.01
[**2178-1-17**] 10:56PM CK(CPK)-31*
[**2178-1-17**] 11:00AM PT-13.3 PTT-22.1 INR(PT)-1.1
[**2178-1-17**] 10:58PM PT-14.9* PTT-100.1* INR(PT)-1.3*
.
LENI:
Extensive DVT in left lower extremity involving femoral,
superficial femoral
and popliteal with small amount of residual flow in those veins.
calf veins
not visualized and may be occluded.
.
CTA Chest:
IMPRESSION:
1. Bilateral pulmonary emboli involving the right interlobar
artery and
branches to the right middle and lower lobes as well as the left
pulmonary
artery with branches to the lingula and lower lobe.
2. Right ventricle larger than left ventricle (RV:LV >1),
suggestive of right heart strain.
3. Ascending aorta measuring up to 4 cm, mildly dilated.
.
Cardiac Echo Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Normal global RV systolic function. Indeterminate
pulmonary pressures. Limited study.
.
CT ABD & PELVIS WITH CONTRAST
CT ABDOMEN WITH IV CONTRAST: There has been interval development
of
peripheral ground-glass opacities in the left lower lobe. Given
the known
left lower lobe pulmonary embolus, these likely represent
pulmonary infarcts.
No pulmonary nodules seen. No pleural effusion seen. No
pericardial effusion
seen.
There is a linear hypoenhancing structure seen superiorly within
the right
lobe of the liver. This is closely related to the middle hepatic
vein which
is attenuated, particularly apparent on the coronal reformats.
The left
hepatic vein is also not seen however. The appearances are
concerning for
thrombus within a hepatic vein, it is not clear whether this is
within the
middle hepatic or left hepatic vein. Ultrasound or multiphasic
CT could
clarify the vascular anatomy. No definite extension into the IVC
is seen
although this is poorly opacified. No other focal liver lesions
are seen. No
biliary duct dilatation. The gallbladder is distended but
otherwise
unremarkable in appearance. The portal vein is patent. There is
a 1 cm
hypoenhancing lesion seen in the lower pole of the right kidney.
While this
most likely represents simple cyst, the measured Hounsfield
units are higher
than one would expect. This could be further characterized on
ultrasound.
There are two small cortical lesions in the left kidney, both of
which are
hypoenhancing but too small to characterize. These may also be
visible on
ultrasound. The spleen is unremarkable in appearance. The
pancreas is
somewhat atrophic but otherwise unremarkable, no pancreatic duct
dilatation
seen. Both adrenal glands are unremarkable in appearance. No
enlarged
mesenteric or retroperitoneal lymph nodes are seen. No free
fluid. The small
and large bowel is normal in caliber.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, rectum
and prostate
are unremarkable in appearance. No free fluid seen. No pelvic
lymphadenopathy. There are prominent veins seen in the left
gluteal region
with thrombus expanding the left common femoral vein and
visualized
superficial femoral vein. The prominent gluteal vessels are
likely
collaterals draining the lower limb.
BONY STRUCTURES: There is a mixed lucent and sclerotic lesion
seen in the
right ilium with adjacent sclerosis inferiorly. This is a
medullary-based
lesion without evidence of cortical involvement and is of
uncertain
significance. No other bony lesion seen.
IMPRESSION:
1. New left lower lobe opacities concerning for pulmonary
infarction in a
patient with known PE.
2. Possible thrombus seen in either the left hepatic or middle
hepatic vein,
correlation with ultrasound is recommended. In addition,
thrombus is seen in
the left common femoral and superficial femoral vein with
prominent collateral
vessels in the left gluteal region.
3. Multiple small hypoenhancing lesions in both kidneys likely
represent
cysts however, this could be confirmed on ultrasound.
Brief Hospital Course:
Mr. [**Known lastname **] is a 68 year old man with a history of ITP on 80 mg
of prednisone intermittently since this Fall, now here with
bilateral PEs, DVT and possible right heart strain. He was
initially admitted to the MICU and treated with continuous
heparin gtt. He was transferred out of the ICU on [**2178-1-19**] for
ongoing care and management.
.
He was treated with IV heparin gtt and transitioned to warfarin
with a goal INR [**2-12**]. The cause of his thrombophilia is unclear.
Hematology was consulted to help guide treatment for his ITP as
well as determine the need for an IVC filter, and thrombotic
workup. His prednisone was decreased from 80 mg to 40 mg on [**1-20**] at their recommendation. His platelet count was monitored
closely. As per Hematology recommendations, he continued 40mg
for three days then started 20mg daily, which he is to continue
until his outpatient hematology follow-up.
.
A CT of the Abd/Pelvis to look for malignancy and possible
compression of the IVC contributing to his distal clot was
ordered and showed: new left lower lobe opacities concerning for
pulmonary infarction in a
patient with known PE, possible thrombus in either the left
hepatic or middle hepatic vein, thrombus in
the left common femoral and superficial femoral vein with
prominent collateral vessels in the left gluteal region,
multiple small hypoenhancing lesions in both kidneys which
likely represent cysts. TTE showed normal global LV and RV
systolic function with indeterminate pulmonary pressures.
Discussion was had with Hematology about placing an IVC filter,
and he underwent successful placement of an IVC filter via IR
guidance on [**1-21**]. He remained clinically stable on a heparin gtt
until his INR was therapeutic ([**2-12**]) for 48 hours, then the
heparin was discontinued.
.
The [**Last Name (un) **] team was consulted to help manage his significant
diabetes, likely in large part related to glucocorticoid use.
They recommended morning and bedtime NPH insulin along with a
humalog sliding scale. His last HbA1C was >10 so he may have
underlying diabetes mellitus type II in addition to
prednisone-induced hyperglycemia. He had Nutritional education
regarding a diabetic diet as well as teaching regarding
self-administration of insulin and checking his blood glucose,
etc. VNA services were arranged
.
On [**1-19**], he was hypertensive and his beta blocker was started
at a lower dose (after all his antihypertensive meds had been
held due to his acute illness). He remained normotensive for the
remainder of the hospitalization without the HCTZ and
lisinopril.
.
# Comm: Wife [**Name (NI) 7346**] (doesn't speak english). Daughter [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1004**] [**Telephone/Fax (1) 55898**], [**Telephone/Fax (1) 55899**]
Medications on Admission:
HCTZ 25mg daily
Lisinopril 40mg daily
Metoprolol Succinate 100mg daily
Omeprazole 20mg daily
Prednisone 80mg daily
Discharge Medications:
1. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: titrate dose as directed by Dr. [**Last Name (STitle) 16120**] clinic.
Disp:*30 Tablet(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): take 30 minutes
before breakfast.
4. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. syringe (disposable) 5 mL Syringe Sig: One (1) Miscellaneous
twice a day.
Disp:*QS box* Refills:*2*
8. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
15 units Subcutaneous before breakfast.
Disp:*QS vial* Refills:*2*
9. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
5 units Subcutaneous at bedtime.
Disp:*QS vial* Refills:*2*
10. glucometer
use as directed
11. Humalog 100 unit/mL Solution Sig: One (1) sliding scale
Subcutaneous four times a day: use as directed; see separate
sheet.
Disp:*QS vial* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Homehealth
Discharge Diagnosis:
# Acute pulmonary embolism with right ventricular strain
# Pulmonary infarction
# Bilateral lower extremity DVT's
# Hepatic vein thrombosis
# idiopathic thrombocytopenic purpura
# steroid-induced diabetes
# hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with blood clots in your lungs and in your
legs. You were treated with heparin and coumadin, and you will
need to stay on coumadin at least six months. This medication
needs to be monitored closely because too much can cause you to
bleed excessively, and too little can predispose you to form
more blood clots. A filter was placed through your right leg
into the blood vessel returning to your heart, in order to
prevent more clots from moving into your lungs. Regarding your
low platelet condition, the Hematology specialists recommended
decreasing your prednisone dose, since your platelet count has
normalized. You are going home on 20mg, which you should stay on
at least until you follow-up with Hematology in clinic. In
addition, you have diabetes, most likely as a result of being on
prednisone. You were evaluated by the [**Last Name (un) **] specialists, who
assisted in treating you with insulin. You will be checking your
glucose at home daily and injecting yourself with insulin. We
have arranged visiting nurses to assist you with all this, and
you should follow-up closely with your primary care doctor, Dr.
[**Last Name (STitle) **]. Lastly, regarding your high blood pressure, please note
we STOPPED your hydrochlorothiazide and lisinopril, and your
blood pressure has been well-controlled.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2178-1-30**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], 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: FRIDAY [**2178-1-30**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: MONDAY [**2178-2-23**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2178-1-26**]
|
[
"401.9",
"453.42",
"249.01",
"287.31",
"530.81",
"V58.67",
"E932.0",
"415.19",
"429.9",
"389.9"
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icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
13076, 13131
|
8729, 11538
|
316, 339
|
13395, 13395
|
3844, 3844
|
15022, 16141
|
3057, 3145
|
11703, 13053
|
13152, 13374
|
11564, 11680
|
13672, 14999
|
3160, 3160
|
264, 278
|
367, 2671
|
3858, 8706
|
13536, 13648
|
2693, 2875
|
2891, 3041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,288
| 179,300
|
38945
|
Discharge summary
|
report
|
Admission Date: [**2172-4-14**] Discharge Date: [**2172-4-15**]
Date of Birth: [**2090-7-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p trauma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81yM on ASA shopping downtown when he was running across the
street in the rain
was struck by a slow moving vehicle in the back of the head and
knocked to the ground. He describes a + LOC, and is amnesic to
events immediately following the trauma. He was taken to [**Hospital3 26616**] hospital for eval and was reported to have a small R
intraparanchymal vs intraventricular hematoma. By report his
C-spine and torso scans were negative. He was transferred to
[**Hospital1 18**] for neursurgical and trauma consultation. In the ED he
complains of occipital pain and discomfort from the foley but
otherwise feels well. He denies any vision changes, numbness or
tingling in the arms or legs. He denies feeling weak.
Past Medical History:
HLD, hypothyroid, HTN, s/p 3 vessel CABG [**2160**] with ? porcine
valve (had short trial of coumadin but was switched to ASA)
Social History:
Denies any etoh, tobacco
Lives with daughter but is independent and drives on his own.
Worked for a long time in concrete manufacturing
Family History:
non-contributory
Physical Exam:
T:97.2 BP:110/68 HR:58 R20 O2Sats 98 on 3L O2
Gen: Elderly gentleman on logroll precautions in C-collar WD/WN,
comfortable, NAD.
HEENT: Pupils: 3-2mm brisk b/l EOMs intact
Neck: in c-collar, no posterior bony tenderness
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: [**3-18**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Pertinent Results:
CT Head [**4-14**]
IMPRESSION:
1. Small left temporal subdural hemorrhage, without mass effect.
2. 4 x11 mm ovoid hyperdensity in the corpus callosal genu on
the right is
not typical in location for contusion. In the setting of trauma,
diffuse
axonal injury typically occur within the corpus callosum.
However, given
history of a conscious patient with reported GCS of 15, this is
unlikely.
This lesion is far remote from the site of impact, and therefore
less likely
to represent contusion. Additional less likely differential
considerations
include focal hemorrhage from a pre-existing vascular
malformation or
metastatic lesion from a primary hyperattenuated malignancy such
as melanoma.
Comparison to more remote prior exam when available would be
helpful.
Ultimately, MRI may be usefult to further characterize.
3. Large right parietooccipital subgaleal hematoma with
laceration as well as
left temporal small subdural hemorrhage, consistent with coup
and contrecoup
injury.
.
CT head [**4-15**]:
IMPRESSION:
Unchanged
Brief Hospital Course:
Patient was brought in as a trauma. He remained stable with no
neuro changes. A repeat Head CT was done with no changes. He
was able to eat and drink and ambulate. PT worked with him and
he was cleared to go home. Neurosurgery said he was fine to
restart his ASA and go home with follow up in 4 weeks with
repeat Head CT.
Medications on Admission:
ASA 325', lasix 20', enalapril 20', simvastatin 20',
spironolactome 25', toprol xl 50', levoxyl 0.15mcg'
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p trauma
R parietoocciptal subgaleal hematoma
right gluteal hematoma
scalp laceration
left temporal small SDH
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were involved in a trauma and had a small amount of bleeding
inside of your head, and some bleeding outside of the head as
well. This bleeding was stable and you had no neurologic
changes.
.
You should avoid driving for 1 week or performing any strenuous
activity. If you notice new headache, changes in vision,
weakness or any other concerning symptoms such as nausea,
vomiting, chest pain, lightheadedness please call or return to
the ER as soon as possible.
Followup Instructions:
please call the [**Hospital 4695**] clinic to schedule a follow up appt
for 4 weeks from now with Dr. [**First Name (STitle) **]. You will need a repeat CT
scan of your head at that time. Call [**Telephone/Fax (1) 1669**] to schedule
and arrange
|
[
"V45.81",
"272.4",
"852.26",
"873.0",
"244.9",
"401.9",
"E814.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
4143, 4149
|
3107, 3435
|
325, 332
|
4305, 4305
|
2057, 3084
|
4944, 5195
|
1398, 1417
|
3590, 4120
|
4170, 4284
|
3461, 3567
|
4453, 4921
|
1432, 1760
|
275, 287
|
360, 1077
|
4320, 4429
|
1099, 1228
|
1244, 1382
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,463
| 185,823
|
33964
|
Discharge summary
|
report
|
Admission Date: [**2119-10-23**] Discharge Date: [**2119-10-27**]
Date of Birth: [**2051-4-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Hemodialysis (CVVH)
History of Present Illness:
Mrs. [**Known lastname **] is a 68 year old female with a history of systolic
congestive heart failure (EF 15%), ESRD on HD, CAD and DMII who
presents with two days of worsening shortness of breath. The
patient has had multiple admissions to this hospital between
[**2119-7-16**] and present for shortness of breath and was most
recently discharged on [**2119-10-14**]. The patient reports that she
was in her usual state of health until two days prior to
admission. She received dialysis as [**Date Range 1988**] on [**2119-10-21**]. She
began to feel short of breath on [**2119-10-22**] with associated dyspnea
on exertion and worsening orthopnea. She reports that she has
had a cough productive of clear sputum for the past month but
this has not worsened acutely over the past two days. She
reports that she does have pressure in her chest and that this
has been present essentially constantly over the past 48 hours.
The chest pressure is associated with her shortness of breath.
It is not clearly associated with exertion. The patient reports
three pillow orthopnea which has not clearly worsened. She does
report a worsening of her dyspnea on exertion. She says that
her daughter helps her taker her medications and that she has
been compliant to her knowledge. She does not report any
dietary indiscretion. The patient uses 3 L oxygen by nasal
cannula at home and has not needed to increase her O2. She also
has been compliant with her home CPAP. The patient reports that
she presented to the emergency room on [**2119-10-22**]. At that time
she had a chest xray which showed improved but persistent
pulmonary edema and small pleural effusions. She had one set of
cardiac enzymes which were notable for a troponin of 0.21 which
is within her baseline. She was discharged with plans to follow
up with her PCP. [**Name10 (NameIs) **] reports that her shortness of breath
acutely worsened the following morning and she represented to
the emergency room.
.
In the emergency room her initial vital signs were T: 95. HR:
100 BP: 131/68 RR: 24 O2: 95% on 100% NRB (88% on RA). Initially
she was hemodynamically stable but while in the emergency room
her blood pressure decreased to the 70s systolic transiently and
she required fluid bolus. She received 0.5 mg IV ativan and was
subsequently noted to be more somnolent. ABG performed revealed
a ph of 7.31, PCO2 of 70 and PO2 of 73. She was placed on BIPAP
with improvement in her mental status. She had a CXR which
showed a new right basilar opacity and increasing pulmonary
congestion. She received 20 mg IV lasix with minimal urine
output. She received ceftriaxone 1 gram, azithromycin 500 mg
PO, Aspirin 325 mg PO, tylenol 500 mg PO and levofloxacin 750 mg
IV. Her EKG showed a ventricularly paced rhythm with no
significant changes from prior tracings. A left IJ central line
was attempted with misplacement in the carotid. Pressure was
held. While in the emergency room her blood pressure improved
to the 100s systolic. Her mental status improved and at the
time of transfer she was satting well on 3 L NC. She was
transferred to the [**Hospital Unit Name 153**] for further management.
.
On review of systems she reports that her shortness of breath is
slightly improved from this morning. She continues to have
constant chest pressure. She denies fevers, chills,
lightheadedness, dizziness, nausea, vomiting, abdominal pain,
dysuria, hemturia, diarrhea, constipation, melena, hematochezia,
leg swelling. She does have persistent left stump pain which is
unchanged from baseline.
Past Medical History:
1. CHF with EF of 15% s/p BiV pacer on coumadin
2. ESRD - on HD since [**2119-8-1**], *EDW 60 kg* at last admit,
T,TH, Sat dialysis
3. CAD s/p MI & CABG x 2 ([**2108**] and revised in [**2118**])
4. DMII x 4yrs on insulin
5. s/p L AKA
6. Hypothyroidism
7. Atrial fibrillation on coumadin
8. No formal diagnosis of reactive airway disease although on
albuterol and fluticasone at home
9. No formal diagnosis of OSA although uses CPAP machine at home
Social History:
Lives at home with daughter who helps her with her medications.
She has VNA services. She has a remote smoking history of less
than 1 year total but her daughter does [**Name2 (NI) **]. She does not
currently drink alcohol. She does not have a history of IVDU.
She is wheelchair bound and does not have a prosthetic.
Family History:
No family history of coronary artery disease. Otherwise
non-contributory.
Physical Exam:
Vitals: T 97.3 HR: 74 BP: 110/68 RR: 24 O2: 100% on 3L
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Right sided tunnelled catheter site intact, left neck with
bandage, JVP 12 cm
Chest: Expiratory wheezing diffusely, decreased breath sounds on
the right, no egophony
CV: RRR, s1 + s2, no murmurs, II/VI SEM at LUSB
GI: soft, non-tender, non-distended, +BS
Ext: Left AKA, right foot with 1 cm ulcer with clean base,
middle toe with small ulcer
Neurologic: Alert and oriented, moving all extremities
Pertinent Results:
[**2119-10-23**] 10:56PM PT-93.5* PTT->150* INR(PT)-12.2*
[**2119-10-23**] 09:56PM GLUCOSE-145* UREA N-28* CREAT-2.6* SODIUM-137
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-32 ANION GAP-12
[**2119-10-23**] 09:56PM CALCIUM-8.9 PHOSPHATE-4.8*# MAGNESIUM-2.0
[**2119-10-23**] 07:09PM TYPE-ART TEMP-36.7 PO2-120* PCO2-54* PH-7.40
TOTAL CO2-35* BASE XS-7
[**2119-10-23**] 07:09PM LACTATE-0.9
[**2119-10-23**] 07:09PM O2 SAT-97
[**2119-10-23**] 07:09PM freeCa-1.23
[**2119-10-23**] 02:20PM PT-15.3* PTT-95.9* INR(PT)-1.4*
[**2119-10-23**] 12:54PM TYPE-ART PO2-73* PCO2-70* PH-7.31* TOTAL
CO2-37* BASE XS-5
[**2119-10-23**] 11:06AM URINE HOURS-RANDOM
[**2119-10-23**] 11:06AM URINE GR HOLD-HOLD
[**2119-10-23**] 11:06AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2119-10-23**] 11:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-NEG PH-5.0 LEUK-SM
[**2119-10-23**] 11:06AM URINE RBC-0-2 WBC-[**7-25**]* BACTERIA-MOD YEAST-MOD
EPI-[**4-19**]
[**2119-10-23**] 10:30AM GLUCOSE-191* UREA N-25* CREAT-2.4* SODIUM-140
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-31 ANION GAP-17
[**2119-10-23**] 10:30AM CK(CPK)-35 ALK PHOS-231* TOT BILI-0.3
[**2119-10-23**] 10:30AM cTropnT-0.20*
[**2119-10-23**] 10:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 78447**]*
[**2119-10-23**] 10:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 78447**]*
[**2119-10-23**] 10:30AM ALBUMIN-3.5
[**2119-10-23**] 10:30AM WBC-7.7 RBC-4.14* HGB-12.4 HCT-41.4 MCV-100*
MCH-29.9 MCHC-29.8* RDW-19.4*
[**2119-10-23**] 10:30AM PLT COUNT-263
[**2119-10-22**] 12:25PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2119-10-22**] 12:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-1 PH-5.0 LEUK-TR
[**2119-10-22**] 12:25PM URINE RBC-0-2 WBC-[**4-19**] BACTERIA-MOD YEAST-NONE
EPI-[**4-19**]
[**2119-10-22**] 10:15AM GLUCOSE-190* LACTATE-1.0 K+-4.1
[**2119-10-22**] 09:50AM UREA N-17 CREAT-2.1*# SODIUM-139 CHLORIDE-96
TOTAL CO2-35*
[**2119-10-22**] 09:50AM estGFR-Using this
[**2119-10-22**] 09:50AM CK(CPK)-25*
[**2119-10-22**] 09:50AM cTropnT-0.21*
[**2119-10-22**] 09:50AM CK-MB-NotDone proBNP-9430*
[**2119-10-22**] 09:50AM CALCIUM-9.3 PHOSPHATE-2.7 MAGNESIUM-1.8
[**2119-10-22**] 09:50AM WBC-5.9 RBC-4.12* HGB-12.1 HCT-41.0 MCV-100*
MCH-29.3 MCHC-29.5* RDW-19.2*
[**2119-10-22**] 09:50AM NEUTS-75.5* LYMPHS-13.6* MONOS-6.6 EOS-3.9
BASOS-0.6
[**2119-10-22**] 09:50AM PLT COUNT-261
[**2119-10-22**] 09:50AM PT-15.4* PTT-33.0 INR(PT)-1.4*
Brief Hospital Course:
1. ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: Continued management
with hemodialysis. Due to mild hypotension, lisinopril was held
and carvedilol was continued.
2. CKD STAGE V ON HD: stable.
3. HYPOTENSION: Resolved
4. ACUTE RESPIRATORY FAILURE: Appears to be secondary to
sedation after receiving benzodiazepines - resolved. During her
ICU admission she was treated empirically for PNA, but the
antibiotics were discontinued when it was determined that she
did not have PNA.
5. CORONARY ARTERY DISEASE: Stable
6. ATRIAL FIBRILLATION: Stable.
7. DIABETES MELLITUS YYPE II: Stable.
8. ISCHEMIC ANKLE ULCER: Followed by podiatry, no role for
revascularization, and they recommended continuing local wound
care.
9. PERIPHERAL VASCULAR DISEASE: The patient will be continued on
aspirin, ACE if she can tolerate by BP, warfarin, per report did
not tolerate statin therapy.
10. END OF LIFE CARE: I had an extensive conversation with the
patients daughter, [**Name (NI) **] [**Name (NI) **] the details of which can be
found in the OMR note dated [**2119-10-26**]. In brief, she is not ready
for hospice yet, but is open to the concept, she did agree that
the patient's code status would be DNR/DNI. A palliative care
consult was obtained so that the daughter will have an
established relationship when the time comes to transition to
comfort measures.Note, the patient defers all medical decision
making to her daughter, and was not part of these conversations.
Medications on Admission:
On Admission:
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg PRN
.
Meds on transfer:
Ciprofloxacin 400mg IV Q12H
Albuterol nebs Q6H prn
Chlorhexidine oral rinse [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Heparin SC TID
Hydrocortisone 100mg IV Q8H
Ipratropium Neb Q6H prn
Magnesium sliding scale
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg Q4H prn
Pantoprazole 40mg po Q24H
Zosyn 4.5mg IV Q8H day#1 [**10-22**]
Potassium sliding scale
Prochlorperazine 10mg Q6H prn
Senna 1 tab po BID
Vancomycin 1000 mg IV Q 12H D#1 [**10-22**]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
7. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: To be titrated at hemodialysis - last dose 5 mg on [**10-27**].
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
19. Insulin Glargine
10 units each evening
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on chronic systolic heart failure
Hypotension
Hypercarbic repiratory failure
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
You will not be on your lisinopril because your blood pressure
is too low. This medication can be restarted by your doctor at
the time of follow-up.
You coumadin dose will be changed as needed until your INR is in
the correct range.
Followup Instructions:
Hemodialysis T/Th/Sat
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2119-10-30**]
1:00
I spent > 30 minutes on discharge related activities for this
patient.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
|
[
"427.31",
"440.4",
"V45.81",
"403.91",
"518.81",
"250.00",
"414.00",
"244.9",
"V49.76",
"707.13",
"458.9",
"428.23",
"585.6",
"V58.61",
"428.0",
"V45.01",
"V58.67",
"412",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11839, 11896
|
8066, 9522
|
335, 356
|
12023, 12032
|
5467, 8043
|
12435, 12767
|
4779, 4855
|
10106, 11816
|
11917, 12002
|
9548, 9548
|
12056, 12412
|
4870, 5448
|
276, 297
|
384, 3953
|
9562, 9614
|
3975, 4425
|
4441, 4763
|
9632, 10083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,759
| 120,031
|
15161
|
Discharge summary
|
report
|
Admission Date: [**2121-11-9**] Discharge Date: [**2121-11-18**]
Date of Birth: [**2071-3-7**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
gentleman who had a helmeted low-speed motorcycle accident.
The patient's initial blood pressure was in the 80s which
responded to 1 liter of IVF in the field. The patient was
transferred to an outside hospital with a GCS of 15 and
underwent a limited workup which included a negative chest CT
and an abdominal CT which was significant with a splenic
laceration grade IV. The patient was transferred when deemed
hemodynamically stable to [**Hospital1 18**] for further evaluation. The
patient is complaining of some left chest and left upper
quadrant pain on arrival to [**Hospital1 18**]. Initial blood pressure
was 118/palpable and heart rate 80. GCS was 15.
PAST MEDICAL HISTORY: Significant for diverticulitis.
PAST SURGICAL HISTORY: Significant for status post colon
resection for diverticulitis.
MEDICATIONS: Zoloft.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On physical examination, the patient
was alert and oriented times three, moving all extremities.
The neck was in a C collar. The chest was clear to
auscultation. No crepitus. There was tenderness on the left
side of the chest. The heart was regular with no murmurs,
rubs, or gallops. The abdomen had bowel sounds. It was
tender in the left upper quadrant, nondistended. The rectal
examination revealed normal tone, Guaiac negative. There was
no guarding and no rebound. The pelvis was stable. There
were no deformities of the extremities. There were DP pulses
bilaterally. There were radial pulses bilaterally. There
was tenderness of the right wrist. Neurologically, the
patient was grossly intact.
LABORATORY/RADIOLOGIC DATA: White count 21, hematocrit 36,
platelets 214,000. Sodium 139, potassium 4.3, chloride 110,
bicarbonate 25, BUN 20, creatinine 0.7, amylase 26. The tox
screen was negative. PT 14.2, PTT 26.8, INR 1.4, fibrinogen
187. The urine had greater than 50 red blood cells, 0-2
white blood cells.
The initial film studies included a C spine which showed no
dislocation or fracture.
Chest x-ray which was a limited study but showed no
abnormalities and a pelvic AP which showed no fracture.
Right shoulder, elbow, and wrist films showed no fracture or
dislocation.
The EKG showed sinus rhythm with no ischemic changes.
Abdominal CAT scan from an outside hospital was read by the
radiologist here which deemed the patient to have a grade IV
splenic laceration which is approximately 4 cm, some free
fluid in the abdomen. No liver lacerations. Question of
hemorrhage from the left kidney or left kidney cyst.
HOSPITAL COURSE: The patient was admitted to the Trauma
Surgery Service. He was placed in the Intensive Care Unit
for close monitoring and serial hematocrit checks. The
patient's hematocrit remained stable initially. He remained
hemodynamically stable. He was placed on bed rest. Repeat
chest film done in the Intensive Care Unit revealed several
rib fractures on the left.
In the following hospital days the patient's hematocrit
dropped from 39 to 30. The patient continued to be observed.
There was no blood transfusion at this time. The patient
continued to remain hemodynamically stable and the hematocrit
remained around 30.
The patient was transferred to the floor on hospital day
number four. On the floor, the patient experienced
tachycardia and increased respiratory distress. His blood
pressure remained stable though. His hematocrit remained
stable at 30. The patient's chest x-ray was significant for
a left pleural effusion and a collapse of the left lower
lobe. A chest tube was placed which produced 600 cc of
serous fluid. There was no pneumothorax and the patient's
respiratory status improved. It was thought that the patient
had been splinting secondary to the multiple rib fractures.
The Acute Pain Service was consulted and an epidural was
placed with excellent pain control. The patient began to
deep breathe, use incentive spirometry, and activity was
liberalized to be out of bed and ambulating with assistance.
On hospital day number nine, the patient's chest tube was
removed. The patient's post chest tube x-ray showed no
pneumothorax, although continued to have decreased lung
volumes. The epidural was removed on hospital day number
ten. The patient had good pain control with the Percocet
pain medication. The patient is stable, tolerating a diet,
ambulating with good pain control and now ready for home.
Of note, during routine urine culturing the patient was found
to have group B Streptococcus and the patient was started on
amoxicillin which he will go home on for a five day course.
DISCHARGE DIAGNOSIS:
1. Status post motorcycle accident with following injuries;
grade IV splenic laceration, ruptured kidney cyst, and left
rib fractures.
2. Left pleural effusion, status post chest tube.
3. Diverticulitis status post colon resection.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325 one to two p.o. q. four hours p.r.n.
2. Colace 100 mg p.o. b.i.d.
3. Amoxicillin 500 mg p.o. q. eight hours times five days.
FOLLOW-UP: The patient will follow-up with the Trauma Clinic
in two weeks.
CONDITION ON DISCHARGE: The patient's condition on discharge
is stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2121-11-18**] 09:06
T: [**2121-11-20**] 19:13
JOB#: [**Job Number 44167**]
|
[
"593.2",
"E819.2",
"511.9",
"807.09",
"865.03",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4833, 5069
|
5095, 5319
|
2785, 4812
|
952, 1094
|
1117, 2767
|
895, 928
|
5344, 5669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,860
| 142,453
|
14413
|
Discharge summary
|
report
|
Admission Date: [**2191-5-6**] Discharge Date: [**2191-5-13**]
Date of Birth: [**2125-3-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 M with CNS lymphoma with last chemo [**8-14**], Waldenstrom's
macroglobulinemia, and PMR who presented to [**Hospital1 18**] with a one
week history of cough productive of whie/tan sputum, shortness
of breath and fevers (up to 102.5 on the night prior to
admission). The patient reported feeling weak, tired, poor
appetite with little po intake. He also reported shaking chills,
night sweats and mild headaches over the top of his head.
.
On ROS, he denied photophobia, neck stiffness, n/v, abdominal
pain. He also denied dysuria, melena, BRBRP, diarrhea, CP,
edema, orthopnea, PND. His baseline gait is reportedly slightly
unsteady, with some forgetfullness since CNS lymphoma diagnosed.
.
The patient was initially admitted to the general medicine floor
where he was treated with Ceftriaxone and Azithromycin for a
multilobar pneumonia. He was intermittently tachypneic and
tachycardic on the floor. On HD2, the patient was felt to be in
impending respiratory failure with persistent supraventricular
tachycardia and was transferred to the MICU. There he received a
diltiazem drip for rate control and diuresis for volume overload
had dramatic improvement in his respiratory status. His
antibiotic regimen was broadened from ceftriaxone/azithromycin
to cefpodoxime/azithromycin.
Past Medical History:
1. CNS lymphoma - followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
-Dx'd by biopsy on [**2188-6-4**] - B-cell CD20+ CNS lymphoma
-Tx'd w/methotrexate high dose IV and intrathecal
-Relapse [**8-12**] tx'd w/induction Rituxan and temozolomide
immunotherapy
-Completed 12 cycles of maintenance temozolomide chemotherapy
[**8-14**]
2. Polymyalgia rheumatica
3. Stage I seminoma in the right testicle treated with
orchiectomy and
irradiation in [**2159**]
4. Waldenstrom's macroglobulinemia - per notes stable. His serum
IgM
from [**2191-2-17**] was 432 (range 20-230). + hypogammaglobulinemia
5. Squamous Cell Carcinoma of the Skin: followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]
s/p electron-beam irradiation for squamous cell carcinoma to
his right neck and mid-back from [**2190-12-28**] to [**2191-1-27**].
6. Bronchiectasis and Granulomatous Lung Mass: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**], M.D.
7. Neurocognitive Dysfunction: Stable on Ritalin LA and Namenda.
8. Low Testosterone on adrogel
9. S/p DVT, IVC placement on lovenox therapy
10. Bovine atrial valve replacement 3 yrs ago at [**Hospital1 112**]
Social History:
Patient lives with his wife and 3 children. He manages auto
dealership. He has >60 pkyr smoking history, quit 20 yrs ago.
He quit EtOH ~30yrs ago, prev heavy but no w/d. He denies
illicit drug use.
Family History:
Father [**Month (only) **] of colon cancer at 80, Mother [**Month (only) **] of CVA at 94
Physical Exam:
Vitals: Tc 97.9 Tm 98.8 BP 112/62 HR 101 (82-122) RR 26
Gen: well-appearing man with right eye closed, NAD, pleasant and
jovial
HEENT: face pink, NCAT, Omaya shunt in place, PERRL, EOMI, mmm,
OP clear
Neck: supple, FROM, JVP ~12cm, no LAD
Lung: bibasilar crackles/rhonchi with expiratory wheezing
throughout
Cor: irregularly irregular, nml S1S2
Abd: NABS, soft NTND
Ext: 1+ bilateral LE edema
Neuro: CNII-XII intact, muscle strength 5/5, sensation intact to
LT, DTR 1+, toes downgoing
Pertinent Results:
[**2191-5-6**] 08:00PM WBC-10.4 RBC-4.65 HGB-13.3* HCT-38.6* MCV-83
MCH-28.6 MCHC-34.4 RDW-15.1
[**2191-5-6**] 08:00PM NEUTS-69 BANDS-4 LYMPHS-8* MONOS-16* EOS-0
BASOS-0 ATYPS-1* METAS-2* MYELOS-0
.
[**2191-5-6**] 08:00PM GLUCOSE-194* UREA N-13 CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
[**2191-5-6**] 08:00PM ALT(SGPT)-11 AST(SGOT)-11 ALK PHOS-94 TOT
BILI-0.5
[**2191-5-6**] 08:00PM ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-1.8*#
MAGNESIUM-1.9
.
CXR ([**5-6**]): Findings most consistent with pulmonary edema, but
atypical viral or mycoplasma infection should be considered. If
the patient immune compromised, this could also represent PCP.
.
CXR ([**5-7**]): Interval worsening of bilateral diffuse opacities
consistent with worsening pulmonary edema. However, worsening
superimposed pneumonia should also be considered.
.
EKG ([**5-8**]): atrial fib/flutter at 125 bpm
MRI of the brain with gadolinium:
Exam compared to prior study of [**4-14**].
FINDINGS: There has been no change from the previous
examination. Abnormalities in the right hemisphere previously
described are not changed. The ventricular catheter remains in
place. Ventricular dimension is expanded but unchanged in size.
There is no evidence of abnormal diffusion. There is no evidence
of new mass effect or hemorrhage. There is no evidence of a new
focal extraaxial lesion or fluid collection.
IMPRESSION: Stable appearance compared to the prior study. No
definte
evidence of new mass effect or hemorrhage.
Brief Hospital Course:
66 M with CNS lymphoma with last chemo [**8-14**], Waldenstrom's
macroglobulinemia, and PMR who presented to [**Hospital1 18**] with a one
week history of productive cough, SOB and fevers called out of
MICU after being treated for rapid AF and heart failure.
.
1. SOB: Multifactorial. Pt likely had multifocal pna which
exacerbated atrial fibrillation which lead to worsening heart
failure in the setting of fluid resuscitation. Will continue Abx
to tx multilobar pneumonia. Pt with continued evidence of heart
failure on exam, with elevated JVP, crackles and mild edema. Pt
just transitioned to [**Hospital1 **] furosemide-continued throughout course
on the floor. Pt also with wheezing on exam, likely attributable
to cardiac wheeze from volume overload but potentially related
to his history of bronchiectasis- continues ipratropium nebs
throughout hospitalization as these have helped him.
- Cefpodoxime day 5 on d/c
- Azithro day 5 on d/c
- Continued lasix 20mg [**Hospital1 **], fluid goal of > -1L as mentioned
above
- Continued beta blocker and diltiazem for rate control as above
- Continued ipratropium for bronchospasm as above
.
2. Tachycardia: Pt appeared to have atrial fibrillation/flutter
by EKGs, likely exacerbated by pulmonary process. Has been
rate-controlled with diltiazem and lopressor. Continued since
leaving MICU - can titrate as necessary as an outpatient.
- Continued on diltiazem 360mg daily
- Continued on lopressor 75mg tid, consider increasing to 100mg
tid if needed
- Held albuterol and ritalin since these would increase heart
rate.
.
3. CNS Lymphoma: Has been asymptomatic and stable. Neurologic
exam [**Last Name (un) **] non-focal throughout. Initial unsteadiness on
admission likely secondary to systemic illness rather than acute
neurologic event. Neuro-Onc followed on the floor. MRI was
without changes.
.
4. FEN: Electrolytes wnl. Full diet. Fluids restricted.
.
5. Prophylaxis: Continued on lovenox for DVT. Given PPI for
prophylaxis.
.
6. Full code
Medications on Admission:
OUTPATIENT MEDS:
Lovenox 60mg sq [**Hospital1 **]
Pulmicort [**Hospital1 **]
Ritalin 40mg po qd, 5mg po qpm
Metoprolol 50mg po bid
Protonix 40mg po qd
Fosamax 35mg po q Thursday
Androgel qd
Caclium 500mg po qd
MVI
Namenda 10mg po bid
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
congestive heart failure
Discharge Condition:
fair
Discharge Instructions:
Please take all of your medication as prescribed
Followup Instructions:
Please make an appointment to follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**]
in the next 2 to 4 weeks.
You have the following appointments:
1. Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2191-5-26**] 1:00
2. Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2191-6-2**]
3:30
3. Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/[**Doctor Last Name 15207**] Where: [**Hospital6 29**]
REHAB SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2191-6-2**]
3:45
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"273.3",
"427.31",
"202.81",
"725",
"428.0",
"518.81",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7581, 7587
|
5301, 7297
|
323, 330
|
7666, 7672
|
3758, 5278
|
7769, 8561
|
3147, 3238
|
7608, 7645
|
7323, 7558
|
7696, 7746
|
3253, 3739
|
274, 285
|
358, 1644
|
1666, 2916
|
2932, 3131
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,735
| 115,565
|
31276
|
Discharge summary
|
report
|
Admission Date: [**2128-7-31**] Discharge Date: [**2128-8-5**]
Date of Birth: [**2101-4-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
[**2128-7-31**] EGD
[**2128-7-31**] L PICC placement
History of Present Illness:
27M with C5 quadripelegia, DVT s/p IVC filter not on
anticoagulation, duodenal AVMs/PUD, with recent [**Hospital1 18**] admission
for hematemesis on [**7-10**], found to have GDA pseudoaneurysm with
communication to pacreatic duct s/p IR embolization, who
presented with 3 days intermittent dark hematemesis.
.
Regarding the patient's recent admission, after 6 episodes of
hematemesis, he underwent MRCP demonstrating a large GDA
pseudoaneurysm with mass effect on the pancreatic head, as well
as chronic pancreatitis. EGD on [**7-13**] showed 2 ulcers and
hemobilia from the major papilla. He subsequently underwent
successful IR guided embolization on [**7-15**]. Throughout his
admission he required 3 units PRBCs for "autonomic instability."
His Hct stabilized at 30 prior to discharge.
.
On admit, Mr. [**Known lastname **] c/o 3 episodes of hematemesis, the first
episode being 4 days PTA, and the last 2 episodes on the AM of
admission. Could not quantify amount. Also of note, he reports
"dark stool" for the last 3-4 days. The first episode of
vomitting he describes as more coffee ground, with subsequent
episodes darker. He also noted lightheadedness.
.
In the ED, VS T 100.6, HR 110, BP 123/84, RR 16, 100%RA . NGT
lavage expressed dark red fluid which cleared with 500ml saline.
2 large bore PIV were placed and IV protonix was given. His Hct
was 29.1 on transfer. He was given 2L NS, as well as morphine
and ativan
.
MICU course:
Endoscopy was performed on admission which showed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
tear without evidence of active bleeding. Repeat thrombin
injection via IR-guidance into pseudoaneurysm, without evidence
of active bleeding. Hct trended down to 19 after the procedure
from admission hct of 29, and patient transfused two units pRBC
with appropriate bump in hct to 27, and then up to 29 in 12
hours without further transfusion. Patient without further
episodes of hematemesis. He was continued on protonix IV bid,
and had a CTA performed to evaluate for presence of aneurysm,
which showed resolution. He is transferred to the floor for
further hct monitoring. Currently has no complaints. Denies
abdominal pain, fevers, chills, hematemesis, BRPBR, melena.
Past Medical History:
-UGIB secondary to GDA pseudoaneurysm s/p IR embolization
-PUD (gastric/duodenal)
-Chronic Pancreatitis
-C5 traumatic fracture sustained in diving accident with
resultant quadriplegia
-Autonomic Instability
-s/p splenectomy for splenic rupture in [**2124**]
-LE DVT s/p IVC filter which is now clotted
-MRSA bacteremia in [**6-19**], finished course of Bactrim
-Recurrent UTIs; pt has indwelling suprapubic catheter [**1-16**]
quadriplegia
Social History:
Previous EtOH - none since 5/07 per patient
Cocaine abuse - 2x/month. none since 5/07 per patient
1 pack per week cigarettes.
denies IVDU
Family History:
Mother died of breast cancer. Grandmother with gastric cancer.
Physical Exam:
VS: AF, VSS
Gen: Appears well. NAD.
Skin: mildly diaphoretic.
HEENT: MMM. no ulcers.
Hrt: RRR.
Lungs: CTAB no RRW
Abd: Soft. Nontender. Multiple well healed scars.
Ext: Bilateral ankle edema 2+.
Pertinent Results:
[**2128-7-30**] 10:45PM WBC-22.3*# RBC-3.42* HGB-9.3* HCT-29.1*
MCV-85 MCH-27.3 MCHC-32.1 RDW-18.5*
[**2128-7-30**] 10:45PM LIPASE-89*
[**2128-7-30**] 10:45PM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-99
AMYLASE-79 TOT BILI-0.5
[**2128-7-31**] 03:37AM PT-15.7* PTT-31.5 INR(PT)-1.4*
[**2128-7-31**] 04:49AM URINE BLOOD-LGE NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2128-7-31**] 01:13PM HCT-23.6*
[**2128-7-31**] 07:17PM HCT-23.2*
[**2128-7-31**] 08:05PM HCT-22.3*
[**2128-7-31**] 10:53PM HCT-22.5*
[**2128-7-31**] EGD: Esophagus: Excavated Lesions [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
with stigmata of recent bleeding was seen in the cardia and
gastroesophageal junction. It was well healed and would have
little chance of rebleeding. Stomach: Normal stomach. Duodenum:
Normal duodenum. Other findings: No blood in duodenum in the
area of the ampulla. This area was observed closely. Impression:
[**Doctor First Name **]-[**Doctor Last Name **] tear. No blood in duodenum in the area of the
ampulla. This area was observed closely. Otherwise normal EGD to
second part of the duodenum
.
[**2128-8-1**] CT abd/pelvis without contrast: This is a technically
limited study due to the lack of oral and intravenous contrast
material. There may possibly be a small hematoma near the site
of pseudoaneurysm clipping although this is an indefinite
finding. No large hematoma is identified nor is there evidence
of large fluid
collections or abscesses.
.
[**2128-8-4**]: CTA abdomen: 1. No evidence of previously identified
GDA pseudoaneurysm status post thrombin injection.
2. Stable findings of pancreatic ductal dilatation and
peripancreatic fluid collections.
3. Stable retroperitoneal lymphadenopathy as noted above.
[**2128-8-5**] 06:40AM BLOOD WBC-10.1 RBC-3.31* Hgb-9.4* Hct-28.7*
MCV-87 MCH-28.5 MCHC-33.0 RDW-17.2* Plt Ct-558*
[**2128-8-1**] 04:28AM BLOOD PT-14.6* PTT-32.8 INR(PT)-1.3*
[**2128-8-5**] 06:40AM BLOOD Glucose-92 UreaN-4* Creat-0.4* Na-134
K-3.8 Cl-97 HCO3-26 AnGap-15
[**2128-8-1**] 04:28AM BLOOD ALT-10 AST-13 LD(LDH)-119 AlkPhos-69
Amylase-23 TotBili-1.5
[**2128-8-1**] 04:28AM BLOOD Lipase-25
[**2128-8-4**] 04:19AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9
[**2128-8-2**] 02:45AM BLOOD Hapto-217*
URINE CULTURE (Final [**2128-8-6**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 73776**] [**2128-8-4**].
URINE CULTURE (Final [**2128-8-2**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
Brief Hospital Course:
*** Patient left AMA, although hematocrits were stable, no
follow up was arranged prior to his departure.
27 M with C5 quadripelegia, splenectomy, DVT s/p IVC filter, and
recent UGIB with PUD and a GDA pseudoaneurysm s/p IR
embolization admitted with 3 days dark hematemesis.
.
#. Hematemesis: The patient was kept NPO and started on an IV
PPI [**Hospital1 **]. An NGT was placed with dark red blood which cleared
with normal saline lavage. Patient had serial hcts q6 hour
initially with admit hct of 29, down to 19 after procedure,
which then responded appropriately to 2u pRBC. EGD showed a
well-healing [**Doctor First Name **]-[**Doctor Last Name **] tear with stigmata of recent bleeding
in the cardia and gastroesophageal junction. This was thought to
have a low likelihood of rebleeding. CT of the abd/pelvis on
[**2128-8-2**] showed evidence of persistent GDA ANR which was treated
with repeat thrombin injection. CTA post-procedure showed
resolution of the aneurysm.
-Continue PPI [**Hospital1 **] - change to po BID.
.
#. Leukocytosis: Admission value of 22.3, but trending down
during hospital course. Has history of UTI and MRSA bacteremia
and UA suspicious for infection, with culture growing CNSA.
Received several doses of ciprofloxacin initially, but d/c'd in
setting of culture results. Given that HD stable, felt to be
colonizer, suprapubic cath changed. Also low grade temps over
the past few days.
.
#. Scrotal tear. Patient noted scrotal tear to RN, but unable to
examine currently because friends in room. Treated with wound
care, dressing changes.
.
#. Chronic Pancreatitis: Diagnosed on prior imaging. Has
significant EtOH history. LFTs unremarkable. Pancreatic enzymes
slightly increased on admission, trended down throughout stay.
No pain secondary to quadraplegia.
.
#. Quadripelegia/Autonomic dysfunction: Has prior record of
diaphoresis and shaking chills due to autonomic instability,
without significant symptoms during this stay.
.
#. DVT s/p IVC filter: Occurred in [**2119**]. IVC filter currently
clotted off. Not on anticoagulation given recent GIB.
.
Medications on Admission:
Meds (on admission)
Acetaminophen 325 mg PO Q6H
Pantoprazole 40 mg PO Daily
Docusate Sodium 100 mg PO BID
Senna 1-2 Tablets PO BID
Valium prn (unsure of dose)
Ritalin prn (unsure of dose)
.
Meds (on transfer)
Tylenol
Bisacodyl
Ativan prn
Morphine prn
Zofran prn
Pantoprazole 40 mg IV q12h
Reglan
Senna
Discharge Medications:
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every [**5-21**]
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
hematemesis
Discharge Condition:
stable
Discharge Instructions:
Pt left AMA
Followup Instructions:
Pt left AMA
|
[
"907.2",
"285.1",
"530.7",
"442.84",
"599.0",
"V12.51",
"344.00",
"337.9",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9430, 9436
|
6394, 8491
|
325, 379
|
9491, 9499
|
3570, 6371
|
9559, 9573
|
3275, 3339
|
8845, 9407
|
9457, 9470
|
8517, 8821
|
9523, 9536
|
3354, 3551
|
274, 287
|
407, 2640
|
2662, 3104
|
3120, 3259
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,194
| 170,383
|
54863
|
Discharge summary
|
report
|
Admission Date: [**2165-5-13**] Discharge Date: [**2165-5-15**]
Date of Birth: [**2147-3-15**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
difficulty speaking, R hand tingling, s/p tPA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Code Stroke at [**Hospital3 26615**], tPA started, therefore not called as
such here.
Neurology at bedside for evaluation after arrival
within: 1 minutes
Time (and date) the patient was last known well: 15:50
(24h clock)
NIH Stroke Scale Score: 0 here, purportedly 8 at OSH
t-[**MD Number(3) 6360**]: At OSH, running on tranfer.
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale:
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 0
10. Dysarthria: 0
11. Extinction and inattention: 0
Chief Complaints: Aphasia
History of the Present Illness:
Mr. [**Known lastname 4135**] is a 17-year-old right-handed man presenting with
aphasia to [**Hospital3 26615**], in the context of migraine-like
headache,
transferred for further management after tPA, on a background of
a diagnosis of ADHD and frequent headaches.
Mr. [**Known lastname 4135**] had his last day of school today. He was sitting in
the
park with some friends, just hanging out. He developed a severe
left-sided headache, what he calls migraine, that has occurring
once every two weeks for a few years. It has not been recently
worsening. He does not get aura. It is typically left
temporofrontal, no radiation, constant pain (not throbbing),
occurs "randomly" without relation to time of day, last for
hours, better with lying down, no neurologic symptoms in past,
never warning or visual symptoms, made better by ibuprofen. No
worsening with posture/cough/strain. He then decided to go home,
but when he got there, was unable to speak to his parents. He
says that he could speak, but not say what he wanted or think or
the right words. He could understand others at all times. These
signs appeared not to evolve. His parents were concerned and
took
him to [**Hospital3 26615**]. There he underwent tele-stroke evaluation
and
was noted to be fluently aphasic and given an NIHSS of 8. tPA
was
thus recommended and started prior to transfer to [**Hospital1 18**]. CT and
CTA of the head and neck were normal. Per EMS report, he would
sometimes apparently involuntarily move his arms or legs early
in
transit and was able to speak, but did not make sense. Gaze was
not noted to be dysconjugate, both limbs seemed symmetric. EMS
mention that when asked to lift his legs, he would lift his arms
and he confused left and right at [**Hospital3 26615**]. While en route to
[**Hospital1 18**] he napped for 10 minutes and awoke to say "I can speak",
then conversing normally with EMS. He was not playing sport,
involved in trauma, and denies use of drugs, etc.
Review of systems negative except as above.
Past Medical History:
- Diagnosis of ADHD
- Migraine, per patient, about once every two weeks
- No clotting disorder, no prior neurologic signs with migraine,
never with aura, no seizure history.
Social History:
Lives with parents. Just completed school. Says did okay at
school - studies in forensics/meteorology/geology. Does not know
what will do after school. No alcohol/tobacco/drugs.
Family History:
No family history of migraine. Does not know family medical
history in detail.
Physical Exam:
Physical Exam on Admission and Discharge:
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Mental status:
Awake and alert, cooperative with exam, normal affect.
Orientation: Oriented to person, place, date and context.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors.
Registration of three words at one trial and recall of all at
five minutes without hints.
Fund of knowledge for recent events within normal limits.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, to
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 symmetric.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Posture normal and no truncal ataxia.
Tone normal throughout.
Power
D B T WE WF FF FAb | IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 | 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 | 5 5 5 5 5 5 5
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Sensation intact to light touch, vibration, joint position,
pinprick bilaterally. Romberg negative.
Normal finger nose, great toe finger, [**Doctor First Name 6361**] bilaterally.
Gait:
Normal stance, Romberg negative.
Pertinent Results:
ADMISSION LABS:
[**2165-5-13**] 06:45PM GLUCOSE-120* UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-20* ANION GAP-18
[**2165-5-13**] 06:45PM WBC-12.7* RBC-4.64 HGB-14.6 HCT-42.4 MCV-92
MCH-31.5 MCHC-34.4 RDW-12.9
[**2165-5-13**] 06:45PM NEUTS-87.4* LYMPHS-9.4* MONOS-2.8 EOS-0.1
BASOS-0.3
[**2165-5-13**] 06:45PM PLT COUNT-207
[**2165-5-13**] 06:45PM PT-11.4 PTT-24.6* INR(PT)-1.1
DISCHARGE LABS:
[**2165-5-15**] 05:50AM BLOOD WBC-6.4 RBC-4.23* Hgb-13.0* Hct-39.2*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.1 Plt Ct-154
[**2165-5-15**] 05:50AM BLOOD Glucose-91 UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-106 HCO3-26 AnGap-10
[**2165-5-15**] 05:50AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.1
REPORTS:
MR [**2165-5-14**]:
IMPRESSION: Normal MRI of the head.
ECHO [**2165-5-15**]:
Conclusions
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Doppler parameters
are most consistent with normal left ventricular diastolic
function. Right ventricular chamber size is normal. with normal
free wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Passage of agitated saline from right to left atrium
at rest consistent with PFO vs. small atrial septal defect.
Normal biventricular regional/global systolic function. Normal
diastolic function.
Brief Hospital Course:
18-year-old man with a history of migraine and ADHD who
presented with fluent aphasia and R hand tingling in the setting
of HA. He presented to an OSH where tele-stroke was called.
CT/CTA/CTP were reportedly negative and he was treated with IV
tPA. He was subsequently transferred to [**Hospital1 18**], and his symptoms
resolved en route. He is currently back to baseline with no
recurrence of his HA or deficits.
Neuro:
He was admitted to the neuro ICU for standard post-tPA
monitoring. BP was closely monitored with goal SBP 120-160,
close neurochecks were performed as per protocol, arterial
punctures, antiplatelets, and anticoagulants were avoided x 24
hours. He remained stable with no recurrence of his symptoms and
no signs of bleeding. MRI was performed and was normal with no
evidence of stroke or other intracranial abnormality. CTA was
reviewed and was negative. Overall the most likely cause of his
symptoms appears to have been a complex migraine, although his
TTE showed a PFO. Therefore, he was started on ASA. In
addition, he will have a panel of hypercoagulable labs drawn as
an outpatient.
CV:
He was maintained on telemetry monitoring. BP was monitored
closely as above. A TTE was completed that showed a PFO and the
patient was started on an ASA.
FEN:
He tolerated a regular diet during his admission. Electrolytes
were monitored and repleted as needed.
Prophylaxis:
He was maintained on pneumoboots and a bowel regimen.
Disposition: He was monitored in the neuro ICU for 24 hours
post-tPA. He remained stable with no complications. He was
discharged home in good condition on [**2165-5-15**]
PENDING RESULTS:
None
TRANSITIONAL CARE ISSUES:
Patient will need close neurological follow-up and treatment for
his migraines.
Medications on Admission:
Concerta 36mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg once a day Disp #*30 Tablet Refills:*6
2. Outpatient Lab Work
Please check anticardiolipin antibody, lupus anticoagulant,
protein C, protein S, factor V leiden, prothrombin gene
mutation, B12, homocysteine.
ICD-9 Code: 434.10
** Please fax the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 33403**] **
Discharge Disposition:
Home
Discharge Diagnosis:
Transient aphasia and right hand tingling
Probable complex migraine vs. cerebral embolism without
infarction
Patent foramen ovale
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: speech fluent, no deficits
Discharge Instructions:
Dear Mr. [**Known lastname 4135**],
You were admitted to [**Hospital1 69**] on
[**2165-5-13**] after developing difficulty speaking and
numbness/tingling in your right hand in the setting of a
headache. You were initially taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
where you were given tPA, a clot busting drug, due to concern
for stroke. You were then transferred to us and your symptoms
resolved while you were in the ambulance. Your neurologic exam
here has remained normal. An MRI was performed and this showed
no signs of stroke or any other abnormality in your brain. We
reviewed the images of your blood vessels from the other
hospital as well and this showed no signs of dissection (tear in
the wall of a blood vessel) or any other abnormalities. We
believe the most likely cause of your symptoms was a complex
migraine, but we cannot completely rule out that this was a
stroke.
You need to stop smoking. Smoking adversely effects your help
and greatly increases your risk of vascular disease and death.
When you are ready to stop smoking, please call your doctor for
a nicotine patch prescription.
You will need to have labs drawn at any lab facility and have
the results faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 33403**].
We made the following changes to your medications:
1) We STARTED you on ASPIRIN 81mg once a day.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
You should see your primary care doctor within 1 week after your
discharge.
Department: NEUROLOGY
When: TUESDAY [**2165-6-18**] at 4:30 PM
With: DRS. [**Name5 (PTitle) 540**]/[**Doctor Last Name 2336**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"346.80",
"314.00",
"784.3",
"434.10",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9614, 9620
|
7360, 9006
|
351, 357
|
9794, 9794
|
5512, 5512
|
11595, 12088
|
3645, 3725
|
9184, 9591
|
9641, 9773
|
9140, 9161
|
9985, 11306
|
5943, 7337
|
3740, 4036
|
11335, 11572
|
266, 313
|
9032, 9114
|
385, 3237
|
4412, 5493
|
5529, 5926
|
9809, 9961
|
3259, 3434
|
3450, 3629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,790
| 137,442
|
41703
|
Discharge summary
|
report
|
Admission Date: [**2129-8-24**] Discharge Date: [**2129-9-2**]
Date of Birth: [**2072-6-16**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Taxol / Zocor
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
progressive leg weakness, inability to urinate or
defecate
Major Surgical or Invasive Procedure:
T2 corpectomy and posterior spinal fusion T1 to T3
History of Present Illness:
57M w/ hx lung cancer and metastatic disease to T2 presents
with 2 days of progressive leg weakness, inability to urinate or
defecate. Not on XRT or chemo for his lung cancer, patient has
been told he has a poor prognosis. He feels pins and needles
throughout his trunk ankd lower extremities and has L > R lower
extremity weakness.
Past Medical History:
lung CA with mets to T2, hereditary hypercoaguability (Lupus
anticoagulant according to patient). He has had PE before
Social History:
1ppd, no etoh
Family History:
non-contrib
Physical Exam:
General: NAD
CV: Pulse RRR
Resp: mildly labored breathing
Abd: Soft, NT
Vascular:
Radial DP
R 2 2
L 2 2
Sensory:
UE C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R intact intact intact intact intact
L intact intact intact intact intact
T2-L1 (Trunk) intact
LE L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R intact intact intact intact intact intact
L intact intact intact intact intact intact
Motor:
UE FG(C8/AIN) WE(C6/R) WF(C7/R) Tricep(C7/R) Bicep C6/MC)
Delt(C5/Ax)
R 5 5 5 5 5 5
L 5 5 5 5 5 5
LE Flex(L1) Add(L2) Quad(L3) TA(L4) [**Last Name (un) 938**](L5) Per(S1)GS(S1-2/T)
R 3 3 3 3 3 3 3
L 4+ 4+ 4+ 4+ 4+ 4+ 4+
No midline tenderness to palpation
Babinski: left toe upgoing, right toe downgoing
[**Doctor Last Name 937**]: Negative
Clonus: Negative
Perianal sensation: intact
Rectal tone: poor
Pertinent Results:
[**2129-9-1**] 03:40AM BLOOD WBC-10.5 RBC-3.82* Hgb-10.1* Hct-30.0*
MCV-79* MCH-26.5* MCHC-33.7 RDW-14.9 Plt Ct-155
[**2129-8-24**] 03:00AM BLOOD Neuts-94.8* Lymphs-3.1* Monos-1.3*
Eos-0.5 Baso-0.3
[**2129-9-1**] 03:40AM BLOOD Glucose-111* UreaN-26* Creat-0.5 Na-135
K-5.1 Cl-94* HCO3-31 AnGap-15
[**2129-9-1**] 03:40AM BLOOD Albumin-3.5 Calcium-9.0 Phos-4.0 Mg-2.2
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU. Post-operatively, he was admitted from the PACU to the
SICU because he was hypotensive requiring pressors and desatting
into the high 80s with increasing O2 requirement. He receieved 1
unit of blood after a post-op Hct of 27.5. On POC, he moves all
four extremities, but left is weaker than right as per baseline.
He was started on a ketamine drip for pain control.
POD1, he was placed on a non non-rebreather. Intermittent CPAP
but stable, though desats into 70s when taken off. Pain control
improved.
POD2 He got out of bed and was weaned from POOP. He was given a
250mL bolus.
POD3 He again received a 250cc bolus.
POD6 Pain service recommended increasing morphine for pain;
palliative care consulted
POD7 No acute issues, palliative care recs: dispo RN home will
follow with patient, OOB chair, wound examined no drainage, no
fluctuance, minimal erythema on the inferior aspect of the
wound. Aggressive bowel regimen instituted.
POD8 LLE weakness of Grade 1 to 2 was recorded. Noon head CT
showed no change to explain anisacoria or LLE weakness. NGT
placed for short time, minimal drainage. made DNR/DNI per
palliative care. weaning ketamine. +flatus, tolerated PO intake
([**Location (un) 6002**])
POD9 Switched to po Prednisone taper. Rehab bed secured.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on pain regimen and tolerating a regular diet. The
neurological status at discharge was Grade 1 to 2 in LLE and
Grade 2 to 3 in RLE. Specifically the LLE Quads was weaker Grade
[**11-28**] than preoperative assessment. As further surgical
interventation is unadvisable considering his present general
medical condition and short life expectancy, further
interventions for deteriorating neurology are not planned.
Medications on Admission:
albuterol, lovenox 80 mg(for hereditary hypercoaguability),
ergocalciferol, loratadine, morphine solution 10mg prn,
omeprazole 20 mg qday, sulfasalazine 500 mg po, tramadol 50 mg
qid prn, ambien
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location (un) 90636**]
Discharge Diagnosis:
metastasis to t2 vertebra
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Bedbound.
Discharge Instructions:
You have undergone the following operation: Thoracic Corpectomy
With Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than
10 lbs for 2 weeks. You will be more comfortable if you do not
sit or stand more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30
minutes as part of your recovery. You can walk as much as you
can tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is
to be worn when you are walking. You may take it off when
sitting in a chair or while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home
medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2
weeks after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Lumbar decompression without fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than
10 lbs for 2 weeks. You will be more comfortable if you do not
sit or stand more than ~45 minutes without moving around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30
minutes as part of your recovery. You can walk as much as you
can tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is
to be worn when you are walking. You may take it off when
sitting in a chair or lying in bed.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
- You should resume taking your normal home
medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2
weeks after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Bedrest with bed position Head of bed at
45 deg
Cervical collar: when OOB
Treatments Frequency:
Site: Back
Description: Dry sterile dressing
Care: Change QD
Patient is DNR/DNI and does not wish to be rehospitalized.
Followup Instructions:
Please call the Spine Center at Phone:
([**Telephone/Fax (1) 72575**] and schedule a follow-up for 2 weeks.
|
[
"733.13",
"162.8",
"795.79",
"198.5",
"344.1",
"336.1",
"287.5",
"560.1",
"997.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"81.62",
"77.49",
"84.51",
"80.99",
"03.53"
] |
icd9pcs
|
[
[
[]
]
] |
4896, 5011
|
2571, 4650
|
336, 389
|
5081, 5128
|
2181, 2548
|
10382, 10494
|
945, 958
|
5032, 5060
|
4676, 4873
|
5216, 5295
|
973, 2162
|
10114, 10215
|
10237, 10359
|
9587, 10096
|
7803, 8017
|
238, 298
|
8548, 9575
|
417, 754
|
5143, 5192
|
776, 897
|
913, 929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,955
| 193,573
|
5487
|
Discharge summary
|
report
|
Admission Date: [**2129-10-20**] Discharge Date: [**2129-10-28**]
Date of Birth: [**2084-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Coricidin / Fish Product Derivatives
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Exertional Chest pain
Major Surgical or Invasive Procedure:
[**10-20**] Coronary artery bypass graft x4 (Left internal mammary
artery > left anterior descending, Saphenous vein graft >
Diagonal, Saphenous vein graft > obtuse marginal, Saphenous vein
graft > posterior descending artery)
History of Present Illness:
This 45W male has had exertional chest pain and had a +ETT. He
underwent cardiac catherization at [**Hospital1 18**] on [**10-10**] which
revealed: LVEF of 35%, LMCA was OK, 90% LAD lesion, 90% LCX
lesion, and a total occlusion of the PDA. He was referred for
elective CABG.
Past Medical History:
Coronary Artery Disease
Hypertension
Elevated cholesterol
Diabetes Mellitus
Social History:
Lives alone and works as a chef.
Tobacco: quit [**2112**]
ETOH: none
Family History:
Father had an MI at age 41.
Physical Exam:
Gen: WDWNWM in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat. without bruits
Lungs: Clear to A+P
CV: RRR without R/G/M, nl s1, s2
Abd: +BS, soft, nontender without masses or tenderness.
Ext. without C/C/E, pulses 2+= bilat. throughout
Neuro: nonfocal
Pertinent Results:
[**2129-10-27**] 07:30AM BLOOD WBC-9.2 RBC-3.91* Hgb-11.4* Hct-32.2*
MCV-82 MCH-29.2 MCHC-35.5* RDW-13.5 Plt Ct-396
[**2129-10-20**] 12:11PM BLOOD WBC-11.1*# RBC-3.21* Hgb-9.6*# Hct-26.7*
MCV-83 MCH-29.9 MCHC-35.9* RDW-13.4 Plt Ct-136*
[**2129-10-26**] 07:35AM BLOOD Neuts-77.6* Lymphs-14.5* Monos-4.7
Eos-2.4 Baso-0.9
[**2129-10-22**] 04:44PM BLOOD Neuts-83.7* Lymphs-12.1* Monos-2.8
Eos-1.2 Baso-0.3
[**2129-10-27**] 07:30AM BLOOD Plt Ct-396
[**2129-10-20**] 01:13PM BLOOD PT-11.5 PTT-25.8 INR(PT)-1.0
[**2129-10-20**] 12:11PM BLOOD PT-13.4* PTT-25.2 INR(PT)-1.2*
[**2129-10-20**] 12:11PM BLOOD Plt Ct-136*
[**2129-10-20**] 12:11PM BLOOD Fibrino-169
[**2129-10-25**] 12:53PM BLOOD ESR-121*
[**2129-10-27**] 07:30AM BLOOD Glucose-215* UreaN-14 Creat-1.0 Na-136
K-4.8 Cl-98 HCO3-26 AnGap-17
[**2129-10-20**] 01:13PM BLOOD UreaN-14 Creat-0.8 Cl-109* HCO3-27
[**2129-10-24**] 06:30AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.4
RADIOLOGY Final Report
CHEST (PA & LAT) [**2129-10-27**] 11:05 AM
CHEST (PA & LAT)
Reason: evaluate for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
45 year old man s/p CABGx4
REASON FOR THIS EXAMINATION:
evaluate for pleural effusions
HISTORY: CABG.
FINDINGS: In comparison with the study of [**2129-10-25**], there is no
significant change. Minimal atelectatic changes persist at the
left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**Doctor First Name **] [**2129-10-27**] 1:54 PM
Cardiology Report ECG Study Date of [**2129-10-23**] 1:25:12 PM
Sinus tachycardia. Non-diagnostic inferior Q waves. Diffuse
minimal
ST segment elevation with PR segment depression. Compared to the
prior
tracing there is no significant change.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 148 90 318/402 37 1 32
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 22189**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 22190**] (Complete)
Done [**2129-10-20**] at 9:22:20 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: [**2084-5-11**]
Age (years): 45 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Coronary artery disease. Left ventricular function.
Preoperative assessment.
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2129-10-20**] at 09:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: 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. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No 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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE BYPASS
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen.
POST BYPASS
Preserved biventricular systolic function. Study is otherwise
unchanged from the prebypass examination.
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) **] [**2129-10-20**] 11:58
Brief Hospital Course:
The patient was admitted on [**2129-10-20**] and underwent coronary
artery bypass surgery. Please see operative report for further
details. He tolerated the procedure well and was transferred to
the CVICU in stable condition on Propofol and Insulin. He had a
stable post op night and was extubated. He was transferred to
the floor in post operative day 1 and had his chest tubes
removed on postoperative day 2. His epicardial pacing wires
removed on post operative day 3 and he continued to progress
with physical therapy. He was persistenly tachycardic which
eventually improved with increased beta blockade and change to
Toprol XL. He continued to have low grade fevers and
diaphoresis, however with normal white count but elevated sed
rate. He was started on motrin and fevers resolved. He was
ready for discharge home with services on post operative day 8.
Medications on Admission:
ASA 325 mg PO daily
Enalapril 10 mg PO daily
Toprol XL 50 mg PO daily
Simvistatin 20 mg PO daily
Glucovance 2.5/500 3 tabs PO daily
Lantus 60-80 units SC qAM
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:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous once a day.
Disp:*20 vials* Refills:*2*
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Glucovance 2.5-500 mg Tablet Sig: Three (3) Tablet PO once a
day.
Disp:*90 Tablet(s)* Refills:*0*
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO at bedtime.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 4 weeks.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease.
Hypertension
Myocardial infarction
Diabetes Mellitus type 1
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**]
Please check blood glucose at least 4 times daily goal BG 70-110
please contact PCP if BG > 200
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) 1637**] in 1 week [**Telephone/Fax (1) 14655**]
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2129-10-28**]
|
[
"414.01",
"285.9",
"272.4",
"413.9",
"E878.2",
"998.89",
"250.00",
"780.6",
"401.9",
"E849.7",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"88.72",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
8999, 9050
|
6902, 7772
|
327, 556
|
9179, 9186
|
1461, 2506
|
9793, 10009
|
1064, 1093
|
7980, 8976
|
2543, 2570
|
9071, 9158
|
7798, 7957
|
9210, 9770
|
5868, 6879
|
1108, 1442
|
266, 289
|
2599, 5819
|
584, 862
|
884, 961
|
977, 1048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,902
| 148,449
|
49579
|
Discharge summary
|
report
|
Admission Date: [**2106-3-18**] Discharge Date: [**2106-3-20**]
Date of Birth: [**2038-11-21**] Sex: M
Service: ECU
CHIEF COMPLAINT:
1. Hypotension status post cath.
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old
male with CAD status post four vessel CABG in [**2096**], admitted
to [**Hospital6 2910**] on [**2106-3-10**] with left sided
chest pain with shortness of breath, positive
lightheadedness, positive nausea. Rule out for MI. He had
diagnostic catheterization and was sent to [**Hospital1 346**] for therapeutic catheterization.
Catheterization on [**2106-3-12**] showed reportedly an 80% left
circumflex stenosis and a questionable stenosis of the LAD.
Today's cath showed a right dominate system, 100% LAD lesion,
90% left circumflex, 100% RCA. The saphenous vein graft to
diagonal was patent, the saphenous vein graft to LAD was high
grade ostial lesion. The saphenous vein graft to RCA was
patent. The LIMA to LAD had 100% stenosis. The patient
received stenting to the left circumflex and Saphenous vein
graft to LAD.
The patient was noted to have an episode of chest pain with
shortness of breath during the catheterization associated
with brief, no reflow after dilation of the saphenous vein
graft to LAD with decreased blood pressures to systolic to
70s to 80s. The patient was treated with Dopamine drip and
nitrites with prompt resolution of chest pain. The patient
was not noted to have EKG changes
REVIEW OF SYSTEMS: The patient has stable, two pillow
orthopnea. Denies PND, claudication, bright red blood per
rectum or melena. The patient does note chest pain at rest of
approximately one to two times per month similar to the pain
that he experienced prompting admission. The patient however
notes that the chest pain that precipitated admission was
longer in duration and had associated shortness of breath
which his normal rest angina does not.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in [**2096**] four
vessel, status post catheterization in [**2103**] no stenting
performed.
2. Diet controlled diabetes mellitus.
3. History of hypercholesterolemia but intolerance to
statins.
4. Status post appendectomy.
5. Glaucoma bilaterally.
MEDICATIONS:
1. Lopressor 50 milligrams po bid.
2. Imdur 60 milligrams po q day.
3. Sublingual nitroglycerin prn.
4. Vitamin C and Vitamin E multiple vitamin.
5. Enteric coated aspirin 325 milligrams po q day.
6. Welchol six tablets q day.
ALLERGIES: Sulfa and silk tape which precipitates rash.
SOCIAL HISTORY: Positive tobacco history quit approximately
[**2084**]. Prior to that the patient smoked five packs a day
times 21 years. He denies alcohol use. He is single, retired
driver.
FAMILY HISTORY: Brothers and father in CAD in 30s and 40s.
PHYSICAL EXAMINATION: Vital signs temperature 97.4 F, heart
rate 84, blood pressure 127/62, respiratory rate 15, O2
saturation 98% on room air. In general the patient is a
middle aged white male lying flat in bed in no apparent
distress. HEENT exam normocephalic, atraumatic. Extraocular
muscles are intact. Bilateral surgical pupils. Mucous
membranes are dry. Neck - soft and supple. JVP of
approximately 6 cm. Heart - distant heart sounds, regular
rate and rhythm. No murmurs, rubs, or gallops. Respirations
- clear to auscultation bilaterally anterior, unable to sit
up secondary to sheath. Abdomen soft, nontender,
nondistended, normoactive bowel sounds. Extremities -
femoral catheter bilaterally in the groin. No hematoma, no
bruit, 2+ dorsalis pedis and posterior tibial pulses.
LABORATORY DATA FROM OUTSIDE HOSPITAL: Hemoglobin 13.8,
hematocrit 40, BUN 24, creatinine 1.1, potassium 3.6, INR
....................
IMPRESSION: A 67 year-old male with CAD status post
catheterization for work up of unstable angina complicated by
no reflow after dilatation of stent to LAD leading to
hypotension and chest pain. The patient admitted to CCU for
monitoring of hemodynamic status.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR - The patient had no further episodes of
hypotension or chest pain while an inpatient at [**Hospital1 346**]. Post catheterization check to the
groin revealed no hematoma or bruit. The patient was
maintained on Integrilin for 18 hours post catheterization as
well as a nitroglycerin drip prn for chest pain. The patient
was not in need of the nitroglycerin drip and the drip was
weaned to off.
The patient was maintained on aspirin, Lopressor and Plavix
as well as Welchol.
Cardiac enzymes were monitored post catheterization with
anticipation with a likely bump secondary to the no reflow
phenomenon. However no such spike in cardiac enzymes were
noted.
2. HEMATOLOGY - The patient's hematocrit was noted to be
stable with no need for transfusion. The patient's platelets
were also stable with no thrombocytopenia secondary to
Integrilin use.
3. FLUIDS, ELECTROLYTES AND NUTRITION - The patient was
noted to tolerated po well and was only supplemented with IV
fluids post catheterization. Electrolytes were monitored
closely and repleted as necessary.
4. RENAL - The patient's BUN and creatinine remained stable
post catheterization with no signs of dye induced
nephropathy.
5. ENDOCRINE - As above patient with diet controlled
diabetes mellitus. The patient's blood sugars were monitored
[**Hospital1 **] with a regular sliding scale insulin for coverage however
the patient was not in need of such coverage.
DISCHARGE CONDITION: Stable. The patient to be discharged to
home with no home services.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post four vessel CABG in
[**2096**]. Status post stenting to left circumflex and saphenous
vein graft to LAD on [**2106-3-18**].
2. Diet controlled diabetes mellitus.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Lopressor 50 milligrams po bid.
2. Imdur 60 milligrams po q day.
3. Sublingual nitroglycerin prn.
4. Vitamin C and E one multiple vitamin po q day.
5. Enteric coated aspirin 325 milligrams po q day.
6. Welchol six tablets q day.1.
7. Plavix 75 milligrams po q day times 30.
FOLLOW UP APPOINTMENTS: Primary care physician and
cardiology at [**Hospital6 2910**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 2054**]
MEDQUIST36
D: [**2106-3-20**] 22:31
T: [**2106-3-22**] 14:22
JOB#: [**Job Number 35477**]
|
[
"V45.81",
"458.2",
"272.0",
"250.00",
"411.1",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"36.02"
] |
icd9pcs
|
[
[
[]
]
] |
5485, 5554
|
2745, 2789
|
5829, 6114
|
5575, 5806
|
4016, 5463
|
2812, 3988
|
1477, 1910
|
150, 185
|
6139, 6430
|
214, 1458
|
1932, 2534
|
2552, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,558
| 105,758
|
28774
|
Discharge summary
|
report
|
Admission Date: [**2187-11-26**] Discharge Date: [**2187-11-30**]
Date of Birth: [**2128-11-20**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 13252**]
Chief Complaint:
prolonged seizure
Major Surgical or Invasive Procedure:
EEG
History of Present Illness:
59yo woman with recently diagnosed renal cell cancer with brain
metastases diagnosed by MRI [**11-14**], presented with a prolonged
seizure at home. Per her husband, she has had no c/o recently
including f/c/cp/sob/gu/gi sx; she was supposed to have a
radiology study and mask fitting in preparation for cyberknife
procedure the morning of admission. Her husband woke up at 4am
and heard some commotion from living room - he walked in to find
the patient standing up, nodding her head up and to the right,
rhythmically, with eye deviation to the right, some blinking
(?rhythmic), not talking. He changed her clothes and helped her
into the car, then drove her to the hospital. Along the way, he
asked her if she could squeeze his hand, and she periodically
gave weak squeezes on command. When she arrived at [**Hospital1 **] (5AM) she
was not following commands, and rhythmic eye-blinking was noted,
with R eye deviation; she received 6mg total ativan, with some
effect (and was following commands again), and given 1gm PHT
load.
Past Medical History:
renal cell cancer diagnosed in [**8-26**] with a left renal mass,
presented with LE swelling. Now s/p L nephrectomy and
adrenalectomy [**9-26**], pathology showing renal cell. On [**2187-11-14**]
had MRI with a hemorrhagic metastasis L frontal, following with
Dr. [**Last Name (STitle) 4253**].
CHF with EF 40-55%
mitral valve regurgitation
HTN
anemia related to folate and iron defic
factor [**Last Name (STitle) **] deficiency
Social History:
Lives with husband and son, HS education; formerly worked at
[**Male First Name (un) 28447**] club/sales, quit tob 30 yrs ago, formerly smoked <1pd x 10
yrs, former etoh, no drugs, no toxic exposures
Family History:
son with sz d/o, father d. lung ca with mets to brain; mother d.
stroke, sister with cervical ca, brother with cad
Physical Exam:
Examination on admission:
Afeb HR 120 BP 144/97 RR 20 99%RA
General appearance: thin white female
HEENT: moist mucus membranes, clear oropharynx
Neck: supple
Heart: regular
Lungs: clear ant only
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Mental Status: The patient has her eyes open, blinking
spontaneously (not rhythmically at this point), staring
straight, but can track on command and follow commands to
squeeze hand wiggle toes, close eyes; no speech heard
Cranial Nerves: Blinks to threat bilat, optic discs are normal
in appearance, eye movements are normal with tracking and with
OCR (both vertical and horizontal), no nystagmus. Pupils
slightly anisocoric (<0.5mm difference, L>R) but both briskly
reactive to light; No obvious facial asymmetry with grimace,
intact corneals; Hearing is intact to voice. The palate elevates
in the midline. The tongue protrudes in the midline and is of
normal appearance.
Sensorimotor: Pt w/d vigorously all 4 ext to stim, squeezes
hands and wiggles toes, but did not raise legs off bed.
Reflexes: The tendon reflexes are brisk throughout, slightly
brisker on the right than the left. The plantar reflexes are
flexor.
Gait, coord could not be tested.
Pertinent Results:
Admission labs:
[**2187-11-26**] 05:16AM BLOOD WBC-7.6 RBC-3.40* Hgb-9.7* Hct-28.6*
MCV-84 MCH-28.7 MCHC-34.1 RDW-17.1* Plt Ct-539*
[**2187-11-26**] 05:16AM BLOOD Neuts-63.3 Lymphs-25.3 Monos-8.0 Eos-3.0
Baso-0.4
[**2187-11-26**] 05:16AM BLOOD PT-14.0* PTT-25.6 INR(PT)-1.2*
[**2187-11-26**] 05:16AM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-137
K-4.3 Cl-99 HCO3-26 AnGap-16
[**2187-11-26**] 05:16AM BLOOD ALT-61* AST-44* AlkPhos-324* Amylase-68
TotBili-0.3
[**2187-11-26**] 05:16AM BLOOD Albumin-3.2* Phos-3.9 Mg-2.0
[**2187-11-26**] 05:16AM BLOOD Lipase-101*
[**2187-11-26**] 05:16AM BLOOD Digoxin-0.5*
.
Imaging:
CXR: No evidence of pneumonia or CHF. Redemonstration of
numerous pulmonary lesions consistent with the patient's known
metastatic renal cell carcinoma.
.
Head CT [**11-26**]: There is a 14 mm ovoid hyperdense focus in the
left frontal lobe, consistent with hemorrhage at the site of the
patient's known metastatic lesion. This focus appears slightly
larger than on prior examination. There is also a significant
increase in hypodensity in the surrounding left frontal lobe
consistent with edema. This edema is compressing the frontal
[**Doctor Last Name 534**] of the left lateral ventricle. There is slight shift of
normally midline structures to the right, as shown by subfalcine
herniation. No new areas of hemorrhage are identified. There is
no hydrocephalus. The osseous and soft tissue structures are
unremarkable.
.
MRI Head [**11-26**]:
The metastasis in the superior left frontal lobe is again
demonstrated. It appears to have increased in size compared to
[**2187-11-14**]. For example, on the sagittal images, it has increased
from approximately 12 mm to 16 mm in oblique superior/inferior
dimension. There is more anterior extension of edema as well.
.
There is now a second punctate lesion in the left cerebellar
hemisphere with surrounding edema, as discussed by the radiology
residents with Dr. [**Last Name (STitle) 42460**] on [**11-27**].
.
The other small areas of FLAIR hyperintensity present on the
current study
were present previously and no underlying enhancing lesions are
seen, most
consistent with small vessel disease. There is new mass effect
on the left frontal [**Doctor Last Name 534**] from the left frontal metastasis and
edema. The cerebellar edema does not affect the fourth
ventricle. As seen previously, there is a degree of
ventriculomegaly. The craniovertebral junction is normal.
.
IMPRESSION:
1. There is a second punctate enhancing lesion in the left
cerebellum with surrounding edema, new since10/25 and most
consistent with a second
metastasis.
2. A left frontal lesion appears to have enlarged from
approximately 12 to approximately 16 mm since [**11-14**] and there is
slightly more surrounding edema with new mass effect on the left
frontal [**Doctor Last Name 534**].
.
EEG [**11-27**]:
ABNORMALITY #1: Sharp and slow wave complexes over the left
anterior quadrant occurred during wakefulness with a frequency
of 0.5-1 Hz. During these discharges, the patient was able to
follow simple commands, but was unable to state the date
appropriately.
BACKGROUND: A 9.5 Hz posterior predominant rhythm was recorded
in the waking state, which attenuated with eye opening. The
normal anterior to
posterior voltage gradient was observed.
HYPERVENTILATION: Contraindicated.
INTERMITTENT PHOTIC STIMULATION: Portable study precluded photic
testing.
SLEEP: The patient remained awake throughout the recording. No
state I or II sleep was recorded.
CARDIAC MONITOR: A generally regular rhythm was recorded, with
an average rate of 90 beats per minute.
IMPRESSION: This is an abnormal EEG in the waking state due to
the periodic sharp and slow wave complexes in the left anterior
quadrant occuring at a frequency of 0.5-1 Hz. No seizures were
recorded.
Brief Hospital Course:
Impression: 58yo woman with RCC with metastases to the brain,
who presented with a prolonged seizure likely to be focal motor
partial status. The seizure focus was felt to be her L frontal
lobe lesion, which was consistent with her symptoms and EEG
findings. She was given 6mg ativan and 1gm dilantin in the ED
with resolution of her symptoms. She was started on decadron in
the ED and continued on this throughout her hospital stay at 4
mg PO Q6. She was initially admitted to the ICU for close
monitoring. An EEG showed L frontal spikes occuring
approximately every 5 seconds. She slowly improved over the
course of the next several days, with persistent non-fluent
aphasia with preserved repetition. She was continued on dilantin
with keppra added for more long term seizure prophylaxis (goal
to wean pt of Dilantin and titrate up Keppra on an outpatient
basis). As her exam improved she was transferred to the floor.
.
She had an MRI by cyberknife protocol on [**11-26**], which showed a
new cerebellar lesion in addition to her frontal lesion. Her
radiation oncology, neurooncology, and neurosurgical teams were
notified of this. They decided that, due to potential impact of
the radiation on the edema surrounding the frontal lesion, it
would be advisable to proceed surgically with the anterior
frontal lesion, scheduled to happen in the week following
discharge by Dr. [**Last Name (STitle) **]. On [**11-28**], the patient was seen at the
radiation planning center for Cyberknife planning regarding the
cerebellar lesion and the lesion was radiated on [**11-29**]. Pt. was
monitored overnight with no clinical evidence of increased edema
or mass effect [**2-22**] radiation.
.
On discharge her exam was significant for a mild non-fluent
aphasia as above and mild R sided UMN pattern weakness and R NLF
flattening. She will be contact[**Name (NI) **] in the week following
discharge re: an appointment to come back into the hospital for
resection of her met, and Dr. [**Last Name (STitle) 4253**] will follow up with her
at that time.
Medications on Admission:
1. Ativan 0.5 mg q.8h. as needed for anxiety.
2. Digoxin 250 mcg a day.
3. Folinic acid 1 mg a day.
4. Ferrous sulfate 325 mg a day.
5. Lisinopril 10 mg a day.
6. Metoprolol 25 mg b.i.d.
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
8. 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*
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Cell Carcinoma with metastases to Lung and Brain
L frontal and cerebellar brain mass
Status epilepticus, focal motor, likely [**2-22**] brain mass
Discharge Condition:
Stable, aphasia improved but present, no seizure activity for >
48 hours, able to walk without assistance, afebrile, no
confusion or lethargy
Discharge Instructions:
Please call your doctor or go to the ER if your speech gets
worse, you develop any headaches, vision changes, double vision,
nausea, vomiting, weakness in your arms or legs, unsteadiness or
trouble walking, confusion, excessive sleepiness, any further
seizures, or any other symptoms that concern you.
Please take all medications as prescribed.
Followup Instructions:
Neuro-Oncology: Dr. [**Last Name (STitle) 4253**] will see you in the hospital when
you come back to have your tumor resected. Please call her
office at [**Telephone/Fax (1) 44**] if you have any questions or problems
before that.
[**Doctor First Name **] from Dr.[**Name (NI) 9034**] office will be in contact with you on
[**Name (NI) 766**] about scheduling a date for your tumor resection by Dr.
[**Last Name (STitle) **]. Please call her office at [**Telephone/Fax (1) 2731**] if you have any
questions about this.
Previously scheduled appointments:
Cardiology: Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2187-12-12**] 10:40
Oncology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-12-19**] 5:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2187-12-19**] 5:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 13255**]
Completed by:[**2187-11-30**]
|
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"280.9",
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"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
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|
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|
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|
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|
1823, 2024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,856
| 152,516
|
1249
|
Discharge summary
|
report
|
Admission Date: [**2204-6-16**] Discharge Date: [**2204-6-24**]
Date of Birth: [**2126-3-16**] Sex: M
Service: MEDICINE
Allergies:
Atenolol / Diovan
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fever, lethargy
Major Surgical or Invasive Procedure:
Right percutaneous nephrostomy tube
PICC line placement
Central line placement
History of Present Illness:
This is a 78 year old nursing home resident who presents to the
ED with fevers. Per NH report, pt was in his usual state of
health until yesterday when he was noted to be lethargic and
febrile to 103. He has also refused all of his medications for
the last 3 days. Per his wife, he is minimally verbal at
baseline, but in the last few days he has been increasingly
lethargic and less interactive. He was brought to the ED from
the NH given concerns for an infection.
.
EDVS: Temp:98 HR:62 BP:88/62 Resp:24 O(2)Sat:94 on RA. He was
given 1.5 L IVF and SBP recovered to 110s. He had a foley
cathether placement by urology requiring cystocope due to
uretheral stricture. Also of note, he had a CT abd/pelvis that
revealed a right hydronephrosis and perinephric stranding with
obstructive nephrolithiasis. Urology recommended broad spectrum
antibiotics and IR consult for perc nephrostomy drainage. He
was started on vancomycin and zosyn and he was sent to the MICU.
.
He arrived from the ED on a NRB. He denies any acute complaints
and nods to yes/no questions.
.
Was transferred to the MICU and fluid resucitated. CT ABD/PElv
showed R hydro and perinephric stranding and 5mm UPJ stone felt
to be causing obstructive urosepsis. He underwent percutaneous
nephrostomy tube placement on the R without complications.
Notably, fever defervesced and WBC normalized. Patient's course
complicated by initial hypoxia and O2 requirement. He had a CXR
that showed patchy L sided retrocardiac density but this was not
felt to be PNA. Also, CEs checked on admission and found to be
elevated with new lateral ST depressions suggestive of [**First Name3 (LF) 7792**].
Given patient's multiple medical problems and comorbidities
[**Name (NI) 7792**] managed conservatively with continued ASA, Plavix and
statin. Heparin gtt not initiated given history of hemorrhagic
CVAs.
.
On arrival to the medical floor, patient has no complaints
including no abdominal pain, chest pain or shortness of breath.
He reports a good appetite and no nausea or vomiting.
Past Medical History:
-Hypertension.
-Seizure disorder.
-Multiple CVAs including cerebellar hemorrhage, has been in NH
for the last few years- First CVA was in [**2193**]. Hemorrhage was in
[**2195**]. Small stroke again [**2195**]. Hemorrhage [**2197**].
-Peripheral vascular disease.
-Abdominal aortic aneurysm repair in [**2191**].
-Hypercholesterolemia.
-Congestive heart failure with ejection fraction of 30%.
-Chronic renal insufficiency.
-Coronary Artery Disease- MI in [**2181**]. Never had a stent,
angioplasty or CABG per wife.
Social History:
No ETOH or illicit drug use. Tobacco: 40 pack year history of
smoking, quit 25 years ago
Family History:
History of asthma and diabetes
Physical Exam:
On admission:
Vitals: T: 102 BP: 99/44 P: 109 R: 19 O2: 100% NRB
General: Awake, able to answer yes/no questions
HEENT: Sclera anicteric, dry MM, no dentures, oropharynx clear
Neck: Supple, no LAD
Lungs: Bibasilar crackles
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: 1+ pulses, cool extremities, no edema
=================================
On discharge:
Vitals: T: 98.6 BP: 142/76 P: 82 R: 18 O2: 99% RA
General: Awake, talkative and interactive, appropriate
HEENT: Sclera anicteric, moist MM, no dentures, oropharynx clear
Neck: Supple, no LAD
Lungs: clear to auscultation 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
GU: Foley in place. R nephrostomy in place, draining.
Ext: 1+ pulses, warm extremities, no edema
Pertinent Results:
Labs on admission:
[**2204-6-15**] 11:30PM WBC-18.6*# RBC-3.73* HGB-10.8* HCT-32.4*
MCV-87 MCH-29.0 MCHC-33.4 RDW-14.1
[**2204-6-15**] 11:30PM GLUCOSE-125* UREA N-57* CREAT-3.1*#
SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-19
[**2204-6-16**] 03:00AM URINE RBC->50 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-1 TRANS EPI-0-2
.
[**Year/Month/Day 7792**] trending cardiac enzymes:
[**2204-6-16**] 05:00AM CK-MB-13* MB INDX-5.2 cTropnT-0.87*
[**2204-6-16**] 08:59PM CK-MB-24* MB INDX-4.5 cTropnT-1.59*
[**2204-6-17**] 03:34AM BLOOD CK-MB-32* MB Indx-6.0 cTropnT-1.77*
[**2204-6-17**] 05:34PM BLOOD CK-MB-27* MB Indx-6.8* cTropnT-2.26*
[**2204-6-18**] 03:36AM BLOOD CK-MB-19* MB Indx-6.9* cTropnT-2.69*
[**2204-6-18**] 03:40PM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-3.36*
[**2204-6-19**] 05:35AM BLOOD CK-MB-6 cTropnT-3.08*
[**2204-6-22**] 10:35AM BLOOD CK-MB-NotDone cTropnT-1.59*
.
Labs on discharge:
[**2204-6-24**] 06:45AM BLOOD WBC-13.0* RBC-3.73* Hgb-10.4* Hct-34.0*
MCV-91 MCH-27.9 MCHC-30.6* RDW-14.4 Plt Ct-367
[**2204-6-23**] 01:33PM BLOOD Glucose-104* UreaN-33* Creat-1.6* Na-141
K-4.1 Cl-111* HCO3-19* AnGap-15
.
Microbiology:
BLOOD CULTURE [**2204-6-15**] 11:15 pm: ANAEROBIC GRAM POSITIVE
ROD(S). NOT RESEMBLING CLOSTRIDIUM SP. - sent out for
sensitivities and further speciation. Results may take up to 1
week.
BLOOD CULTURE ([**2204-6-19**]): No growth to date.
URINE CULTURE (Final [**2204-6-19**]): NO GROWTH.
URINE CULTURE (Final [**2204-6-21**]): ESCHERICHIA COLI. ~3000/ML.
Sensitive to Cefepime and others.
.
Imaging:
[**2204-6-22**]: CT Head w/o Contrast: 1. No hemorrhage, edema, or
evidence of acute process. 2. Unchanged pattern of severe small
vessel ischemic change, focal encephalomalacia, and atrophy.
[**2204-6-22**]: CXR: There has been interval removal of the right PICC.
Mildly enlarged cardiac silhouette is unchanged. Tortuous aorta
is unchanged. Worsening left lower lobe consolidation and new
small left pleural effusion is noted. There is also a new
consolidation within the right lower lobe. No pneumothorax is
detected.
[**2204-6-19**]: CXR Right PICC with tip in the lower SVC without
complications.
[**2204-6-17**]: CT Head w/o Contrast: Stable appearance of multiple
chronic infarcts. If an acute infarct is suspected clinically,
MRI scanning with diffusion-weighted images is more sensitive
than the present non-contrast head CT scan.
[**2204-6-16**]: CT Abdomen: 1. Abdominal aortic aneurysm, measuring up
to 3.8 cm suprarenally and 3.5 cm infrarenally. Follow-up of
aortic and iliac aneurysms is suggested in one year by CT. 2.
Patient is status post aortobiiliac graft. Vascular patency is
not assessed without intravenous contrast. 3. No retroperitoneal
or periaortic hematoma to suggest active aneurysmal bleed. 4.
Mild-to-moderate right hydronephrosis, with associated stone in
the proximal right ureter/at the UPJ. Additional non-obstructing
stones identified in the right kidney. 5. Status post
cholecystectomy. 6. Sigmoid diverticulosis without evidence for
diverticulitis. 7. Bibasilar ground-glass opacities at the lung
bases, may represent atelectasis versus developing pneumonia.
Radiographic followup is suggested if the possibility of
pulmonary infection is a significant clinical concern.
[**2204-6-16**]: Echocardiogram: EF 30-35%. Suboptimal image qualtity.
Regional left ventricular dysfunction consistent with
multivessel CAD. Mild mitral regurgitation. Borderline pulmonary
hypertension.
Brief Hospital Course:
This is a 78 yo with a history of HTN, CAD admitted with fever,
leukocytosis and hypotension found to have obstructing
nephrolithiasis in R ureter.
.
# Urosepsis: CT on admission showed obstructing nephrolithiasis
thought to be cause of urosepsis. Initial hypotension improved
with IVF resuscitation in the ICU. IR placed percutaneous
nephrostomy tube which drained franc pus. Vanc/zosyn were
started for empiric coverage initially then switched to cefepime
for total 14 days via PICC ([**Date range (3) 7793**]). Urine cultures
grew ~3000 colonies of E. Coli.Blood cxs grew gram positive rods
not resembling Clostridium sp, further speciation and
sensitivities are pending send-out - will likely return in 1
week. Patient treated with 7 day course of cepepime and 7 day
course of vancomycin.
.
# Obstructing R UPJ Stone: As noted above, percutaneous
nephrostomy tube in place. Pt has urology f/u at which time it
will be determined if surgical intervention to remove stone will
occur. Foley catheter should remain in place until this
appointment. If stone is not surgically removed, possible that
perc nephrostomy tube will remain indefinitely in which case it
will need to be changed by Interventional Radiology in 3 months.
.
# Acute on chronic renal failure: Last Cr 1.3 in [**2197**], difficult
to know patient's true baseline prior to this acute insult.
Etiology of renal function felt to be ATN (due to hypotension,
prolonged ischemic state)versus loss of right kidney function.
Cr trended down from 3.3 to 1.6 throughout hospital stay, with
resolution of sepsis and volume resuscitation.Holding
lisinopril. Would suggest restarting when Cr at baseline.
.
# [**Year (4 digits) 7792**]: Thought to be secondary to urosepsis. Cardiac enzymes
elevated on admission and ECG with inferolateral ST depressions.
ECHO with globalhypokineses suggestive of multivessel CAD as
well as moderate TR. Seen by cardiology who recommended
conservative management given he was asymptomatic and
hemodynamically stable. Heparin gtt not intiated given bleeding
risk due to previous hemorrhagic strokes. Atorvastatin increased
to 80mg daily, asa 325mg started and metoprolol tartrate 12.5mg
[**Hospital1 **] started. Plavix 75mg was continued. ACE held due to renal
failure. Pt remained CP free without SOB. Would suggest
continuing high dose statin, full dose ASA x 1 mo and then
decrease to 81mg daily, and BB. Restart ACE when renal failure
improves or his Cr plateaus (presumably his baseline).
.
# Hospital Acquired PNA: Patient became more lethargic and
mildly hypoxic to 93% on RA on [**6-22**] and found to have LLL and
RLL consolidation on CXR. Levofloxacin was added to his
antibiotic regimen of cefepime and vancomycin. Patient has
received 7 day course of cefepime/vanco. He will require total 5
day course of levofloxacin with last dose on [**2204-6-26**].
.
# Seizure d/o: Dilantin found to be subtherapeutic. He was given
300 Dilantin IV to become therapeutic, and daily dilantin
changed from 100mg [**Hospital1 **] to 100mg QAM and 200mg QPM. While in
hospital, level increased from 2.1 to 2.6, but still
subtherapeutic. He will need to have dilantin level rechecked in
the next week and dilantin level adjusted as needed to maintain
a therapeutic range.
.
# Peripheral neuropathy: Patient complained of foot pain while
in the MICU, states this has been chronic. He was given
gabapentin 300mg qHS with good effect.
.
# Osteoporosis: Patient was continued on home calcium/vitamin D,
though Actonel was held.
Medications on Admission:
Simvastatin 20
Calcium 600 D 200 [**Hospital1 **]
Dilantin 100 [**Hospital1 **]
Remeron 15 daily
Actonel 35 wkly
HCTZ 25
Lisinopril 2.5
MVI
Plavix 75
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Calcium 600 with Vitamin D3 Oral
6. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours): last dose on [**6-26**].
11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO QAM (once a day (in the morning)).
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO QPM (once a day (in the evening)).
13. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
14. Calcium Carbonate-Vitamin D3 Oral
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary: Urosepsis, Nephrolithiasis, Non-ST Elevation Myocardial
[**Hospital 7794**] Hospital Acquired Pneumonia, Acute on chronic renal
failure.
Secondary: ischemic cardiomyopathy,seizure disorder,
osteoporosis, peripheral vascular disease
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:
You were admitted to [**Hospital1 **] with a fever and
lethargy. You were found to have a kidney stone on your right
side, that was managed by putting in a tube to help fluid drain.
This will be kept in place for urology to follow-up with you in
the outpatient setting.
While you were here, you also had a heart attack but no chest
pain or shortness of breath. For this, you were continued on
your home medicines that all help - aspirin, statin,
beta-blocker, and Plavix.
You also developed a pneumonia which was also treated by
antibiotics.
New medications:
===============
Levofloxacin 750mg every 48 hrs last dose [**2204-6-26**]
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Atorvastatin increased from 20 mg to 80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2204-6-25**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 5727**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Patient will need to follow up with interventional radiology in
3 months if percutaneous nephrostomy tube is still in place. The
interventional radiologists will call him with an appointment.
If you do not hear from IR in the next 4 weeks pls call ([**Telephone/Fax (1) 7795**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2204-6-24**]
|
[
"591",
"428.0",
"414.8",
"996.1",
"403.90",
"584.5",
"443.9",
"486",
"272.0",
"E879.8",
"276.2",
"345.90",
"V15.82",
"355.8",
"592.1",
"412",
"733.00",
"294.8",
"038.9",
"410.71",
"585.9",
"995.92",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
12429, 12523
|
7711, 11223
|
293, 373
|
12808, 12808
|
4213, 4218
|
13931, 14666
|
3109, 3142
|
11423, 12406
|
12544, 12787
|
11249, 11400
|
12984, 13908
|
3157, 3157
|
3677, 4194
|
4608, 5110
|
238, 255
|
5129, 7688
|
401, 2446
|
4232, 4591
|
12823, 12960
|
2468, 2986
|
3002, 3093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,234
| 153,448
|
41996+42033+58496
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2152-1-10**] Discharge Date: [**2152-1-11**]
Date of Birth: [**2124-10-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
IVC mass
Major Surgical or Invasive Procedure:
Biopsy of IVC mass [**2152-1-10**]
History of Present Illness:
Mr. [**Known lastname 116**] is a 27 year old male, well known to the West 1 service,
with known IVC mass, suspected to be leiomyosarcoma. He
underwent percutaneous biopsy of this mass on [**2152-1-10**] and is
admitted for overnight observation. He complains of back pain
near his biopsy access site. He denies fevers, chills,
abdominal pain, nausea, vomiting, diarrhea, light headedness,
chest pain, shortness of breath, and leg edema.
Past Medical History:
PMH: GERD, hypothyroid, breast Ca
PSH: left modified radical mastectomy, removal of benign R thigh
tumor, D+C
Social History:
Moved here from [**Location (un) 18317**] 3 yrs ago. Living with his fiancee. No
children. Works full-time in security at [**Location (un) **]. Denies ever
smoking. ETOH occasionally, none since recent PE.
Family History:
Mother A&W at age 52. Father age 55 with PVD s/p recent
aneurysm repair and right leg amputation. Maternal grandmother
86 years old and healthy. Maternal grandfather died in his 50s
status post a fall. Paternal grandmother died in her 70s of lung
cancer. Paternal grandfather died in his 70s.
Physical Exam:
Vitals: Temp 98.1 HR 73 BP 108/69 R 18 97% Room Air
Gen: NAD, AOX3
CV: RRR
Resp: CTAB
Abd: +BS, NTNT
Ext: No edema bilat
Back: dressing c/d/i over biopsy site. No hematoma
Pertinent Results:
[**2152-1-10**] 06:00PM HCT-39.4
[**2152-1-11**] 05:30AM HCT-36.2
Brief Hospital Course:
Mr. [**Known lastname 116**] was admitted overnight following his percutaneous biopsy
of his caval mass. He tolerated this procedure well. There were
no complications. A heparin drip was started overnight. It was
discontinued in the morning and he was restarted on his home
Lovenox regimen. He was advanced to a regular diet overnight
which he tolerated well. He was hemodynamically stable. He had
no respiratory, GI, or GU issues. He was given oral pain
medication for his back pain secondary to the biopsy. He was
discharged home and given instructions for readmission on
[**2152-1-12**] for preoperative management for his planned operation on
[**2152-1-13**].
Medications on Admission:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
2. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
3. flexeril prn spasm
4. Ambien 10 mg PO qhs prn insomnia
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not take over 2 grams in one day.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
please take while on narcotics to prevent constipation.
Available over the counter.
6. flexeril prn spasm
7. Ambien 10 mg PO qhs prn insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
IVC/infra-renal mass s/p biopsy [**2152-1-10**].
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
increased abdominal pain, pain in the back, shortness of breath,
chest pain, bleeding at the puncture site, hematoma formation
around the puncture site, nausea, vomiting or any other
concerning symptoms.
Your surgery is scheduled for Thursday [**2152-1-13**].
Followup Instructions:
Surgery Thursday morning [**2152-1-13**]. You will be readmitted on
Wednesday for preoperative heparin drip. Our office will call
you to facilitate this.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2152-1-11**] Admission Date: [**2152-1-12**] Discharge Date: [**2152-1-24**]
Date of Birth: [**2124-10-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Inferior Vena Cava mass
Major Surgical or Invasive Procedure:
[**2152-1-13**]: Resection of IVC mass plus IVC, right nephrectomy.
History of Present Illness:
Mr. [**Known lastname 116**] is a 27 year old male with known IVC mass, suspected to
be leiomyosarcoma s/p percutaneous biopsy on [**2152-1-10**]. His
initial presentation was with LE DVT in 8/[**2150**]. At that point he
was treated with Lovenox and Coumadin. Subsequently, he was
diagnosed with a large right PE despite a therapeutic INR. Upon
hematology workup, ABD CT showed a 7.4 x 7.4 x 9.7 right
suprarenal caval mass. A repeat chest CT and triphasic CT scan
of abdomen/pelvis were done [**2152-1-5**] to delineate extent of the
IVC mass and thrombus. TTE was done [**2152-1-6**], there was no
extension of caval mass into the atrium. Right middle and lower
lobe mass confirmed on chest CT. This is planned to be resected
by Dr.[**Last Name (STitle) **] at a later time.
He is being admitted to the HPB service for preoperative
management prior to his caval thrombectomy tomorrow. He is
complaining of some posterior back pain secondary to his recent
percutaneous biopsy. This has been well controlled with PO
Dilaudid and Tylenol at home. He also has hemoptysis with blood
tinged sputum on tissue. He denies fevers, chills, nausea,
vomiting, diarrhea, abdominal pain, constipation, dysuria, or
lower extremity swelling.
Past Medical History:
childhood asthma, anxiety, Hx L leg DVT ([**6-/2151**]), Hx PE
PSH: none
Social History:
Moved here from [**Location (un) 18317**] 3 yrs ago. Living with his fiancee. No
children. Works full-time in security at [**Location (un) **]. Denies ever
smoking. ETOH occasionally, none since recent PE.
Family History:
Mother A&W at age 52. Father age 55 with PVD s/p recent
aneurysm repair and right leg amputation. Maternal grandmother
86 years old and healthy. Maternal grandfather died in his 50s
status post a fall. Paternal grandmother died in her 70s of lung
cancer. Paternal grandfather died in his 70s.
Physical Exam:
PE: T 97.4, HR 108 BP 143/83 RR 20 O2 98% RA
Gen: A&O, NAD, very pleasant
ENT: Anicteric sclerae, pharynx wnl
Lungs: CTAB
CV: RRR, no murmurs
Abd: Soft, non-distended, non-tender, no guarding, no HSM
Back: No bruising or hematoma over biopsy site. Mildly tender
Ext: No lower extremity edema
Pertinent Results:
On Admission: [**2152-1-12**]
WBC-8.6# RBC-3.95* Hgb-11.7* Hct-34.3* MCV-87 MCH-29.5 MCHC-34.1
RDW-13.6 Plt Ct-297
PT-12.9* PTT-61.0* INR(PT)-1.2*
Glucose-114* UreaN-13 Creat-0.9 Na-136 K-4.4 Cl-98 HCO3-32
AnGap-10
ALT-34 AST-18 AlkPhos-99 TotBili-0.5
Albumin-4.1 Calcium-9.5 Phos-4.2 Mg-2.0
At Discharge: [**2152-1-24**]
WBC-13.9*# RBC-3.15* Hgb-9.6* Hct-27.3* MCV-87 MCH-30.4
MCHC-35.1* RDW-14.5 Plt Ct-580*
PT-17.0* PTT-63.3* INR(PT)-1.6*
Glucose-111* UreaN-12 Creat-1.4* Na-131* K-3.9 Cl-99 HCO3-23
AnGap-13
ALT-76* AST-40 AlkPhos-117 TotBili-0.9
Calcium-8.4 Phos-4.0# Mg-2.0
Albumin-3.0*
Brief Hospital Course:
27 y/o male admitted pre-op for heparin bridge prior to surgery.
The patient was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
resection of the IVC mass plus IVC and right nephrectomy.
At the time of the surgery, the patient had a large mass in the
IVC. By intraoperative ultrasound and TEE, the mass ended
approximately 3.5 cm below the confluence of the hepatic veins
and the inferior vena cava. The mass was able to be completely
resected along with the right kidney. He tolerated the procedure
well, received three units of RBCs. Please see the operative
note for further detail. He was transferred to the SICU for
further care.
On chest xray done to verify line placement, it was noted the
patient had a massive right-sided pleural effusion, possibly
representing hematoma, with collapse of right lung, and leftward
shift of the mediastinum and heart. This was immediately
following surgery, and a 25 G needle was placed and the patient
was on wall suction. The chest tube initially put out 900 cc
sanguinous output. The output decreased daily and on POD 3 the
drain was removed. On POD 4 he was taken to the OR with Dr.
[**Last Name (STitle) **] for a Right video assisted thoracic surgery
decortication. Clot was noted, and there was rind trapping the
right lung, which once freed, allowed the lung to expand nicely.
A new apical chest tube was then placed. When that chest tube
was removed, there was pneumothorax which had remained stable.
O2 requirements diminished. Clot culture was sent at time of
VATS, which was reported no growth.
The patient remained in the ICU post op for several days. Pain
management was an initial issue as well as the hemothorax. Once
these issues were more satisfactorily controlled, he was able to
be transferred to the regular surgical floor.
NG tube was removed on POD 5.
At that point he was having return of bowel function, and in
fact was having daily diarrhea and large volume stool output. C
diff was sent and negative, and he was started on loperamide
with good control of amount of stooling.
The patient was maintained on a heparin drip until the day of
discharge. Once therapeutic and stable, daily PTTs were around
60. He was started on lovenox for home discharge.
Patient is s/p right nephrectomy. Creatinine was 0.9 on
admission. His maximum creatinine rose to 2.3 on POD 5, and was
down to 1.4 by day of discharge. Urine output has been adequate.
The JP drain left in place from surgery was noted to look
slightly thick, outputs daily ranged from 150 - 300 cc daily. A
triglycerides was sent on the fluid (308) with 81 % lymphs.
Dietary recommendations were to continue regular diet, and
monitor both drain output amount and appearance.
The patient was tolerating regular diet, ambulating and as
noted, had return of bowel function. He remained afebrile
throughout the hospital stay.
The JP drain site appeared slightly erythematous and some
fibrinous material around drain site. Additionally there was
slight drainage from the upper apex of the incision which will
be kept covered with a DSD.
Patient will have outpatient PET scan Thursday and was given
specific dietary instruction sheet.
Medications on Admission:
Lovenox 80mg sc bid, klonopin 1mg prn anxiety, Ativan 0.5-1 [**Hospital1 **]
PRN anxiety, flexeril prn back spasms, ambien prn (hasn't used)
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: Maximum 6 tablets daily.
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stools.
Disp:*20 Capsule(s)* Refills:*0*
4. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
5. Klonopin 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety: use cautiously when taking pain medication.
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior Vena Cava Mass, Leiomyosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarrhea, constipation, increased abdominal
pain or pain not controlled by usual pain medications.
Monitor the incision for redness, drainage or bleeding. Keep the
top area of incsion covered for now with a dry gauze.
Drain and record the JP bulb output three times daily and as
needed. Please call if the drainage increases significantly,
changes in color or becomes cloudy or foul smelling in
appearance.
Monitor the drain exit site daily for increased redness, or
drainage. Keep a dry dressing around the drain exit site. Change
daily or after you shower.
You [**Known lastname **] shower, allow water to run over incision and drain site
and pat dry gently, do not rub. Replace the drain sponge, this
should always be a dry dressing.
Do not allow the drain to hang freely, even in the shower.
No tub baths or swimming until notified you [**Known lastname **] do so.
Avoid lifting greater than 10 pounds.
No driving if taking narcotic pain medications
Monitor for signs of bleeding from lovenox to include nosebleed,
rectal bleeding or blood in stool/dark/tarry stool or easy
bruising. Please call if this occurs as it [**Known lastname **] suggest need to
lower lovenox dosing.
It is recommended to use an electric razor while on
anticoagulant therapy
Followup Instructions:
Provider: [**Name10 (NameIs) **] MEDICINE [**Hospital Ward Name **] Building, [**Hospital Ward Name 516**],
Phone:[**Telephone/Fax (1) 2103**] Date/Time:[**2152-1-27**] 12:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2152-2-2**] 1:40
.
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-2-4**] 9:30
Dr [**Last Name (STitle) 77624**] will be in touch regarding future thoracic
procedures
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2152-1-24**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14378**]
Admission Date: [**2152-1-10**] Discharge Date: [**2152-1-11**]
Date of Birth: [**2124-10-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 48**]
Addendum:
Please note inaccurate PMH and PSH:
PMH: GERD, hypothyroid, breast Ca
PSH: left modified radical mastectomy, removal of benign R thigh
tumor, D+C
Correct information is as follows:
PMH:childhood asthma,anxiety, DVT, and pulmonary emboli
PSH:unremarkable
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2152-1-21**]
|
[
"511.89",
"277.4",
"198.89",
"493.90",
"197.0",
"599.71",
"E878.6",
"998.11",
"453.77",
"786.30",
"289.81",
"724.5",
"427.89",
"171.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.52",
"34.91",
"55.51",
"38.65"
] |
icd9pcs
|
[
[
[]
]
] |
14624, 14784
|
7587, 10787
|
4672, 4742
|
11674, 11674
|
6970, 6970
|
13224, 14601
|
6341, 6637
|
10980, 11561
|
11611, 11653
|
10813, 10957
|
11825, 13201
|
6652, 6951
|
7276, 7564
|
4609, 4634
|
4770, 6003
|
6984, 7262
|
11689, 11801
|
6025, 6101
|
6117, 6325
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
406
| 100,765
|
45911
|
Discharge summary
|
report
|
Admission Date: [**2126-3-11**] Discharge Date: [**2126-3-26**]
Date of Birth: [**2058-1-29**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Vancomycin / Codeine
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
Dysuria, abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous CT scan guided drainage of abdominal fluid.
History of Present Illness:
Patient is a 68 yo F, h/o cervical CA, radiation cystitis,
radiation colitis, frequent line infections, recurrent UTIs who
presented after developing acute on chronic severe abdominal
pain. Four days prior to admission, patient woke with severe
abdominal pain that was worsened with movement. She had some
dysuria in the days prior. She also complained of nausea and
vomiting. Her abdominal pain was worsened by movement. She
denied fevers or chills.
.
She was brought by ambulance to an outside hospital. There she
had a CT of her abdomen which was notable for mild ascites, but
no acute process. She was mildly hypotensive to SBP of 90s and
was given 3 L NS. Given levofloxacin/flagyl. She was transferred
to the [**Hospital1 18**] ED. On arrival T 100.8, hr 107, bp 100/71. Soon
thereafter SBP dropped to the 70s and she was bolused a total 5L
NS. Her ostomy output was heme negative. U/A showed gross blood
and + WBC. She was given one dose of meropenem 500mg IV, as this
is what she was discharged on previously. Her pain was also
treated with tylenol and dilaudid. She became mildly hypotensive
with dilaudid. Pt was then transfer to the MICU her VS were T
98, 120/51, 15, 99/ra.
.
On arrival to the ICU, she again become hypotensive and required
levophed. She also recieved one unit of PRBCs for HCT of 22. She
was continued on meropenem for presumed urosepsis, and had
received a total of 8L of IV fluids while in the ICU. She was
then transferred to the floor after she stabilized on [**3-13**].
.
The morning of [**3-14**], she was noted to be in marked respiratory
distress. Her oxygen saturation at times dropped to 80% on
non-rebreather, and was noted to be hypertensive into the 160s
systolic. She was given 20mg lasix x 2, her usual dose of
dilaudid and hydralazine without marked improvement, and the
MICU resident was called. Examination demonstrated bilateral
crackles and JVP elevated to the angle of the mandible. CXR
demonstrated marked pulmonary edema. She was given
nitroglycerin SL and transferred to the ICU for possible
initiation of BIPAP.
.
When she arrived in the ICU, her respiratory status had markedly
improved and she denied any shortness of breath or chest pain.
She continued however to have abdominal pain.
Past Medical History:
1. Cervical CA s/p TAH/XRT s/p hysterectomy [**2096**] with recurrence
in [**2097**]
2. Radiation cystitis
3. Urinary Retention; straight catheterization ~8x per day
4. R ureteral stricture
-- c/b recurrent infections
-- s/p right nephrectomy ([**2123**])
5. Recurrent UTIs: (Klebsiella (amp resistant) and Enterococcus
(Levo resistant)
6. Short gut syndrome since [**2109**] s/p colostomy from radiation
enteritis.
7. Osteoporosis
8. Hypothyroidism
9. Migraine HA
10. Depression
11. Fibromyalgia
12. Chronic abdominal pain syndrome
13. Multiple admits for enterococcus, klebsiella, [**Female First Name (un) **]
infections
14. DVT / thrombophlebitis from indwelling central access
15. Lumbar radiculopathy
16. Multiple Prior PICC line / Hickman infections
-- See multiple surgical notes [**2115**] to date
17. H/O SBO followed by surgery
[**33**]. H/O STEMI [**2-20**] Takotsubo CM, with clean coronaries on cath in
[**4-27**]. EF down to 20% in setting of illness, but EF recovered to
55-60%, in setting of klebsiella PNA.
19. Hyponatremia: previously attributed to hctz use
Social History:
She lives with her husband in an [**Hospital3 4634**] [**Last Name (un) **]. She
reports a 80 PY smoking history but quit 18 years ago. Denies
alcohol or drugs. She walks with a walker but has a history of
frequent falls. Independent of ADLS.
Family History:
Father with ETOH abuse, CAD. [**Last Name (un) **] with renal ca, CAD. 3 healthy
children.
Physical Exam:
Admission Exam:
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact.
.
Discharge Exam:
VS: T 98.8 , BP 120/56 , P 81 , RR 16 , O2 99 % on RA,
Gen: Thin woman in NAD
HEENT: Normocephalic, anicteric, OP benign, MM appear dry
CV: RRR, no M/R/G; there is no jugular venous distension
appreciated, DP pulses 2+ bilaterally
Pulm: Expansion equal bilaterally, but overall decreased air
movement, worst at right lung field
Abd: Soft, ND, BS+, ostomy bag in place. Mild tenderness to
palpation
Extrem: Warm and well perfused, no C/C/E
Neuro: A and Ox3, strength 3/5 in lower extremities, [**4-23**] in
upper extremities
Psych: Pleasant, cooperative.
Pertinent Results:
ADMISSION LABS:
[**2126-3-11**] 08:45PM BLOOD WBC-7.6# RBC-3.20* Hgb-9.4* Hct-28.5*
MCV-89 MCH-29.2 MCHC-32.9 RDW-13.1 Plt Ct-175
[**2126-3-11**] 08:45PM BLOOD Neuts-93.8* Lymphs-3.5* Monos-2.6 Eos-0
Baso-0.1
[**2126-3-11**] 08:45PM BLOOD Glucose-93 UreaN-17 Creat-1.4* Na-134
K-5.2* Cl-106 HCO3-17* AnGap-16
[**2126-3-11**] 08:45PM BLOOD ALT-16 AST-26 LD(LDH)-145 CK(CPK)-203*
AlkPhos-81 TotBili-0.2
[**2126-3-11**] 08:45PM BLOOD Lipase-27
[**2126-3-11**] 08:57PM BLOOD Lactate-3.2*
.
ICU LABS:
[**2126-3-15**] 04:00PM BLOOD CK-MB-4 cTropnT-<0.01
[**2126-3-16**] 04:28AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2468*
[**2126-3-17**] 02:23PM BLOOD ANCA-NEGATIVE B
[**2126-3-17**] 02:23PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2126-3-17**] 02:23PM BLOOD CRP-188.2*
[**2126-3-17**] 02:23PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2126-3-17**] 02:23PM BLOOD B-GLUCAN-PND
.
DISCHARGE LABS:
[**2126-3-26**] 06:00AM BLOOD WBC-3.6* Hgb-7.4* Hct-22.5* MCV-87
MCH-28.6 MCHC-32.8 RDW-13.2 Plt Ct-565
[**2126-3-26**] 06:00AM Reticulocyte Count, Manual 1.7*
[**2126-3-26**] 06:00AM LDH 119 T.Bili 0.1 Direc Bili 0.1 Indirect
bili 0.0
[**2126-3-26**] 05:44AM BLOOD Glucose-86 UreaN-36 Creat-1.2 Na-136
K-4.5 Cl-105 HCO3-22
[**2126-3-26**] 05:44AM BLOOD Calcium-9.6* Phos-4.8 Mg-2.1
.
MICROBIOLOGY:
[**2126-3-11**] Blood Cx: negative
[**2126-3-11**] Urine Cx: 10,000-100,000 ORGANISMS/ML. Alpha hemolytic
colonies consistent with alpha streptococcus or Lactobacillus
sp.
[**2126-3-12**] Stool Cx: negative
[**2126-3-12**] Blood Cx: negative
[**2126-3-16**] Urine Legionella Ag: negative
[**2126-3-18**] Influenza swab: negative
.
IMAGING:
[**2126-3-11**] CXR:
In comparison with the study of [**2-11**], there is some increased
opacification at the left base, which does not silhouette the
hemidiaphragm or left heart border. Although this could
conceivably represent a region of pneumonia, it more likely
reflects artifact of soft tissues pressed against the cassette.
No evidence of vascular congestion or pleural effusion. Tip of
the central catheter again lies in the mid-to-lower portion of
the SVC.
.
[**2126-3-12**] CT Abdomen/Pelvis w/ con:
1. New moderate ascites and small bilateral pleural effusions.
No evidence of abscess or pyelonephritis.
2. Unchanged fullness of the left renal pelvis, likely due to
UPJ obstruction.
3. Stable moderate common bile duct dilation in this patient who
is post-cholecystectomy.
.
[**2126-3-16**] CT Chest w/o con:
1. Extensive fibrotic changes and ground-glass opacity
suggestive of pneumonitis such as hypersensitivity pneumonitis,
drug toxicity or NSIP.
2. No evidence of edema or pneumonia.
.
[**2126-3-18**] ECHO:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild aortic
regurgitation. Mild mitral regurgitation. Compared with the
prior study (images reviewed) of [**2125-10-30**], mild mitral
regurgitation is now seen.
.
[**2126-3-19**] chest x-ray:
In comparison with the study of [**3-18**], there has been decrease in
the diffuse bilateral pulmonary opacifications, consistent with
improving
pulmonary edema or hemorrhage. Blunting of the costophrenic
angle on the
right persists consistent with a small effusion. Increasing
opacification at the left base is consistent with pleural
effusion and some volume loss.
Central catheter remains in place.
.
[**2126-3-21**] KUB: Dilated loops of bowel in the left mid abdomen up to
4.8 cm which raise concern for small-bowel obstruction. CT
provides more specific
information if clinical concern remains.
.
[**2126-3-21**] KUB: Supine and upright abdominal radiographs were
obtained. A dilated loop of bowel in the left lower quadrant
measures 4.8 cm and is essentially unchanged in four hours.
Surgical clips project over the mid abdomen and pelvis. A
calcified right breast implant is seen. Dilated bowel loop
remains concerning for small-bowel obstruction.
.
[**2126-3-22**] CT abdomen:1. Multiple intra-abdominal fluid collections,
with rim enhancement and pockets of air, highly suspicious for
abscess. 2. Interval development of marked left hydronephrosis.
3. Status post right nephrectomy. Appearance of fluid-filled
tubular structure at the expected location and course of the
right ureter. If the patient did not have right ureteral
resection, this could represent a urine-filled right ureteral
stump. Recommend clinical correlations. 4. Thickened, diffuse
bladder wall, likely radiation change such as radiation
cystitis. 5. No bowel obstruction. Oral contrast has reached the
RLQ ileostomy bag.
.
[**2126-3-25**] Abd US:1. A small subhepatic fluid collection measuring
4.5 cm. Previously seen right paracolic gutter and pelvic fluid
collections are not well visualized. Please note that ultrasound
is less sensitive for detecting loculated intra-abdominal fluid
collections. 2. Stable appearance of the mild intra- and
extra-hepatic biliary dilatation.
3. Moderate left hydroureteronephrosis, slightly improved since
the prior
study.
.
At time of discharge, intraabdominal fluid culture pending
(prelim result no growth to date).
Brief Hospital Course:
MICU Course: [**Date range (1) 70244**]
# Sepsis of likely urinary origin:
Upon presentation to [**Hospital1 18**] on [**3-11**], had blood pressure drop to
70s sytolic. She was given 5L IVF in ED and transferred to MICU.
CXR was unrevealing. U/A showed increased leuks and WBC on urine
micro. Was empirically started on meropenem in MICU given that
patient had recently been on carbapenems for a UTI in end of
1/[**2126**]. In MICU her BP was intially stable and then fell and
patient was started on norepinephrine, which she remained on for
approximately 17 hours on [**3-12**]. Given patient's severe abdominal
pain, received a CT abd/pelvis in the ED which showed moderate
ascites, though no other acute changes. Surgery consult was
called and felt that there was no acute surgical intervention
indicated and followed the patient's course in the MICU. We also
trended patient's lactate level, which was 3.2 at presentation
and trended down to 1.3 with fluid resuscitation. Checked cdiff
toxin, which was negative. IV team was called to assist in
managment of patient's tunneled double lumen catheter and they
suggested ethanol dwells between TPN infusions in order to
prevent line infection. Blood cultures from [**3-11**] and [**3-12**] were
negative.
.
# Abdominal pain:
Pain with severe abdominal pain upon presentation. We reassured
after ruling out acute intra-abdominal process with CT scan and
serial exams. Given frequent (Q1hour) IV dilaudid requirements
on morning of [**3-13**], pain service consult was called; however,
prior to pain service seeing patient her pain improved to point
that dilaudid could be given less frequently. Was felt that we
had been behind on pain control after sleeping overnight,
possible due to held doses of gabapentin. She was continued on
methadone, dilaudid, and gabapentin.
.
# Anemia:
HCT was found to be 22, pt was transfused 1 unit of PRBCs.
Post-transfusion HCT was 26.9.
.
Medicine Floor Course: [**Date range (1) 32116**]:
Patient was called out from the MICU on [**2126-3-13**] after she had
been normotensive for 24 hours without pressors. She had a new
oxygen requirement (94% on 4L) thought [**2-20**] volume overload (8 L
+ for LOS). Overnight, she was hypertensive to 188/80. In the
morning she was found to be hypoxic to 81% on 4L. She was put on
a non-rebreather with intermittent improvement of her oxygen
sats to low 90s but would then drop to low 80s. She was also
given iv lasix 20 mg x 2 and she put out 2 L in 2 hours. Her
blood pressure was treated with hydralazine 20 mg iv x1 and SL
nitro. Despite these interventions she was still hypoxic in the
80s on a non-rebreather and was transferred back to the MICU for
positive pressure ventilation and aggressive diuresis.
.
MICU Course: [**Date range (1) 97780**]:
CXR was c/w volume overload, likely from fluid resuscitation she
received in the MICU. She was diuresed with IV lasix and started
on azithromycin for atypical pneumonia coverage. CT chest
performed later revealed extensive fibrotic changes and
ground-glass opacities suggestive of pneumonitis such as
hypersensitivity pneumonitis, drug toxicity, or NSIP.
Pneumonitis workup was initiated. ESR =83, CRP = 188.2, [**Doctor First Name **],
ANCA, Beta-glucan, and galactomannan were all negative. She was
stable and was transferred to the floor for further evaluation.
.
Medicine Floor Course: [**Date range (1) 20494**]:
Pt was stable and continued to improved.
Active issues:
.
# Hypoxemia/Pulmonary infiltrates: Oxygenation gradually
improved and pt was weaned off oxygen supplement gradually.
Etiology of infiltrates was unclear, possibilities included
[**Name (NI) **] and medication-induced lung toxicity. Pt received 1 course
of azithromycin for possible atypical pneumonia. Her flu and
legionella screenings were negative. She was weaned off O2 and
mantained 95%+ saturation on room air at the time of discharge.
.
# Urosepsis: Pt remained hemodynamically stable on the floor.
She received meropenem for total of 7 days ([**Date range (1) 28666**]). She
remained without urinary complaints. Pt was given Hyoscyamine
for bladder spasm pain.
.
#Anemia: The patients hematocrit trended down throughout her
hospitalization from around 27 to a low of 22. Her baseline over
the last few months has been 25-28. This was attributed to her
ongoing inflammation secondary to her radiation enteritis and
cystitis, although the precise etiology remains unclear, and
infection and myelodysplasia should be considered as well. Her
manual reticulocyte count was found to be 1.7 (corrected 0.53),
indicating insufficient marrow response. Her ostomy output was
found to be guiac negative and her C+ CT scan of the abdomen and
pelvis demonstrated no evidence of active bleeding. Hemolysis
labs demonstrated no evidence of ongoing hemolytic process,
however corrected retic count was low. This can be due to
illness or medication suppression. Recent iron studies were all
within normal limits. Pt was instructed to follow up with
primary care physician about this issue, with repeat
Hct/reticulocyte count and further workup as needed.
.
# Abdominal pain/fluid collections: The patient had known
chronic abdominal pain related to cervical cancer and radiation
complications. C. diff was been negative. We continued her home
medication (methadone and oxycodone), and added dilaudid. Pt was
able to eat and drink, and did not have any vomiting. She was
evaluated with KUB for possible obstruction, which showed
dilated loops of bowel. CT of abdomen demonstrated multiple
fluid collections, enlarged fluid filled bladder, L
hydronephrosis, and a dilated fluid filled ureteral stump.
Urology was consulted, and a foley was placed for decompression.
When the patient was taken for CT-guided drainage of the
collections, the collections had almost completely disappeared,
potentially related to decompression from the foley catheter.
Fluid from the remaining collection was sampled and sent for
culture and analysis, which demonstrated no bacteria and a
creatinine of 1.8 (not consistent with urinoma). Repeat
ultrasound demonstrated interval resolution of the previoulsy
noted hydronephrosis and stable appearance of the fluid
collections compared to the most recent CT scan.
.
Chronic issues:
.
# CKD: Pt Cr remained at her her baseline, and no new acute
issues.
.
# Short Gut Syndrome: We continued pt's TPN and she was also
followed by the nutritionist while she was in the hospital.
.
# Anxiety/depression: We continued pt's home meds (alprazolam,
fluoxetine).
.
# Chronic Pain/Fibromyalgia: We continued the pt's home meds
(gabapentin, methadone).
.
# Hypothyroidism: We continued the pt's home med
(levothyroxine).
.
# Osteoporosis: We continued the pt's home med (vitamin D,
calcium).
.
#HTN: We restarted pt's Lisinopril on [**3-19**] after her blood
pressure returned to its chronically high level.
Medications on Admission:
1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 5X/WEEK (MO,TU,WE,TH,FR).
3. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
6. levothyroxine 50 mcg 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. pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours).
9. methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 6 days.
[**Month/Day (4) **]:*7 grams* Refills:*0*
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
12. Pyridium 100 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
13. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
14. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*2*
15. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection
Injection once a month.
16. darifenacin 15 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO at bedtime.
17. hyoscyamine sulfate 0.125 mg Tablet, Rapid Dissolve Sig: One
(1) Tablet, Rapid Dissolve PO four times a day as needed for
bladder spasm.
18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
19. Vivelle-Dot 0.0375 mg/24 hr Patch Semiweekly Sig: One (1)
Transdermal semiweekly.
20. zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for headache.
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
22. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for headache.
23. optics mini drops Sig: 1-2 drops once a day.
24. Metrogel 1 % Gel Sig: One (1) Topical twice a day.
25. Ethanol 70% Catheter DWELL (Tunneled Access Line) Sig: Two
(2) mL once a day: 2 mL DWELL DAILY
Not for IV use. To be instilled into central catheter port (both
ports) for local dwell. For 2 hour dwell following TPN. Aspirate
and follow with normal flushing.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. levothyroxine 50 mcg 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. methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
8. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
bladder spasm.
10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Maalox Advanced Oral
13. Vivelle-Dot 0.0375 mg/24 hr Patch Semiweekly Sig: One (1)
Transdermal 2XWEEK ().
14. Salagen 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
15. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
17. ethanol (ethyl alcohol) 98 % Solution Sig: Two (2) ML
Injection DAILY (Daily).
18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*0*
20. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Urosepsis, anemia, pulmonary infiltrates, hydronephrosis,
abdominal fluid collections
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance.
Discharge Instructions:
Dear Ms. [**Known lastname 13275**],
.
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for a severe infection of the
urinary tract, anemia, low blood pressure and shortness of
breath.
.
-For your urinary tract infection, you were given a course of IV
antibiotics and your infection resolved.
.
-For your low blood pressure, you were given IV fluids and
medications to help maintain your blood pressure initially. Your
low blood pressure was related to your urinary tract infection
and improved as this issue improved. After you returned to your
baseline blood pressure (high), we restarted your blood pressure
medication.
.
-For your anemia, you were transfused 1 unit of packed red blood
cells. You should follow up regarding this issue with your
primary care doctor as an outpatient.
.
-For your shortness of breath, you were given oral antibiotics,
supplementary oxygen and diuretics, and you improved. We think
that your shortness of breath may have been related to an
adverse reaction to a blood transfusion that you received. You
will follow up as outpatient at the pulmonary clinic (see
below).
.
-For your abdominal pain, we obtained a CT scan which initially
showed multiple fluid collections in your abdominal cavity.
These collections resolved spontaneously following placement of
a foley catheter, and so we suspect that they were related to
your bladder. We took you to interventional radiology to sample
fluid from one of these collections, and found no evidecne of
infection. You were also followed by urology, who recommended
keeping the foley in place until you have an appointment with
them in 2 weeks.
.
We made the following changes to your medications:
CHANGED Oxycodone 5mg 1-2 tablets by mouth every 6 hours to PO
Dilaudid 2mg 1-2 tablets every 4 hours as needed for pain.
.
STARTED Hyocyamine 0.125mg SL every 6 hours as needed for
bladder spasm
STARTED Clotrimazole 1 troc by mouth 4 times a day.
Followup Instructions:
Name: [**Last Name (LF) 6692**], [**Name8 (MD) 41356**] NP
Specialty: Urology
Address: [**Street Address(2) **], Ste#58 [**Location (un) 538**], [**Numeric Identifier 7023**]
Phone: [**Telephone/Fax (1) 16240**]
Appointment: Thursday [**4-11**] at 1:30PM
Radiology Department: WEDNESDAY [**2126-4-17**] at 11:45 AM
Building: [**Hospital6 29**] [**Location (un) 861**], [**Telephone/Fax (1) 327**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** An order has been placed for you to have a chest x-ray prior
to your Pulmonary appointments
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2126-4-17**] at 12:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2126-4-17**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2126-4-17**] at 1 PM
Please call your primary care physician when you leave rehab for
an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
Completed by:[**2126-3-27**]
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,980
| 102,602
|
42075
|
Discharge summary
|
report
|
Admission Date: [**2192-11-27**] Discharge Date: [**2192-12-10**]
Date of Birth: [**2117-3-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Intubation in ED; Extubated in MICU
ArcticSun Cooling
Coronary Catheterization
EP study
ICD placement
History of Present Illness:
75 year old female with past medical history of CAD MIx4 s/p 3v
CABG [**2174**], who was living at [**Hospital3 2558**] after two staged
spinal surgery [**2192-11-12**] complicated by NSTEMI.
.
She had an stress dobutamine echo prior to the surgery for risk
stratification. Per report, it was normal with no clear evidence
of ischemia. She remained intubated after the second surgery out
of concern for aggressive IVF resuscitation, with peak lactate
of 3.5 intra-operatively. She experienced an NSTEMI on [**11-14**]
with TWI in lateral leads and Troponins up to 2.667. Echo at the
time showed EF 50-55%, with inferolateral wall akinesis, basal
to mid-inferior wall is akinetic. Mid anterolateral hypokinesis
and the discrete mid-laterall wall aneurysm noted on dobutamine
stress images from [**2192-11-7**] was not visualized. Cardiology
consult was obtained and it was decided to medically manage her
NSTEMI.
.
According to the report, she was found pulseless and
unresponsive [**2192-11-27**], code blue was called and patient received
6 cycyles of CPR, AED was applied and shock advised after which
SROC occurred. She was transferred to [**Hospital1 18**] for further
managment and had agonal breathing in the ED, she was intubated
and admitted to the MICU. She was found to have multiple
pulmonary emobli and a possible ileopsoas abscess. She was
treated with the post arrest cooling protocol. She was started
on heparin bridge to warfarin, and was briefly treated with
antibiotics for supposed ileopsoas abscess however suspicion for
abscess was low and abx were discontinued. She had ECHO [**11-14**]
which showed EF of 50-55%%. Head CT was negative. [**2192-12-3**] She
was extubated and transferred to the general medical floor.
.
Cardiac enzymes were trended which never increased.
.
Following transfer to the general medical floor at [**Hospital1 18**], the
working diagnosis was that arrest was precipitated by PE versus
cardiac arrhythmia. She was seen by electorphysiology who
requested transfer to Inpatient cardiology service for an EP
study and possible ICD palcement.
.
Per Ms [**Known lastname 91304**] son, she was independent prior to her surgery.
She had limited motion due to her back pain but heart has not
been a problem for her since the CABG operation. Her son recalls
use of NTG only twice over the last 10 years. She did not have
any orthopnea, PND or lower extremity edema prior to her
surgery.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Advanced DJD lumbar spine, s/p L1-S1 ALIF, T11-ilium PSIF on
[**2192-11-3**]
[**11-13**] of this year
-CAD s/p MI x 4, s/p 3V CABG [**2174**]
-Hypertension
-Hyperlipidemia
-PVD s/p Right lower extermity angioplasty [**12-10**]
-Tobacco abuse
-Aortic stenosis
-Osteoporosis
-Cataract
Social History:
Lives in nursing home in [**Location (un) **]. Smokes 10 cigarettes per day.
Drinks very rarely with no drug use. Per family, she is fairly
independent and does not drive. Husband is no longer alive. Son
is an ER physician in [**Name9 (PRE) 531**].
Family History:
Colon cancer in sister, DM in mother
Physical Exam:
Admission physical exam in ICU:
VS: 37.2, HR 71 (regular), BP 118/60, RR 22, SpO2 99% on 70%
face tent
Gen: Elderly woman in NAD but appears chronically ill in ICU
bed. Opens eyes and responds to voice, but falls asleep easily
during conversation.
HEENT: Conjunctivae injected but not icteric. MMM, OP clear.
Face symmetric. Neck supple without JVD.
CV: s1-s2 normal, regular rate and rhythm, + holosystolic murmur
RLSB and apex. no rubs or gallops appreciated.
Lungs: Diffuse rhonchi. No wheeze.
Abd: Soft, NT/ND, +NABS. No HSM. No guarding.
Extrem: Trace edema bilateral lower extremities
Neuro: Normal tone, somewhat responsive as above. Full neuro
exam limited by lethargy
.
Discharge physical exam:
VS T 98, BP 138/61, HR 60s, RR 15, O2 Sat 96% RA
GENERAL: in NAD. Oriented x3. Mood, affect appropriate. sitting
at bed side comfortably
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm above sternal angle at 45 degrees
CARDIAC: RR, normal S1, S2. No rubs or gallops. 3/6 systolic
murmur best heard at right 2nd intercostal space, radiating to
carotids, but heard all over the precordium. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c. No femoral bruits. +1 pitting edema up to
tibial tuberosity on right side, with 0-+1 pitting edema up to
mid-shin on left side.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
CBC:
[**2192-11-27**] 12:43PM BLOOD WBC-13.8* RBC-3.43* Hgb-10.5* Hct-31.9*
MCV-93 MCH-30.8 MCHC-33.1 RDW-15.9* Plt Ct-382
[**2192-12-10**] 06:45AM BLOOD WBC-5.9 RBC-3.04* Hgb-9.6* Hct-28.9*
MCV-95 MCH-31.5 MCHC-33.1 RDW-17.5* Plt Ct-180
.
Coagulation profile:
[**2192-12-10**] 06:45AM BLOOD PT-25.8* PTT-35.2* INR(PT)-2.5*
[**2192-12-9**] 05:59AM BLOOD PT-37.9* PTT-38.1* INR(PT)-3.8*
[**2192-11-27**] 12:43PM BLOOD PT-14.4* PTT-25.6 INR(PT)-1.2*
.
Blood chemistry:
[**2192-12-10**] 06:45AM BLOOD Glucose-96 UreaN-12 Creat-0.6 Na-141
K-3.7 Cl-106 HCO3-26 AnGap-13
[**2192-11-27**] 12:43PM BLOOD Glucose-119* UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-104 HCO3-24 AnGap-13
[**2192-11-27**] 12:43PM BLOOD ALT-74* AST-67* CK(CPK)-174 AlkPhos-133*
TotBili-1.1
[**2192-11-28**] 01:22AM BLOOD ALT-52* AST-45* LD(LDH)-486* CK(CPK)-196
AlkPhos-114* TotBili-0.8
[**2192-12-10**] 06:45AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1
[**2192-11-27**] 12:43PM BLOOD Albumin-3.0* Calcium-8.1* Phos-4.1 Mg-2.0
.
Cardiac markers:
[**2192-11-28**] 01:22AM BLOOD CK-MB-5 cTropnT-0.03*
[**2192-11-27**] 06:46PM BLOOD CK-MB-4 cTropnT-0.04*
[**2192-11-27**] 12:43PM BLOOD cTropnT-0.03*
.
Others:
[**2192-11-27**] 01:49PM BLOOD Lactate-1.6
[**2192-11-29**] 04:15AM BLOOD Lactate-1.4
[**2192-12-9**] 05:59AM BLOOD VitB12-289 Folate-5.4
[**2192-11-27**] 12:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-
NEG Tricycl-NEG
.
IMAGING:
[**2192-11-27**]
ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is an inferobasal and posterobasal left
ventricular aneurysm. Overall left ventricular systolic function
is moderately depressed (LVEF= 35 %) secondary to severe
hypokinesis/akinesis of the inferior septum, inferior free wall,
and posterior wall. The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. with depressed
free wall contractility. The aortic root is mildly dilated at
the sinus level. The ascending aorta is mildly dilated. 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. The mitral valve leaflets are mildly
thickened. There is mild bileaflet mitral valve prolapse. Mild
to moderate ([**2-5**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. At least moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2192-11-27**]
CT HEAD without contrast
FINDINGS: There is no intracranial hemorrhage, masses, edema, or
shift in
normally midline structures. There is preservation of the
white-[**Doctor Last Name 352**] matter differentiation with no evidence of acute
large vessel territorial infarct. There is mild mucosal
thickening of the ethmoidal air cells and a small air-fluid
level in the left frontal sinus. Otherwise, the paranasal and
mastoid airspaces are clear. Osseous structures and soft tissues
are
unremarkable. The cavernous carotids are heavily calcified
bilaterally while the vertebral arteries are calcified
moderately. Osseous structures and soft tissues are
unremarkable.
IMPRESSION: No acute intracranial process.
.
[**2192-11-27**]
CT Chest with and without contrast, CT abd-pelvis with contrast
IMPRESSION:
1. Large retroperitoneal abscess which involves the right
iliopsoas muscle
with extension through the abdominal wall with corresponding
soft tissue
edema.
2. Multiple pulmonary embolisms seen in the left upper lobe,
left lower lobe and right lower lobe pulmonary branches. No sign
of right heart strain.
3. Multiple bilateral anterior rib fractures (right #[**2-9**], left
#[**3-10**]), likely secondary to CPR.
4. Bilateral dependent atelectases with adjacent small pleural
effusions.
5. Endotracheal tube is seen coursing through the trachea into
the right
mainstem bronchus. Staff was notified.
6. Left adnexal mass seen, which is not age concordant and
requires
outpatient ultrasound follow-up in order to exclude malignancy.
7. Marked spinal malalignment of indeterminate acuity.
Comparison with
immediate postop imaging would be helpful if made available.
.
[**2192-12-3**]
ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal inferior and inferolateral akinesis to
dyskinesis (aneurysmal). The remaining segments are normal.. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal with normal free wall contractility. The ascending aorta
is mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-11-27**],
the LV and RV appear more vigorous (may be due to increased HR).
.
[**2192-12-4**]
Coronary Catheterization
COMMENTS:
1. Coronary angiography of this right dominant sytem revealed
severe
native two vessel coronary artery diseae. The LMCA had no
significant
stenosis. The LAD had a 90% narrowing at its origin and diffuse
disease
distally up to 90% in narrowing after a high D1. The LCx system
had no
significant flow limiting disease. The RCA had a total
occlusion
proximally with filling through left to right collaterals,
mostly via
the LIMA.
2. Selective graft angiography revealed two stump occluded
venous
grafts, one to the RCA and one likely to the D1 The LIMA to LAD
was
widely patent supplying the LAD and RCA through collaterals.
Based on
graft amd native anatomy and collateral distribution, the
moderate sized
d1 is comproomised without patent graft or collaterals.
FINAL DIAGNOSIS:
1. Severe native 2 vessel coronary artery disease.
2. Occluded SVG to RCA and diagonal (presumed target); Patent
LIMA to
LAD.
.
Lower Extremity venous US:
FINDINGS: There is normal flow, augmentation and compressibility
of the
common femoral vein, superficial femoral vein and popliteal
veins bilaterally. There is normal flow and compressibility of
the peroneal and posterior tibial veins bilaterally.
IMPRESSION: No evidence of deep vein thrombosis in either lower
extremity.
.
[**2192-12-8**]
CXR
IMPRESSION:
Status post median sternotomy for CABG with overall stable
cardiac and
mediastinal contours. Interval placement of a dual lead
pacemaker with its
leads terminating over the expected location of the right atrium
and right
ventricle, respectively. There is persistent blunting of the
left
costophrenic sulcus which may represent pleural thickening
and/or a small
pleural effusion. Linear opacities at the left base may reflect
post-inflammatory scarring or subsegmental atelectasis; an early
pneumonia is less likely. No evidence of pulmonary edema. No
pneumothorax. Spinal
fixation hardware overlies the thoracic and upper lumbar spine.
.
[**2192-12-6**]
Cardiac MRI: final report pending, this is prelim report
Impression:
1.Severely increased left ventricular cavity size with thinned
and akinetic basal to mid inferior and inferolateral walls,
consistent with a previous infarct. The LVEF was mildly
depressed at 45%.
2.The aforementioned akinetic segments were not visualized in
the LGE sequences due to technical issues. No CMR evidence of
prior myocardial scarring/infarction in the other visualized
segments.
3.Normal right ventricular cavity size and systolic function.
The RVEF was normal at 56%.
4.Aortic regurgitation (not quantified). Mild pulmonic and
tricuspid regurgitation.
5.The indexed diameters of the ascending and descending thoracic
aorta were both severely increased. The main pulmonary artery
diameter index was mildly increased.
6.Mild [**Hospital1 **]-atrial enlargement.
Brief Hospital Course:
Mrs [**Known lastname **] is a 75 year old female with CAD (MI x 4, CABG) and
aortic stenosis who presents status post cardiac arrest. Patient
was resuscitated in the field and received one shock from AED
she was transferred to [**Hospital1 18**] where she was treated with the post
arrest cooling protocol with full neurologic recovery. She was
found to have bilateral pulmonary emboli on CTA chest without
evidence of right heart strain. Coronary catheterization showed
non-intervenable coronary artery disease, with the ability to
induce polymorphic Ventricular tachycardia. ICD was placed and
discharged back to rehabilitation in stable condition.
.
#Cardiac Arrest:
In the MICU, patient was managed with continuation of intubation
during cooling protocol. Cardiac enzymes were followed which
never increased. Echo revealed an ejection fraction of 35%,
which may be consistent with her cooling. Because of uncertainty
over whether pulmonary emboli fully accounted for the arrest
cardiology was consulted for concern of an ischemic insult or
arrhythmia. EEG throughout cooling protocol demonstrated
findings consistent with sleeping and no evidence of seizure
activity or neurologic deficits. After cooling protocol, patient
was extubated successfully after one attempt. Patient's
neurologic status returned to baseline soon after extubation.
Antibiotics were stopped as final read on CT abdomen
demonstrated seroma. Of note, patient had QT prolongation on
EKG, and EP was consulted for evaluation as well as ICD
placement. Once she was awake, stable and sent to the floor, she
had a coronary catheterization which showed non-intervenable
coronary vessel disease (please see pertinent results section).
Electrophysiologic study revealed inducible non-sustained VT
only, both uniform and polymorphic. It is believed that
ischemia may have contributed to her arrest. She had an ICD
placed based on EP findings. Pulmonary emboli may also have
contributed to her arrest. This is being treated with warfarin
anticoagulation.
.
#Pulmonary Embolism: She reported no shortness of breath or
chest pain during her inpatient stay. As work up for her arrest,
she had CT chest which revealed bilateral segmental and
subsegmental pulmonary emboli. She was initially placed on
heparin with bridging to warfarin. She was discharged on
warfarin of 3 mg daily with INR of 2.5 on the day of discharge.
Given recent surgery with immobilization, this is likely a
provoked pulmonary embolism. She will need to continue warfarin
to maintain INR [**3-8**] until [**2192-5-28**] (6 months of therapeutic
anticoagulation).
.
#CAD: Given her extensive cardiac history, patient was continued
on atorvastatin and aspirin throughout her inpatient stay. Her
ACEi, beta blocker and Imdur were restarted after she was stable
in the floor post ICU course.
.
#Constipation: She was constipation in the first few days of her
stay. Milk of mag and bisacodyl supp PRN were provided to help
her have good bowel movements.
.
#Back Pain: Her pain regimen at rehabilitation was continued
while in the hospital. In the last few days, oxycontin was
discontinued, but gabapentin and Tylenol were continued.
Percocet [**2-5**] tab every 4 hours was added to be used as needed.
.
.
.
Transitional issues:
1. please follow INR three times a week and adjust warfarin
accordingly She will need 6 months of anticoagulation for
pulmonary embolism, final day [**2192-5-28**].
2. please follow up cardiac MRI final report
Medications on Admission:
Medications on transfer:
Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation
Acetaminophen 650 mg PO/NG Q6H
Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
Bisacodyl 10 mg PO DAILY:PRN constipation
Aspirin 81 mg PO/NG DAILY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Docusate Sodium 100 mg PO BID
Gabapentin 300 mg PO/NG [**Hospital1 **] at 2pm and at 9p
Gabapentin 200 mg PO/NG DAILY at 9am
Senna 1 TAB PO/NG DAILY constipation
Polyethylene Glycol 17 g PO/NG DAILY
traZODONE 50 mg PO/NG HS:PRN insomnia
Heparin IV Sliding Scale
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO every other day.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: as directed by INR 3 times a week.
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cardiac arrest
Pulmonary embolism
Back Pain
Recent myocardial infarction
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 **],
.
It was a great pleasure taking care of you as your doctor.
.
As you know you were hospitalized for a cardiac arrest that you
experienced while at your living facility. You were
resuscitated, intubated and stabilized, and placed on
anticoagulation in lieu of finding pulmonary embolisms on
imaging.
.
During your stay, you had heart vessel catheterization which
showed narrowness in some vessels that were not intervenable.
You were evaluated by heart electricity doctors
(electrophysiologist) and they found that your heart has the
potential to develop abnormal life-threatening rhythm.
Therefore, a shocking device is placed which will shock when
such rhythms are detected by the device.
.
On discharge, you were in stable condition, alert, and oriented.
.
We made the following changes in your medication list:
-please STOP atenolol
-please STOP oxycontin
-please START aspirin 81 mg daily
-please START metoprolol 25 mg twice daily
-please START coumadin 3 mg daily. This is a blood thinner for
the clots in your lungs. The coumadin level (INR) will be
checked three times a week and according to it the doses might
be adjusted.
-please CONTINUE percocet. It contains acetamenophen. Please
make sure if you take extra acetamenophen, the total per day
does not exceed 4 grams.
-please TAKE milk of magnesia for constipation AS NEEDED for
constipation.
.
Please continue the rest of your medications the way you were
taking them at home prior to admission.
.
Please follow your appointments as illustrated below.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2192-12-13**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2193-1-17**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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78,215
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31581
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Discharge summary
|
report
|
Admission Date: [**2119-10-5**] Discharge Date: [**2119-10-27**]
Date of Birth: [**2050-7-13**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Allopurinol / Vancomycin / Ciprofloxacin
/ Augmentin / Azithromycin / Linezolid / Cefepime / Iodine
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Skin biopsy
History of Present Illness:
69M with AML s/p clofarabine with prolonged remission then
recurrence, now on decitabine s/p completion of cycle 9 on
[**2119-9-4**], COPD/emphysema, presenting to [**Hospital 3242**] clinic on [**2119-10-5**]
with worsening shortness of breath. He was noted to have a
low-grade temp to 99.9F and SaO2 of 92-95% on room air, up to
96% on 2L NC. He had a CXR done, which demonstrated a small LLL
PNA. His wbc was 1.2 with 29%N for an ANC of around 400, which
is consistent with his recent baseline. He has multiple
antibiotic allergies and intolerances, including:
Sulfa: Unknown
Vancomycin: Rash (morbilliform, not red man)
Cipro: Rash
Augmentin: Rash
Azithromycin: Rash
Linezolid: Subjective SOB
Several of these, however, were questionable, due to concurrent
use of other medications. He was seen by [**First Name8 (NamePattern2) 2602**] [**Doctor Last Name 2603**] on [**2119-10-5**]
in anticipation of this current admission, who noted that the
PCN/Augmentin allergy was based on an uncertain history, but
recommendation had been made for desensitization to any
pencillins or carbapenems. He noted, however, that the
cross-reactivity for 3rd or 4th generation cephalosporins is
<4%, and that a trial of such could be tried at full dose. He
therefore received cefepime 2gm in [**Hospital 3242**] clinic prior to
admission, with no adverse effects. Admitted for further
evaluation. After admission, spiked to 103.2F.
He denies any preceding sore throat, nasal/sinus congestion, and
admits only a mild non-productive cough. He denies any new rash,
pruritis, or oropharyngeal swelling since starting cefepime. He
does endorse significant nausea/vomiting over the last day, with
no abdominal pain or diarrhea.
Past Medical History:
PMH: Oncologic history:
Patient initially presented in summer [**2116**] with easy bruising
and dropping cell counts (pancytopenic) as well as some
SOB/fatigue. BMBx was consistent by report with myelodysplastic
syndrome with presence of a 15-20% immature cells consistent
with blasts; Dr. [**Last Name (STitle) **] felt the pathology was consistent with
MDS with excess blasts in transformation, suggesting
acceleration of the disease towards acute leukemia.
.
Pt underwent induction and reinduction with single [**Doctor Last Name 360**]
clofarabine per protocol 07-013, last treated in 09/[**2116**]. Since
that time, he showed signs of dysplasia was dropping cell lines
and bone marrow biopsy done in [**9-/2118**] showed blasts occurring
in small clusters occupying an estimated 20% of the marrow
cellularity. Cytogenetics showed deletion of the long arm of
chromosome 20 and he was treated on [**2118-9-19**] with his first
cycle of decitabine. C2 decitabine started [**2118-11-1**]. He has
previously opted not to undergo allogeneic stem cell transplant
due to quality of life desires.
.
PAST MEDICAL HISTORY:
- COPD/emphysema
- GERD
- ? Angina (has been prescribed SL nitro for CP/neck pain that
occurs on exertion with SOB, but states the tabs do not help,
and reportedly has had normal stress MIBI)
- Degenerative joint disease/arthritis of the spine
.
PAST SURGICAL HISTORY:
- plan for port insertion next Tuesday
- Appendectomy as a child - age 8
- Submucous resection - age 12
- Left meniscus repair of the knee - age 37
- Right meniscus repair of the knee - age 64
- Hernia repair left side - age 65
Social History:
Personal: married 44 years; 4 children (2 sons, 2 daughters) -
lives with one son's family. Family involved in patient's care.
- Tobacco: smoked heavily [**3-8**] ppd x 40 years, quit [**2096**]
- Alcohol: significant past alcohol intake, quit [**2091**]
- Occupation: former veteran from [**Country 3992**], ? exposure to [**Doctor Last Name **]
[**Location (un) **]. Retired from food and beverage industry.
- Hobby: sports
Family History:
His mother is deceased at age [**Age over 90 **] from a bowel obstruction. His
father is deceased at age [**Age over 90 **] from prostate cancer. He has no
siblings.
Physical Exam:
T: 100.2F, BP: 114/80, HR: 92, RR: 20, SaO2: 96% 3L NC
Gen: Lying in bed, shedding skin, in NAD
HEENT: Sclerae anicteric, oropharynx dry
Neck: Supple
CV: RRR, S1/S2, no m/r/g
Chest: CTAB
Abd: Soft, NT/ND, +BS
Skin: Exfoliative scaling on the forehead, cheeks, neck with
minimal
residual erythema. No mucose membrane lesions. Conjunctival
injected. Gluteal fold, biopsy site c/d/i. 1+ edema in both LE,
with erythema and RBC extravasation.
Neuro: A&Ox3
Pertinent Results:
1. Labs on admission:
[**2119-10-5**] 08:35AM BLOOD WBC-1.2* RBC-3.31* Hgb-10.7* Hct-32.0*
MCV-97 MCH-32.3* MCHC-33.4 RDW-19.1* Plt Ct-153#
[**2119-10-5**] 08:35AM BLOOD Neuts-29* Bands-0 Lymphs-67* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-2* NRBC-1*
[**2119-10-7**] 04:15AM BLOOD PT-15.0* INR(PT)-1.3*
[**2119-10-6**] 06:01AM BLOOD Gran Ct-690*
[**2119-10-5**] 08:35AM BLOOD UreaN-13 Creat-0.9 Na-136 K-4.6 Cl-103
HCO3-26 AnGap-12
[**2119-10-5**] 08:35AM BLOOD ALT-22 AST-19 LD(LDH)-164 AlkPhos-60
TotBili-0.4
[**2119-10-5**] 08:35AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
.
2. Labs on discharge:
[**2119-10-27**] 12:15AM BLOOD WBC-1.8* RBC-3.14* Hgb-9.7* Hct-30.2*
MCV-96 MCH-30.9 MCHC-32.1 RDW-18.4* Plt Ct-125*
[**2119-10-27**] 12:15AM BLOOD Neuts-21* Bands-0 Lymphs-76* Monos-1*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 NRBC-1*
[**2119-10-27**] 12:15AM BLOOD PT-13.0 INR(PT)-1.1
[**2119-10-27**] 12:15AM BLOOD Gran Ct-372*
[**2119-10-27**] 12:15AM BLOOD Glucose-111* UreaN-16 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-28 AnGap-11
[**2119-10-27**] 12:15AM BLOOD ALT-29 AST-22 LD(LDH)-197 AlkPhos-61
TotBili-0.4
[**2119-10-20**] 12:00AM BLOOD CK-MB-1 cTropnT-<0.01
[**2119-10-10**] 12:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**2119-10-9**] 06:16PM BLOOD CK-MB-2 cTropnT-<0.01
[**2119-10-9**] 10:04AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-2307*
[**2119-10-27**] 12:15AM BLOOD Albumin-3.0* Calcium-8.4 Phos-1.9* Mg-1.9
[**2119-10-7**] 05:30PM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-negative
[**2119-10-7**] 05:30PM BLOOD B-GLUCAN-negative
.
3. Imaging/diagnostics:
- CXR: Minor new left lower lobe opacity, minimal pneumonia is
possible,
unlikely to be bacterial.
- CT chest: Marked diffuse centrilobular emphysema, unchanged.
No focal airspace consolidation to suggest typical bacterial
pneumonia. Interval resolution of right upper lobe pneumonia.
Mild septal thickening compatible with mild fluid overload. Mild
bibasilar atelectasis, left worse than right. No pneumothorax,
pleural effusion, or lymphadenopathy.
- Video and barium swallow: Mild oropharyngeal dysphagia,
without evidence of penetration or gross aspiration or
significant residue. Normal esophageal contour without evidence
of stricture. Intraesophageal reflux visualized with nonspecific
impairment of gastric motility as described
above. No gastroesophageal reflux is visualized.
- Right buttock skin biospy: The histologic features are most
consistent with a bullous hypersensitivity reaction, such as to
a drug.
- Repeat CT chest: Generalized ground-glass attenuation
throughout both lungs and septal thickening particularly in the
dependent lower lobes, increased since [**2119-10-7**], likely pulmonary
edema, either cardiogenic or non-cardiogenic (including drug
reaction), less likelyatypical infection.
Severe centrilobular emphysema, stable since [**2116-10-9**].
- V/Q scan: Low likelihood ratio for acute pulmonary embolism.
- Bronchioaveolar lavage: Negative for malignant cells
- Lower extremity ultrasound: No evidence of DVT in the right
lower extremity.
Brief Hospital Course:
69M with AML, s/p completion of cycle 9 decitabine on [**2119-9-4**],
also with COPD, presenting with worsening dyspnea over the last
several days with non-productive cough, spiking fever in [**Hospital 3242**]
clinic, with CXR showing minor LLL infiltrate.
.
# Pulmonary opacity: On admission, patient had recent history of
neutropenia. Fever up to 99.9 in [**Hospital 3242**] clinic and allergy
consulted. Recommended starting Cefepime for empiric coverage
despite penicillin allergy. Patient received a total of 3 doses,
but had high fever (>102) and developed rash. Cefepime was
stopped, and patient underwent meropenenm desensitization in the
ICU. Desensitization was notable for breath episodes of
subjective throat tightness that resolved after treatment with
hydroxyzine, benadryl, and famotidine. Patient never devloped
respiratory compromise.
CT chest showed emphysematous changes, fluid overload, but no
obvious signs of pneumonia. Thus, antibiotics were stopped.
Fever returned and patient started on aztreonam and daptomycin.
Bronchoscopy was done, and BAL cultures were all negative.
Antibiotics stopped. Patient remained afebrile for the remainder
of the hospitalization.
.
# Drug rash: Patient developed an non-pruritis, macular,
blanching, whole-body rash after receiving Cefepime. Allergy was
consulted and given need for empiric coverage in the setting of
possible pulmonary infection and neutropenia, decision was made
to de-sensitize patient to meropenem. Patient was also started
on low dose prednisone. Both antibiotics and steroids were
stopped. Patient began to exfoliative, from the face downward.
Dermatology was consulted who obtained a biopsy, the result of
which is consistent with a drug-induced hypersensitivity
reaction. Patient was treated symptomatically for pain and
discomfort. Two days prior to discharge (off antibiotics),
patient was noted to develop another morbiliform rash, which was
consistent with drug-rash per dermatology. They did not
recommend any interventions.
.
# Shortness of breath: Patient has COPD at baseline and is
overall deconditioned. He was able to maintain oxygen saturday
of >96% on 3L NS. On room air, oxygen saturation is ~92%. CT
chest showed baseline emphysematous changes. Patient was kept on
home regimen of albuterol inhalor throughout the
hospitalization. He had two episodes of hypoxia (O2 sat 88% on 3
L NS) during coughing spells. Responsive to oxygen through
facemask. Started on IV methylprednisone and aggressive
diuresis. Patient improved and steroid tapered. On discharge,
patient had oxygen saturation >94% on room air sitting. On
ambulation, he can drop as low as 85% but returns with rest.
Patient was set up for home oxygen prior to discharge.
.
# Angina: Patient had history of exertional angina treated with
PRN sublinguial nitro in the past. During the hospitalization,
patient had one episode of chest pain with ST-depression on EKG.
Three sets of cardiac enzymes were negative. Cardiology was
consulted and recommended no catherization or medical
interventions given low platelet count. Recommends followup with
outpatient cardiologist.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 vial inhaled via nebulizaiton every 4 to 6
hours as needed for shortness of breath or wheezing
DOXYCYCLINE HYCLATE - 100mg PO bid (chronic)
ADVAIR DISKUS 250 mcg-50 mcg - 1 Disk(s) inhaled twice a day
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 103 mcg (90 mcg)-18
mcg/Actuation Aerosol - 1 (One) inhaled four times a day
LORAZEPAM - 0.5mg PO q6h as needed for nausea
METOPROLOL TARTRATE - 25mg PO twice a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually once a day as needed for chest pain, tightness
ONDANSETRON HCL - 8mg PO every eight (8) hours as needed for
nausea
PROCHLORPERAZINE MALEATE - 10mg PO every eight (8) hours as
needed for nausea
LANSOPRAZOLE 15mg PO once a day
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea or anxiety.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
5. Ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
7. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: One
(1) Inhalation four times a day.
10. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*0*
11. Home oxygen
2L O2/min continuous for portability and pulse dose system
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary:
Pneumonia
Allergic pneumonitis
Drug-induced rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 22130**], you were admitted to the [**Hospital1 **]
Hospital because you had fever and increasing shortness of
breath. We did a chest x-ray and a CT scan to look at your
lungs. It looked like you might have had a pneumonia. Given that
you were neutropenic recently, we decided to treat you for
possible infection. We asked the allergy specialist to help us
choose an antibiotic for you. You were started on Cefepime, and
also got de-sensitized to meropenem. You developed a body rash
and high fevers, which we thought might have been related to the
antibiotcs. We asked the dermatologist to look at your rash and
they did a biopsy, the result was consistent with a drug rash.
We took you off the antibiotics and you felt better. You had
chest pain one night, with changes in your EKG. We checked lab
tests and you did not have signs of heart damage. We also asked
the cardiologist to come see you and they did not recommend any
interventions. You had a video swallow and barium swallow done.
The results showed that you were not aspirating and did not have
gastric reflux. You started having fevers again, so we placed
you back on antibiotics. We also asked the lung doctors to [**Name5 (PTitle) 788**]
[**Name5 (PTitle) **] and they did a bronchoscopy, which did not show any
abnormalities. The culture from the fluid they collected did not
show any growth. During one episode of coughing spell your
oxygen level dropped. We gave you steroid and also lasix to
remove fluid from your lungs. You got better. We tapered the
steroids and stopped the antibiotics. You improved and at the
time of discharge you were able to ambulate on your own.
.
We added Cefepime to your allergy list. We made the following
changes to your medications:
STARTED:
- acyclovir 400 mg by mouth three times a day
- voriconazole 200 mg by mouth every 12 hours
.
STOPPED:
- Doxycyclin 100 mg by mouth twice a day
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2119-10-31**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2119-10-31**] 11:30
Please make an appointment and follow up with your outpatient
cardiologist in the next month.
Completed by:[**2119-10-27**]
|
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icd9cm
|
[
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[]
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[
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icd9pcs
|
[
[
[]
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13053, 13109
|
7967, 11095
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404, 418
|
13211, 13211
|
4910, 4918
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|
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|
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|
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|
3812, 4240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,178
| 153,436
|
12098
|
Discharge summary
|
report
|
Admission Date: [**2141-6-28**] Discharge Date: [**2141-7-1**]
Date of Birth: [**2085-9-15**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Angina
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37932**] is a 55-year-old
gentleman with a history of coronary artery bypass graft in
[**2134**]. Grafts at this time included left internal mammary
artery to diagonal, saphenous vein graft to obtuse marginal
I, saphenous vein graft to posterior descending artery.
Since then, he has required several interventions and
stenting. Despite these interventions, Mr. [**Known lastname 37932**] has
continued to experience exertional angina and chest pain at
rest. Repeat cardiac catheterization on [**2141-6-22**] revealed
left anterior descending with proximal occlusion and filling
retrogradely through the left internal mammary artery to
diagonal. The left circumflex had a 90% stenosis, ostial
sub-branch obtuse marginal I with moderate disease proximally
in both sub-branches. Right coronary artery is known
occluded. Right saphenous vein graft to right posterior
descending artery revealed minor disease in previously-placed
stents, with 50 to 60% re-stenosis in-stent at the distal
anastomosis. Left internal mammary artery to diagonal
revealed 50 to 60% ostial in-stent re-stenosis and 90%
in-stent re-stenosis just before distal anastomosis. Given
these findings, Mr. [**Known lastname 37932**] [**Last Name (Titles) **] was evaluated for
repeat cardiac surgery.
PAST MEDICAL HISTORY:
1. Vertigo
2. Pericarditis in [**2124**]
3. Coronary artery disease/IMI status post coronary artery
bypass graft
4. Chronic rhinitis
5. Tonsillectomy
6. Oral surgery
7. Head injury in [**2122**] with brain contusion
ALLERGIES: Sulfa and amoxicillin/penicillin
MEDICATIONS: Lopressor 100 mg twice a day, Accupril 10 mg
once daily, aspirin 325 mg once daily, Lipitor 40 mg once
daily, Zoloft 50 mg twice a day, Prilosec 40 mg once daily,
pentoxifylline 400 mg twice a day, Imdur 60 mg twice a day,
folic acid 1 mg once daily, Plavix 75 mg once daily, ferrous
sulfate twice a day.
PHYSICAL EXAMINATION: Vital signs: Pulse 69, blood pressure
121/69, oxygen saturation 98% on room air, respirations 18.
Mr. [**Known lastname 37932**] is a pleasant, anxious gentleman, in no
apparent distress. The head is normocephalic, atraumatic.
The neck is supple, with no jugular venous distention or
bruits. The lungs are clear to auscultation bilaterally.
The heart is regular rate and rhythm. The abdomen is soft,
nontender, nondistended, with normal active bowel sounds.
The extremities are without edema.
HOSPITAL COURSE: Mr. [**Known lastname 37932**] was taken to the operating
room on [**2141-6-28**] for re-do coronary artery bypass graft x 4.
Grafts included radial artery to D1 and [**Doctor First Name **], saphenous vein
graft to obtuse marginal II, saphenous vein graft to
posterior descending artery. The procedure was performed
without complication, and Mr. [**Known lastname 37932**] was [**Known lastname **]
transferred to the CSRU. In the unit, he was extubated,
weaned off drips, and hemodynamically stabilized. His stay
in the Unit was unremarkable, and he was [**Known lastname **]
transferred to the floor on postoperative day one.
Mr. [**Known lastname 37932**] recovered quickly on the floor. His chest
tubes were removed on postoperative day two, and his pacing
wires were removed on postoperative day three. He was
tolerating an oral diet, and his pain was controlled with
oral medications. He was ambulating well without assistance.
On [**2141-7-1**], Mr. [**Known lastname 37932**] was felt stable for discharge home.
Examination at discharge included vital signs of a
temperature of 98.9, pulse 92, blood pressure 109/40,
respirations 18, oxygen saturation 95% on 2 liters. The
heart is regular rate and rhythm. The lungs are mildly
coarse at the bilateral bases. The abdomen is soft,
nontender, nondistended, with normal active bowel sounds.
The extremities are without cyanosis, clubbing or edema.
DISCHARGE MEDICATIONS: Metoprolol 50 mg twice a day,
docusate 100 mg twice a day, aspirin 325 mg once daily,
Plavix 75 mg once daily, Imdur 60 mg once daily, pantoprazole
40 mg once daily, Sertraline 50 mg once daily, Trental 400 mg
three times a day with meals, percocet one to two tablets
every four to six hours as needed for pain, ibuprofen 400 mg
every six hours as needed for pain, lasix 20 mg once daily
for seven days, potassium chloride 20 mEq once daily for
seven days.
FOLLOW UP: Mr. [**Known lastname 37932**] should follow up with Dr. [**Last Name (STitle) 37933**]
in three to four weeks, and Dr. [**Last Name (STitle) 1537**] in four weeks.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 37932**] is to be discharged home.
DISCHARGE DIAGNOSIS:
1. Status post re-do coronary artery bypass graft x 4
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2141-7-1**] 18:25
T: [**2141-7-2**] 00:40
JOB#: [**Job Number **]
|
[
"411.1",
"V45.82",
"414.01",
"412",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
4751, 4837
|
4093, 4551
|
4858, 5183
|
2652, 4069
|
4563, 4729
|
2135, 2633
|
165, 173
|
202, 1500
|
1522, 2112
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,951
| 128,686
|
19566
|
Discharge summary
|
report
|
Admission Date: [**2125-4-9**] Discharge Date: [**2125-4-26**]
Date of Birth: [**2056-3-7**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This is a 69-year-old gentleman
who has a history of having an aortic valve replacement in
[**2109**] who now presented to his primary care physician with
dyspnea on exertion and a positive exercise treadmill test.
The patient had an echocardiogram in [**2124-10-9**] which
showed an ejection fraction of 55%, left ventricular
hypertrophy, a well-seeded St. [**Male First Name (un) 923**] aortic valve, and severe
mitral stenosis.
The patient was referred to [**Hospital1 188**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Status post aortic valve replacement with a St. [**Male First Name (un) 923**]
aortic valve in [**2109**].
4. Status post hernia repair.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lescol 80 mg by mouth once per day.
2. Mavik 4 mg by mouth twice per day.
3. Furosemide 40 mg by mouth once per day.
4. IC-Klor 10 mEq by mouth every day.
5. Coumadin once per day.
REVIEW OF SYSTEMS: Significant for symptoms of claudication
after walking a short distance. The patient denies current
tobacco use.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to [**Hospital1 69**] on [**4-9**] and
underwent a cardiac catheterization. Catheterization showed
pulmonary artery pressures of 68/35, 50% left main lesion,
90% proximal left anterior descending artery lesion, and 80%
second obtuse marginal lesion.
On the morning on hospital day three, the patient developed a
moderate sized bleed from his right groin femoral cardiac
catheterization site. The patient required a long period of
pressure to stop the bleeding. This incident was complicated
by a vagal episode associated with hypotension and
bradycardia which resolved with atropine.
The patient underwent imaging of his carotids which showed a
60% to 69% right internal carotid artery stenosis and a 40%
to 59% left internal carotid artery stenosis. The right
vertebral artery was not visualized, and the left vertebral
artery had antegrade flow.
On the evening on hospital day four, the patient developed
another bleed from his right groin catheterization site.
Manual pressure was applied, and hemostasis was achieved.
The heparin infusion was discontinued at that time.
On [**4-13**], the patient was taken to the operating room with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for an off-pump coronary artery bypass
graft with left internal mammary artery to the left anterior
descending artery. The decision had been made prior to
surgery to have the patient evaluated by Cardiology for
potential mitral valvuloplasty as the patient was felt to be
a good candidate for this.
The patient was transferred to the Intensive Care Unit
postoperatively in stable condition. The patient was weaned
and extubated from mechanical ventilation on his first
postoperative day. He had good hemodynamics postoperatively.
On postoperative day one, the patient had an episode of
hypertension and shortness of breath. A chest x-ray was
obtained which showed congestive heart failure. The patient
was treated with intravenous Lasix which resulted in good
diuresis. The patient continued to have good hemodynamics
with an adequate cardiac output.
On postoperative day two, the patient's pulmonary catheter
was removed. The patient was started on Lopressor which he
tolerated well. The patient continued to receive Lasix for
diuresis.
On postoperative day three, the patient developed atrial
fibrillation which was treated with intravenous Lopressor,
and he subsequently converted into a sinus rhythm. The
patient's heparin drip was restarted for his mechanical
aortic valve, and the patient was transferred from the
Intensive Care Unit to the regular part of the hospital.
The patient was seen by Physical Therapy upon arriving to the
floor. At that time, he was able to ambulate 500 feet
without difficulty.
In the evening on postoperative day three, the patient again
developed atrial fibrillation. The patient was started on
amiodarone. The patient converted to a sinus rhythm, but the
patient continued to have episodes of intermittent atrial
fibrillation, decreasing frequency as the patient's beta
blocker was increased. The patient was continued on a
heparin drip.
On postoperative day six, after further evaluation by the
Interventional Cardiology team, it was determined by
evaluating the patient's echocardiogram that in addition to
the patient's mitral stenosis he also had an element of
mitral regurgitation, and that combined with other data it
was decided the patient was not a good candidate for a
balloon valvuloplasty. It was determined by the health care
team that the patient's mitral stenosis and mitral
regurgitation would be managed medically as he was also not
an optimal candidate for surgical mitral valve replacement.
Therefore, the patient was restarted on his Coumadin, and
plans were made to discharge to home as soon as his INR was
therapeutic.
Due to the significant number of episodes of atrial
fibrillation and atrial tachycardia, a Cardiology
consultation was obtained for management of the atrial
dysrhythmias. It was recommended the patient be on no
amiodarone and simply increasing his Lopressor which was done
with good resolution of the dysrhythmias. The patient
continued to receive Coumadin and remained in the hospital on
a heparin drip awaiting his INR to become therapeutic.
The patient was cleared by Physical Therapy. By
postoperative day thirteen, the patient's INR had reached 2,
and the patient was cleared for discharge to home.
CONDITION AT DISCHARGE: Temperature 98, his pulse was 68 (in
sinus rhythm), his blood pressure was 108/60, his respiratory
rate was 16, and oxygen saturation was 98% on room air.
Laboratory data revealed white blood cell count was 9.5, his
hematocrit was 31.4, and his platelet count was 504. Sodium
was 139, potassium was 4.6, chloride was 101, bicarbonate was
29, blood urea nitrogen was 33, creatinine was 1.2, and blood
glucose was 96. The patient's prothrombin time was 17.2 and
INR was 2. The patient was alert, awake, and oriented times
three. Heart regular in rate and rhythm with a sharp valve
click. No murmurs. Breath sounds were clear bilaterally.
No wheezes, rhonchi, or rales. The abdomen was soft,
nontender, and nondistended. Positive bowel sounds. The
patient was tolerating a regular diet and having normal bowel
movements. Sternal incision was clean and dry. There was no
erythema or drainage. The sternum was stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Status post aortic valve replacement in [**2125**].
[**Male First Name (un) 923**] mechanical valve.
4. Mitral stenosis/mitral regurgitation.
5. Postoperative atrial dysrhythmias.
MEDICATIONS ON DISCHARGE:
1. Zantac 150 mg by mouth twice per day.
2. Enteric-coated aspirin 81 mg by mouth every day.
3. Colace 100 mg by mouth twice per day.
4. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed.
5. Lopressor 75 mg by mouth three times per day.
6. Lasix 40 mg by mouth once per day.
7. Lescol 80 mg by mouth once per day.
8. Coumadin (daily dose to be determined by Dr. [**Last Name (STitle) 53073**]
office).
DISCHARGE DISPOSITION: Discharged to home in stable
condition.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 53073**] office by
phone on [**4-27**] after his INR is drawn by the visiting
nurse, and he was to see Dr. [**First Name (STitle) **] in the office in one to two
weeks.
2. The patient was to follow up with Dr. [**Last Name (STitle) 7047**] in one to
two weeks.
3. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2125-4-27**] 09:45
T: [**2125-4-27**] 09:46
JOB#: [**Job Number 53074**]
|
[
"416.0",
"458.29",
"428.0",
"997.1",
"427.31",
"998.11",
"V43.3",
"394.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"37.22",
"88.42",
"88.57",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7479, 7520
|
6733, 6995
|
7021, 7454
|
948, 1138
|
7553, 8318
|
1308, 5771
|
5786, 6712
|
1158, 1279
|
171, 682
|
704, 922
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,571
| 157,801
|
6731
|
Discharge summary
|
report
|
Admission Date: [**2176-7-28**] Discharge Date: [**2176-7-30**]
Date of Birth: [**2120-9-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Motrin / Dexamethasone / Vitamin C / Ibuprofen /
morphine
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
right hip/thigh pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year old female with pulmonary sarcoidosis, seizure disorder
on lacosamide and zonesamide, chronic back pain on PT, closed
treatment of her right proximal humerus fracture in [**Month (only) **]
[**2174**], right bimalleolar ankle fracture and psychotic disorder
NOS. She presents to ED with one day history of sudden onset
pain to the right thigh, extending from her knee to her hip. It
started yesterday when she bent over to get something under her
bed. When she stood up she started getting pain in her thigh.
Throughout the day, she was moving several small boxes in and
out the closet. Per husband, she has had several musculoskeletal
strain on her right side due to falling after seizures (she was
previously going to physical therapy for her R ankle and arm).
Thigh pain resolved without any medications and her husband
reports she slept well and woke up this morning without pain.
While they were shopping for shoe inserts and trying them, the
right thigh pain started again and thus ED presentation. It has
been constant and nothing has made it better. She does not
report fever or chills.
In the ED, initial vitals were 97.9 111 123/61 18 100%RA. LENIS
did not show DVT. Right hip films were normal without fracture
or dislocation. Labs notable for normal D-dimer, troponin and
Chem10. She had mild leukocytosis with WBC of 13.9 and CRP of
10.9. UA normal.
While in the ED, she had a generalized seizure witnessed by
nursing lasting 1-2 minutes. She was given 10 mg haldol, 3 mg of
ativan and 4 mg of versed and subsequently admitted to MICU for
further evaluation and management.
Past Medical History:
pulmonary sarcoidosis
seizure disorder on lacosamide and zonesamide
chronic back pain on PT
closed treatment of her right proximal humerus fracture in
[**2175-8-31**]
right bimalleolar ankle fracture
psychotic disorder NOS.
Benign thyroid nodule
Congenital decreased vision in left eye
tardive dyskinesia
Social History:
Married. Spends the day with her mother when her husband is
working - in the past he worked from 3pm to 11pm. She used to
work for an insurance company as an administrator, but stopped
due to sexual harassment. Met her current husband 8 years ago.
Tobacco - denies.
EtOH - denies.
Drug use - denies.
Family History:
No family history of epilepsy. Mother has [**Name (NI) 2481**] disease.
Physical Exam:
Admission Exam
General: Sleeping. Following commands.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused. No edema
Right hip: While she was sleeping, I was able to fully flex,
extend, internally and externally rotate her hips without her
waking up on wincing in pain.
Discharge Exam
Vitals: T:97.8 BP:89-108/44-71 P:94 R: 13-26 O2:95-98% RA
General: comfortable, NAD
HEENT: MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
BACK: no tenderness to palpation along spine and paraspinal
muscles
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused. No edema
R thigh: no erythema or swelling. Negative straight leg raise.
+pain in R groin region with internal/external rotation of the
hip. Hip with full range of motion. Sensation to soft touch
intact b/l. Strength 5/5 in lower extremities.
Pertinent Results:
[**2176-7-28**] 03:18PM BLOOD WBC-13.9*# RBC-4.72 Hgb-14.7 Hct-43.4
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.0 Plt Ct-215
[**2176-7-28**] 03:18PM BLOOD Neuts-83.1* Lymphs-12.5* Monos-3.5
Eos-0.6 Baso-0.4
[**2176-7-28**] 03:18PM BLOOD Glucose-133* UreaN-19 Creat-0.9 Na-140
K-4.4 Cl-105 HCO3-23 AnGap-16
[**2176-7-28**] 03:18PM BLOOD cTropnT-<0.01
[**2176-7-28**] 03:18PM BLOOD D-Dimer-369
[**2176-7-28**] 03:18PM BLOOD CRP-10.9*
[**2176-7-28**] 03:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2176-7-28**] 03:49PM BLOOD Lactate-2.8*
[**2176-7-30**] 07:00AM BLOOD WBC-6.3*# RBC-4.71 Hgb-14.6 Hct-43.8
MCV-93 MCH-30.9 MCHC-33.2 RDW-13.1 Plt Ct-149
[**2176-7-30**] 07:00AM BLOOD Glucose-89* UreaN-13 Creat-0.7 Na-138
[**2176-7-30**] 09:28AM BLOOD Lactate-2.6
[**2176-7-28**] LENIS: Exam was somewhat limited due to patient's
inability to cooperate. Within this limitation, Grayscale and
Doppler son[**Name (NI) **] was performed of the right common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins. Normal compressibility, flow and augmentation noted
throughout.
IMPRESSION: No right lower extremity deep vein thrombosis.
[**2176-7-28**] R Hip x-ray: AP view of the pelvis and AP and crosstable
lateral views of the right hip are compared to previous exam
from [**2174-10-14**]. There is no visualized fracture or acute
osseous abnormality. Femoroacetabular joint is anatomically
aligned. Pubic symphysis and SI joints are unremarkable.
IMPRESSION: No fracture.
[**2176-7-28**] CXR: No definite acute cardiopulmonary process.
Proximal right humeral fracture which is incompletely visualized
and may be old; however, clinical correlation is suggested and
dedicated exam can be performed if clinically indicated.
Brief Hospital Course:
55 year old female with pulmonary sarcoidosis, seizure disorder
on lacosamide and zonesamide, chronic back pain on PT, closed
treatment of her right proximal humerus fracture in [**Month (only) **]
[**2174**], right bimalleolar ankle fracture and psychotic disorder
NOS presents with one day history of right thigh pain
complicated by seizure in the ED.
# Seziure. History of seizure disorder on AED. It appears she
missed her AEDs in setting of the all the events of the day. s/p
ativan and versed. Could be secondary to underlying metabolic
or infectious etiology. Has normal electrolytes. CXR normal.
UA normal. Restarted home lacosamide 250 mg po BID and
zonesamide 100 mg TID
. Neurology saw the patient with no new recs and concluded
seizure likely part of her known seizure disorder. Patient had
no other seizure episodes in the hospital.
.
# Right thigh pain: Physical exam intact with no signs of
neurological cause, septic joint or trauma. Pain is diffuse
throught the thigh and not localized to one anatomical site or
structure. Negative straight leg raise, no neurological deficits
on physical exam. Studies for fracture and DVT negative. Likely
IT band or muskuloskeletal.
.
# Leukocytosis: Unsure of the etiology. Stress vs infectious.
UA normal. CXR normal. Blood cultures are pending. Low pre-test
probability for septic joint. Leukocytosis normalized prior to
discharge.
# Psychotic disorder NOS: One night during hospitalization
reported hearing voices. Continued home haldol 10 mg po qhs. EKG
normal QT interval. Made appointment to follow up with Dr. [**Last Name (STitle) **]
(cognitive neurology-psychiatry) on [**2176-10-22**].
# chronic overactive bladder: patient on enablex 15mg qd but did
not take during hospital stay.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Lacosamide 250 mg PO BID
2. Zonisamide 100 mg PO TID
3. Haloperidol 10 mg PO HS
4. Enablex *NF* (darifenacin) 15 mg Oral daily
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Fluticasone Propionate NASAL [**1-1**] SPRY NU DAILY
7. Hydrocortisone Acetate Suppository 1 SUPP PR [**Hospital1 **]:PRN rectal
pain
Discharge Medications:
1. Outpatient Physical Therapy
Evaluatation and treatment for right hip and right knee pain.
2. Enablex *NF* 15 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
3. Haloperidol 10 mg PO HS
4. Lacosamide 250 mg PO BID
5. Zonisamide 100 mg PO TID
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *8 HOUR PAIN RELIEVER 650 mg 1 tablet(s) by mouth every six
(6) hours Disp #*60 Capsule Refills:*0
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate NASAL [**1-1**] SPRY NU DAILY
9. Hydrocortisone Acetate Suppository 1 SUPP PR [**Hospital1 **]:PRN rectal
pain
Discharge Disposition:
Home
Discharge Diagnosis:
Right groin muscle strain
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a great pleasure to take care of you at [**Hospital1 18**]. You were
admitted to the hospital because of right groin and thigh pain.
You also had a seizure while you were at the hospital. The
neurology team saw you and determined that you can continue with
the same dosage of your seizure medications. Orthopedics also
saw you and reviewed your right leg x-rays. You do not have a
fracture or infection. Your right groin/leg pain is most likely
a muscle strain and should get better with physical therapy.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2176-8-6**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY/[**Hospital Ward Name **] 503
When: FRIDAY [**2176-8-16**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5285**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
We are working on a follow up appointment for your
hospitalization in Cognitive Neurology with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. It
is recommended you be followed up within 1 month of discharge.
The office will contact you at home with the appointment
informtation. If you have not heard within a few days please
call the office at [**Telephone/Fax (1) 1690**].
Completed by:[**2176-8-1**]
|
[
"596.51",
"517.8",
"345.41",
"E928.9",
"135",
"843.9",
"724.2",
"327.23",
"298.9",
"V49.87",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8816, 8822
|
5841, 7601
|
354, 360
|
8901, 8901
|
4041, 5818
|
9622, 10753
|
2660, 2733
|
8097, 8793
|
8843, 8880
|
7627, 8074
|
9052, 9599
|
2748, 4022
|
293, 316
|
388, 1995
|
8916, 9028
|
2017, 2324
|
2340, 2644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,541
| 169,826
|
47605
|
Discharge summary
|
report
|
Admission Date: [**2184-6-3**] Discharge Date: [**2184-6-8**]
Date of Birth: [**2127-3-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Splenic rupture
Major Surgical or Invasive Procedure:
[**2184-6-4**] Splenectomy
History of Present Illness:
57 yo male recently hospitalized following a motor vehicle crash
where he sustained a splenic laceration. He was hospitalized for
several days for close monitoring. He was discharged to home and
reportedly went to the dentist the following day when he began
to fell very lightheaded. He returned to the ED here at [**Hospital1 18**],
underwent abdominal CT scan which revealed a moderate amount of
fluid in the abdomen.
Past Medical History:
DM
HTN
Chronic low back pain
PTSD
Family History:
Noncontributory
Pertinent Results:
[**2184-6-3**] 09:21PM HCT-22.6*
[**2184-6-3**] 11:30AM GLUCOSE-316* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2184-6-3**] 11:30AM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2184-6-3**] 11:30AM WBC-6.1 RBC-3.11* HGB-10.1* HCT-29.0* MCV-93
MCH-32.5* MCHC-34.7 RDW-13.4
[**2184-6-3**] 11:30AM PLT COUNT-236
[**2184-6-3**] 11:30AM PT-10.6 PTT-19.2* INR(PT)-0.9
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: bleed- IV contrast ONLY
Field of view: 50 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with L abd pain s/p MVC 4 days ago with splenic
lac
REASON FOR THIS EXAMINATION:
bleed- IV contrast ONLY
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 57-year-old man with lower abdominal pain status
post MVC four days ago with apparently known splenic laceration.
No prior studies are available for comparison.
TECHNIQUE: MDCT axial images through the abdomen and pelvis
without and with IV contrast. 3' delayed images were also
obtained. Coronal and sagittal reformatted views were displayed.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The lung bases
are clear. The liver is diffusely hypodense consistent with
fatty infiltration. The gallbladder is normal. The spleen
demonstrates a 9.7 x 3.8 cm hypodense lesion in the lateral
aspect consistent with subcapsular hematoma. 3.7 x 2.8 cm
hypodense lesion in the anterior aspect of the spleen could
represent a cyst. There is an irregular linear hypodensity
transversing the inferior pole of the spleen consistent with
laceration. Moderate amount of hyperdense fluid within the
abdomen is seen. No evidence of active contrast extravasation.
The pancreas and adrenal glands are normal. There is no evidence
of free air. No oral contrast was given which limits the
evaluation for loops of bowel, however, no gross abnormality is
identified. The kidneys demonstrate symmetrical enhancement and
excretion without evidence of hydronephrosis. The right kidney
demonstrates a simple cyst in the upper pole measuring 3.1 x 3.3
cm. A tiny cortical density in the lower pole of the left kidney
is noted, too small to characterize.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, prostate, seminal
vesicles, and sigmoid are unremarkable. Free hyperdense fluid in
the pelvis is seen. No evidence of pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. No evidence of fracture.
IMPRESSION:
1. Findings are consistent with spleen laceration, spleen
hematoma and hemoperitoneum.
2. Fatty liver.
3. 3.3 x 3.1 cm right renal cyst.
Findings were discussed with Dr. [**Last Name (STitle) **] at the time of the
dictation.
NOTE ADDED IN ATTENDING REVIEW: As above, there is a large
splenic subcapsular hematoma, indenting virtually the entire
lateral margin of the spleen. There is a complex laceration, or
series of discrete lacerations, involving its lower pole,
reaching the surface of the spleen in several places, but not
involving its hilum or those vessels (Grade II). The arterial
phase images (3:39) raise the possibility of a small focus of
extravasation in the lower pole; the delayed phase demonstrates
no pooling of contrast at this site, or elsewhere. There is a
moderately large amount of complex fluid (up to 45HU) gathered
around the spleen and in the low pelvis, as well as over the
dome of the liver; no hepatic or other visceral injury is seen.
According to Dr. [**Last Name (STitle) 33863**] (Trauma [**Doctor First Name **]), the pelvic blood is new
from the OSH study (not scanned into PACS, and therefore, not
available or review). The well-defined non-enhancing 3.5cm
cystic (7 [**Doctor Last Name **], pre-contrast) structure, at the medial aspect of
the splenic dome (3:20), likely represents an acquired cyst,
related to more remote trauma.
Brief Hospital Course:
He was admitted to the Surgery Service and was taken to the
operating room for splenectomy. There were no intraoperative
complications. Postoperatively he has done well, his hematocrits
have been stable. His pain is being controlled with prn Dilaudid
and his home dose of Methadone 80 mg daily was resumed. He was
given the recommended immunizations because of his splenectomy
and was given instructions to follow up with Dr. [**Last Name (STitle) **] next
week.
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble
PO DAILY (Daily).
Disp:*60 Tablet, Soluble(s)* Refills:*0*
2. Clonazepam 1 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*qs Patch 24 hr(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Splenic rupture
Discharge Condition:
Stable
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chest
pain, dizziness, lightheadedness, weakness, abdominal pain and
any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] next week, call [**Telephone/Fax (1) 600**] for an
appointment.
Completed by:[**2184-6-8**]
|
[
"300.00",
"865.09",
"285.9",
"309.81",
"724.2",
"401.9",
"305.90",
"E819.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
6594, 6600
|
4791, 5255
|
327, 356
|
6660, 6669
|
914, 1437
|
6889, 7028
|
878, 895
|
5278, 6571
|
1474, 1542
|
6621, 6639
|
6693, 6866
|
272, 289
|
1571, 4768
|
384, 805
|
827, 862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,963
| 120,433
|
6750
|
Discharge summary
|
report
|
Admission Date: [**2194-3-31**] Discharge Date: [**2194-4-10**]
Date of Birth: [**2113-2-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Comtan / Shellfish Derived
Attending:[**Last Name (un) 11974**]
Chief Complaint:
ventricular tachycardia
Major Surgical or Invasive Procedure:
VT ablation
History of Present Illness:
Mr. [**Known lastname **] is an 81y/o gentleman with Parkinson's Disease, CAD s/p
CABG, sCHF (LVEF 25%), AFib on coumadin, and AICD who presented
with hypotension, was found to be in VT, and is being
transferred to the CCU due to recurrent VT after ablation today.
.
Of note, he was recently admitted [**Date range (1) 15037**] for pacer firing, and
was started on Amiodarone 400mg daily. Due to nausea and loose
stools, his dose was decreased to 200mg daily on [**3-7**].
.
Per [**Hospital1 1516**] admission note, on this admission he initially
presented from home yesterday ([**3-31**]) with a caregiver for low BP
(80/60) and elevated HR (140-145). He had felt fatigued for the
past 1.5 days, with baseline level of dyspnea. Somewhat
decreased PO intake. In the ED, initial vitals were T 96.8, HR
144, BP 82/61, RR 18, and SpO2 100% on RA. He triggered for
tachycardia and initial EKG was concerning for VT at 145 bpm.
He was given NS 500 ml. CXR showed moderate cardiomegaly and
pulmonary edema. Labs were significant for Hct 33.9 near recent
baseline, INR subtherapeutic at 1.6, Cr 1.2 near baseline,
largely unremarkable electrolytes, Digoxin 0.5, and Troponin
0.07 up from prior values 0.02-0.03. EP was consulted and he
was pace terminated with ramp. He was admitted to the [**Hospital1 1516**] EP
service for continued management.
.
In the EP lab, he was found to have various morphologies of VT
and underwent ablation. After the procedure, he was found to be
unarousable even off sedation, with right-gaze. Code Stroke was
called and he underwent CTA head/CT brain which did not suggest
acute process.
.
He had 4 episodes of VT after his ablation:
1) In CT scanner. ATP did not pace him out-->externally
defibrillated.
2) Outside CC3 elevator. Received Amio 150 bolus.-->externally
defibrillated again.
[No bed was available in the CCU so he was taken to EP lab
holding area in the meantime.]
3) EP lab holding area. Lidocaine 100 bolus given.
-->ATP-terminated.
4) EP lab holding area. Lidocaine drip started.-->defibrillated
with his device.
.
On arrival to the CCU, patient is intubated, sedated. Is on a
Lidocaine drip; had been on low-dose Phenylephrine while in the
EP lab holding area but this was discontinued.
In ICU, pt was extubated on [**2194-4-2**] without complications. He
weaned off of lidocaine and has remained out of vtach. Since
extubation, pt has been experiencing some hypokinesia, and
confusion, likely secondary to parkinsons. Neuro is following
and recommended continuing with home parkinsons meds.
Pt was also on heparin drip. restarted coumadin on [**2194-4-2**] and
INR is now 3.2. Pt was also diuresed with IV lasix in ICU and
was net negative 1L during stay there. This AM, his cr bumped
from 1.1 to 1.8, likely from overdiuresis. Pt also has bicarb
of 17 this am with gap of 20.
On transfer, pt's vitals are stable 98.3, 80, 148/72, 18, 97%
2L. Pt is oriented, but hypokinetic and hypophonic.
Past Medical History:
1. CARDIAC RISK FACTORS:
# Dyslipidemia
# Hypertension
2. CARDIAC HISTORY:
# CAD -- MI in [**2163**]
# CABG ([**2175**]) -- (LIMA-LAD, SVG-Diag, SVG-OM1, SVG-OM2,
SVG-RPDA)
# Cath ([**2184-9-28**])
-- 1. Native 3 vessel coronary artery disease.
-- 2. Severely depressed ventricular function.
-- 3. Patent vein grafts to the D1, OM1, OM2.
-- 4. Patent LIMA to LAD.
-- 5. Focal stenosis of SVG graft to R-PDA.
-- 6. Successful stenting of the SVG to PDA.
# AICD: Implantation in [**9-/2184**] with generator change in [**2189**].
# Chronic atrial fibrillation -- on Coumadin
# Cardiomyopathy / Systolic CHF -- LVEF 25%
# Sustained and nonsustained VT History
# Dilated aortic root -- moderate AR and MR
-- aortic sinus 4.0 cm by TTE in [**2190**]
3. OTHER PAST MEDICAL HISTORY:
# Parkinson's disease
# Left femoral neck fracture ([**1-/2191**])
-- s/p hemiarthroplasty c/b MRSA infx post-operatively
-- s/p multiple washouts with retention of prosthetic joint
material
-- suppressive abx since [**2190**]
# C diff History
# Gonorrhea History
Social History:
# Home: Lives alone, has 24H HHA, uses wheelchair.
# Work: Former stockbroker
# Tobacco: None currently, smoked cigars 1-2 per day for 10
years.
# Alcohol: None currently, 2 drinks per day for 10 years.
# Illicit: None
Family History:
All parents and siblings are deceased, many due to cancer and
heart disease. Father had MI. Brother with cardiac problem. [**Name (NI) 21206**]
was relatively healthy.
Physical Exam:
Admission
VS: T= 97.9 BP= 139/92 HR= 63 RR=20 O2 sat= 100 2L
GENERAL: cachectic man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to ear
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. systolic murmur [**1-28**] best heard over
RUSB. 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, slightly distended. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No pulses 1+, feet are cold to touch. No femoral
bruits.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Physical Exam on Admission to CCU:
VS: BP=120/67 HR=80 RR=16 O2 sat=100%
FiO2 100%, PEEP 5, RR 18, TV 500
GENERAL: elderly gentleman, intubated and sedated
HEENT: NCAT. Sclera anicteric. VOR intact. Pupils 3mm and
reactive to light bilaterally.
NECK: Supple, no JVD.
CARDIAC: S1 and S2, systolic murmur [**1-28**] best heard over RUSB.
LUNGS: CTA throughout all fields anteriorly.
ABDOMEN: (+)bowel sounds; no masses; nontender.
EXTREMITIES: No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
1+ DP and PT pulses bbilaterally.
Physical Exam on Discharge:
vitals: 97.6, 106/68 60 20 100% RA
wt = 85.4 kg
HEENT: PEERLA, OP clear
Neck no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. systolic murmur [**1-28**] best heard over
RUSB, but can be heard throughout precordium. 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, slightly distended. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: peripheral pulses 1+, feet are cold to touch. No
femoral bruits.
NEURO: CN II-XII intact. no cogwheel rig. AOx3, some
hyperkinesis
Pertinent Results:
Labs on Admission:
[**2194-3-31**] 03:40PM WBC-5.6 RBC-3.81* HGB-10.0* HCT-33.9* MCV-89
MCH-26.3* MCHC-29.6* RDW-17.6*
[**2194-3-31**] 03:40PM NEUTS-84.3* LYMPHS-10.8* MONOS-3.7 EOS-0.9
BASOS-0.4
[**2194-3-31**] 03:40PM PT-16.7* PTT-36.8* INR(PT)-1.6*
[**2194-3-31**] 03:40PM DIGOXIN-0.5*
[**2194-3-31**] 03:40PM CALCIUM-9.3 PHOSPHATE-4.4 MAGNESIUM-2.2
[**2194-3-31**] 03:40PM GLUCOSE-114* UREA N-33* CREAT-1.2 SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2194-3-31**] 04:12PM LACTATE-2.3*
Relevant Imaging:
TTE [**2191-7-22**]:
Severely impaired left ventricular systolic function (25-30%)
with akinesis of the inferior and inferolateral walls. Mild to
moderate aortic regurgitation with mild aortic stenosis. Mild
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension. No obvious evidence of
endocarditis. If clinically indicated, a transesophageal echo
may better characterize valves and implantable cardiac
defibrillator leads for possible vegetations. Compared with the
prior study (images reviewed) of [**2190-6-9**], mild aortic stenosis
is now present. The severity of aortic regurgitation and mitral
regurgitation has increased slightly. The severity of tricuspid
regurgitation is similar.
.
\
.
CXR [**2194-3-31**]:
No acute cardiopulmonary process.
.
CTA HEAD/CT BRAIN [**2194-4-1**]: [preliminary report]
1. No acute intracranial abnormality.
2. No perfusion abnormality to suggest acute infarct.
3. A linear hypodensity in the mid cervical segment (C2-C3
level) of the left internal carotid artery which may represent a
dissection flap or streak artifact. Further evaluation with MRA
of neck (dissection protocol) is advised if clinically indicated
and if there is no contra-indication for MRI.
4. No evidence of stenosis, occlusion or aneurysm greater than 3
mm in the
arteries of head.
.
Chest x-ray [**2194-4-1**]:
ET tube is in standard position. The tip is 4.2 cm above the
carina.
Moderate-to-severe pulmonary edema has worsened. There is no
pneumothorax. If any there is a small bilateral pleural
effusion, larger on the right side. In the left lower lobe,
there is a combination of atelectasis and worsening pulmonary
edema. Transvenous pacemaker leads are in the standard position
with the tips in the right atrium and right ventricle.
Mediastinal widening is increased due to engorgement of the
vasculature. cardiomegaly is grossly unchanged.
[**2194-4-1**]:
VT ablation.
1. 4 separate inducable VT morphologies
2. successful targeted ablation of inner loop of clinical VT
with termination during ablation
3. successful substrate ablation of inferior LV scar
4. Inability to wean from intubation, with ongoing stroke workup
5. Post-VT ablation spontaneous VT (VT4) treated successfully
from ICD with internal cardioversion
[**2194-4-5**]
EEG
This is an abnormal EEG in the awake state due to the
presence of a slow, disorganized background. This finding is
consistent with a mild to moderate encephalopathy which
indicates
widespread cerebral dysfunction but is non-specific as to
etiology.
There were no focal or epileptiform features. Note is made of a
regular
tachycardia on the cardiac monitor.
discharge
[**2194-4-9**] 05:33AM [**Month/Day/Year 3143**] WBC-7.6 RBC-3.88* Hgb-9.9* Hct-34.5*
MCV-89 MCH-25.6* MCHC-28.8* RDW-18.1* Plt Ct-271
[**2194-4-4**] 03:21PM [**Year/Month/Day 3143**] Neuts-89.3* Lymphs-6.7* Monos-2.9 Eos-0.9
Baso-0.2
[**2194-4-9**] 05:33AM [**Month/Day/Year 3143**] Plt Ct-271
[**2194-4-9**] 05:33AM [**Month/Day/Year 3143**]
[**2194-4-9**] 05:33AM [**Month/Day/Year 3143**] Glucose-92 UreaN-36* Creat-1.3* Na-146*
K-3.8 Cl-115* HCO3-20* AnGap-15
[**2194-4-4**] 03:21PM [**Year/Month/Day 3143**] CK(CPK)-336*
[**2194-4-9**] 05:33AM [**Month/Day/Year 3143**] Calcium-8.7 Phos-3.2 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] is an 81y/o gentleman with Parkinson's Disease, CAD s/p
CABG, sCHF (LVEF 25%), AFib on coumadin, and AICD who presented
from home with hypotension/VT, underwent VT ablation, and
subsequently had recurrent unstable VT.
.
#. Monomorphic sustained ventricular tachycardia: s/p VT
ablation with recurrent VT: Patient with various VT morphologies
as seen in EP lab. Became hemodynamically unstable in VT. Had
4 episodes after VT ablation two of which required external
defibrillation. No more after device re-programming and
Lidocaine drip. Was loaded wtih amiodorone. Did not have any
more episodes of VT in the CCU. Lidocaine was weaned off on [**4-2**]
am. Amiodorone was discontinued. Maintained on metoprolol. Of
note, patient was treated with Vancomycin IV for peri and post
procedure ppx. On the floor, amiodarone and lidocaine were
discontinued. He had an additional run of slow sustained VT on
[**2194-4-4**] with HRs in 120s. He given lidocaine bolus and initial
drip and EP antitachycardial paced him out of the rhythm. Pacer
was reset and he did not have any additional runs of vt for
remainder of hospitalization.
.
.
#. Unresponsiveness/right-gaze: This occurred in the setting of
VT. Patient was evaluated by the neurology team and CT/CTA head
did not show any focal abnormalities. EEG was also obtained
which showed diffuse encephalopathy, consistent with delerium.
Neurology stroke team felt that pt's symptoms were more likely
secondary to a parkinsonian crisis as he missed numerous doses
of sinemet during procedure. Pt was intubated initially for
airway protection. Extubated on [**2194-4-2**]. He was called out to
the floor on [**2194-4-3**]. Pt's delerium waxed and waned throughout
stay, but with frequent reorientation and controlling his sleep
wake cycle, as well as restarting all of his home antiparkinsons
medications, his mental status improved to baseline at time of
discharge. Neurology recommended maintaining all of his home
antiparkinsons meds and he should follow up with his outpt
neurologist.
.
#. h/o Afib: CHADS2 is 3. Continued metoprolol for rate control
and Coumadin for anticoagulation. For procedure, his coumadin
was held. it was restarted on [**2194-4-3**] and his INR became
supratherapeutic after one day of coumadin at home dose (1mg).
He decreased his dose to 0.5 but INR trended down, so was
restarted on home dose. Last INR was 2.4.
.
#.Chronic systolic heart failure: LVEF 25%. Appeared euvolemic
to dry. Continued
metoprolol. Held lisinopril in the setting of [**Last Name (un) **], but was
restarted. Monitored daily I/Os and weights.
.
# [**Last Name (un) **] ?????? baseline cr was 1.1. Before discharge from CCU, his cr
was 1.8. Ulytes showed pre-renal etiology. Pt was diuresed in
CCU and was not taking PO during ccu stay. Was given 500cc bolus
x3 over 24 hrs and cr improved to 1.3. His urine output
continued to be borderline low, but it picked up by time of
discharge. His cr remained at 1.3, which might be a new
baseline for him.
.
#. CAD s/p MI: with mild troponin elevation on admission.
Never had chest pain. Presented with troponin 0.07, MB 6 and
then twelve hours later troponin 0.08. EKG difficult to
interpret with regards to ischemia, but possibly represents
demand ischemia. Continued home aspirin, statin, metoprolol and
ACE.
.
#. HTN: BP controlled with home medications. All BP meds were
held during CCU stay, but restarted when he came back to floor.
.
#. Parkinson's Disease: with bradykinesia at baseline.
Continued carbidopa/levodopa. Please see "unresponsive episode"
above for more details
Transitional:
- Dr. [**First Name (STitle) **], PCP will follow pts INR please see discharge paperwork
- will need to be followed up in device clinic
- if cannot take po's and needs dose of sinemet, give parcopa
(oral disintegrating version) at 1:1 dose
Medications on Admission:
Aspirin 325 mg PO DAILY
Warfarin 1 mg PO DAILY
Atorvastatin 10 mg PO DAILY
Metoprolol succinate 25 mg PO DAILY
Lisinopril 5 mg PO DAILY
Amiodarone 200 mg PO DAILY
Digoxin 125 mcg PO every other day
Furosemide 20 mg PO DAILY
Carbidopa-levodopa 25-100 mg 1.5 Tabs PO TID
-- Please give at 0800, 1500, and [**2211**]
Carbidopa-levodopa 25-100 mg 1 Tab PO TID
-- Please give at 1100, 1330, and 1800
Minocycline 100 mg PO BID
Quetiapine 50 mg PO QHS
Ropinirole ER 6 mg PO DAILY
Trazodone 100 mg PO QHS
Latanoprost 0.005% One Drop QHS
Discharge Medications:
1. Outpatient Lab Work
Please draw PT, INR, BUN, creatinine, potassium and sodium on
[**2193-4-11**] and forward results to Dr. [**First Name (STitle) **] at fax # [**Telephone/Fax (1) 25663**]
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
5. carbidopa-levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
6. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: no more than 4g/day.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for increased secretions.
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. quetiapine 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 10140**] Nursing Center - [**Location (un) 10059**]
Discharge Diagnosis:
monomorphic sustained ventricular tachycardia
parkinsonian crisis
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] for ventricular tachycardia (VT). We
performed a procedure called a VT ablation and changed your
pacemaker/ICD to prevent further episodes of this abnormal heart
rhythm. After the procedure, you had a several more episodes of
VT, and there was concern that you were having a stroke. This
required you to be temporarily intubated and externally
defibrillated and you had a short stay in the cardiac intensive
care unit. Our neurologists determined that you did not have a
stroke and we got your heart rhythm under control. We now think
that your pacemaker/ICD have your heart rate under control and
it is safe for you to go to rehab.
We have made the following changes to your medications:
change aspirin from 325mg daily to 81mg daily
change metoprolol succinate 25mg daily to 100mg daily
stop amiodarone 200mg daily
stop digoxin 125mcg daily
start guaifenesin 5-10ml by mouth every 6hrs as needed for
increased oral secretions
we have arranged for follow up appointments for you with your
cardiologist and neurologist. Please see below for details
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2194-4-16**] at 9:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2194-4-16**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Doctor Last Name **]-[**Last Name (LF) 25664**],[**Name8 (MD) **] MD
Address: [**Hospital Unit Name 25665**], [**Location (un) 86**],[**Numeric Identifier 18406**]
Phone: [**Telephone/Fax (1) 25666**]
***The office is working on an appt for you in the next [**11-25**]
weeks and will call you at home with an appt. IF you dont hear
from the office by Friday, please call them directly to book.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
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9,871
| 121,460
|
49213
|
Discharge summary
|
report
|
Admission Date: [**2168-3-1**] Discharge Date: [**2168-3-4**]
Date of Birth: [**2089-8-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Shortness of breath, fatigue
Major Surgical or Invasive Procedure:
endoscopy
colonoscopy
small bowel capsule study
History of Present Illness:
Patient is a 78 year old female with past medical history of
autoimmune cirrhoisis and esophageal varices, hypertension, and
diabetes mellitus, who presents with weakness and dyspnea.
Pt reports being in her USOH until approximately 1 month ago
when she had a URI, with cough. Since then she reports feeling
fatigued, increasingly dyspneic on exertion, having abdominal
distention and blood sugars running high. 2 days PTA, she
reports having increasing abdominal pain, and passing a large
"tomato red" bowel movement. She then felt dizzy, fell to the
ground and hit her head, but denies LOC. Abdominal pain resolved
with bowel movement. She then felt weak, with difficulty getting
up. Of note she does report baseline abdominal pain, worse with
constipation, and BMs at baseline black, also today.
Pt also reports exertional shortness of breath and chest
pressure. She has been having a cough, productive of white
phlegm. ROS also positive for chills but no fevers, epistaxis
(5times over last month)and occasional nausea/vomiting
(nonbloody).
.
In the ED, HR 50's, 122/24 121/82, RR nl, 94% RA, 100% 2L. Pt
had CXR with RLL infiltrate c/w PNA. Labs were significant for
Hct 19, Cr 1.2 (baseline), hyponatremia (131, baseline normal),
and INR 1.3 (at baseline). Cardiac enzymes were negative and EKG
was sinus bradycardia with TW flattening in leads V1-V3. No
lavage was performed as suspicion for upper source was low. She
was given 40 mg IV protonix, and 750 mg of IV levofloxacin. 2U
pRBCs were ordered but not transfused.
.
Upon arrival to the ICU, pt was comfortable, afebrile 98, with
HR 49, BP 144/78, RR 16, satting 100% on 2L.
Past Medical History:
- Diabetes
- Thyroid nodule
- Hypertension
- Anemia, baseline HCT ~30
- Cirrhosis secondary to auto-immune hepatitis
- History of variceal bleeding, with obliteration of varices
through endoscopy, last done [**2166-2-20**]
- Depression
- Status-post cholecystectomy and cataract surgery
- History of pyelonephritis
- History of positive PPD
Social History:
Patient lives alone but with family close by. Granddaughter
[**Name (NI) 698**] helps take care of her. Has home health Aide. Used to
work at the [**Hospital1 18**] as housekeeping. Originally from [**Country 3594**]
Family History:
non-contributory
Physical Exam:
GEN: pleasant elderly lady, appears stated age, WN/WD, alert and
talkative, with granddaughter translating.
HEENT: PERRLA, EOMI, + conjunctival pallor, MMM, no oral lesions
or OP erythema/swelling. No LAD
CV: Bradycardic, no murmurs, nl S1/S2
PULM: Diffuse minimal crackles, worst at Right lower lung. Do
not clear with cough.
Abdomen: Soft, slightly TTP in epigastrium and RLQ,
nondistended, +BS, no HSM, liver edge not palpable, no [**Doctor Last Name **]
sign, no rebound or guarding. No ascites
Ext: Strong distal pulses, no edema
Neuro: A+Ox3, follows commands and answers questions
appropriately. Sensation and strength in tact throughout, CN2-12
in tact.
Discharge exam:
VSS, Afebrile
no gross bleeding
pleasant
abd benign
Pertinent Results:
[**2168-3-1**] 02:00PM BLOOD WBC-5.4# RBC-2.42* Hgb-5.8*# Hct-19.0*#
MCV-79*# MCH-24.1*# MCHC-30.7* RDW-16.3* Plt Ct-122*
[**2168-3-2**] 02:02AM BLOOD WBC-7.1 RBC-3.26*# Hgb-8.4*# Hct-25.4*#
MCV-78* MCH-25.9* MCHC-33.2 RDW-17.3* Plt Ct-116*
[**2168-3-1**] 02:00PM BLOOD Neuts-77* Bands-0 Lymphs-15* Monos-6
Eos-2 Baso-0
[**2168-3-2**] 02:02AM BLOOD PT-15.0* PTT-29.4 INR(PT)-1.3*
[**2168-3-1**] 02:00PM BLOOD Glucose-191* UreaN-32* Creat-1.2* Na-131*
K-4.1 Cl-98 HCO3-26 AnGap-11
[**2168-3-2**] 02:02AM BLOOD Glucose-67* UreaN-26* Creat-1.1 Na-133
K-4.2 Cl-101 HCO3-24 AnGap-12
[**2168-3-2**] 02:02AM BLOOD ALT-18 AST-21 LD(LDH)-195 AlkPhos-125*
TotBili-1.0
[**2168-3-1**] 02:00PM BLOOD CK(CPK)-53
[**2168-3-1**] 02:00PM BLOOD cTropnT-<0.01
[**2168-3-2**] 02:02AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.6 Mg-2.0
[**2168-3-2**] 02:02AM BLOOD WBC-7.1 RBC-3.26*# Hgb-8.4*# Hct-25.4*#
MCV-78* MCH-25.9* MCHC-33.2 RDW-17.3* Plt Ct-116*
[**2168-3-2**] 09:20PM BLOOD Hct-26.4*
[**2168-3-3**] 07:00AM BLOOD WBC-6.3 RBC-3.22* Hgb-8.3* Hct-24.7*
MCV-77* MCH-25.9* MCHC-33.7 RDW-17.6* Plt Ct-132*
[**2168-3-3**] 07:10PM BLOOD Hct-27.3*
[**2168-3-4**] 07:05AM BLOOD WBC-4.8 RBC-3.30* Hgb-8.4* Hct-25.9*
MCV-79* MCH-25.4* MCHC-32.4 RDW-18.4* Plt Ct-133*
[**2168-3-2**] 02:02AM BLOOD Glucose-67* UreaN-26* Creat-1.1 Na-133
K-4.2 Cl-101 HCO3-24 AnGap-12
[**2168-3-3**] 07:00AM BLOOD Glucose-104 UreaN-18 Creat-0.9 Na-130*
K-3.5 Cl-96 HCO3-27 AnGap-11
[**2168-3-4**] 07:05AM BLOOD Glucose-49* UreaN-15 Creat-0.9 Na-135
K-3.8 Cl-100 HCO3-28 AnGap-11
[**2168-3-2**] 02:02AM BLOOD ALT-18 AST-21 LD(LDH)-195 AlkPhos-125*
TotBili-1.0
[**2168-3-3**] 11:06AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2168-3-3**] 11:06AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2168-3-3**] 11:06AM URINE RBC-7* WBC-4 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
---------
colonoscopy [**2168-3-3**]
Findings:
Mucosa: The mucosa of the colon was very friable.
Flat Lesions A single small angioectasia was seen in the
ascending colon that started oozing upon examination. There were
2 small AVM's noted in the transverse colon that were not
bleeding. A gold probe was applied for hemostasis successfully
to the ascending colon AVM.
Other There were [**1-26**] cords of engorged veins noted in the
rectum suggestive of rectal varices. There was no active
bleeding noted in this area.
Impression: Angioectasia in the ascending colon (thermal
therapy)
Abnormal mucosa in the colon
There were [**1-26**] cords of engorged veins noted in the rectum
suggestive of rectal varices. There was no active bleeding noted
in this area.
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: 1. Follow serial Hct
2. Consider small bowel capsule study to evaluate small bowel
for AVM's.
3.Follow up with clinical team.
Additional notes: The efficiency of colonoscopy in detecting
lesions was discussed with the patient. It was explained that
colon cancer and colon polyps on rare occasions may be missed
during a colonoscopy.The procedure was done with attending
physician and GI fellow. The patient's reconciled home
medication list is appended to this report.
---------
EGD [**2168-3-3**]
Findings: Esophagus:
Mucosa: Patchy erythematous mucosa was noted in the
gastroesophageal junction.
Protruding Lesions Trace varices that flattened with air
insufflation were noted at the GE junction.
Stomach:
Mucosa: Patchy mild erythema, congestion and mosaic appearance
of the mucosa were noted in the fundus, stomach body and antrum.
These findings are compatible with mild portal gastropathy.
Duodenum:
Mucosa: Normal mucosa was noted in the first part of the
duodenum and second part of the duodenum.
Impression: Esophageal varices
Erythema in the gastroesophageal junction
Erythema, congestion and mosaic appearance in the fundus,
stomach body and antrum compatible with mild portal gastropathy
Normal mucosa in the first part of the duodenum and second part
of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: 1. Continue Nadolol
2. Colonoscopy for further evaluation.
3. Follow up clinically
Additional notes: The procedure was done with attending
supervision. The patient's reconciled home medication list is
appended to this report
Brief Hospital Course:
Patient is a 78 year old female with past medical history of
autoimmune cirrhosis, diabetes mellitus, and hypertension who
presents with fatigue, SOB and exertional chest pain in setting
of chronically bloody stools and Hct of 19.
#1) Anemia/GIB: Pt's baseline Hct fluctuating around 30, last
checked in [**Month (only) 404**]. Reports having black bowel movements
regularly (not taking iron) and one large bowel movement with
frank blood. No active bleeding since arrival. Hct responded
appropriately to 2U pRBCs and pt reported symptomatic
improvement in her strength and dyspnea. Regarding etiology of
bleed, EGD was unremarkable (see reports section) and
colonoscopy remarkable for AVMs.
Pt was followed by the liver service while the hospital. She
had no further evidence of active bleeding. She was advised of
her rectal varices, and continued on nadolol. She also
underwent a capsule study on the last day of her admission, to
assure there was no small bowel source of bleeding. The results
remain to be read on discharge. She has follow up with Dr.
[**Last Name (STitle) **], her PCP, [**Name10 (NameIs) **] one week for a Hct check and follow up with
Dr. [**Last Name (STitle) 7033**] in one month.
#2) ?Pneumonia: CXR in ED with questionable infiltrate and pt
given 750 mg of levofloxacin. However given her subacute
presentation, afebrile, no leukocytosis, levofloxacin was
discontinued..
#3) Weakness/fall: Likely related to bleed, as has been gradual.
Also given report of fall in setting of large bowel movement,
with associated nausea, may be a vagal reaction. Neuro exam is
reassuring as pt retains full strength, bulk and tone. Pt
reports subjective improvement s/p transfusion. Culture data
without infectious etiology to date and no cardiac events on
telemetry.
#4) Diabetes Mellitus type 2: Followed by [**Last Name (un) **] and on Lantus
50U daily with Humalog 10U TID at home. Started on home regimen
at 1/2 dose while on clears/NPO. She was monitored and treated
with QID FS with SS in addition to her standing doses on
insulin.
#5) Hypertension: Pt's BP meds were initially held in setting of
GIB but given SBP >150, she was restarted on HCTZ and
lisinopril. Nadolol was held due to bradycardia and restarted
prior to transfer to the floor as BP and HR improved and for
simultaneous variceal bleeding protection.
#6) [**Doctor First Name 48**]: Peaked at Cr 1.2, now at baseline 1.1 after blood
volume resuscitation, thought to be prerenal in etiology. Pt
made good volume of urine throughout the admission.
#7) Cirrhosis: Followed at Liver Center at [**Hospital1 18**] as outpt and by
liver team while admitted. Known to have secondary varices with
h/o bleeds and banding. Liver function: INR 1.3, Albumin last
normal, Plt 120s. Last abdominal ultrasound [**4-29**] with cirrhosis
and splenomegaly. No focal hepatic lesions. No signs of ascites.
Medications on Admission:
1) Ursodiol 300mg qAm and 600mg qPm
2) Lantus 50U daily
3) Lexapro 10mg qAM
4) Humalog 10U TID
5) Nadolol 40mg PO daily
6) Ativan 1mg po qhs
7) HCTZ 25mg daily
8) Lisinopril 30mg po daily
9) Timolol .5% q drop both eyes [**Hospital1 **]
10) Omeprazole 40mg delayed release po daily
11) Drisdol 50,000U PO qweek
12) Zolpidem 5mg po hs
13) Carmol 40% topical cream AAA [**Hospital1 **]
14) Docusate 100mg PO daily prn
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Nadolol 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
11. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
TID before meals: please take as previously prescribed by Dr.
[**Last Name (STitle) **].
Discharge Disposition:
Home
Discharge Diagnosis:
1. chronic blood loss anemia, likely from colonic AVMs
2. cirrhosis with esophageal varices
3. rectal varices
Discharge Condition:
hematocrit stable, afebrile
Discharge Instructions:
You were admitted with anemia, likely from losing blood from
your gastrointestinal tract. Please call Dr. [**Last Name (STitle) **] with
concerns and questions, and return to the hospital if you have
vomiting, bloody or black stool, chest pain, lightheadedness,
abdominal distension or any other alarming symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2168-3-23**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2168-3-24**] 11:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2168-4-7**] 3:45
Please make sure you attend your next visit: [**2168-4-27**] 09:15a
[**Last Name (LF) **],[**First Name3 (LF) **] (LIVER CENTER)
LM [**Hospital Unit Name **], [**Location (un) **] LIVER CENTER (SB)
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule your
appointment for next week to check your blood level.
|
[
"456.21",
"250.00",
"537.89",
"455.0",
"241.0",
"280.0",
"401.9",
"569.85",
"571.5",
"V58.67",
"593.9",
"571.42",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
12200, 12206
|
7828, 10718
|
341, 391
|
12360, 12390
|
3484, 7805
|
12754, 13545
|
2694, 2712
|
11185, 12177
|
12227, 12339
|
10744, 11162
|
12414, 12731
|
2727, 3396
|
3412, 3465
|
273, 303
|
419, 2069
|
2091, 2443
|
2459, 2678
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,391
| 191,328
|
102
|
Discharge summary
|
report
|
Admission Date: [**2163-7-5**] Discharge Date: [**2163-7-15**]
Date of Birth: [**2097-6-11**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Ciprofloxacin / Codeine
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo F with h/o PE, renal failure last Cr 5, seizure d/o was
found down apparently x9 days after an unwitnessed seizure. Pt
managed to crawl to window, yell for help, EMS arrived which
took pt to OSH. Pt has been recently hospitalized for malaise
[**Date range (1) 1163**]/[**2163**] and found to be in renal failure, which was
thought to be pre-renal in the setting of poor PO intake,
hypotension from adrenal insufficiency while off steriods. Her
Cr improved from 5.6 to 1.3 with IVF. She was also discharged on
cefuroxime for a UTI, abx to be completed [**6-24**]. Pt was
discharged to extended care facility on [**6-17**].
.
OSH: Arrived via EMS, speech slurred, found pt in filthy appt,
dried feces on legs, cat feces and urine feces everywhere.
Initial VS 96.1 BP 84/50 HR 103 86%RA FS 73. Initial BUN/Cr
110/10.1 K 4.4, Alb 2.7, WBC 19.7, HCT 33.2, PLT 444, 5%Bands,
INR 2.1. Tox screen +benzos and opiates. Serum ethanol-none
detected. Received Cefuroxime 750mg PO x1, solumedrol 125mg IV
x1, linezolid 600mg x1. Pt was transferred to [**Hospital1 18**] for furhter
management of ARF.
.
[**Hospital1 18**] ED Course: Initial VS 98.4 BP 96/44 HR 94 18 96%RA. SBP
dropped to 84/53 received 3.3 L NS IVF, SO2 dropped to 89% RA
increased to 96% 4L NC. She was noted to have rhabdo as well as
acute on chronic renal failure. Aggressive fluid resuscitation
was started and her renal function has improved since and her ck
has been trending down. Her UA was noted to be equivocal for UTI
and grew VRE which per ID was likely colonization. SHe was noted
to have gram positive cocci bacteremia and was started on
vancomycin for this. speciation is currently pending. pt's
subsequently transferred to the floor for further management. on
arrival she has no specific complaint other than refusing her
vancomycin although she agrees to take her anti-seizure
medicationse.
.
Per pt ROS: She denies any f/c/s. No cough. No chest pain /
palpitations. No abdominal pain/N/V/Diarrhea. c/o dysuria. She
is confused, c/o HA but no visual changes. Poor historian,
paranoid, very tangential speech--could not fully evaluate.
Past Medical History:
-History of multiple pulmonary emboli on anticoagulation
-Recurrent UTIs, VRE UITs on linezolid
-seizure disorder
-Crohn's disease on chronic steroids, quiescent on sulfasalazine
-Thyroid nodules
-Hypothyroidism
-Fibromyalgia
-Diverticulosis
-left breast mass diagnosed in [**2154**]
-Sjogren's disease
-Depression
-ADHD
-Asthma
-? Hyperparathyroidism
-S/P Cholecystectomy
-L Total knee replacement
-Sever OA R knee
-morbid obesity
Social History:
Lives alone with several cats, found in filthy apt full of
feces. Apt apparently condemned. SW involved. Pt has refused VNA
and elder services in the past. Able to do ADLs. Never smoked.
Patient has difficult social situation. VNA has public health
department involved for condemning the house. Son and daughter
contacts.
Family History:
Non-contributory
Physical Exam:
PE
VS: 97.5 BP 120/88 HR 88/min RR 22/min 92% on 2LNC
GEN: appears comfortable at rest, no apparent distress
HEENT: PERRL, oropharynx clear, tm clear
Neck: supple, no jvd, no nodes
CV: rrr, nl s1+s2, no m/r/g
RESP: ctab, nl effort
ABD: distended, soft, non tender, nl bs
EXT: no o/c/c
NEURO: A&OX2 (Self, year), cns [**2-14**] grossly intact
Pertinent Results:
Admit [**Month/Year (2) **]:
[**2163-7-5**] 04:50AM WBC-20.1*# RBC-3.62* HGB-10.8* HCT-32.4*
MCV-90 MCH-29.9 MCHC-33.4 RDW-16.6*
[**2163-7-5**] 04:50AM NEUTS-95.1* BANDS-0 LYMPHS-3.1* MONOS-1.2*
EOS-0.5 BASOS-0.1
[**2163-7-5**] 04:50AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL BURR-1+
BITE-OCCASIONAL ACANTHOCY-OCCASIONAL FRAGMENT-OCCASIONAL
[**2163-7-5**] 04:50AM PLT SMR-HIGH PLT COUNT-468*
[**2163-7-5**] 04:50AM PT-26.2* PTT-36.7* INR(PT)-2.7*
[**2163-7-5**] 07:35AM ALT(SGPT)-26 AST(SGOT)-68* LD(LDH)-304*
CK(CPK)-1467* ALK PHOS-122* AMYLASE-17 TOT BILI-0.2
[**2163-7-5**] 07:35AM LIPASE-16
[**2163-7-5**] 07:35AM ALBUMIN-2.9* CALCIUM-9.5 PHOSPHATE-3.1
MAGNESIUM-2.0
..
...
...
Cardiac enzymes/CK's:
[**2163-7-5**] 04:50AM cTropnT-0.03*
[**2163-7-5**] 07:35AM CK-MB-19* MB INDX-1.3
cTropnT-0.03*CK(CPK)-1467*
[**2163-7-5**] 03:48PM CK-MB-16* MB INDX-1.4 cTropnT-0.01
[**2163-7-5**] 03:48PM CK(CPK)-1141*
[**2163-7-6**] 04:51AM BLOOD CK(CPK)-511*
[**2163-7-7**] 06:50AM BLOOD CK(CPK)-203*
[**2163-7-5**] 03:48PM BLOOD CK-MB-16* MB Indx-1.4 cTropnT-0.01
[**2163-7-6**] 04:51AM BLOOD CK-MB-8 cTropnT-<0.01
.
Anemia work-up:
[**2163-7-5**] 07:35AM VIT B12-1098* FOLATE-4.8
[**2163-7-5**] 07:35AM TSH-0.38
..
..
Discharge [**Month/Day/Year **]:
.
CT head [**7-5**]:
There is no evidence of intracranial hemorrhage, mass effect,
shift
of midline structures, hydrocephalus, or acute major vascular
territorial
infarct. [**Doctor Last Name **]-white differentiation appears preserved and there
is unchanged appearance to age appropriate atrophy. Mild
calcifications noted within the carotid siphons bilaterally.
Soft tissues and osseous structures appear unremarkable.
Paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
No acute intracranial pathology.
..
..
CT C-spine [**7-5**]:
FINDINGS: There is no evidence of acute fracture or
dislocation. There is multilevel degenerative joint and
degenerative disc disease. No prevertebral soft tissue swelling
is identified. Visualized contents of the intrathecal sac
appear unremarkable.
Please note overall examination was slightly limited due to a
large amount of artifact from the shoulders.
IMPRESSION:
No acute fracture or dislocation.
..
..
[**7-5**] CXR(portable)
FINDINGS: Other than linear atelectasis noted at the left base,
lungs appear clear. There is mild indistinctness to the
perihilar vessels and engorgement of the pulmonary vasculature
which may suggest mild amount of fluid overload
in this patient with known renal failure. No evidence of
pneumothorax.
Cardiomediastinal silhouette and hilar contours are not
significantly changed. No large right effusion is identified,
however the left costophrenic angle is not included on current
film.
Surgical hardware from right total shoulder replacement is again
identified.
IMPRESSION:
1. No evidence of pneumonia. Left lower lobe linear
atelectasis.
2. Perihilar haziness and congestion of the pulmonary
vasculature likely
relates to fluid overload in this patient with known renal
failure.
..
..
[**7-5**] ECG:
Sinus rhythm 89. Borderline first degree A-V block. Compared to
tracing
of [**2163-6-14**] the premature atrial beats are absent.
..
[**7-8**] Echo:
Conclusions:
Limited images obtained. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). There
is no pericardial effusion.
..
..
Brief Hospital Course:
66 yo F with paranoid and seizure d/o, CKD, PE on
anticoagulation found down for 9 days and was noted to have
acute on chronic renal failure, apparent gram positive cocci
bacteremia. Patient admitted to [**Hospital Unit Name 153**] on [**7-5**], transferred to the
floor on [**7-7**]. The following issues were addressed on this
admission:
.
1. Neuro/MS change: Patient was noted to be down at home.
Etiology thought to be secondary to seizure. Patient maintained
on TID klonopin alone for seizure prophylaxis at home. Patient
head CT negative, Utox positive for benzos and opiates.
Metabolic derangements as below. Had no evidence of trauma or
acute process by CT, cardiac enzymes cycled and remained flat.
EKG is unchanged from baseline. Patient's mental status
improved throughout her stay and she is at her baseline on
discharge. Neurology consulted on the patient and recommended
initiation of dilantin for seizure management. Had no seizures
throughout stay. Initially on klonopin 1mg TID and then
dilantin loaded on [**7-8**] evening and to start daily dilantin
dosing, 600mg qhs on [**7-9**]. On [**7-10**] patient started on Keppra as
recommended by neuro and dilantin discontinued because of
difficult dosing given patient weight and difficulty managing
coumadin dosing with dilantin interaction. The keppra has been
titrated up and patient will be discharged on a dose of 1000mg
po twice daily. She has had no further evidence of seizure
activity during this hospitalization.
.
2.. Renal: Creatinine of 9.4 on presentation. Acute on chronic
renal failure likely secondary to dehydration. Evidence of ATN
here (muddy brown casts, non-oliguric). Peak CK 1400 making
rhadbomyolysis less likely. Patient recieved aggressive fluid
resuscitation (3L in ED, 3L in ICU - with 1L D5 with 3amp HCO3)
within first 24-48 hours. Continued to require IVF's until [**7-7**].
Nephrology followed patient throughout hospitalization. Renal
failure improved rapidly and by time of discharge creatinine was
1.0. Massive post-ATN diuresis. Lytes aggressivly repleted.
NSAIDS held throughout stay. Sulfasalazine initially held and
then re-started [**7-7**]. The patient's creatinine normalized during
the hospitalization and on discharge it is 0.8.
3. Hypotension: Pt initial SBP 80s responded to fluids, never
febrile but received Abx. She has a h/o relative adrenal
insufficiency and a h/o hypotension while off steroids during
her recent admission in [**2163-6-3**]. Most likely volume related
and relative adrenal insufficiency while off steroids and no PO
intake for several days. Resolved with aggressive hydration and
re-initiation of home dose prednisone of 5mg daily(for Crohn's).
Empiric vancomycin was initiated from [**Date range (1) 1164**] and discontinued
beyond this time.
4. ID: Patient has a history of VRE UTIs in the past. On [**7-10**]
she began to have rising leukocytosis but remained afebrile.
Patient's UA was borderline for a UTI at that time with 5 wbc's.
A repeat was performed the following day and a subsequent
culture grew out >100,000 gram negative rods, later identified
as e. coli. The patient was initially placed on levofloxacin po
however sensitivities showed resistance to this and she was then
switched to IV ceftriaxone. Of note, prior to the ceftriaxone
she received one dose of Unasyn. While still on the
levofloxacin the patient developed spiking temperatures to 101
with some AMS and tachycardia. Blood cultures were obtained
which subsequently grew out e.coli with similar sensitivities.
As above, an ID consult was obtained and they recommended a two
week course of ceftriaxone 2gm IV daily for a total of 14 days.
A PICC line was placed on the day of discharge by IR for
antibiotic therapy.
.
5. Crohn's: re-started sulfasalazine on [**7-7**]. No diarrhea or
Crohn's symptoms while here. Also maintained on prednisone 5mg
daily.
.
6.Psych: History of Depression, Anxiety, Paranoia: On admission
patient felt to be paranoid, found in filthy apartment. Per last
admission she's refused services due to paranoia. Head CT
negative. Psych evaluated and started standing haldol with
haldol for agitation. Continued clonopin. By [**7-7**] with
improvement in mental status, patient's paranoia improved and
haldol discontinued. Doxapin and restoril re-initiated as
patient at previous baseline. Patient deemed to have capacity
to make all decisions.
7. h/o PE on anticoagulation: INR at admission 2.9, coumadin
initially held on admission. She resumed her coumadin at an
outpatient dose of 2 mg po daily. She will need Lovenox 40mg sc
daily until she become therapeutic as her INR today is 1.9. Her
goal is between [**2-5**].
.
8. Hypothyroidism: TSH 0.38 (wnl here). continued on
levothyroxine 200mcg daily here.
.
9. Asthma: maintained on home regimen of singulair. Prednisone
as above for Crohn's.
10.Social: Patient found by EMS in "filthy" conditions (multiple
animals, urine, feces). Department of Public Health involved
and trying to clean house along with patient's son. [**Name (NI) **]
deemed to have capacity and will return to current living
situation after rehab after housing has been cleaned.
.
CODE STATUS: Full throughout
.
#. Communication: with pt and HCP.
[**Name (NI) **] [**Name (NI) 1151**] [**Name (NI) 1165**], HCP, [**Telephone/Fax (1) 1152**]
Friend [**Name (NI) **], 1-[**Telephone/Fax (1) 1153**]
Niece [**Name (NI) 1154**] [**Name (NI) 1155**] [**Telephone/Fax (1) 1156**]
Medications on Admission:
1. Levothyroxine 200 mcg qAm
2. Clonazepam 2 mg TID
3. Methylphenidate 10 mg daily
4. Citalopram 20 mg daily
5. Montelukast 10 mg daily
6. Doxepin 50 mg qhs
7. Warfarin 2 mg daily
8. Prednisone 5 mg daily
Adjust dose as directed by primary care physician.
9. Nabumetone 750 mg qhs
10. Sulfasalazine 500 mg [**Hospital1 **]
11. Cyclobenzaprine 10 mg daily
12. Hydromorphone 4 mg q6hr PRN
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Pain, fever.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO twice a
day.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day). Capsule(s)
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 13 days days.
17. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day: Until INR is >2 on coumadin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing Center - [**Location (un) 1157**]
Discharge Diagnosis:
1. urosepsis
2. acute renal failur
3. seizure
Secondary:
Pulmonary ebmolism
Asthma
Crohn's disease
depression
adrenal insufficiency
Discharge Condition:
Stable, taking good PO.
Discharge Instructions:
Patient will be discharged to a rehab facility. She will
continue on IV Ceftriaxone for two weeks duration.
Followup Instructions:
You must follow up with your primary care doctor.
You should follow up with your gastroenterologist
For your seizures, you must follow up with neurology. Dr. [**Last Name (STitle) 724**]
has seen you here and you can follow up with him. His number is
[**Telephone/Fax (1) 1166**]
|
[
"296.20",
"345.90",
"599.0",
"585.9",
"584.9",
"555.9",
"728.88",
"038.42",
"V58.65",
"V43.65",
"V12.51",
"255.4",
"278.01",
"715.36",
"493.90",
"244.9",
"V58.61",
"995.92",
"729.1",
"710.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14579, 14664
|
7196, 12672
|
297, 304
|
14842, 14868
|
3653, 7173
|
15025, 15311
|
3258, 3276
|
13109, 14556
|
14685, 14821
|
12698, 13086
|
14892, 15002
|
3291, 3634
|
254, 259
|
332, 2446
|
2468, 2903
|
2919, 3242
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,794
| 135,513
|
14189
|
Discharge summary
|
report
|
Admission Date: [**2162-12-2**] Discharge Date: [**2162-12-4**]
Date of Birth: [**2115-8-30**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 yo previously healthy female beyond h/o aspergillosis in
[**2158**], treated with antimicrobials for at least one year by an
infectious disease doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 12017**], NH (Dr. [**Last Name (STitle) **]. She
reports she has been feeling very well since then, however
developed cough approx 11 days ago. She reports daily episodes
of a small amt of bloody sputum upon waking up in the morning,
but denies associated sx of fevers/chills, no brown/yellow
sputum, no SOB, no chest pain. She further denies other URI sx
and she denies sick contactss. She has been able to do a cardio
workout at the gym without difficulty. She called her ID doctor
who treated for aspergillus upon onset of her hemoptysis. He
recommended going to the ER for further evaluation, however she
was concerned about inability to afford the copay for ED visit.
Instead she provided sputum samples that apparently couldn't be
processed because she did not refrigerate them.
.
Last night, she reports a coughing fit w/ more substantial
episode of hemoptysis at home (perhaps half cup of bright red
blood). She presented to [**Hospital 8641**] Hospital and coughed up 100cc of
hemoptysis per report. Otherwise she nauseated all day due to
anxiety, no vomiting. Review of systems otherwise negative.
.
Of note, she reports multiple respiratory infections as child
and through adulthood requiring antibiotics at least once yearly
(sometimes extended courses d/t unsuccessful 1st course of rx).
She does not have asthma. She denies any weight loss, fevers,
night sweats. She denies rashes. UOP has been normal, nonbloody,
not foamy. She has had multiple industrial exposures and reports
she previously worked in factory making test tubes of
fiberglass. Ovens used there contained asbestos, but she reports
she always wore appropriate protective mask/respirator whenever
required at work. For the last 3 years, she has worked in a
factory making computer chips with the chemical thixotropic. She
denies TB risk factors including no travel, incarceration,
homelessness, contacts. PPD was placed 4 years ago in the
setting of hemoptysis and reportedly was negative.
.
She reports that 4 years ago she developed hemoptysis in the
setting of "lung congestion". She underwent bronchoscopy at that
time and reports MDs were initially concerned for TB; tests
however came back negative for this. PPD and HIV reportedly
negative at that time. It was at that time that she was
diagnosed instead with pulmonary aspergillosis. She says that
she was followed by ID in [**Location (un) 12017**] and reports having taken 7
pills daily for a year, but she is unsure of the medication
names. As above, she reports she has been doing well since then.
.
In the ED, her VS were T: 98.0 BP 145/85 HR 70 RR 17 O2sat 98%.
A pulmonology c/s was requensted in the ED. PPD placed in R
forearm. CT chest showed a cavitating lesion measuring 1.4 cm
with thick walls consistent with possible fungal infection. Labs
revealed a normal hct and normal renal function. She was in no
respiratory distress.
.
ROS: The patient denies any fevers, chills, weight change,
+nausea and poor appetite in setting of anxiety with hemoptysis,
no vomiting, abdominal pain, diarrhea, constipation, melena,
hematochezia, steatorrhea, chest pain, shortness of breath,
orthopnea, PND, lower extremity edema, cough, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
Past Medical History:
Pulmonary Aspergillosis, Mycobacterium Scofulacem treated in
[**2158**]
G1P1
Migraines
GERD
h/o multiple ear surgeries
TMJ surgery
Episiotomy repair
Social History:
Lives in [**Location **] with her daughter and boyfriend. Quit smoking
several years ago and endorse approx 15 packyear history prior
to that. Very infrequent EtOH (only at special occasions). No
illicits. Works in factory as outlined above.
Family History:
Father had DM and died of MI. Brother had MI. Sisters all with
DM. Sister had "neck, lung, and LN cancer."
Physical Exam:
GEN: Well-appearing, well-nourished, intermittently tearful due
to anxiety
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Mild crackles LUL, however lungs o/w clear without
rhonchi/wheezing.
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Strength and sensation to soft touch grossly
intact.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2162-12-2**] 03:50AM NEUTS-80.5* LYMPHS-16.5* MONOS-2.0 EOS-0.6
BASOS-0.4
[**2162-12-2**] 03:50AM PLT COUNT-399
[**2162-12-2**] 03:50AM PT-14.4* PTT-29.0 INR(PT)-1.3*
[**2162-12-2**] 03:50AM WBC-8.3 RBC-4.22 HGB-13.3 HCT-36.8 MCV-87
MCH-31.4 MCHC-36.1* RDW-12.7
[**2162-12-2**] 03:50AM ALBUMIN-4.4
[**2162-12-2**] 03:50AM ALT(SGPT)-14 AST(SGOT)-18 LD(LDH)-99 ALK
PHOS-79 TOT BILI-0.3
[**2162-12-2**] 03:50AM GLUCOSE-104 UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
[**2162-12-2**] 10:46AM HCT-34.9*
[**2162-12-2**] 09:13PM HCT-34.0*
[**2162-12-2**] 09:13PM POTASSIUM-3.5
Discharge labs:
[**2162-12-4**] 03:14AM BLOOD WBC-11.2*# RBC-4.18* Hgb-12.8 Hct-35.8*
MCV-86 MCH-30.6 MCHC-35.6* RDW-12.2 Plt Ct-303
[**2162-12-4**] 03:14AM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-138
K-3.6 Cl-105 HCO3-21* AnGap-16
[**2162-12-4**] 03:14AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
Microbiology: [**2162-12-3**] 11:10 am SPUTUM Source:
Expectorated.
GRAM STAIN (Final [**2162-12-3**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2162-12-5**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ASPERGILLUS FUMIGATUS.
ID PERFORMED ON CORRESPONDING FUNGAL CULTURE.
FUNGAL CULTURE (Preliminary):
ASPERGILLUS FUMIGATUS.
ACID FAST SMEAR (Final [**2162-12-4**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
DUE TO DUPLICATE SPECIMEN concentrated smear not
available.
ACID FAST CULTURE (Final [**2162-12-4**]):
TEST CANCELLED, PATIENT CREDITED.
DUPLICATE SPECIMEN.
SPECIMEN COMBINED WITH SAMPLE # 261-2492V, [**2162-12-3**].
MULTIPLE SPECIMENS COLLECTED ON DIFFERENT DAYS ARE
RECOMMENDED FOR
OPTIMAL RECOVERY OF MYCOBACTERIUM SPECIES.
[**2162-12-2**] CTA chest:
IMPRESSION:
1. No evidence of pulmonary embolism within a segmental or large
subsegmental branch.
2. Scattered centrilobular nodules, with bronchiectasis in the
left lower
lobe and lingula. These findings can be consistent with
aspergillus
infection. Although there is no convincing evidence for invasive
aspergillosis, the presence of nodules suggest an active
endobronchial
process, and developing mycetomas within bronchiectatic segments
cannot be
excluded, particularly in the left base (3:82).
Brief Hospital Course:
Ms. [**Known lastname 42210**] is a 47 yo female with hx of treated aspergillosis
[**2158**] who presents now with hemoptysis.
.
# Hemoptysis: Upon admission to the [**Hospital Unit Name 153**] the source was almost
certainly pulmonary based on CT findings. Pt w/ hx of
aspergillosis, mycobacterium scofulaceum with unknown risk
factors. Cavitary lesion on CT scan may be consistent with
recurrence of aspergillosis, m. scofulaceum also w/
bronchiectasis. The differential of the cavitary lung lesion
included: TB, other fungal infxn, malignancy, autoimmune
(Wegener's), or bacterial infection. Initially, she was started
on azithromycin and ceftriaxone for empiric PNA coverage. Her
prior work-up was all at outside hospitals. HIV was repeated
here and was negative. Cultures from [**Company **] were
obtained from [**11-26**] and [**11-30**] which showed MSSA growth. Thus,
the pt was sent home with a 7 day prescription of levofloxacin.
A beta-glucan was sent and came back positive after the pt's
discharge. Aspergillus galactomannan antigen was negative,
however. After her discharge, when Aspergillus studies came
back positive, results were faxed to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 42211**] at
[**Telephone/Fax (1) 42212**]. At time of discharge, pt was ambulating well
without desaturation or hemoptysis. Hct was stable at 35. PPD
was placed and read here and was negative.
.
# Coagulopathy: Very mildly elevated INR to 1.3. No history of
easy bleeding/bruising. No known h/o liver dz and no LFTs in our
system. ? nutritional. Seems unlikely to be contributing
significantly to above bleeding. Pt's LFTs and coags were
monitored in house and she recieved vit K prior to discharge.
.
# GERD: Continued PPI (pantoprazole while in house, prevacid as
outpatient).
Medications on Admission:
Prevacid
Fioricet
Benadryl
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*1 bottle* Refills:*0*
3. Prevacid 15 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnosis:
Allergic Rhinitis
Discharge Condition:
Good- stable O2 sat while walking. Hemoptysis resolved.
Discharge Instructions:
You were admitted because you were coughing up blood. While you
were here, we determined that you have a lung infection most
likely not from TB but from a common bacteria called MSSA (a
type of Staph). To treat this, we put you on 7 days of
Levofloxacin. Please continue this medication until it runs
out. Also, please continue the guaifenesin as needed for cough.
.
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 42213**],
in the next week. Also, please see your infectious disease
doctor in the next 2 wks. Either your PCP or your ID doctor
should refer you to a pulmonary doctor to follow up.
.
If you have worstening cough, fever, cough productive of blood,
shortness of breath, chest pain, or any other concerning
symptoms, please return to the hospital or call your doctor.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 42213**],
in the next week. Also, please see your infectious disease
doctor in the next 2 wks. Either your PCP or your ID doctor
should refer you to a pulmonary doctor to follow up.
We also recommend you talk to your ID physician or pulmonologist
about getting repeat CT scan in 3 months. You should also talk
to your pulmonologist about getting pulmonary function tests
during the change in seasons when your symptoms are at their
worst.
Completed by:[**2162-12-7**]
|
[
"482.41",
"786.3",
"530.81",
"286.9",
"477.9",
"494.0",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9975, 9981
|
7738, 9542
|
279, 286
|
10093, 10151
|
5077, 5077
|
11009, 11554
|
4282, 4390
|
9620, 9952
|
10002, 10002
|
9568, 9597
|
10175, 10986
|
5743, 6534
|
4405, 5058
|
6570, 7715
|
229, 241
|
314, 3834
|
10052, 10072
|
5093, 5727
|
10021, 10031
|
3856, 4007
|
4023, 4266
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,385
| 137,332
|
5176+5177+55645
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2134-4-14**] Discharge Date: [**2134-4-22**]
Date of Birth: [**2064-5-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 69-year-old gentleman
with past medical history of coronary artery disease, status
post coronary artery bypass graft in [**2128**] with left internal
mammary artery to the left anterior descending with
biprosthetic MVR and paroxysmal atrial fibrillation on
Coumadin who is admitted to [**Hospital3 **] Hospital on [**4-13**] with
shortness of breath and pneumonia. The patient also had
difficulty walking distance of 30 to 40 feet. The patient
usually ascends about one flight of stairs without difficulty
and can ambulate half a month. He reports chills, cold
sweats, occasional though, myalgia. The patient always
requires two pillow elevation during sleeping. No change
over the past three to four days. Denies chest pain, back
pain, paroxysmal nocturnal dyspnea, denies productive cough,
nausea, vomiting, BPR and melena. Notes loose water stools
over the past few days yet denies abdominal discomfort. When
the patient presented to [**Hospital3 **] Hospital he was febrile to
101.8. Labs were notable for a sodium in the 120's, white
blood count of 14.9 with a left shift.
The patient was given a dose of Azithromycin and was
transferred to CCU for monitoring. Given decreased systolic
blood pressure the patient was started on Vasopressin. Today
[**5-2**] blood cultures grew out gram positive cocci in clusters.
The patient was given 1 gram of Vancomycin, concerned about
biprosthetic mitral valve. The patient was transferred to
the [**Hospital1 69**] for further
management.
.
PAST MEDICAL HISTORY: Positive for severe pulmonary
hypertension, paroxysmal atrial fibrillation, bioprosthetic
MVR with severe MR. Coronary artery disease with
catheterization in [**2128**] at the [**Hospital1 756**] and Women with 50%
mid-LAD, 50% proximal left circumflex. In 10/98 he had a
porcine MVR and left internal mammary artery to the left
anterior descending surgery complicated by postop atrial
fibrillation, gout, diverticulitis, recent echo in [**2133**] with
preserved left ventricular systolic function. RV cavity
enlargement with pressure overload, Tricuspid regurgitation
velocity suggests PA- systolic pressure greater than 100 mm
of mercury. Chronic renal insufficiency, baseline 1.2.
Renal mass, status post resection six years ago and a Triple
A repair. He has a history of macular degeneration of the right
eye.
ALLERGIES: Penicillin which causes joint swelling.
MEDICATIONS ON TRANSFER:
1. Vancomycin 1 gram q 24 hours.
2. Zithromax 100 mg q 24 hours.
3. Lopressor 12.5 mg twice a day.
4. Rythmol 150 mg three times a day.
5. Coumadin was held.
6. Spironolactone 25 mg q day.
7. Multivitamin one tablet q day.
8. Vasopressin drip.
OUTPATIENT MEDICATIONS:
1. Oxazepam 50 mg p.o. q day.
2. Coumadin
3. Atenolol 50 mg p.o. q day.
4. Lasix 40 mg p.o. q day.
5. Rythmol 150 mg three times a day.
6. Spironolactone 25 mg p.o. q day.
7. Multivitamin.
8. Vitamin E.
9. Folate.
10. Digoxin q day.
SOCIAL HISTORY: Lives with his wife on [**Hospital3 **]. He has two
children. Negative for alcohol. Former tobacco with a few
pack per day times 25 years. No drugs. He was a retired
professor of business.
FAMILY HISTORY: Positive for hypertension in his mother and
congestive heart failure in father.
PHYSICAL EXAMINATION: On admission temperature 100.9, blood
pressure 165/125, heart rate 28, respiratory rate 27. Sats
96% on four liters nasal cannula.
In general he appeared acutely ill with shaking chills and rapid
breathing. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Nasopharynx clear. Neck supple, distended. JVP
about 8 cm. No lymphadenopathy, no carotid bruits.
Cardiovascular is regular rate and rhythm. Normal S1 and S2.
3/6 systolic ejection murmur at the apex and axilla. Lungs
with occasional expiratory wheezes. Abdomen soft, nontender,
nondistended, positive bowel sounds. Midline scar, no
hepatosplenomegaly. There was no cyanosis, clubbing or
edema. Skin no rashes, no ulcer, no lesions, no splinter
hemorrhages.
LABORATORY: On admission from outside hospital sodium 125, K
4.3, chloride 91, bicarbonate 95, BUN 39, creatinine 1.8,
glucose 154. White count 10.9 with 92% neutrophils, 2%
lymphs, hematocrit 36. Platelets 194. Calcium 7.7, INR 6.
BNP of 2865, albumin 3.4, ESR 78. Alk phos 67. Total bili
1.1, direct bili 0.4. Blood cultures were growing in [**5-2**] bottles
gram positive cocci in clusters.
Chest x-ray at the outside hospital: Cardiomegaly, marked
predominance of central pulmonary vasculature, porcine MV,
possible mild chronic obstructive pulmonary disease.
Electrocardiogram was normal sinus rhythm at 80 beats per
minute. PR- interval of 240 milliseconds, QRS 144, QTC 435.
Left atrial enlargement, right axis deviation, right bundle
branch block.
Echo at the outside hospital raised the question of vegetation on
the mitral valve.
HOSPITAL COURSE: This is a 69-year-old gentleman with
coronary artery disease, biprosthetic mitral valve and
pulmonary hypertension was transferred from outside hospital
for management of endocarditis given gram positive cocci
bacteremia and question mitral valve.
1. Fevers. The patient had high fever on the night of admission
with rigors. Cultures from the outside
hospital returned as gram positive, Methicillin resistant
Staphylococcus aureus in [**9-5**] bottles total. The patient was
treated empirically for endocarditis. He did have
transesophageal echocardiogram which did not have any clear
evidence of a vegetation or abscess but in light of patient's
biprosthetic valve and high grade staph aureus bacteremia the
patient was started on Vancomycin given his Penicillin
allergy. The patient was also started on gentamycin for
synergy for 2 weeks . His Vancomycin was titrated per renal
dosing and levels to 1 gram q 12 dosing. GIven the absence of
vegatations and high grade bacteremia plans were made to have a
tagged white blood cell scan to further evaluate for any
other source of infection but the patient
Plans were made to treat empirically for six weeks for presumed
endocarditis. Initially the patient refused blood
cultures during his episode of rigors but
daily sets of blood cultures sent while in house and only had
one positive blood culture. The other cultures drawn on
admission on [**4-14**] at 7 PM 1/2 bottles and anaerobic bottle he
did have a staph species growing, further speciation was to
follow but this is likely consistent with what was growing in
[**Hospital **] [**Hospital **] Hospital. He had a very high grade bacteremia.
Surveillance cultures after the 17th are so far negative and
the patient defervesced eventually on therapy. Eventually
the patient allowed a central line to be placed for
better access in case the patient required further pressors.
He was intermittently on and off Vasopressin to treat hypotension
secondary to septic shock. The patient responded to this and
eventually to fluid boluses and was titrated off pressors by [**4-16**]
and his blood pressures remained stable through the rest of his
stay. Also started back on low dose Lasix on a p.r.n. basis as
needed.
2. Multifocal atrial tachycardia. The patient was in sinus
rhythm with occasional ectopy, and was restarted on low dose
beta-blocker which he tolerated without difficulty and
otherwise was also restarted on Rythmol without difficulty.
His rhythm remained stable and he had fewer episodes of
ectopy on telemetry. He had several episodes of paroxysmal
atrial fibrillation one of which was during anemia.
3. Acute on chronic renal failure. The patient with history
of chronic renal insufficiency, status post nephrectomy six
years ago and doing well. The patient's creatinine was
continued to be monitored and urinalysis were overall
negative. The patient was continued on regular diet. Ultimately
his creatinine rose and the differential diagnosis of gentamycin
toxicity versus embolization was raised by the renal service.
His creatinine was decreasing and he remained non-oliguric.
4. Anemia. The patient's goal hematocrit was greater than
30. Initially the patient had guaiac positive stools but
this was continued to be a monitored. The patient has
history of diverticulitis in the past. The patient did
required transfusion.
5. Coagulopathy. The patient was on Coumadin at home for
his paroxysmal atrial fibrillation, came in therapeutic and
after restart of Coumadin the patient's INR also became super
therapeutic to the 7. The patient did not receive Vitamin K
as he needed to be anti-coagulated. The patient's Coumadin
was held and will continue to follow this. Signs of bleeding
can consider reversal. The patient likely has some added
synergy from his antibiotics causing increasing Coumadin
level.
6. Physical therapy. Secondary to the patient's
deconditioning and infection the patient was slightly
deconditioned and physical therapy recommended [**Hospital 3058**]
rehabilitation to improve strength and training.
7. Central retinal artery occlusion. He developed decreased
vision in the left eye. When this was brought to the attention
of the Attending Physician the next day, an urgent ophthamology
consult was obtained. Paracentesis did not restore vision
7. DISCHARGE STATUS: Ultimately will probably need rehabilition
and completion of a full six-week antibiotic course .
CONDITION ON DISCHARGE: Stable.
The patient with a PICC line in his left basilic vein. The
patient ambulating without difficulty, not requiring oxygen.
Discharge status is to rehabilitation with physical therapy
and complete intravenous antibiotics.
DISCHARGE DIAGNOSIS
1. Staph aureus septicemia
2. Endocarditis.
3. Septic shock
4. Coronary artery disease
3. Paroxysmal atrial fibrillation.
4. Anemia.
5. GI bleeding
6. Acute renal insufficiency.
7. Hypoxia.
8. Central retinal artery occlusion
9. Hyponatremia
10. Severe pulmonary hypertension
11. Mitral regurgitation
12. Pulmonic insufficiency
13. Macular degeneration
DISCHARGE MEDICATIONS:
1. Oxazepam 50 mg p.o. q h.s. p.r.n.
2. Atenolol 25 mg p.o.q day.
3. Vancomycin 1 gram intravenous q 12.
4. Rifampin for five more weeks, 300 mg p.o. q 8
5. Epotropein nebs one neb inhaled q 4 hours p.r.n.
6. Digoxin 0.0625 mg p.o. q day.
7. Tylenol 325 mg to 650 mg p.r.n.
8. Senna one tab p.o. twice a day p.r.n.
9. Colace 100 mg p.o. twice a day.
10. Propfanone 150 mg p.o. three times a day.
DISCHARGE FOLLOW-UP: The patient is to follow-up with his
PCP [**Last Name (NamePattern4) **] 7 to 10 days. The patient is to follow-up with his
Cardiologist in two to four weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-153
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2134-4-20**] 20:18
T: [**2134-4-20**] 22:34
JOB#: [**Job Number 21169**]
Admission Date: [**2134-5-2**] Discharge Date: [**2134-5-8**]
Date of Birth: Sex: M
Service: CCU
ADDENDUM: This Addendum will cover the dates [**2134-5-2**]
through [**2134-5-8**].
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. ENDOVASCULAR BACTEREMIA ISSUES: The patient had
methicillin-sensitive Staphylococcus aureus bacteremia.
Subsequent cultures at this hospital after several days of
vancomycin/rifampin treatment showed clear surveillance
cultures which were no growth.
Because an echocardiogram showed no evidence of actual
endocarditis, but questionable plaque in the descending aorta
which may have been a source of infection, he will be
continued on a 6-week course of vancomycin/rifampin given his
bioprosthetic mitral valve. He has been given 1 gram of
vancomycin for levels of less than 15, which has amounted to
about one dose every three days. His therapy should stop on
[**2134-5-25**].
The Infectious Disease team was briefly called regarding
alternative antibiotic regimens; however, they agreed that
his current regimen was the most optimal given his penicillin
allergy.
2. LEFT CENTRAL RETINAL ARTERY THROMBOSIS ISSUES: Dr.
[**First Name (STitle) 2523**] from Neurology/Ophthalmology re-evaluated the patient
prior to discharge and noted that there was mild improvement
in retinal edema. Prior to the date of this dictation, the
source of emboli had been investigated but was unclear as he
was therapeutic at the time on Coumadin and a carotid
ultrasound showed only 40% stenosis. In addition, there was
no thrombus source seen on echocardiography.
Given that he had been on Coumadin at the time, he will be
maintained on a slightly higher range of INR; 2.5 to 3.5
instead of 2 to 3.
3. PAROXYSMAL ATRIAL FIBRILLATION ISSUES: The patient was
noted prior to the time period of this dictation to have
occasional runs of atrial fibrillation with a rapid
ventricular response. However, during the remainder of his
hospitalization his telemetry showed only occasional
premature ventricular contractions and couplets with no
further atrial fibrillation. He was continued on his home
regimen of propafenone and digoxin. He also continues on
Coumadin; again with a goal INR of 2.5 to 3.5.
4. ACUTE RENAL FAILURE ISSUES: The Renal team continued to
provide input, and it appears that he had a urine sediment
consistent with acute tubular necrosis as many muddy casts
were seen. He was given 2 units of packed red blood cells
blood transfusion as well as several fluid boluses with
normal saline with improvement in his creatinine to a nadir
thus far of 2.5. He should be encouraged to take in plenty
of fluids once he is off of intravenous hydration.
5. HEMATOLOGIC ISSUES: The patient's hematocrit remained
stable at about 34 after transfusion.
6. ANTICOAGULATION ISSUES: Continued Coumadin,
alternating with 3 mg and 4 mg as dictated below to maintain
an INR of 2.5 to 3.5; which was to be followed by the
patient's primary care physician (Dr. [**Last Name (STitle) 5395**].
7. MENTAL STATUS ISSUES: The patient appeared to be quite
depressed initially during this time period given his
multiple medical conditions. The Psychiatry team briefly
stopped by and spoke with the patient's family; although, the
patient decided that he did not wish to speak to Psychiatry.
As his renal function improved, his spirits seem to lighten.
He never showed signs of suicidal ideation. He appeared to
derive much pleasure in spending time with his family who
were frequent visitors.
8. BOWEL REGIMEN ISSUES: Colace/Senna.
9. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: A cardiac diet.
Repleted electrolytes as needed.
10. INTRAVENOUS ACCESS ISSUES: The patient had left
peripherally inserted central catheter placed through which
he will continue to receive vancomycin.
11. DISPOSITION ISSUES: Physical Therapy worked with the
patient several times and deemed that he should be referred
to a [**Hospital 3058**] rehabilitation facility.
12. CONTACTS: I have spoken with Dr. [**Last Name (STitle) 21170**] office
several times (telephone number [**Telephone/Fax (1) 21171**]) to give him a
summary of the patient's condition. He is aware of the
events that have transpired during the patient's
hospitalization and agreed to continue following the INR.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Staphylococcus aureus bacteremia.
2. Central retinal artery thrombosis of left eye.
3. Paroxysmal atrial fibrillation.
4. Acute renal failure.
5. Anemia.
6. Bioprosthetic mitral valve replacement (mitral valve
prolapse with severe mitral regurgitation).
7. Pulmonary hypertension.
8. Coronary artery disease.
9. Gout.
10. Diverticulitis.
11. Chronic renal insufficiency (with a baseline creatinine
of 1.2).
12. Abdominal aortic aneurysm repair.
MEDICATIONS ON DISCHARGE:
1. Propafenone 150 mg by mouth three times per day.
2. Senna one tablet by mouth twice per day as needed (for
constipation).
3. Acetaminophen 325 mg to 650 mg by mouth q.4-6h. as
needed.
4. NACL 0.65% aerosol nasal spray four times per day as
needed.
5. Bisacodyl 10 mg by mouth once per day as needed (for
constipation).
6. Colace 100 mg by mouth twice per day as needed (for
constipation).
7. Oxazepam 15 mg by mouth at hour of sleep (per home
medication dose).
8. Rifampin 300 mg by mouth q.12h. (for 17 days - to end on
[**2134-5-25**]).
9. Vancomycin 1 gram intravenously for vancomycin random
level less than 15 up until [**2134-5-25**] (17 days).
10. Atenolol 25 mg by mouth once per day.
11. Ipratropium meter-dosed inhaler 2 puffs q.4-6h. as
needed.
12. Albuterol nebulizers q.6h. as needed.
13. Digoxin 0.0625 mg by mouth once per day.
14. Epogen 5000 units subcutaneously twice per week (on
Tuesday and Friday).
15. Warfarin 3 mg by mouth at hour of sleep (every
Wednesday, Thursday, Friday and Saturday).
16. Warfarin 4 mg by mouth at hour of sleep (every Sunday,
Monday, and Tuesday).
17. Lorazepam 0.5 mg to 1 mg intravenously q.4h. as needed
(for anxiety).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 5395**] in the next couple of weeks as
needed.
2. The patient was also instructed to follow up with his
cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**]).
3. The patient was to make an appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 19658**] on [**Location (un) **] for a Neurology/Ophthalmology appointment
in the next one to two weeks.
All decisions of the medical team were communicated to the
patient and his family as well as his home doctors.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36
D: [**2134-5-7**] 16:00
T: [**2134-5-7**] 17:22
JOB#: [**Job Number 21172**]
Name: [**Known lastname 3516**], [**Known firstname **] Unit No: [**Numeric Identifier 3517**]
Admission Date: [**2134-4-14**] Discharge Date: [**2134-5-1**]
Date of Birth: [**2064-5-30**] Sex: M
Service:
ADDENDUM: This dictation covers time period from [**2134-4-22**],
through [**2134-5-1**].
HOSPITAL COURSE:
1. Fevers - The patient continued to be treated for
Staphylococcus aureus bacteremia and presumed endovascular
infection. The patient was initially treated with
Vancomycin, Rifampin and Gentamicin. However, once his renal
function began to worsen, Gentamicin was discontinued. He
was maintained on Vancomycin and Rifampin. The Vancomycin
dose was adjusted for decrease in creatinine clearance.
Approximately two weeks into the hospital course, the
patient's creatinine clearance continued to decrease and the
Vancomycin was changed to dosing by level with serum level
being checked every day. The patient did not have any
further fevers and his repeat blood cultures remained
negative. There was a plan to do a white blood cell tagged
scan for evaluation of source of infection, however, the
patient refused this. The plan was to continue the patient
on antibiotics treatment for six weeks for presumed
endocarditis. At the time of this dictation, there is also
plan to consult infectious disease service for possibility of
changing the patient's Vancomycin to another antibiotic that
would adequately cover Staphylococcus aureus but that would
not result in any allergic reaction the patient receives with
Penicillin and Penicillin derivatives.
2. The patient had been treated with beta blocker and
Rythmol for multifocal atrial tachycardia. The beta blocker
was held for a period during the time that he was
hypotensive. The patient after being discharged from the
unit and being on the regular floor did develop atrial
fibrillation with a rapid ventricular response. This
spontaneously converted back to sinus rhythm. He was
maintained on Rythmol. Eventually when his blood pressure
became more stable, the patient was also restarted on
Atenolol 25 mg once daily. At the time of this dictation,
the patient is in sinus rhythm with occasional ectopy. In
addition, the patient was being anticoagulated for atrial
fibrillation. His INR goal was 2.5 to 3.5 and his Coumadin
was titrated to this goal.
3. Acute on chronic renal failure - The patient continued to
have worsening acute renal failure at the time of this
dictation. His creatinine was 3.2. The renal service had
been consulted and it was felt that the most likely cause was
Gentamicin toxicity. Cardioembolic cause was also considered
and urine eosinophils were sent which were negative and
complement levels were sent which were also normal. The
patient continue to be managed in a supportive way with
adequate hydration and continued monitoring of his creatinine
and electrolytes. Renal function has begun to improve.
4. Retinal artery thrombosis - Approximately one week prior
to this dictation, the patient was noted to have blurriness
of his vision by the house officer Initially, he only complained
of blurriness with no pain or discomfort in the eyes.
Subsequently, ophthalmology was consulted immediately when the
the attending was notified the next day that the patient had a
change in vision. Ophthalmology examination showed the patient
likely had a central retinal artery thrombosis. Paracentesis was
done emergently, however, the patient's vision did not change for
one week after the procedure. The patient was also started
on Ciprofloxacin eye drops for one week. The patient was
anticoagulated as above with Coumadin. Neuro-ophthalmology
service was also consulted for evaluation of possible
etiologies of the patient's retinal thrombosis. They felt
that the most likely cause was cardioembolic. There was less
concern for temporal arteritis given the fact that the
patient did not have any other symptoms. The patient's
visual examination was monitored daily, however, there were
no changes.
The patient had initially been made DNR/DNI upon admission to
the CCU per the wishes of the patient. However, subsequently
upon rediscussion with the family, they and the patient both
wished him to be full code and felt that there was confusion
initially during the DNR/DNI discussion. The patient was
therefore made full code and continued to be full code at the
time of this dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**], M.D. [**MD Number(1) 3519**]
Dictated By:[**Name8 (MD) 3520**]
MEDQUIST36
D: [**2134-5-3**] 15:47
T: [**2134-5-3**] 20:13
JOB#: [**Job Number 3521**]
|
[
"996.61",
"584.5",
"038.11",
"286.9",
"427.31",
"995.92",
"428.0",
"362.31",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"12.91",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
3337, 3418
|
15501, 15970
|
10253, 11290
|
15997, 17195
|
18496, 22860
|
17228, 18479
|
11325, 15416
|
2865, 3109
|
3441, 5131
|
15431, 15479
|
160, 1670
|
2590, 2841
|
1693, 2565
|
3126, 3320
|
9616, 10230
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,798
| 174,012
|
23033
|
Discharge summary
|
report
|
Admission Date: [**2148-4-6**] Discharge Date: [**2148-4-12**]
Date of Birth: [**2099-8-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1190**]
Chief Complaint:
found at home by husband, unresponsive
Major Surgical or Invasive Procedure:
Artificial ventilation
History of Present Illness:
48 yo woman with HIV/AIDS (last CD4 40/VL 78K), HTN, HepC,
asthma, was found at home by her husband 5 days ago with
epistaxis and decreased mental status. She was brought to the
[**Hospital1 2177**] ED and was found to have labored breathing, was
unresponsive. CT of the head at [**Hospital1 2177**] showed left basal ganglia
hemorrhage, likely originating in the thalamus and extending
into the ventricles causing a 4 mm midline shift. The pt was
intubated and hypoventilated, given mannitol 60 mg x 1, vitamin
K 10 mg sq, labatolol, and 6 Units of FFP. She was evaluated by
Neurosurgery at [**Hospital1 2177**] and was not thought to be a surgical
candidate. She was then transferred to the [**Hospital1 18**] for further
care.
Past Medical History:
1. AIDS - diagnosed 12 years ago. Her most recent CD4 = 79
([**2147-12-29**] per report). Pt was started on HAART at [**Hospital1 112**], which was
self-discontinued for the past 1 year secondary to side effects
(stiffness in lower extremities). She has since transferred care
to her PCP, [**Name10 (NameIs) **] has not restarted therapy
2. HCV - Increased AFP w/ negative MRI liver [**7-19**], with some
evidence of portal htn on abd u/s per report. She has since
refused treatment and liver bx.
3. Asthma/COPD
4. Pancytopenia
5. Depression
6. Substance abuse (cocaine, EtOH)
Social History:
Pt currently lives in home with her boyfriend of 16 years and
his son. She has two sons from a previous relationship. She has
recent cocaine and heavy alcohol use over past 2 months. No
IVDU; occassional drinking.
Family History:
Notable for hx of diabetes in mother and heart disease in
brother, but reports no family hx of cancer.
Physical Exam:
VS BP 96/47, HR 66, RR 17, O2 sat 93% RA
Gen: ill-appearing woman unresponsive to questions, lying in bed
with eyes closed and NP airway in mouth
HEENT: MMM, no JVD
CV: reg s1/s2, no s3/s4/m/r
Pulm: CTA anteriorly, no crackles or wheezes
Abd: +BS, soft, ND
Ext: warm, no edema
Neuro: unresponsive to questions, remainder of exam deferred for
pt and family comfort
Pertinent Results:
[**2148-4-6**] 12:41PM WBC-2.2* RBC-1.93*# HGB-6.5*# HCT-19.7*#
MCV-102* MCH-33.5* MCHC-32.9 RDW-17.9*
[**2148-4-6**] 12:41PM PLT COUNT-72*
[**2148-4-6**] 12:41PM NEUTS-80.2* LYMPHS-15.4* MONOS-2.7 EOS-1.1
BASOS-0.5
[**2148-4-6**] 12:41PM PT-14.2* PTT-38.5* INR(PT)-1.3
[**2148-4-6**] 12:41PM FIBRINOGE-142*#
[**2148-4-6**] 12:41PM GLUCOSE-87 UREA N-21* CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-115* TOTAL CO2-19* ANION GAP-11
[**2148-4-6**] 12:41PM ALBUMIN-2.9* CALCIUM-7.8* PHOSPHATE-3.8
MAGNESIUM-1.8
[**2148-4-6**] 12:41PM ALT(SGPT)-29 AST(SGOT)-61* LD(LDH)-325* ALK
PHOS-94 TOT BILI-0.5
[**2148-4-6**] 12:41PM HAPTOGLOB-27*
[**2148-4-6**] 12:41PM OSMOLAL-303
[**2148-4-6**] 01:20PM LACTATE-1.6
[**2148-4-6**] 01:20PM TYPE-ART TEMP-37.2 TIDAL VOL-600 PEEP-0
O2-100 PO2-390* PCO2-27* PH-7.44 TOTAL CO2-19* BASE XS--3
AADO2-307 REQ O2-56 INTUBATED-INTUBATED VENT-CONTROLLED
[**2148-4-6**] 03:23PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.034
[**2148-4-6**] 03:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2148-4-6**] 03:23PM URINE RBC-[**1-5**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-[**4-20**]
Head CT:
1. Large intracranial hemorrhage in the left hemisphere with
involvement of the bilateral lateral ventricles and 3rd
ventricle. There is mild shift of the rightward shift of the
midline structures, and significant diffuse brain edema with
effacement of all of the sulci. Unfortunately the comparison is
not avaiable.
2. There is loss of the [**Doctor Last Name 352**]/white matter differentiation a
portion of the left parietal lobe.
3. Fluid blood level is noted in the left temporal lobe, of
uncertain clinical significance.
Brief Hospital Course:
A/P: 48-year-old woman w/ h/o HIV/AIDS, chronic HCV, asthma was
admitted to MICU w/ spontaneous intracerebral hemorrhage, now
transferred to Medicine for continued palliative care.
1. Intracerebral hemorrhage: she was found unresponive by her
boyfriend at home, and was taken to [**Hospital1 2177**] where head CT
demonstrated large intracerebral hemorrhage as per the HPI. At
[**Hospital1 18**], repeat head CT confirmed left sided intracerebral
hemorrhage causing midline shift. This was of unclear etiology.
Possible causes include aneurysm, occult trauma, cocaine use w/
subsequent HTN, and spontaneous bleed in the setting of
coagulopathy. She was admitted to the MICU, placed on SIMV, and
did not show spontaneous breathing. Admission exam was notable
for upgoing Babinski, no corneal reflexes, possible posturing to
pain, and fixed dilated pupils. She was initially treated w/
mannitol to reduce intracerebral pressure and loaded w/ dilantin
for seizure prevention. Evaluation by Neurosurgery confirmed
that she was not a surgical candidate. Neurology evaluation
indicated very poor prognosis, and virtually no chance of
meaningful recovery. The pt spent 5 days in the MICU in which
she did not demonstrate any functional improvement. On HD#5, a
family meeting was held that resulted in a decision by the
family to pursue palliative care. The pt was extubated at that
time and was started on morphine gtt for comfort. She was then
transferred to the Medicine floor for ongoing palliative care.
Treatment was continued w/ morphine gtt, ativan prn for
agitation, and scopolamine patch to control production of
secretions. She appeared to be comfortable during the rest of
her hospital stay. She died on [**2148-4-12**]. The next of [**Doctor First Name **]
declined post-mortem examination.
Medications on Admission:
1. prozac
2. bactrim ss daily
3. albuterol INH prn
Discharge Disposition:
Expired
Discharge Diagnosis:
intracerebral hemorrhage
Discharge Condition:
deceased
|
[
"070.70",
"331.4",
"780.01",
"276.2",
"431",
"286.7",
"V66.7",
"493.20",
"518.81",
"401.9",
"305.60",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6193, 6202
|
4277, 6092
|
352, 376
|
6270, 6281
|
2494, 3713
|
1989, 2093
|
6223, 6249
|
6118, 6170
|
2108, 2475
|
274, 314
|
406, 1141
|
3723, 4254
|
1163, 1741
|
1757, 1973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,504
| 100,908
|
31421
|
Discharge summary
|
report
|
Admission Date: [**2113-1-2**] [**Month/Day/Year **] Date: [**2113-1-6**]
Service: MEDICINE
Allergies:
Prednisone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 29250**] is a [**Age over 90 **] year old male with a history of CHF who
presents in CHF exacerbation as a transfer from [**Location (un) 745**]-[**Location (un) 3678**].
He reports feeling extremely short of breath this morning at
approximately 9 PM yesterday. This was preceeded by a day of
increasing dyspnea, but no symptoms otherwise including no
shortness of breath or syncope. Of note he has had mild
presyncope for a few weeks. He reports that while he is very
compliant with his low salt diet he did eat a lot more food
during the [**Holiday **] holiday. Especially the day prior to
admission, he ate foods that he knew were high in salt and not
ideal for his congestive heart failure. While at the OSH he was
found to have a blood pressure of 220s and was started on a
nitro gtt as well as a heparin gtt and aspirin. He was given
large doses of diuretics (unclear amounts) and was reportedly
incontinent of large volumes of urine. He was transferred to the
[**Hospital1 18**] ER. At the OSH, he was started on heparin gtt, but this
was stopped at [**Hospital1 18**] ED. Additionally the patient reports a
sharp left shoulder pain that was not associated with any other
symptoms and did not radiate that was treated with morphine. It
promptly resolved after the morphine and has not recurred.
In the ED initial vitals were 98.2 60 130/84 24 97% 10LNRB. The
patient received lasix and diuril with 200mL out. However, per
report he desatted and became tachypnec after decreasing the
oxygen.
Of note he was last seen by Dr. [**First Name (STitle) 437**] on [**12-21**] where he was
noted to be in good control of his CHF and his hydralazine was
increased to 75 mg TID.
Currently he feels much improved. While he does have persistent
shortness of breath, he is much improved. He is currently chest
pain free.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. He has had no nausea,
vomiting, or diarrhea. He has chronic constipation. He has
noAll of the other review of systems were negative.
Cardiac review of systems is notable for positive presyncope x
several weeks and persistent lower extremity edema. There is
the absence of chest pain, paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope.
Past Medical History:
CAD s/p at least 2 MIs per patient, first at age 58
CHF with past hospital admissions for this
Chronic Kidney Disease
DM II
Peptic Ulcer Disease s/p rx for H.pylori
HTN
h/o Testicular cancer
h/o pancreatitis
s/p cholecystectomy
s/p L parotidectomy complicated by facial nerve paralysis
Social History:
The patient lives with his wife in a senior housing where they
have their own apartment. He is a retired truck driver. He
smoked tobacco for about 50 years at two to four packs per day
and quit in [**2080**] after his first myocardial
infarction. No ETOH. He has two daughters and four
grandchildren and six great grandchildren with one on the way.
Family History:
He has multiple other relative with hypertension, coronary
artery disease, and diabetes.
Physical Exam:
VS: T 97.8, BP 165/72, HR 59 , RR 24 , O2 100 % on NRB ED
weight 160, ICU 166 lbs
Gen: Elderly aged male with rapid breathing. Able to speak, but
not more than short sentences. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mucous
membranes were dry
Neck: Supple with JVP 16 cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, soft S3. Systolic murmur at RUSB
Chest: Resp were rapid, abdominal movement with breathing.
Crackles at upper lung fields, dullness at bases.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 1+ lower extremity bilateral edema. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ ; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ ; 2+ DP
Pertinent Results:
Admission labs:
Trop-T: 0.07
CK: 52 MB: Notdone
.
143 107 61
---------------< 213
4.7 24 2.7
proBNP: 5006
.
WBC: 8.9
HCT: 41
Plt: 193
N:78.4 L:16.0 M:3.9 E:1.5 Bas:0.2
.
PT: 16.9 PTT: 150 INR: 1.5
.
[**2113-1-2**]: ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg.There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal severe hypokinesis
of the basal inferior wall. The remaining segments contract
normally (LVEF = 50 %). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened. No aortic valve stenosis is present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-9**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2112-9-15**], the
severity of mitral regurgitation is slightly increased. :Left
ventricular systolic function is similar.
.
CLINICAL IMPLICATIONS:
Based on [**2112**] 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.
.
[**2113-1-3**] CXR:
Comparison is made to prior study performed a day earlier.
Cardiac size is normal. Small bilateral pleural effusions
greater in the left side are unchanged. There is persistent
left lower lobe retrocardiac
atelectasis, moderate pulmonary edema is unchanged
.
EKG: Sinus rhythm. Incomplete left bundle-branch block.
Non-specific ST-T wave changes. Prolonged QTc interval. Compared
to tracing of [**2113-1-2**] no
significant change. QTc 483
.
MRI BRAIN: There are no areas of abnormal restricted diffusion.
There is no evidence of intracranial hemorrhage, mass effect, or
shift of normally midline structures. [**Doctor Last Name **]-white matter
differentiation is preserved. There is mild diffuse global
atrophy. Periventricular white matter FLAIR hyperintensity along
with a few focal areas within the deep and subcortical white
matter bilaterally are consistent with chronic microvascular
infarctions. Old small infarctions are noted within the
cerebellum bilaterally. The left maxillary sinus is opacified.
The mastoid air cells and surrounding osseous and soft tissue
structures are unremarkable.
IMPRESSION: No evidence of infarction.
.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man walking w/ PT. Hurt ankle while walking.
REASON FOR THIS EXAMINATION:
Looking for fractures
INDICATION: [**Age over 90 **]-year-old man hurt ankle while walking.
COMPARISON: None.
THREE VIEWS OF THE LEFT ANKLE
There is no evidence of acute fracture or dislocation. The talar
dome is intact and the mortise is grossly congruent. Vascular
calcifications noted.
IMPRESSION: Unremarkable views of the left ankle.
.
[**1-3**] CXR: REASON FOR EXAM: Cardiac failure exacerbation.
Comparison is made to prior study performed a day earlier.
Cardiac size is normal. Small bilateral pleural effusions
greater in the left side are unchanged. There is persistent left
lower lobe retrocardiac atelectasis, moderate pulmonary edema is
unchanged.
.
TRENDS:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-1-6**] 4.5 3.99* 12.5* 36.2* 91 31.3 34.4 14.8 172
[**2113-1-5**] 4.7 4.13* 12.5* 37.1* 90 30.1 33.6 15.0 172
[**2113-1-4**] 4.7 4.14* 12.7* 37.0* 89 30.7 34.3 15.1 151
[**2113-1-3**] 6.0 4.07* 12.3* 36.1* 89 30.3 34.2 15.1 179
[**2113-1-2**] 5.7 4.27* 13.2* 39.0* 91 31.0 33.9 15.0 196
[**2113-1-2**] 8.9# 4.59* 14.3 41.1 90 31.1 34.7 15.1 193
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-1-6**] 06:05AM 132* 80* 3.1* 143 3.7 102 29 16
[**2113-1-5**] 06:15AM 127* 80* 3.3* 142 4.0 101 28 17
[**2113-1-4**] 06:40PM 200* 79* 3.4* 139 3.9 101 28 14
[**2113-1-4**] 05:50AM 132* 82* 3.5* 139 3.9 100 28 15
[**2113-1-3**] 05:43PM 113* 79* 3.6* 139 3.6 99 27 17
[**2113-1-3**] 06:33AM 111* 76* 3.3* 137 4.1 101 26 14
LP ADDED 12:45PM
[**2113-1-2**] 11:37PM 146* 73* 3.2* 141 3.6 103 25 17
[**2113-1-2**] 04:06PM 170* 68* 3.0* 139 4.21 104 27 12
[**2113-1-2**] 09:28AM 179* 65* 2.9* 140 4.5 103 27 15
[**2113-1-2**] 01:15AM 213* 61* 2.7* 143 4.7 107 24 17
[**2112-12-21**] 05:49PM 60* 2.6* 142 3.5 104 27 15
.
CK: 52 - 45 - 36 - 36
Trop: 0.07 - 0.08 - 0.08 - 0.09
.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2113-1-3**] 06:33AM 199 160*1 28 7.1 139*
Brief Hospital Course:
Hospital course by problem:
.
Diastolic CHF exacerbation: Systolic function relatively
preserved, 50% LVEF. Ruled out for acute MI, likely etiology of
CHF exacerbation was hypertension and dietary indescretion.
Patient was admitted to the CCU initially and had a significant
O2 requirement. He had an echo which showed slightly worse
mitral regurgitation but no other changes when compared to his
previous echo in [**2112-9-7**]. His home weight is 156-160 lbs
(dry weight), his weight upon [**Year (4 digits) **] was 158. Diuresis was
acheived with IV lasix. He will continue on his aspirin, beta
blocker and hydralazine, imdur was added to his regimen to
provide some decrease in preload and BP and also to provide a
survival benefit in heart failure. He should continue a low
sodium diet and a fluid restriction to 1.5 liters per day. He
will continue his home lasix dose of 40mg po daily.
.
TIA/Neuro: On [**1-5**], patient had dysarthia. Neuro was consulted
(pls see OMR note for details). MRI was obtained as above. His
symptoms rapidly resolved. This was considered a TIA. A
carotid u/s was pending upon [**Month/Year (2) **] and he has f/u with
neuro. He should remain on atorvastatin 80 and ASA 325.
.
Hypercholesterolemia- total 199, trig 160, LDL 139, HDL 28.
Lipitor 40mg po daily was added to his regimen. This was
increased to 80mg daily after his TIA.
.
Renal insufficiency: Baseline from last hospitalization appears
to be approx 2.2. Currently with slight elevation, but likely
in the setting of CHF exacerbation. Creatinine initially
increased with diuresis to a peak Creatinine of 3.6, this
trended downward to 3.4 upon [**Month/Year (2) **]. He likely had some
renal impairment not only from his CHF exacerbation but also
during his diuresis, as his home regimen was reinstated he was
diuresing well and Creatinine was improving. Continue to trend
creatinine while on lasix as an outpatient. Patient will follow
up with his outpatient nephrologist Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] in
[**2113-1-7**].
- please check a repeat electrolyte panel in [**2-9**] weeks.
.
Code status; Pt requests to be resuscitated but NOT intubated
.
Communication: Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73985**] [**Telephone/Fax (1) 73986**]
Medications on Admission:
ASPIRIN 325 mg--1 tablet(s) by mouth daily
COLACE 100 mg--1 capsule(s) by mouth twice a day
COREG 25 mg--1 tablet(s) by mouth twice a day
DEBROX 6.5 %--5 drops both ears at bedtime for 7 days in both
ears starting [**2113-1-18**]
GLIPIZIDE 2.5 mg--1 tab(s) by mouth daily
HYDRALAZINE 25 mg--1 tablet(s) by mouth three times a day with
50mg tablet
Hydralazine 50 mg--1 tablet(s) by mouth three times a day
LASIX 40 mg--1 tablet(s) by mouth daily
NEURONTIN 100 mg--2 capsule(s) by mouth three times a day
SENOKOT 8.6 mg--1 tablet(s) by mouth twice a day
[**Month/Day/Year **] Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
9. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
10. Neurontin 100 mg Capsule Sig: Two (2) Capsule PO three times
a day.
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Hospital **] rehab
[**Hospital **] Diagnosis:
Primary diagnosis:
- Acute on Chronic Diastolic Heart Failure
- Status post TIA
- CAT s/p AMIs in the past
- CKD
- DMII
Secondary:
- PUD in past
- HTN
- hx testicular cancer
[**Hospital **] Condition:
stable
[**Hospital **] Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters per day
You were admitted with high blood pressure (hypertension) and
fluid overload. The fluid was taken off you with diuretic
medications (lasix). Your breathing improved.
Additionally, you likely had a TIA while you were admitted. You
had mild symptoms which resolved on their own. This is likely a
result of your coronary artery disease. You should continue to
take all your medications as directed and follow up with your
doctor [**First Name (Titles) **] [**Last Name (Titles) **].
You should call your doctor if you have any weight gain greater
than 3 pounds, shortness of breath, chest pain or any other
concerning symptom.
Please note that you have some medication changes:
1. Imdur is added to your regimen
2. You have been started on lipitor
Followup Instructions:
You have the following appointments:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2113-1-11**]
2:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], D.O. Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2113-1-25**] 1:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2113-1-25**] 1:30
Please see Dr. [**Last Name (STitle) **] in neurology on [**2-22**] at 2:30.
His office is in [**Hospital Ward Name 23**] [**Location (un) **]. His number is [**Telephone/Fax (1) **]
|
[
"435.9",
"V10.47",
"425.4",
"414.01",
"272.0",
"403.90",
"585.9",
"250.00",
"412",
"428.0",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9158, 9158
|
244, 251
|
4454, 4454
|
14243, 14899
|
3409, 3499
|
7042, 7115
|
11520, 13086
|
3514, 4435
|
5602, 7005
|
14149, 14220
|
197, 206
|
7144, 9135
|
9186, 11494
|
279, 2714
|
4470, 5579
|
13105, 14129
|
2736, 3023
|
3039, 3393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,372
| 103,641
|
37681
|
Discharge summary
|
report
|
Admission Date: [**2113-11-10**] Discharge Date: [**2113-11-14**]
Date of Birth: [**2063-12-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 m with history of EtOH abuse and withdrawal seizures, now
transferred from [**Hospital **] Hospital with acute subdural hematoma.
Patient reports he fell off bicycle approximately 1 week ago. He
was unhelmeted and hit head, although denies LOC. Since the
fall,
he has experienced frontal headaches and nausea. Patient reports
drinking 1pint Vodka per day "to ease the pain." Over the past
few days, patient had 2-3 episodes of emesis - non-bloody,
non-bilious. No fever or chills. Denies dizziness, unsteady
gait,
loss of balance. On presentation to [**Hospital **] Hospital, patient
had
tonic-clonic seizure - lasted <1 minute and was given 2mg ativan
with cessation of seizure. The patient was subsequently
transferred to [**Hospital1 18**] for further neurosurgical evaluation.
Past Medical History:
PMH: EtOH abuse, withdrawal seizures - 3 hospitalizations w/in
past 1 year
PSH: L. inguinal hernia repair
Social History:
EtOH per HPI, smokes 1 ppd cigarettes, denies recreational
drug use
Family History:
non contributory
Physical Exam:
T: 97.4 BP: 151/95 HR:83 R:16 O2Sats: 97%RA
A&O X 3, comfortable, NAD
PERRL, 3 to 2mm bilateral, EOMI
No neck pain on palpation. C-collar in place.
RRR
Lungs CTAB
Abdomen soft, NT/ND, normal bs
L. flank bruise, non-tender
L. thigh bruise, non-tender
LE warm b/l
Pertinent Results:
[**2113-11-10**] 12:50AM WBC-9.6 RBC-3.63* HGB-11.9* HCT-34.0* MCV-94
MCH-32.9* MCHC-35.1* RDW-13.3
[**2113-11-10**] 12:50AM NEUTS-91.2* LYMPHS-5.2* MONOS-3.0 EOS-0.4
BASOS-0.2
[**2113-11-10**] 12:50AM PLT COUNT-195
[**2113-11-10**] 12:50AM PT-10.6 PTT-24.3 INR(PT)-0.9
[**2113-11-10**] 12:50AM ASA-NEG ETHANOL-NEG CARBAMZPN-4.3
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-11-10**] 12:50AM GLUCOSE-256* UREA N-4* CREAT-0.6 SODIUM-127*
POTASSIUM-3.0* CHLORIDE-87* TOTAL CO2-30 ANION GAP-13
[**2113-11-10**] 10:45AM CALCIUM-8.9 PHOSPHATE-2.3* MAGNESIUM-2.0
[**2113-11-10**] 10:45AM GLUCOSE-121* UREA N-4* CREAT-0.6 SODIUM-130*
POTASSIUM-3.4 CHLORIDE-92* TOTAL CO2-27 ANION GAP-14
[**2113-11-14**] 06:05AM BLOOD WBC-6.3 RBC-3.71* Hgb-11.8* Hct-35.3*
MCV-95 MCH-31.7 MCHC-33.3 RDW-14.4 Plt Ct-328
[**2113-11-14**] 06:05AM BLOOD Glucose-119* UreaN-7 Creat-0.7 Na-136
K-3.8 Cl-99 HCO3-29 AnGap-12
[**2113-11-14**] 06:05AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8
[**2113-11-10**] C Spine CT :
1. No fracture or malalignment of the cervical spine.
2. Posterior disc bulge at C4-5 contacting the thecal sac. If
neurologic
symptoms are referable to this location, MRI is recommended for
assessment of the spinal cord.
[**2113-11-10**] Head CT :1. Stable appearance of right subdural hematoma
overlying the right cerebral convexity and layering within the
falx and left tentorium. This is unchanged from the prior study
of approximately three and a half hours earlier.
2. No new areas of hemorrhage. No herniation.
[**2113-11-10**] Abd CT : . Possible acute, nondisplaced fractures of
posterior right 9th-12th ribs superimposed upon chronic
fractures in this location. Correlate clinically.
2. No retroperitoneal hematoma.
3. Markedly distended urinary bladder.
[**2113-11-10**] Repeat Head CT :
The right frontal subdural mixed-density hematoma is relatively
stable. There is also stable subdural along the left tentorial
reflection. There is encephalomalacia, left greater than right
inferior frontal lobes which may be related to prior trauma and
is unchanged.
The ventricles and sulci are stable in size and configuration.
IMPRESSION:
No significant change compared to the prior study.
[**2113-11-13**] Echo:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic 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 appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 84474**] was admitted to the hospital for close neurologic
observation and monitoring of his vital signs. He was admitted
to the hospital on Tegretol and therefore did not receive
Dilantin. He was followed by the Neurosurgery service and a
repeat head CT was done 24 hours after admission and revealed no
shange in the hematoma. His neuro exam did not change. His
tegretol level was 4.3. He did not have any seizures during his
hospitalization. Valium was used to treat the signs and
symptoms of withdrawal.
On multiple occasions he was seen by the social worker to help
assess his adiction needs as well as his families needs. Mr.
[**Known lastname 84474**] has been doing poorly for many months and his drinking has
put him in a dangerous situation in regards to his safety and
his families ability to cope and care for him.
He developed rapid atrial fibrillation on [**2113-11-12**] with a
ventricular response to 150 BPM. This prompted transfer to the
ICU for treatment with a diltiazem drip. He denied chest pain,
shortness of breath, nausea or vomiting and serial enzymes were
negative. A cardiac echo was done which showed a normal EF and
no wall motion abnormalities. He converted to sinus rhythme
about 24 hours later and was converted to oral Lopressor. His
heart rate was maintained at 74 bpm.
Following his transfer back to the Trauma floor he was up and
walking without difficulty, tolerating a regular diet and
preparing to deal with his addictions problem. [**Name (NI) 3003**] to
discharge he had a PPD placed. He remained in sinus rhythm,
vital signs were stable, pain well controlled.
Medications on Admission:
Tegretol 20mg [**Hospital1 **], Metoprolol 25mg [**Hospital1 **], Flonase prn
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. right subdural hematoma
2. Right rib fractures [**10-21**]
3. Atrial fibrillation, now resolved
Discharge Condition:
stable
Discharge Instructions:
DO NOT DRINK ANY ALCOHOL
?????? Take your pain medicine as prescribed but gradually wean it
off.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
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:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 84475**] for a follow up appointment in 2
weeks
Call Dr. [**Last Name (STitle) 2093**] for a follow up appointment in [**2-10**] weeks.
Arrange for [**Hospital **] Rehabilitation based on the Social Workers
recommendations
Have and MD [**First Name (Titles) **] [**Last Name (Titles) **] read the PPD that was placed prior to DC
between 48-72h after placement.
|
[
"E849.5",
"300.00",
"807.03",
"427.31",
"851.81",
"303.01",
"E826.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6975, 6981
|
4664, 6303
|
327, 334
|
7124, 7133
|
1704, 4641
|
8155, 8581
|
1380, 1398
|
6432, 6952
|
7002, 7103
|
6329, 6409
|
7157, 8132
|
1413, 1685
|
278, 289
|
362, 1148
|
1170, 1278
|
1294, 1364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,493
| 117,146
|
18223
|
Discharge summary
|
report
|
Admission Date: [**2150-3-24**] Discharge Date: [**2150-3-27**]
Date of Birth: [**2092-8-31**] Sex: F
Service: MEDICINE
Allergies:
Diphenhydramine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
Pt is a 57 year old female with relapsed stage II C, grade II
papillary serous ovarian cancer on Phase I trial (SNS 032)
presenting with hypoxia, worsening [**Last Name (NamePattern4) **].
.
Pt has known history of lung parenchymal disease from her
ovarian cancer as well as bilateral pleural effusions. She was
started on phbase 1 trial of Sunesis on [**3-23**]. Has developed
progressive SOB, [**Month/Year (2) **], hypoxia with low grade fever (in the ED)
over this time. Wears oxygen at baseline and has been having
increasing requirement from 2L up to 5L oxygen. At baseline,
patient is able to walk around her house, but unable to walk
short distances without becoming SOB. She denies fevers at home,
sick contacts, productive [**Name2 (NI) **], hemoptysis, chest pressure,
pleuritic chest pain, or lightheadedness on standing. Patient
was intiially found in the ED to have O2sats to 85% on RA, up to
94% on NRB, with HR 100-130s. CTA negative for PE. Patient was
found to have increased bilateral pleural effusions from prior.
Patient admitted to ICU for hypoxia.
.
ROS: Recently has noted some N/V. Also mild constipation. Also
complaining of significant fatigue. Patient denies significant
abdominal pain, headache, chills, weight loss, bruising or
bleeding.
.
Onc History:
Dx'd [**8-/2140**] with Stage IIC ovarian cancer. Pathology showed serous
papillary adenocarcinoma. She underwent TAH, Rt SPO and
cytoreduction which did not remove all lesions. She was then
treated with six cycles of carboplatin and Taxol until
[**2140-12-16**]. She relapsed in [**2146-1-9**] in the form of a mass
in the left hemipelvis. She underwent a second cytoreductive
surgery on [**2146-1-18**] followed by four cycles of carboplatin and
Taxol until [**2146-4-9**], which was discontinued because of
disease progression. She was then treated with topotecan 1.25
mg/m2 x5 days IV every three weeks for four cycles from [**Month (only) 547**]
[**2146**] until [**2146-7-10**] that was discontinued because of a rise in
her CA-125. She was treated with Doxil 40 mg per meter squared
for two cycles on [**2146-8-30**] and [**2146-9-30**], which was
discontinued because of disease progression based on a CA-125
that was rising.
She also developed a rash, mucositis, and hand-foot syndrome.
She has been on weekly Taxol and Arimidex from [**2146-11-9**] to
[**2148-12-10**] and this was discontinued because of disease
progression. She received three cycles of gemcitabine but had
significant
disease progression. She was then on Navelbine in [**Month (only) 958**] but
discontinued this in [**2149-7-10**] due to disease progression. She
was treated with Xeloda but progressed on this therapy. She was
started on oral etoposide in [**2149-11-9**] but discontinued it in
[**12-15**] [**3-13**] GI side effects and fatigue.
.
Currently on started phase 1 trial on [**3-23**] with Sunesis.
Past Medical History:
- IBS
- Anxiety
- metastatic ovarian ca as above.
Social History:
She has been married for over 30 years. She has 2 kids and 1
grandchild. No alcohol or tobacco use. She lives at home with
her husband.
Family History:
Mother and sister with breast cancer
Physical Exam:
T 100.4 BP 120/88 HR 120s RR 93% O2sat on NRB. RR 33.
Gen: Awake, increased WOB. Coughing throughout interview.
HEENT: PERRL, EOMI, clear OP, anicteric, mucous membranes dry.
Neck: No LAD, JVD. +Supraclavicular lymph node 1 cm rubbery.
Lymph: Right supraclavicular LN. Left axillary LN. No cervical
or inguinal LAD.
Lungs: Decreased BS throught left lung. Dullness to percussion
over left lung, and base of right lung. No wheezing, rales, or
rhonchi.
Heart: Tachycardic.
Abd: Soft, NT, ND +BS. Purplish subcutaneous 3 cm nodule to left
of umbilicus, representing metastatic disease.
Ext: No edema, 2+ DP/PT.
Neuro: A&O times 3, no focal deficits
Pertinent Results:
.
Labs/studies:
138 100 16 / 107 AGap=13
------------
3.8 29 0.6 \
Ca: 7.9 Mg: 2.0 P: 3.9
ALT: 28 AP: Tbili: 0.3
AST: 26
UricA:2.6
85
6.8 D \ 14.5 / 440
--------
43.0
N:74.3 Band:7.9 L:6.9 M:8.9 E:0 Bas:0 Atyps: 2.0
.
CXR- As best can be compared across modalities, there is a
markedly
stable radiograph with bilateral pleural effusions, left much
greater than right. The left effusion has loculated components
with a large intrafissural subcomponent as well.
.
CTA Chest:
1. No pulmonary embolism. No aortic dissection.
2. Interval worsening of large left loculated pleural effusion
and small right pleural effusion.
3. Similar appearance of right lower lobe total consolidation
due to
aspiration.
4. Interval slight worsening of thoracic metastatic disease.
Brief Hospital Course:
This is a 57 yo female with relapsing ovarian cancer with
metastatic disease to the lymph nodes, lungs, pleural effusions
presents with worsening dyspnea.
.
1. [**Name (NI) 1621**] Pt. with known bilateral pleural effusions secondary
to malignant effusions from ovarian cancer. She just started a
phase 1 chemotherapy trial with SNS03 on [**3-23**] and presented to
[**Hospital1 **] with SOB. There was no evidence of PE on CTA but the CT did
show worsening of the loculated bilateral pleural effusions,
which was the most likely etiology of her dyspnea. She also had
low grade fevers and was immunosupressed from chemotherapy.
Therefore, she was started on levofloxacin for possible
underlying pneumonia. The patient was oxygen dependent was
being treated with standing nebulizer treatments. Additionally,
we performed a therapeutic thoracentesis under ultrasound
guidance. Overtime the shortness of breath did not improve,
despite these measures. The patient continued to deteriorate. A
family meeting was called to discuss further options for
intervention and goals of care. After extensive conversation
with the attending and the family and patient, the following was
decided upon: no further chemotherapy, no further interventions.
The patients code status was made DNR/DNI and the focus of her
care became comfort measures. The patient expired on [**2150-3-27**] at
3:20pm with her family at her bedside.
2. Ovarian Cancer- Unfortunately the patient had relapsed
disease and failed multiple chemo regimens. On presentation to
[**Hospital1 **] she was on a phase 1 trial drug, sunesis. The decision was
made to stop chemotherapy.
Medications on Admission:
- Paxil 20 mg daily
- Centrum Silver multivitamin 1 tablet daily (start unknown)
- Warfarin 1mg daily
- Lorazepam 1 mg prn
- Ambien 10mg qpm
- Albuterol Nebulizer PRN (approx 3 times a week)
- Chemotherapy regimen Sunesis Cycle 1/Day 2
- Prednisone (recently completed course - ?for breathing)
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
ovarian cancer
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2150-3-27**]
|
[
"486",
"197.2",
"V10.43",
"196.2",
"285.22",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7004, 7013
|
4987, 6626
|
291, 307
|
7072, 7083
|
4179, 4964
|
7140, 7316
|
3459, 3497
|
6971, 6981
|
7034, 7051
|
6652, 6948
|
7107, 7117
|
3512, 4160
|
244, 253
|
335, 3214
|
3236, 3288
|
3304, 3443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,044
| 156,214
|
33161
|
Discharge summary
|
report
|
Admission Date: [**2193-1-5**] Discharge Date: [**2193-1-28**]
Date of Birth: [**2153-5-27**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Fall from window
Major Surgical or Invasive Procedure:
s/p ICP Bolt placement and removal
s/p Chest tube placement and removal
History of Present Illness:
39 year old male who presented as a trauma transfer from a
referring hospital after he presumedly fell from a window
approximately 30 feet high. Paramedics at the scene found him on
the ground and unresponsive with a GCS of 3. He was intubated
and stabilized at the referring hospital and subsequently
transferred to [**Hospital1 18**] for further care.
Past Medical History:
Depression
Social History:
Past history of suicide attempt per family
History of drug and alcohol abuse per family
Family History:
Noncontributory
Physical Exam:
Upon admission:
HR 92
BP 101/57
RR 18
O2 100% on vent, AC mode
Generally, there is hemotympanum behind right ear drum, +right
ear CSF leakage. No Battle's sign, raccoon eyes, CSF
rhinorrhea.
Prior to additional Versed, unresponsive to voice. Does not
open
eyes spontaneously or in response to noxious. Does not follow
commands.
Pupils 2.5-2mm, equal, round, reactive. No blink to threat.
OCR
not tested as in hard collar. Face grossly symmetric. +Gag.
Normal bulk, tone. Moves all extremities spontaneously,
somewhat
more often and vigorously on the left. Withdraws to noxious.
No clonus, toes upgoing.
Pertinent Results:
Admit:
[**2193-1-5**] 08:55PM TYPE-ART TEMP-38.3 RATES-18/ TIDAL VOL-500
PEEP-5 O2-40 PO2-125* PCO2-30* PH-7.36 TOTAL CO2-18* BASE XS--6
-ASSIST/CON INTUBATED-INTUBATED
[**2193-1-5**] 05:28PM GLUCOSE-99 UREA N-5* CREAT-0.6 SODIUM-143
POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-15* ANION GAP-17
[**2193-1-5**] 05:28PM CALCIUM-7.0* PHOSPHATE-2.5* MAGNESIUM-2.2
[**2193-1-5**] 01:11PM LACTATE-2.7*
[**2193-1-5**] 09:20AM WBC-11.2* RBC-2.91* HGB-9.7*# HCT-29.4*
MCV-101* MCH-33.4* MCHC-33.0 RDW-15.0
[**2193-1-5**] 06:51AM AMYLASE-162*
[**2193-1-5**] 06:51AM ASA-NEG ETHANOL-316* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2193-1-5**] 06:51AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN
Reason: Assess interval change
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with left epidural and right IPH
REASON FOR THIS EXAMINATION:
Assess interval change
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 39-year-old man with left epidural and right
intraparenchymal hemorrhage. Assess for interval change.
COMPARISON: Head CT from five hours prior.
NON-CONTRAST HEAD CT: Lentiform high-density collection in the
right temporoparietal space with adjacent sulcal effacement is
stable measuring 8 mm in greatest diameter. Convex subdural
hemorrhage layering over the left frontoparietal cortex is also
stable measuring 6 mm in greatest diameter. Left frontal lobe
hemorrhagic contusion is stable measuring 2.2 x 1.0 cm with a
rim of surrounding edema and associated subarachnoid hemorrhage
extending into the adjacent sulci. Two millimeters of rightward
midline shift is stable. There is no evidence of
intraventricular hemorrhage.
Dedicated bone windows were not obtained due to the recent CT.
Again seen is a complex temporal bone fracture extending through
the middle ear, into the sphenoid bone and involving the right
sphenoid sinus. This fracture extends in the vicinity of the
right cavernous sinus. Again seen is opacification of the
sphenoid sinuses, ethmoid air cells, right mastoid air cells and
right inner ear cavity from hemorrhage.
An intracranial pressure monitor bolt has been inserted via the
left frontal calvarium terminating in the subcortical white
matter.
IMPRESSION:
Interval placement of an intracranial pressure monitor bolt. No
significant interval change in right epidural hematoma, left
subdural hematoma, left intraparenchymal hemorrhage with
associated subarachnoid hemorrhage, and complex right temporal
bone fracture. The fracture is again noted to extend to the
sphenoid sinus in close proximity to the right cavernous carotid
artery, and a CT angiogram is recommended to exclude vascular
injury, as [**First Name9 (NamePattern2) **] [**Male First Name (un) **] prior CT head.
Repeat [**2193-1-13**] CT HEAD W/O CONTRAST
Reason: assess for worsening or new bleed s/p fall
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with intracranial hemorrhage s/p fall from
standing when getting out of bed.
REASON FOR THIS EXAMINATION:
assess for worsening or new bleed s/p fall
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 39-year-old male with intracranial hemorrhage status
post fall.
COMPARISON: CT head from [**2193-1-12**].
TECHNIQUE: MDCT contiguous axial images were obtained through
the head without intravenous contrast.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: Lentiform high-density
collection in the right parietal region consistent with epidural
hematoma is stable measuring approximately 12 mm in greatest
diameter. The left frontal parenchymal hemorrhage with
surrounding edema appears unchanged in size. Left frontal and
temporal subarachnoid blood as well as left frontoparietal, and
tentorial and occipital subdural hemorrhage are unchanged. No
evidence of shift of normally midline structures, hydrocephalus
or major territorial infarcts are seen. The basal cisterns are
not effaced. The ventricles are stable in size. There is stable
complex right temporal bone fracture and opacification of the
right middle ear and inferior right mastoid air cells.
Aerosolized hyperdense material within the sphenoid sinus
consistent with blood products is again demonstrated. There is
mild fluid/mucosal thickening within the left maxillary sinus
which is stable.
IMPRESSION: Overall no significant change in hemorrhage as
described above. No evidence of new hemorrhage, mass effect,
hydrocephalus or acute infarction.
[**2193-1-11**] CHEST (PA & LAT)
Reason: Please perform between [**11-6**] and evaluate for PTX
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with PTX now with chest tube placed to water
seal
REASON FOR THIS EXAMINATION:
Please perform between [**11-6**] and evaluate for PTX
HISTORY: Pneumothorax with chest tube on waterseal.
FINDINGS: In comparison with the study of [**1-10**], there is little
overall change. Pleural thickening or fluid is again seen along
the right lateral chest wall and in the right apex. No definite
pneumothorax.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery was
immediately consulted given his head injuries. He was loaded
with Dilantin. An ICP bolt was placed; he was subsequently taken
to the Trauma ICU for close monitoring. He initially remained
sedated and intubated for several days in the ICU. Serial head
CT scans were followed and remained stable. The ICP bolt was
eventually removed and his sedation was weaned; he was then
extubated. His mental status once fully awake was consistent
with someone with a traumatic brain injury. He was
intermittently restless with poor safety awareness therefore
requiring a 1:1 sitter. There were no aggressive behaviors
noted. The 1;1 sitters were eventually discontinued and he
remains cooperative; alert and oriented to self and family;
occasionally to place and time. He will continue on Dilantin
until follow up with Dr. [**First Name (STitle) **], Neurosurgery, in 4 weeks. He
will undergo repeat head CT imaging at that time.
Orthopedics was consulted given his right scapular fracture;
this injury was nonoperative. He was placed in a sling and will
follow up in [**Hospital 5498**] clinic in 4 weeks for repeat imaging.
He was also noted to have increased right shoulder pain with
movement; a repeat shoulder film was obtained and revealed a
right AC separation. He is to remain non weight bearing on that
extremity and continue to wear sling for comfort. He will follow
up with Dr. [**Last Name (STitle) 2719**] [**1-30**] (see appointment on discharge
worksheet), at that time a plan will be discussed regarding
repair of his shoulder.
A Psychiatry consult was done given some question of previous
suicide attempts per family report and question as to whether or
not this was such an attempt. Because he has been unable to give
any account of what transpired prior to his fall; this a result
of his brain injury; he was not deemed a risk to harm himself.
It was recommended discontinuing the use of Ativan and he was
started on Olanzapine which has been effective. It was requested
by the rehab facility that the Olanzapine be stopped and so it
was discontinued. There have not been any behavioral issues
since stopping this medication.
Social work was closely involved in his care throughout his stay
providing emotional support for patient and his family.
Physical and Occupational therapy were consulted and initially
recommended rehab post acute hospital stay. Functionally he has
had significant improvements; cognitive because of his short
term memory there are safety concerns. Occupational therapy has
continued to work with him for cognitive training.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month (only) **]: Two (2) Tablet PO every four
(4) hours as needed for fever/pain.
2. Senna 8.6 mg Tablet [**Month (only) **]: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
6. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 4-6 hours as
needed for pain.
7. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day as
needed for constipation.
8. Dilantin Infatabs 50 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet,
Chewable PO three times a day for 2 weeks.
9. Multivitamin,Tx-Minerals Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
s/p Fall
1) Traumatic Brain Injury
2) Multiple Right Rib Fractures
3) Right Scapular Fracture
4) Right AC separation
5) Right Pneumothorax
Discharge Condition:
Good
Discharge Instructions:
DO NOT bear any weight on your right arm because of your
fracture.
Continue to wear a sling for comfort.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in approximately 2 weeks. You
may call his office at [**Telephone/Fax (1) 6429**] to schedule an appointment.
Follow up with Dr. [**Last Name (STitle) 2719**], Orthopedics, on [**2193-1-30**] at 1:50 p.m.
for your right shoulder dislocation. He will discuass with you
surgery options at that time.
Follow up with Dr. [**First Name (STitle) **], Neurosurgery, in 2 weeks, call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that a
repeeat head CT scan will be needed for this appointment.
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 4 weeks for your
right scapular fracture. Call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2193-1-28**]
|
[
"958.7",
"458.9",
"811.00",
"292.0",
"V64.2",
"864.05",
"311",
"860.0",
"388.61",
"304.21",
"E849.8",
"801.26",
"V15.81",
"E957.0",
"807.08",
"861.21",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.10",
"96.72",
"34.04",
"38.93",
"94.68",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10393, 10440
|
6623, 9240
|
283, 357
|
10623, 10630
|
1564, 2387
|
10784, 11540
|
895, 912
|
9300, 10370
|
6183, 6249
|
10461, 10602
|
9266, 9275
|
10654, 10761
|
927, 929
|
227, 245
|
6278, 6600
|
385, 740
|
2748, 4487
|
943, 1545
|
762, 774
|
790, 879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
235
| 117,941
|
25580
|
Discharge summary
|
report
|
Admission Date: [**2137-7-8**] Discharge Date: [**2137-7-12**]
Date of Birth: [**2060-4-14**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
77y/o M with DM2, CAD s/p 3v CABG, HTN, Hypercholesterolemia,
CHF, developed chest pain at around 7pm while watching the
begining of the red sox game. His pain was across his chest,
[**1-3**], non radiating, no shortness of breath, did have some
associated lightheadedness/dizziness and weakness, no
diaphoresis, no n/v. He took 1 old [**Month/Year (2) 9181**] without relief then
went to his neighbors house who then gave him two [**Name (NI) 9181**] from
hers but did not help with the chest pain either. There he was
having visual blurriness/double vision. She took his blood
pressure which was 112/66, his pain at that time had increased
to [**8-3**]. His friend then convinced him to let her call 911, EMS
arrived by 9pm. They transported him to [**Hospital 1474**] hospital, upon
arrival his cp was [**3-3**] ECG was read at STEMI by ED, he was
given 3 additional [**Month/Year (2) 9181**] with min relief, decreasing his pain to
[**1-31**]. They then gave him lopressor 5mg iv x one, heparin 4000U x
one, placed him on oxygen and then med flighted him to [**Hospital1 18**] for
emergent cath.
Here he was started on heparin iv, integrellin iv and was taken
up to cardiac cath.
Cath showed:
HD: Ao 150/66, right dominant system
LMCA: mod disease
LAD: diffusely diseased w/ serial 60% and 70% stenosis, D1 is a
large vessel w/ 90% stenosis.
Lcx: TO px, a large OM fills via L-L collaterals
RCA: TO px, the PDA and PL fill via L-R collaterals
SVG-RCA: atritic and occluded
SVG-OM: TO px
LIMA-LAD: atritic w/o flow into LAD.
Past Medical History:
1. DM2 for 6 years
2. CAD s/p 3v CABG
3. HTN
4. Hypercholesterolemia
5. CHF
Social History:
TOB: 2 packs for 40yrs, quit in [**2123**]
ETOH: quit in 80's.
Lives by self, does ADLS by self, drives. Walks with cane.
Family History:
Father died 66 from heart failure
Mother died 59 from cervical cancer.
Diabetes in fathers family as well as heart disease.
Physical Exam:
T: 93.1 axillary, BP: 131/63, HR: 59, 98% 2L NC
GEN: AxOx3, NAD, pleasant male with family in room
HEENT: EOMI, PERRL, mmdry, o/p clear
NECK: no JVP appreciated, no bruits appreciated
CV: RRR, no m/r/g, normal s1/s2
PULM: CTA b/l, no w/r/r
ABD: large, bowel sounds present, obese, NT/ND
EXT: no c/c, edema present to mid legs 1+ b/l. DP/PT palpated
1+ b/l
Neuro: CN II-XII grossly intact.
Groin: right groin w/o hematoma, non tender, no bruit
appreciated, gauze and dressing in place with minimal blood
staining.
Pertinent Results:
ECG: sinus 68, inferior q waves, 1mm ST depression I, AVL.
*******************
CATH
1. Severe three vessel native coronary artery disease.
2. All three bypass grafts occluded.
Carotid Series + Venous Duplex
1. Findings consistent with 40%-59% stenosis of the right
internal carotid artery secondary to atherosclerotic plaque.
2. Occlusion of the left internal carotid artery.
3. Nonvisualization and query occlusion of the right vertebral
artery.
4. Patent left greater saphenous vein with dimensions provided
above.
*******************
ECHO
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is very
mildly depressed with focal basal inferior and infero-lateral
thinning and akinesis The remaining LV segments appear
hyperdynamic. Right ventricular chamber size and free wall
motion are normal.
The aortic root is moderately dilated. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
*******************
P-MIBI
Moderate inferior and inferolateral partially reversible
perfusion
defect. Mild global hypokinesis that is worse in the region of
the patient's perfusion defects. EF 45%
********************
Stress
No angina and no EKG changes suggestive of ischemia. Nuclear
report sent separately.
********************
[**2137-7-9**] 01:25PM BLOOD CK-MB-13* MB Indx-10.2* cTropnT-0.13*
[**2137-7-8**] 11:30PM BLOOD CK-MB-4 cTropnT-0.01
[**2137-7-9**] 01:25PM BLOOD CK(CPK)-128
[**2137-7-8**] 11:30PM BLOOD CK(CPK)-87
Brief Hospital Course:
A/P: 77y/o M with DM2, CAD s/p 3v CABG, HTN,
Hypercholesterolemia, [**Hospital 27810**] transferred from [**Hospital 1474**] hospital
for STEMI and found to have severe 3VD w/ occluded grafts on
cath, no STEMI. Had cardiac cath w/ no intervenable lesions but
with severe 3vd and occluded grafts. ECG reread and no evidence
of STEMI though sent over for emergent intervention. Start
metoprolol 25mg [**Hospital1 **], aspirin 325mg once a day, atorvastatin 80mg
once a day, no lisinopril given ARF, c/w integrellin, heparin
o/n. Patient did not want to undergo any further surgical
intervention and so patient was managed medically.
Medications on Admission:
1. Lisinopril
2. Amaryl
3. Bumetanide
4. Avandia
5. Simvastatin
6. Atenolol
7. ASA
Discharge Medications:
1. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO twice a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*5*
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for pain.
Disp:*60 * Refills:*5*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
CAD
HTN
DM type 2
CHF
Hypercholesterolemia
CAD
HTN
DM type 2
CHF
Hypercholesterolemia
CAD
HTN
DM type 2
CHF
Hypercholesterolemia
Discharge Condition:
Pt is chest pain free, with stable vital signs
Discharge Instructions:
If you experience any chest pain, lightheadedness, passing out,
shortness of breath, palpitations you should seek medical
attention immediately.
You have appointments set up for you to see a kidney doctor and
heart doctor.
You should also follow up with your PCP at the VA in the next
1-2 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2137-7-18**] 11:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2137-9-12**] 11:00
Completed by:[**2137-9-3**]
|
[
"272.0",
"724.3",
"414.02",
"401.9",
"250.00",
"414.01",
"593.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6533, 6604
|
4682, 5314
|
279, 305
|
6779, 6828
|
2795, 4659
|
7174, 7578
|
2120, 2245
|
5447, 6510
|
6625, 6758
|
5340, 5424
|
6852, 7151
|
2260, 2776
|
229, 241
|
333, 1865
|
1887, 1965
|
1981, 2104
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,187
| 113,865
|
33658+57867
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-3-17**] Discharge Date: [**2113-3-30**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p AVR(#21StJude porcine)CABGx2(SVG-PDA,SVG-OM)[**3-24**]
History of Present Illness:
83 yo female with known severe AS, CAD presents with acute on
chronic diastolic heart failure.
Past Medical History:
PAST MEDICAL HISTORY:
# Deaf, communicates well & reads lips well
# HTN
# H/O TIA
# COPD (emphysema) - on albuterol
# Hysterectomy
# Appendectomy
Social History:
Cardiac Risk Factors: Hypertension, tobacco
Family History:
NC
Physical Exam:
VS:Hr:73, 126/83,RR-20, 96% on 2Lpm
General:AxOx3
Lungs: (B) basilar crackles
CVS: SEM III/VI, RRR
ABD:benign
EXT: o C/C/E
No varicosities/No carotid bruits
Pertinent Results:
[**2113-3-28**] 05:15AM BLOOD WBC-7.7 RBC-3.07* Hgb-8.0* Hct-25.3*
MCV-82 MCH-26.1* MCHC-31.7 RDW-16.0* Plt Ct-297
[**2113-3-25**] 03:18AM BLOOD PT-13.1 PTT-36.8* INR(PT)-1.1
[**2113-3-28**] 05:15AM BLOOD Glucose-114* UreaN-8 Creat-0.4 Na-137
K-3.7 Cl-103 HCO3-30 AnGap-8
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2113-3-27**] 4:19 PM
CHEST (PORTABLE AP)
Reason: ? ptx s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p chest tube removal
HISTORY: Chest tube removal. Pneumothorax.
A single portable radiograph of the chest demonstrates interval
removal of the support lines seen on [**2113-3-24**]. There are
bilateral pleural effusions, worse on the left than the right.
Bibasilar atelectasis is present as well. Patient is status post
CABG. The aorta is calcified and tortuous.
IMPRESSION:
Interval removal of support lines. No pneumothorax.
Persistent left-sided pleural effusion and bibasilar
atelectasis.
DR. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 77924**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77925**]
(Complete) Done [**2113-3-24**] at 2:44:54 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2029-5-27**]
Age (years): 83 F Hgt (in): 64
BP (mm Hg): 123/57 Wgt (lb): 125
HR (bpm): 82 BSA (m2): 1.60 m2
Indication: Intra-op TEE for AVR, CABG, ? MVR
ICD-9 Codes: 786.05, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2113-3-24**] at 14:44 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.3 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: *0.26 >= 0.29
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Stroke Volume: 79 ml/beat
Left Ventricle - Cardiac Output: 6.44 L/min
Left Ventricle - Cardiac Index: 4.03 >= 2.0 L/min/M2
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *98 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 67 mm Hg
Aortic Valve - LVOT pk vel: 0.68 m/sec
Aortic Valve - LVOT VTI: 25
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.5 m/sec
Mitral Valve - Mean Gradient: 4 mm Hg
Mitral Valve - Pressure Half Time: 94 ms
Mitral Valve - MVA (P [**12-7**] T): 2.3 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. Moderate to severe spontaneous
echo contrast in the LAA. Depressed LAA emptying velocity
(<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe
mitral annular calcification. Calcified tips of papillary
muscles. Cannot exclude MS. [**Name13 (STitle) 15110**] to co-existing AR, the pressure
half-time estimate of mitral valve area may be an OVERestimation
of true area. Mild to moderate ([**12-7**]+) MR.
TRICUSPID VALVE: Physiologic 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 under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is mildly dilated. Moderate spontaneous echo
contrast is present in the left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
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. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Moderate (2+) aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is
severe mitral annular calcification. The study is inadequate to
exclude significant mitral valve stenosis. Due to co-existing
aortic regurgitation, the pressure half-time estimate of mitral
valve area may be an OVERestimation of true mitral valve area.
Mild to moderate ([**12-7**]+) mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. A bioprosthesis is well seated in the aortic position.
Leaflets open well. Mean gradient across the valve is 16 mm of
Hg. No AI jets are seen.
2. MR is trace to mild.
3. Aorta is intact post decannulation
4. [**Hospital1 **]-ventricular function is preserved
Brief Hospital Course:
on [**2113-3-17**] Mrs.[**Known lastname **] was admitted to MWMC with acute
exacerbation of CHF.She was stabilized and transferred to [**Hospital1 18**]
for further cardiac workup. She has known severe AS ([**Location (un) 109**] 0.8
cm'2), CAD, recent UGIB with duodenal ulcer and AVMs associated
with SOB. GI was consulted for her recent history of GI bleed
and guiac positive stools. Serial hematocrits were followed and
on [**2113-3-20**] EGD was performed which showed previous treated
AVM now resolved. GI cleared her for the OR. Preoperative workup
revealed a UTI in which Ciprofloxacin was started. She was taken
to the OR on [**2113-3-24**] where she underwent AVR/CABG x2. Please
refer to operative note for further details.Mrs. [**Known lastname **] was
transferred from the OR to the ICU in stable condition.
Postoperatively she was extubated without incident. POD#2 her
rhythm was Rapid Atrial Fibrillation 120s, treated with Beta
blockade.In attempts to rate controll her AFib, given Beta
blocker, she blocked down to a junctional rhythm in the 70s and
her Beta blocker was subsequently discontinued.POD#3 she was
transferred to the floor. [**2113-3-28**] Beta blocker was
reinstituted with rate and rhythm recovery. She had a large
pleural effusion for which she was diuresed with improvement in
the effusion. She was started on fluconazole for a yeast UTI,
and keflex for her vein harvest incision. She was ready for
discharge to home on [**3-30**].
Medications on Admission:
simvastatin 10', metoprolol 37.5'', asa 81', ferrous sulf 325',
alb prn, prevacid 40'.
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days: For LLE vein harvest site erythema.
Disp:*20 Capsule(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
s/p AVR(#21StJude porcine)CABGx2(SVG-PDA,SVG-OM)[**3-24**]
CAD (LM 30%, LCx 30%, RCA 60%), htn, COPD, prior TIA, deafness,
appy, hys.
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name (STitle) **] in 1 week ([**Telephone/Fax (1) **]) please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-3-30**] Name: [**Known lastname **],[**Known firstname 12592**] Unit No: [**Numeric Identifier 12593**]
Admission Date: [**2113-3-17**] Discharge Date: [**2113-3-30**]
Date of Birth: [**2029-5-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Discharge diagnoses updated.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2057**] Hospice and VNA
Discharge Diagnosis:
s/p AVR(#21StJude porcine)CABGx2(SVG-PDA,SVG-OM)[**3-24**]
chronic diastolic heart failure
h/o GI bleed likely due to duodenal ulcer and AVMs
CAD (LM 30%, LCx 30%, RCA 60%), htn, COPD, prior TIA, deafness,
appy, hys.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2113-4-26**]
|
[
"041.04",
"997.1",
"428.0",
"414.01",
"511.9",
"427.31",
"112.2",
"537.82",
"E878.2",
"428.33",
"424.1",
"492.8",
"401.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.30",
"35.21",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
12040, 12106
|
7698, 9167
|
271, 332
|
10654, 10661
|
900, 1302
|
11173, 12017
|
704, 708
|
9304, 10391
|
1339, 1371
|
12127, 12466
|
9193, 9281
|
10685, 11150
|
723, 881
|
228, 233
|
1400, 7675
|
360, 456
|
500, 626
|
642, 688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,378
| 198,030
|
25013
|
Discharge summary
|
report
|
Admission Date: [**2108-9-5**] Discharge Date: [**2108-9-9**]
Date of Birth: [**2075-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
nausea, swelling, pain and warmth in Left leg, fever, altered
mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33 year-old healthy male with a long history of lower extremity
edema and intermittent erythema who presents to the ED after a
motor vehicle accident. According to te patient, his fiancee,
and his mother, he was feeling well up until earlier today when
his left leg became painful and erythematous. He remembers
getting in his car to drive somewhere, and then his next memory
is of walking around after the accident. He reportedly was the
restrained driver in a motor vehicle accident in which his
vehicle hit a tree or a pole.
.
He was thoroughly evaluated in the ED for any evidence of
traumatic injury, and had negative films including a chest
x-ray, pelvis films, and left knee films. He had CT scans of the
head, C-spine, and entire Torso that did not show any evidence
of traumatic inhury, fracture, source of infection, or bone
abnormality. On arrival he was noted to be febrile to 104.8,
tachycardic, and hypotensive at one point with a blood pressure
of 93 systolic. His exam in the ED was remarkable for bbilateral
lower extremity edema, and for mild erythema of the left lower
leg with leg tenderness. A left lower extremity doppler study
showed no evidence for DVT.
.
An attempt was made at an LP, but the procedure was unable to be
completed. Given the patient's high fever, altered mental
status, and leukocytosis he was treated for both cellulitis and
meningitis. His other labs were notable for a normal urinalysis
without any blood or protein, a normal serum sodium, and a
normal BUN/Creatinine of 19/1.9. His serum toxicology screen was
negative as well.
.
On further historical review, his fiancee and mother state that
he has had lower extremity edema since age 5. This has always
fluctuated, but has never disappeared. He has also had the
erythema of the left leg twice in the past, and he has been
treated with naproxen and antibiotics for presumed cellulitis.
The erythema usually lasts for a week, and it never goes above
the knee. There is no history of skin breakdown or subcutaneous
nodules. However, he reports having occasional skin blisters
when his edema is severe. he has no history of hematuria,
dysuria, sore throat, cough, SOB, DOE, orthopnea, rash, eye
inflammation, urehtral inflammation, joint pains or swelling,
and he has not had any easy bruising, prolonged bleeding, or
blood clots.
.
His medical history is significant for only his chronic lower
extremity edema. He has no PCP, [**Name10 (NameIs) **] was previously treated for
similar left leg symptoms and fever at [**Hospital 8**] Hospital ED. he
has a known right Bell's Palsy, and possibly a history of a left
Bell's Palsy 5 years ago.
Past Medical History:
Chronic LE edema with multiple episodes of cellulitis (two
episodes a year)
Bell's palsy of Left side of face 5 years ago
Bell's palsy of Right side of face 2 weeks ago
Social History:
He works in [**Company 62819**] and is on his feet all day. He has no known
sick contacts, but has a history of TB exposure for which he was
treated for 6 months with one drug (presumably INH). He has no
tick exposure, and no travel outside of the US. He lives in the
city, and does not go camping or hiking. He did visit [**Hospital3 **]
once this summer, but was not exposed to animals or insects. he
does not smoke and does not drink alcohol. He does not use IV
drugs.
Family History:
His family history is significant for a father who died of
complications from Rheumatic heart disease. He may have also had
a DVT and an embolic or thrombotic stroke. His mother is
healthy. He has no family history of bleeding disorders, kidney
disease, rheumatologic diseases, vasculitis, or blood
malignancies
Physical Exam:
EXAM:
INITIAL VITALS: T 104.8, HR 125, BP 132/65, RR 12, O2sat 100% on
2L
VITALS: T 101.9, HR 118, BP 110/44, O2sat 100% on 2L NC
GEN: Alert, mildly diaphoretic, slightly pale.
HEENT: Anicteric sclera. PERRL. Neck supple. MMM. Clear o/p. No
cervical lymphadenopathy. No thyroid nodules or masses. No
external ear pain.
CV: Regular tachycardia. Possibly a very faint systolic ejection
murmur at the base. No visble JVD.
LUNGS: CTAB
ABD: Soft. Mild superficial muscle tenderness. No obvious HSM,
but the exam was limited. There is some healing ecchymosis in
the RUQ.
EXT: Cool left arm. Other extremities are warm. 2+ PT pulses.
There is erythema and warmth over the left shin extending from
above the ankle to [**1-5**] inches below the patella. The erythema
has a well-defined border and there are no petechiae or skin
lesions visualized. There is no subcutaneous emphysema. No
lymphangitic streaking. There is 1+ bilateral pitting LE edema
with more prominent pedal edema. No peripheral stigmata of
endocarditis.
NEURO: Alert. Oriented. There is right peripheral facial
paralysis with diminished ability to close the right eye and
with loss of the forehead skin wrinkles. PERRL. EOMI. Midline
uvula. Sensation to light touch grossly intact in all 4 limbs.
SKIN: No other skin rashes or lesions.
LYMPH: No axillary, cervical supraclavicular, or inguinal lymph
nodes appreciated.
Pertinent Results:
EKG: Sinus tachycardia, normal axis, normal intervals. No
ischemic ST changes. S1Q3.
.
LABS:
WBC 14.3 (88P, 3B, 8L), HCT 45.8, MCV 84, PLT 340
Na 142, K 3.8, Cl 103, HCO3 26, BUN 19, Creat 1.1
INR 1.0, PTT 20.7, Fibrinogen 367
Serum tox screen - negative
Amylase 53
Lactate 4.5 -> 2.5
UA - No blood, no protein, no ketones, no glucose, no cells
.
CT HEAD: No hemorrhage or mass.
.
CT Torso: No bone abnormalities, no pneumonia, no intrabdominal
pathology with the exception of a small liver lesion (TSTC).
.
LEFT LENI: no DVT.
.
CXR, PELVIS FILMS, LEFT KNEE FILMS - no fracture
LEFT ANKLE AND FOOT CT
FINDINGS: There is soft tissue thickening and edema within the
soft tissues
of the dorsum of the foot, but no fluid collection or gas is
evident within
the soft tissues. There is no evidence of fracture, bone
destruction, or
dislocation. The tendons crossing the ankle joint are within
normal limits.
The Achilles tendon and plantar fascia are similarly grossly
unremarkable.
IMPRESSION: No evidence of abscess or soft tissue gas.
Brief Hospital Course:
1. Cellulitis- His exam was consistent with cellulitis. Other
etiologies such as vasculitis or erythema nodosum were
considered, but were not worked up because he improved with
antibiotics. Initially, he was placed on Vancomycin, Ceftriaxone
(at meningitis doses given his altered mental status on
admission) and Metronidazole for broad spectrium coverage. On
discharge from the ICU, his coverage was limited to Vanc and
Ceftriaxone while waiting for cultures to come back. However,
he continued to spike fevers and oxacillin was added to his
coverage. Given his continued fevers, a CK was done to evaluate
for myonecrosis which returned mildly elevated at 223, a lactate
was normalized at 2.0 and a LLE CT was ordered which showed no
evidence of necrotizing fascitis or abscess. On HD3, he
improved and the ceftriaxone was removed. He was discharged on
HD4 on keflex after being afebrile overnight and with a
declining WBC count. All of his blood cultures showed NGTD, and
his UCx were negative.
- Continue Keflex for 11 days.
.
2. Chronic LE edema - This is a chronic condition for him and
likely represents venous insufficiency. He has no
lymphadenopathy that could account for lymphatic drainage
problems. [**Name (NI) **] has no protein or blood in his urine which argues
against renal causes such as nephrotic syndrome, though his
albumin is on the low side of normal, but it's a negative acute
phase reactant. A TTE was normal making a cardiac etiology very
unlikely.
.
4. Loss of consciousness - It is unclear from the history
whether he had a loss of consciousness preceeding the accident
or whether he has post-concussive amnesia. With his infection
and high fever he may have had orthostasis or a vasovagal
episode causing his syncope. He has no historical evidence of
cardiogenic or neurocardiogenic syncope. The infection and
critical illness is the likely cause. He had no events on
telemetry and a TTE showed no structural cardiac causes of
syncope.
5. FEN: He was hypophosphatemic on transfer from the MICU, and
was supplemented x 1, after which he resumed a normal diet with
good results.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 11 days.
Disp:*44 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
cellulitis
syncope
s/p MVC
Discharge Condition:
good
Discharge Instructions:
Please take all medications as instructed. Please keep all
follow-up appointments.
Please return to the emergency department if you have
fevers/chills, leg pain, shortness of breath, lightheadedness or
any other worrisome symptoms
Followup Instructions:
Please contact your primary physician for an appointment within
the next week. (Tues or Wed)
Completed by:[**2108-9-9**]
|
[
"682.6",
"780.2",
"782.3",
"E819.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8945, 8951
|
6543, 8660
|
388, 395
|
9022, 9029
|
5483, 5830
|
9310, 9433
|
3755, 4068
|
8715, 8922
|
8972, 9001
|
8686, 8692
|
9053, 9287
|
4083, 5464
|
273, 350
|
423, 3058
|
5839, 6519
|
3080, 3250
|
3266, 3739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,836
| 124,116
|
13607
|
Discharge summary
|
report
|
Admission Date: [**2170-5-8**] Discharge Date: [**2170-5-10**]
Date of Birth: [**2116-11-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 53-year-old male with
a history of alcoholic cirrhosis and esophageal varices who
presented to [**Hospital 4199**] Hospital on the night of [**5-6**] with
hematemesis, and coffee-grounds emesis, and a hematocrit in
the middle 20s.
He was transfused with 2 units of packed red blood cells and
started on Sandostatin. Over the course of his
hospitalization he was transfused with a total of 3 units of
packed red blood cells. He also underwent an upper endoscopy
which revealed oozing at the lower esophageal sphincter and
gross blood in the stomach. He was transferred to [**Hospital1 1444**] for further evaluation.
He underwent a repeat esophagogastroduodenoscopy at [**Hospital1 1444**] where he also received
2 units of fresh frozen plasma. He remained hemodynamically
stable throughout his hospital stay but was sent to the
Medical Intensive Care Unit after leaving the endoscopy
suite.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis.
2. History of upper gastrointestinal bleed.
3. Esophageal varices.
4. Status post partial colectomy secondary to colonic
polyps.
5. History of abdominal hernia and repair.
MEDICATIONS ON TRANSFER: Medications on transfer included
nadolol 20 mg p.o. b.i.d., Pepcid 20 mg p.o. b.i.d., thiamine
and folate, librium 50 mg p.o. q.d., and Sandostatin drip.
SOCIAL HISTORY: An ex-priest. History of alcohol; last
drink on [**5-4**]. No history of drugs or smoking.
FAMILY HISTORY: Family history was noncontributory. Parents
are still alive.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 99.4,
blood pressure of 148/74, pulse in the 90s, 98% on room air.
In general, an alert and oriented, mildly jaundiced male.
Head, eyes, ears, nose, and throat revealed extraocular
muscles were intact. Sclerae were anicteric. Pupils were
equal, round, and reactive to light and accommodation. Neck
was supple with no lymphadenopathy. Lungs were clear to
auscultation bilaterally. Cardiovascular examination was
regular. No murmurs, rubs or gallops. The abdomen was
mildly distended, question of a fluid wave, positive bowel
sounds. No hepatosplenomegaly and nontender. Extremities
were warm with fair pulses. Skin revealed several lesions,
erythematous, on the legs and knees.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from
the morning of [**5-8**] revealed a sodium of 142, potassium
of 4, chloride of 107, bicarbonate of 18, blood urea nitrogen
of 9, creatinine of 0.4, blood sugar of 81. Hematocrit
of 33.2 and platelets of 91. Albumin of 3.1, calcium of 7.7,
total bilirubin of 3.2, alkaline phosphatase of 109, AST
of 48, ALT of 19. Coagulations revealed a PT of 16.7, INR
of 1.8, and PTT of 39.8. Hematocrit on [**5-6**] was 27 at
the outside hospital; the patient then received 2 units of
packed red blood cells, and his hematocrit bumped to 32.
RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus
rhythm at a rate of 80, normal axis, Q-T corrected at 0.456,
and no acute ST changes.
IMPRESSION: A 53-year-old alcoholic male with a history of
liver disease and esophageal varices who presented from an
outside hospital after an episode of hematemesis and
nondiagnostic esophagogastroduodenoscopy.
HOSPITAL COURSE: (GASTROINTESTINAL): The patient with an
upper gastrointestinal bleed. A central line was placed in
the right internal jugular. Hematocrits were followed q.6h.
The patient's blood was typed and crossed, and 4 units of
packed red blood cells were made ready.
The patient was seen by the Gastrointestinal Service who
planned an esophagogastroduodenoscopy for that evening. He
was continued on a octreotide at 50 mcg per hour. He also
was started on Protonix 45 mg intravenously q.d.
Additionally, the patient was also given three subcutaneous
shots of vitamin K. The patient was placed on a CIWA scale
with Ativan p.r.n., and the Substance Abuse team was
consulted to help with his discharge planning.
A repeat esophagogastroduodenoscopy showed [**Doctor First Name **]-[**Doctor Last Name **] tear
and grade I varices with persistent blood in the stomach.
The patient received 2 units of fresh frozen plasma and
vitamin K for his INR of 1.8. In the Medical Intensive Care
Unit, his hematocrit remained stable, and he remained
hemodynamically stable. At the time of discharge to the
floor (on [**5-9**]), the patient was tolerating clear liquids
and was showing no evidence of withdrawal.
An abdominal ultrasound from [**5-9**] showed ascites and
gallbladder stones and sludge. There was also an irregular
cirrhotic liver. The hepatic and portal veins were patent.
There was also splenomegaly.
Once the patient was transferred to the floor, his hematocrit
was followed for one more day; which remained stable. He was
continued on his nadolol 20 mg p.o. b.i.d. and on Protonix.
The patient was also started on Lasix and Aldactone for
treatment of his ascites.
A diagnostic paracentesis was done which revealed no evidence
of spontaneous bacterial peritonitis. It did have a
serum-ascites albumin gradient of greater than 1. One and a
half liters of clear/yellow fluid were removed. Cytology was
pending at the time of discharge. It was decided as
spontaneous bacterial peritonitis prophylaxis would not be
started at this time, and that it could be looked into
further on outpatient followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] of the
Gastroenterology Service. The patient's diet was advanced
prior to discharge, and he was tolerating a regular diet.
The patient was seen by the Case Manager who gave the patient
several numbers and programs to look into for alcohol
rehabilitation.
Additionally, the patient with thrombocytopenia, likely
secondary to splenomegaly. His thrombocytopenia remained
stable during his hospital stay. This should be followed up
as an outpatient.
DISCHARGE DIAGNOSES: Upper gastrointestinal bleed and
hepatic cirrhosis.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was discharged to home.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg p.o. q.d.
2. Aldactone 100 mg p.o. q.d.
3. Vitamin K 5 mg p.o. times two days.
4. Nadolol 20 mg p.o. b.i.d.
5. Protonix 40 mg p.o. q.d.
6. Thiamine 100 mg p.o. q.d.
7. Folate 1 mg p.o. q.d.
8. Multivitamin 1 tablet p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary care physician (Dr. [**Last Name (STitle) 41074**] in [**Location (un) 1456**] in one week;
at which time his electrolytes should be rechecked now that
he is on Lasix and Aldactone. The patient should also follow
up with Dr. [**First Name (STitle) 17185**] on his next available appointment. The
patient should also follow up with Dr. [**Last Name (STitle) 10689**] for a
gastrointestinal esophagogastroduodenoscopy repeat in three
to four weeks; and finally, Dr. [**First Name (STitle) 17185**] will arrange any
hepatology workup needed.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2170-5-17**] 17:02
T: [**2170-5-18**] 09:09
JOB#: [**Job Number **]
|
[
"535.41",
"285.1",
"578.9",
"789.5",
"571.2",
"456.21",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1597, 3361
|
6044, 6107
|
6240, 6489
|
3381, 6021
|
6122, 6214
|
6511, 7318
|
156, 1064
|
1314, 1469
|
1086, 1288
|
1486, 1580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,991
| 146,377
|
36062
|
Discharge summary
|
report
|
Admission Date: [**2159-7-31**] Discharge Date: [**2159-8-11**]
Date of Birth: [**2108-6-12**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Lisinopril / Morphine / oxycodone-acetaminophen /
Shellfish Derived
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
transfer from OSH with right putamen intracranial hemorrhage
Major Surgical or Invasive Procedure:
[**Last Name (NamePattern1) 282**] tube placement [**2159-8-8**]
History of Present Illness:
The pt is a 51 year-old woman with PMHx of HTN, ESRD, uterine
malignancy, history of L periventricular white matter infarct
and DM2 who presented from [**Hospital3 4107**] for an ICH that is
likely hypertensive in etiology. Per [**Hospital3 4107**] records,
the patient was at her baseline earlier on [**7-30**], then went to
dialysis in the afternoon. When she returned home, she had a
rightward gaze and "wasn't acting right", so her family called
EMS (arond 8pm). She was brought to [**Hospital3 4107**] where a
NCHCT was completed that showed a 4.1cm R lentiform ICH w/ 4mm
of midline shift. Her BP at [**Hospital1 **] was initially in the 230's,
and she was given IV labetalol 20mg x2 with good effect. She
was then transferred to [**Hospital1 18**] for further evaluation. In the
ED, she was seen by neurosurgery who felt that there was no
intervention to be done (per Dr. [**First Name (STitle) **], and recommended
admission to the neurology service.
Unable to complete ROS as pt is intubated and sedated. However,
[**First Name8 (NamePattern2) **] [**Hospital1 **] records the patient had been c/o a headache when she
returned home from dialysis.
Past Medical History:
- ESRD due to Hypertension, diabetes, HD since [**2152**] MWF, left AV
fistula
- infarct of unknown timing in left periventricular white matter
- Hemochromatosis with grade 1 varices and cirrhosis.
- Diabetes type 2, on insulin.
- Osteoporosis.
- C. diff infection.
- Cardiomyopathy, followed by Dr. [**Last Name (STitle) 171**].
- Drop attacks and falls.
Social History:
Works as a secretary at the IRS. She lives with her husband and
friend. [**Name (NI) **] tobacco, alcohol, or drug use.
Family History:
DM - in mother and 1 sisters. 2 sisters and mom passed away
young.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.6 P: 66 R: 16 BP: 129/63 SaO2: 99% on RA
General: intubated, sedated (even off propofol, midazolam given
recently)
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: patient intubated and sedated. Not following
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 1.5 to 1mm and brisk. Funduscopic exam difficult due
to small size of pupils, but what was visualized revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: unable to test.
V: unable to test
VII: ETT in place, unable to test
VIII: unable to test
IX, X: gag intact.
[**Doctor First Name 81**]: unable to test
XII: ETT in place, unable to test
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. Withdraws the
RUE and RLE briskly to noxious. Does not withdraw the LUE or
LLE to noxious but does localize (grimaces and moves the
R-side).
-Sensory: withdraws to noxious as above
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was mute bilaterally.
-Coordination: Unable to test
-Gait: Deferred
Physical Exam on Discharge:
Pertinent Results:
Labs on Admission:
[**2159-7-31**] 01:05AM WBC-9.4 RBC-4.75 HGB-12.3 HCT-39.2 MCV-82
MCH-25.8* MCHC-31.3 RDW-17.0*
[**2159-7-31**] 01:05AM PT-12.1 PTT-29.8 INR(PT)-1.1
[**2159-7-31**] 01:05AM FIBRINOGE-434*
[**2159-7-31**] 01:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2159-7-31**] 01:05AM TSH-4.9*
[**2159-7-31**] 01:05AM OSMOLAL-301
[**2159-7-31**] 01:05AM TRIGLYCER-211* HDL CHOL-27 CHOL/HDL-6.1
LDL(CALC)-97
[**2159-7-31**] 01:05AM ALBUMIN-4.3 CALCIUM-8.1* PHOSPHATE-5.3*
MAGNESIUM-2.1 CHOLEST-166
[**2159-7-31**] 01:05AM CK-MB-4 cTropnT-0.09*
[**2159-7-31**] 01:05AM LIPASE-79*
[**2159-7-31**] 01:05AM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-292*
CK(CPK)-213* ALK PHOS-100 TOT BILI-0.4
[**2159-7-31**] 01:05AM UREA N-25* CREAT-4.4*
[**2159-7-31**] 01:16AM GLUCOSE-341* NA+-136 K+-3.6 CL--93* TCO2-30
[**2159-7-31**] 11:14AM CK-MB-4 cTropnT-0.08*
Imaging:
NCHCT [**2159-7-31**]
FINDINGS: There is a parenchymal hematoma centered in the right
external
capsule, displacting the right lentiform nucleus medially, and
extending into the corona radiata, which measures 3.9 x 1.7 cm
(2:18), not significantly changed in size. The extent of
surrounding edema is also unchanged. There is no new
intracranial hemorrhage. There is mild effacement of the
frontal [**Doctor Last Name 534**] and body of the right ventricle, and a minimal
leftward shift of the septum pellucidum, also unchanged. There
is no herniation. The basal cisterns are not compressed. Sulci
are more prominent than would be expected for the patient's age,
indicating cerebral atrophy.
Bilateral mastoid air cells and visualized paranasal sinuses are
clear. There is evidence of right cataract surgery. The bones
are unremarkable.
IMPRESSION:
Parenchymal hemorrhage centered in the right external capsule
and corona
radiata, displacing the lentiform nucleus medially, with mild
associated mass effect, unchanged compared to approximately 4
hours earlier. While this could represent a hypertensive
hemorrhage, a vascular malformation or a mass could also be
considered. The latter possibilities could be investigated by
MRI/MRA, if clinically warranted.
Chest x-ray [**2159-8-1**]
There is moderate cardiomegaly. The mediastinum is widened.
There is mild pulmonary edema. If any, there are small
bilateral pleural effusions. NG tube tip is in the stomach.
Labs on Discharge:
Brief Hospital Course:
Ms. [**Known lastname 284**] is a 51 year-old woman with PMHx of HTN, ESRD,
uterine malignancy, history of L periventricular white matter
infarct and DM2 who presented from [**Hospital3 4107**] with left
sided weakness, aphasia and was found to have an ICH that is
likely hypertensive in etiology.
# NEURO: Patient was eating dinner when suddently her left and
and face "felt funny." Per her friend who was present, she was
unable to speak and could not stand up from her chair. Friend
called 911. SBP at OSH was in the 230s on arrival. Head CT was
obtained and showed a right putaminal hemorrhage. The bleed was
most likely in the setting of hypertension (Of note, a recent
discharge summary from [**2159-5-31**] stated that her home labetalol
dose was 300mg PO BID; however on admission her home dose was
reportedly 100mg PO BID). Other possibilities would be a
hemorrhagic conversion of a stroke (although this is a less
likely location for that) or bleeding into a malignancy, but
again this is less likely than hypertensive hemorrhage given the
location and elevated BP on arrival to the OSH. Her
neurological exam on admission was notable for minimal movement
of her L-side to noxious stimuli, which would fit with her R ICH
location. She was admitted to the neuro ICU for further
evaluation and workup. Aspirin/Simvastatin were held in the
setting of a bleed. Shortly after arrival in the ICU, she was
successfully extubated. Her blood pressure was initially quite
well controlled on labetalol 100mg PO BID. On HD #5 she became
persistently hypertensive to SBP 170s so amlodipine 5mg PO daily
was added to her antihypertensive regimen. In addition, due to
increased lethargy and possible ?eye opening apraxia during
hospitalization, she was started on modafinil to increase her
alertness -- this seemed to be helpful. On discharge, her neuro
exam was notable for dense hemiparesis of left face, arm and leg
and severe dysarthria and dysphagia with preserved mental
status. For her continued dysphagia, patient underwent [**Month/Day/Year 282**]
placement on [**2159-8-8**].
# ID: On [**2159-8-2**] (HD #3) patient spiked fever to 101.4. She was
noted to have extremely purulent-appearing respiratory
secretions, and in setting of severe dysphagia s/p stroke
etiology was felt most likely to be aspiration pneumonia vs.
HCAP vs. VAP (the latter being less likely as duration of
intubation was <24 hours). She was empirically started on
Vancomycin, Cefepime and Levaquin to cover for HCAP vs.
aspiration pneumonia and rapidly defervesced. Sputum cultures
grew out [**Last Name (LF) **], [**First Name3 (LF) **] her vancomycin was discontinued. As her sputum
culture grew out pan-sensitive Ecoli, antibiotics were narrowed
to levaquin and she completed her 10 day course on [**2159-8-10**].
After her [**Date Range 282**] placement, she had low grade temperature to 99.9
and leukocytosis to 13, so blood cultures were drawn. However,
as her temperature improved on its own, leukocytosis was thought
to be more reactive and no further antibiotics were given.
# CARDIOVASCULAR: Patient had likely hypertensive ICH in setting
of SBP 230. Her home labetalol dose was 100mg PO BID on
admission. This initially controlled her BP well; amlodipine 5mg
daily was later added when she became persistently hypertensive
to 170s on HD #5. Of note, pt also had significant cardiomegaly
and pulmonary vascular congestion noted on TTE. She very likely
has CHF secondary to hypertension. She remained euvolemic during
hospitalization, with volume status controlled via hemodialysis.
Simvastatin was initially held given her hypertensive IPH, but
it was restarted later. Her goal blood pressure was placed at
SBP below 160
# ENDOCRINE: Patient's home simvastatin was held in setting of
hypertensive ICH given friability of cerebral vasculature s/p
hemorrhagic stroke, but restarted at later date. Her home
insulin was continued for her IDDM.
# RENAL: Patient has ESRD secondary to DM II and HTN, on HD MWF.
Continued HD while in house. Continued home sevelamer,
nephrocaps. Per renal recs, added calcium acetate TID as phosph
binder.
# FEN/GI: Patient repeatedly failed speech and swallow tests
during hospitalization secondary to stroke-related dysphagia and
lethargy. As she failed her speech/swallow evaluation even after
improvement in [**Last Name (LF) 81823**], [**First Name3 (LF) 282**] was placed on [**2159-8-8**].
=====================
TRANSITIONS OF CARE:
-CODE/CONTACT: Full, confirmed. Sister [**Name (NI) **] [**Telephone/Fax (1) 81824**]
and Husband [**Name (NI) 1939**]: [**Telephone/Fax (1) 81825**]. [**Name2 (NI) 4906**] is disabled and unable
to visit often, so prefers phone updates.
[] Blood pressure control with goal SBP in 110-160s
Medications on Admission:
(per last discharge summary [**2159-5-31**]):
-Nephrocaps 1 capsule daily
-Glargine 33 units qHS
-Labetalol 300mg PO BID
-Sevelamer 800mg PO BID with meals
-Simvastatin 20mg PO qHS
-Acetaminophen 500mg PO during dialysis MWF
-ASA 81mg PO daily
-Bisacodyl 5-10mg PO qHS PRN constipation
-Omeprazole XR 20mg PO daily
-Miralax 17g PO daily PRN constipation
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
ACUTE ISSUES:
1. Hemorrhagic stroke
2. Hospital acquired pneumonia
CHRONIC ISSUES:
1. End-stage renal disease, on hemodialysis
2. High blood pressure
3. Insulin dependent diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic Status: eyes closed most of the time, opens to loud
voice or touch. Occasionally requires noxious stimuli to arouse.
Oriented to place, time and person and has some recall of recent
events. L visual field deficit. L facial droop and some
dysarthria. RUE/RLE moves briskly to noxious stimuli, LUE is
plegic. LLE has some movements on the bed but is not
antigravity.
Discharge Instructions:
Ms. [**Known lastname 284**],
You were admitted to the [**Hospital1 **] ICU after
suffering a hemorrhagic stroke (brain hemorrhage). We believe
this stroke was most likely caused by extremely high blood
pressure. The stroke resulted in near-complete paralysis of your
left face, left arm and left leg. It also made swallowing
difficult for you, so you were started on tube feeds and had [**Hospital1 282**]
tube placed for long term feeding. You developed pneumonia after
leaving the ICU, which may have been caused by aspiration of
oral secretions: this was treated with IV antibiotics. You are
being discharged to a rehab.
Please attend the follow-up appointment listed below with
Neurologist Dr. [**First Name (STitle) **] [**Name (STitle) **]. Once you are discharged from
rehab you should also follow up with your PCP.
Followup Instructions:
Call your primary care physician and make [**Name Initial (PRE) **] follow up
appointment once you are discharged from the rehab.
Department: NEUROLOGY
When: TUESDAY [**2159-10-2**] at 3:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2159-8-11**]
|
[
"V10.42",
"456.21",
"507.0",
"V58.66",
"285.9",
"V45.11",
"787.20",
"784.69",
"V15.88",
"V45.79",
"V58.67",
"348.5",
"288.60",
"482.82",
"V10.09",
"784.51",
"V88.01",
"272.4",
"431",
"275.3",
"733.00",
"278.00",
"342.90",
"250.42",
"585.6",
"V12.04",
"571.5",
"404.93",
"327.23",
"425.4",
"V12.54",
"428.0",
"372.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6",
"96.71",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
11474, 11571
|
6304, 10755
|
412, 479
|
11795, 11795
|
3864, 3869
|
13201, 13622
|
2206, 2274
|
11592, 11659
|
11095, 11451
|
12351, 13178
|
2927, 3816
|
2289, 2303
|
3845, 3845
|
312, 374
|
6281, 6281
|
507, 1673
|
3883, 6261
|
11810, 12327
|
10776, 11069
|
11675, 11774
|
1695, 2052
|
2068, 2190
|
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