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72,979
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|
41589+58459
|
Discharge summary
|
report+addendum
|
Admission Date: [**2196-1-6**] Discharge Date: [**2196-1-11**]
Date of Birth: [**2133-5-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Macrolide Antibiotics / Sulfa (Sulfonamide Antibiotics)
/ Gemfibrozil / Loracarbef
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
intubation + ventilation
History of Present Illness:
62F h/o COPD, asthma, ?CHF (on lasix a home), on home O2 2L NC
with 1 day hx worsening SOB, fatigue, lethargy. EMS report: "per
husband was really sleepy all day, only responded to name by
lifting head and going back to sleep" and today found home by
EMS with O2 saturation 70% 2L (home O2 requirement), brought to
OSH where she was unresponsive initial gas was 7.22/94/80/40,
intubated with good response to hypoxia PaO2> 100, s/p
solumedrol, albuterol via CPAP, levaquin, did not recieve fluids
in OSH, transferred for further evaluation. No recent travel,
Has dog at home, denies other animal exposures, denies contact
with [**Name2 (NI) **] people. Unknown if had flu vaccine
.
Per husband had 4 hospitalizations over past year for pulmonary
issues as well as a recurrent RLE cellulitis. Most recently was
admitted to [**Location (un) **] ~ 4 weeks ago. Was treated with Abx,
unknown which.
.
On arrival to our ED vitals were 98.4, 86, 96/78, 14, 100% on
100% FiO2, her exam was notable for bil coarse weezes and
diffuse erythema over panus + RLE erythema and edema. CXR
question of aspiration per RML infiltrate, her labs were notable
for WBC = 11,700, Neu = 95%, Hct = 51, K = 5.3, ABG:
7.23/102/384, HCO3 = 39. Trop X1 neg.
On ED admission proved to be difficult to ventilate, and was
sedated with propofol and versed with SBP drop from 90 to 70
shortly thereafter, got 2 L fluids, and required Levofed with
improvement in her BP's. Blood cultures were drawn X 2. Also
given Vancomycin s/p levaquin in OSH. Prior to transfer to ICU
was on Levofed 0.03 mg/kg/min on perippheral IV, vent settings
were CMV FiO2 40% PEEP 10 RR 16 TV 460. Transfer vitals were 82
106/54 16 97%. .
.
Past Medical History:
.
COPD/Emphysema
Recurrent RLE cellulitis
HLD
HTN
? DM
s/p cholecystectomy
s/p hysterectomy
.
Allergies: Iodine, Macrolids, Azithromycine, Sulfa, Gemfibrozil,
Loracarbef (unkown severity)
Social History:
Smoking > 30 pack years, no alcohol
Married + 5. 2 kids live with the parents aged 32 and 36.
Husband is HCP. Reduced ADL over past 2-3 months, can't walk
more than 5 feet, can't bathe herself.
Family History:
Family History: unknown
Physical Exam:
On ICU admission:
.
VS: Temp:99.1 BP: 152/ 72 HR:79 RR:17 O2sat 98%
GEN: Obese, intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, heard to
asses jvd d/t habitus, no carotid bruits, no thyromegaly
RESP: ronchorus bilaterally
CV: distant HS, heard to assess
ABD: obese, NTnd, +b/s, soft, nt, hard to assess masses or
hepatosplenomegaly, diffuse erythematous intertrigenous eruption
under panus and in bilateral inguinal areas with satellite
lesions. Without local discharge
EXT: RLE pretibial edema, erythema and chronic skin peau
d'orange-type chronic skin changes. Otherwise well and warm
perfused extremities.
splinters
NEURO: PERRL,DTR [**Name (NI) 90427**] and [**Name2 (NI) 90428**], flexor plantar
responses.
.
Pertinent Results:
Labs:
.
WBC = 11,700, Neu = 95%, Hct = 51, PLT = 237
139 92 36
-------------176
5.3 39 1.0
Ca/Mg/P = 9.2/2.3/5.3
ABG: 7.23/102/384
.
INR = 1.0, PTT = 36
ALT = 28, AST = 35, ALP = 126, T.Bili = 1.3
.
EKG: sinus tachycardia 100, border line left axis, PRWP, small
QRS voltage,
.
Imaging:
CXR: semi-upright AP film, NG tube in place, ET tube at Carina,
exenuated lung hiluses with vascular congestion, cephalization
as well as some peribronchial thickening, there is loss of bil
heart borders as well as diaphragmatic contours concerning for
effusions and possible infiltrate.
Brief Hospital Course:
62 year old woman with COPD, asthma, ?CHF (on Lasix at home), on
home O2 2L NC admitted intubated and ventilated from OSH with
acute on chronic respiratory failure from the day of her
admission likely [**12-23**] to COPD exacerbation. The patient was
intubated and ventilated at OSH prior to transfer to our
institution. ABG on admission was consistent with acute on
chronic respiratory acidosis. She is on 2L nasal canula at home.
Acute respiratory failure was attributable to pneumonia, COPD
exacerbation and fluid overload from CHF exacerbation. CXR
showed possible bilateral effusions and basilar infiltrates. TTE
showed normal to hyperdynamic EF with diastolic dysfunction.
STREPTOCOCCUS PNEUMONIAE grew in sputum. Patient was initially
treated with Levofloxacin + Ceftriaxone + Vancomycin and then
only oral Levaquin. She was covered for Influenza with Tamiflu
for 3 days until she ruled out per nasal swab. Patient was
extubated on day 2 of admission, following extubation she had
some hypoxia which improved with IV Lasix 40 mg (acute diastolic
heart failure). She was subsequently started on her home dose of
Lasix 40 mg [**Hospital1 **]. Patient was additionally treated with a course
of prednisone as well as Albuterol and Ipratropium nebs and
Advair 250/50 1 puff [**Hospital1 **]. She had abdominal/inguinal superficial
skin infection which appeared fungal and improved markedly with
topical treatment. She had hypotension on admission was from
sedation agents. AM cortisol was elevated, ruling out adrenal
insufficiency. Levophed was weaned quickly without any need for
pressors since AM of [**1-6**]. She had RLE edema: from chronic
lymphedema without recurrent cellulitis. No evidence of DVT on
U/S. She was discharged home on [**12-24**] L of oxygen without rales or
wheezing.
Medications on Admission:
Medications at home (confirmed with husband):
.
Lassix 40mg [**Hospital1 **]
Norvasc 5mg QD
Potassium 8meq [**Hospital1 **]
Aspirin 81mg QD
B12 Inj 1000mcg Q3weeks
Xanax 0.5mg PRN
Fioricet 2 tabs q4h PRN for Jaw pain
Oxygen 2 L
pharmacy [**Telephone/Fax (1) 90429**]
.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 4 days: then 3 tablets daily for 3 days then 2 tablets daily
for 2 days then 1 tablet for 1 day.
Disp:*30 Tablet(s)* Refills:*0*
9. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
smoking
streptococcal pneumonia
acute COPD exacerbation
acute diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please stop smoking because smoking give you lung cancer. You
had pneumonia and acute COPD exacerbation. You will take
antibiotic and prednisone taper for few days.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 28612**]
Name: [**Known lastname 14287**],[**Known firstname 1911**]-[**Known firstname **] Unit No: [**Numeric Identifier 14288**]
Admission Date: [**2196-1-6**] Discharge Date: [**2196-1-11**]
Date of Birth: [**2133-5-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Macrolide Antibiotics / Sulfa (Sulfonamide Antibiotics)
/ Gemfibrozil / Loracarbef
Attending:[**First Name3 (LF) 9498**]
Addendum:
Patient remained in hospital for additional 24 hours (she
changed her mind about discharge because of husband's pressure).
She requested discharge the following day. She had more
improvement without cough or fever. Her dyspnea and oxygen
requirement was close to baseline.
Chief Complaint:
same
Major Surgical or Invasive Procedure:
None
History of Present Illness:
same
Past Medical History:
same
Social History:
same
Family History:
same
Physical Exam:
same
Pertinent Results:
same
Brief Hospital Course:
same
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 4 days: then 3 tablets daily for 3 days then 2 tablets daily
for 2 days then 1 tablet for 1 day.
Disp:*30 Tablet(s)* Refills:*0*
9. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
smoking
streptococcal pneumonia
acute COPD exacerbation
acute diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please stop smoking because smoking give you lung cancer. You
had pneumonia and acute COPD exacerbation. You will take
antibiotic and prednisone taper for few days.
Followup Instructions:
[**Last Name (LF) 14289**],[**First Name3 (LF) 126**] G. [**Telephone/Fax (1) 14290**]
[**First Name4 (NamePattern1) **] [**Name8 (MD) **] MD [**Last Name (un) 9499**]
Completed by:[**2196-1-11**]
|
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"272.4",
"401.9",
"428.0",
"491.21",
"250.00",
"111.9",
"482.39",
"518.84",
"428.33",
"692.9",
"V46.2",
"305.1",
"276.2"
] |
icd9cm
|
[
[
[]
]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,132
| 117,606
|
17759
|
Discharge summary
|
report
|
Admission Date: [**2142-3-10**] Discharge Date: [**2142-3-14**]
Date of Birth: [**2074-7-10**] Sex: F
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is a 67 year old female
severe steroid dependence, home oxygen dependent chronic
obstructive pulmonary disease, congestive heart failure, who
had a colonoscopy performed on [**3-7**], at an outside
hospital for the second part of the large 4 to 5 cm polyp
removal by colonoscopy. The patient was not an operative
candidate due to her underlying cardiopulmonary disease and
this was the second operation to remove the large polyp in
question when seen at an earlier date. She was observed over
night at the hospital and discharged on [**3-9**]. She was to
be seen the following day after discharge for bleeding at
home, however, was stable there and discharged again. She
had a second episode again after her second admission at the
outside hospital for a large amount of hematochezia, and
presented herself to [**Hospital6 256**]
Emergency Department where she had another large episode of
bright red blood per rectum. She denied having any abdominal
pain, nausea, vomiting, back pain, fevers, chills, difficulty
breathing or chest pain. Actually her breathing was at her
baseline severe chronic obstructive pulmonary disease status.
Her initial hematocrit in the Emergency Department was 37.8,
however, she was in some mild acute renal failure with a
creatinine of 1.2 which after intravenous fluids and
normalization of her creatinine decreased to 30 to 31 range
later in the hospital course where it remained constant
throughout her hospitalization.
PAST MEDICAL HISTORY: Previous medical history includes - 1.
Severe chronic obstructive pulmonary disease on 3 liters of
cannula oxygen at rest, 4 liters/minute activating on chronic
Prednisone therapy for at least two months. 2. Congestive
heart failure, unknown etiology, no coronary artery disease.
3. Hypertension. 4. Gastroesophageal reflux disease. 5.
Type 2 diabetes mellitus felt to be related to steroid use.
6. Status post cholecystectomy. 7. Status post right knee
surgery.
MEDICATIONS PRIOR TO ADMISSION:
1. Losartan 50 mg b.i.d.
2. Lasix 60 mg b.i.d.
3. Spironolactone 25 mg b.i.d.
4. [**Doctor First Name 233**]-Ciel 30 mg b.i.d.
5. Combivent, Advair, Flovent inhalers
6. Singular 10 q.h.s.
7. Prednisone 20 mg q.o.d. and 10 mg q.o.d., alternating
days.
8. Nortriptyline 25 mg h.s.
9. Paxil 10 mg h.s.
10. Clonazepam 0.25 mg t.i.d.
11. Numerous Vitamins
12. Pantoprazole
13. Insulin sliding scale.
ALLERGIES: She states she is allergic to numerous
medications, however, after chart review with her primary
care nurse practitioner, the only documented allergies we
could find were rashes with Bactrim, Ceftin and Keflex. She
had reported myalgias with fluoroquinolones but there is no
report of any rash or difficulty breathing associated with
that class of medication. She has had reported shortness of
breath with Tetracycline, however, no rash, and has reported
that she has tolerated Macrolides in her chart despite giving
a history of rash.
SOCIAL HISTORY: The patient no longer smokes, however, has
an extensive smoking history and is now home oxygen
dependent. She lives with her husband in [**Name (NI) 5450**],
[**State 350**]. She denies frequent alcohol use or illicit
drugs.
HOSPITAL COURSE: She was admitted to the Medicine Intensive
Care Unit with a baseline hematocrit of 38 prior to
resuscitation of her hypovolemic status where she was
tachycardiac in the Emergency Department, however, never
hypotensive. Upon intravenous fluid replacement, her
creatinine decreased. Her tachycardia resolved and her
hematocrit decreased, ranging between 30 to 33, where it
remained stable throughout her hospital course. She never
required transfusion during her hospital stay. After being
observed in the Medicine Intensive Care Unit and not having
any further bright red bowel movements, she was transferred
to the floor. She had three small dark maroon stools without
associated decreases in her hematocrit or abdominal pain that
was felt to be residual blood from her proximal large bowel
lesion. The Gastroenterology Service followed the patient
closely throughout her course and the plan was made for
colonoscopy.
On hospital day #5, however, the patient had brown, clear,
rectal affluent and had no blood. Given this fact, her
stable hematocrit, and the lack of having fresh bleeding
since admission to the hospital in the Emergency Department,
the decision was made to forego colonoscopy and have the
patient discharged with close follow up. The patient
understands that if she should have any recurrence of bright
red blood per rectum that she should immediately return to
the Emergency Department via ambulance as there is the
potential for rapid rebleeding should the surgical site where
her mass was resected start to bleed again.
This was discussed with her nurse practitioner and she has an
appointment on Monday with her at Dr.[**Name (NI) 49335**] office for
repeat hematocrit check. Throughout her hospital stay she
had no associated problems related to her chronic obstructive
pulmonary disease. She was maintained on her home level of
oxygen as well as continued on her chronic obstructive
pulmonary disease medications including her steroids and she
had no associated dyspnea or orthopnea with it from her
congestive heart failure. She does continue to be limited by
her inability to walk distances greater than 20 feet due to
dyspnea, but this is stable per the patient. She will be
discharged on hospital day #5 with the following diagnosis.
DISCHARGE DIAGNOSIS:
1. Lower gastrointestinal bleed, status post 4 cm mass
excision in the proximal colon via colonoscopy seven days
ago.
2. Anemia due to bleeding, hematocrit stable for several
days now.
3. Chronic obstructive pulmonary disease, stable, continue
on her home oxygen and Prednisone.
4. Acute renal failure, upon admission, resolved with
intravenous rehydration.
5. Congestive heart failure which has been stable throughout
her hospital course.
6. Gastroesophageal reflux disease, has been stable on
Protonix.
She will follow up with her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 20932**] on Monday, for hematocrit check and she will also
follow up with the [**Hospital 6283**] Clinic in one to two
weeks where she will return to the Emergency Department if
she has any further bleeding or other problems.
DISCHARGE MEDICATIONS:
1. Lasix 80 mg p.o. b.i.d.
2. Albuterol
3. Fluticasone
4. Serevent
5. Singular 10 mg q.d.
6. Levoxyl 1 to 2 mcg q.d.
7. Spironolactone 25 mg b.i.d.
8. Clonazepam .5 mg b.i.d.
9. Protonix 40 mg b.i.d.
10. Raloxifene
11. Prednisone 20 mg q.o.d. and 10 mg q.o.d., alternating
days.
12. Paxil 10 mg q.d.
13. Amitriptyline 25 mg h.s.
14. Insulin per sliding scale.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2142-3-14**] 15:25
T: [**2142-3-14**] 18:24
JOB#: [**Job Number 49336**]
|
[
"584.9",
"998.11",
"280.0",
"401.9",
"251.8",
"496",
"428.0",
"E878.8",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6557, 7199
|
5688, 6534
|
3390, 5667
|
2171, 3127
|
178, 1643
|
1666, 2139
|
3144, 3372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,259
| 130,325
|
7401+55830
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-8-21**] Discharge Date: [**2106-8-27**]
Date of Birth: [**2026-12-30**] Sex: F
Service: VSU
CHIEF COMPLAINT: Left amputation stump with pain and
numbness and cold temperature for 48 hours. The patient had
no relief with Tylenol.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old female who
has known peripheral vascular disease who has a history of
aortic occlusion in [**2104-11-15**] and underwent a left ax-
fem, bifem bypass with a left common femoral artery
thrombectomy who presents with a cold left BKA. She denies
any constitutional symptoms. The patient was initially
evaluated in the emergency room and admitted to the vascular
service for definitive treatment.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 daily, Plavix 75 mg
daily, Lasix 40 mg b.i.d., Lopressor 50 mg daily, Procardia
60 mg daily, Isordil extended-release 30 mg daily, Lipitor 10
mg daily.
SOCIAL HISTORY: The patient is a nonsmoker, nondrinker and
denies drug use.
PHYSICAL EXAMINATION: Vital signs are 96.9, 61, 179/81, 20,
oxygen saturation 95% on room air. General appearance is an
alert, cooperative, white female. Lungs are clear to
auscultation. Heart is a regular rate and rhythm without
murmurs, gallops or rubs. Abdominal exam is unremarkable.
Extremity exam shows palpable left axillo-fem graft, palpable
fem-fem graft. Left femoral pulse is 1+ and is a monophasic
Dopplerable signal. The right femoral pulse is palpable. The
right PT and DP are palpable. On the left, there is no
popliteal pulse. The foot stump is cold.
HOSPITAL COURSE: The patient was initially evaluated in the
emergency room and begun on IV heparin with bolus. Coag's
were monitored and heparin dosing was adjusted. The patient
was consulted to the vascular service and admitted under the
care of Dr. [**Last Name (STitle) **]. IV heparinization was continued. Dr.
[**Last Name (STitle) **] [**Name (STitle) 27199**] for Dr. [**Last Name (STitle) **]. She felt that the
stump was not acutely threatened and the heparinization was
continued and continue to monitor serial peripheral vascular
exams. Would plan a duplex of the ax-fem, fem-fem bypass and
plan for an arteriogram. The patient had an arterial duplex
study done on [**2106-8-21**] which occlusion of the left
axillary femoral bypass distal to the confluence of the fem-
fem and ax-fem graft. The iliofemoral graft was not
identified. Findings were reviewed with the physician taking
care of the patient. On [**2106-8-24**], the patient was taken
to the angio suite to undergo a diagnostic arteriogram. This
was aborted because the patient had an anaphylactic reaction
to the Kefzol and went into respiratory arrest requiring
intubation. The patient then was transferred to the surgical
intensive care unit for continued mechanical ventilation. The
patient did have enzymes done which were negative for acute
myocardial infarction. She remained in the SICU overnight and
was extubated and transferred to the VICU for continued care.
The patient continued to do well and was discharged on [**2106-8-27**] to home in stable condition. Instructions were that
the patient should follow up with Dr. [**Last Name (STitle) **] in 1 week's
time, to call for an appointment at [**Telephone/Fax (1) 3121**].
DISCHARGE MEDICATIONS: Metoprolol 50 mg b.i.d., nifedipine
60 mg sustained-release daily, isosorbide dinitrate 30 mg
t.i.d., atorvastatin 10 mg daily, acetaminophen 500 mg
tablets, [**1-17**] q.4-6h. p.r.n., aspirin 325 mg daily, Lasix 40
mg b.i.d., Plavix 75 mg daily, Pletal 100 mg b.i.d.,
chlorpropamide 100 mg daily, oxycodone/acetaminophen 5/325 mg
tablets, [**1-17**] q.4-6h. p.r.n. for pain.
DISCHARGE DIAGNOSES: Ischemic left below-knee amputation,
Kefzol allergy with anaphylaxis, respiratory arrest,
resuscitated, peripheral vascular disease status post left
axillary-femoral-femoral, status post left below-knee
amputation, status post iliofemoral-femoral with
thrombectomy, status post right femoral-popliteal bypass,
history of asthma, history of aortic insufficiency, history
of aortic occlusion, history of hypertension, history of type
2 diabetes with neuropathy, history of coronary artery
disease status post myocardial infarction, status post
coronary artery bypass grafts.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2106-8-27**] 13:09:49
T: [**2106-8-27**] 14:35:16
Job#: [**Job Number 27200**]
Name: [**Known lastname 4677**],[**Known firstname 4678**] Unit No: [**Numeric Identifier 4679**]
Admission Date: [**2106-8-21**] Discharge Date: [**2106-8-27**]
Date of Birth: [**2026-12-30**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Cefazolin
Attending:[**First Name3 (LF) 1546**]
Addendum:
allergies: sulfa, cefzolin and contrast
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2106-9-8**]
|
[
"424.1",
"401.9",
"250.60",
"V45.81",
"357.2",
"E930.5",
"V49.75",
"412",
"414.00",
"440.20",
"995.0",
"427.5",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5004, 5166
|
3731, 4981
|
3332, 3709
|
786, 951
|
1616, 3308
|
1052, 1598
|
155, 276
|
305, 759
|
968, 1029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,453
| 163,483
|
32350
|
Discharge summary
|
report
|
Admission Date: [**2132-4-11**] Discharge Date: [**2132-4-15**]
Date of Birth: [**2089-3-19**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
upper endoscopy
History of Present Illness:
42 year old male EtOH cirrhosis w/ Varices, chronic
pancreatitis, who presents with abdominal pain x 2 days and
melanotic stools. The patient was recently admitted from
[**Date range (1) 42061**] with similar abdominal discomfort.
.
Patient states pain is epigastric and was a [**9-28**]. Describes
the pain as "stabbing" and radiating to RUQ and "straight
through" his abdomen. Pt states this pain is most similar to
previous variceal bleeds. He reports vomiting x 2 today with
"coffee ground emesis." He further reports that his stool has
been "jet black" x 2 days.
.
Patient states last drink was 6 hours ago and last oral intake
was the same. No history of withdrawal seizures or DTs.
.
In the [**Hospital1 18**] ED, 98.3 92 108/61 16 100. Patient had NG lavage
that was negative for blood. Got 2L NS. HCT initally was 34
and 37 on recheck. A rectal exam was performed with green stool
that was guaiac positive. Hemodynamically stable. The patient
was started on Protonix 40mg IV x 1 + gtt, and Octreotide gtt.
Transfer VS are stable on transfer.
.
Currently, the patient is complaining of nausea and abdominal
pain above baseline. Denies any CP/SOB, f/c/s, diarrhea, or
hematochezia.
.
ROS: As above, otherwise negative.
Past Medical History:
1. Hepatic Cirrhosis
2. Esophageal Varices
- Grade II and s/p banding procedures
- s/p multiple variceal bleeds, 6 episodes from [**2128**] to [**11-26**]
s/p multiple bandings
- [**12-30**] EGD: 3 cords of grade I varices were seen in the lower
third of the esophagus. +Gastritis present
3. Chronic Pancreatitis
4. Alcohol Abuse
5. Bipolar Disorder
6. s/p CCY in [**5-28**]
7. s/p Right ACL replacement and meniscectomy in [**2126**]
Social History:
Currently homeless. Divorced. Has daughter in [**Name (NI) 614**] and son
in [**Name (NI) 3320**]. 12 year history of drinking 1-1.75 liters of vodka
daily. Denies tobacco or other illicits.
Family History:
History of alcoholism. Paternal grandfather died of prostate
cancer. Maternal grandmother died of MI; no other family h/o
CVD. Father alive, with h/o kidney cancer. Mother and children
healthy.
Physical Exam:
Gen: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema
CV: Nl S1+S2, no m/r/g
Pulm: CTAB
Abd: S/ND, +bs, TTP worst in epigastrum/RUQ. No rebound or
guarding.
Ext: No c/c/e. 2+ dp/pt bilaterally.
Neuro: AOx3, no asterixis. CN II-XII intact.
Pertinent Results:
Labs on admission:
[**2132-4-11**] 04:50PM BLOOD WBC-4.2# RBC-4.31* Hgb-11.5* Hct-34.3*
MCV-80* MCH-26.7* MCHC-33.5 RDW-18.2* Plt Ct-94*
[**2132-4-11**] 04:50PM BLOOD Neuts-69.6 Lymphs-22.3 Monos-3.1 Eos-4.4*
Baso-0.5
[**2132-4-11**] 04:50PM BLOOD PT-14.5* PTT-28.6 INR(PT)-1.3*
[**2132-4-11**] 04:50PM BLOOD Glucose-136* UreaN-4* Creat-0.5 Na-137
K-4.2 Cl-103 HCO3-24 AnGap-14
[**2132-4-11**] 04:50PM BLOOD ALT-98* AST-342* AlkPhos-313* TotBili-0.9
[**2132-4-12**] 04:05AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.7
[**2132-4-11**] 04:50PM BLOOD ASA-NEG Ethanol-142* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Labs on discharge:
[**2132-4-15**] 07:35AM BLOOD WBC-1.7* RBC-3.56* Hgb-9.8* Hct-29.8*
MCV-84 MCH-27.4 MCHC-32.7 RDW-18.7* Plt Ct-102*
[**2132-4-15**] 07:35AM BLOOD PT-14.7* PTT-32.6 INR(PT)-1.3*
[**2132-4-15**] 07:35AM BLOOD Glucose-115* UreaN-5* Creat-0.5 Na-139
K-4.0 Cl-104 HCO3-27 AnGap-12
[**2132-4-15**] 07:35AM BLOOD ALT-68* AST-98* LD(LDH)-174 AlkPhos-249*
TotBili-0.6
[**2132-4-15**] 07:35AM BLOOD Albumin-3.2* Calcium-8.1* Phos-4.0 Mg-1.9
.
EGD [**2132-4-15**]: Varices at the lower third of the esophagus and
gastroesophageal junction. Distal 7 cm esophagus with erythema
consistent with grade B esophagitis. Retained food and exudate
on mucosa. Food in the fundus and stomach body. Otherwise
normal EGD to third part of the duodenum.
.
Microbiology:
- [**2132-4-11**] MRSA screen - negative
- [**2132-4-12**] H. pylori Ab - negative
Brief Hospital Course:
42 year old male EtOH cirrhosis w/ Varices, chronic
pancreatitis, melanotic stools now presenting with coffee ground
emesis, guaiac positive stools, and worsening abdominal pain.
.
# GI bleeding: Gastric lavage in the ED was negative. The
patient was initially admitted to the MICU for close monitoring,
but his vital signs and hematocrit remained stable overnight, so
he was transferred to the medical floor. The patient underwent
upper endoscopy on [**2132-4-15**], which showed esophagitis and grade 1
esophageal varices without stimata of recent bleeding. The
patient's stomach was [**Male First Name (un) **] adequately visualized due to residual
food, so the patient will need to follow up for repeat upper
endoscopy in 1 month. The patient was discharged on omeprazole
and sucralfate.
.
# Alcoholic cirrhosis: Continued lactulose. Initially held
nadolol due to concern that the patient would develop
hypotension. Restarted nadolol when it becamse clear that the
patient was stable.
.
# Alcoholism: The patient was started on a CIWA scale and given
thiamine, folate, and a multivitamin. The patient was urged to
stop drinking. Social work was consulted.
.
# Anemia: Chronic. Hct stable.
.
# Chronic pancreatitis: The patient was treated with Dilaudid
prn for pain as an inpatient. Held pancreatic enzymes while the
patient was NPO but restarted this as the patient's diet was
advanced.
.
# Psych: History of bipolar disorder and anxiety. Continued
citalopram and seroquel.
.
# Communication: [**Known lastname **],[**Name (NI) **] (mother) [**Telephone/Fax (1) 75519**],
[**Telephone/Fax (1) 75524**]
Medications on Admission:
Quetiapine 200 mg HS
Citalopram 40 mg DAILY
Nadolol 10 mg DAILY
Multivitamin DAILY
Folic Acid 1 mg DAILY
Trazodone 200 mg HS
Omeprazole 40 mg DAILY
Gabapentin 600 mg Q8H
Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Daily
Lactulose 30ML PO DAILY
Zolpidem 5 mg HS
Hydromorphone 2 mg 1-2 Tablets q6hrs prn pain
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Nadolol 20 mg Tablet Sig: one half ([**12-22**]) Tablet PO once a
day.
7. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
11. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO once a day.
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. esophagitis
2. alcoholism
3. cirrhosis
4. esophageal varices
.
Secondary:
1. chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with blood in your vomiting and your
stool. You had an upper endoscopy procedure, whiched showed some
inflammation and dilated veins in your esophagus. However, no
source of bleeding was identified. Due to residual food, the
endoscopy was not able to adequately visualize your stomach.
Therefore, the endoscopy will need to be repeated in about a
month. Talk to you primary care doctor about this.
.
You must stop drinking alcohol. If you continue drinking
alcohol, you will do further damage to you liver, resulting in
liver failure and death. Drinking also places you at risk for
serious bleeding from your esophagus, stomach, and intestines.
.
Take all of the same medications that you were taking prior to
admission, with the following change:
START sucralfate
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Specialty: primary care
Date and Time: [**Last Name (LF) 2974**], [**4-25**] at 11 a.m.
Address: [**Last Name (un) 12264**], [**Doctor Last Name **] 108, [**Location (un) **],[**Numeric Identifier 10614**]
Phone: [**Telephone/Fax (1) 5135**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"070.70",
"578.1",
"287.5",
"303.91",
"577.1",
"296.80",
"530.19",
"572.3",
"285.9",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7314, 7320
|
4297, 5905
|
310, 327
|
7474, 7474
|
2816, 2821
|
8445, 8864
|
2277, 2472
|
6268, 7291
|
7341, 7453
|
5931, 6245
|
7625, 8422
|
2487, 2797
|
256, 272
|
3445, 4274
|
355, 1593
|
2835, 3426
|
7489, 7601
|
1615, 2053
|
2069, 2261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,115
| 184,574
|
5989
|
Discharge summary
|
report
|
Admission Date: [**2103-2-26**] Discharge Date: [**2103-3-29**]
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentleman
with past medical history of hypertension, COPD,
hypercholesterolemia, and diabetes, who presents with acute
onset of shortness of breath at 1 a.m. that morning without
chest pain, but with associated nausea and diaphoresis. He
presented to an outside hospital. Initial vital signs by the
EMTs showed him to be tachypneic with a respiratory rate of
28-30 and O2 saturations to 91% on nonrebreather and cyanotic
nailbeds were noted. At the outside hospital Emergency
Department, he was given CPAP and his O2 saturation increased
to 97% with resolution of his cyanosis.
EKG at that time showed [**Street Address(2) 1766**] elevations in V1 and V2 and
V5 and V5 had ST depressions. Initial laboratories showed a
white count of 26.5. ABG of 7.42/43/263/27. Cardiac enzymes
were as follows: CK 201, troponin less than 0.1. Patient
was given aspirin at home and at the outside hospital. He
was transferred to [**Hospital3 **] for further evaluation and
management.
An echocardiogram was done on presentation, which showed an
ejection fraction of 30-35% and wall motion abnormalities
including basal mid inferior and inferolateral and septal
hypo and akinesis. There is focal hypokinesis of the apical
free wall of the right ventricle. Aortic regurgitation 1+.
PAST MEDICAL HISTORY:
1. COPD without baseline O2 requirement.
2. Hypertension.
3. Hypercholesterolemia.
4. History of hemoptysis with pneumonia in [**2096**].
5. Diabetes.
6. Status post cholecystectomy.
7. Asthma.
8. History of diverticulosis status post partial colonic
resection 25 years ago.
9. Status post appendectomy.
MEDICATIONS ON ADMISSION: Doses not listed.
1. Lipitor.
2. Cartia XL.
3. Cozaar.
4. Hydrochlorothiazide.
5. Aspirin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient has 120 pack year history of
cigarette smoking. He stopped approximately 20 years ago.
He is a former insurance salesman. He has a fiancee. His
son lives in the area and is involved in his care.
PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 99.2,
blood pressure 118/66, heart rate 78, respiratory rate 20, O2
requirement 99% on nonrebreather to 96% on 5 liters.
General: Elderly male with productive cough, purulent yellow
sputum. HEENT: EOMI. Anicteric sclerae. Oropharynx clear.
Neck is supple. No JVD. Lungs: Coarse breath sounds with
rhonchi and scattered basilar rales. Heart: Regular rate
and rhythm, normal S1, S2. Abdomen is soft, nontender, and
nondistended, positive bowel sounds. Lower extremities:
Trace edema bilaterally.
LABORATORY DATA: White count 26.6, 93.2% neutrophils, 0
bands, 5% lymphocytes, 1.7% monocytes, hematocrit 38.1,
platelet count 272. INR 1.2. Urinalysis is significant for
30 protein, otherwise negative. Electrolytes: Sodium 136,
potassium 4.2, chloride 96, bicarbonate 29, BUN 23,
creatinine 1.0. CK 257, MB 14, MB index of 5.4, troponin
8.15.
Chest x-ray: New bibasilar patchy opacities, which represent
pneumonia or possibly atelectasis.
EKG on admission: Normal sinus rhythm, modest nonspecific
ST-T wave changes, rate at 83.
Echocardiogram results as reported above.
HOSPITAL COURSE:
1. Cardiovascular: With regard to the patient's coronary
artery disease and presentation with elevated troponins, was
taken to cardiac catheterization laboratory on hospital day
#2, where proximal and mid RCA were found to be diffusely
diseased with discrete 70% stenosis of the left main and 50
and 60% stenoses of the mid LAD and distal LAD respectively.
Final diagnosis included left main coronary artery disease,
moderate systolic and diastolic ventricular dysfunction.
Recommendations were for ongoing medical therapy for this
non-ST segment myocardial infarction.
Patient was initiated on appropriate medications for medical
therapy for myocardial infarction including [**First Name8 (NamePattern2) **] [**Last Name (un) **],
metoprolol, aspirin, Lipitor. The patient had been continued
on Plavix until the point of catheterization as described
above.
On [**2-27**], the Cardiac Surgery team was consulted for
intervention in regard to the patient's left main disease.
Subsequently, the patient was prepared for CABG off bypass
pump. A LIMA to LAD bypass graft was accomplished on [**3-6**]. Patient's postoperative course was complicated by
pneumonia. Sputum was positive for MRSA. Patient's
shortness of breath did persist throughout much of his
hospital stay. It was thought that further intervention at
the left main site may benefit the patient's ongoing
shortness of breath.
On [**3-26**], the patient underwent second cardiac
catheterization, which is 60% left main, 70% mid left circ,
and 80% PDA stenoses were observed. The LM lesion was
assessed with a pressure wire. This evaluation was
complicated by dissection/occlusion of the left circumflex
requiring two stents to be placed subsequently. When flow
returned to this region, patient did have an episode of V-fib
arrest, which did resolve with one electric cardioversion 200
joules. Patient's left main and PDA stenoses were also
stented.
Patient had a subsequent echocardiogram on [**2103-3-28**],
which showed an ejection fraction greater than 60%, normal
left ventricle wall thickness, cavity size, and systolic
function, mild aortic stenosis.
Following the patient's catheterization that had a
complication of V-fib arrest on [**3-26**], he was noted to
be in AFib transiently post catheterization, and was
therefore started on a course of amiodarone, which was
discontinued on [**3-29**] due to concerns of pulmonary
toxicity. The patient did remain in normal sinus rhythm and
had no significant ectopy on telemetry monitoring
subsequently.
Medical management of his coronary disease was continued with
aspirin, Plavix with the addition of atorvastatin on [**3-28**], losartan and metoprolol for rate control. The patient
was continued on Lasix for evidence of mild fluid overload by
chest x-rays on multiple occasions during his hospital stay.
At the time of discharge, the patient was in normal sinus
rhythm, hemodynamically stable with ongoing mild shortness of
breath and decreasing oxygen requirement.
2. Respiratory: Patient was continued on albuterol,
Atrovent, and Advair inhalers throughout his hospital stay.
Chest PT was recommended. His postoperative course was
complicated by pneumonia and was treated with Zosyn and
vancomycin in addition to a short course of Flagyl. Patient
did have an elevated white blood cell count, which did
resolve. His sputum cultures did reveal MRSA. Patient's O2
requirement did slowly decrease throughout his hospital stay.
At the time of this dictation, his O2 requirement had fallen
to 1 liter.
During his hospital course on [**3-13**], the patient was
seen by the Pulmonary service, who recommended continuing
Atrovent and albuterol nebulizers, encouragement of
ambulation, chest PT, incentive spirometry, gentle diuresis
for the management of his lung disease. Pulmonary function
tests were obtained during his hospital stay, which showed a
severe obstructive ventilatory defect and a suggestion of a
concurrent restrictive process. Reduced diffusion capacity
was also seen consistent with emphysema.
3. Type 2 diabetes: Patient was continued on repaglinide and
regular insulin-sliding scale during his hospital stay. The
[**Last Name (un) **] Diabetes team followed his management throughout his
hospital stay.
4. Renal: Patient's renal function was normal at the time of
presentation and throughout much of his hospital stay by
[**3-28**], it did increase to 1.5. Prerenal etiology was
suspected. Patient did receive a unit of blood during that
night and at the time of this dictation, his renal function
was improving to 1.3. This mild elevation in his creatinine
may have also been the result of contrast nephropathy given
his recent cardiac catheterization.
5. Fluids, electrolytes, and nutrition: Patient was
continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] 2-gram sodium fluid restricted diet,
cardiac prudent.
6. Infectious disease: Patient was noted to have a pneumonia
postoperatively. He was treated with a course of Zosyn,
vancomycin, and Flagyl per recommendations of the Infectious
Disease team were consulted during the hospital stay, and the
patient's sputum culture did grow MRSA, which required the
use of vancomycin course for coverage. His white count
trended to normal slowly during his hospital stay gradually
reaching a point of 9.9 on [**3-24**]. It did increase again
to 14.6 shortly after his catheterization, but at the time of
this dictation, it had fallen to 11.9. Blood cultures drawn
throughout this hospital stay were without growth. At the
time of this dictation, serial Clostridium difficile samples
were negative. All urine cultures were without growth.
7. Hematology: Patient did require transfusions of PRBCs on
two incidences during his hospital stay, [**3-7**] and [**3-28**]. The GI team was consulted in regard to his hematocrit,
which remained near 30 throughout much of his hospital stay.
The GI fellow recommended outpatient evaluation with
colonoscopy/EGD for further evaluation of a possible GI
source to his ongoing anemia.
8. Disposition: Physical Therapy service was consulted
during the hospital stay. They recommended rehabilitation.
DISCHARGE CONDITION: Afebrile, hemodynamically stable,
asymptomatic.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Hypercholesterolemia.
3. Hypertension.
4. Type 2 diabetes.
5. Severe chronic obstructive pulmonary disease.
6. Congestive heart failure.
7. Hyponatremia.
8. Anemia.
9. Ventricular fibrillation arrest.
10. Atrial fibrillation.
11. Renal failure.
12. Pneumonia.
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg p.o. q.d.
2. Losartan 50 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. for nine months.
4. Miconazole powder 2% topical b.i.d. to the coccyx.
5. Furosemide 80 mg p.o. t.i.d.
6. Repaglinide 2 mg p.o. t.i.d. with meals.
7. Trazodone 25 mg p.o. h.s. prn.
8. Advair Diskus one puff inhaled b.i.d.
9. Docusate sodium 100 mg p.o. b.i.d.
10. Mucinex 1200 mg p.o. b.i.d.
11. Atrovent nebulizer one nebulizer q.6h.
12. Ranitidine 150 mg p.o. b.i.d.
13. Aspirin enteric coated 325 mg p.o. q.d.
14. Albuterol nebulizer one nebulizer inhaled q.6h.
15. Regular insulin-sliding scale.
DISCHARGE INSTRUCTIONS: Patient should follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] in the next week and
should follow up with his cardiologist in [**7-7**] days.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2103-3-29**] 10:28
T: [**2103-3-29**] 10:28
JOB#: [**Job Number 23593**]
|
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"482.41",
"427.5",
"997.1",
"428.0",
"250.00",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"37.22",
"36.15",
"99.62",
"99.04",
"88.56",
"36.05",
"36.06",
"36.07",
"88.53",
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] |
icd9pcs
|
[
[
[]
]
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9518, 9606
|
9627, 9917
|
9940, 10527
|
1798, 1928
|
3314, 9496
|
10552, 10987
|
143, 1444
|
3182, 3297
|
1466, 1771
|
1945, 2166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,418
| 176,589
|
37712
|
Discharge summary
|
report
|
Admission Date: [**2173-2-24**] Discharge Date: [**2173-3-3**]
Date of Birth: [**2108-11-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
lung cancer with tumor invasion of bronchi
Major Surgical or Invasive Procedure:
[**2173-2-25**] - flexible bronchoscopy
[**2173-2-26**] - Rigid bronchoscopy, tumor debridement using mechanical
debridement and cryotherapy of the right main stem/bronchus
intermedius tumor, placement of an uncovered 12 x 20-mm stent in
the
bronchus intermedius with balloon dilation of the stent,
placement of right Pleurx catheter into the right pleural space
under ultrasound guidance with drainage of pleural effusion
[**2-28**] - Rigid bronchoscopy, tumor destruction with mechanical
debridement and ablation argon plasma coagulation
[**2-28**] - Flexible bronchoscopy with tumor debridement and
therapeutic aspiration of secretions
History of Present Illness:
Mrs. [**Known lastname **] is a 64 y/o female with a history of stage IV lung
cancer that was first diagnosed on [**2168**] and treated at that time
with chemoradiation therapy. She was recently admitted to [**Hospital 8641**]
Hospital on [**2173-1-12**] for progressive cough and weakness and
was found to have an enlarging right hilar mass, with associated
pleural effusion and a thoracentesis that yielded positive
cytology. She was considering palliative chemotherapy, but
unfortunately she has become progressively weaker, with
increasing and disturbing cough - productive of sputum lately,
and with worsening dyspnea. She denies any fevers or chills. She
was started on antibiotics (Zosyn) at OSH for a possible
postobstructive pneumonia.
During her hospital stay in [**Hospital 8641**] Hospital she was also found
to have recurrent SVTs with reentry, atrial flutter/fibrillation
in/out that had been partially responsive to iv diltiazem. These
have been completely asymptomatic and have improved considerably
with beta blockage. She denies any chest pain.
She is now being transferred to [**Hospital1 18**]/Interventional Pulmonology
service for evaluation of her airway and possible stent or other
symptom relief procedure.
Past Medical History:
PAST MEDICAL HISTORY:
Rheumatoid arthritis
Lung cancer - stage IIIb NSCLC, which has been in remission for
three years. She was treated with chemotherapy and radiation
only.
SURGICAL HISTORY: She has had both hands operated on for
ligamentous issues secondary to her rheumatoid arthritis. She
has also had her right foot reconstructed secondary to
rheumatoid
arthritis in [**2164**]. She has also had two biopsies, one from the
right clavicle and one from her right lung.
Social History:
The patient is unsure of her ethnicity background. She is a
bookkeeper/cashier. She used to smoke tobacco, but quit
approximately three years ago. She does not drink alcohol.
Family History:
Significant for cancer of her father and two brothers, all lung
cancer. Also, lung disease in general runs in the family.
Physical Exam:
VS 99.8 84 108/66 20 99 3.5L NC
Gen: NAD, A&O x3
CV: RRR
Chest: b/l diffuse wheezes, decreased BS at right base
Abd: soft, nondistended
Ext: WWP
Pertinent Results:
CT chest [**2173-2-26**]:
1. Following bronchus intermedius stent placement, persistent
airway obstruction distal to the stent, with minimally
aerosolized material, as well as encasement/marked narrowing of
the right pulmonary artery. Pronounced post- obstructive
collapse of the right middle and right lower lobe, which has
increased from the prior study. Pronounced volume loss is
evidenced by increased rightward mediastinal shift and elevation
of the right hemidiaphragm. Close followup is warranted.
2. Interval decrease in right pleural fluid following placement
of pleural
catheter at the right lung base.
3. Unchanged appearance of right suprahilar consolidative
opacity and right upper lobe and anterior left upper lobe lung
masses.
4. Stable appearance of hepatic cyst and small hepatic lesions
in the right lobe.
Chest x-ray [**2173-2-27**]:
The mediastinum is currently more centrally positioned with
better aeration of the right lung that might represent overall
improved aeration of the right lung. Still present right
perihilar consolidation and right basal consolidation represents
a combination of known lung cancer, atelectasis and potentially
post-obstructive infection. The Pleurx catheter on the right has
been slightly repositioned. The left lung is unremarkable. There
is no pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2173-2-24**] and underwent
flexible bronchoscopy on [**2-25**] which deomonstrated tumor invasion
of the right mainstem bronchus and right bronchus intermedius.
She was continued on unasyn for treatment of presumed
postobstructive pneumonia and an admission WBC of 17. On [**2-26**]
she underwent mechanical debridement and cryotherapy of the
airway with placement of a 12 x 20mm stent as well as placement
of a right sided PleurX catheter into the right pleural space.
On [**2-28**] she underwent rigid bronchoscopy for further tumor
debridement and was taken back later that day for flexible
bronchoscopy and further tumor debridement a second time.
Postoperatively she was tachypneic and tachycardic and O2
saturations were transiently in the 50%s on room air; she was
placed on CPAP noninvasive ventilation and O2 saturations rose
quickly to the high 90%s. ABG at that time revealed significant
respiratory acidosis with 7.13/80/71, and she was planned for
admission to SICU. After several minutes of CPAP her ABG
improved to 7.37/39/126, and upon admission to the SICU she was
transitioned off the CPAP to face mask.
Overnight she did well, however CXR in the AM of [**3-1**]
demonstrated collapse of the right upper lobe and a right
pleural effusion. Her PleurX catheter was drained and she had
some symptomatic relief of symptoms. She also underwent a
flexible bronchoscopy at the bedside which reportedly did not
reveal any abnormality, with the stent in good place.
She was evaluated by the radiation oncology department during
this hospitalization. Given that she had completed 36 Gy of XRT
in the past, she was deemed not a candidate for Cyberknife,
however she could potentially undergo conventional
re-irradiation. The patient and her family discussed her
options with radiation oncology as well as interventional
pulmonology, and she decided, given her grim prognosis, to
transition to a hospice approach to her care, with the intention
to go home as soon as possible. Her wishes to be DNR/DNI status
were confirmed with Dr. [**Last Name (STitle) **], and on [**3-2**] she was transferred
from the ICU to the regular floor.
On [**3-3**] she was transferred to the floor. Her WBC count was
down to 13 and she was afebrile throughout the admission. She
was transitioned to PO augmentin for a total 14-day course of
antibiotics, and he was sent home for transition to home
hospice.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Magnesium oxide 400'', Senna prn, Milk of Mg prn, Bisacodyl prn,
Colace 100'', Digoxin 0.125', Metoprolol 12.5''', MVI',
Diltiazem
gtt (off now), Lidocaine nebs as needed for cough, Zosyn 3.375
q6iv, Tylenol 650 q6prn, Albuterol nebs, dilaudid 0.5 q3prn iv,
Tessalon 100 q4h prn, Tussionex 5cc q12prn, Paxil 20', Ativan
0.5-1 hs
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for no bm.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q4H (every
4 hours) as needed for severe cough.
Disp:*60 Capsule(s)* Refills:*2*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*2*
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*400 ML(s)* Refills:*2*
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*qs 1 month* Refills:*2*
12. Morphine 10 mg/5 mL Solution Sig: [**6-21**] mL PO every four (4)
hours as needed for pain.
Disp:*600 mL* Refills:*2*
13. Lidocaine (PF) 10 mg/mL (1 %) Solution Sig: 2.5 MLs
Injection Q4H (every 4 hours) as needed for coughing.
Disp:*300 ML(s)* Refills:*2*
14. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for nausea.
Disp:*40 Tablet(s)* Refills:*2*
15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. oxygen
2L - 6L home O2 as needed by nasal cannula or face mask / face
tent, titrate to patient comfort.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 8300**] Hospice
Discharge Diagnosis:
Stage IV non small-cell lung cancer
Discharge Condition:
stable
Discharge Instructions:
Please do not hesitate to contact Dr.[**Name (NI) 5070**] office or come to
the emergency room if you have any acute care concerns, such as
fevers/chills, nausea/vomiting, or sudden onset shortness of
breath. Refer to home hospice providers for symptom control as
needed.
Followup Instructions:
Follow up on an as-needed basis by calling Dr.[**Name (NI) 5070**] office at
[**Telephone/Fax (1) 3020**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2173-3-9**]
|
[
"511.81",
"714.0",
"519.19",
"518.0",
"518.89",
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] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"32.28",
"34.04",
"96.05",
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] |
icd9pcs
|
[
[
[]
]
] |
9235, 9293
|
4632, 7107
|
363, 1007
|
9373, 9382
|
3294, 4609
|
9703, 9952
|
2985, 3110
|
7512, 9212
|
9314, 9352
|
7133, 7133
|
9406, 9680
|
3125, 3275
|
281, 325
|
1035, 2272
|
7158, 7489
|
2316, 2773
|
2789, 2969
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,502
| 199,505
|
50229
|
Discharge summary
|
report
|
Admission Date: [**2133-4-9**] Discharge Date: [**2133-5-2**]
Date of Birth: [**2067-11-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubated [**4-9**], Extubated [**5-1**].
ICU procedures including placement of central venous line,
arterial line, bronchoscopy, thoracentecis, and placement of
pleurex catheter.
History of Present Illness:
Mrs. [**Known lastname 76783**] is a 56 yo f with COPD on 2L home O2 who was
brought in by ambulance when found cyanotic by daughter at home.
Had altered mental status today and was not answering the phone
when her daughter called. She was intubated in the field for an
O2 sat in 60's with bp 220/110. Per family patient had 3 week
hx of uri/copd exacerbation sx and was treated with po
prednisone until about 1 week ago. Was again prescribed
prednisone 60mg qd and levoquin on tuesday by her pcp.
In ED, patient was febrile 101.2 rectal HR 130 BP 144/91 RR 12
100% on bag ventilation.
She was treated with combivent, solumedrol 125mgx1, 1L NS,
Ceftriaxone 1g IV, Azithromycin 500mg IV.
Propofol bolus was given for agitation and patient's blood
pressure dropped to 73/50, propofol was turned off and ivf bolus
was given. One hour later bp dropped again with no response to
fluid resuscitation. Levophed started.
Of note, pt did recieve influenza vaccine and pneumovax
Past Medical History:
1. COPD [**4-19**] PFTs FEV1 0.81 liters (37% predicted), FVC 1.8
liters (59% predicted).
2. Hypercholesterolemia
3. Carotid disease 70-80% occlusion
4. Cervical degerative disease
Social History:
SH: +tobacco- 50-60 pack years
Family History:
Her mother died at age 74 from lung cancer.
Father died at age 39 from rheumatic heart disease. She has 2
sisters aged 70 and 63 in good health. She has a brother who is
in good health.
Physical Exam:
PE: Tm 101.4 HR 95 BP 140/79 AC 500 18 5 100% CVP 18
Gen: intubated sedated
HEENT: mmm, PERRLA, jvp unable to be evaluated
Lungs: expiratory wheezes bilaterally, good air movement
Heart: s1 s2 no m/r/g
Abd: soft nt/nd +bs
Ext: 1+ pitting edema
Pertinent Results:
Labs:
Microbiology:
[**4-9**] sputum: MRSA.
[**4-10**] BAL: MRSA, AFB negative.
[**4-11**] sputum: MRSA.
[**4-11**] flu: positive for influenza A.
[**4-20**] BAL: MRSA, pan-sensitive Klebsiella.
[**4-25**] Pleural fluid: gram stain 4+ PMNs, no organisms, culture
negative.
[**4-9**], [**4-22**] blood: negative.
Cytology:
[**4-10**] bronchial washings: negative.
[**4-/2094**] [**Doctor Last Name **] needle biopsy: positive for malignant cells c/w poorly
differentiated non-small cell carcinoma.
Imaging:
[**4-9**] Initial CXR:
IMPRESSION: Extensive right upper lobe consolidation consistent
with
pneumonia. Question of possible cavitary lucency within the
right upper lobe.
Serial CXRs demonstrated persistent right upper lobe
consolidation and eventual opacification of nearly the entire
right hemithorax due to consolidation and progressive pleural
effusion.
[**4-10**] Chest CT:
1) Large consolidation in the right upper lobe with bulky
mediastinal and
right hlar lymphadenopathy. These findings together with the
narrowing of the segmental right upper lobe bronchi raise the
differential diagnosis of bulky reactive nodes from an
infectious process vs. a post-obstructive pneumonia due to
neoplastic process. Further evaluation of the patient with
bronchoscopy and/or close follow-up with chest CT in [**4-18**] weeks
after antibiotic therapy is reccomended.
2) Moderate dependent right pleural effusion.
[**4-20**]/ Chest CT:
1) Worsening right upper lobe bronchial obstruction with
complete right upper lobe collapse. Increase in bulky
mediastinal and right hilar adenopathy. Increase in size of
right pleural effusion with new small left pleural effusion.
Findings are concerning for neoplasm such as primary lung cancer
with postobstructive changes in right upper lobe.
Brief Hospital Course:
Mrs. [**Known lastname 76783**] is a 65 yo female with a history of COPD (FEV1
0.81 liters/37% predicted) who presented with respiratory
distress.
1. Respiratory distress:
Her respiratory distress was thought to be due to a combination
of pneumonia (MRSA on sputum [**4-9**], klebsiella on BAL [**4-20**]),
influenza (positive influenza A [**4-11**]), her underlying COPD, and
a non-small cell lung cancer and associated right sided effusion
discovered during this admission. She was intubated in the
ambulance on her way to the ED and remained intubated until [**5-1**]
(see below). Her MRSA pneumonia was treated with vancomycin and
her klebsiella was treated with a seven day course of
levofloxacin. Her COPD was treated with albuterol, atrovent and
steroids. Her NSCLCa was treated with five doses of palliative
XRT (finished [**4-30**]). Her right effusion which was thought to be
due to her malignancy was treated first with a therapeutic
thoracentecis ([**4-25**]) and eventually IP was consulted to place a
pleurex catheter ([**4-29**]) for continued drainage. Despite all of
this treatment she required excessive settings on the ventilator
including FiO2 up to 70% and a PEEP of 15 to keep her O2 sat in
the 90s. Eventually both she and her family decided to extubate
her (see below).
2. Dispo:
Multiple family discussions were had both with Mrs. [**Known lastname 76783**] and
her family about her course and prognosis. Her combination of
severe COPD, pneumonia, and the new diagnosis of NSCLCa with
likely malignant pleural effusion made it very difficult to wean
her off the ventilator. She made it clear that she would not
like to have a tracheostomy and that she would like to have some
time extubated to talk with her family. She also was clear that
she would not like to be re-intubated if necessary. Thus on
[**5-1**] she was extubated and started on a morphine drip. She
passed away on [**5-2**] at approximately 4:45 pm.
Medications on Admission:
Flovent 2 puffs b.i.d.,
Serevent 1 puff b.i.d., Atrovent 3 puffs q.i.d.,
albuterol p.r.n., Plavix, aspirin, and Tylenol.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Non-small cell lung cancer.
2. COPD.
3. MRSA and Klebsiella pneumonia.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2133-5-2**]
|
[
"482.41",
"785.52",
"V17.3",
"496",
"518.81",
"V16.1",
"V66.7",
"487.0",
"281.9",
"458.29",
"162.3",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"33.26",
"38.93",
"92.24",
"34.91",
"96.72",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6217, 6226
|
4063, 6018
|
321, 502
|
6343, 6352
|
2246, 4040
|
6404, 6437
|
1778, 1967
|
6189, 6194
|
6247, 6322
|
6044, 6166
|
6376, 6381
|
1982, 2227
|
274, 283
|
530, 1509
|
1531, 1713
|
1729, 1762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,486
| 145,122
|
15624
|
Discharge summary
|
report
|
Admission Date: [**2185-4-29**] Discharge Date: [**2185-5-29**]
Date of Birth: [**2128-6-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
End stage liver disease
Major Surgical or Invasive Procedure:
liver transplant
History of Present Illness:
ESLD status post hepatitis C infection and cirrhosis with a 3x 4
lesion in segment II treated with ablation on final path was 1.2
cm hepatocellular carcinoma in pathology specimen, recovery was
prolonged by persistent ascites
Past Medical History:
ESLD, Hep C, HCC, Psoriasis, Grade I varices, Left sciatic pain,
arthritis, H/O lyme disease, diverticulosis, B/L inguinal hernia
repair, r cataract surgery, discectomy L-[**4-5**]
Social History:
PPD for 25 years quit [**8-4**], H/O cocaine, denied IVDA, H/O heavy
drinking, disabled carpenter, married one son
Family History:
NC
Physical Exam:
AXO X3, CN 2-12 intact, MAE no defecits [**5-5**], reflexes symmetric
[**Last Name (un) **], PERRL, NC, At, no LAD, anicteric, EOM-I, no JVD, no
bruit, no thyroidmegaly
CTA-B/L
S1, S2, trace SEM LLSB no R/G
S-Nt-ND, no masses no RT no guarding
+ fem B/L, + DP b/L
Pertinent Results:
[**2185-4-29**] 11:46PM TYPE-ART PO2-179* PCO2-40 PH-7.39 TOTAL
CO2-25 BASE XS-0
[**2185-4-29**] 11:25PM GLUCOSE-216* UREA N-12 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-23 ANION GAP-13
[**2185-4-29**] 11:25PM ALT(SGPT)-652* AST(SGOT)-1840* ALK PHOS-72
TOT BILI-1.7*
[**2185-4-29**] 11:25PM ALBUMIN-2.0* CALCIUM-8.0* PHOSPHATE-4.1
MAGNESIUM-1.9
[**2185-4-29**] 11:25PM PT-17.7* PTT-56.1* INR(PT)-2.1 RADIOLOGY
Final Report
CHEST (PORTABLE AP) [**2185-4-29**] 11:20 PM
CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVIC
Reason: LINE PLACEMENT
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with S/P LIVER trasnplant
REASON FOR THIS EXAMINATION:
LINE PLACEMENT
INDICATION: Status post liver transplant with line placement.
CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 10
hours earlier. There is an endotracheal tube with tip at the
thoracic inlet. A right internal jugular Cordis catheter and
right internal jugular Swan-Ganz catheter are present. The tip
of the Swan-Ganz catheter is in the pulmonary trunk. The
cardiomediastinal silhouette is within normal limits. The lungs
are clear. There are two JP drains overlying the right upper
quadrant.
IMPRESSION:
Tubes and lines as described above.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: SUN [**2185-5-1**] 8:39 PM
PROCEDURE: Written informed consent was obtained from the
patient after the patient's questions were answered. A
pre-procedure time checklist confirming patient identity and the
procedure to be done was performed. Under sterile technique and
ultrasound guidance, the right internal jugular vein was
accessed with a micropuncture needle and a wire was passed into
the superior vena cava (SVC) under fluoroscopic guidance. The
needle was exchanged for a micropuncture sheath. Through this, a
[**Last Name (un) 7648**] wire was advanced into the inferior vena cava (IVC). The
catheter was upsized to a 5 French sheath.
Through the sheath and over the wire, a catheter was advanced
into the right hepatic vein. Venograms were obtained in two
projections (AP and LAO caudo- cranial) with the catheter tip in
the right hepatic vein. Then, transcatheter pressure
measurements were obtained at multiple levels in this vein and
in the IVC.
The catheter was then exchanged over the wire for a 5 French
pigtail catheter, which was advanced under fluoroscopy in the
IVC up to the level of the renal veins, and a cavogram was
obtained. Transcatheter pressure measurements were obtained
along the infra and retrohepatic IVC up to the right atrium.
The findings were then discussed in person with the transplant
team and no intervention was performed. The sheath was removed
and hemostasis obtained.
IMPRESSION:
1. Smoothly tapered, long narrowing of the retrohepatic segment
of the IVC, associated with a 7 mm Hg gradient (mean pressure).
This is located caudally to the IVC anastomosis (which appears
well patent) and could possibly be related to extrinsic
compression from the overlying liver and surrounding structure
in supine position.
2. No focal areas of stricture suggesting significant venous
anastomotic stenosis.
Findings reviewed with Dr. [**Last Name (STitle) **] prior to termination of the
procedure.
ADIOLOGY Preliminary Report
[**Numeric Identifier **] TUBE CHOLANGIOGRAM [**2185-5-24**] 10:04 AM
Reason: to gravity to check biliary leak
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with elevated alk phos s/p liver tx [**4-29**]
REASON FOR THIS EXAMINATION:
to gravity to check biliary leak
INDICATION: Status post liver transplant [**2185-4-29**], with leak on
prior T-tube cholangiogram.
TECHNIQUE/FINDINGS: This procedure was performed by Dr. [**First Name (STitle) **] and
Dr. [**Last Name (STitle) 19420**] with Dr. [**Last Name (STitle) 19420**] present and supervising. Through the
T-tube, Conray nonionic contrast was connected to the patient's
T-tube via three way stopcock and placed to gravity. There was
free filling of the intrahepatic bile ducts proximal to the tip
of the T-tube as well as free flow of contrast into the
jejunostomy. There is no evidence of extraluminal extravasation.
Findings were discussed with Dr. [**Last Name (STitle) **] at the time of the
examination.
IMPRESSION: Tube cholangiogram demonstrates no evidence of leak.
There is free filling of intrahepatic bile ducts as well as free
flow of contrast into the jejunostomy.
T-TUBE CHOLANGIO (POST-OP) [**2185-5-18**] 2:31 PM
T-TUBE CHOLANGIO (POST-OP)
Reason: ?patency of vessels ? collection
[**Hospital 93**] MEDICAL CONDITION:
56 year old man s/p liver transplant on [**2185-4-29**] with elevated
lft'ss
REASON FOR THIS EXAMINATION:
?patency of vessels ? collection
HISTORY: 56-year-old man status post liver transplant with
rising LFTs.
COMPARISON: [**2185-5-13**].
PROCEDURE AND FINDINGS: The procedure was performed by Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) **], who was present and supervising. Gravity
cholangiogram was performed with Optiray nonionic contrast. This
revealed a nondilated common duct above and below the level of
the T-tube. Contrast was seen passing into the small bowel.
However, there was brisk extravasation of contrast observed at
the level of the common duct anastomosis. Examination with the
patient in lateral decubitus position revealed the contrast to
be collecting anteriorly. The exam was subsequently
discontinued. These findings were discussed with Dr. [**Last Name (STitle) **] at
the time of the exam. The T-tube was subsequently recapped.
IMPRESSION: Gravity cholangiogram demonstrating extravasation of
contrast at the common duct anastomosis.
[**2185-5-14**] 4:00 pm PERITONEAL FLUID
**FINAL REPORT [**2185-5-20**]**
GRAM STAIN (Final [**2185-5-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2185-5-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2185-5-20**]): NO GROWTH.
HCV VIRAL LOAD (Final [**2185-5-8**]):
6,620,000 IU/mL.
HCV viral load end-point determination.
Performed by RT-PCR.
Detection range: 60,000 - 70,000,000 IU/ml.
FOR RESEARCH USE ONLY..
NOT FOR USE IN DIAGNOSTIC PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
If HCV genotype on patient's sample is desired, please
contact
laboratory at ext. [**7-/3198**] within two weeks.
**FINAL REPORT [**2185-5-8**]**
HBV Viral Load (Final [**2185-5-8**]):
HBV DNA not detected.
Performed by PCR.
Detection Range: 300 - 200,000 copies/ml.
FOR RESEARCH USE ONLY..
NOT FOR USE IN DIAGNOSTIC PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
Brief Hospital Course:
Admitted S/P OLT [**2185-02-28**], Post Op uneventful, please see
operative report,given crystalloind and product support,
extubated and transferred to floor POD # 2 was aggressively
rehabilitated. He continued to show improvement and his LFTS
were followed closely as well as his immunosuporession levels
Below :is order of diagnostic examinations performed please
evaluate individual reports
[**2185-5-27**] Pathology Tissue: LIVER CORE BX. [**2185-5-27**] [**Last Name (LF) **],[**First Name3 (LF) **]
W. Not Finalized
[**2185-5-27**] Radiology BX-NEEDLE LIVER BY RADIOLOGIST
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-27**] Radiology GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US
(S&I) [**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-25**] Radiology US ABD LIMIT, SINGLE ORGAN [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-25**] Radiology CHEST (PA & LAT) [**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-24**] Radiology [**Numeric Identifier 23564**] CHALNAGIOGRAPHY VIA EXISTING CATHETER
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 45133**]
[**2185-5-24**] Radiology [**Numeric Identifier **] TUBE CHOLANGIOGRAM [**Last Name (LF) **],[**First Name3 (LF) **] W.
[**First Name3 (LF) 45133**]
[**2185-5-23**] Radiology PARACENTESIS DIAG. OR THERAPEUTIC
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-23**] Radiology US ABD LIMIT, SINGLE ORGAN [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-20**] Radiology PARACENTESIS DIAG. OR THERAPEUTIC
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology GUIDANCE FOR [**Female First Name (un) **]/ABD/PARA CENTESIS US
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology IVC GRAM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 45134**]
[**2185-5-20**] Radiology [**Numeric Identifier 45135**] 1SR ORDER BRANCH VENOUS SYSTEM
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology [**Numeric Identifier 45136**] HEPATIC VENOGRAM WITH PRESSURES
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology [**Numeric Identifier 45137**] IVC GRAM [**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology C1769 GUID WIRES INCL INF [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-20**] Radiology C1769 GUID WIRES INCL INF [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-20**] Radiology C1894 INT.SHTH NOT/GUID,EP,NONLASER
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology C1894 INT.SHTH NOT/GUID,EP,NONLASER
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-20**] Radiology NON-IONIC 50 CC [**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-19**] Radiology CT ABDOMEN W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-19**] Radiology CT PELVIS W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-18**] Radiology T-TUBE CHOLANGIO (POST-OP) [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-18**] Radiology DUPLEX DOPP ABD/PEL [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-17**] Radiology US ABD LIMIT, SINGLE ORGAN [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-17**] Radiology DUPLEX DOPP ABD/PEL [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-15**] Radiology UNILAT LOWER EXT VEINS RIGHT [**Last Name (LF) **],[**First Name3 (LF) **]
W. APPROVED
[**2185-5-14**] Radiology CT ABD W&W/O C [**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-14**] Radiology CT PELVIS W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-14**] Radiology CT 150CC NONIONIC CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-14**] Radiology PARACENTESIS DIAG. OR THERAPEUTIC
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-13**] Radiology DUPLEX DOPP ABD/PEL [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-13**] Radiology T-TUBE CHOLANGIO (POST-OP) [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-12**] Radiology MRI ABDOMEN W/O & W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **]
W. APPROVED
[**2185-5-12**] Radiology MR CONTRAST GADOLIN [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-12**] Radiology US ABD LIMIT, SINGLE ORGAN PORT
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-12**] Radiology -59 DISTINCT PROCEDURAL SERVICE
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-12**] Radiology DUPLEX DOPP ABD/PEL [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-6**] Radiology LIVER OR GALLBLADDER US (SINGLE ORGAN)
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-6**] Radiology DUPLEX DOPP ABD/PEL [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-4**] Radiology [**Numeric Identifier 23564**] CHALNAGIOGRAPHY VIA EXISTING CATHETER
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-4**] Radiology [**Numeric Identifier **] TUBE CHOLANGIOGRAM [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-1**] Radiology LIVER OR GALLBLADDER US (SINGLE ORGAN)
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-5-1**] Radiology DUPLEX DOPP ABD/PEL [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-5-1**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-4-30**] Radiology US ABD LIMIT, SINGLE ORGAN PORT
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
[**2185-4-30**] Radiology DUPLEX DOPP ABD/PEL PORT [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-4-30**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-4-29**] Cardiology ECG [**2185-5-3**] [**Last Name (LF) **],[**First Name3 (LF) **] W.
[**2185-4-29**] Pathology Tissue: LIVER AND GALLBLADDER. [**2185-4-30**]
[**Last Name (LF) **],[**First Name3 (LF) **] W.
[**2185-4-29**] Radiology CHEST (PRE-OP PA & LAT) [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-4-29**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] W.
APPROVED
[**2185-4-29**] Radiology -59 DISTINCT PROCEDURAL SERVICE
[**Last Name (LF) **],[**First Name3 (LF) **] W. APPROVED
Pt was down to pre-operative weight and was without pedal edema
or with minimal ascites, feeling well ambulating/ mentating
normally prior to D/C
Medications on Admission:
Protonix 40, clotrimozole cream, oxycodone 5, potasium, Eye
drops
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q
3-6PRN ().
Disp:*45 Tablet(s)* Refills:*2*
8. Valganciclovir HCl 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Sirolimus 1 mg Tablet Sig: Seven (7) Tablet PO ONCE (once)
for 1 weeks.
Disp:*49 Tablet(s)* Refills:*0*
10. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day) for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
11. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q24H
(every 24 hours).
Disp:*QS ML(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic once a day: until [**6-2**].
Disp:*QS ML(s)* Refills:*2*
14. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1)
Appl Ophthalmic once a day: until [**6-2**].
Disp:*QS ML(s)* Refills:*2*
15. Chlorhexidine Gluconate 0.12 % Liquid Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*900 ML(s)* Refills:*2*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): While taking Percocets, do not take if stools
are loose.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
S/P liver transplant
Discharge Condition:
stable
Discharge Instructions:
Please if any symptoms of malaise, fevers, chills, redness or
drainage at wound site return for immediate evaluation, you will
need to take all medications prescribed and please make certain
to arrange and attend all f/u appointments and the medication
levels will need to be followed closely as instructed, for you
laboratory schedule will be as follows.
Call transplant office if you have any fevers/chills,
nausea/vomiting, inability to take your medications,
redness/oozing from your incision site, decreased urine output
or no urine output.
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorous, ast, t.bili, urinalysis and trough prograf level.
Results to be fax'd to [**Hospital1 18**] Transplant office [**Telephone/Fax (1) 697**]
No heavy lifting, no driving while on pain medication
[**Month (only) 116**] shower with soap/water. Pat incision dry. apply gauze to old
right drain site
Chem &, CBC Ca, Po4, AST, T bili, UA, Prograf level, Must be
done [**Hospital1 **]- Weekly (Monday and Thursday) Lab results must be faxed
to [**Telephone/Fax (1) 697**] transplant coordinator levels
Followup Instructions:
F/U appointment with [**Last Name (un) **] and with transplant office: Call to
transplant office [**Telephone/Fax (1) 673**] to set up F/U appointment with
both the [**Last Name (un) **] Biabetes center and the transplant office
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2185-7-1**]
|
[
"070.70",
"571.5",
"276.1",
"572.3",
"155.0",
"401.9",
"250.00",
"789.5",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"50.59",
"87.54",
"50.11",
"00.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
17284, 17338
|
8332, 15192
|
336, 354
|
17403, 17411
|
1264, 1842
|
18566, 18952
|
961, 965
|
15308, 17261
|
6046, 6123
|
17359, 17382
|
15218, 15285
|
17435, 18543
|
980, 1245
|
273, 298
|
6152, 8309
|
382, 609
|
631, 813
|
829, 945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,596
| 175,550
|
37367
|
Discharge summary
|
report
|
Admission Date: [**2118-3-28**] Discharge Date: [**2118-3-31**]
Date of Birth: [**2053-11-10**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / ceftriaxone
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
slurred speech, left sided weakness
Major Surgical or Invasive Procedure:
endotracheal intubation and removal
History of Present Illness:
64F with hx Multiple Sclerosis with chronic foley catheter, PVD,
diplegia of lower extremities, presenting with abrupt change in
mental status noted by staff at nursing home around 9am,
including increased slurred speech, L sided weakness today as
well as episode of emesis en route by EMS. Patient had received
AM meds at nursing home, at which time she was noted to be at
baseline blood pressure and mental status. Soon afterwards, she
complained to another staff member that she was hot and wanted a
drink; when nurse returned with a drink, she was more lethargic
with elevated BP 180/90. In the ambulance, patient was noted to
not be withdrawing to pain on the left side.
Of note, per nursing home staff, patient's foley [**Last Name (un) **] has been
changed about 3 times since [**2118-3-24**] because it has either fallen
our or was noted to have increased urine sediment.
In the ED, initial vs were: 101.9 92 152/72 16 100% 4L NC. Both
eyes were deviated downwards, and patient was not following any
commands. She was agitated and had another episode of emesis in
the ED in setting of altered mental status. [**Name8 (MD) **] RN note, she
was noted to be 83% on ?room air, presenting with some
difficulty breathing. Patient was intubated for airway
protection with etomidate and succynlcholine, pretreated with
lidocaine 100mg x1 IV. ETT was initially placed in Right
Mainstem Bronchus, pulled back about 4-5cm with bilateral breath
sounds noted on exam. She dropped BPs initially on propofol, so
she was switched to midazolam and fentanyl for sedation.
Patient was previously DNR/DNI, but husband revoked this and
made her Full Code in the ED. Code Stroke was called in the ED
at 12:45pm. CTA and CT-perfusion unremarkable. On Neurology
team exam post intubation, patient was moving all extremities.
She was noted to have significant UTI and was given a dose of IV
ciprofloxacin 500mg x1. Given fever and hx of UTIs, Neurology
team suspects that symptoms were secondary to UTI rather than a
central neurologic process. Vitals in ED prior to ICU transfer
were as follows: 65 127/62 100% on AC FiO2 100% RR 15 PEEP
5.
On arrival to the MICU, patient was intubated and sedated,
appearing comfortable, unable to provide further history.
Past Medical History:
Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
- wheelchair at baseline, lives in nursing home
- has no use of her lower extremities, sometimes spastic
movements
UTI
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C Diff
Hx of Sacral [**Name (NI) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol
Social History:
Lives in nursing home for last 3.5 [**Name (NI) 1686**]. Husband is HCP, lives
with one of their daughters. [**Name (NI) **] daughter married and lives
in the area. Wheelchair at baseline, dependent for transfers
and some of ADLs. Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none
Family History:
No family members with Multiple Sclerosis.
Physical Exam:
Admission
Vitals: T: 100.4 BP: 127/56 P: 77 R: 18 O2: 100% on FiO2 100% AC
General: intubated and sedated, no acute distress
HEENT: Sclera anicteric, pupils 1.5mm equal, sluggish, dry mm,
cannot visualize oropharynx with ETT in place
Neck: supple, JVP not elevated
Lungs: Clear to auscultation laterally, no wheezes, rales, but
soft upper airway sounds audible diffusely
CV: Regular rate and rhythm
Abdomen: mildly distended, no grimace to palpation, bowel
sounds present, no rebound tenderness or guarding
GU: foley catheter in place
Ext: warm, well perfused, pulses, no peripheral edema
Pertinent Results:
[**2118-3-28**] 09:42PM TYPE-ART PO2-148* PCO2-45 PH-7.35 TOTAL
CO2-26 BASE XS-0
[**2118-3-28**] 04:12PM LACTATE-4.1*
[**2118-3-28**] 09:42PM LACTATE-0.6
[**2118-3-28**] 04:04PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2118-3-28**] 04:04PM URINE RBC->182* WBC-83* BACTERIA-NONE
YEAST-NONE EPI-<1
[**2118-3-28**] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2118-3-28**] 02:00PM URINE RBC-92* WBC-60* BACTERIA-MANY YEAST-NONE
EPI-0
[**2118-3-28**] 12:50PM GLUCOSE-129* UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2118-3-28**] 12:50PM CK(CPK)-56
[**2118-3-28**] 12:50PM CK-MB-1 cTropnT-<0.01
[**2118-3-28**] 12:50PM WBC-10.2 RBC-4.21 HGB-14.1 HCT-38.6 MCV-92
MCH-33.4* MCHC-36.4* RDW-14.2
[**2118-3-30**] 06:25AM BLOOD WBC-4.9 RBC-3.66* Hgb-11.7* Hct-35.3*
MCV-96 MCH-31.9 MCHC-33.1 RDW-14.1 Plt Ct-172
[**2118-3-30**] 06:25AM BLOOD Glucose-77 UreaN-9 Creat-0.6 Na-141 K-3.6
Cl-107 HCO3-25 AnGap-13
[**2118-3-30**] 06:25AM BLOOD ALT-19 AST-18 AlkPhos-104 TotBili-0.3
[**2118-3-31**] 07:40AM BLOOD Phos-1.6*
[**2118-3-28**] 09:42PM BLOOD Lactate-0.6
[**2118-3-28**] 4:04 pm URINE Site: CATHETER
**FINAL REPORT [**2118-3-29**]**
URINE CULTURE (Final [**2118-3-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**2118-3-28**] 4:17 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2118-3-29**]):
Reported to and read back by DR. [**Last Name (STitle) **]. HEDGE ON [**2118-3-29**] AT
0635.
GRAM NEGATIVE ROD(S).
[**2118-3-29**] 10:45 am BLOOD CULTURE x 2 Source: Venipuncture.
Blood Culture, Routine (Pending):
[**2118-3-30**]: ct abdomen/pelvis with contrast
IMPRESSION:
1. No evidence of intra-abdominal source for the patient's
bacteremia.
2. Essentially normal abdomen and pelvic CT.
Brief Hospital Course:
64F with hx of Multiple Sclerosis, chronic indwelling foley,
presenting with altered mental status, including slurred speech
and temporary left-sided weakness, found to have UTI, hypoxia,
intubated after emesis x2 in setting of altered mental status.
Altered Mental Status, urinary tract infection based on + u/a
but culture with mixed colonization, e coli bacteremia:
Patient was noted to have altered mental status in addition to
new Left-sided arm weakness and worsening of baseline slurred
speech on presentation to EMS and in ED. On Neurology
examination post-intubation, patient was moving both upper
extremities spontaneously, and CT Head and Neck Perfusion showed
no acute process. Neurology team felt that symptoms likely
represented delirium in setting of UTI and not likely central
process. No known stroke history. Patient does have hx of
multiple sclerosis, so UTI likely exacerbated multiple sclerosis
symptoms. Patient had negative cardiac enzymes and UTI was
treated. She was extubated on [**3-29**] without complication. Her
mental status after extubation was at baseline. Neurologic
symptoms improved with treatment of infection.
E coli bacteremia: Blood cultures grew E coli so Meropenem was
added to Cipro morning of [**3-29**]. Ciprofloxacin had been started
in the ED. Surveillance blood cultures were sent. Surveillance
cultures negative, E coli grew from +BCx and was ESBL. She will
require an additional 11 DAYS OF MEROPENEM FOR A TOTAL 14 DAY
COURSE, LAST DAY OF ANTIBIOTICS SHOULD BE [**2118-4-11**]. CT of the
abdomen / pelvis done to search for other cause of bacteremia
given that the u/a had mixed flora, this was negative for any
acute intraabdominal findings. In addition LFTs were normal
making a biliary source unlikely. Foley was replaced in ED as
the most likely source. Lactate elevated to 4.1 in ED which
decreased to 0.6.
Hypoxia
Patient intubated in ED to protect airway due to emesis in
setting of altered mental status. She was reportedly not having
any respiratory symptoms in the ED, though nursing report shows
O2sat of 83% prior to intubation. Patient was extubated on [**3-29**]
without complication.
Code: Full Code (confirmed with family in ED and on arrival to
MICU)
Patient was DNR/DNI previously, but husband revoked it in the
[**Name (NI) **], [**First Name3 (LF) **] she is now Full Code. PCP was emailed with this new
status.
Communication: Husband HCP = [**Name (NI) **] [**Name (NI) **]
Medications on Admission:
Simvastatin 20mg at bedtime
Tegretol XR 100mg - 3 tabs [**Hospital1 **] ;
Carbamazepine 1000mg daily at 12 noon
cyclobenzaprine 10mg [**Hospital1 **]
baclofen 5mg [**Hospital1 **]
Copaxone 20mg/ml 20mg daily
OsCal 500 1250mg daily
alendronate 70mg weekly
citalopram 40mg daily
Aricept 10mg at bedtime
trazodone 25mg QHS
cranberry supplements 2 tabs [**Hospital1 **]
Norvasc 5mg daily
aspirin 81mg daily
albuterol nebs daily in AM and prn
ipratroprium nebs daily in AM and prn
acetaminophen 650mg Q6H prn
vitamin E 400u daily
senna 8.6mg x2tabs at bedtime
multivitamin daily
potassium chloride 20meq daily
fleet enema MWF evenings
docusate 100mg [**Hospital1 **]
oyster [**Doctor First Name **] 500mg daily
Flovent HFA 110mg 2x daily
.
Allergies: Zosyn/Ceftriaxone --> bad rash while on both of
these medications, unclear which is the offender
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. carbamazepine 100 mg Tablet Extended Release 12 hr Sig: Three
(3) Tablet Extended Release 12 hr PO BID (2 times a day).
3. carbamazepine 200 mg Tablet Sig: Five (5) Tablet PO once a
day: at noon.
4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
6. Copaxone 20 mg Kit Sig: Twenty (20) mg Subcutaneous once a
day.
7. Os-Cal 500 + D Oral
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
12. cranberry Oral
13. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation once a day: qam and
prn.
16. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation once a day: qam and prn.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
18. vitamin E Oral
19. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
21. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
q mon, wed, fri.
22. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
23. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
24. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 11 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
Primary Diagnosis:
E coli bacteremia
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with a severe blood stream
infection which was caused by a severe urinary tract infection.
You will need antibiotics IV for the next 11 days for a total 2
week course. No other medication adjustments have been made.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge
from the hospital: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 608**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,081
| 120,634
|
3305
|
Discharge summary
|
report
|
Admission Date: [**2197-12-10**] Discharge Date: [**2197-12-22**]
Date of Birth: [**2152-5-24**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
seizure.
Major Surgical or Invasive Procedure:
Burr hole and aspiration of right frontal brain abscess.
PICC line placement.
History of Present Illness:
CC: new onset seizures, brain mass, intubated at OSH. History
per husband.
HPI: 45 year old woman originally from [**Country 2045**] with little
significant past medical history presents with new onset seizure
activity. She was in her USOH until this AM when patient's
husband noted her to be sleepy, not answering his questions at
8:30am. He assumed she was tired, so he took a shower to get
ready for church. At 9am after getting out of the shower he
noted patient to have stiff, shaking arms (bilateral), head
deviated to the left, drooling out of the left side of her
mouth.
Legs covered with blanket. Unresponsive to his questions.
Lasted
one minute. She subsequently attempted to wipe the drool from
her face, but still did not answer his questions. EMS was
called
and transferred her to [**Hospital3 **]. Notation is patchy,
but
it appears as though she received doses of valium en route, and
seized again at OSH, requiring ativan and loading of one gram of
fosphenytoin. She was intubated secondary to respiratory
depression (?) from medications (O2 sat 80%). Head CT from OSH
showed 1.5 cm mass in right frontal lobe with edema. Transferred
to [**Hospital1 18**] for further management and neurosurgical consultation.
Husband states that she underwent lithotripsy for kidney stone
on
[**2197-11-23**] and since then has been fatigued, 2 pound weight loss.
Some difficulty urinating and some constipation secondary to a
pain medication she had been taking. But no fevers, chills,
recent illnesses, personality changes, weakness, numbness. She
may have had a mild headache one or two days ago, but nothing
out
of the ordinary per husband. [**Name (NI) **] emesis or nausea. NO bloody
stools. No difficulty breathing, no chest pain. She goes to
the
doctor [**Last Name (Titles) 15374**] (PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13959**] at [**Location (un) **]) and keeps up with
her health (h/o mammograms, no colonoscopy).
Past Medical History:
s/p TAH BSO
recurrent nephrolithiasis (s/p 3 surgeries?)
Social History:
moved here from [**Country 2045**] 20 yrs ago, no tob/etoh/drugs, 3
healthy children, supportive husband (cell [**Telephone/Fax (1) 15375**]) [**Doctor Last Name **]
[**Known lastname **]. denies HIV risk facors, most recent travel was to [**Country **]
[**Country **] one year ago, denies consuming undercooked meats or smoked
sausages.
Family History:
Brother recently died of colon cancer at age 49. mom with
stroke in her 60's. both mom and dad deceased. 3 healthy kids.
one sister with multiple sclerosis.
Physical Exam:
General Exam:
Vitals: afebrile since yesterday
Gen: WDWN, NAD
Head: NC/AT, non-icteric, MMM
Neck: supple, no LAD
CV: nl S1, S2 regular (-)MRG
Pulm: CTA bilaterally
Abd: S,NT,ND
Back: Rt flank tenderness, no spinal tenderness
Ext: no edema nor rashes
Neurological Exam:
Mental Status:
Awake, alert, cooperative but inattentive. Memory intact to
distant and recent past. Speech is fluent without paraphasic
errors. Naming and repitition are intact. There is no
neglect. She has marked motor impersistence and some
perseveration. She appears to maintain continuity of events.
Postive snout.
Cranial Nerves:
II. Discs flat and sharp, no hemorrhage or emboli visualized,
visual fields intact to confrontation. pupils normal, round and
reactive to light, no rAPD
III, IV, VI. Extraocular movements intact and without nystagmus,
V, VII. Normal facial sensation. Subtle lt facial droop.
Strength
full and symmetric.
VIII. Hearing intact to finger rub bilaterally
IX, X, XII. Normal oropharyngeal movemement. Tongue midline
without fasciculations. Sternocleidomastoid and trapezius normal
bilaterally
Motor:
Normal bulk and tone without adventitious movements.
Slight pronator drift and slowing of RAMs on the lt.
Left deltoid is 4+/5 otherwise,
Full strength throughout the upper and lower extremities.
Sensory: Intact to light touch, cold, proprioception,
stereognosis, and graphesthesia
Reflexes:
Tri [**Hospital1 **] Br Pat Ach Toes
L 2+ 3 2+ 2+ 2+ down
R 2+ 2+ 2+ 2+ 2+ down
Coordination: Without dysmetria, intact to FNF and HTS.
Gait: Narrow, normal based. Initiation normal with normal
stride. Romberg sign absent.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2197-12-20**] 02:15PM 9.2 4.41 12.4 36.7 83 28.0 33.7 13.6 347
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2197-12-20**] 02:15PM 75.8* 15.7* 5.9 2.3 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2197-12-11**] 02:56AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION PT PTT Plt Smr Plt Ct INR(PT)
[**2197-12-20**] 02:15PM 347
MISCELLANEOUS HEMATOLOGY ESR
[**2197-12-20**] 02:15PM PND
T LYMPHOCYTE SUBSET WBC Lymph Abs [**Last Name (un) **] CD3% Abs CD3 CD4% Abs CD4
CD8% Abs CD8 CD4/CD8
[**2197-12-12**] 07:00PM 14.1* 15 [**Telephone/Fax (2) 15376**] 35 741 18 370 2.0
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2197-12-20**] 02:15PM 0.6
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2197-12-20**] 02:15PM 23 13 79 0.2
OTHER ENZYMES & BILIRUBINS Lipase
[**2197-12-10**] 07:51PM 34
LFTS ADDED @ 21:46
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2197-12-20**] 05:04AM 9.4 3.8 1.9
HEMATOLOGIC calTIBC Hapto Ferritn TRF
[**2197-12-11**] 12:40PM 244 521* 179* 188*
DIABETES MONITORING %HbA1c
[**2197-12-10**] 07:51PM 5.8
OTHER CHEMISTRY Ammonia
[**2197-12-10**] 07:51PM 13
PITUITARY TSH
[**2197-12-11**] 02:56AM 0.401
1 NEW METHOD AS OF [**2196-4-18**]
IMMUNOLOGY CRP
[**2197-12-20**] 02:15PM PND
HIV SEROLOGY HIV Ab
[**2197-12-11**] 05:17PM NEGATIVE
CONSENT RECEIVED
ANTIBIOTICS Vanco
[**2197-12-17**] 08:08PM 13.4*
@Trough
NEUROPSYCHIATRIC Phenyto
[**2197-12-17**] 08:08PM 13.0
@Trough
LAB USE ONLY RedHold
[**2197-12-10**] 12:40PM HOLD
Blood Gas
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2197-12-10**] 01:02PM 2.9*
Miscellaneous
ECHINOCOCCUS ANTIBODY (IGG)
[**2197-12-12**] 07:00PM PND
Frontal brain mass path: PYOGENIC ABSCESS.
[**Doctor Last Name **] MRI with GAD: 2x2cm right frontal brain lesion, ring
enhancing, bright on diffustion suggestive of abscess.
TEE: no endocarditis, normal.
CT torso: 1. Nephroureteral stent terminating in the urinary
bladder on the left side. There are several calcified stones
within the lower calices on the left kidney and
moderate-to-severe hydronephrosis. 2. Patchy infiltrates on the
left lung base, unchanged from prior CT from yesterday. No
mets, no abscesses.
PICC: IMPRESSION: Left PICC line tip in the upper right atrium,
withdrawal by 3 cm recommended. These findings were discussed
with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2197-12-15**].
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Neuro ICU as she was intubated for
airway protection at OSH after receiving multiple
benzodiazipines and fosphenytoin load. She was quickly
extubated and did well from a respiratory standpoint. CT from
OSH showed a right frontal brain mass, thus MRI was obtained.
MRI showed a 2x2cm ring enhancing lesion, bright on DWI, in the
right frontal lobe suspicious for abscess. (Note: report says
GBM but after multiple readings with neuroradiology this was not
felt to be the case.) She denied risk factors such as eating
raw meat, HIV positivity, tooth infections, etc. She was tested
for HIV and found to be negative. ID was consulted and she was
started on vanco/ceftriaxone/flagyl (antibx started on
[**2197-12-11**]). She eventually underwent brain biopsy/aspiration of
this lesion on [**2197-12-19**] after repeat MRI showed ENLARGING mass;
6cc of pus was drained and sent for cultures/path. She did well
post op. ID recommended discontinuation of the vanco,
conversion to PO flagyl, and continuation of IV ceftriaxone for
another 6 weeks.
The source of the infection is still not clear, but we suspect
it may have come from her renal stones and ureteral stent
(foreign body). Urology was consulted re: the need to remove
the stent and they felt this was not the nidus of infection, and
so it remains as is. UTI was treated with antibiotics as above.
Blood cultures came back positive for strep viridans, however
later these cultures were determined to be comtaminants. In the
interim, she underwent TEE to evaluate for endocarditis as a
cause of abscess; this was negative for veggitations.
She was diagnosed with iron deficiency anemia, and required 2 u
pRBCs for dropping hct at the beginning of her hospitalization.
Given her family history of early colon cancer, she should have
a screening colonscopy at as outpatient. Started on oral iron
replacement.
For her seizure, she was maintained on dilantin. She was also
maintained on decadron for brain edema. She will be discharged
on dilantin and a decadron taper. No further seizures during
hospitalization.
Clinically, she has a very mild left lower face droop and
hemiparesis, improving over the course of hospitalization.
Medications on Admission:
ALLERGIES: NKDA
MEDS:
rare prn percocet
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
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. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 weeks.
Disp:*126 Tablet(s)* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ceftriaxone Sodium 2 g Piggyback Sig: One (1) Intravenous
once a day for 6 weeks.
Disp:*49 2gram doses* Refills:*0*
8. Decadron taper
Decadron 4mg tabs PO
Taper as follows: 4mg TID x 1 week, 4mg [**Hospital1 **] x 1 week, 4mg daily
x 1 week, 4mg every other day x 1 week, then off.
Disp: 46 tabs
No refills.
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**5-2**]
hours as needed for pain for 10 doses: [**Month (only) 116**] cause drowsiness.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Brain abscess
Nephrolithiasis
UTI
Focal onset seizure with secondary generalization
Discharge Condition:
Good - ambulating, eating, mild left deltoid weakness otherwise
no other focal deficits.
Discharge Instructions:
Call your PCP or go to an emergency room if you have any surren
onset of weakness, numbness, tingling sensation that last longer
than 30 minutes, changes in speech, visual changes or new
seizures.
Take all medications and attend all followup appointments.
Followup Instructions:
1. Follow up at Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] neurosurgery clinic at [**Hospital Unit Name 15377**] on Monday, [**1-8**] at 11AM to
have your staples removed.
2. Call [**Telephone/Fax (1) 541**] to register at Dr.[**Name (NI) 11858**] [**Name (STitle) **]
[**Hospital 878**] clinic to make a follow up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7673**] for 4 weeks from now.
3. Follow up at the infectious disease clinic with Dr. [**Last Name (STitle) 15378**]
on Tuesday [**1-29**] at 9:30 AM.
|
[
"280.9",
"780.39",
"790.6",
"V16.0",
"599.0",
"592.0",
"591",
"041.09",
"790.7",
"324.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"01.39",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10954, 11015
|
7441, 9687
|
328, 409
|
11143, 11233
|
4766, 7418
|
11537, 12122
|
2863, 3024
|
9779, 10931
|
11036, 11122
|
9713, 9756
|
11257, 11514
|
3039, 3293
|
3312, 3312
|
280, 290
|
437, 2409
|
3658, 4747
|
3330, 3642
|
2431, 2490
|
2506, 2847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,400
| 187,337
|
15200
|
Discharge summary
|
report
|
Admission Date: [**2188-3-28**] Discharge Date: [**2188-4-1**]
Date of Birth: [**2130-12-20**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 57-year-old man with a
history of alcoholic cirrhosis complicated by ascites status
post TIPS, most recently complicated by TIPS occlusion in
[**2188-3-11**] with apparent inability to make the TIPS
patent by Interventional Radiology. The patient was admitted
to [**State 44256**], and discharged on [**2188-3-28**]
with hepatic encephalopathy without any apparent trigger
found. The patient was possibly intubated during that
hospital stay and the encephalopathy resolved with lactulose.
The patient returns to the [**Hospital1 188**] on [**2188-3-28**] with feelings of weakness, tiredness,
lightheadedness, dizziness. His last bowel movement he noted
some bright red blood per rectum and he also had one bowel
movement with darker blood. He presented to the Emergency
Room with a blood pressure of 79/56 and was noted to be
orthostatic. Her required several units of normal saline
with improvement in his blood pressure. A rectal examination
was performed in the Emergency Room with internal hemorrhoids
and gross blood noted. The patient was felt to be stable at
that time, and was transferred to the floor as his hematocrit
was at baseline.
However, on [**2188-3-29**] at approximately 5 o'clock in the
morning, the patient had two additional melanotic stools, and
his blood pressure was noted to be in the 90s. The patient
had a nasogastric lavage performed, and it was unable to be
cleared. Lavage revealed black material with clots present
approximately 500 cc. The patient denies any fever or
chills, chest pain, abdominal pain, or shortness of breath.
PAST MEDICAL HISTORY:
1. History of gastrointestinal bleeds with recent hospital
admission in [**2188-2-23**] for gastrointestinal bleed due to
portal gastropathy and small varices were noted which were
grade I. Her hematocrit was stable.
2. Alcohol cirrhosis, patient quit alcohol three years ago.
3. Depression and posttraumatic stress disorder.
4. History of esophageal varices status post banding.
5. Ascites.
6. Status post TIPS in [**2187-9-25**] complicated by
thrombosis with revision x2 and re-occlusion in [**2188-9-24**].
7. Hepatic encephalopathy.
8. TIPS occlusion in [**2188-3-11**] with inability to make
patent by IR.
9. Barrett's esophagus.
10. Mild artery systolic hypertension as noted on
echocardiogram in [**2188-2-23**] with pulmonary artery
systolic pressures of 26-36 mm Hg.
MEDICATIONS:
1. Lasix 40 mg po q day.
2. Aldactone 50 mg po q day.
3. Pepcid.
4. Darvocet prn.
SOCIAL HISTORY: Patient is divorced and now remarried.
Former alcohol and cocaine abuser. Quit alcohol
approximately three years ago. He is a former [**Country 3992**] vet.
PHYSICAL EXAMINATION: In general, patient was alert and
oriented times three, though clearly confused about his
recent history. Heart rate 101, blood pressure 107/62,
respiratory rate 14, and oxygen saturation is 100% on room
air. HEENT: Pupils are equal, round, and reactive to light.
Mucous membranes moist. Sclerae are anicteric. Neck: No
lymphadenopathy, 2+ carotid pulses bilaterally.
Cardiovascular: Regular, rate, and rhythm with a normal S1,
S2 without murmurs, rubs, or gallops. Chest was clear to
auscultation bilaterally. Abdomen: Soft, nontender,
slightly distended with shifting dullness. Extremities: No
peripheral edema or palmar erythema, warm lower extremities.
Neurologic: No asterixis.
LABORATORIES: White count 8.3 with hematocrit of 29.8 which
decreased to 26.8 on repeat check after his melanotic stools,
platelets 169, PT 15, PTT 41.6, INR of 1.5. Sodium 125 with
baseline sodium of 123-130, potassium 4.1, chloride 95,
bicarbonate 17, BUN 56, creatinine 2.8 with a baseline
creatinine of 1.6, glucose 91. ALT 21, AST of 38, alkaline
phosphatase of 244, amylase 64, albumin 2.3, total bilirubin
0.9. Ammonia 77, serum osms 296.
MR of the abdomen on [**2188-3-13**]: Extensive portal venous
thrombosis with extension into the splenic vein, superior and
inferior mesenteric veins. Small segment of the clot also
extends out into the cranial aspect of the TIPS and into the
inferior vena cava. The patient was also noted to have
cirrhosis, portal hypertension, and upper abdominal ascites.
CHEST X-RAY: Lungs are clear without infiltrate or effusion.
HOSPITAL COURSE:
1. GI bleed: Although the patient was initially admitted to
the floor, because of the patient's melanotic stools and
hypertension, the patient was transferred to the Medical
Intensive Care Unit on [**2188-3-29**]. Patient had 3 units of
packed red blood cells in total transfused for his hematocrit
of 26, which improved to 30 after transfusions, portal
hypertension. In addition, the patient received 2 units of
fresh-frozen plasma and vitamin K 10 units subcutaneously x3
days to reverse his coagulopathy and elevated INR.
The patient's hematocrits were monitored serially and
Barrett's esophagus, varices and the patient's hematocrit
stabilized at 36. The patient had a femoral line placed for
access in the fundus and the body of the stomach, and the
patient was started on an octreotide drip given his history
of portal hypertension and prior episodes of gastrointestinal
bleeds. He also was fluid resuscitated for his low blood
pressures. The patient was started on Protonix
intravenously, which was converted to po 40 mg [**Hospital1 **] once the
patient was able to tolerate a po diet.
The patient had an EGD performed on [**2188-3-31**] which
revealed Barrett's esophagus, varices at the middle third of
the esophagus, varices which were completely sclerosed within
8 cm of the gastroesophageal junction, mild portal
hypertensive gastropathy in the fundus and body, but no
active signs of bleeding or recent bleeding.
The patient was initially made NPO on admission, but his diet
was gradually advanced, and on the date of discharge, the
patient was able to tolerate a normal diet without any
difficulties. He did not have any episodes of hematemesis,
nausea, or vomiting while in the hospital. Patient continued
to have bowel movements in the hospital, but were without
blood or melena.
2. Ascites: Patient was started on ciprofloxacin
intravenously for spontaneous bacterial peritonitis
prophylaxis for a seven day course. The patient was
converted over to ciprofloxacin po 500 mg q day once he was
able to tolerate a diet. In addition, the patient had a
paracentesis performed on [**2188-3-31**], which was negative
for any evidence of infection.
In addition, the patient was given albumin intravenously
while he was in the hospital. The patient's diuretics were
held while he was in the hospital given his hypotension. The
patient will follow up in Liver Clinic on [**4-3**], and at
that time the patient should be restarted on his diuretics
and electrolytes should be rechecked.
3. Hepatic encephalopathy: Patient notably was
encephalopathic upon admission with slurred speech and
confusion. The patient's mental status cleared with
lactulose. He was also started on Flagyl 250 mg po bid to
help with his encephalopathy. The patient will continue to
take Kristalose at home for his encephalopathy.
4. Renal: The patient was noted to have an elevated
creatinine upon admission from a baseline of 1.6-2.6. His
creatinine did improve with hydration and on discharge, his
creatinine was 2.0. There was a concern that the patient
might have developed hepatorenal syndrome, however, given the
rapid improvement with hydration, it is likely that the
patient was just dehydrated and had decreased perfusion as a
result of his GI bleed.
5. Cardiology: The patient was noted to have mild systolic
pulmonary artery hypertension on his echocardiogram in [**2188-2-23**] with pulmonary artery systolic pressures of 25-36 mm
Hg. Cardiology was consulted, however, an extensive
Cardiology note was not completed by the time the patient was
discharged from the hospital. The patient will probably need
a right heart catheterization in the future to definitively
determine his pulmonary artery systolic pressures in order to
determine if the patient is a transplant candidate.
6. Hyponatremia: Patient is chronically hyponatremic
secondary to his cirrhosis. Patient was on a free water
restricted diet, and his sodium remains stable between
127-130.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Alcoholic cirrhosis.
3. Depression.
4. Varices.
5. Status post TIPS with TIPS occlusion.
6. Hepatic encephalopathy.
7. Hyponatremia.
8. Barrett's esophagus.
9. Pulmonary artery systolic hypertension by echocardiogram.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po bid.
2. Ciprofloxacin 500 mg po q day x3 days.
3. Flagyl 250 mg po bid.
4. Lactulose 30 mL po tid titrate to a goal of [**2-26**] bowel
movements per day.
FOLLOWUP: The patient will follow up in the Liver Clinic on
[**2188-4-3**] at 2 o'clock. At that time, the patient
should resume his diuretics and his electrolytes should be
checked. The patient also has a Social Work appointment on
the same day. He should also follow up with his primary care
physician within the next two weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1379**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2188-4-1**] 16:13
T: [**2188-4-2**] 07:10
JOB#: [**Job Number 44257**]
|
[
"572.2",
"789.5",
"571.2",
"456.21",
"285.1",
"572.3",
"276.1",
"276.5",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8443, 8478
|
8499, 8748
|
8771, 9553
|
4439, 8421
|
2848, 4422
|
166, 1751
|
1773, 2648
|
2665, 2825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,677
| 191,294
|
45885
|
Discharge summary
|
report
|
Admission Date: [**2171-4-4**] Discharge Date: [**2171-4-8**]
Date of Birth: [**2088-7-18**] Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Lower abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yo M with h/o CAD, DM, HTN, presented to ED with 1 week of
fatigue, chills and not feeling well with some lower abdominal
pain. Also with recent UTI on 14 day Ciprofloxacin course that
had recently stopped. In ED, initial VS were 97.7, 120, 160/85,
18 and 97%/RA. His Tmax was 101.5 in ED for which he was given
Tylenol. He was treated with IV fluid, Ciprofloxacin 400mg IV,
Aspirin 81mg, Ondansetron IV and Morphine IV. He was also noted
to have a sinus tach since presentation with HR to 120s. No
chest pain or SOB. EKG was obtained and revealed ST depressions
laterally. After recieivign 1-2L IVF in ED, SBP dropped from
150 to 107 upon transfer. Given that his BP had dropped down 50
points from admission, there was concern that he may be becoming
septic so was admitted to ICU. Upon sign-out from ED, VS 118,
107/60, 16, 95%/RA. Has 18g IV upon transfer, no repeat EKG.
Upon transfer, per nursing, pt with SBP 90s, RR 28 and 95/3L.
.
On arrival to the ICU, VS 98.4, 124/75, 123, 30, 94% on 4L/NC.
Patient states that he began feeling poorly the morning of
admission when he noticed his urine had become 'black' and
cloudy. He additionally developed new onset diarrhea with some
lightheadedness. Confirms poor po intake at basline and doesn't
'like water'. Also with some SOB today, but may have worsened
in the ED. Felt nauseated in ED, couldn't vomit. Per
discussion with his daughter, [**Name (NI) 18945**], pt has been poorly with
fatigue and malaise for several days. This infection is unlike
others in that it was so rapid onset and he now is confused
about the date (usually very sharp and does math in his head).
At baseline, poor po intake and not medication compliant. Only
really eats soup.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest tightness, palpitations.
Denied arthralgias or myalgias.
Past Medical History:
Hypotonic hyposensitive bladder with incomplete emptying, s/p
indwelling foley since [**1-24**] c/b frequent UTIs
BPH
CAD s/p CABG x 3 in [**2158**] (LIMA to LAD, SVG to OM, and SVG to
RCA), s/p stenting [**2164**] of mid RCA, PTCA of proximal RCA and PDA
s/p AVR/re-do CABG [**2169-4-18**]
Type 2 Diabetes Mellitus
Hypertension
Chronic constipation
Hyperlipidemia
Depression
Asbestosis
Spinal stenosis
Anxiety
Social History:
Widower. Patient lives with his daughter, pet dog. Denies
tobacco, ETOH, illicit drug use.
Family History:
non-contributory
Physical Exam:
VS: 98.4, 124/75, 123, 30, 94% on 4L/NC
GEN: pleasant, elderly male lying in bed with mildly short of
breath
HEENT: anicteric, EOMI, OP without exudate, no erythema, MM dry
CV: RRR, nl S1, S2, distant but no appreciable m/g/r
CHEST: CTAB anteriorly with slight crackles posteriorly in his
bases
ABD: ND, soft, NABS with slight suprapubic tenderness; R CVA TTP
EXT: L > R LE assymetry, no pitting edema
SKIN: No rashes, mild chronic venous changes in LE bilaterally
Neuro: A&O x2 (date close = [**4-1**]); able to move all
extremities equally, strength 5/5
Rectal: No stool, Prostate diffusely enlarged and nontender
Pertinent Results:
[**2171-4-4**] 05:30PM BLOOD WBC-11.2* RBC-5.88 Hgb-17.0 Hct-49.1
MCV-84 MCH-28.9 MCHC-34.6 RDW-16.3* Plt Ct-153
[**2171-4-8**] 06:40AM BLOOD WBC-3.8* RBC-5.01 Hgb-14.4 Hct-42.7
MCV-85 MCH-28.8 MCHC-33.8 RDW-16.5* Plt Ct-193
[**2171-4-4**] 05:30PM BLOOD Neuts-92.6* Lymphs-4.2* Monos-2.1 Eos-0.9
Baso-0.2
[**2171-4-5**] 04:29AM BLOOD D-Dimer-As of [**12-18**]
[**2171-4-4**] 05:30PM BLOOD Glucose-186* UreaN-18 Creat-1.0 Na-137
K-4.3 Cl-98 HCO3-28 AnGap-15
[**2171-4-8**] 06:40AM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
[**2171-4-4**] 05:30PM BLOOD ALT-18 AST-23 LD(LDH)-286* CK(CPK)-105
AlkPhos-101 TotBili-1.3
[**2171-4-4**] 05:30PM BLOOD cTropnT-0.04*
[**2171-4-5**] 08:10AM BLOOD CK-MB-6 cTropnT-0.07* proBNP-3025*
[**2171-4-5**] 08:16PM BLOOD CK-MB-7 cTropnT-0.08*
[**2171-4-6**] 06:25AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2171-4-5**] 08:10AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.6
[**2171-4-6**] 06:25AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.2
[**2171-4-5**] 04:29AM BLOOD D-Dimer-510*
[**2171-4-5**] 01:04AM BLOOD Type-ART O2 Flow-4 pO2-73* pCO2-38
pH-7.40 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
[**2171-4-5**] 01:04AM BLOOD freeCa-1.06*
[**2171-4-4**] 09:02PM BLOOD Lactate-3.7*
[**2171-4-5**] 01:04AM BLOOD Lactate-1.7
[**2171-4-4**] EKG
Sinus tachycardia. Right bundle-branch block. Compared to
tracing #1
the ventricular rate is slightly slower. The findings are
otherwise similar.
TRACING #2
[**2171-4-4**] CXR
FINDINGS: As noted on multiple prior examinations, the left
hemidiaphragm is
elevated. Nodular density is again identified laterally in the
left mid lung
zone. Somewhat hazy opacity is less distinct in the left
perihilar region.
All these findings demonstrate relative marked stability dating
back to [**Month (only) 547**]
[**2169**]. Evidence of prior median sternotomy and CABG is again
evident. The
right lung is largely clear. Please note however in this
examination, the
extreme right costophrenic angle has been excluded from view. No
pneumothorax
is evident. Degenerative changes are noted throughout the
thoracic spine.
IMPRESSION: Stable chest x-ray examination dating back through
several
studies to [**2169-4-16**]. No superimposed acute process identified.
[**2171-4-5**]
Echo
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is moderately dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**2171-4-5**] LE veins
No DVT in the left lower extremity.
[**2171-4-7**] CT abd/pelvis
1. No evidence of renal abscess.
2. Solid enhancing mass arising from the upper pole of the right
kidney,
highly concerning for renal cell carcinoma.
3. Enlarged prostate with areas of decreased attenuation, which
may be
related to BPH, however if prostate abscess cannot be ruled out,
and this may
be better evaluated with pelvic MR.
[**2171-4-4**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
[**2171-4-4**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
[**2171-4-4**] URINE URINE CULTURE-FINAL {STAPH AUREUS COAG +, STAPH
AUREUS COAG +} EMERGENCY
Brief Hospital Course:
82-year-old male with a medical history of hypertension, type 2
diabetes, hyperlipidemia, urinary retention with indwelling
catheter, urinary catheter, recurrent UTI & pyelonephritis,
admitted with UTI. He was admitted to the MICU for close
observation given borderline BP. the foley was changed in the
ED. He was treated with IVF, CTX/Vanco. Urine cultures were
sent. The patient was seen by [**Year (4 digits) 159**] and outpatient follow up
was recommended. The patient did have some mild hypoxia after
3-4 L IVF, thought to be related to volume overload. A TTE and
LENIs were performed. Cardiac enzymes were cycled. The patient
had no chest pain while in the MICU. He had an indeterminate
troponin. He was transferred to the floor for further care.
# UTI: Initially concerning for urosepsis on admission, but pt
never became truly hypotensive, only relative hypotension.
Lactate was 3.7 on admission, down to 1.7 on admission to
floor. Blood cultures remained negative and urine cultures grew
MRSA. He was switched to PO tetracycline per sensitivities and
his BP, temperature and WBC remained stable. He was scheduled
for close follow up with his PCP. [**Name10 (NameIs) 159**] had previously
discussed possibility of suprapubic catheter with him and he
will follow up with them for this.
.
# New O2 requirement: He was given large volume of fluid
resuscitation while relatively [**Name2 (NI) 24420**] and developed an O2
requirement for several days which resolved without
pharmacologic diuresis.
.
# Hypertension: Restarted on atenolol on d/c.
.
# Hyperlipidemia: Continued Atorvastatin
.
# CAD: Denied chest pain in ED, but then complained of some
discomfort upon arrival to ICU. Could not state if entirely in
chest. He did not have further episodes and 3 sets neg CE.
.
# DM, type 2: Diet controlled. Finger sticks were discontinued
and his glucoses remained slightly elevated on a.m. labs.
.
# FEN: regular diabetic diet
.
# Prophylaxis: Subcutaneous heparin, bowel regimen PRN
.
# Access: peripherals
.
# Code: DNR/DNI (confirmed with patient & daughter on admission)
Medications on Admission:
Confirmed with daughter, though she confirms he intermittently
takes these medications
ATENOLOL - 50 mg Tablet once a day
ATORVASTATIN - 80 mg Tablet once a day
CITALOPRAM - 20 mg Tablet - one Tablet(s) by mouth daily
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth once a day PRN
pain
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
ASPIRIN [ENTERIC COATED ASPIRIN] 81 mg Tablet once a day
BISACODYL - 10 mg Tablet - by mouth daily prn
DOCUSATE SODIUM - 100 mg Capsule - one Capsule(s) by mouth twice
a day
Lactulose 30cc by mouth daily prn
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
7. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. Lactulose 10 gram/15 mL Solution Sig: One (1) Cup PO once a
day as needed for constipation.
10. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
11. Sorbitol-Saccharin Syrup Sig: One (1) lollipop PO once a
day as needed for constipation.
12. NitroQuick Sublingual
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Primary
Urosepsis
Chronic indwelling foley catheter
Secondary
Diabetes mellitus type II
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a severe urinary tract
infection. You were started on intravenous antibiotics and then
switched to oral antibiotics.
.
We started you on tetracycline 500mg orally four times per day
until [**2171-4-18**].
We did not change any of your other medications.
.
If you have any fevers, chills, chest pain, vomiting, bleeding,
confusion or any other concerning symptoms call your doctor or
go to the emergency department immediately.
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-4-11**] 4:00
Provider [**Name9 (PRE) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2171-4-12**]
12:30
Provider [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2171-4-29**] 8:50
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2171-5-31**] 8:00
Completed by:[**2171-4-10**]
|
[
"272.4",
"414.00",
"300.4",
"786.51",
"276.6",
"236.91",
"250.00",
"501",
"600.01",
"276.52",
"788.21",
"518.82",
"599.0",
"427.89",
"V45.81",
"041.12",
"V64.2",
"V45.82",
"790.5",
"724.00",
"E879.6",
"596.4",
"458.8",
"996.64"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11123, 11200
|
7471, 9560
|
310, 316
|
11333, 11342
|
3549, 7448
|
11856, 12380
|
2879, 2897
|
10165, 11100
|
11221, 11312
|
9586, 10142
|
11366, 11833
|
2912, 3530
|
250, 272
|
2091, 2318
|
344, 2073
|
2340, 2754
|
2770, 2863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,333
| 175,824
|
17658
|
Discharge summary
|
report
|
Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-16**]
Date of Birth: [**2076-7-26**] Sex: M
Service: Cardiothoracic Service
HISTORY OF PRESENT ILLNESS: This is a 71 year old man with
hypertension and hyperlipidemia, presently with shortness of
breath since 1 AM on the day of admission. The patient
describes one similar episode two years ago at which time he
was admitted to [**Hospital6 **] and underwent cardiac
catheterization. At that time he reports being told he
needed coronary artery bypass grafting but declined and he
has remained well at home since then. He denies any history
of angina, although he does have chronic dyspnea on exertion
and fatigue. No paroxysmal nocturnal dyspnea and no
orthopnea until last night when he awoke at 1 AM with
shortness of breath. Over the next several hours he woke up
with shortness of breath and had to sit up to relieve the
shortness of breath. Finally he called emergency medical
services at 6 AM and was brought to the Emergency Room. In
the Emergency Room the patient was found to be tachycardiac
and markedly hypertensive with a systolic blood pressure
greater than 200 and oxygen saturations less than 89% on room
air. Electrocardiogram initially showed sinus tachycardia
with PR prolongation, evidence of an old inferior myocardial
infarction and a question anterior myocardial infarction with
diffuse ST wave changes. At that time he was given Aspirin,
Lasix, and Nitroglycerin and subsequent became bradycardia
with a heartrate in the 50s. Electrocardiogram revealed
sinus bradycardia with deep anterolateral T wave inversions,
initial enzymes were negative. The patient does not have any
lower extremity edema.
MEDICATIONS ON ADMISSION: Medications at home include
Lipitor, Zestril, Atenolol and Aspirin.
ALLERGIES: He has no known drug allergies.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, status post myocardial infarction, question of an
angioplasty at [**Hospital6 **]. Congestive heart
failure, hyperlipidemia, hypertension.
SOCIAL HISTORY: Denies alcohol use, denies tobacco use.
Unemployed. Married. Lives at home.
PHYSICAL EXAMINATION: Afebrile. Heartrate was 50 to 60.
Blood pressure 123/61, respiratory rate 17 and oxygen
saturation 97% on room air. General, in no acute distress.
Neurologically appropriate. Alert and oriented times three.
Head, eyes, ears, nose and throat, mucous membranes moist.
Oropharyngeal mucosa clear. Neck, 6 to 8 cm of jugulovenous
distension. Cardiovascular, regular rate and rhythm. No
murmurs, rubs or gallops. Pulmonary, diffuse crackles
bilaterally. Abdomen, soft, nontender, nondistended with
positive bowel sounds. Extremities, no edema. 2+ pulses
bilaterally.
LABORATORY DATA: On admission sodium 141, potassium 4.1,
chloride 110, carbon dioxide 26, BUN 20, creatinine 1.4,
glucose 133, creatinine kinase 224, MB 5, troponin less than
.03. White blood count 12.3, hematocrit 40, platelets 203,
PTT 13.1, INR 1.1. Chest x-ray shows congestive heart
failure without cardiomegaly. Electrocardiogram, sinus
rhythm, Qs in 2 and F, ST elevation in 3 and F, ST depression
in V5 and 6. Echocardiogram done after admission shows an
ejection fraction of 25% with global hypokinesis, posterior
basal inferior akinesis, 3+ mitral regurgitation with an
eccentric jet.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service, seen by the Cardiology Service and referred for
cardiac catheterization. On [**5-1**], the patient was
brought to the Catheterization Laboratory. Please see the
catheterization report for full details and summary. This
catheterization showed an ejection fraction of 25%, left main
with mild disease, left anterior descending with 50% proximal
and 80% mid lesion. Large diagonal with an 80% lower pole
stenosis, the left circumflex was occluded, mid distal with
an 80% obtuse marginal 1 and right coronary artery was
occluded, mid distal and fills by collaterals. Following
cardiac catheterization, Cardiothoracic Surgery was
consulted. The patient was seen by Cardiothoracic Surgery
and was accepted for coronary artery bypass grafting. On
[**5-3**], he was brought to the Operating Room at which time
he underwent coronary artery bypass grafting times five.
Please see the operative report for full details. In
summary, the patient had coronary artery bypass graft times
five with left internal mammary artery to the left anterior
descending, saphenous vein graft to the diagonal and a Y
graft to obtuse marginal 1 and obtuse marginal 3 and a
saphenous vein graft to the posterior descending artery. He
tolerated the surgery well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit. At
the time of transfer, the patient had a mean arterial
pressure of 48, a central venous pressure of 12, he was
atrioventricularly paced at 84 beats/minute. He had
Neo-Synephrine at 0.3 mcg/kg/min and Propofol at 50
mcg/kg/min. The patient did well in the immediate
postoperative period. His anesthesia was reversed and the
sedation discontinued. The patient moved all extremities,
although at that time he was unable to follow commands. He
became very anxious and hypertensive. Therefore he was
resedated. On postoperative day #1, the patient was
hemodynamically stable. The sedation was again weaned.
Following the discontinuation of his sedation, the patient
awoke at which point he was agitated and thrashing about in
bed, unable to follow commands. Therefore he was resedated
with Precedex and another attempt was made to awaken and wean
the patient while on a Precedex drip. Despite the Precedex,
the patient again awoke thrashing in bed, unable to follow
commands with a systolic blood pressure in the 170s and
heartrate in the 110s. He was again started on Propofol and
resedated. On postoperative day #2 another attempt was made
to extubate the patient. He remained sedated with a Precedex
infusion. His blood gases were adequate with 5 of pressure
support and 5 of positive end-expiratory pressure and he was
successfully extubated. Following extubation, the patient
remained hemodynamically stable and his sedation was weaned
to off. Following the weaning of the patient's sedation he
did continue to be somewhat agitated, consistently following
commands. At that time psychiatry was consulted as was the
stroke service. It was felt that the patient had a likely
toxic metabolic encephalopathy and he was treated as such.
Over the next several days, the patient remained in the
Intensive Care Unit while a toxic metabolic workup was being
completed. He remained somewhat lethargic with periods of
confusion and agitation. He could not consistently follow
commands. From a cardiopulmonary standpoint he remained
hemodynamically stable with a productive cough and sating 95%
on nasal cannula. Head computerized axial tomography scan
was done which showed old white matter disease with no new
infarctions. On postoperative day #6, it was decided that
the patient was stable and ready to be transferred to the
floor where he could undergo further postoperative care and
cardiac rehabilitation. Once on the floor, the patient's
activity level was increased with the assistance of the
nursing staff and physical therapy. He continued to be
somewhat confused neurologically although much less agitated
and not combative. The patient remained on the floor for
several days showing gradual improvement. He continued to
followed by the Neurology Service who felt that this course
was consistent with a toxic metabolic encephalopathy. The
patient remained hemodynamically stable throughout this
period.
On postoperative day #13, it was felt that the patient was
stable and ready to be transferred to the rehabilitation
center for continuing postoperative care and cardiac
rehabilitation. At the time of that decision the patient's
physical examination was as follows: Vital signs,
temperature 98, heartrate 87 sinus rhythm, blood pressure
142/82, respiratory rate 20, oxygen saturation 96% on room
air. Weight preoperatively was 89.9 kg and the day prior to
discharge is 86.1 kg. Laboratory data revealed white count
13.5, hematocrit 32, platelets 476, sodium 140, potassium
4.0, chloride 107, carbon dioxide 20, BUN 28, creatinine 0.8,
glucose 84. On physical examination he was responsive, moves
all extremities and follows commands, oriented times two.
Respiratory, scattered rhonchi. Heartsounds, regular rate
and rhythm, S1 and S2, no murmurs. Sternum is stable.
Incision clean and dry, open to air. Abdomen is soft,
nontender, nondistended, normoactive bowel sounds.
Extremities are warm and well perfused with no edema. Right
leg incision was open to air, clean and dry.
DISCHARGE MEDICATIONS:
Enteric coated Aspirin 325 q.d.
Metoprolol 100 mg b.i.d.
Prilosec 40 mg q.d.
Atorvastatin 40 mg q.d.
Magnesium oxide 400 mg b.i.d.
Ferrous Gluconate 300 mg q.d.
Vitamin D 500 mg b.i.d.
Zinc sulfate 220 mg q.d.
Captopril 50 mg t.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: He is to have follow up with Dr. [**Last Name (STitle) **] in three
to four weeks after he is discharged from rehabilitation and
follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 49159**]
MEDQUIST36
D: [**2148-5-15**] 15:04
T: [**2148-5-15**] 14:47
JOB#: [**Job Number 49160**]
|
[
"410.71",
"412",
"414.01",
"401.9",
"424.1",
"428.0",
"272.4",
"285.9",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.14",
"88.53",
"39.61",
"36.15",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
8790, 9024
|
1741, 1855
|
3371, 8767
|
9070, 9573
|
2179, 3353
|
184, 1714
|
1878, 2060
|
2077, 2156
|
9049, 9058
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,783
| 134,791
|
47948+59042
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-7-15**] Discharge Date: [**2173-7-18**]
Date of Birth: [**2118-6-20**] Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
55yoF with h/o throat ca in remission who presented to [**Last Name (un) 4199**]
ED with syncope, hematemesis, and black stools and admitted to
MICU for further management.
.
She is a somewhat tangential historian but reports not feeling
well for the past week with headaches and feeling tired. Also
with nausea and GERD for the past week. Today, she went to nap
with her granddaughter and woke up not feeling well; she put the
kid in a crib then went to lay down on the cough; unclear what
exactly happened but she "fell onto the couch" and when she woke
up was covered with dark brownish red blood from her mouth/nose
and covering her chest. She likely had LOC. She then went to the
toilet and had a BM of "black stuff." She denies and bright red
blood from above or below. She denies any NSAIDs, EtOH, not on
anticoagulation, ASA, Plavix.
.
She was not having any abdominal pain until about an hour before
admission to MICU when she reported LLQ pain for for the past
week, but it appears in Atrius records this pain has been going
on for at least half a year, see below. She told her PCP about
the [**Name9 (PRE) 25714**] pain, who ordered a colonoscopy but she didn't have it
yet.
.
She went to [**Hospital 4199**] Hospital where vitals there SBP 110 and p96
with Hct 28. She was given 80 mg Protonix, 1.5L NS, and NGT
placed. Tranfer to [**Hospital1 18**].
.
In the ED, initial VS's: 97.4 86 104/69 16 100%RA.
Orthostatics: 102/60 p100 lying down, and 110/65 p115 sitting
up. Hct was 25.7 She was noted to look pale and unwell, with NG
tube in place, abdomen benign without any tenderness. Rectal
exam with guaic positive black stool, no blood, no bleeding
hemorrhoids. She was started on Protonix gtt, 2 PIV's were
placed, type and screened, blood was ordered. Was given another
1L NS in ED (total 2.5L by transfer). Blood hanging by the time
of transfer.
.
GI was consulted and recommended NG lavage to see if any bright
red blood, in which case plan was to scope tonight; otherwise in
the am. She was NG lavaged with 300 cc's of coffee grounds then
bilious fluid, no BRB.
.
EKG showed new TWI inferolaterally, new from EKG [**2165**] in Atrius
records.
.
Of note Atrius notes indicate pt has LLQ pain off/on for the
past yr and was seen in PCP office in [**3-/2173**] for this. Notices
the pain more while at work (pushing/pulling, standing all day).
Last a few days, better with rest. Also c/o left LBP with h/o
bulging disk. MD at that time thought possible L sciatica
contributing to LLQ pain, recommended conservative management,
fiber and fluids for ? constipation; she was also reminded that
she was overdue for colonoscopy at that time. She had normal
lumbar plain film at that time.
.
Vitals before transfer: 98 p90 112/66 18 100% 2LNC.
.
ROS as above, also with chest pain on exertion, relieved with
rest for a few years, last stress test years ago.
Past Medical History:
- T1, N2B squamous cell carcinoma of the left tonsil, which was
moderately differentiated, s/p left modified radical neck
dissection and diagnostic tonsillar biopsy on [**2170-1-10**]. Had
positive LN's, s/p radiation therapy that ended in 4/[**2172**]. F/u
CT scan without evidence of recurrence, unclear when -- followed
by Dr. [**Last Name (STitle) 1837**]
- Left mandibular pain after radiation
- Mitral valve prolapse
- H/o thyroid nodule
- H/o positive PPD
- Biapical nonspecific pulmonary nodules less than 5 mm in size
noted on surveillance CT, stable per last ENT note
- Uterine fibroids
- LGSIL on Pap smears
- H/o hematuria
- Depression
Social History:
No ETOH, but prior heavy use. 1ppd x35 yrs, but quit in [**2170**]. No
smoking - quit with throat CA diagnosis, no motrin. No drugs.
Lives with son.
Family History:
M -- alive, CVA's
F -- alive, CVA's in 80's
Physical Exam:
On admission
98.2 p83 107/70 (107-129) 15 100%RA
Thin, tangential somewhat redirectable F in no distress,
conversant
EOMI, no scleral icterus, conjunctivae not pale
MMM, normal appearing. NGT in place, draining light pinkish
fluid
CTAB except light L base crackles
RRR without m/g
Abd soft NT ND, benign
No BLE edema. Extrems are warm
CN 2-12 intact, no focal neuro deficits, moving all 4
extremities
Pertinent Results:
ADMISSION LABS:
139 107 41
-----------------< 80
4.0 23 0.6
.
CK 55 MB 2 Trop <0.01
Ca 7.7 Mg 1.6 Phos 2.2
ALT 12 AST 20 AlkP 39 Tbili 0.3 Alb 3.6
WBC 15.3 N93 L4 o/w normal
Hct 25.7 MCV 90
Plts 215
Coags 12.9 / 22.0 / 1.1
.
EKG: [**2165-1-30**]: NSR, normal axis, normal EKG
[**2173-7-15**]: NSR with normal intevals, TWF in V2 is new, inverted
T's in V3-6 are new, and TWI in all inferior leads are new. PR
prolongation.
.
Imaging: none
Brief Hospital Course:
55yoF with h/o throat ca in remission who was admitted to MICU
Green with ? syncopal episode in the setting of hematemesis and
later with melena.
1. Acute Blood Loss Anemia, GI bleed: Pt presented with 1wk h/o
nausea and GERD, possibly consistent with PUD. We did not
suspect LLQ pain was relevant, given that these symptoms had
been present for 6 mos to 1 yr. She received supportive care for
GI bleed including PIV x3, Octreotide gtt, IVF's, 2u PRBC's and
had EGD the day after admission which showed duodenitis in the
proximal duodenum and small ulcer at GE junction.
Of note the pt became oversedated and had an apneic episode at
the end of the EGD which was likely due to the Fentanyl/Versed;
she received Narcan and Flumazenil, was bag-masked, and did not
need to be intubated although a respiratory code had been
called. She had no further respiratory issues thereafter.
She continued to have lowish blood pressures and melena and
received further IVF's. She was monitored with serial Hct's and
eventually switched from PPI gtt to IV bid. She was called out
to the floor. Her BP and Hct remained stable overnight and she
was switched to an oral highdose PPI. She was discharged home in
stable condition.
2. Chest pain: She reported anginal history with occasional
chest pain worsened while she was at work, and relieved with
rest. She has not had a stress test in "a long time." Her EKG's
showed inverted TW in V3-6 and inferior leads -- all new since
last EKG in [**2165**]. Her cardiac enzymes were negative x2. Through
her course, her EKG's had normalization of TW's laterally.
------
Transitional issues:
- Patient may benefit from outpatient stress test
Medications on Admission:
- Ranitidine 150 mg [**Hospital1 **]
- Fluticasone 50 mcg nasal spray each nostril daily
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day: Take 30 min prior
to eating.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed secondary to Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for a GI bleed. An edoscopy of your
stomach showed evidence of an ulcer. You were transfused several
units of blood and your bleeding was stabilized.
.
While you were here we made the following changes to your
medications:
We stopped your ZANTAC
We STARTED you on omeprazole
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11950**] at [**Telephone/Fax (1) 101176**] TOMORROW to
schedule a follow up appointment and to discuss the results of
your H Pylori testing.
Name: [**Known lastname 76**],[**Known firstname **] M Unit No: [**Numeric Identifier 16237**]
Admission Date: [**2173-7-15**] Discharge Date: [**2173-7-18**]
Date of Birth: [**2118-6-20**] Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending:[**First Name3 (LF) 653**]
Addendum:
Please see below
Brief Hospital Course:
Transitional issues:
Patient has pending H Pylori serology that will need to be
followed up
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]
Completed by:[**2173-7-20**]
|
[
"285.1",
"218.1",
"V10.02",
"553.3",
"424.0",
"427.89",
"535.61",
"532.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8447, 8608
|
8330, 8330
|
285, 291
|
7235, 7235
|
4543, 4543
|
7725, 8307
|
4054, 4100
|
6842, 7129
|
7179, 7214
|
6728, 6819
|
7386, 7702
|
4115, 4524
|
8352, 8424
|
234, 247
|
319, 3199
|
4559, 5007
|
7250, 7362
|
3221, 3871
|
3887, 4038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,839
| 135,428
|
48336+48337
|
Discharge summary
|
report+report
|
Admission Date: [**2101-9-7**] Discharge Date:
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Chest pain, shortness of breath.
HISTORY OF THE PRESENT ILLNESS: This is a 78-year-old male
with history of coronary artery disease, congestive heart
failure, atrial fibrillation, recently admitted to my service
with the chest pain and shortness of breath. The patient now
presents with worsening of his symptoms. He is well known to
me from a previous admission during which he presented with a
several-week course of generalized weakness, fatigue,
shortness of breath, and left shoulder pain. Workup was
positive for left-sided pleural effusion, which is believed
to be due to pneumonia. He was, therefore, discharged to
home with a ten-day course of Levofloxacin PO. However, at
home he continued to do poorly without experiencing
significant improvement in his shortness of breath. On
[**9-6**], the patient had a follow-up appointment with the
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at which point followup
chest x-ray was obtained to evaluation the left sided pleural
effusions. Despite the course of Levofloxacin, however, the
pleural effusion has worsened. On the following day, the
patient experienced continuing chest pain, which persisted
for over one hour. There was also radiation to the shoulders
and neck. He also complained of shortness of breath,
diaphoresis, but he denied any nausea, vomiting, abdominal
pain, fever or chills. The patient is a poor historian, so
it unclear whether the pain is pleuritic in origin or not.
The patient also relates increasing fatigue, lethargy, and
poor PO intake.
PAST MEDICAL HISTORY:
1. Coronary artery disease. The patient is status post PTCA
and cardiac catheterization in [**2097**], which showed two-vessel
disease. The most recent admission resulted in P-MIBI stress
test, which revealed multiple reversible inferior-wall defect
consistent with the stress MIBI in [**2097**].
2. Congestive heart failure. Ejection fraction by
Persantine MIBI is about 50%. However, there are notes
regarding previous echocardiograms in [**2097**], which showed only
20% to 30%. Therefore, it is unclear as to the actual EF.
3. Paroxysmal atrial fibrillation. The patient is on
Coumadin.
4. History of renal cell carcinoma status post right
nephrectomy in [**2070**]. This was followed by chemotherapy.
5. Benign prostatic hypertrophy.
6. History of transient ischemic attacks.
7. History of retinal hemorrhages, status post laser
treatment.
8. Status post DDD pacer for atrioventricular block.
9. Hypothyroidism.
10. Hypertension.
11. Colon cancer status post partial colectomy.
12. Increased cholesterol.
13. Depression.
14. Bladder cancer, status post BCG treatment of the bladder.
15. History of TB status post INH times 12 months in [**2079**].
16. Dementia of unclear etiology.
MEDICATIONS:
1. Bumex 1 mg PO q.d.
2. Aldactone 12.5 mg PO q.d.
3. Aricept 10 mg PO q.d.
4. Concerta 80 mg PO q.a.m.
5. Provigil 200 mg q.a.m.
6. Proscar 5 mg q.d.
7. Synthroid 75 mcg q.d.
8. Wellbutrin 150 mg b.i.d.
9. Flomax 4 mg q.d.
10. Celexa 40 mg q.d.
11. Prilosec 20 mg q.d.
12. Potassium chloride 20 mg q.d.
13. Quinine 260 mg q.d.
14. Lipitor 20 mg q.d.
15. Atrovent 4 puffs t.i.d.
16. Albuterol 2 puffs p.r.n.
17. Coumadin 10 mg q.d. except on Thursdays and Sundays, when
he takes 50 mg q.d.
ALLERGIES: The patient is allergic to SULFA, PENICILLIN, AND
LASIX.
SOCIAL HISTORY: The patient was originally born in [**Country 532**].
He survived six years in the concentration camp, where he
lost all his family members. [**Name (NI) **] immigrated to the United
States soon following that. He is a dentist with degrees
from several institutions. He has more than 100 pack per
year history of smoking, but he is not currently smoking
cigarettes. There is no history of alcohol abuse.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Examination revealed the following:
GENERAL: The patient is uncomfortable, breathing labored.
Vital signs: Temperature 99.7, heart rate 88, blood pressure
100/54, respiratory rate 24, oxygen saturation 98% on two
liters. HEENT: PERRLA, extraocular muscles are intact.
Oropharynx clear with mucous membranes being dry. NECK:
There was no lymphadenopathy, no JVD. PULMONARY: The
patient has decreased bilateral breath sounds, left worse
than right. There are occasional crackles. CARDIOVASCULAR:
Irregularly irregular with no murmurs, rubs, or gallops.
ABDOMEN: Soft, nontender, nondistended with a large ventral
hernia. EXTREMITIES: No evidence of edema, 1+ pulses
bilaterally. NEUROLOGICAL: The patient is somnolent, but
arousable. Cranial nerves intact. MOTOR STRENGTH AND
SENSORY: Intact.
LABORATORY DATA: Laboratory data revealed the following:
White count 18.8, hematocrit 38.2, platelet count 393,000.
Sodium 141, potassium 4.4, chloride 105, bicarbonate 28, BUN
26, creatinine 1.4, TSH 1.0, initial CK 30, troponin less
than 0.3.
EKG: Revealed paced rhythm, unchanged from baseline.
Chest x-ray showed worsening of the bibasilar consolidations,
continuing bilateral pleural effusions, and maybe mild CHF.
HOSPITAL COURSE:
#1. CARDIOVASCULAR: The patient was originally admitted
with rule out myocardial infarction. This was reasonable
given his consistent chest pain and shortness of breath
especially given the findings of a reversible inferior defect
on the stress MIBI one month prior to admission. The patient
ruled out by enzymes. However, he continued to remain
shortness of breath and had episodic chest pain. A repeat
chest x-ray showed increase in the cardiac, as well as
worsening CHF. Therefore, the patient was treated more
aggressively for CHF with IV diuretics. He had a good
response with relatively good urine output initially.
However, he continued to feel very short of breath and
experienced chest pain. CT was obtained at that point to
evaluate the pleural effusions and possible pneumonia, but
there is an incidental finding of large pericardial effusion
noted. This was followed by echocardiogram, which confirmed
the findings of a large pericardial effusion, but no evidence
of tamponade. The patient, at this point, was transferred to
the [**Hospital Unit Name **] Service. Given the first day on the [**Hospital Unit Name **] Service,
the patient was extremely uncomfortable and as the day
progressed the patient became acutely shortness of breath.
The patient was now developing signs of constrictive
physiology. Notably, he had increase in the JVD, as well as
pulsus paradoxus of over 20 mmHg. He appeared extremely
uncomfortable and he was scheduled for drainage of the
pericardial effusion. The patient pericardial effusion was
drained in the cardiac laboratory and fluid was sent for
cytology, as well as microbiology. The differential
diagnosis of this pericardial effusion included tuberculosis
given his history of previous TB, as well as spending six
years in a concentration camp, malignant process,
particularly in the context of three prior primary foci, or
autoimmune process. Of course, the pericardial effusion
could also be related to the congestive heart failure. At
this point, all the studies from the pericardial fluid have
been completely negative including cytology and microbiology.
The patient tolerated the procedure relatively well. The
patient was transferred back to the floor.
Initially, he experienced significant improvement and the
shortness of breath symptomatically improved. However,
repeat chest x-ray the day following pericardial effusion
drainage, revealed worsening of the CHF with severe pulmonary
congestion. He was, therefore, started on aggressive IV
diuresis with initially very good response. However, on day
#2, following the effusion, the diuresis tapered off and the
urine output decreased. A FENa at that point was less than
0.1% revealing intramuscular depletion in the larger picture
of total volume-body overload. Therefore, diuresis was
discontinued and the patient was allowed to equilibrate.
At this point, it appeared that this is a more of
straightforward CHF picture. The patient was started on the
beta blocker Carvedilol ....................and maximized on
his ACE inhibitor titrated up to Captopril 50 mg t.i.d. This
was switched to Lisinopril 20 mg q.d. on the day of day to
the floor.
Despite these interventions, he continued to remain shortness
of breath and he felt very uncomfortable. Repeat
echocardiogram was obtained and this now showed multiple
blood and fibrin clots in the pericardial space leading to
decreased left ventricular filling, Therefore, surgery was
consulted and decision was made to take the patient to the
operating room for pericardial window. This was done on
[**9-15**]. However, during the procedure, no pericardial
effusion, fibrin or clots were identified in the pericardium.
A piece of tissue was obtained from the pericardium for
diagnosis and sent to pathology. The patient tolerated the
procedure well with no complications.
NOTE: The diuresis was temporarily on hold during the acute
decompensation in the context of enlarging pericardial
effusion. However, given the evidence now, that there is no
remaining pericardial fluid in the pericardial sac, a
decision was made to restart the diuresis. He is now started
on Bumex 2 mg PO and Spironolactone 25 mg PO q.d.
#2. PULMONARY: The patient has remained relatively short of
breath throughout the hospital stay. This has been largely
attributed to the CHF. Other causes would include
pericardial constriction secondary to the effusion, as well
as smoldering pneumonia. The pulmonary service was consulted
and given the fact that the effusions were believed to be due
to CHF, no tapping of the effusions was advised at that
point. Differential diagnosis would include CHF, pneumonia,
or an inflammatory process. It is highly unlikely that the
pneumonia alone would explain the effusions, as the patient
has already received a two-week course of Levofloxacin PO and
a ten-day course of IV Ceftriaxone. The patient experienced
occasional symptomatic relief with nebulizers, although he
never had any frank wheezing.
#3. INFECTIOUS DISEASE: On initial presentation, there was
significant concern about continuing pneumonia. The patient
was started on Ceftriaxone IV and Flagyl. However, with the
developed of the pericardial effusion it became much more
likely that the shortness of breath is due to constrictive
physiology. The Flagyl was, therefore, stopped, but the
Ceftriaxone was continued per Infectious Disease
recommendations.
NOTE: The patient initially presented with a white count of
18 and the white count subsequently decreased with
Ceftriaxone treatment. All microbiological studies,
including sputum, blood cultures, pericardial fluid cultures
had been completely negative.
It is very interesting that the patient has a history of
treated of TB with a 12-month course of Isoniazid. We were
not able to obtain the exact records as to the circumstances
around that treatment. However, given the high-risk factors
for TB, AFB sputum cultures were sent. The acid-fast stains
were negative and the cultures were still pending. Given the
additional presence of pyuria, urine was sent for AFB
culture. It is also quite likely that the bladder washing
with BCG during the treatment of the bladder cancer could
have lead to dissemination of M Bovine infection. Therefore,
cultures for M Bovine were sent.
#4. HEMATOLOGY: The patient was originally anticoagulated
with Coumadin for paroxysmal atrial fibrillation. This was
held in the context of his repeated procedures and he
required several units of FSP to reverse his Coumadin. Now
that no more procedures are anticipated, he is being
restarted on his 10 mg q.h.s. dosing. He never had any signs
of active bleeding.
#5. RENAL: Baseline creatinine was about 1.1. The patient
became slightly prerenal in the context of aggressive
diuresis with the creatinine around 1.4. This was
anticipated as optimal diuresis should lead to slight
increase in creatinine.
NOTE: The patient was briefly started on indomethacin for
symptomatic relief of his possible pericarditis. However,
given that this coincided with his decrease in creatinine,
the indomethacin was stopped and believed to contribute to
his worsening renal function. He is currently receiving
Bumex 2 mg PO q.d. and Aldactone 20 mg PO q.d. for diuresis.
#6. PSYCHIATRY: The Psychiatric Service was consulted.
Apparently, the patient had trouble falling asleep at night
and then dozing off during the day. Ritalin was discontinued
and he was started on Risperidone 0.5 mg q.d. EKG was
performed and showed no QT prolongation following the
initiation of Risperidone therapy, Risperidone 0.5 mg as well
as Wellbutrin and Celexa for depression, Aricept for dementia
and Provigil.
#7. GASTROINTESTINAL: In general, the patient's PO intake
has been relatively poor. However, GI symptoms have remained
completely stable with no specific complaints. He is
receiving Protonix 40 mg q.d. given the poor PO intake.
#8. ENDOCRINE: The patient's has history of hypothyroidism.
TSH was checked on two occasions during the admission and
normal both times. He was continued on his regular dose of
Synthroid.
#9. GENITOURINARY: The patient has history of benign
prostatic hypertrophy. He had a Foley for most of his
hospital stay. On a couple of occasions, this resulted to
mild occlusion requiring flushing, which eventually lead to
resume of urine flow. In general, the patient has a lot of
hesitancy while voiding on his own, but he has not had any
frank retention while in the hospital.
#10. RHEUMATOLOGY: The patient denies any specific joint or
muscle complaints. However, given these persistent pleural
effusions as well as pericardial effusion, it is reasonable
to send [**First Name8 (NamePattern2) **] [**Doctor First Name **]. Please see addendum to this discharge
summary for further hospital course and discharge
medications.
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**]
Dictated By:[**First Name3 (LF) 101819**]
MEDQUIST36
D: [**2101-9-15**] 10:06
T: [**2101-9-15**] 16:08
JOB#: [**Job Number 101820**]
Admission Date: [**2101-9-7**] Discharge Date: [**2101-9-21**]
Service:
CODE STATUS: Do-Not-Resuscitate, Do-Not-Intubate
CHIEF COMPLAINT: Status post pericardial window placement
and pericardial fluid drainage.
HISTORY OF PRESENT ILLNESS: This is a 78 year old white male
with a past medical history of multiple medical problems
including coronary artery disease, atrial fibrillation,
congestive heart failure with ejection fraction of about 20%,
multiple cancers, pericardial effusion, now status post
cardiothoracic surgery for pericardial window and drainage.
The patient had been feeling weak for several months and was
admitted to a hospital in [**State 792**]with negative workup.
The beginning of [**Month (only) 205**] he had complaint of shoulder pain,
vague chest pain and shortness of breath. The patient was
ruled out for myocardial infarction and had P-MIBI which was
unchanged from prior study of [**2097-12-2**] which showed a
reversible inferior wall defect. The patient was treated for
pneumonia at this time with a two week course of Levaquin
which was discontinued on [**8-29**]. The patient continued to
the hospital on [**9-7**], with continued weakness, chest pain
for about one hour and shortness of breath. Chest x-ray at
the time showed larger bilateral effusions from the prior
study and a computerized axial tomography scan of the chest
showed a large pericardial effusion, small pleural effusion,
nonspecific mediastinal lymphadenopathy and no evidence of
pneumonia. The patient was increased for increased shortness
of breath and increased effusion, despite recent antibiotic
treatment.
Laboratory studies on admission [**9-7**], showed white count
of 18.8, hematocrit 30.2, sodium 141, potassium 4.5, chloride
105, bicarbonate 28, BUN 26, creatinine 1.4, negative cardiac
enzymes. In the hospital the patient continued to have
shortness of breath despite aggressive diuresis. Chest x-ray
of [**2101-9-10**] showed increased cardiac silhouette
consistent with cardiac tamponade. Pericardial effusion was
drained. About 550 cc of straw colored fluid were removed,
no organisms, acid fast bacillus negative. 1358 white blood
cells, 8,025 red blood cells, 46% polys, 33% lymphocytes, all
cultures negative. The patient continued to have congestive
heart failure-like picture despite aggressive diuresis and
developed decreased urine output with a fractional sodium
excretion of less than 1%. Another echocardiogram was
performed which showed an ejection fraction of 25 to 30% on
[**2101-9-10**], moderate effusion and no tamponade. The
patient went to Cardiothoracic Surgery for pericardial window
and pericardial biopsy on the day of transfer and in surgery
minimal effusion was drained, although most recent the day
before surgery [**9-14**], shows reaccummulation of pericardial
fluid consistent with blood.
PAST MEDICAL HISTORY: 1. Transitional renal cell carcinoma
status post right nephrectomy, status post chemotherapy; 2.
Benign prostatic hypertrophy with urinary outflow
obstruction; 3. Transient ischemic attack; 4. Retinal
hemorrhage; 5. Coronary artery disease, status post
percutaneous transluminal coronary angioplasty in [**2097**] with
two vessel disease and stents placed; 6. Atrial
fibrillation, on chronic anticoagulation; 7. Ventricular
pacer secondary to A-V blocks; 8. Hypothyroidism; 9.
Hypertension; 10. Congestive heart failure; 11. Colon
cancer, status post colectomy; 12. Mild dementia; 13.
Hypercholesterolemia; 14. Depression/sleep disturbances/post
traumatic stress disorder; 15. Bladder cancer treated with
intravesicular BCG; 16. History of tuberculosis exposure
status post INH times 12 months.
ALLERGIES: Sulfa, Bactrim, Penicillin, Ampicillin, Lasix,
Cardizem.
MEDICATIONS ON DISCHARGE: Lisinopril 40 mg p.o. q.d.;
Carvedilol 25 mg b.i.d.; Bumetanide 2 mg p.o. q.d.;
Spironolactone 12.5 mg p.o. q.d.; Senna 1 tablet p.o. b.i.d.;
Bisacodyl 10 mg p.o. p.r. q.h.s.; Risperidone 0.5 mg p.o.
q.h.s.; Enteric coated Aspirin 325 mg p.o. q.d.; Milk of
Magnesia 30 cc p.o. q. 6 prn; Tylenol 650 mg p.o. q. 4-6
hours prn; Nitroglycerin sublingual tablet 0.5 mg sublingual
prn; Hydrocortisone 1% p.r. prn; Bupropion SR 150 mg p.o.
b.i.d.; NF 200 mg p.o. q. AM, Docusate 100 mg p.o.
b.i.d., 10 mg p.o. q.h.s.; Finasteride 5 mg p.o. q.d.;
Levothyroxine 75 mcg p.o. q.d.; Tamsulosin 0.5 mg p.o.
q.h.s.; Pantoprazole 40 mg p.o. q. 24 hours; Citalopram 40 mg
p.o. q.d.; Quinine 260 mg p.o. q.h.s.; Atorvastatin 20 mg
p.o. q.h.s.; Ipatropion 4 puffs inhaled t.i.d.; Warfarin 10
mg p.o. h.s.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: World War II concentration camp survivor
times six years from [**Country 532**], retired industry professor,
tobacco use 50 to 100 pack years.
PHYSICAL EXAMINATION: The patient complaining of mild
epigastric tenderness at surgical site, no complaints of
chest pain or shortness of breath. The patient feels sleepy.
Vital signs revealed temperature 97.9, blood pressure 130/70,
pulse 82, respirations 20, 94% on 1.5 liters per nasal
cannula. General, large male, sleepy but arousable in no
distress. Neurological, alert and oriented times three.
Answers questions appropriately but slowly. Pulmonary, loud
breathsounds, fine crackles at the left base. Coronary,
heartsounds distant, normal S1 and S2, no murmurs, rubs or
gallops are heard. Abdomen, tender to mild palpation in the
epigastrium, large ventral hernia, large midline surgical
scar, positive bowel sounds, no rebound and no guarding.
Extremities, trace edema over ankles, +[**3-12**], dorsalis pedis
pulse bilaterally, feet warm. Head, eyes, ears, nose and
throat, oral mucosa moist, no injections seen, extraocular
motions intact.
HOSPITAL COURSE: 1. Cardiovascular - The patient had Beta
blocker and ACE inhibitor slowly titrated over the hospital
course from 6.5 mg b.i.d. of Carvedilol to a final dose of 25
mg b.i.d. for Carvedilol. The patient was initially switched
to Zestril 20 mg q.d. and titrated up to Zestril 40 mg q.d.
The patient tolerated titration well. Heartrate and blood
pressure were stable at all times. The patient at all times
was chestpain free. The patient was not noted to have any
changes in electrocardiogram. The patient was noted to have
paced rhythm. The patient had pericardial biopsy at time of
pericardial window placement. Pericardial fluid cytology
revealed no malignant cells, numerous neutrophils and
lymphocytes, acid fast bacillus staining of pericardium was
negative. Pericardial biopsy revealed resolving fibrinous
pericarditis with underlying chronic inflammation, possible
etiologies offered are: 1. Fungal/viral/bacterial
infection, not tuberculosis; 2. Trauma; 3. Uremia although
does not usually present with chronic inflammation; 4. Post
myocardial infarction changes; 5. Connective tissue
disorder, rheumatologic; 6. Drug reaction, again not usually
seen with chronic inflammation. The patient is known to have
atrial fibrillation on chronic anticoagulation. Warfarin was
stopped for cardiothoracic surgery, however, it was restarted
at 10 mg q.h.s. INR was slowly rising during the hospital
course to 1.7 on [**2101-9-21**]. The patient was initially
short of breath but this slowly resolved with continued
diuresis, ACE inhibitor and Beta blocker. The patient had
good urine output throughout the hospital course and
tolerated diuresis well.
Pulmonary - The patient had repeat chest x-ray on [**9-16**]
with lateral decubitus films which showed bilateral pleural
effusion, persistent pericardial effusion with findings
consistent with tamponade and systemic venous congestion, no
evidence of pulmonary venous congestion. The patient
continued to be short of breath throughout hospital course,
however, resolved somewhat later on in the stay, eventually
not requiring oxygen per nasal cannula to be comfortable with
eventual pulse oximetry of 100% on room air.
Rheumatologic - The patient was found to be [**Doctor First Name **] negative.
Endocrine - The patient was known to be hypothyroid.
Levothyroxine 75 mcg q.d. was continued throughout hospital
course. TSH was checked once and was found to be 1.3, within
normal limits. TSH should be followed up in three months.
Infectious disease - The patient was followed closely by the
infectious disease team throughout the hospital course which
offered various etiologies for the recurrent pericardial
effusions, including viral, fungal and tubercular.
Tubercular effusion was ruled out by acid fast bacillus
staining, bacterial effusion ruled out by cytology and
culture of pericardial fluid. Mycoplasma IgG, IgM titers
pending for patient. Pericardial effusions may still be of
viral etiology.
Psychiatry - The patient was followed by a psychiatry team in
the hospital which recommended continuing him on his current
medications of Citalopram, Bupropion SR and Risperidone. The
patient's mood elevated throughout the hospital course as he
was feeling physically better.
Neurology - The patient has a history of mild dementia and
was continued on Aricept 10 mg p.o. q.h.s.
Genitourinary - Later on in the hospital course the patient
complained of Foley irrigation and leaking. The Foley
catheter was discontinued and voiding trial for six hours was
done. The patient voided 250 cc within the six hours and
subsequently continued to void well. The patient is taking
Flomax at his regular dose. Urinalysis and urine cultures
were done prior to Foley being discontinued which revealed
specific gravity of 1.012, red blood cells [**Pager number **], blood large,
3 white blood cells, 30 protein and pH of 5.0. Urine culture
done at the time was negative.
Renal - The patient's chem-7 was checked daily. BUN and
creatinine were stable throughout the hospital course,
ranging BUN between 21 to 35 and creatinine between 1 and
1.3.
Gastrointestinal - The patient complained of diarrhea once
during the hospital course and had a large loose bowel
movement. Clostridium difficile study was sent and came back
negative. The patient's bowel medications were held. The
patient was restarted on Docusate and Senna. The patient was
previously on Lactulose and that was further held. Recommend
to hold Lactulose until further constipation developed.
Fluids, electrolytes and nutrition - The patient tolerated
full p.o. diet at all times.
Prophylaxis - The patient is currently on Warfarin 10 mg p.o.
q.h.s., has subtherapeutic INR but it is rising daily, INR
should be checked within the next 48 hours. The patient is
taking enteric coated Aspirin daily, the patient is taking
Proton pump inhibitor.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To [**Hospital **] [**Hospital **] Hospital with
medications as listed above.
DISCHARGE DIAGNOSIS:
1. Pericardial effusion of unknown etiology, status post
pericardial window.
2. Benign prostatic hypertrophy
3. Coronary artery disease
4. Congestive heart failure
5. Atrial fibrillation
6. Hypothyroidism
7. Hypertension
8. Colon cancer, status post colectomy
9. Dementia
10. Depression
11. Bladder cancer
12. Renal cancer, status post nephrectomy
13. Urinary outflow obstruction
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**]
Dictated By:[**Name8 (MD) 101821**]
MEDQUIST36
D: [**2101-9-21**] 18:54
T: [**2101-9-21**] 19:23
JOB#: [**Job Number 101822**]
cc:[**Hospital1 101823**]
|
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] |
icd9cm
|
[
[
[]
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] |
[
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] |
icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,792
| 197,287
|
24236
|
Discharge summary
|
report
|
Admission Date: [**2106-3-19**] Discharge Date: [**2106-4-4**]
Date of Birth: [**2026-7-24**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Capsule endoscopy
History of Present Illness:
The patient is a 79 year old male with a history of PE, COPD,
Atrial fibrillation, hypertension, diastolic dysfunction and
hypothyroidism presenting with bright red blood per rectum. The
patient was in his usual state of health until approximately
three weeks ago when he developed sudden onset dyspnea and was
hospitalized with pneumonia. The patient was discharged to a
[**Hospital1 1501**] to complete a course of IV antibiotics. He was subsequently
hospitalized from [**Date range (1) 61516**] with a pulmonary embolism and was
treated with Lovenox and transitioned to Coumadin.
.
The patient was on both Lovenox and Coumadin prior to this
admission. On the day prior to admission, he developed acute
onset abdominal cramping and asked to use the commode. According
to the [**Hospital 100**] Rehab records, the patient had a large grossly
bloody bowel movement (approx 1 Liter). He was hemodynamically
stable and transferred to the ED for further evaluation. He was
feeling otherwise well, aside from continued dyspnea on
exertion, and denies nausea, vomiting, chest pain, headaches,
change in diet, dysuria, fevers or chills.
.
In the ED, his initial vitals were 97.6, BP 135/45, HR 74, RR
17, 94% on 4 L NC. He reports that his abdominal pain subsided
to intermittent "rumblings," and his review of systems was
otherwise negative. He denies a history of blood per rectum
before. He had another soft, marroon stool while in the ED. He
also developed some worsened shortness of breath during his ED
course and was treated with 20 mg IV lasix. He was transferred
to Medicine for furhter evaluation.
Past Medical History:
COPD
Atrial fibrillation (one brief episode recently, started on
digoxin)
HTN
BPH
Hypothyroidism s/p partial thyroidectomy
CAD (per records, no h/o MI or cardiac cath)
h/o Klebsiella, MRSA, Pseudomonas infections
h/o VRE UTI
.
PSH:
s/p appy
s/p laminectomy
s/p right partial hip replacement
s/p bowel obstruction s/p SB resection
Social History:
Positive for tobacco use for 67 yrs, 1.5 ppd. No EtOH or IVDU.
Retired child psychiatrist and member of Army. Used to only use
oxygen at night, now requiring approximately 4 liters after
recent PE and pneumonia. Married, 3 children.
Family History:
Father with lung CA. Mother with HTN, [**Name (NI) 10322**], and CVA. Sister with
ovarian CA. Brother with brain CA.
Physical Exam:
Vital signs:
99.7, 126/65, 95, 16, 94% on 4.5 L NC
Gen: well appearing, elderly man, no distress, able to speak in
complete sentences, nasal cannula in place
HEENT: MM dry, OP clear
Neck: no JVD
Car: RRR no murmur
Resp: diffuse wheeze and intermittent ronchi, R>L
Abd: soft, distended, ventral hernia, + bowel sounds, nontender
to palpation. dull to percussion on flanks
Ext: 4+ edema with compression stockings (stable per patient-h/o
lymphedema)
Pertinent Results:
Admission Labs:
[**2106-3-18**] 10:00PM GLUCOSE-152* UREA N-38* CREAT-1.1 SODIUM-139
POTASSIUM-5.8* CHLORIDE-101 TOTAL CO2-30 ANION GAP-14
[**2106-3-18**] 10:00PM CALCIUM-8.2* PHOSPHATE-2.9 MAGNESIUM-2.4
[**2106-3-18**] 10:00PM WBC-8.7 RBC-3.44* HGB-10.1* HCT-30.2* MCV-88
MCH-29.4 MCHC-33.5 RDW-14.8
[**2106-3-18**] 10:00PM NEUTS-88.0* LYMPHS-7.0* MONOS-4.5 EOS-0.4
BASOS-0.1
[**2106-3-18**] 10:00PM NEUTS-88.0* LYMPHS-7.0* MONOS-4.5 EOS-0.4
BASOS-0.1
[**2106-3-18**] 10:00PM PT-32.0* PTT-40.4* INR(PT)-3.4*
[**2106-3-19**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2106-3-18**] 11:17PM K+-4.9
[**2106-3-19**] 05:35AM HGB-9.9* calcHCT-30
[**2106-3-19**] 07:10PM PT-32.3* PTT-36.8* INR(PT)-3.5*
.
Portable chest xray ([**2106-3-19**]): Patchy opacity projecting over
the right mid and lower hemithorax progressed since prior
examination. Differential for this finding includes early
aspiration pneumonitis, pneumonia, with asymmetric alveolar
pulmonary edema felt less likely. Interval followup radiographs
is suggested.
.
Chest CT [**2106-3-26**]: FINDINGS: Superimposed upon marked
centrilobular emphysema are ground- glass opacities and
subsegmental atelectasis in the dependent portion of the right
upper and lower lobes, and to a smaller degree in the superior
segment of the left lower lobe. Secretions and a small fluid
level is identified in segmental branches of the right bronchus.
There are no pleural effusions. Multiple tiny calcified sub 3-
mm granulomas are scattered throughout the lungs. A multinodular
thyroid is partially visualized. There are coronary artery and
aortic vascular calcifications, but the heart and great vessels
at the mediastinum are otherwise unremarkable. No pathologic
adenopathy is present. Evaluation of the visualized abdomen is
limited secondary to arm- related artifact, but there is an
indeterminate soft tissue structure abutting the upper pole of
the right kidney. Degenerative changes are present in the
osseous structures, but no suspicious lesions are identified.
IMPRESSION:
1. Dependent right lung ground-glass opacities with bronchial
secretions is most suggestive of aspiration or evolving
aspiration pneumonitis.
2. Right renal upper pole structure, which may be due to a renal
lesion or adjacent bowel; ultrasound is recommended to exclude
possibility of a renal mass.
.
Renal ultrasound [**2106-3-26**]:
1. Simple-appearing cyst in the superior pole of the right
kidney measuring 5.7 cm, corresponding to the abnormality seen
on recent chest CT. Small left renal cyst.
2. Incompletely distended bladder. Poorly defined structure at
the base of the bladder likely represents an enlarged prostate,
though a bladder mass cannot be entirely excluded. Repeat
examination with a full bladder could be performed.
.
[**2106-3-29**] VIDEO OROPHARYNGEAL SWALLOW: A study done in
conjunction with speech and swallow division. Multiple
consistencies of barium were administered to the patient under
constant video fluoroscopy. Oral phase was characterized by
mildly impaired bolus control with premature spillover with thin
liquids. Pharyngeal phase is characterized by mildly reduced
laryngeal elevation with all consistencies of barium. There was
a mild amount of residue within the valleculae after all
consistencies. Patient demonstrated penetration with consecutive
sips of thin liquids. There was one mild aspiration with
teaspoons of thin liquid.
.
Echo [**2106-3-22**]
MEASUREMENTS:
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
Aortic Valve - Peak Velocity: 2.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 228 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Suboptimal technical quality, a focal LV
wall motion
abnormality cannot be fully excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and 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 appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely
represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild mitral
regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2105**] 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.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2106-3-22**]
14:56.
.
EGD [**2106-3-30**]
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum
.
Colonoscopy [**2106-3-30**]
A single 1 cm polyp of benign appearance was found in the
proximal ascending colon. A single 1 cm polyp of benign
appearance was found in the proximal ascending colon. Otherwise
normal colonoscopy to ascending colon.
Repeat colonoscopy in 6 weeks due to sub optimal prep.
.
[**2106-3-24**] 12:52 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2106-3-27**]**
GRAM STAIN (Final [**2106-3-24**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2106-3-27**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. MODERATE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
MICU course:
Transferred to the MICU for respiratory distress, likely due to
flash pulmonary edema in setting of COPD exacerbation and PNA.
Pt had been doing well until time of transfer to MICU when being
turned in bed, developed sudden acute SOB w/ HR to 100s, SBP to
190s, O2 sat to 90s on FM, RR 45 on continuous neb. ABG on NRB
7.34/61/161/34 during acute episode. During this episode, given
40IV lasix, NTG SL, 2mg morphine, and bronchodilator with good
effect. During ICU evaluation, pt had diffuse rales, wheezes,
and poor air movement. Able to speak in 2 word gasps, but full
sentences. Diuresis yielded ~240cc within first hour.
.
On arrival to MICU, pt feeling better, however, RR still ~30s,
given an additional 2mg morphine with good effect.
.
Of note, pt stated that he had dull chest pressure in
epigastrium prior to this acute episode, similar to what he had
had previously when tachycardic during last admission. Has had
stress test which was "many years ago" and normal.
.
Pt had previously developed similar anginal symptoms during last
admission to MICU in setting of tachycardia associated w/ 1-2mm
ST depressions in V4-6, presumed to be rate-related ischemia
indicative of a stable angina syndrome.
.
Pt will need cardiac evaluation and stress testing once his
respiratory status is stabilized. Once diuresis was achieved,
his oxygen requirement returned to his baseline 3-4 L NC. A BB
was added to his regimen for further medical optimization.
On the Floor:
A/P: 79 year old male with a history of COPD with recent
admissions for PE and pneumonia, on anticoagulation, presenting
with bright red blood per rectum.
.
1. BRPBR: On admission the patient was anticoagulated and was
supratherapeutic. Patient has never had a GI bleed in the past
and has never had colonoscopy previously. The hematocrit was
stable. Colonoscopy did not show source of bleed, but it was
felt that it was resonable to restart anticoagulation. Result
attached.
.
2. PE: INR drifted down and we started a heparin drip when INR
<2.0. No history of DVT by ultrasound during previous
admission. Patient was maintained on heparin until GIB was
cleared by colonoscopy and then until therapeutic x 48 hours
with INR >2.0 on coumadin. Outpatient f/u to decide on length
of treatment.
.
3. COPD/Pneumonia: Patient with wheezing on exam and is on
steroid taper for recent COPD flare. Complicated by worsening
pneumonia by CXR. Started Vanc/Ceftaz given recent weeks in
hospital/nursing home setting with cough and worsened infiltrate
on CXR. Sputum had MRSA and with history of VRE, etc and little
clinical improvement, patient was treated with 14 day course of
meropenum and linezolid. He had round the clock nebs and some
minor changes to regimen in house, but at discharge restarted
outpatient regimen of nebs, Singulair, Advair, and Spiriva. He
was also given rxn for mucomyst nebs. Because of the prolonged
steroid course, ID recommended 1SS bactrim for 3-6 months after
final taper of steroids (instead of DS to help with INR/coumadin
levels).
- outpt f/u by pulmonology
.
4. Atrial fibrillation: Resolved. Thought to be in acute setting
of PE in combination of underlying lung disease. Patient on
telemetry, maintained sinus rhythm. Discontinued digoxin.
.
5. Hypertension: Treated with lisinopril, Diltiazem, and
betablocker.
.
6. Diastolic dysfunction: required IV Lasix in the ED for volume
overload. Continue outpatient regimen and judicious IVF as
needed.
.
7. CAD: hold aspirin given bleeding, re-evaluate with
cardiologist as an outpatient.
.
8. BPH: continue finasteride, Tamsulosin.
.
9. Hypothyroid: continued outpatient Levothyroxine
10. renal finding: Outpatient follow up of renal finding on
ultrasound.
.
.
Medications on Admission:
Prednisone 10 mg daily
Lovenox 120 mg [**Hospital1 **]
Spiriva daily
Zyvox 600 mg [**Hospital1 **]
Singulair 10 mg daily
RISS
Cardizem 480 mg daily
Colace
Lasix 40 mg daily
Protonix 40 mg [**Hospital1 **]
Aspirin 325 mg daily
Lisinopril 20 mg [**Hospital1 **]
Advair
Digoxin 0.25 mg daily
Flomax
Senna
Levoxyl 75 mcg daily
Discharge Medications:
1. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q4-6H (every 4 to 6 hours) as needed.
[**Hospital1 **]:*QS ML(s)* Refills:*0*
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation every four (4) hours as needed.
[**Hospital1 **]:*qs qs* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day): [**Month (only) 116**] take tums in place
of this medication. Must also take a vit D supplement. .
[**Month (only) **]:*120 Tablet, Chewable(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Titrate to 1 stool per day. This medication is
also over the counter. .
[**Month (only) **]:*60 Capsule(s)* Refills:*2*
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month (only) **]:*30 Tablet(s)* Refills:*0*
6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
[**Month (only) **]:*1 inhaler* Refills:*0*
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
[**Month (only) **]:*qs qs* Refills:*0*
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month (only) **]:*30 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): [**Month (only) 116**]
take 20mg of OTC Prilosec in place of this medication. .
[**Month (only) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Prednisone 5 mg Tablet Sig: Per Taper Tablet PO once a day
for 21 doses: Please take 30mg x 1days, 25mg x 5d, 20mg x 5days,
10 x 5days, 5mg x 5 days.
[**Month (only) **]:*QS Tablet(s)* Refills:*0*
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month (only) **]:*30 Tablet(s)* Refills:*0*
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Month (only) **]:*30 Tablet(s)* Refills:*0*
13. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
[**Month (only) **]:*60 Capsule, Sustained Release(s)* Refills:*0*
14. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
[**Month (only) **]:*30 Tablet(s)* Refills:*0*
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Titrate to 1 BM/day.
[**Month (only) **]:*qs Tablet(s)* Refills:*0*
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
[**Month (only) **]:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily): Take with calcium
.
[**Month (only) **]:*qs Tablet(s)* Refills:*2*
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
[**Month (only) **]:*90 Tablet(s)* Refills:*2*
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: [**Month (only) 116**]
buy over the counter. .
[**Month (only) **]:*30 Tablet(s)* Refills:*2*
20. Outpatient Lab Work
Please have VNA draw INR on Tuesday, [**4-6**], and call the result
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9385**] at [**Telephone/Fax (1) 25161**].
21. Outpatient Pulmonary rehab
Please provide pulmonary rehab at [**Hospital1 18**] [**Location (un) **].
22. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please discuss dose readjustment with your primary care doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
23. Oxygen-Air Delivery Systems Device Sig: Three (3) L
Miscellaneous continuous: Home O2 continuous by nasal cannula.
[**Last Name (Titles) **]:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
GI bleed
COPD flare
Pulmonary Embolism
Pneumonia
Hypertension
Benign Prostatic Hypertrophy
Discharge Condition:
Stable. Requiring supplemental oxygen at pre-hospital levels.
Discharge Instructions:
You were admitted with a GI bleed in the setting of a
supratherapeutic INR. You also were treated for a COPD flare
and pneumonia.
.
You had several changes in medications. Please refer to the list
of medications at discharge. Please discuss how long you should
remain on Coumadin with your primary care doctor. You will
likely be on this medication for 3-6 months.
.
Please follow up with your appointments. (see below)
.
Please return to the ED emergently if you have further bleeding
per rectum, difficulty breathing, chest pain or any other acute
problems.
Followup Instructions:
Please follow up with your PCP in the next 2 weeks ([**4-16**]).
He will also need to adjust your coumadin based on your INR.
.
Please follow up with your cardiologist [**4-6**] as you have
scheduled.
.
Please follow up with your pulmonologist in the next 2 weeks.
.
You will also have the following appointment scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3833**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2106-6-1**]
9:00
|
[
"482.41",
"600.00",
"285.1",
"414.01",
"790.92",
"491.21",
"211.3",
"V12.51",
"244.0",
"427.31",
"428.33",
"401.9",
"V58.61",
"413.9",
"428.0",
"578.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
18700, 18749
|
10863, 14599
|
299, 335
|
18893, 18958
|
3198, 3198
|
19567, 20042
|
2595, 2714
|
14972, 18677
|
18770, 18872
|
14625, 14949
|
18982, 19544
|
2729, 3179
|
8824, 10840
|
232, 261
|
363, 1973
|
3214, 8801
|
1995, 2326
|
2342, 2579
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,883
| 115,790
|
22431
|
Discharge summary
|
report
|
Admission Date: [**2120-9-27**] Discharge Date: [**2120-9-29**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer from outside hospital for biventricular pacemaker
placement and further medical management
Major Surgical or Invasive Procedure:
biventricular pacemaker placement, [**2120-9-27**]
History of Present Illness:
[**Age over 90 **] y/o male with complicated cardiopulmonary PMHx notable for
CAD s/p MI [**4-4**], CABG x 4 complicated by wound staph infection
leading to sternectomy. Dialated cardiomyopathy with EF 10-20%.
Also with DM, CRI, esophageal mass obstruction, s/p bx with
indeterminate path; s/p stenting with relief of obstruction.
Also with COPD, O2sats high 80s on RA baseline. Presented at OSH
on [**2120-9-18**] with COPD exacerbation, ? asp PNA and dehydration
with increased Cre. Stay was c/b over diuresis and pressor
dependent hypotension felt to be [**3-4**] diuresis and ACEI therapy.
Pt also c. diff positive and Rx flagyl day 7 of 10 on [**9-27**]. ECG
revealed wide LBBB. [**Name (NI) 1094**] son Dr. [**First Name4 (NamePattern1) **] [**Known lastname 58305**] arranged for transfer
to [**Hospital1 18**] for consideration for biventricular PM to help pt from
recurrent CHF hospitalizations. Lenghty discussion with son and
pt with EP fellow and Dr. [**Last Name (STitle) **] re: risk/benefit of
[**Hospital1 **]-ventricular pacer placement in elderly pt with co-morbidity.
Pt son understood the risk including possibility of obtaining
little clinical benefit; but still wished to proceed. Pt
remianed full code.
Past Medical History:
CAD s/p CABG
COPD
Congestive heart failure
Social History:
former TOB
Family History:
noncontributory
Physical Exam:
GEN: Elderly M in NAD
HEENT: NCAT, PERRLA, OP clear
Heart: S1S2 tachycardic
Lungs: CTA anteriorly
Abdomen: nontender, nondistended
Extremities: trace pulses throughout, no edema
Brief Hospital Course:
Pt transferred from outside hospital and brought directly to EP
laboratory where he underwent biventricular pacemaker placement
without complication. Pt tolerated procedure well and then
brought to CCU for close monitoring. Pt did well in CCU without
symptoms, mentating well, answering questions appropriately. Pt
then transferred to [**Hospital Ward Name 121**] 3 but remained on CCU team. About 5 AM
[**2120-9-29**], pt found to have SBP in 50s and CCU team called
emergently. Pt found to be hypoxic with O2 sats in 70s, not
mentating appropriately, and emergently intubated. Pt brought
back to CCU and started on dopamine for BP support. Pt's
hypotension continued despite increasing dopamine and adding
levophed & dobutamine, with MAPs in the 30s. [**Name (NI) 1094**] son was
called & came to bedside. Per family wishes, no further
aggressive measures were undertaken. Pt went into ventricular
fibrillation at 1:30 PM [**2120-9-29**] and passed away within minutes.
[**Name (NI) 1094**] son declined post-mortem.
Medications on Admission:
digoxin, protonix, zocor, advair, aspirin, prednisone 5 qd,
lasix 90 qd, flagyl, insulin sliding scale, colace, Zofran.
Discharge Medications:
none
Discharge Disposition:
Extended Care
Facility:
passed away
Discharge Diagnosis:
ventricular fibrillation and cardiac arrest
congestive heart failure
coronary artery disease
Discharge Condition:
passed away
Discharge Instructions:
passed away
Followup Instructions:
passed away
Completed by:[**2120-9-29**]
|
[
"425.4",
"V45.81",
"427.41",
"008.45",
"250.00",
"496",
"412",
"428.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.50",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3263, 3301
|
2034, 3064
|
383, 435
|
3437, 3450
|
3510, 3552
|
1800, 1817
|
3234, 3240
|
3322, 3416
|
3090, 3211
|
3474, 3487
|
1832, 2011
|
244, 345
|
463, 1690
|
1712, 1756
|
1772, 1784
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,638
| 152,985
|
12266
|
Discharge summary
|
report
|
Admission Date: [**2106-11-25**] Discharge Date: [**2106-12-4**]
Date of Birth: [**2056-3-4**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2106-11-25**]: Exploratory laparotomy, resection of ileostomy
takedown site, cholecystectomy and ileostomy (Dr. [**Last Name (STitle) **]
History of Present Illness:
Ms. [**Known lastname 1001**] is a 50-year-old woman s/p proctocolectomy, ileal
pouch-anal anastomosis and 9 days prior to admission, ileostomy
takedown. She presented to the [**Hospital1 18**] ED on [**2106-11-25**] with the
acute onset of abdominal pain, distension, and peritoneal signs
and was found to have free air and fluid in the abdomen.
Past Medical History:
PMH: Seizure disorder [**3-3**] neurocysticercosis, medically
refractory UC, internal hemorrhoids
PSH: Laparoscopic TAC/ileostomy ([**6-9**] [**Doctor Last Name **]), Lap converted to
open proctectomy with IPAA via stapled anastomosis ([**10-10**]
[**Doctor Last Name **]), ileostomy takedown ([**11-9**] [**Doctor Last Name **]), Exploratory
laparotomy, resection of ileostomy takedown site,
cholecystectomy and ileostomy ([**11-9**] [**Doctor Last Name **])
Social History:
From [**Country 3587**], Portuguese speaker who has been in the US for
11 yrs. She has 4 children (2 who live in the US and 2 in her
home country). Her daughter, [**Name (NI) **] lives ~ 30 min away and
comes to check on her mother [**4-2**] x per week.
Occasional EtOH, denies tobacco and drug use
Family History:
Sister has abd pain and hemorrhoids.
no h/o seizures or IBD
Physical Exam:
PHYSICAL EXAM on Admission:
VS: 98.4 139 122/83 18 100% RA
Gen: AAOX3, mild distress
CVS: tachycardic, sinus
Pulm: CTAB
Abd: distended and diffusely tender abdomen to mild palpation,
healing ostomy site with no cellulitis
Ext: no edema, extrem warm
GU: rectal deferred
Pertinent Results:
CXR [**11-25**]
IMPRESSION: Large amount of pneumoperitoneum and dilated loops
of small bowel seen in the upper left abdomen. This is more free
intraperitoneal air than expected in a patient nine days post
ileostomy takedown, and findings are concerning for perforation.
Further evaluation can be obtained with CT.
CT ABD & PELVIS W/O CONTRAST [**11-25**]
IMPRESSION:
1. Large amount of pneumoperitoneum and free fluid within the
abdomen. No
contrast extravasation from the bowel identified after rectally
administered contrast, and both the right lower quadrant small
bowel anastamosis and ileoanal anastamosis appear intact.
2. Diffusely dilated loops of small bowel with no discrete
transition points noted.
3. Small amount of subcutaneous air and skin thickening seen in
the area of the recent ileostomy takedown.
CXR [**11-26**]:
Endotracheal tube, with the chin down, is 15 mm above the carina
and could be pulled back 15-20 mm for standard positioning.
Volumes in both lungs are low. Greater opacification at the lung
bases could be due to developing pneumonia and needs to be
followed carefully. There is no pulmonary edema or pleural
effusion. Upper lungs are clear. Heart size is normal. Right
jugular line ends at the superior cavoatrial junction.
Nasogastric tube has been withdrawn to the mid stomach. No
pneumoperitoneum.
CXR [**11-28**]:
The endotracheal tube has been removed. The NG tube is either in
the distal stomach or proximal duodenum. There is a mildly
dilated loop of
bowel in the left upper quadrant that is likely small bowel,
minimally dilated at 3.2 cm. There is a new small left pleural
effusion. There is volume loss at both bases with dense
retrocardiac opacity consistent with both volume loss and
associated infiltrate, as well as the effusion.
[**2106-11-25**] 10:45AM BLOOD WBC-11.2*# RBC-4.68 Hgb-11.1* Hct-35.7*
MCV-76* MCH-23.7* MCHC-31.0 RDW-16.0* Plt Ct-817*#
[**2106-11-26**] 12:08AM BLOOD WBC-7.8 RBC-5.15 Hgb-14.0 Hct-41.6
MCV-81* MCH-27.2 MCHC-33.7 RDW-18.6* Plt Ct-558*
[**2106-11-27**] 12:22PM BLOOD WBC-12.4* RBC-3.72* Hgb-10.0* Hct-30.1*
MCV-81* MCH-27.0 MCHC-33.3 RDW-18.3* Plt Ct-594*
[**2106-12-1**] 04:45AM BLOOD WBC-15.5* RBC-4.52 Hgb-12.2 Hct-36.5
MCV-81* MCH-27.0 MCHC-33.4 RDW-18.8* Plt Ct-901*
[**2106-12-3**] 04:45AM BLOOD WBC-11.5* RBC-3.77* Hgb-9.8* Hct-30.5*
MCV-81* MCH-26.0* MCHC-32.1 RDW-19.1* Plt Ct-871*
[**2106-11-25**] 11:00AM BLOOD Glucose-85 UreaN-13 Creat-0.6 Na-134
K-4.4 Cl-89* HCO3-28 AnGap-21*
[**2106-11-26**] 12:08AM BLOOD Glucose-162* UreaN-9 Creat-0.4 Na-132*
K-4.2 Cl-102 HCO3-22 AnGap-12
[**2106-11-27**] 01:35AM BLOOD Glucose-77 UreaN-6 Creat-0.3* Na-139
K-4.0 Cl-104 HCO3-27 AnGap-12
[**2106-12-1**] 04:45AM BLOOD Glucose-83 UreaN-3* Creat-0.4 Na-137
K-4.0 Cl-97 HCO3-27 AnGap-17
[**2106-12-3**] 04:45AM BLOOD Glucose-93 UreaN-5* Creat-0.4 Na-138
K-4.2 Cl-101 HCO3-25 AnGap-16
[**2106-11-25**] 11:00AM BLOOD ALT-22 AST-35 AlkPhos-335* TotBili-0.4
[**2106-11-29**] 06:45AM BLOOD ALT-12 AST-20 LD(LDH)-279* AlkPhos-259*
TotBili-0.5
[**2106-11-30**] 04:52AM BLOOD ALT-11 AST-20 LD(LDH)-250 AlkPhos-259*
TotBili-0.4
[**2106-11-25**] 11:00AM BLOOD Albumin-4.2 Calcium-9.8 Phos-5.1*# Mg-1.8
[**2106-11-29**] 06:45AM BLOOD Albumin-2.4* Calcium-8.3* Phos-2.7 Mg-1.8
[**2106-12-3**] 04:45AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7
Brief Hospital Course:
Ms. [**Known lastname 1001**] presented to the [**Hospital1 18**] ED on [**2106-11-25**] following the
acute onset of severe abdominal pain 9 days following ileostomy
takedown. She was found to have peritoneal signs, and CXR
demonstrated free air concerning for bowel perforation. A STAT
CT was obtained, which confirmed the diagnosis of bowel
perforation, and after timely preparation and informed consent,
Ms. [**Known lastname 1001**] was taken emergently for exploratory laparotomy,
ileostomy takedown site resection, ileostomy, and
cholecystectomy on [**11-25**]. Surgeon was Dr. [**First Name (STitle) **] [**Name (STitle) **]. The
patient tolerated the procedure well, and was admitted to the
surgical intensive care unit for post-operative monitoring and
recovery. She was kept intubated overnight and extubated on
[**11-26**]. In the ICU she was tachycardic with heart rate in the
150s, somewhat low (likely near baseline) urine output of 20
cc/hr, and low but stable blood pressure. She was given several
boluses of normal saline with improvements in urine output and
blood pressure. She was given metoprolol IV for control of her
tachycardia. Her pain was controlled with dilaudid PCA. She
was transferred to the surgical floor on [**Hospital Ward Name 1950**] 7 on [**11-27**].
On the floor, her nasogastric tube was removed after residuals
were minimal. She was started on sips of liquids, and her diet
was advanced as she tolerated. She was started on nystatin
swish and swallow for treatment of thrush.
On [**11-30**] it was noted that the patient was somewhat lethargic
and responding slowly or incompletely to questions. She was
seen by the Neurology service who wanted an EEG to evaluate for
potential subclinical seizure activity. On [**12-1**] a 24 hour EEG
was started and found to be normal the next day. Additional
Neurology recommendations were to increase the patient's dose of
carbamazepime.
On [**12-1**], the patient was started on fluconazole because
peritoneal fluid cultures from [**11-25**] demonstrated yeast, and in
the setting of elevated WBC count. In addition, the patient's
ostomy output had been somewhat high, so she was started on
psyllium wafers [**Hospital1 **], and loperamide. Her loperamide was
titrated up the in the next two days to further decrease her
high ostomy output, and tincture of opium started on [**12-3**].
On [**12-3**], she was discharged to skilled nursing facility for
further physical rehabilitation. On discharge she was able to
tolerate a regular diet and ambulate with assistance. She was
alert and responsive. Her pain was controlled with oral pain
medications oxycodone and tylenol.
Medications on Admission:
carbamazepine 800mg'', keppra 500mg''', mesalamine 1,000mg'
Discharge Medications:
1. Outpatient Lab Work
Patient needs to have a Tegretol level drawn on [**2106-12-5**]. Please fax results to her neurologist, Dr. [**Last Name (STitle) **]. [**Doctor Last Name **], @
([**Telephone/Fax (1) 38312**] as soon as possible thereafter. Thank you.
2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. carbamazepine 200 mg Tablet Extended Release 12 hr Sig: Three
(3) Tablet Extended Release 12 hr PO DAILY (Daily).
9. carbamazepine 200 mg Tablet Extended Release 12 hr Sig: Four
(4) Tablet Extended Release 12 hr PO DAILY (Daily).
10. psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day).
11. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
12. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day).
13. opium tincture 10 mg/mL Tincture Sig: Five (5) Drop PO Q4H
(every 4 hours) as needed for high ileostomy output.
14. lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for agitation/siezure.
Discharge Disposition:
Extended Care
Facility:
Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**]
Discharge Diagnosis:
Bowel perforation
Peritonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a having an exploratory
laparotomy with resection of the small bowel and ileostomy for
surgical management of your torn bowel. You have recovered from
this procedure well and you are now ready to start
rehabilitation. You have tolerated a regular diet, passed gas
and your pain is controlled with pain medications by mouth. You
may now be transferred to your rehabilitation facility to finish
your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge, which is
acceptable, however it is important that you have a bowel
movement in the next 3-4 days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright
red blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve, please call
the office. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) **]. You may gradually increase
your activity as tolerated but avoid heavy excersise.
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
You also have a new ileostomy. The most common complication from
a new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
you find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if you notice
your ileostomy output increasing, take in more electrolyte drink
such as gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If you notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. You may eat a
mosified regular diet with your new ileostomy.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for buldging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic within a few days after
surgery.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please followup with Dr. [**First Name (STitle) **] [**Name (STitle) **] within the next [**1-31**]
weeks. Call his office early next week at [**Telephone/Fax (1) 160**] to make
this appointment.
Our scheduling system also indicates that you have the following
appointments:
[**Name6 (MD) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2107-1-17**] 10:30
Completed by:[**2106-12-4**]
|
[
"345.80",
"123.1",
"556.9",
"997.49",
"574.10",
"567.9",
"998.32",
"569.83",
"112.0",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"51.22",
"99.15",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
9566, 9665
|
5352, 8031
|
317, 460
|
9739, 9739
|
2023, 5329
|
14840, 15259
|
1657, 1719
|
8142, 9543
|
9686, 9718
|
8057, 8119
|
9890, 14817
|
1734, 1748
|
263, 279
|
488, 837
|
1762, 2004
|
9754, 9866
|
859, 1323
|
1339, 1641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,766
| 131,912
|
52893
|
Discharge summary
|
report
|
Admission Date: [**2162-2-11**] Discharge Date: [**2162-2-15**]
Date of Birth: [**2104-5-16**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
CHEST PAIN
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stent to the left
anterior descending artery
History of Present Illness:
57F w/ HTN, DM, HL, Obesity, pAFIB who presented w/ chief
complaint of chest pain. The patient awoke at 4 PM with SSCP,
band-like feeling across chest and nausea. She tried mylanta and
motrin, but the pain came back. She called 911 by 5pm. She was
brought in by ambulance and threw up all the meds she was given
en-route and went immediately up to lab, without getting off
ambualnce stretcher or stop in ED. She got ASA 325, heparin
5000, and was started on integrillin in lab. She was pain free
before getting on the table. After access through the right
radial, she got ballooned and stented to her LAD. She also had a
distal cut off in the LAD which was not repaired. OM1 was 60%
diseased and not internvened upon. She was transferred to the
CCU afterwards. She remained hemodynamically stable throughout.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- Paroxysmal afib diagnosed in [**4-9**], s/p DCCV, now on rhythm
control
3. OTHER PAST MEDICAL HISTORY:
- Hx of asthmatic bronchitis
- Autonomic Neuropathy
- GERD
- Vocal cord surgery
- Cholelithiasis
- Hiatal hernia
Social History:
Nurse [**First Name (Titles) **] [**Last Name (Titles) **] 4 but unable to work since [**Month (only) **]
- Tobacco history: 10 pack years, quit in 98
- ETOH: -
- Illicit drugs: -
Family History:
both parents, alive in 80s, have afib and htn
Physical Exam:
ADMISSION:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not seen.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. 1+
pedal edema
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISHCARGE:
VS: 97.7 BP 105-113/47-54 HR 60-68 RR 18-20 97-99% RA
FS:169>199>113>108; AM?
I/O:[**Telephone/Fax (1) 109047**]+
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Obese
HEENT: NCAT. Sclera anicteric. PERRL, EOMI
NECK: Supple with JVP not seen.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, distant S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. obese
EXTREMITIES: No c/c trace edema, obese
Pertinent Results:
LABS ON ADMIT:
[**2162-2-11**] 06:15PM BLOOD WBC-10.8 RBC-4.75 Hgb-13.7 Hct-38.8
MCV-82# MCH-28.8 MCHC-35.3* RDW-13.3 Plt Ct-249
[**2162-2-11**] 07:15PM BLOOD PT-14.6* PTT-150* INR(PT)-1.4*
[**2162-2-11**] 06:15PM BLOOD Glucose-327* UreaN-27* Creat-1.3* Na-134
K-3.4 Cl-95* HCO3-23 AnGap-19
[**2162-2-11**] 06:15PM BLOOD ALT-60* AST-33 CK(CPK)-73 AlkPhos-72
Amylase-33 TotBili-0.4
[**2162-2-11**] 11:51PM BLOOD CK-MB-27*
[**2162-2-12**] 05:25AM BLOOD CK-MB-47* cTropnT-1.29*
[**2162-2-12**] 12:08PM BLOOD CK-MB-22* MB Indx-5.6 cTropnT-0.52*
[**2162-2-11**] 06:15PM BLOOD VitB12-749
[**2162-2-11**] 06:15PM BLOOD %HbA1c-11.3* eAG-278*
LABS ON DC:
[**2162-2-15**] 07:15AM BLOOD WBC-6.7 RBC-4.35 Hgb-12.5 Hct-38.5 MCV-89
MCH-28.6 MCHC-32.3 RDW-13.3 Plt Ct-250
[**2162-2-15**] 07:15AM BLOOD PT-18.5* PTT-43.6* INR(PT)-1.7*
[**2162-2-15**] 07:15AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-137
K-4.6 Cl-103 HCO3-27 AnGap-12
[**2162-2-15**] 07:15AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.1
CATH [**2162-2-11**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two vessel coronary disease. The LMCA was patent.
The LAD
had a 95% proximal occlusion with visible thrombus. The LCX had
an 80%
lesion in the OM1. The RCA had mild disease diffusely.
2. Limited resting hemodynamics revealed systemic arterial
hypertension.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. STEMI
3. GOT DES TO LAD
ECHO [**2162-2-12**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with mild apical
aneurysm/dyskinesis and akinesis of the distal inferior wall
(clip [**Clip Number (Radiology) **]). The distal septum is also mildly hypokinetic. The
remaining segments contract normally (LVEF = 55 %). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are mildly thickened (?#).
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No
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.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (distal
LAD distribution). Mild aortic valve stenosis.
Compared with the prior study (images reviewed) of [**2161-4-10**],
the findings are new.
Brief Hospital Course:
HOSPITAL COURSE: 57 year old female w/ HTN, HL, DM 2, pAFIB who
presented w/ STEMI - got stented to her LAD and admitted to CCU
for post-cath monitoring. Discharged in stable condition.
ACTIVE ISSUES:
# STEMI: Pt presented with STE in V1-6 and was found to have an
LAD lesion. She got ballooned and DES to LAD and the procedure
was uneventful. She has an unrepaired distal LAD lesion and a
60% OM1. Pt found to have apical dyskinesises in TTE. CEs were
downtrending. We started asa 325, plavix 75, d/ced pradaxa and
started lovenox bridge until INR therapeutic on warfarin.
# AFIB: Pt has paroxysmal AFIB that was diagnosed last year
after w/u for cholelithiasis. Underwent DCCV and was started on
pradaxa, flecainide, metoprolol. Was last seen in clinic by Dr
[**Last Name (STitle) **] in [**2161-11-16**] at which time she was seen to be doing
well. Was initially started on Sotalol 80 which increased her
QTc to abt 480-500. Dose reduced to 40 [**Hospital1 **] on which qtc was 470
2 hr post dose. We continued warfarin and lovenox bridge
# HTN: BPs in 160s on transfer but stable since call out. We
increased lisinopril to 30 and then d/c on home 40.
# HL: Last lipid panel Chol 286* TG 187*1 HDL 55 LDL calc 194*
in [**2-7**]. We started her on atorva 80 and co enzyme q to prevent
msucle cramps
# DM 2: pt insulin dependant and on metformin. Obesity
increasing. Followed in [**Last Name (un) 387**]. Hba1cs >10. Also has autonomic
neuropathy. We held metformin but kept increasing her insulin
doses. She was on HISS (30, 25, 40 standing) and lantus (45, 50)
[**First Name8 (NamePattern2) **] [**Last Name (un) 387**] dosing.
# Asthma: stable. We continued home inhalers, fexofenadine
# Depression: stable. We continued home citalopram
# Hypothyroid: stable. we continued synthroid
# GERD: stable. we continued omeprazole
CODE: FC (confirmed)
COMM: patient, husband [**Telephone/Fax (1) 109048**]
TRANSITIONAL ISSUES: We stopped Wellchol, Dabigitran,
metoprolol, odansetron, hydrochlorothiazide, and flecainide and
started asa, plavix, warfarin (w/ lovenox), sotalol, mg oxide,
co-enzyme q and atorva. INR will be checked on Wednesday at Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office during appt.
Medications on Admission:
albuterol inhaler 2 puffs p.r.n.
Astelin in each nostril 2 inhalations p.r.n.
citalopram 10 mg daily
WelChol 3.75-g powder daily
dabigatran 150 mg b.i.d
flecainide 150 mg b.i.d.
HISS as directed per sliding scale; 25 Units QAM, 35 Units at
noon and 35 Units QPM
Lantus; 50 units HS and 45 units QAM
Levothyroxine 25 mg daily
lisinopril 40 mg daily
loratadine 10 mg daily
meclizine 25 mg b.i.d. p.r.n.
metformin ER 1000 mg b.i.d.
metoprolol ER 25 mg daily
omeprazole 20 mg daily
ondansetron 4 mg b.i.d. p.r.n
vitamin D
calcium replacement therapy.
htz 25 qam
Discharge Medications:
1. Outpatient Lab Work
Please check INR and chem-7 on [**2162-2-17**] with results to Dr. [**First Name8 (NamePattern2) 3296**]
[**Last Name (NamePattern1) 3297**],[**First Name3 (LF) 3295**] I.
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
ICD-9 427.31
Fax: [**Telephone/Fax (1) 4647**]
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
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. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
6. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Astelin Nasal
8. insulin lispro 100 unit/mL Solution Sig: as per sliding scale
units Subcutaneous three times a day.
9. Lantus 100 unit/mL Solution Sig: Forty Five (45) units
Subcutaneous once a day: 50 units at night.
10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. meclizine 25 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for vertigo.
14. metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. coenzyme Q10 200 mg Capsule Sig: One (1) Capsule PO daily
().
Disp:*30 Capsule(s)* Refills:*2*
19. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
20. enoxaparin 150 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*8 syringe* Refills:*2*
21. sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
22. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ST elevation myocardial infarction
Secondary: Atrial fibrillation
Diabetes Mellitus
Hypertension
Dyslipidemia
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 at [**Hospital1 18**].
You were admitted for a heart attack. You were treated with a
drug eluting stent to your left anterior descending artery. You
will need to take aspirin and plavix every day without fail to
ensure that your stent remains open and does not clot off and
cause another heart attack. Do not stop taking aspirin and
plavix unless Dr. [**Last Name (STitle) **] tells you it is OK. Your heart
function still remains good but there is an area that is not
moving well after the heart attack. Therefore, you have been
changed from dabigitran to warfarin until your heart wall motion
improves.
It is very important that you take all of your medicines and
optimize your blood sugar control.
.
We made the following changes to your medicines:
1. STOP taking Wellchol, Dabigitran, metoprolol, odansetron,
hydrochlorothiazide, and flecainide
2. START taking Aspirin 325 mg daily and Plavix 75 mg daily to
prevent the stents from clotting off.
3. START taking atorvastatin to lower your cholesterol
4. START taking warfarin instead of dabigitran to prevent blood
clots and a stroke
5. START taking nitroglycerin if you have chest pain at home.
Take one tablet under your tongue and wait 5 minutes, you can
take another tablet if you still have chest pain but please call
911 if the chest pain persists.
6. Start Co enzyme Q12 to prevent muscle aches from the
atorvastatin
7. START enoxaparin sc to take twice daily until the INR is >
2.0
8. START Mag oxide twice daily to increase your magnesium
levels.
You can get your INR checked on Wednesday at Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
office during your appt.
Followup Instructions:
The following appointments were made for you:
Department: BIDHC [**Location (un) **]
When: Wedenesday [**2-17**] at 9:15 am.
With: [**First Name11 (Name Pattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3296**] [**Last Name (NamePattern1) 3297**], MD [**Telephone/Fax (1) 608**]
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS Best Parking:
Department: CARDIAC SERVICES
When: THURSDAY [**2162-3-18**] at 10:20 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: THURSDAY [**2162-7-22**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19249**], MD [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"530.81",
"780.4",
"272.4",
"250.60",
"311",
"414.01",
"493.90",
"278.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.66",
"99.20",
"36.07",
"37.22",
"00.40",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11855, 11861
|
6517, 6517
|
293, 382
|
12024, 12024
|
3916, 5265
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11882, 12003
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2304, 3897
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|
8452, 8764
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243, 255
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6720, 8431
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410, 1696
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12039, 12151
|
1911, 2025
|
1718, 1786
|
2041, 2225
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,260
| 169,649
|
34570
|
Discharge summary
|
report
|
Admission Date: [**2130-7-25**] Discharge Date: [**2130-8-15**]
Date of Birth: [**2056-8-19**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Generalized weakness, N/V, chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73yo Russian speaking only woman with h/o DM2, HTN,
hyperlipidemia followed at [**Hospital1 336**] who presents with complaint of
generalized weakness, N/V. She reports feeling generally weak
and unwell over the past few days and has not been
eating/drinking well due to decreased appetite and mild nausea.
Overnight, she awoke feeling very unwell with increased nausea
and dizziness. She took her BS and it was 77 so she drank some
juice and ate honey. She then awoke a second time feeling even
worse with nausea, lightheadedness, and dizziness. She then
took her BP which she reports was 240/110. She took 5mg of
nifedipine which eventually brought her blood pressure down to
160s. She denies headache at the time of hypertension at home,
however she reports she had a headache in the ED which has since
resolved. She endorses intermittent chest discomfort/tightness
that radiates to her jaw. She reports it is difficult to
discern whether this is due to her N/V or whether it is "due to
her heart". She denies radiation down her arm nor to her back
(although she reports upper back pain/burning which is not new).
She does report intermittent "tachycardia" and palpitations at
home last evening. She denies significant associated SOB, no
diaphoresis. She reports she had one episode of nonbloody
emesis at home and then again in the emergency department. She
reports her symptoms were alleviated by zofran and GI cocktail
and she is now feeling a bit better and hungry. She denies
abdominal pain currently although she endorsed epigastric
discomfort in the setting of her N/V in the ED. No diarrhea,
blood in stool, no dark/tarry colored stool. She is passing
gas, last BM yesterday. She denies sick contacts. She further
denies fevers/chills. No dysuria/hematuria. No cough. She has
had dizziness and lightheadedness in the setting of poor PO.
.
Of note, she was admitted to [**Hospital 3278**] Medical Center in [**4-4**] with
abdominal pain, N/V at which time KUBs showed she was FOS.
Althoguh she did not undergo formal gastric emptying study, she
was discharged on reglan with presumptive diagnosis of chroinic
constipation and gastroparesis. Per her PCP, [**Name10 (NameIs) **] then followed
up with gastroenterology at [**Hospital1 3278**] who felt her symptoms of
abdominal discomfort and distention were due to chronic
constipation and they recommended metamucil. Per her PCP, [**Name10 (NameIs) **]
patient never took reglan because she was concerned about side
effects. Also of note, she underwent PMIBI at that time which
demonstrated a small, mild reversible perfusion defect in the
anteroapical area.
.
In the ED, initial vitals were T: 96.9 BP: 150/66 HR: 75 RR: 15
O2 sat: 100%RA. Initial FS was 140. Labs were notable for
sodium of 126, bicarb of 19 with AG of 18. UA was negative.
WBC was mildly elevated to 11.5 with 88% neutrophilia, no bands.
Potassium was 3.2 for which she received 40mEq PO KCL. CXR was
negative for clear infiltrate. EKG demonstrated TWI III, V1-V3.
Cardiac enzymes were sent and were negative x1. She
experienced nausea without vomiting while in the ED for which
she received IV zofran x1. She also received GI cocktail for
epigastric discomfort that she experienced in the setting of
N/V.
.
She is now being admitted for r/o MI and further rx and
evaluation of her N/V.
.
ROS: As above. Additionally she denies orthopnea/PND. No
changes in vision; she wears glasses at baseline. No
dysuria/hematuria. She denies rashes. Endorses chronic back
pain which is unchanged.
Past Medical History:
DM2
Hypertension
Hypothyroidism
Hyperlipidemia
Constipation
Back pain
Vulvar atrophy
?Gastroparesis
Osteopenia
Social History:
Lives alone in [**Location (un) 86**]. Was married, but has since separated.
Practiced as a trauma surgeon in [**Country 532**] prior to moving to the
US nearly 20 years ago. She has never smoked and denies EtOH.
No illicits. Has a neice who lives locally.
Family History:
NC
Physical Exam:
Gen: Sitting up in bed, NAD. Pleasant.
HEENT: PERRL, mildly dry MM.
Neck: Supple, no JVD appreciated.
CV: RRR, soft systolic murmur heard best at RUSB
Resp: fine rales at right lung base, otherwise lungs clear
without wheezes, rales, rhonchi.
Abd: Hypoactive BS, mildly TTP over lower abdomen, no
rebound/guarding, no epigastric pain.
Ext: No c/c/e, WWP
Skin: No rashes.
Neuro: AAOx3, CN2-12, strength, sensation to soft touch all
grossly intact.
Pertinent Results:
Labs from PCP ([**2130-6-29**]):
TSH 0.91
FT4 1.32
HgbA1c 6.2%
T. Cholesterol 165
TG 77
HDL 57
LDL 92
.
PMIBI from [**Hospital1 3278**] ([**2130-2-8**]): Patient experienced chest pain and
dizziness during the examination for which 75mg aminophyllie was
given, with subsequent resolution of symptoms. No diagnostic
ECG changes. Small, mild, reversible perfusion defect in the
anteroapical area. Normal global LV function, with LVEF=63% and
normal regional wall motion on gated SPECT images.
.
EKG: NSR at rate of 73 bpm. Borderline 1st degree AV delay,
TWI III, V1-V3 and TW flattening in aVF. Otherwise without
significant ST changes. There is no prior in our system with
which to compare.
.
Studies:
.
[**2130-7-25**] CXR (prelim): Limited by low lung volumes. Cardiac
silhouette mildly enlarged. Linear atelectasis at bases. No
definite acute cardiopulmonary process.
Brief Hospital Course:
A/P: 73yo Russian speaking woman with h/o DM2, HTN,
hyperlipidemia, hypothyroidism and gastroparesis who initially
presented with N/V and chest discomfort & subsequently found to
be found to be hyponatremic who subsequently became acutely
tachypneic and coded in the setting of a seizure and AMI.
.
#Hyponatremia: Sodium on admission was 126.
Hydrochlorothiazide was held, and she received IV NS. Serum
sodium fell to 116. In this context she had a generalized
tonic-clonic seizure and PEA arrest. She was effectively
rescucitated and transferred to the ICU where she received
hypertonic saline and fluid restriction. The renal team was
involved. The cause of hyponatremia was thought to be a
combination of her hypovolemia, hydrochlorothiazide, poor PO
intake, and vomitting. There was also concern for SIADH. CT
head was without evidence of tumor. Her sodium normalized to
140's and remained there throughout the duration of her
admission. Further workup of SIADH was deferred to her
outpatient physician.
.
#Myocardial Infarction: On her initial presentation in the [**Name (NI) **],
pt reported chest discomfort with EKG unchanged from baseline.
One day later, in the context of low sodium and seizure, she had
an NSTEMI in proximal LAD distribution. Stat echo showed large
anterior wall hypokinesis and LVEF of 25%, consistent with an
ischemic event. The cardiology team was involved. Plavix and a
beta blocker were started, and ASA and statin were increased.
Lipids were checked and were at goal (LDL 75). Cardiac
catheterization was deferred until her acute issues were
resolved. Troponin peaked at 0.71 on [**7-26**]. Repeat echo showed
a recovery of LVEF to 55% and moderate mitral regurgitation. She
had subsequent episodes of R-sided chest discomfort without EKG
changes, thought to be secondary to musculoskeletal trauma from
chest compressions.
.
#Respiratory failure: The patient developed severe tachypnea
and metabolic alkalosis in the setting of her STEMI, thought to
be a consequence of both pulmonary edema from an acutely
decompensated heart and aspiration pneumonia. She was
intubated. Sputum showed moderate strep pneumo-pan sensitive,
and she received 10 days of levofloxacin and 5 days of
vancomycin. Extubation was complicated by laryngeal inflammation
and edema, with initial attempt requiring reintubation. She was
later succuessfully extubated with heliox, and subsequently
quickly weaned off nasal cannula oxygen. She was discharged
with O2 Sats in the upper 90's on room air and a normal WBC
count.
.
#Seizure: The patient had a tonic clonic seizure in the context
of severe respiratory alkalosis (pH 7.7) and hyponatremia (Na
116). These metabolic derangements were thought to account for
her seizure, and no further neurologic workup was pursued.
After her respiratory status was improved and sodium corrected,
she had no additional seizures.
.
#Hypertension: The patient was initially hypertensive in the
150s. After the arrest, she was hypotensive requiring pressors.
This was thought to be secondary to a combination of sepsis and
CHF after STEMI. Her home meds including calcium channel
blocker and HCTZ were held, and ACEI and metoprolol were
uptitrated as tolerated as she was weaned off pressors.
.
#Leukocytosis: The patient's WBC count rose transiently after
extubation, with no evidence of new pneumonia. Blood, urine,
and catheter tip cultures were negative. The leukocytosis was
thought to be secondary to an inflammatory reaction to traumatic
extubation. It resolved without intervention.
.
#Anemia: Hematocrit hovered between 26 and 30. Iron studies
were normal. Stool guaiac was initially positive and later
negative. Given the stability of the finding, further workup
including age appropriate cancer screening was deferred for
outpatient management.
.
#Acute Renal Failure: Creatinine 0.8 on admission rose to 1.3
in the setting of STEMI and sepsis. Lisinopril was held
initially and restarted when creatinine stabilized at 1.2-1.3.
.
#Hypothyroidism: TSH was normal; outpatient dose of
levothyroxine was continued.
.
#Supraventricular Tachycardia: Patient had a single asymptomatic
run of SVT with rate in 190's. No ischemic changes on EKG,
electrolytes normal. Beta blockade was increased.
.
#Diabetes: Metformin was held given acute worsening of renal
function. Fingersticks were mostly in the 120-140 range, with
few sliding scale doses required.
Medications on Admission:
Synthroid 88mcg daily
HCTZ 25mg daily
Metoprolol 25mg [**Hospital1 **]
Lipitor 20mg daily
Diovan 160mg daily
Cosopt 2%-0.5% eye gtt
Metformin 1g daily
Nifedipine
ASA 81mg daily
Calcium
Miralax prn
Colace [**Hospital1 **]
Reglan 10mg PO tid
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day:
Please give in addition to 200 mg tablet.
12. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical TID (3 times a day).
13. Calcium Citrate With D 250-100 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
primary: hyponatremia, seizure, pneumonia
secondary: diabetes, hypertension, hypothyroidism,
hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you were nauseas and
vomitting. You were found to have a very low sodium level in
your blood. You had a seizure and a heart attack, probably
because of the low sodium. You went to the intensive care unit
and had a tube in your throat to help you breathe. You
recovered well. Several medications have been changed.
Medications that were changed:
Atorvastatin was increased to 80 mg daily
Aspirin was increased to 325 mg daily
Metoprolol was increased to metoprolol SR 250 mg daily
Medications that were started in the hospital:
Plavix (clopidogrel) 75 mg daily
Lisinopril 5 mg daily
Trazodone 25 mg before bed
Bacitracin ointment for your lip
Medications that were stopped:
Hydrochlorothiazide was stopped
Diovan (valsartan) was stopped
Metformin was stopped
Nifedipine was stopped
Reglan was stopped
Please do not take hydrochlorothiazide, valsartan, metformin, or
nifedipine.
The doctors did not determine for certain the cause of your low
sodium. You should follow up with your primary care doctor who
may want to do other tests to find out the cause.
Because you had a heart attack, please follow up with the
cardiologist Dr. [**Last Name (STitle) 171**] as below. He may recommend that you
have a cardiac catheterization to diagnose and treat the
blockage in your arteries that caused the heart attack.
Please return to the emergency deparment if you have chest pain
or shortness of breath. In addition, seek medical advice if you
experience high fevers and chills, intractable nausea and
vomitting, or other symptoms that are worrisome to you.
Followup Instructions:
Primary Care: Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 79361**]. [**2134-8-18**] pm
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**2130-9-20**] 11:20
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2130-8-16**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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11725, 11811
|
5746, 10182
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324, 330
|
11964, 11973
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4838, 5723
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4063, 4325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,098
| 166,746
|
24244
|
Discharge summary
|
report
|
Admission Date: [**2112-3-19**] Discharge Date: [**2112-3-27**]
Date of Birth: [**2039-11-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Cefazolin / [**Doctor Last Name 3646**] Flavor / Nut Flavor /
Grape / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
transferred from VA for interventional pulmonary procedure
Major Surgical or Invasive Procedure:
Bronchoscopy with excision/APC of tumor in LLL
History of Present Illness:
THis is a 72yo M with history of inoperable bladder cancer and
right ureteral tumow s/p stent placement, ischemic
cardiomyopathy with EF 25% s/p 2 IMI(last [**2100**]), s/p CABG in
[**2100**] and ICD placement, diabetes with triopathy who presented to
VA with hemoptysis and acute renal failure.
HIs renal failure resolved with hydration and his creatinine was
back to basline at 2-2.4.
He was intially treated with zithromax for possible bronchitis.
ENT was unremarkable. CT revealed LLL mass for which he had a
bronchoscopy on [**3-18**] which showed a large exophytic mass
engulfed in clot(old, no active bleed) at LLL bronchus at the
level of secondary carina. Brush and endobronchial biopsy was
performed. The mass was friable. ON that evening, he became
hypoxic(low 80s on 4L) and tachypneic with unchanged EKG. CXR
showed pulmonary edema with no collapse/PTX. He was treated with
lasix with good outcome. HE again desatted to low 802 on 4L. ABG
showed 7.41/30/68 on 100%NRB. Portable chest X ray showed LLL
collapse.
Past Medical History:
Bladder CA, s/p TURP, s/p BCG, XRT, ureteral stent placed in
[**8-22**] (stents changed Q 3 months)
CRI, baseline Cr 2.1-2.6
CAD s/p MI, s/p CABG [**2100**]
ischemic CHF, EF 25-30%
h/o VT, s/p AICD [**2107**]
DM-2
hypercholesterolemia
anxiety d/o
GERD
hypertension
Social History:
smokes 4 ppd for 40 years, denies alcohol
has never been married, has no kids, no family member
veteran at Korean war
Family History:
noncontributory
Physical Exam:
BP 102/79 P87 98% on NRB
Gen-anxious looking elderly gentleman
HEENT-anicteric, mucous membrane dry, neck supple, no
cervical/axillary lymphadenopathy, JVP 9cm
CV-rrr, no r/m/g, faint heart sounds
resp-poor air entry bilaterlly, crackles at right base,
?bronchial breath sounds on left base
[**Last Name (un) 103**]-NT/ND, soft, active BS
ext-no edema, DP 1+ b/l
Pertinent Results:
see OSH for detailed CT chest report:
large mass posterior to the left mainstem bronchus, c/w with
lung carcinoma metastatic to hilar lymph nodes
[**2112-3-19**] 07:28PM BLOOD WBC-11.0 RBC-3.79* Hgb-10.0* Hct-31.0*
MCV-82 MCH-26.4* MCHC-32.3 RDW-14.9 Plt Ct-228
[**2112-3-20**] 05:10AM BLOOD WBC-8.9 RBC-3.74* Hgb-10.0* Hct-30.8*
MCV-82 MCH-26.7* MCHC-32.4 RDW-15.0 Plt Ct-205
[**2112-3-21**] 06:11AM BLOOD WBC-12.5* RBC-4.04* Hgb-10.5* Hct-33.4*
MCV-83 MCH-25.9* MCHC-31.4 RDW-14.6 Plt Ct-227
[**2112-3-22**] 04:00AM BLOOD WBC-12.0* RBC-3.48* Hgb-9.1* Hct-28.9*
MCV-83 MCH-26.2* MCHC-31.5 RDW-14.6 Plt Ct-163
[**2112-3-23**] 04:40AM BLOOD WBC-8.9 RBC-3.58* Hgb-9.3* Hct-29.9*
MCV-83 MCH-26.1* MCHC-31.3 RDW-14.8 Plt Ct-166
[**2112-3-24**] 04:14AM BLOOD WBC-7.6 RBC-3.62* Hgb-9.5* Hct-30.2*
MCV-83 MCH-26.4* MCHC-31.7 RDW-14.9 Plt Ct-160
[**2112-3-20**] 05:10AM BLOOD PT-14.6* PTT-43.0* INR(PT)-1.4
[**2112-3-21**] 06:11AM BLOOD PT-14.2* PTT-62.3* INR(PT)-1.3
[**2112-3-21**] 12:10PM BLOOD PT-14.2* PTT-70.4* INR(PT)-1.3
[**2112-3-22**] 04:00AM BLOOD PT-14.2* PTT-99.7* INR(PT)-1.3
[**2112-3-23**] 04:40AM BLOOD PT-13.6* PTT-71.6* INR(PT)-1.2
[**2112-3-24**] 08:26AM BLOOD PT-13.2 PTT-41.5* INR(PT)-1.2
[**2112-3-22**] 01:20PM BLOOD Thrombn-65.0*
[**2112-3-19**] 07:28PM BLOOD Glucose-115* UreaN-27* Creat-2.4* Na-145
K-4.3 Cl-115* HCO3-19* AnGap-15
[**2112-3-20**] 05:10AM BLOOD Glucose-103 UreaN-33* Creat-2.9* Na-143
K-4.0 Cl-113* HCO3-21* AnGap-13
[**2112-3-21**] 06:11AM BLOOD Glucose-198* UreaN-41* Creat-3.3* Na-144
K-4.5 Cl-113* HCO3-19* AnGap-17
[**2112-3-22**] 04:00AM BLOOD Glucose-129* UreaN-47* Creat-3.2* Na-144
K-4.6 Cl-119* HCO3-17* AnGap-13
[**2112-3-23**] 04:40AM BLOOD Glucose-111* UreaN-49* Creat-3.3* Na-146*
K-4.6 Cl-118* HCO3-17* AnGap-16
[**2112-3-24**] 04:14AM BLOOD Glucose-126* UreaN-46* Creat-2.8* Na-155*
K-4.0 Cl-122* HCO3-21* AnGap-16
[**2112-3-20**] 05:10AM BLOOD CK(CPK)-269*
[**2112-3-21**] 01:15AM BLOOD CK(CPK)-406*
[**2112-3-21**] 06:11AM BLOOD CK(CPK)-485*
[**2112-3-20**] 05:10AM BLOOD CK-MB-3 cTropnT-0.03*
[**2112-3-21**] 01:15AM BLOOD CK-MB-3 cTropnT-0.03*
[**2112-3-21**] 06:11AM BLOOD CK-MB-3 cTropnT-0.03*
[**2112-3-21**] 01:15AM BLOOD Albumin-3.0*
[**2112-3-21**] 01:15AM BLOOD Cortsol-19.0
[**2112-3-21**] 02:20AM BLOOD Cortsol-41.6*
[**2112-3-20**] 09:29PM BLOOD Type-ART pO2-49* pCO2-33* pH-7.39
calHCO3-21 Base XS--3
[**2112-3-20**] 10:30PM BLOOD Type-ART Temp-38.7 FiO2-100 O2 Flow-15
pO2-91 pCO2-41 pH-7.32* calHCO3-22 Base XS--4 AADO2-591 REQ
O2-96 Intubat-NOT INTUBA
[**2112-3-21**] 01:37AM BLOOD Type-ART Temp-38.1 O2 Flow-15 pO2-83*
pCO2-44 pH-7.29* calHCO3-22 Base XS--4 Intubat-NOT INTUBA
Comment-NON-REBREA
[**2112-3-21**] 12:15PM BLOOD Type-ART Temp-37.2 FiO2-70 pO2-84*
pCO2-48* pH-7.24* calHCO3-22 Base XS--6 Intubat-NOT INTUBA
[**2112-3-21**] 01:49PM BLOOD Type-ART Temp-37.2 FiO2-50 pO2-72*
pCO2-40 pH-7.28* calHCO3-20* Base XS--7 Intubat-INTUBATED
[**2112-3-21**] 04:15PM BLOOD Type-ART Temp-36.7 FiO2-50 pO2-85 pCO2-40
pH-7.29* calHCO3-20* Base XS--6 Intubat-NOT INTUBA
[**2112-3-22**] 08:17AM BLOOD Type-ART Temp-38.1 FiO2-100 O2 Flow-15
pO2-128* pCO2-42 pH-7.24* calHCO3-19* Base XS--8 AADO2-558 REQ
O2-90 Comment-NON-REBREA
[**2112-3-22**] 06:01PM BLOOD Type-ART Temp-37.1 FiO2-40 O2 Flow-10
pO2-86 pCO2-38 pH-7.30* calHCO3-19* Base XS--6 Intubat-NOT
INTUBA Comment-NEBULIZER
[**2112-3-23**] 04:54AM BLOOD Type-ART Temp-37.0 FiO2-40 pO2-85 pCO2-38
pH-7.29* calHCO3-19* Base XS--7 Intubat-NOT INTUBA
Comment-NEBULIZER
[**2112-3-23**] 03:07PM BLOOD Type-ART Temp-35.6 Rates-/27 FiO2-50
pO2-75* pCO2-42 pH-7.28* calHCO3-21 Base XS--6 Intubat-NOT
INTUBA
[**2112-3-23**] 11:21PM BLOOD Type-ART Temp-37.0 pO2-88 pCO2-41
pH-7.34* calHCO3-23 Base XS--3
[**2112-3-24**] 04:35AM BLOOD Type-ART Temp-36.2 pO2-61* pCO2-42
pH-7.33* calHCO3-23 Base XS--3
[**2112-3-20**] 09:29PM BLOOD Lactate-1.5
CXR [**3-19**]: The radiograph is markedly suboptimal in technique and
motion of the patient.
The heart is enlarged. There is consolidation of the left lower
lobe with mass in the left hilar area. There is probably a small
bilateral pleural effusion.
The patient has prior CABG and median sternotomy. Combined AICD
and pacemaker leads probably terminate in the right atrium and
right ventricle, which is obscured by the motion.
CXR [**3-20**]: Limited chest x-ray demonstrating cardiac enlargement
and findings suggestive of congestive heart failure. It is
difficult to fully exclude underlying pneumonia.
In this patient with history of lung mass, there is a
questionable opacity at the right apex for which standard PA and
lateral chest radiographs are suggested as well as comparison to
the patient's outside films.
CXR [**3-21**]: Interval placement of right IJ central venous catheter
in satisfactory position with no pneumothorax seen on this
supine radiograph. Persistent CHF and left lower lobe
consolidation/collapse.
ECG: Sinus rhythm, Right bundle branch block, Prior
inferolateral myocardial infarct
PATHOLOGY:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Last Name (LF) 61524**],[**Known firstname **] [**2039-11-7**] 72 Male [**Numeric Identifier 61525**] [**Numeric Identifier 61526**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 42491**]/mtd
SPECIMEN SUBMITTED: ENDOBRONCHIAL BX, LEFT MAINSTEM TUMOR,
ENDOBRONCHIAL BX F/S.
Procedure date Tissue received Report Date Diagnosed
by
[**2112-3-23**] [**2112-3-23**] [**2112-3-24**] DR. [**Last Name (STitle) **]. FU/cma??????
DIAGNOSIS:
1. Endobronchial biopsy (A):
Predominantly necrotic tissue with rare atypical cells.
2. Left mainstem tumor (B-D):
Poorly-differentiated non-small cell carcinoma, favor
adenocarcinoma, with extensive necrosis.
Clinical: Airway obstruction; endobronchial biopsy and left
mediastinum tumor.
Gross: The specimen consists of three tissue fragments
measuring up to 1.0 cm in greatest dimension. The entire
specimen is frozen. Frozen section diagnosis made by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as: "Endobronchial biopsy; extensive necrotic
tissue; few atypical cells, suspicious for malignancy.
Respiratory type epithelium with mild atypia". The frozen
section remnant is submitted in cassette A.
Part 2 of the specimen is additionally labeled as "left main
stem tumor" and consists of multiple fragments of hemorrhagic
shiny tissue that measure in aggregate 4 cm x 3.6 cm x 0.5 cm.
It is entirely submitted in cassettes B-D.
BRONCH:
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on [**Doctor First Name **] [**2112-3-24**]
11:09 AM
Name: [**Last Name (LF) **], [**Known firstname **]
Unit No: [**Numeric Identifier 61526**]
Service: MED
Date: [**2112-3-23**]
Date of Birth: [**2039-11-7**]
Sex: M
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
PROCEDURE:
1. Rigid bronchoscopy.
2. Flexible bronchoscopy.
3. Tumor excision, left lower lobe.
4. Tumor destruction and Argon plasma coagulation.
ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD
PREOPERATIVE DIAGNOSIS: Left mainstem tumor.
POSTOPERATIVE DIAGNOSIS: Tumor eminating from the basilar left
lower lobe.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from
the patient. Indications and possible complications to the
procedure were explained to the patient, after which he was
brought to the operative theater number 12. General
anesthesia was instituted. Once an adequate level of
anesthesia was reached, the patient was intubated easily with
a bronchoscope 12-13mm and thorough examination of the
tracheobronchial tree was done flexibly.
FINDINGS:
The vocal cords were normal in structure. The trachea was
patent.
The carina was splayed, suggestive subcarinal lymphadenopathy.
The right mainstem, right upper lobe, bronchus intermedius and
lower lobes are patent. The left main stem proximally is patent,
but there was 85% distal obstruction from a tumor eminating from
the lower lobe. The lower lobe was completely obstructed, and
the left upper lobe is patent.
The rigid scope was advanced into the left mainstem and under
direct vision, using the rigid forceps, biopsy and tumor
excision
was done. At that moment, the left lower lobe was opened and
there was evidence of tumor emanating mostly from the
basilar segments. Tumor destruction was also done with Argon
plasma coagulation and hemostasis was accomplished. The
superior segment of the left lower lobe was patent.
BLOOD LOSS: Approximately 150 ml.
The patient was extubated and he was transferred to the
Medical ICU. Note that a frozen section pathology was done on
the
slides which showed necrotic tissue, highly suggestive of
carcinoma. Final pathology is pending.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]
Brief Hospital Course:
1. Hypoxia: The pt was felt to be hypoxic secondary to a
post-obstructive pneumonia (LLL consolidation on CXR),
superimposed on lungs damaged by COPD. He did not appear to be
in CHF and actually appeared volume depleted on exam. He was
weaned from a non-rebreather to a 40% face tent. His baseline
O2 sat is probably in the high 80s-low 90s, and so his oxygen
was titrated to that. He underwent a bronchoscopy which
revealed a LLL tumor completely obstructing his bronchus. They
excised the tumor and destroyed it with APC, wiht resultant
patent airways (did not require a stent.) After the procedure
he was extubated in the OR without complication. He
intermittently became hypoxic to the 70s-low 80s, which was felt
to be due to his pneumonia and COPD. He was treated with
levofloxacin and metronidazole for his post-obstructive
pneumonia, for a total 14 day course (last day will be [**2112-4-1**].)
He was continued on atrovent and albuterol nebulizers as well
as a salmeterol inhaler. He has been stable on 6 L NC and
occasoianally deasturates and needs a NRB facemask.
2. Hypotension: He became hypotensive and febrile a day after
admission, and was transferred to the MICU. He was fluid
resuscitated, vancomycin was added to the levofloxacin and
metronidazole, and begun on dopamine. He was weaned off the
dopamine on [**3-22**]. His [**Last Name (un) 104**]-stim test was appropriate (19-->41).
His blood cultures were negative to date, and a urine culture
was negative. By the day of transfer back to the VA, he was
actually hypertensive in the 140s-150s, and was restarted on his
home regimen of Atenolol. He was not given an ACE due to his
renal failure. He continued to require IV fluid boluses for a
low CVP (1-5 range).
3. Hx of ischemic cardiomyopathy: His ACE was held due to renal
failure. He was restarted on his atenolol once his bp
stabilized. He was continued on his atorvastatin. He had no
signs of failure on his exam here, although one night his sats
acute dropped to the low 80s and he was given Lasix. He put out
3 liters, and the next morning appeared volume depleted (with Na
155), and so he likely is not in failure.
4. bladder cancer: the foley was kept in throughout his
admission.
5. Acute on chronic renal failure: His baseline is 2.1-2.6, but
peaked at 3.3. He was down to 2.8 by discharge. This was felt
to be due to prerenal physiology.
6. Anemia: He was anemic in the low 30s throughout his stay,
and dropped to a low of 28. Given his CAD, he was transfused
one unit, but responded only to 29. The next day, he had an
episode of melena/dark red blood per rectum. His hematocrit was
checked and was stable. He needs a GI workup once he is back at
the VA. He remained hemodynamically stable throughout.
7. Endocrine: He was kept on an insulin sliding scale.
8. Electrolytes: He developed hypernatremia to 155 after he was
given Lasix and put out 3 liters in a day. This resolved with
free water boluses.
9. Mental status: This appeared to wax and wane. He would
intermittently become confused (knew he was in a hospital,
didn't know the city). It was likely due to ICU delirium vs.
hypernatremia. On discharge, he was still delerious.
10. Nutrition: The patient needs to be on a pureed diet. He
mainly ate isce cream during this admission. He needs a
nutrition consult once transferred and may need a PEG at some
point depending on his goals of care.
11. Code status: This was discussed repeatedly on this
admission. The patient was never very articulate about his goals
of care. He understands that her has a terminal illness and at
times said he did not want to be intubated or rescusiated.
However, he then said he wanted to "go for broke." Therefore he
was full code here, but this needs and a health care proxy needs
to be addressed by his oncologist or PCP.
Medications on Admission:
Atenolol 50 daily
Captopril 25 tid
Lovastatin 20 mg daily
Nitro sublingual prn
Lasix 40 mg daily
Omeprazole 20 mg daily
Oxybutynin 5 mg daily
Buspiron 10 mg tid
Ferrous gluconate 325 mg daily
Codeine prn
Gatifloxacin 200 mg daily
Ipratropi8um 2 puffs tid
Guaifenesin prn
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
2. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours).
7. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q4H (every 4 hours).
12. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) puff Inhalation Q12H (every 12 hours).
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: last dose [**2112-4-1**].
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 7 days: last dose [**2112-4-1**]. Tablet(s)
15. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
19. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
21. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed.
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding scale insulin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
Lung CA
Pneumonia
Ischemic cardiomyopathy
Acute Renal Failure
Discharge Condition:
stable, O2 saturations in low 90s with 40% face tent
Discharge Instructions:
Call your doctor or come back to the emergency room if you
experience dizziness, palpitations, coughing up blood, shortness
of breath, chest pain, nausea/vomiting, diarrhea, abdominal
pain, decreased urine output, or any other concerns.
Followup Instructions:
Follow up per the instructions of your doctor at the VA.
|
[
"V45.81",
"496",
"584.9",
"507.0",
"276.0",
"V45.02",
"V58.67",
"403.91",
"196.1",
"428.0",
"578.1",
"518.82",
"250.40",
"188.8",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"00.17",
"32.28"
] |
icd9pcs
|
[
[
[]
]
] |
17680, 17728
|
11477, 14460
|
433, 482
|
17834, 17888
|
2389, 11454
|
18173, 18233
|
1974, 1991
|
15645, 17657
|
17749, 17813
|
15350, 15622
|
17912, 18150
|
2006, 2370
|
335, 395
|
510, 1535
|
14476, 15324
|
1557, 1823
|
1839, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,168
| 125,341
|
33399
|
Discharge summary
|
report
|
Admission Date: [**2148-3-14**] Discharge Date: [**2148-3-21**]
Date of Birth: [**2068-2-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**3-17**]
History of Present Illness:
80 year old female with hypertension who presented to OSH with 5
hours of chest and abdominal discomfort. She also had nausea and
vomit and questionable diarrhea. This persisted for 5 hours and
then when the family was guiding her to the bathroom, she
syncopized and her family called 911.
.
At OSH, she had ongoing chest heaviness and shortness of breath.
Serial EKGs showed possible ST elevations with evolving changes
and her cardiac markers are trending up. She was transferred to
[**Hospital1 18**] CCU for further care. She was put on a nitro gtt because
she was hypertensive to SBP 200's and morphine was given for her
ongoing chest discomfort. She was given lasix at OSH for
pulmonary congestion.
.
Unable to do review of systems because patient is somnelent and
minimally arousable from the morphine boluses.
Past Medical History:
Hypertension
Chronic renal insufficiency, baseline cr 2.5
Anemia
Recent "Myoview echo" that was reportedly negative for ischemia
and with LVH and normal systolic function
.
Cardiac Risk Factors: Hypertension
.
Cardiac History: No MI's, no CABG, no caths
Social History:
From [**Country 10181**], speaks mainly Korean, very limited English. Lives
with son. Widowed.
[**Name2 (NI) **] tobacco or alcohol history.
Family History:
Unknown.
Physical Exam:
VS: 96.8, 130/73, 75, 10, 98%2LNC
GEN: Somnelent and diffucult to arouse. Will open eyes to voice
briefly and will squeeze hands to command but falls asleep
quickly.
HEENT: OP clear, MMM
NECK: JVP about 10cm
CV: RRR, II/VI SEM at LUSB, no rubs, gallops
PULM: CTAB, no W/R/R
ABD: Soft, NT, ND, +BS
EXT: No pedal edema
PULSES: 1+PT and DP pulses bilaterally
Pertinent Results:
Coronary catheterization report: "The initial angiography
revealed a heavily calcified 90% long mid LAD lesion."
.
"Successful stenting of the mid LAD with a 2.5 X 24 mm Endeavor
DES
with less than 20% residual stenosis (see PTCA comments for
detail).
Abdominal aorta and ilaic angiography revealed distal aortic
stenosis
with a pseudoaneurysm and bilateral iliac calcified disease
(mild on the
right and severe at the bifurcation of the external and internal
iliac
on the left)."
.
[**2148-3-14**] 02:15AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.9* Hct-28.0*
MCV-86 MCH-30.2 MCHC-35.3* RDW-14.4 Plt Ct-281
[**2148-3-20**] 07:00AM BLOOD WBC-5.7 RBC-3.09* Hgb-9.2* Hct-26.2*
MCV-85 MCH-29.9 MCHC-35.3* RDW-14.0 Plt Ct-280
[**2148-3-14**] 02:15AM BLOOD Glucose-136* UreaN-40* Creat-3.4* Na-138
K-4.6 Cl-103 HCO3-22 AnGap-18
[**2148-3-15**] 05:54AM BLOOD Glucose-98 UreaN-47* Creat-3.8* Na-139
K-4.3 Cl-104 HCO3-24 AnGap-15
[**2148-3-20**] 07:00AM BLOOD Glucose-99 UreaN-35* Creat-2.9* Na-142
K-4.3 Cl-108 HCO3-23 AnGap-15
[**2148-3-14**] 02:15AM BLOOD ALT-54* AST-109* LD(LDH)-414*
CK(CPK)-375* AlkPhos-94 Amylase-78 TotBili-0.3
[**2148-3-14**] 02:15AM BLOOD CK-MB-25* MB Indx-6.7* cTropnT-3.39*
[**2148-3-15**] 05:54AM BLOOD CK-MB-8 cTropnT-1.74*
[**2148-3-14**] 02:15AM BLOOD Albumin-3.8 Calcium-9.0 Phos-5.5* Mg-1.7
[**2148-3-20**] 07:00AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
[**2148-3-16**] 06:24AM BLOOD calTIBC-207* VitB12-385 Folate-13.6
Ferritn-181* TRF-159*
[**2148-3-16**] 06:24AM BLOOD PTH-63
[**2148-3-16**] 06:24AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2148-3-16**] 06:24AM BLOOD HCV Ab-NEGATIVE
[**2148-3-15**] 03:33PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2148-3-15**] 03:33PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2148-3-15**] 03:33PM URINE RBC-1 WBC-6* Bacteri-NONE Yeast-NONE
Epi-1
[**2148-3-16**] 10:38AM URINE Hours-RANDOM Creat-110 TotProt-136
Prot/Cr-1.2*
[**2148-3-15**] 07:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2148-3-15**] 07:30AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2148-3-15**] 07:30AM URINE RBC-0-2 WBC-[**5-7**]* Bacteri-RARE Yeast-NONE
Epi-0-2 TransE-0-2
[**2148-3-15**] 07:30AM URINE Hours-RANDOM Creat-113 Na-44
[**2148-3-15**] 03:33PM URINE Osmolal-274
.
[**2148-3-21**] 07:10AM Hct 25.9* MCV 86 Plt Ct 298
[**2148-3-21**] Creatinine 3.0* mg/dL
.
Echo:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
.
RENAL U.S. PORT [**2148-3-15**] 11:45 AM
FINDINGS: The right kidney is atrophic measuring only 6.2 cm.
The left kidney measures 9.9 cm. Both kidneys demonstrate no
hydronephrosis or cysts or solid masses. Both kidneys have an
overall echogenic appearance consistent with chronic renal
disease.
IMPRESSION: Atrophic right kidney and small left kidney with an
appearance suggestive of diffuse chronic parenchymal disease. No
hydronephrosis.
.
ART DUP EXT LO UNI;F/U [**2148-3-18**] 9:30 AM
FINDINGS: Duplex and color Doppler of the right inguinal area
demonstrate no evidence of a pseudoaneurysm, AV fistula, or
hematoma.
.
Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary artery disease. The LMCA was
normal.
The LAD had a long 90% lesion after D1. The LCx had mild
disease. The
RCA had diffuse mild disease with a 50% mid lesion in the PL
branch.
2. Limited resting hemodynamic measurement revealed an elevated
systemic
arterial pressure of 168/71 mmHg.
3. Successful stenting of the mid LAD with a 2.5 X 24 mm
Endeavor DES
with less than 20% residual stenosis (see PTCA comments for
detail).
4. Abdominal aorta and ilaic angiography revealed distal aortic
stenosis
with a pseudoaneurysm and bilateral iliac calcified disease
(mild on the
right and severe at the bifurcation of the external and internal
iliac
on the left).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful stenting of the LAD with endeavor DES.
3. Aortoiliac disease and aortic pseudoaneurysm that may require
further
imaging and if indicated, endovascular management.
.
ABDOMEN U.S. (COMPLETE STUDY) [**2148-3-21**] 10:29 AM
FINDINGS: Evaluation of the liver reveals a questionable
perihepatic lesion measuring 3.6 x 2.4 cm. It is questionable
whether this is distinct from the liver. Differential
considerations do include an adrenal lesion. Therefore, CT scan
is recommended for further characterization.
Evaluation of the aorta reveals moderate diffuse atherosclerotic
calcification. However, the patient's suspected pseudoaneurysm
is not definitively identified. Therefore, this area may also be
further evaluated by CT scan. The spleen measures 8.2 cm and
appears grossly unremarkable. The left kidney measures 9.6 cm.
The right kidney measures 8.6 cm. The kidneys are grossly
unremarkable. The visualized portions of the pancreas are
grossly unremarkable.
IMPRESSION:
1. Pseudoaneurysm, not definitively identified. CT scan is
recommended for further evaluation.
2. Questionable perihepatic mass as noted adjacent to the
posterior aspect of the right lobe of the liver medially. Again,
this may be evaluated by CT scan.
.
CHEST (PORTABLE AP) [**2148-3-14**] 2:24 AM
The heart is moderately enlarged, accompanied by vascular
engorgement, perihilar haziness and bilateral interstitial
opacities attributed to pulmonary edema from congestive heart
failure. Small pleural effusions are present, left greater than
right.
.
ECHO [**2148-3-14**]:
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
.
ECG Study Date of [**2148-3-14**] 5:06:36 AM
Sinus rhythm. ST segment elevation in leads V1-V2 with T wave
inversions
in leads I, aVL and across the precordium. Consider ST segment
elevation
myocardial infarction in evolution. Q-T interval prolongation.
Clinical
correlation is suggested. No previous tracing available for
comparison.
TRACING #1
.
ECG Study Date of [**2148-3-14**] 9:18:36 AM
Sinus rhythm. Since the previous tracing no significant change.
TRACING #2
.
ECG Study Date of [**2148-3-15**] 8:42:26 AM
Sinus rhythm. Anterior and lateral ST-T wave changes - consider
myocardial
ischemia. Clinical correlation is suggested. Compared to the
previous tracing of [**2148-3-14**] findings are similar.
.
ECG Study Date of [**2148-3-16**] 4:19:20 PM
Sinus rhythm. Anterolateral ST-T wave abnormalities suggest
ischemia.
Clinical correlation is suggested. Since the previous tracing of
[**2148-3-15**]
precordial lead ST-T wave changes appear slightly less prominent
but may be no significant change.
TRACING #1
.
ECG Study Date of [**2148-3-17**] 8:21:12 AM
Findings are as outlined on previous tracing of [**2148-3-16**] with
precordial lead ST-T wave changes appearing slightly less
prominent.
TRACING #2
.
ECG Study Date of [**2148-3-17**] 9:17:04 AM
Findings are as outlined on previous tracing earlier the same
date and are
without significant change.
TRACING #3
.
ECG Study Date of [**2148-3-18**] 8:00:24 AM
Findings are as outlined on previous tracing of [**2148-3-17**] and are
without
significant change.
TRACING #4
.
ECG Study Date of [**2148-3-19**] 7:14:00 AM
Sinus rhythm. Diffuse non-specific ST-T wave changes. As
compared with
prior tracing of [**2148-3-18**] there is variation in precordial lead
placement.
However, the ischemic appearing ST-T wave changes in the
anterolateral leads recorded on [**2148-3-18**] have mostly abated
consistent with active ischemic process. Followup and clinical
correlation are suggested.
Brief Hospital Course:
This 80 year old Korean woman with a history of hypertension and
chronic kidney disease (baseline Cr 2.5) presented to an outside
hospital with epigastric discomfort and was found by EKG and
cardiac enzymes to have an MI and was transferred to [**Hospital1 18**] for
further care and cardiac catheterization. On presentation the
patient was hypertensive to SBP 200's and was started on a
nitroglycerin drip. The patient was maintained on aspirin and
heparin gtt and plavix loaded. Her EKG was concerning for
evidence of ST elevations in the LAD territory and appeared to
be consistent for [**Last Name (un) 46104**] Syndrome in the precordial leads.
Given the amount of myocardium at risk, the plan was to take her
to catheterization. Repro (abciximab) was started. Hindering
this was her kidney disease which had apparently worsened with
Cr up to the 3-3.8 range so initially, medical management was
pursued. Echo showed mild symmetric LVH, normal regional global
systolic function LVEF >55%.The patient remained hemodynamically
stable and did not complain of chest pain, except for a brief
episode on HD 3. On HD 4 however, the patient developed
worsening chest pain at rest and she was taken for urgent
catheterization that AM. Mucomyst and bicarbonate infusion were
given in an effort to protect her kidney function. After
catheterization, her kidney function continued to improve and
her creatinine improved, 3.0 upon discharge.
.
# CAD: On catheterization, a mid LAD 90% lesion was visualized
and successfully stented with a drug eluting stent. The
procedure was without complication. She will need aspirin and
plavix as managed by her cardiologist, Dr.[**Doctor Last Name 3733**]. She was
sent out on aspirin, plavix, bblocker, ace-i, statin.
.
# Hypertension: The patient persisted with hypertension, and
blood pressures ranging 160's/70's. She was placed on metoprolol
and titrated up to toprol XL 150mg daily. Amlodipine was added
and titrated up to 10mg daily. Lisinopril was initially held
given her acute renal failure, however after catheterization her
creatinine began to decrease back to her baseline. Lisinopril
was therefore added and titrated up to 20mg PO daily, then 40mg
PO daily to help control her blood pressure.
.
# Acute on Chronic Renal failure: baseline Cr is 2.5, presented
with 3.4, increased to 3.8. Upon discharge, it was 3.0 5 days
after catheterization. Continued creatinine above baseline of
2.5 possibly from cath dye load. She will need continued
monitoring as an outpatient and titration of her lisinopril prn.
Renal ultrasound showing atrophic kidneys as above. She has
follow-up with Dr. [**Last Name (STitle) 4090**], nephrology.
.
# Anemia: Iron studies revealed iron deficiency anemia in the
setting of anemia of chronic disease. The patient was
administered one dose of IV ferrlecit, and continued on oral
iron supplements. She was instructed to follow up with
nephrology, who plan to administer epogen once her blood
pressure is under better control.
.
# Distal aorta psuedoaneurysm and distal aortic stenosis:
Visualized on cardiac cath, recommended to receive further
imaging. Because of her renal failure, no CTA could be done, so
a U/S was completed which did not definitively show a
psuedoaneurysm. Further imaging with CT was recommended for the
psuedoaneurysm and stenosis, which we are recommending be done
as an outpatient.
.
# Rhythm: Sinus rhythm.
.
# Valves: Echo without valvular abnormality
.
# Questionable perihepatic mass: as noted on U/S adjacent to the
posterior aspect of the right lobe of the liver medially. Again,
this may be evaluated by CT scan and should be followed up as an
outpatient.
.
# Prophylaxis: heparin sc. bowel regimen.
.
# Code: full
.
# Communication: [**Name (NI) **] [**Name (NI) **] (HCP) [**Telephone/Fax (1) 77511**]
.
# The patient was administered a pneumococcal vaccine prior to
discharge.
Medications on Admission:
Lopressor
NTG prn
Lisinopril
Isosorbide
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*1 Tablet(s)* Refills:*12*
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
take up to three tablets, 5 minutes apart.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
NSTEMI
Hypertension
Acute Renal Failure
Discharge Condition:
Good. ambulating with assistance. tolerating PO, afebrile
Discharge Instructions:
You were admitted to the hospital with chest pain. You were
found to have had a heart attack. You received a stent to one of
your coronary arteries to restore blood flow to your heart.
.
Please take your medications as prescribed.
.
Please follow-up with your cardiologist and nephrologist as
below.
.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 77512**] as below. he will
need to schedule imaging to evaluate a pseudoaneurysm of your
aorta.
.
Please give results to staff physician, [**Name10 (NameIs) **] fax to Dr. [**Last Name (STitle) 4090**]
(fax:[**Telephone/Fax (1) 12142**] phone:[**Telephone/Fax (1) 435**]) and Dr. [**Last Name (STitle) **]
(fax:[**Telephone/Fax (1) 11259**] phone:[**Telephone/Fax (1) 10381**]).
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fever, or any other
concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 77513**]. [**2148-3-29**]
2:20pm
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2148-4-4**]
3:00
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 10381**] [**2148-4-9**]
10:30am
.
Please call if you need to reschedule.
|
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icd9cm
|
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,764
| 191,922
|
47230
|
Discharge summary
|
report
|
Admission Date: [**2104-4-25**] Discharge Date: [**2104-5-1**]
Date of Birth: [**2026-12-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
77F with hx CAD, DM, SLE/RA on prednisone, presented to ED with
N/V (no hematemesis) and bloody diarrhea (brbpr, no melena)
today. Crampy mid-abd pain, no fevers/travels. Mild nausea, no
vomiting. Hct 28 (base 33-34). HD stable. BRB on rectal exam in
ED. Pt received 3 units pRBCs in ED, Hct bumped to 32 after 2
units. Attempted placement of NGT for lavage unsuccessful,
unable to pass NGT X 3 attempts.
.
In ED, GI consulted: impression likely ischemic colitis in
setting decreased PO intake. Rec: IVF, PRBC to keep hct>30,
scope on Mon if stable. Keep hydrated.
.
Upon arrival to ICU, pt has mild low abdominal pain, crampy in
nature and still feels like she will have continued BMs. Denies
nausea, vomiting.
.
ROS: Pt denies CP, SOB, palpitations, orthop
Past Medical History:
* Fibular Fx and Tibial Fx s/p ORIF on [**2103-6-25**]. Fell on the
stairs, no LOC. Head CT neg.
* SLE - followed by Dr. [**Last Name (STitle) **] @ [**Hospital1 **]
* Insulin dependent diabetes - followed by Dr. [**Last Name (STitle) 713**] @ [**Last Name (un) **]
* HTN
* Hypercholesterolemia
* s/p MI in [**2077**]
* Rheumatoid arthritis
* Headaches
* Osteoporosis
* Cervical dysplasia
* Bell palsy
* Syphillis s/p penicillin Rx
Social History:
Currently undergoing rehab at [**Hospital 392**] Rehabilitation and
Nursing Center, [**Telephone/Fax (1) 92342**]. Daughter lives in the area. Former
book-keeper at a furniture store in [**Country **]. Moved from [**Country **]
in [**2069**].
Family History:
Mother - DM, CVA. Daughter - DM
Physical Exam:
PE: VS: T98.5 HR 77 BP 129/47 R 16 100% 2L
Gen: NAD
HEENT: EOMI, PERRL
Neck: supple, no LAD
Chest: CTAB
CV: RRR nl s1 s2 no mrg appreciated
Abd: soft, NT, ND +BS
Ext: no edema, no rash
Neuro: moves all 4, no focal deficits
Pertinent Results:
[**2104-4-25**] 01:20PM BLOOD WBC-9.8 RBC-3.03* Hgb-9.4* Hct-27.8*
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.5 Plt Ct-213
[**2104-4-26**] 05:38AM BLOOD WBC-15.6*# RBC-3.82*# Hgb-11.8* Hct-35.3*
MCV-92 MCH-30.8 MCHC-33.4 RDW-14.3 Plt Ct-136*
[**2104-5-1**] 05:40AM BLOOD WBC-8.7 RBC-3.76*# Hgb-11.9*# Hct-33.2*#
MCV-88 MCH-31.7 MCHC-35.9* RDW-16.7* Plt Ct-161
[**2104-4-25**] 01:20PM BLOOD Neuts-72.4* Lymphs-21.0 Monos-4.1 Eos-1.5
Baso-1.0
[**2104-4-26**] 05:38AM BLOOD Neuts-85.3* Bands-0 Lymphs-10.7*
Monos-3.5 Eos-0.3 Baso-0.1
[**2104-4-26**] 05:38AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2104-4-25**] 01:20PM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.1
[**2104-4-25**] 01:20PM BLOOD Plt Ct-213
[**2104-5-1**] 05:40AM BLOOD Plt Ct-161
[**2104-4-25**] 01:20PM BLOOD Glucose-195* UreaN-42* Creat-1.2* Na-139
K-5.5* Cl-106 HCO3-25 AnGap-14
[**2104-5-1**] 05:40AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-142
K-3.8 Cl-109* HCO3-23 AnGap-14
[**2104-4-27**] 04:47AM BLOOD LD(LDH)-172 TotBili-0.6
[**2104-4-26**] 05:38AM BLOOD Calcium-7.5* Phos-3.6 Mg-2.2
[**2104-5-1**] 05:40AM BLOOD Mg-1.8
[**2104-4-27**] 04:47AM BLOOD Hapto-49
[**2104-4-30**] 05:45AM BLOOD Phenyto-11.6
[**2104-4-27**] 11:41AM BLOOD Phenyto-10.6
[**2104-4-26**] 12:30AM BLOOD Phenyto-<0.6*
[**2104-4-25**] 05:34PM BLOOD Lactate-1.8
[**2104-4-25**] 01:39PM BLOOD Hgb-9.3* calcHCT-28
.
[**4-25**] EKG: Sinus rhythm with borderline left atrial abnormality
and 1st degree A-V block Consider left ventricular hypertrophy
Axis less leftward Since previous tracing, no significant change
.
CT 150CC NONIONIC CONTRAST [**2104-4-25**] 5:59 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval for infection
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with lupus on prednisone, here w/ n/v/ bloody
diarrhea
REASON FOR THIS EXAMINATION:
eval for infection
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Lupus on prednisone, here with bloody diarrhea.
COMPARISON: CTA chest, [**2103-7-26**].
TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and
pelvis with coronal and sagittal reformats was reviewed.
CT ABDOMEN WITH CONTRAST: Traction bronchiectasis and chronic
interstitial changes are unchanged from [**2103-7-26**]. The
liver enhances normally without focal lesions. The gallbladder,
pancreas, spleen, adrenals, and kidneys are normal. The small
bowel loops are normal caliber. There is no evidence for free
fluid, free air, focal fluid collections, or fat stranding in
the abdomen and pelvis. Small non-pathologically enlarged
mesenteric and retroperitoneal lymph nodes are present.
CT PELVIS WITH CONTRAST: The rectum is distended with air and
stool. The sigmoid, and remaining large bowel are unremarkable
without evidence for bowel wall thickening, fat stranding, or
fluid collections. The terminal ileum is normal appearing. The
appendix is likely identified and contains air. There is no free
fluid in the pelvis. The distal ureters and bladder appear
normal. Small inguinal lymph nodes are present.
BONE WINDOWS: The osseous structures are remarkable for
degenerative disease but no suspicious lytic or sclerotic
lesions are identified.
IMPRESSION:
1. No radiographic explanation for bloody diarrhea.
2. Chronic stable interstitial changes within visualized lung
bases.
.
CHEST (PORTABLE AP) [**2104-4-26**] 5:28 AM
CHEST (PORTABLE AP)
Reason: r/o PNA
[**Hospital 93**] MEDICAL CONDITION:
77F with hx CAD, DM, SLE/RA on prednisone, presented to ED with
N/V (no hematemesis) and bloody diarrhea
REASON FOR THIS EXAMINATION:
r/o PNA
AP CHEST [**4-26**], 5:52 A.M.
HISTORY: Coronary artery disease, diabetes, and lupus. On
prednisone. Nausea and vomiting.
IMPRESSION: PA and lateral chest compared to [**2103-7-14**]
read in conjunction with a CT of the torso on [**4-25**].
Heterogeneous opacification of the lung bases has an
interstitial quality which could be due to lupus lung disease,
alternatively scarring and mild edema. Heart is normal size.
There is no focal consolidation to suggest bacterial pneumonia
and no pleural effusion is present.
Brief Hospital Course:
MS. [**Known lastname 99188**] is a 77 year old lady with SLE, RA, HTN, DM admitted
with N/V, abd pain and LGIB who was admitted to the ICU from the
ED for workup of bright red blood per rectum (BRBPR). On initial
evaluation, an NG lavage was not possible secondary to
difficulty in NGT placement. The pt continued to have frequent,
grossly bloody bowel movements (approximately [**12-28**] BMs over 6
hours) when she arrived at the [**Hospital Unit Name 153**]. She was hydrated with
normal saline and was transfused 3U PRBC. Ms. [**Known lastname 99188**] had one
episode of vasovagal syncope, lasting approximately 10 seconds,
during one of the bowel movements. She subsequently remained
hemodynamically stable. GI was consulted and the pt underwent an
EGD which showed no source for the GI bleed. The pt was prepped
for c-scope for Monday. She was transfused to goal HCT > 28-30
(given h/o CAD), given a PPI [**Hospital1 **], and all her anti-hypertensives
were held. Patient was then transferred to the floor given she
was hemodynamically stable and no longer bleeding. Initially
colonoscopy was aborted due to poor preparation. She was
therefore re-prepped for repeat colonoscopy which showed
diverticulosis with segmental colitis. Source of bleeding likely
diverticular per the GI consultants. The pt was also noted to be
subtherapeutic on Dilantin (for seizure disorder). She was
loaded with Dilantin and started on a daily IV dilantin dose.
Subsequently, per the patient's daughter, she has been off
Dilantin for some time per her Neurologist. This was therefore
d/ced upon discharge. Her steroids for SLE/RA were continued.
Stress dose steroids were not given, given pt's stable hospital
course. Her hospital course by individual problem is summarized
below.
.
# LGIB: Likey diverticular based on findings of large
diverticula on c-scope.
Patient's Hct remained stable at >30 but eventually trending
down to 27 likely secondary to IVF hydration and phlebotomy. She
was transfused another two units of pRBCs given a history of CAD
(total 5 units). She was also treated with Protonix 40 mg IV BID
for gastritic/erosion on EGD. Upon discharge she no longer had
any blood per rectum, felt well, VSS.
.
# SLE/RA: Continued plaquenil and prednisone. Patient was
initially treated with IV solumedrol (since not taking POs) and
later discharged on her home regimen. No evidence of hemolysis
on labs given h/o SLE (remote history of hemolytic anemia).
.
# HTN: BP slightly elevated. Intially her antihypertensives were
held in the setting of GI bleeding, then restarted once
hemodynamically stable.
.
# Hyperlipidemia: continued Lipitor
.
# CAD: No CP. Hold ASA. EKG unchanged. Transfused to goal Hct
28-30.
# DM: QID FSBS, Hum ISS.
.
# Seizure D/O: No recent sz activity however subtherapeutic on
dilantin. s/p loading currently on IV. Apparently not taking
Dilantin anymore per daughter. Discharged on home regimen.
.
# FEN: Initially NPO, then advanced diet as tolerated.
Tolerating PO's on discharge. Monitored and replaced
electrolytes prn. IVF while NPO.
# PPx: Protonix, pneumoboots, PT eval-->cleared for d/c home.
.
# Access: 2 18g PIV
# Comm: Daughter [**Name2 (NI) 100011**] [**Telephone/Fax (1) 100012**] /work [**Telephone/Fax (1) 100013**]
Medications on Admission:
ASPIRIN E.C. 325 MG--One every day
COLACE 100 mg PO BID
ENALAPRIL 20 MG PO QAM
Enalapril 10 mg qPM
FOSAMAX 70MG PO qwk
HUMULIN N 100 unit/mL--30 units once a day
HYDROCHLOROTHIAZIDE 25MG--One every day
HYDROXYCHLOROQUINE 200 MG--One tablet twice a day
LIPITOR 10MG--One every day
NORVASC 2.5 mg--1 tablet(s) by mouth once a day
PHENYTOIN 50 mg--2 tablet(s) by mouth three times a day take 2
tabs by mouth 3 times per day
PREDNISONE 5MG--One tablet every day
PROTONIX 40MG--One by mouth every day
Trazodone 50 mg--1 tablet(s) by mouth hs
Tylenol-Codeine #3 300-30 mg--1 tablet(s) by mouth every six (6)
hours as needed for for pain every 4-6hrs as needed for pain
Discharge Medications:
1. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use to soften stools.
Disp:*60 Capsule(s)* Refills:*2*
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed units Subcutaneous once a day: take your NPH insulin as
directed by your primary care doctor.
9. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain.
10. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day: take every morning for your high blood pressure.
11. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO at
bedtime: take each night for additional blood pressure control
.
12. ASPIRIN
talk with your primary care doctor before starting your daily
aspirin again--want you to avoid taking it at this time
13. Norvasc
Talk with your doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] your medication
norvasc--your blood pressure in the hospital showed you may not
need it for a while
14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Lower gastrointestinal bleeding
diverticulosis
blood loss anemia
SLE
rheumatoid arthritis
hypertension
hyperlipidemia
coronary artery disease
diabetes type 2
seizure disorder
Discharge Condition:
good
Discharge Instructions:
Take all of your medications as directed. Please note the
medication list we are sending you home with, talk with your
primary care doctor if it differs with medications you have at
home. Do not take your aspirin or norvasc/amlodipine medication
anymore until your primary care doctor tells you to restart it.
Please call your doctor if you see any more blood in your stool
or if you have a fever, try not to strain with your bowel
movements, call your doctor and go to the emergency room if you
have a lot of bleeding or become lighthheaded.
Keep all of your doctor appointments as noted below.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2104-6-11**] 10:20
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2104-6-19**] 1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2104-7-15**] 10:40
Completed by:[**2104-5-6**]
|
[
"733.00",
"401.9",
"412",
"710.0",
"780.39",
"272.0",
"515",
"V58.67",
"714.0",
"562.12",
"250.00",
"285.1",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.24",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11937, 11986
|
6301, 9560
|
318, 331
|
12205, 12212
|
2145, 3882
|
12858, 13342
|
1853, 1886
|
10275, 11914
|
5614, 5719
|
12007, 12184
|
9586, 10252
|
12236, 12835
|
1901, 2126
|
275, 280
|
5748, 6278
|
359, 1120
|
1142, 1576
|
1592, 1837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,231
| 178,554
|
31831
|
Discharge summary
|
report
|
Admission Date: [**2119-10-30**] Discharge Date: [**2119-11-3**]
Date of Birth: [**2050-6-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
[**10-30**] Coronary Artery Bypass Graft x3 (Left Internal Mammary
Artery > Left Anterior Descending Artery, Saphenous Vein Graft >
Obtuse Marginal 1, Saphenous Vein Graft > Obtuse Marginal 2)
History of Present Illness:
69 yo M with exertional chest pain that had positive stress test
and 3 vessel coronary artery disease per cardiac catherization.
Referred for surgical revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Anxiety
Kidney stones
Coronary Artery Disease
Tonsillectomy
Social History:
retired
lives alone
denies tobacco
denies etoh
Family History:
NC
Physical Exam:
NAD 77 16 165/91
Neck supple without carotid bruits
Lungs CTAB
Heart RRR, No M.R.G
Abdomen Soft/NT/ND, +BS
Extrem warm, no edema, no varicosities
Pertinent Results:
[**2119-11-3**] 07:25AM BLOOD WBC-7.8 RBC-3.47* Hgb-11.0* Hct-32.7*
MCV-94 MCH-31.8 MCHC-33.7 RDW-13.3 Plt Ct-198
[**2119-10-30**] 10:54AM BLOOD WBC-12.6*# RBC-3.19*# Hgb-10.0*#
Hct-29.9* MCV-94 MCH-31.3 MCHC-33.3 RDW-13.1 Plt Ct-213
[**2119-11-3**] 07:25AM BLOOD Plt Ct-198
[**2119-10-30**] 10:54AM BLOOD Plt Ct-213
[**2119-10-30**] 12:28PM BLOOD PT-13.6* PTT-45.2* INR(PT)-1.2*
[**2119-11-3**] 07:25AM BLOOD Glucose-108* UreaN-20 Creat-0.9 Na-138
K-4.1 Cl-102 HCO3-29 AnGap-11
[**2119-10-31**] 02:07AM BLOOD Glucose-134* UreaN-12 Creat-0.8 Na-133
K-5.3* Cl-104 HCO3-25 AnGap-9
[**2119-11-2**] 07:30AM BLOOD Mg-2.1
[**2119-10-31**] 02:07AM BLOOD Mg-2.9*
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2119-11-1**] 8:13 AM
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with CABG and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
HISTORY: CABG with chest tube removal, to assess for
pneumothorax.
FINDINGS: In comparison with study of [**10-30**], the left chest tube
has been removed. No evidence of pneumothorax. The patient has
taken a much poorer inspiration. There are bibasilar atelectatic
changes, more marked on the left.
DR. [**Known firstname 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: WED [**2119-11-1**] 11:11 AM
Cardiology Report ECG Study Date of [**2119-10-30**] 3:45:12 PM
Baseline artifact. Sinus rhythm at a rate of about 60 beats per
minute.
Borderline low voltage diffusely. Slight ST segment elevations
consistent
with early repolarization variant. Compared to previous tracing
of [**2119-10-20**]
no diagnostic change.
Read by: [**Last Name (LF) 22387**],[**First Name3 (LF) **] L.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 152 90 378/379 48 24 32
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 74674**], [**Known firstname 1569**] [**Hospital1 18**] [**Numeric Identifier 74675**] (Complete)
Done [**2119-10-30**] at 8:40:05 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2050-6-23**]
Age (years): 69 M Hgt (in): 64
BP (mm Hg): 123/74 Wgt (lb): 148
HR (bpm): 55 BSA (m2): 1.72 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 745.5, 786.51, 440.0, 424.1
Test Information
Date/Time: [**2119-10-30**] at 08:40 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 #: 2007AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. PFO is present. Left-to-right shunt across
the interatrial septum at rest.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Physiologic MR (within
normal limits).
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
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 normal in size. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits).
7. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine
1. Biventricular systolic function is preserved
2. Aortic contours are intact post decannulation
3. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician
Brief Hospital Course:
Mr. [**Known lastname **] was taken to the operating room on [**10-30**] where he
underwent a CABG x 3. He was transferred to the ICU in stable
condition. He awoke and was extubated later that same day. He
was weaned from his neosynephrine by POD #2, and he was
transferred to the floor. On POD 2 he had rapid atrial
fibrillation for which he was given IV lopressor and was started
on an amiodarone drip. He converted and remained in normal sinus
rhythm. Physical followed patient during entire post-op course
for strength and mobility. He continued to make steady process
without any further post-op complications and was discharged
home with VNA services on post-op day four.
Medications on Admission:
Plavix 75', Simvastatin 20', Atenolol 25', Amlodipine 5',
Aspirin 325', Cod liver oil daily, Garlic pills daily, Vitamin E
400 IU daily, MVI daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day until [**11-8**] then decrease
to 400mg once a day until [**11-15**], then decrease to 200mg daily
and follow up with cardiologist.
Disp:*80 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
caregroup vna
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post operative Atrial Fibrillation
Hypertension
Hyperlipidemia
Anxiety
Kidney stones
Discharge Condition:
Good.
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**First Name (STitle) 26317**] in 2 weeks [**Telephone/Fax (1) 26318**]
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] 2-3 weeks
Wound check appointment [**Hospital Ward Name 121**] 2 - please schedule with RN
[**Telephone/Fax (1) 3633**]
Completed by:[**2119-11-3**]
|
[
"413.9",
"E878.2",
"272.4",
"427.31",
"401.9",
"997.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9099, 9143
|
6940, 7620
|
344, 539
|
9305, 9313
|
1115, 1883
|
9825, 10193
|
929, 933
|
7817, 9076
|
1920, 1961
|
9164, 9284
|
7646, 7794
|
9337, 9802
|
948, 1096
|
283, 306
|
1990, 6917
|
567, 738
|
760, 849
|
865, 913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,411
| 114,965
|
40204
|
Discharge summary
|
report
|
Admission Date: [**2149-5-10**] Discharge Date: [**2149-5-24**]
Date of Birth: [**2123-2-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**5-14**]: Right frontal burr hole, cyst evacuation and EVD
placement.
[**5-23**]: Right VP shunt placement
History of Present Illness:
26M who presented to an OSH with one year of progressively
increasing headache, memory problems (both long and short term),
and vision blurriness who was found to have new mass on CT scan.
His symptoms have been progressively increasing both in
intensity and frequency as his headaches are now daily.
Past Medical History:
Denies
Social History:
Works at Domino's pizza restaurant as a manager. Denies EtOH,
tobacco, or illicit drug use.
Family History:
denies any history of stroke, brain cancer, or seizures.
Positive family history for CAD and breast cancer.
Physical Exam:
On Admission:
Physical Examination
97.8 88 123/70 19 96%RA
Gen: Comfortable, NAD.
HEENT: Pupils: 2 to 1.5 mm bil EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Appropriate, cooperative with exam, normal
affect.
Orientation: AOx3.
Language: Fluent.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5 mm
bilaterally. Visual fields intact
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus or diplopia.
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 [**5-29**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: no dysmmetria on finger-nose-finger
Discharge Exam;
gen - pleasant, stable acromegaly, pleasant and cooperative
skin - incisions are clian and dry, no rash no eccymosis
CV - RRR, S1 and S2 nl
Pulm - CTAB no w/c/r
GI - soft, obese, distal umbilical incision c/d/i, NT/ND
Ext - No c/c/e
Neuro - AO x 3, PERRL, bilateral homonymous hemianopsia,
full motor, sensory to light touch intact, no pronator drift
Pertinent Results:
[**2149-5-10**] MRI BRAIN w/ & w/o contrast:
FINDINGS: A mass measuring approximately 5 x 5 x 6 cm appears to
arise from the sella turcica and extend into the suprasellar
cistern. The mass is inhomogeneous in intensity, but
predominantly hypointense to brain on the short TR images and
markedly hyperintense on FLAIR and long TR spin echo images.
There is a prominent cystic component anteriorly, extending into
the right frontal lobe. This measures approximately 4 x 5 x 6
cm. The mass enhances inhomogeneously after contrast
administration. The sella turcica is markedly enlarged. The mass
extends into the prepontine cistern and grossly fills the left
cavernous sinus. The left internal carotid artery is encased in
its cavernous and supraclinoid portions as it courses through
the mass. The optic chiasm is traumatically elevated by the
lesion, and I cannot identify the course of the optic nerves as
they pass over this lesion to approach the optic canals. This
lesion appears most likely to represent a pituitary adenoma.
The mass elevates the third ventricle and causes compression at
the level of the foramen of [**Last Name (un) 2044**]. This apparently is
responsible for bilateral dilatation of the lateral ventricles,
more severe on the right than left.
CONCLUSION: Massive sellar and suprasellar enhancing neoplasm,
most likely a pituitary adenoma. There is compression of the
optic chiasm and hydrocephalus due to elevation and compression
of the ventricular system at the level of the foramen of [**Last Name (un) 2044**].
[**2149-5-11**] CTA Head: Large sellar and suprasellar mass with
components in the pontine cistern, cavernous sinus, suprasellar
cistern, and invaginating into the right frontal lobe. The
appearance remains consistent with a pituitary adenoma. There
is encasement of the left internal carotid artery and the
anterior cerebral arteries bilaterally course through the
lesion.
[**5-14**] CT Head:
No significant change in large suprasellar mass leading to right
lateral ventricular dilation. There is no evidence of interval
hemorrhage.
[**5-14**] CT Head postop:
In comparison to a study obtained five hours prior, there is
notable
improvement in right lateral ventricular dilatation and right
frontal cystic lesion. There is no hemorrhage along the course
of the right ventriculostomy catheter, which is terminating in
the third ventricle. Small-to-moderate pneumocephalus is likely
post-surgical.
[**5-15**] CT Head: In comparison to [**2149-5-14**] exam, there is mild
improvement in ventricular size. No evidence of acute
intracranial hemorrhage. Small-to-moderate pneumocephalus
persists, likely post-surgical.
[**5-17**] CT Head -
1. Stable size of the ventricles compared to [**2149-5-15**], with mild
dilatation of the right lateral ventricle.
2. The large sellar/suprasellar mass, with a large cystic
component indenting the right frontal lobe
[**5-23**] Ct head - s/p r VP shunt, no acute hemorrhage
Brief Hospital Course:
26M who was admitted to Neurosurgery for a right frontal cystic
lesion and a sellar/suprasellar mass with subsequent
hydrocephalus. He admitted to the ICU for close observation
given his imaging. A MRI was obtained on [**5-10**] to better evaluate
the lesions.
On [**5-11**] a CTA head was obtained for surgical planning. Endocrine
was also consulted given the sellar/suprasellar mass. Per
Endocrine request, labs were ordered and a cortisol stimulation
test was done on [**5-12**] AM. Hydrocortisone was held in order to
perform cortisol stim test.a 1 gram Dilantin bolus was given for
a serum dilantin level of 0.8. Overnight the patient became very
aggitated, pulling out his IV line requiring ativan. The
patient got out of bed and wanted to leave the hospital "Against
Medical Advice"
On [**5-12**], patient was seen to have bitemporal hemianopsia, but
was otherwise intact on examination. The Cortisol Stim teast was
performed and the cortisol levels at 30 minites, 60 minites and
90 minites were.2-30 mins,21-60 mins,22- 90 mins. Neuro-optho
was consulted for formal visual field testing which was done on
[**2149-5-13**] which demonstrated stable bitemporal hemianopsia.
Endocrine recommended stopping the hydrocortisone and decreasing
the decadron. Neuro and rad oncology were also consulted.
On [**2149-5-14**], Patient underwent am aspiration of the right frontal
cyst and EVD placement. He tolerated the procedure well without
intraoperative complications. Please review dictated operative
report for details. He was extubated and transferred to the ICU.
Post operative Head CT revealed no hemorrhage and significant
decompression. He was bolused with 500mg of Dilantin for a
subtherapeuric level of 7.2 and his dose was increased to 200mg
[**Hospital1 **].
On [**5-15**] the EVD was clamped after CT head demonstrated stable
ventricular size however it had to be opened approximately
2.5hrs after clamping for severe headache and episode of
confusion. It was opened at 10cm above the tragus. Per
Endocrinology the patient was given cabergoline 0.5mg as a
one-time dose and the patient was switched from dexamethasone to
prednisone 7.5mg daily according to their recommendations. He
was given a Dilantin bolus of 500mg for a Dilantin level of 9.6.
On [**5-16**] the patient's mental status was stable and so an EVD
wean was started. The patient tolerated elevation of the drain
to 20cm above the tragus. Dilantin level was therapeutic at
12.9. Pt was transfered to the stepdown unit. His ventricular
drain was clamped several times but patient continued to have
elevated ICPs and severe headaches. Plan for VP shunt was
postponed on [**5-20**] for fever to 102.7. Fever workup was negative
for DVT with lower extremity Dopplers, negative consolidation on
chest xray. Blood, urine and CSF cultures were sent on [**5-20**].
He devoloped a total body rash that resembled a reaction to
dilantin and so the patient was transitioned to Keppra, Dilantin
was stopped and the rash was treated topically with
hydrocortisone cream and with Oral benadryl PRN. No respiratory
distress, no oral swelling. He was afebrile on [**5-21**] and was
neurolopgically stable with EVD in place while awaiting VP shunt
placement.
On [**2149-5-23**], patient had a right VP shunt place by Dr. [**First Name (STitle) **]. On
the day of surgery he had stress dose steroids with
Hydrocortisone 50mg Q8 and then resumed prednisone 7.5mg daily.
Now DOD, pt is afebrile, vital signs are stable, and tolerating
a good oral diet. His pain is well controlled and incision
appear clean/dry/intact. He is set for d/c home in stable
condition.
Medications on Admission:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Right frontal cystic mass
Sellar and suprasellar mass
Hydrocephalus
Increased intracranial pressures
Post operative confusion
Post-op fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-3**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 2 weeks with a head CT
- On Every other week, you will need visual field testing with
Dr [**Last Name (STitle) **] call [**Telephone/Fax (1) 253**] to follow-up. [**Hospital 8095**] clinic has
been contact[**Name (NI) **] and they will call you for an appointment within
1 week of discharge.
Endocrinology
- You will need a f/u with Dr. [**Last Name (STitle) 88269**] in 2 weeks on [**6-6**], at
4:40pm. [**Hospital Ward Name 23**] Building - Medical specialty clinic [**Location (un) 442**].
[**Telephone/Fax (1) 1803**] if you have questions.
Completed by:[**2149-5-26**]
|
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"377.49",
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icd9cm
|
[
[
[]
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"01.09",
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icd9pcs
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[
[
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282, 392
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28,660
| 185,655
|
16046
|
Discharge summary
|
report
|
Admission Date: [**2188-12-13**] Discharge Date: [**2188-12-23**]
Date of Birth: [**2113-5-27**] Sex: F
Service: MEDICINE
Allergies:
Zestril / Maxaquin / Norvasc / Percocet
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
shortness of breath, CHF exacerberation
Major Surgical or Invasive Procedure:
Intubation/Extubation
History of Present Illness:
75 yo F with h/o HTN, CHF, DM II, ? h/o prior MI, and lung CA
s/p partial lung resection [**2179**] who presents with worsening
shortness of breath and cough X 1 week along with subjective
fevers. The pt reports that her cough is productive in nature
and began on Monday. Since then, she has had a steadily
increasing sensation of shortness of breath. Further history was
unable to be obtained [**2-22**] respiratory distress.
.
In the ED, initial vitals were T 101, SBP 210s, HR 90s, O2 sat
86% on RA. On exam, she was speaking in full sentences without
overt difficulty. She was given metoprolol 5 mg IV X 2 for her
elevated SBP with worsening of her shortness of breath and the
pt was placed on a [**Month/Day (2) 597**] with O2 sats in the upper 90s. An EKG
showed increased ectopy but otherwise no new dynamic ischemic
changes and a CXR was significant for increased fluid suggestive
of CHF exacerbation and a basilar opacity in the left lower lobe
could not be ruled out for possible pneumonia. She was given 100
IV lasix with 800 ccs urine output over 1 hr, ceftriaxone 1 gm X
1, azithromycin 500 mg X 1, and started on a nitro gtt with
improvement in SBPs down to the 150s. An ABG on either RA or [**Name (NI) 597**]
(unclear from charting) was 7.40/34/57/22. She was then admitted
to the CCU for CHF exacerbation.
.
Of note, the pt was admitted in [**12-25**] with similar symptoms of
cough and shortness breath and was treated for a CHF
exacerbation as well as PNA. She had a TTE performed that showed
a LVEF 45% with septal hypokinesis and RV apical free wall
hypokinesis. A p-MIBI showed no perfusion defects and a LVEF
54%. She was discharged and followed up with Dr. [**Last Name (STitle) **] in [**5-26**]
whose impression was that diastolic heart failure exacerbation
was the etiology of her admission.
.
Further ROS of systems unable to be obtained [**2-22**] respiratory
distress, pt placed on BIPAP.
Past Medical History:
- HTN
- DM2
- peripheral neuropathy
- h/o lung CA s/p resection
- h/o A.fib
- LE edema/venous stasis
- s/p TAH/BSO
- anxiety
- Anemia - mild renal insuffic, normal iron, b12, folate, retic
- chronic urticaria/hives
.
Cardiac Risk Factors: Diabetes, Hypertension
.
Cardiac History: no prior CABG, PCI, or PPM
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Family History:
Non-contributory
Physical Exam:
VS: T 96.5, BP 141/59, HR 77, RR 29, O2 98% on BIPAP FiO2 100%,
PS 10 PEEP 5
Gen: WDWN elderly female in respiratory distress, improved with
BIPAP. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP distended up to angle of jaw
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3, no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were initially labored with accessory muscle use, improved with
initiation of BIPAP. crackles half up lung fields b/l, coarse
upper airway breath sounds
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
Labs:
[**2188-12-13**] 01:00AM BLOOD WBC-11.3* RBC-3.61* Hgb-10.4* Hct-30.1*
MCV-83 MCH-28.7 MCHC-34.4 RDW-15.1 Plt Ct-271
[**2188-12-14**] 05:13AM BLOOD WBC-10.3 RBC-2.89* Hgb-8.3* Hct-24.7*
MCV-86 MCH-28.7 MCHC-33.6 RDW-15.1 Plt Ct-222
[**2188-12-15**] 05:09AM BLOOD WBC-9.1 RBC-3.28* Hgb-9.4* Hct-27.1*
MCV-83 MCH-28.8 MCHC-34.9 RDW-15.1 Plt Ct-177
[**2188-12-16**] 02:34AM BLOOD WBC-9.4 RBC-3.35* Hgb-9.5* Hct-27.9*
MCV-83 MCH-28.2 MCHC-33.9 RDW-15.2 Plt Ct-186
[**2188-12-17**] 05:14AM BLOOD WBC-13.0* RBC-4.17* Hgb-11.9*# Hct-35.5*
MCV-85 MCH-28.4 MCHC-33.4 RDW-15.2 Plt Ct-307#
[**2188-12-17**] 04:20PM BLOOD WBC-10.4 RBC-3.83* Hgb-10.7* Hct-32.0*
MCV-84 MCH-28.1 MCHC-33.6 RDW-15.0 Plt Ct-261
[**2188-12-19**] 06:41AM BLOOD WBC-10.8 RBC-3.51* Hgb-10.0* Hct-30.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-15.1 Plt Ct-270
[**2188-12-20**] 07:01AM BLOOD WBC-7.1 RBC-3.32* Hgb-9.4* Hct-28.0*
MCV-84 MCH-28.4 MCHC-33.7 RDW-15.2 Plt Ct-213
[**2188-12-21**] 07:02AM BLOOD WBC-6.7 RBC-3.12* Hgb-8.9* Hct-26.9*
MCV-86 MCH-28.4 MCHC-33.1 RDW-15.1 Plt Ct-225
[**2188-12-22**] 07:15AM BLOOD WBC-6.3 RBC-3.08* Hgb-8.8* Hct-26.8*
MCV-87 MCH-28.4 MCHC-32.6 RDW-15.4 Plt Ct-290
[**2188-12-13**] 01:00AM BLOOD Neuts-79.4* Lymphs-13.3* Monos-5.3
Eos-1.9 Baso-0.2
[**2188-12-16**] 02:34AM BLOOD Neuts-86.9* Lymphs-8.2* Monos-3.6 Eos-1.3
Baso-0.1
[**2188-12-18**] 03:42AM BLOOD Neuts-86.5* Lymphs-6.9* Monos-5.0 Eos-1.5
Baso-0.1
[**2188-12-19**] 06:41AM BLOOD Neuts-78.3* Lymphs-12.0* Monos-5.1
Eos-4.5* Baso-0.1
[**2188-12-20**] 07:01AM BLOOD Neuts-77.0* Lymphs-13.6* Monos-5.3
Eos-4.1* Baso-0.1
[**2188-12-13**] 01:00AM BLOOD PT-36.6* PTT-37.7* INR(PT)-3.9*
[**2188-12-14**] 05:34AM BLOOD PT-31.3* PTT-54.3* INR(PT)-3.2*
[**2188-12-15**] 05:09AM BLOOD PT-30.7* PTT-53.3* INR(PT)-3.2*
[**2188-12-16**] 02:34AM BLOOD PT-26.2* PTT-40.0* INR(PT)-2.6*
[**2188-12-17**] 05:14AM BLOOD PT-15.9* PTT-29.7 INR(PT)-1.4*
[**2188-12-17**] 06:37PM BLOOD PT-16.9* PTT-50.6* INR(PT)-1.5*
[**2188-12-18**] 03:42AM BLOOD PT-18.7* PTT-59.5* INR(PT)-1.7*
[**2188-12-18**] 01:52PM BLOOD PT-19.0* PTT-78.7* INR(PT)-1.8*
[**2188-12-19**] 06:41AM BLOOD PT-17.7* PTT-75.2* INR(PT)-1.6*
[**2188-12-21**] 07:02AM BLOOD PT-18.9* PTT-150 * INR(PT)-1.8*
[**2188-12-22**] 07:15AM BLOOD PT-17.0* PTT-29.5 INR(PT)-1.5*
[**2188-12-13**] 01:00AM BLOOD Glucose-166* UreaN-35* Creat-1.2* Na-139
K-3.7 Cl-105 HCO3-20* AnGap-18
[**2188-12-13**] 03:24PM BLOOD Glucose-87 UreaN-42* Creat-1.6* Na-142
K-3.6 Cl-106 HCO3-23 AnGap-17
[**2188-12-14**] 05:13AM BLOOD Glucose-153* UreaN-49* Creat-1.8* Na-141
K-4.4 Cl-111* HCO3-20* AnGap-14
[**2188-12-15**] 05:09AM BLOOD Glucose-76 UreaN-58* Creat-1.8* Na-145
K-3.9 Cl-113* HCO3-19* AnGap-17
[**2188-12-16**] 02:34AM BLOOD Glucose-97 UreaN-65* Creat-1.3* Na-143
K-3.9 Cl-115* HCO3-19* AnGap-13
[**2188-12-16**] 04:17PM BLOOD Glucose-179* UreaN-63* Creat-1.4* Na-144
K-3.9 Cl-113* HCO3-20* AnGap-15
[**2188-12-17**] 05:14AM BLOOD Glucose-145* UreaN-56* Creat-1.3* Na-144
K-3.6 Cl-109* HCO3-22 AnGap-17
[**2188-12-18**] 03:42AM BLOOD Glucose-205* UreaN-68* Creat-1.4* Na-143
K-4.4 Cl-112* HCO3-26 AnGap-9
[**2188-12-20**] 07:01AM BLOOD Glucose-156* UreaN-59* Creat-1.8* Na-139
K-4.0 Cl-106 HCO3-19* AnGap-18
[**2188-12-21**] 07:02AM BLOOD Glucose-197* UreaN-60* Creat-1.7* Na-143
K-4.5 Cl-109* HCO3-20* AnGap-19
[**2188-12-22**] 07:15AM BLOOD Glucose-203* UreaN-65* Creat-1.5* Na-141
K-4.3 Cl-109* HCO3-23 AnGap-13
[**2188-12-13**] 01:00AM BLOOD CK(CPK)-136
[**2188-12-13**] 06:06AM BLOOD CK(CPK)-177*
[**2188-12-13**] 03:24PM BLOOD CK(CPK)-270*
[**2188-12-13**] 09:51PM BLOOD CK(CPK)-269*
[**2188-12-14**] 05:13AM BLOOD LD(LDH)-284* CK(CPK)-218* TotBili-0.3
[**2188-12-17**] 05:14AM BLOOD CK(CPK)-107
[**2188-12-17**] 04:20PM BLOOD CK(CPK)-110
[**2188-12-18**] 03:42AM BLOOD CK(CPK)-105
[**2188-12-13**] 01:00AM BLOOD CK-MB-4 proBNP-2879*
[**2188-12-13**] 01:00AM BLOOD cTropnT-0.03*
[**2188-12-13**] 06:06AM BLOOD CK-MB-8 cTropnT-0.18*
[**2188-12-13**] 03:24PM BLOOD CK-MB-10 MB Indx-3.7 cTropnT-0.77*
[**2188-12-13**] 09:51PM BLOOD CK-MB-10 MB Indx-3.7 cTropnT-0.77*
[**2188-12-14**] 05:13AM BLOOD CK-MB-9 cTropnT-0.51*
[**2188-12-17**] 05:14AM BLOOD CK-MB-4 cTropnT-0.39*
[**2188-12-17**] 04:20PM BLOOD CK-MB-5 cTropnT-0.47*
[**2188-12-13**] 06:06AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.2
[**2188-12-13**] 03:24PM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2188-12-13**] 09:51PM BLOOD Albumin-2.8* Calcium-7.9* Phos-4.4 Mg-1.8
[**2188-12-14**] 05:13AM BLOOD Calcium-7.7* Phos-4.6* Mg-1.9
[**2188-12-15**] 05:09AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2
[**2188-12-16**] 02:34AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.4
[**2188-12-17**] 04:20PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.5
[**2188-12-18**] 03:42AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.4
[**2188-12-19**] 06:41AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.4
[**2188-12-20**] 07:01AM BLOOD Calcium-7.9* Phos-4.9* Mg-2.4
[**2188-12-14**] 05:13AM BLOOD Hapto-264*
[**2188-12-18**] 03:42AM BLOOD TSH-2.4
[**2188-12-14**] 05:13AM BLOOD Cortsol-25.9*
[**2188-12-17**] 07:36AM BLOOD Lactate-1.5
[**2188-12-20**] 07:01AM BLOOD Metanephrines (Plasma)-PND
.
Imaging/Studies:
.
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with chf exacerbation, decreased oxygenation
REASON FOR THIS EXAMINATION:
evaluate for acute change
STUDY: AP chest, [**2188-12-13**].
HISTORY: 75-year-old woman with congestive heart failure and
decreased oxygenation.
FINDINGS: Comparison is made to the previous study from [**12-13**], [**2188**], at 8:54 a.m.
There has been placement of an endotracheal tube whose distal
tip is at the level of the clavicles. Nasogastric tube sideport
is just below the gastroesophageal junction. There remains
bilateral airspace opacities, right side worse than left which
are stable.
.
ECHO [**12-13**]: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. There is moderate thickening of
the mitral valve chordae. At least mild to moderate ([**1-22**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation is probably significantly
UNDERestimated.] The pulmonary artery systolic pressure could
not be determined. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2188-1-11**], the left ventricle is now hyperdynamic;
hypokinesis of the interventricular septum and of the right
ventricle is no longer seen.
IMPRESSION: hyperdynamic left ventricle
.
[**12-15**]: CT Abd/Pelvis:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Bibasilar opacities in the lungs suggestive of pneumonia
and/or aspiration with associated small simple pleural
effusions.
.
CXR [**12-15**]:IMPRESSION: Continued improvement in pulmonary edema
particularly in the right upper lobe. Left pleural effusion with
atelectasis persists though underlying pneumonia cannot be
excluded.
.
CXR [**12-17**]: IMPRESSION: After extubation, patient has redeveloped
moderate-to-severe pulmonary edema with predominance in the
right upper lobe, which raises the question whether the patient
has mitral regurgitation. There is some increase in small left
pleural effusion and atelectasis and probable small right
pleural effusion.
.
Renal US: IMPRESSION:
1. Normal Doppler examination of the kidneys, with no
son[**Name (NI) 493**] evidence of renal artery stenosis.
2. Simple cyst of the right kidney.
.
CXR [**12-19**]: IMPRESSION: Unchanged moderate asymmetric pulmonary
edema with left greater than right small pleural effusions. Left
retrocardiac opacity likely represents pleural effusion with
atelectasis although consolidation cannot be excluded. Overall
unchanged from one day prior.
.
CXR [**12-21**]: IMPRESSION:
1. Interval improvement in right upper lobe pneumonia with mild
decrease in consolidation.
2. Continued left lower lobe consolidation with small left
pleural effusion. Cardiomegaly.
.
C. Diff toxin: Negative x1
.
BCX: All no growth
.
Direct Influenza A and B antigen: Negative
.
Legionella Urinary Antigen: Negative
Brief Hospital Course:
# Hypertensive urgency: The patient presented with systolic
blood pressures in the 200s. At the time, the patient developed
flash pulmonary edema leading to decreased oxygen saturation to
the 80s and significant respiratory distress. This required
BiPAP which initially increased her O2 sats, and then intubation
during the first day of her admission due to inability to
tolerate less invasive methods. She subsequently developed
several other episodes of anxiety after extubation complicated
by systolic blood pressures in the 200s with flash pulmonary
edema. She intermittently required a nitro gtt for control of
her blood pressures. Renal ultrasound was negative for renal
artery stenosis. Additionally, urinary metanephrines were sent
for work up of pheochromocytoma to evaluate for secondary causes
of hypertension. This was pending at the time of discharge. TSH
was within normal limits as well. Unclear if the patient's
hypertensive episodes are entirely secondary to anxiety and
agitation or if there is another cause. The patient's
hypertensive regimen was increased and she is discharged on new
doses of hydral and imdur. She should follow up with her
outpatient physician for further management of her hypertension.
.
#) Respiratory failure/Multifocal pneumonia: As above, patient
was admitted with significant pulmonary edema, known diastolic
CHF as well as a multifocal pneumonia. She was treated for
community acquired pneumonia with 5 days of azithromycin and 7
days of ceftriaxone. Additionally, she was diuresed with
clinical improvement. She continues to improve both clinically
and radiographically. All blood cultures during admission were
negative.
.
#) Cardiac
-Ischemia: Patient with transient ischemic changes on ECG during
her hypertensive episodes. Troponins were slightly elevated at
0.03 with no change in CK. No history of cardiac cath, though no
ischemic changes on p-MIBI in 12.06. Patient should have
outpatient follow up for evaluation of coronary artery disease.
She should continue on aspirin, atorvastatin and carvedilol as
above.
-Pump: Prior history of diastolic dysfunction with LVEF 54% on
p-MIBI in [**12-25**]. ECHO on [**12-13**] showing hyperdynamic left
ventricle. Patient was continued on hydralazine and Isordil
with up-titration for tighter blood pressure control.
Additionally, she was aggressively diuresed in the setting of
significant pulmonary edema during her admission. She is
currently on standing Lasix 40mg PO daily. This can be further
adjusted based on her fluid status as an outpatient.
-Rhythm: History of paroxysmal atrial fibrillation. Currently in
sinus rhythm. INR was supratherapeutic at 3.9 on admission.
Coumadin initially held then started on heparin gtt. On coumadin
with INR of 1.7 on discharge [**12-23**]. Please continue coumadin and
increase dose if INR not therapeutic, next INR check on [**12-26**].
Bradycardia to 40s, sinus, asymptomatic with pauses of up to 3.9
seconds. Please check EKG within 2 days of discharge and if
symptomatic bradycardia decrease lopressor dose (now 50mg po
bid)
.
#) Anemia: Baseline as per OMR appears to be Hct of 28-30 with
normal MCV. Hematocrit was 30 on admission. Hct initially
decreased over two days to 23. She received 3 units of pRBCs
with an appropriate bump in her hematocrit. Guaiac and NG
aspirate were negative. CT of abdomen and pelvis were negative
for RP or other source of bleeding. Hematocrit continued to
remain stable for the duration of admission. Prior iron studies
within normal limits. Will likely need work up as an
outpatient.
.
#) Agitation/anxiety: Per the patient and her family, she has
significant anxiety at home. She states she takes lorazepam 1mg
daily at home with occasional prn doses as needed. Here, during
an episode of significant anxiety, patient was given 1mg IV
ativan and became significantly more agitated. Geriatrics
consult recommended oxazepam 15mg qhs with once daily prn dosing
for anxiety attacks. Additionally, patient was started on
sertraline 25mg qhs, to be increased on 50mg qhs on [**2188-12-29**].
She should continue breathing and visualization exercises prior
to taking pm medications. She can follow up in the Geriatric
[**Hospital **] Clinic for further management of her depression and
anxiety symptoms.
.
#) DM II: Initially, Glyburide was held in the setting of
intubation with decreased POs and mild ARF. She was placed on
an insulin sliding scale initially. Glyburide restarted at
2.5mg daily prior to discharge. As POs and renal function become
normalized, this can be increased to her home regimen of 5mg po
daily of glyburide. HgbA1c 6.6 in [**9-26**].
.
#) Renal Insufficiency: Baseline Cr 1.3 - 1.5, Cr on admission
1.2. Her creatinine increased to 1.9 on her first day of
admission, but has returned to baseline at the time of discharge
(discharge INR 1.5 on [**12-23**]). Urine eosinophils negative.
.
#) Code - FULL
Medications on Admission:
ASA 162 mg daily
Hydralazine 50 mg tid
Isosorbide Mononitrate 120 mg daily
Lasix 80 mg daily
Metoprolol 50 mg [**Hospital1 **]
Pravastatin 40 mg daily
Coumadin 5 mg daily
Trazodone 25 mg qhs prn
Ativan 0.5 mg tid prn
Latanoprost 0.005% 1 drop daily
Cosopt 0.5-2% 1 drop R eye [**Hospital1 **]
Glyburide 5 mg tid
Docusate 100 mg [**Hospital1 **] prn
Mineral oil 1 tbsp daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
Disp:*360 Tablet(s)* Refills:*0*
6. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
7. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily)
as needed.
Disp:*15 Capsule(s)* Refills:*0*
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO As directed:
Take half tablet daily until [**2188-12-29**]. Then take one tablet
daily at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): humalog sliding scale, 2 units
sc insulin qac and qhs, scale to begin at blood glucose of 150
and increase by 2 units insulin for ever 50 points increase in
blood glucose above 150.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Imdur 120 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
15. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: give with 120mg
tablet of imdur.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
CHF exacerbation
Multifocal community acquired pneumonia
.
Secondary diagnoses:
Normocytic anemia
Type II DM
Hypertension
Anxiety
Depression
Discharge Condition:
Stable
Discharge Instructions:
If you develop shortness of breath, increased cough, dizziness,
changes in vision, chest pain, severe headache or any other
changes that concern you, you should go to the nearest Emergency
Room or call your primary care doctor as soon as possible.
.
We have made a number of changes to your medications. These
include:
1. Serax (Oxazepam) has taken the place of Lorazepam. Please
take this medication as directed.
2. Zoloft (Sertraline) has been started. You should take this as
directed.
3. Your Hydralazine has been changed to 75mg four times a day.
4. Metoprolol 50mg twice daily
5. Your imdur has been switched to isordil.
.
It is very important that you continue to do your breathing and
visualization exercises to improve your anxiety. Please take
all your medications and keep your follow up appointments.
Followup Instructions:
Please keep the following appointments:
.
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2189-2-16**] 9:10
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-2-19**] 8:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2189-2-19**] 8:50
|
[
"427.31",
"V10.11",
"412",
"518.81",
"403.90",
"459.81",
"584.9",
"285.21",
"300.4",
"486",
"585.9",
"428.0",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
19341, 19427
|
12346, 17271
|
342, 366
|
19612, 19621
|
3875, 8946
|
20483, 20934
|
2871, 2889
|
17696, 19318
|
8983, 9046
|
19448, 19507
|
17297, 17673
|
19645, 20460
|
2904, 3856
|
19528, 19591
|
263, 304
|
9075, 12323
|
394, 2315
|
2337, 2648
|
2664, 2855
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,543
| 117,993
|
44751
|
Discharge summary
|
report
|
Admission Date: [**2141-10-13**] Discharge Date: [**2141-10-19**]
Date of Birth: [**2092-4-6**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2141-10-14**] renal transplant
History of Present Illness:
49M with ESRD [**1-30**] DM1 maintained on HD MWF (right AVF).
Last HD [**10-13**] (full session). Patient feels well. Denies f/c,
SOB, CP. Makes little urine (a little bit over a teaspoon/day).
No history of abdominal surgeries.
Past Medical History:
1. CAD s/p [**Month/Year (2) **] to OM1 in [**9-2**] and [**Month/Day (1) **] to RCA in [**5-5**]
2. End-stage renal disease, on HD since [**6-3**] (MWF)
3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin,
c/b nephropathy, neuropathy, and retinopathy status post
multiple laser surgeries. Right upper extremity fistula. Chronic
ulcers on left foot.
4. Hypertension
5. Hyperlipidemia
6. Obstructive sleep apnea
7. G6PD deficiency
8. Right fifth toe amputation, [**2137-3-29**].
9. History of hepatitis B infection
10. Sexual dysfunction s/p penile prosthesis implantation
11. Kidney transplant, right iliac fossa [**2141-10-14**].
Social History:
The patient lives with his wife and 2 sons in [**Name (NI) 669**].
Previously worked at NSTAR as a janitor, and is currently on
diability. No tobacco or EtOH use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother has diabetes mellitus. Father is healthy
and multiple half brothers and sisters. Two children, both boys,
are healthy. Multiple aunts and uncles decreased from
complications of diabetes. No family hx of Wegener's or
[**Last Name (un) 95749**]-[**Doctor Last Name 3532**] disease.
Physical Exam:
98.6, 70, 160/77, 16, 98RA
NAD, A+OX3
RRR
CTAB
Soft, NT/ND +BS
no c/c/e, 2+ femoral pulses b/l, weak DP pulses b/l
Right AVF + thrill, no erythema
Pertinent Results:
[**2141-10-14**] 12:55AM BLOOD WBC-6.4 RBC-4.00* Hgb-11.3* Hct-36.0*
MCV-90 MCH-28.1 MCHC-31.3 RDW-16.6* Plt Ct-254
[**2141-10-15**] 02:34AM BLOOD WBC-10.9 RBC-3.41* Hgb-9.8* Hct-31.0*
MCV-91 MCH-28.7 MCHC-31.6 RDW-16.4* Plt Ct-210
[**2141-10-15**] 02:53PM BLOOD Hct-23.9*
[**2141-10-19**] 05:12AM BLOOD WBC-5.5 RBC-3.78* Hgb-11.2* Hct-34.0*
MCV-90 MCH-29.6 MCHC-33.0 RDW-16.5* Plt Ct-153
[**2141-10-17**] 05:32AM BLOOD PT-13.2 PTT-27.3 INR(PT)-1.1
[**2141-10-17**] 05:32AM BLOOD ALT-20 AST-14 AlkPhos-72 TotBili-0.3
[**2141-10-14**] 02:01PM BLOOD CK-MB-11* MB Indx-8.6* cTropnT-0.25*
[**2141-10-14**] 07:54PM BLOOD CK-MB-23* MB Indx-10.1* cTropnT-0.65*
[**2141-10-15**] 12:35PM BLOOD CK-MB-17* MB Indx-11.2* cTropnT-1.13*
[**2141-10-15**] 10:44PM BLOOD CK-MB-10 MB Indx-8.8* cTropnT-0.72*
[**2141-10-16**] 03:26AM BLOOD CK-MB-NotDone cTropnT-0.65*
[**2141-10-19**] 05:12AM BLOOD Calcium-8.2* Phos-5.7* Mg-1.9
[**2141-10-19**] 05:12AM BLOOD tacroFK-7.7
Brief Hospital Course:
On [**2141-10-14**], he underwent kidney transplant into right iliac
fossa. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. A double-J ureteral stent
was not placed due to small ureteral size. A 19 [**Doctor Last Name 406**] drain was
placed in the retroperitoneum. Induction immunosuppression (ATG,
solumedrol and cellcept)were administered. Please refer to
operative notes for complete details. After closing, he was
hypotensive requiring pressor support. ECG had new ST segment
depressions laterally and ST elevation in aVR. A NTG drip was
given. Cardiology was consulted. TTE was performed with moderate
LVH, MAC, small LVcavity, mild inferior and inferolateral HK but
overall preserved EF, and nl RV/septal motion. Cardiac enzymes
were checked showing a troponin leak. He was transferred to the
SICU where a heparin drip was run. Hypotensive response was felt
to be possibly due to ATG. Cardiology recomended lopressor and
statin with repeat TTE during this admission.
Hct dropped from 35 to 31. He was given PRBC. Heparin drip was
stopped and hct stabilized. Home doses of [**Doctor Last Name **] and plavix were
resumed.
A total of 3 doses of ATG were given after premedication with
tylenol/benadryl and higher doses of solumedrol as well as
slower administration of ATG. Over the next few days, urine
output increased to 3-4 liters and creatinine trended down to
5.5. Foley was removed without incident. IV fluids were stopped.
Diet was advanced and tolerated. Pain was controlled with oral
meds.
Extensive medication teaching was done. Steroids were tapered.
Cellect was well tolerated. Prograf was up-titrated to 12mg [**Hospital1 **]
for slowly rising prograf levels (7.7).
A repeat TTE was done per Cardiology demonstrating severe
symmetric left ventricular hypertrophy. Overall LVSF was normal
(LVEF>55%)with possible focal inferior hypokinesis (although not
seen consistently in all views). Doppler parameters were most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction" and moderate pulmonary artery systolic
hypertension. Lopressor doses were increased for SBPs up to
190. Home doses of hydralazine were resumed, isosorbide was
increased and Norvasc was added with some improvement of BP.
Of note, he required an insulin drip for a day to control
hyperglycemia from the steroids. This was switched to SQ insulin
(NPH and Humalog)with improved glucose control.
He was ambulatory. PT cleared him for home with a cane. VNA
services were arranged as he was discharged with his JP drain
which averaged 90-145cc of serosanuinous fluid.
Medications on Admission:
Lyrica 25', Humalog SSI (usually 12 units qmeal), Levamir 28
Units [**Last Name (LF) 5910**], [**First Name3 (LF) **] 325', Nefidical 90", Isosorbide 30', Loperamide
2', Lipitor 80', Hydralazine 75''', Toporol 350', Plavix 75',
Trazadone 50', Lisinopril 20', Zetia 10'
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO three times
a day.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO QAM (once a day
(in the morning)).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO QPM (once a day
(in the evening)).
12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
14. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for incision pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
18. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
19. Outpatient Lab Work
Outpatient Labs: Sat [**2141-10-21**] @ [**Hospital Ward Name 516**], [**Hospital Ward Name 1826**] Building
[**Location (un) **]
cbc, chem 7 and trough prograf level
20. NPH Insulin Human Recomb 300 unit/3 mL Insulin Pen Sig:
Thirty Five (35) units Subcutaneous every morning: and 20 units
at supper.
Disp:*10 pens* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
esrd
HTN
DM
CAD
hypotensive reaction to ATG
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever,
chills,nausea, vomiting, inability to take any of your
medication, abdominal distension, increased incisional pain,
incision redness/bleeding/drainage or jp drain site is red.
Call if drain output stops
You will need to have labs drawn twice weekly at [**Last Name (NamePattern1) 8028**] Lab every Monday and Thursday prior to 9am
[**Month (only) 116**] shower
No heavy lifting/straining
No driving while taking pain medication
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2141-10-23**] 8:30
Provider: [**Name10 (NameIs) 2841**] LABORATORY Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2141-11-6**]
1:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2141-11-8**] 8:00
Completed by:[**2141-10-22**]
|
[
"271.0",
"458.29",
"070.32",
"250.53",
"414.01",
"272.4",
"V45.82",
"410.71",
"250.43",
"276.2",
"585.6",
"E878.0",
"584.5",
"327.23",
"250.63",
"428.0",
"403.91",
"E933.1",
"362.01",
"997.1",
"428.32",
"V58.67",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
8042, 8099
|
2982, 5596
|
291, 327
|
8186, 8193
|
2005, 2959
|
8742, 9191
|
1453, 1822
|
5916, 8019
|
8120, 8165
|
5622, 5893
|
8217, 8719
|
1837, 1986
|
246, 253
|
355, 591
|
613, 1256
|
1272, 1437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,463
| 128,854
|
14003
|
Discharge summary
|
report
|
Admission Date: [**2102-11-7**] Discharge Date: [**2102-11-12**]
Date of Birth: [**2024-7-13**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Amiodarone Analogues
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
78 year old male with DM, AS, afib, CAD s/p CABG [**06**] years ago
presented with left sided chest pain. The patient reports that
he was sitting paying his bills today when he had sudden onset
severe [**8-10**] left sided chest pain, non-radiating, no
diaphoresis, no SOB. The pain was unrelenting; he called his
physician who advised him to call 911 and go the the ED. En
route, he received 4 baby ASA and 2 nitro sprays w/o releif. In
the OSh ED, he received metoloprolol, morphine and was placed on
a nitro drip with [**Month (only) **] in pain to [**3-12**]. EKG showed non-specific
Twave abnl. Trop reported as 6.5 and pt transfered NSTEMI. En
route, he developed increasing CP in the ambulance requiring
that the nitro be titrated up.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Type 2 diabetes mellitis
Hypertension
Atrial fibrillation, on coumadin
Coronary artery disease s/p CABG
Moderate aortic stenosis
Social History:
The patient is a retired salesman and lives with his wife. [**Name (NI) **]
has a distant smoking history. He drinks an occassional glass
of wine, no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - 08.3 107/75 80 20 100%3L
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. 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. Healed midline scar from CABG.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Femoral 2+ DP 2+
Left: Femoral 2+ DP 2+
Pertinent Results:
Labs:
BLOOD WBC-8.8 RBC-3.58* Hgb-12.0* Hct-33.1* MCV-93 MCH-33.6*
MCHC-36.3* RDW-13.1 Plt Ct-253
PT-25.7* PTT-37.6* INR(PT)-2.5*
Glucose-103 UreaN-17 Creat-0.8 Na-135 K-4.2 Cl-103 HCO3-23
Calcium-8.5 Phos-3.6 Mg-1.9
%HbA1c-6.7*
Triglyc-64 HDL-33 CHOL/HD-3.6 LDLcalc-72 Cholest-118
Digoxin-0.8*
[**2102-11-7**] 11:29PM BLOOD CK(CPK)-638* CK-MB-75* MB Indx-11.8*
cTropnT-1.54*
[**2102-11-8**] 05:22AM BLOOD CK(CPK)-557* CK-MB-61* MB Indx-11.0*
cTropnT-1.88*
[**2102-11-7**] EKG: Atrial fibrillation with controlled ventricular
response. Downsloping ST segment depressions with T wave
inversions in leads V3-V6 suggestive of anterior myocardial
ischemia. Low limb lead voltage. Clinical correlation is
suggested. No previous tracing available for comparison.
[**2102-11-8**] CXR: Positioning is markedly lordotic making it
difficult to assess left lower lobe, but there appears to be
abnormal lung obscuring lower thoracic aorta. Routine
radiographs recommended to distinguish consolidation from lung
mass. Lower aspect left costal pleural margin excluded from the
examination. Other pleural surfaces are normal. Pulmonary
mediastinal vascular engorgement suggests volume overload but
there is no pulmonary edema.
[**2102-11-9**] Cardiac cath: COMMENTS:
1. Selective coronary angiography in this right dominanat system
revealed three vessel natvie coronary diease. The LMCA wsa free
of
angiographically apprent CAD. The LAD was occluded proximally.
The LCX
had a high grade stenosis and a small diffusely disease AV
groove
segment. The RCA was occluded rpoximally.
2. Selective venous conduit angioography revealed a patent
SVG-OM1,
SVG-diag, SVG-RPDA with diffuse and high grade disease at the
graft
inertion site.
3. Conduit arteriography revealed a patent but diffusely disease
LIMA-LAD.
4. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 17 mmHg and LVEDP of 27 mmHg. There was
severe
aortic stenosis with a to peak to peak gradient of 55 mmHg, a
mean
gradient of 35 mmHg and a calculated [**Location (un) 109**] of 0.78 cm2. The
cardiac index
5. Left ventriculography revealed a depressed LVEF of 40% and
moderate
mitral regurgitation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG to OM, SVG to diag, LIMa to LAD and evidence of
insertion
site stenosis of SVG-RPDA.
2. Moderate mitral regurgitation.
3. Severe aortic stenosis.
4. Mild systolic and diastolic ventricular dysfunction.
[**2102-11-10**] ECHO: There is extensive calcified atheroma of the
aortic root and ascending aorta. The left atrium is mildly
dilated. There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
mildly-to-moderately depressed (LVEF= 40 %) secondary to
hypokinesis of the inferior and posterior walls, and of the
apex. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with depressed free wall contractility. The ascending
aorta is mildly dilated. There are focal calcifications in the
aortic arch. The aortic valve leaflets are severely
thickened/deformed. There is moderate-to-severe aortic valve
stenosis (area 1.0 cm2). 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 tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2102-11-10**] Carotid ultrasound: IMPRESSION: Minimal plaque, no
internal or common carotid stenosis.
[**2102-11-10**] CXR: IMPRESSION:
1. No evidence of pneumonia.
2. Small bilateral pleural effusions.
3. Probable COPD.
Brief Hospital Course:
78 year old male with diabetes, atrial fibrillation, aortic
stenosis, and CAD s/p CABG who presents with NSTEMI.
#. NSTEMI: The patient had a TIMI risk score of 6 and ruled in
for an NSTEMI. EKG showed non-specific Twave abnormalities in
multiple leads. He remained pain free during his first night in
the hospital, however, was maxed out on a nitro drip and
required morphine. He was started on metoprolol 12.5 mg [**Hospital1 **],
loaded with clopidogrel, started on a heparin drip,
eptifibatide, and atorvastatin 80 mg. He was continued on
aspirin. The morning after admission he remained pain free and
the nitro drip was gradually titrated off. He was given vitamin
K 5 mg PO in anticipation of cardiac catheterization the
following morning. He was not immediately cathed due to an
elevated INR and he was symptomatically stable. He subsequently
became intermittantly bradycardic to the high 40s and had a
brief episode of lightheadedness after eating lunch that
resolved with sitting up. This was likely due to the added
metoprolol on top of long-acting verapamil. These medications
were discontinued and he was transfered to the CCU. Short
acting metoprolol was restarted the following day. He underwent
cardiac catheterization and no lesions intervenable by stenting
were found. The patient was transfered back to the floor. In
discussion with the patient medical management vs. redo bypass
was discussed. Given the patient's age and other comorbidities
it was decided to pursue medical management instead with
aspirin, clopidogrel, metoprolol, and atorvastatin. A panel of
labs for coagulability were drawn during this hospitalization
and the results were still pending at discharge. These results
should be followed up by his outpatient cardiologist.
# Aortic Stenosis: Valve area 0.81, with mean gradient 34 per
OSH records. ECHO here showed area of 1.0 cm2 with a mean
gradient of 33.
#. Pump: ECHO after cardiac cath showed LVEF = 40% secondary to
hypokinesis of the inferior and posterior walls, and of the
apex.
#. Atrial Fibrillation: The patient has a history of afib and
was in afib on admission without RVR. He admission INR was 2.5.
Warfarin was held for cardiac cath and the patient was placed
on heparin IV. Following cath his warfarin was restarted and
his INR was 1.9 on the morning of discharge. Digoxin was
initially held on admission and restarted on discharge.
Verapamil was stopped after the first dose and the patient was
transitioned to metoprolol. Consideration to uptitrating
metoprolol should be given as an outpatient.
#. Diabetes, type 2: Glyburide was held and the patient was
placed on an insulin sliding scale.
# HTN: The patient was initially continued on his home dose of
lisinopril and verapamil. Verapamil was held after the first
dose and the patient was transitioned to metoprolol that was
gradually titrated up based on heart rate. He was discharged on
metoprolol and lisinopril.
#. Hyperlipidemia - A fasting cholesterol panel showed an LDL
72, HDL 33, TG 64. Given his CAD history, his goal LDL should
be <70. He was started on atorvastatin 20 mg daily.
Medications on Admission:
Verapamil 240 mg ER
Digoxin 0.25 mg Tues, [**Last Name (un) **], Sat, Sun; 0.375 mg Mon, Wed, Fri
Diabeta 5 mg QPM, 2.5 mg QAM
Coumadin 2.5 mg daily except for 5 mg QSunday
Lisinopril 5 mg daily
MVI
Discharge Medications:
1. Diabeta 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
2.5 mg in the morning, 5 mg in the evening.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take 2.5 mg daily except take 5 mg every Sunday.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: Three (3) Tablet PO every other
day.
9. Digoxin 125 mcg Tablet Sig: Two (2) Tablet PO every other
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Final Diagnoses:
1. NSTEMI
2. 3 vessel coronary artery disease
Secondary Diagnoses:
1. Atrial fibrillation, on warfarin
2. Hypertension
3. Type 2 diabetes mellitus
4. Aortic Stenosis
Discharge Condition:
Stable, pain free, satting well on room air.
Discharge Instructions:
You were admitted to the hospital for evaluation of chest pain
and you had a heart attack. You had a cardiac catheterization
that showed significant coronary artery disease that could not
be fixed by stenting. You were evaluated to determine if you
could be a candidate for another coronary artery bypass and it
was decided to manage your symptoms with medications instead.
The following changes were made to your medications:
Please stop taking Verapamil.
You should start taking Metoprolol XL, Plavix (clopidogrel),
Lipitor (atorvastatin) and aspirin.
Please call your physician or return to the hospital if you
develop chest pain or pressure, shortness of breath, or other
concerning symptoms.
Followup Instructions:
Please call Dr.[**Name (NI) 31656**] office to make a follow-up appointment to
see him within 2-3 weeks. His phone number is: [**Telephone/Fax (1) 14525**].
|
[
"410.71",
"V45.81",
"401.9",
"396.2",
"250.00",
"496",
"414.01",
"272.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
10953, 10959
|
6716, 9852
|
321, 346
|
11187, 11234
|
2904, 5095
|
11983, 12145
|
1985, 2067
|
10101, 10930
|
10980, 10980
|
9878, 10078
|
5112, 6693
|
11258, 11960
|
2082, 2885
|
11065, 11166
|
10997, 11044
|
271, 283
|
374, 1621
|
1643, 1774
|
1790, 1969
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,957
| 105,006
|
30506
|
Discharge summary
|
report
|
Admission Date: [**2132-3-17**] Discharge Date: [**2132-4-1**]
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
coming for aspirin desensitization prior to cath, found to have
LMand 3VD referred for CABG
Major Surgical or Invasive Procedure:
[**3-17**] Cardiac catheterization
[**3-20**] CABG x 4 (LIMA->LAD, SVG->OM, SVG->L PLV, SVG->PDA)
History of Present Illness:
This is a 83 y/o M with h/o BPH, HTN, carotid stenosis who
presents for aspirin desensitization prior to cardiac cath after
positive MIBI.
Of note patient was referred to Dr [**First Name (STitle) **] for evaluation of
peripheral vascular disease. [**2131-11-19**] he was going up
stairs to pick up his mail, then he had a flash of light and
fell. He may have lost consciousness for a short period of time.
During this fall he dislocated his right shoulder and fx his
left shoulder. He denied any chest pain, palpitations,
headaches, shortness of breath or any other symptoms associated
with the episode.
After being seen by Dr [**First Name (STitle) **], stress MIBI was performed that
showed Moderate, reversible defects of the distal anterior and
septal walls respectively in addition to left ventricular cavity
dilatation consistent with subendocardial ischemia consistent
with LAD territory.
He also had a carotid ultrasound that reported carotid stenosis
with velocities >200 specially on the left side.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
At cath patient was found to have 60% LM, occluded LAD, 80% LCx,
60-70% RCA. Pt also found to have L renal artery stenosis
Past Medical History:
PAST MEDICAL HISTORY:
Bilateral hernias
BPH
Hypertension
Recent syncopal episode with fall resulting in bilateral
shoulder and arm fractures. [**2131-10-31**]
Peripheral vascular disease,
Carotid artery stenosis.
Social History:
Married. Lives with his wife. Distant history of smoking chewing
tobacco. Alcohol occasionally. Initially work in construction.
He has 5 children
Family History:
Mother with DM. No history of premature heart disease or sudden
death.
Physical Exam:
Admission
BP 159/64 HR 56 RR 16 Sats 96 % on RA
General: well developed, pleasant, well nourished. Oriented to
person, place and time.
HEENT: pupils equal and reactive to light. External ocular
movements preserved. No JVD appreciated. no thyromegaly. Moist
oral mucosa.
+ Left side carotid bruit.
Lungs: occasional crackles in both bases.
Cardiovascular. Palpation of PMI showed to be located in the 5th
intercostal space, mid clavicular line. Regular rate and rhythm,
s1-s2 normal. Soft holosystolic murmur in the apex radiated to
the axilla. No S3 or S4 appreciated. No rubs.
Abdomen: BS+, soft non tender, non distended. obese. no
hepatomegaly appreciated.
Extremities: no clubbing, no cyanosis. 1+ lower extremity edema.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge
VS 97.8 HR 52SR BP150/56 RR 18 O2sat 92% RA
Gen NAD
Neuro A&Ox3 nonfocal exam
Pulm Clear but dim throughout
CV RRR no murmur. Sternum stable, incision CDI
Abdm soft, NT/ND/+BS
Ext warm 2+pedal edema bilat Skin multiple tears from tape
Pertinent Results:
[**2132-3-17**] 09:52PM WBC-9.8# RBC-3.44* HGB-10.9* HCT-32.0* MCV-93
MCH-31.8 MCHC-34.2 RDW-13.4
[**2132-3-17**] 09:52PM PLT COUNT-206
[**2132-3-17**] 09:27PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2132-3-17**] 06:00PM GLUCOSE-136* UREA N-21* CREAT-1.0 SODIUM-139
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-32 ANION GAP-8
[**2132-3-17**] 06:00PM ALT(SGPT)-11 AST(SGOT)-15 CK(CPK)-39 ALK
PHOS-59 AMYLASE-49 TOT BILI-0.5
[**2132-3-17**] 06:00PM ALBUMIN-3.4 CALCIUM-8.4 CHOLEST-146
[**2132-3-17**] 06:00PM PT-13.2* PTT-31.9 INR(PT)-1.1
[**2132-3-28**] 06:40AM BLOOD WBC-9.5 RBC-3.05* Hgb-9.1* Hct-28.8*
MCV-95 MCH-29.9 MCHC-31.7 RDW-13.7 Plt Ct-398
[**2132-3-28**] 06:40AM BLOOD Plt Ct-398
[**2132-3-25**] 02:55AM BLOOD PT-13.0 PTT-28.0 INR(PT)-1.1
[**2132-3-28**] 06:40AM BLOOD Glucose-104 UreaN-46* Creat-2.0* Na-141
K-4.6 Cl-103 HCO3-32 AnGap-11
CHEST (PA & LAT) [**2132-3-26**] 5:15 PM
CHEST (PA & LAT)
Reason: evaluate pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
83 year old man s/p CABGx4
REASON FOR THIS EXAMINATION:
evaluate pleural effusion
PA AND LATERAL CHEST RADIOGRAPHS
INDICATION: Status post CABG, evaluate pleural effusion.
COMPARISON: Series of radiographs, most recent dated [**2132-3-22**].
FINDINGS: Again noted right internal jugular approach central
venous catheter device with the distal tip projected over the
right atrium. Cardiac silhouette is enlarged and mediastinum is
mildly widened, consistent with post-operative state, not
overtly changed from previous examination. Lung volumes are
improved on this study, however, still evident a left lower lung
atelectasis with moderate-sized left pleural effusion. Pulmonary
vascularity is normal.
IMPRESSION: Not significantly changed degree of left lower lobe
atelectasis and moderate-sized pleural effusion. Improved lung
volumes bilaterally.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
RENAL U.S. [**2132-3-24**] 10:08 AM
RENAL U.S.
Reason: Assess kidney's
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with ATN
REASON FOR THIS EXAMINATION:
Assess kidney's
INDICATION: 83-year-old with ATN assess kidneys.
RENAL ULTRASOUND: No prior studies for comparison. The right and
left kidneys measure 9.5 and 10.1 cm respectively. There is an
approximately 2cm exopohytic, hypoechoic mass off the mid to
lower pole of the right kidney, concerning for a neoplasm. No
other solid or cystic lesions. No hydronephrosis.
IMPRESSION:
1) 2-cm exophytic hypoechoic mass off the mid to lower pole of
the right kidney, concerning for malignancy; MRI is recommended
for further characterization.
2) No hydronephrosis. Cortical echogenicity is somewhat
difficult to evaluate but appears likely within normal limits.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
PATIENT/TEST INFORMATION: Echo
Indication: Intraoperative TEE for CABG procedure
Height: (in) 65
Weight (lb): 167
BSA (m2): 1.83 m2
BP (mm Hg): 145/78
HR (bpm): 56
Status: Inpatient
Date/Time: [**2132-3-20**] at 09:47
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: *2.8 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 7 mm Hg
Tricuspid Valve - Peak TS Velocity: 2.0 m/sec
TR Gradient (+ RA = PASP): >= 17 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Low normal
LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Mildly dilated ascending aorta. Focal
calcifications in ascending
aorta. Simple atheroma in aortic arch. Mildly dilated descending
aorta.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was
under general anesthesia throughout the procedure. The patient
appears to be in sinus rhythm. Results were personally reviewed
with the MD caring for the patient.
Conclusions:
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are simple
atheroma in the
aortic arch. The descending thoracic aorta is mildly dilated.
There are
complex (>4mm) atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is
seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
Post Bypass
1.Patient is being AV paced.
2. Biventricular systolic function is unchanged.
3. Mild mitral regurgitation persists.
4. Aorta intact post decannulation.
5. On arrival to the CRSU acute ST elevation seen in the
inferior leads. TEE examination did not show any new wall motion
abnormalities in either the right or left ventricle. No evidence
of aortic dissection. Mild mitral regurgitation seen. Dr [**Last Name (STitle) **]
aware of findings.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2132-3-20**] 14:01.
Brief Hospital Course:
Mr. [**Name13 (STitle) 72457**] was admitted for aspirin desensitization which he
tolerated. Cardiac catheterization on [**3-17**] showed LM and 3VD and
he was referred for CABG. He awaited plavix wash out. He had a
history of a syncopal episode for which he was seen by
cardiology with no indication for pacer found. He was taken to
the operating room on [**3-20**] where he underwent a
CABGx4(LIMA->LAD, SVG->OM, LPLV, PDA). He was transferred to the
cardiac surgery ICU in critical but stable condition. He was
extubated later that same day. He was seen by nephrology for a
rising creatinine. The patient did well in the immediate post-op
period, he remained in the ICU for several days to monitor his
renal function. On POD 4 he was transferred to the floors after
his creatinine plateaued at 3.5. Over the next several days his
renal function improved, his activity level was advanced with
nursing and PT help. And on POD8 it was decided he was stable
and ready to discharge to rehabilitation.
Medications on Admission:
Plavix 75
Diovan 80
terazosin 5,
hydrochlorothiazide 25
finasteride 5
iron 65
multivitamin
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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
CAD
HTN
BPH
Infrarenal AAA
melanoma
syncopal episode [**11-4**] with bilat shoulder and arm fractures
SBO s/p repair
s/p excision of melanoma on face
bilat hernia s/p repair
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, rednes or drainage from incision or weight gain
more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 2-3 weeks
Dr. [**Last Name (STitle) 8430**] 2-3 weeks
Dr. [**First Name (STitle) **] 4 weeks
Patient will need an MRI of his kidneys as an outpatient when
her creatinine has improved secondary to an inconclusive finding
on a renal ultrasound during her stay.
Completed by:[**2132-3-28**]
|
[
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"276.7",
"790.01",
"997.1",
"997.3",
"V10.82",
"427.31",
"707.11",
"518.0",
"793.5",
"414.01",
"401.9"
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icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.04",
"88.56",
"88.45",
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"38.91",
"89.64",
"38.93",
"34.04",
"88.72",
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12530, 12588
|
10207, 11208
|
312, 412
|
12806, 12814
|
3549, 4527
|
13112, 13433
|
2341, 2414
|
11349, 12507
|
5746, 5771
|
12609, 12785
|
11234, 11326
|
12838, 13089
|
6755, 10184
|
2429, 3530
|
181, 274
|
5800, 6729
|
440, 1925
|
1969, 2161
|
2177, 2325
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,805
| 118,115
|
51349
|
Discharge summary
|
report
|
Admission Date: [**2161-11-1**] Discharge Date: [**2161-11-5**]
Date of Birth: [**2097-12-15**] Sex: F
Service: MEDICINE
Allergies:
Zestril / Cozaar
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
"dizziness, headache, and possible syncopal episodes"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 yoF NIDDM, htn, cri p/w dizziness and ? 4 syncopal episodes
over the previous two days due to weakness. Pt reports
compliance with her medications, adequate PO intake, adequate
urine output. Complains of +cough, non-mucous producing.
Denies vaginal discharge, dysuria, diarrhea. Admits to
intermittent abd discomfort. Denies fevers, chills, nausea,
vomiting.
In ED, t 98.3, hr 88, bp 143/60, o2 sats 99%, AG 17, UA
showed gluc 1000, ARF cr 6.2, mild hyperkalemia 5.6, hct 33, CT
head (-), CXR (-). Initiated on insulin gtt 5u/hr, IVF,
potassium repletion with drop to 3.9, asa 325.
Past Medical History:
1. hypertension - clonidine uptitrated in previous 3 months for
more adequate BP control, in addition to [**Last Name (un) **].
2. diabetes - outpatient regimen changed [**8-18**] from metformin,
glyburide to glipizide 5, with maximum increase on [**9-9**] to
10mg/[**Hospital1 **] due to uncontrolled hyperglycemia with last PCP plan to
consider lantus initiation. Pt recently had nutrition consult
[**10-6**] for better control of blood glucoses.
3. renal insufficiency - nephrologist, Dr. [**Last Name (STitle) 118**]
4. hpylori gastritis/gerd - prescribed prevpac [**7-18**]
5. gout
Social History:
NC
Family History:
NC
Physical Exam:
At admission:
PE: T: 97.1 BP: 115/54 HR: 78 RR: 16 100%ra
Gen: NAD, A/Ox3, lying in bed, conversant, cooperative.
HEENT: no conjunctival pallor, no scleral icterus appreciated,
dry membranes, no posterior pharyngeal erythema appreciated.
NECK: no posterior/anterior LAD, no JVD appreciated. No carotid
bruits appreciated bilaterally.
CV: RRR, S1+S2+S3-S4-, gentle 2/6 sem lsb.
LUNGS: CTAB, good air movement bilaterally, no crackles
appreciated, no wheezes appreciated
ABD: NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT: no lower extremity edema. 2+ palpable pulses bilaterally
dorsalis pedis, posterior tibial, radial, ulnar, all 2+.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy. Preserved sensation throughout. MSK 4+/5
bilaterally, upper extremities and lower extremities. 1+
reflexes L4 bilaterally.
PSYCH: Listens and responds to questions appropriately
Pertinent Results:
At admission: hct 33 mcv 90 wbc 8.5 plat 407 cr 6.2 (1.4 -
2.8), ag 17, gluc 525, bun 48, trop 0.02.
.
STUDIES:
[**10-16**] - ECHO - LV wall thickness, cavity size, systolic fx
normal (LVEF>55%). RLVWM nl. Mild (1+) AR, mitral valve
leaflets mildly thickened. Mild (1+) MR seen.
[**8-18**] - stress MIBI - Average functional exercise tolerance for
age. No anginal symptoms or ischemic ST segment changes.
Exaggerated blood pressure response to exercise. Nuclear report
sent separately.
[**10-31**] chest PA/LAT - pending
[**11-1**] CT head - Soft tissues and osseous structures appear
unremarkable. The paranasal sinuses and mastoid air cells are
well aerated. No evidence of intracranial hemorrhage, mass
effect, shift of midline structures, hydrocephalus, or acute
major vascular territorial infarct. [**Doctor Last Name **]-white matter
differentiation is well preserved.
Brief Hospital Course:
64 yo F with htn, niddm, cri p/w dizziness, found to have DKA,
arf.
.
# DKA/hyperosmolar hyperglycemic state. At admission anion gap
was 17, glucose 525, urine gluc 1000, urine ketone (-), acetone
(+), altered sensorium, bicarb >15. This appeared as a mixed
picture of HHS and medication non-compliance, possibly
complicated by infection. With fluid resuscitation, NA was
corrected to 145, and pt became euvolemic. Pt remained good UOP.
Hyperglycemia was treated wtih an insulin drip, and was
transitioned to RISS. Electrolites were checked, and glucose
was checked q 2 hours until the anion gap was closed on the
morning of [**11-1**]. Urine culture, blood culture and CXR were
checked for nidus of infection, and were negative at time of d/c
from the ICU. EKG showed no changes. [**Last Name (un) **] stim was performed
to rule out adrenal insuffiency given the initial electorlyte
abnormalities on admission, and was nl. [**Last Name (un) **] was consulted to
see the patient. Patient was taken off their home glipizide,
and started on a humalog SS and lantus. These were titrated to
establish an effective schedule. The patients anion gap
corrected and acidemia corrected. At discharge, the patient was
without any more symptoms. She was scheduled with follow up in
[**Last Name (un) 387**] patient education clinic to further assist in insulin
administration and instruction on syringe magnifying options,
was instructed on insuling administration on the floor, and was
seen by nutrition for further diabetic teaching.
.
# Acute renal failure - baseline cri with arf. FeNa 0.7, FeUrea
10%, both pre-renal, likely [**2-13**] to significant volume depletion
as above. UA with mild bacturia, +pyuria. urine electrolytes
were rechecked with FeNa of 1.7, as patient was more euvolemic.
Renal US was performed to eval for kidney perfusion, showed
normal renal flow. Patient was givin IVF and has daily
improvement of Cr from 6.5 back to baseline of 2.6 by time of
discharge. Patient was consulted on by renal, who recomended
holding dinovan, lasix, and allopurinol at time of discharge, to
be restarted as outpatient.
.
# Syncopal episodes - by nursing report, pt has had [**1-13**]
'blacking out' episodes over previous two days, but were unable
to determine pre-aura or other assoc symptoms from history. Pt
was placed on telemetry with no events noted. CE were also
sent, which were nl.
.
# hypertension - hold [**Last Name (un) **] [**2-13**] arf. Verapimil and clonidine were
additionally initially held, then restarted as partial doses.
Patient had sbp of 120-140 at time of discharge on partial
doses, and patient was discharged on these smaller doses.
.
# GERD/gastritis - reportedly completed prevpac for hpylori+
gastritis with biopsies on upper scope. Acid suppression not on
recent med list. H2 blocker to start.
.
Medications on Admission:
1. allopurinol 300mg qd
2. clonidine 0.3mg [**Hospital1 **]
3. diovan 160mg [**Hospital1 **]
4. glipizide 5mg [**Hospital1 **]
5. lasix 40mg qd
6. verapamil 360 qd
Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Verapamil 360 mg Cap,24 hr Sust Release Pellets Sig: One (1)
Cap,24 hr Sust Release Pellets PO once a day.
3. Insulin Glargine 100 unit/mL Solution Sig: 0.25 ml
Subcutaneous at bedtime.
Disp:*10 ml* Refills:*2*
4. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: apply provided sliding scale
after checking finger sticks as instructed.
Disp:*10 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Care Group Home Care
Discharge Diagnosis:
diabetic ketoacidosis
acute renal failure
hypertension
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after an admission
for a condition called diabetic ketoacidosis. This is caused
from high blood sugars which causes your blood to become acidic.
It was responsible for the symptoms you were experiencing.
During the admission, you acid levels were corrected and your
blood sugars were normalized. You also became dehydrated, which
saused acute renal failure, which has also be corrected with
fluids.
In order to acheive successful blood sugar control, you will
to take daily insulin. This will require checking your finger
sticks and administering insulin before meals as directed.
We will have you hold your regular taking of allopurinol,
dinovan, and lasix, which will restarted as an outpatient. We
will also be discharging you on a smaller dose of your blood
pressure med clonidine, and your normal home verapimil dose.
You should follow up with your PCP as given below. If you
develop HA, blurred vision, lightheadedness, chest pain,
palpitations, abdominal pain, or any other concerning symptoms,
you should call your PCP.
Followup Instructions:
[**Hospital **] Clinic Insulin Teaching w/ [**First Name5 (NamePattern1) 16883**] [**Last Name (NamePattern1) 106494**] on the [**Location (un) **]
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-11-6**]
11:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-11-16**]
10:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2161-12-2**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
|
[
"403.90",
"250.12",
"584.9",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7112, 7163
|
3521, 6372
|
334, 340
|
7262, 7271
|
2615, 3498
|
8402, 9160
|
1615, 1619
|
6592, 7089
|
7184, 7241
|
6398, 6569
|
7295, 8379
|
1634, 2596
|
240, 296
|
368, 962
|
984, 1579
|
1595, 1599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,045
| 144,997
|
31217
|
Discharge summary
|
report
|
Admission Date: [**2119-9-5**] Discharge Date: [**2119-9-14**]
Date of Birth: [**2040-7-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ceftin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
[**2119-9-8**] CABGx3(LIMA-LAD,SVG-OM,SVG-PDA)
1. left hip removal of hardware and conversion to total hip
replacement
2. left hip revision acetabulm
3. left hip open reduction
History of Present Illness:
79 yo female w/ ho DM, HTN, DVT, CAD s/p PCI [**2-/2118**] at OSH
(unclear which vessel, no records), admitted [**2119-9-5**] for Left
hip replacement (had fall [**2118-1-8**], requiring a screw at that
time, had non [**Hospital1 **] and poor healing, leading to current
admission for a revision of that surgery). Surgery was
complicated requiring revision same day. Post op ([**9-6**] at 10AM)
pt complained of chest pain with HR in 100s, given 500cc NS,
maalox and oxycodone, pain resolved, EKG and enzymes were
checked, with ST depressions suggestive of left main
involvement, CKMB and Tnt elevated.
.
Pre-Op done by Dr. [**Last Name (STitle) **] on [**8-21**]. Pt denied angina symptoms at
that time with ambulation or with rehab exercises. Decides no BB
preop at due to low HR and no need to continue Warfarin given
single event of DVT, also stopped plavix given distant h/o
stent, decided pt only needs to be on ASA 81
.
ORTHO SURGERY INFO:
#1: REMOVAL OF HARDWARE AND CONVERSION TO COMPLEX L THA
#2: REVISION L HIP ACETABULUM (posterior wall fx)
#1: EBL ~ 900, 250 back with cell [**Doctor Last Name 10105**]
#2: EBL ~ 5-600, ~100 back with cell [**Doctor Last Name 10105**] and 2u PRBCs/1 or 2
of
Labs and imaging significant for *****
Patient given: 1U RBC after surgery after Hct 26.0 from 29.4
.
On arrival to the floor, patient was comfortable
VS: BP 113/56, HR 109, 95% 2L
.
REVIEW OF SYSTEMS
Cardiac review of systems is notable for chest pain only with
movement in bed, no DOE, no orthopnea, leg swelling, no
palpitations.
Past Medical History:
[**2119-9-8**] CABGx3(LIMA-LAD,SVG-OM,SVG-PDA)
[**2119-9-5**] L THR
-alcohol-related neuropathy
-diabetes mellitus
-prior ankle fracture
-hip fracture in [**2119-2-8**]: an intertrochanteric fracture with
subtrochanteric extension at [**Hospital **] Hospital. The fracture
subsequently went on to nonunion.
-? previous DVT given fact that she is on coumadin and has a
radiographic finding of remodelled clot on her ultrasound
-total abdominal hysterectomy
- appendectomy
- tonsillectomy
Social History:
The patient lives alone. Currently living in Avory manor. She
is a former smoker. She has one daughter. [**Name (NI) 3003**] to admission to
rehab, drank a third of a bottle of vodka per day and has been
doing so for 10 years. Occasional marijuana use. She had been
walking with a walker two years prior to hip fracture due to
alcohol-related neuropathy of the lower extremities. She has
been unable to ascend and descend stairs for at least two years
prior to her fall.
Family History:
Noncontributory for sudden cardiac death, arrhythmia, or
coronary artery disease.
no history of gout, CPPD, arthritis
Physical Exam:
Physical Exam on Admission to the CCU:
VS: 98.9, 113/56, 109, RR 18, 96% on 1L
GENERAL: NAD. Oriented x3. Mood, affect appropriate. She is not
clear about the events surrounding current admission, but tries
to answer
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva pink, some
pallor of skin, although no baseline.
NECK: Supple without JVD.
CARDIAC: PMI non displaced, tachycardic, no m/r/g, +s1+s2
LUNGS: Could only auscultate anteriorly, as patient is not able
to lean forward with hip pain. Resp were unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness.
EXTREMITIES: left leg in cast, and multiple cushioning, JP drain
on left draining blood.
PULSES - 2+ DP/PT on right, left is wrapped.
Discharge Exam
VS 97.8 123/65 59SR 18 95% RA
Wt 88.5 kg
Gen NAD
Neuro: A&O x3, MAE-nonfocal exam
Pulm: CTA-diminished bases bilat
CV: RRR, no murmur. Sternum stable incision CDI
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. Left hip incision w/staples-CDI
trace pedal edema bilat
Pertinent Results:
Admission:
[**2119-9-5**] 10:32AM PLT COUNT-313
[**2119-9-5**] 10:32AM HGB-10.4* HCT-29.4*
[**2119-9-5**] 10:48AM freeCa-1.10*
[**2119-9-5**] 10:48AM HGB-10.6* calcHCT-32 O2 SAT-96
[**2119-9-5**] 10:48AM GLUCOSE-159* LACTATE-1.4 NA+-129* K+-4.1
CL--98
[**2119-9-5**] 12:58PM URINE MUCOUS-RARE
[**2119-9-5**] 12:58PM URINE RBC->182* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
[**2119-9-5**] 12:58PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2119-9-5**] 12:58PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2119-9-5**] 06:53PM freeCa-1.01*
[**2119-9-5**] 06:53PM HGB-6.8* calcHCT-20
[**2119-9-5**] 06:53PM GLUCOSE-154* LACTATE-2.1* NA+-130* K+-4.4
CL--102
[**2119-9-5**] 06:53PM TYPE-ART RATES-/10 TIDAL VOL-600 PEEP-2 O2-50
PO2-213* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2119-9-5**] 08:30PM PLT COUNT-143*#
[**2119-9-5**] 08:30PM WBC-15.1*# RBC-3.19*# HGB-9.7* HCT-28.2*
MCV-88 MCH-30.5 MCHC-34.5 RDW-14.5
[**2119-9-5**] 08:30PM CALCIUM-7.5* PHOSPHATE-5.0* MAGNESIUM-1.3*
[**2119-9-5**] 08:30PM estGFR-Using this
[**2119-9-5**] 08:30PM GLUCOSE-177* UREA N-18 CREAT-0.9 SODIUM-132*
POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-21* ANION GAP-13
Discharge labs
[**2119-9-14**] 05:40AM BLOOD WBC-11.7* RBC-3.04* Hgb-9.1* Hct-28.1*
MCV-93 MCH-29.8 MCHC-32.2 RDW-14.7 Plt Ct-317
[**2119-9-14**] 05:40AM BLOOD Plt Ct-317
[**2119-9-14**] 05:40AM BLOOD PT-16.7* PTT-28.6 INR(PT)-1.6*
[**2119-9-13**] 04:13AM BLOOD PT-21.7* PTT-32.7 INR(PT)-2.1*
[**2119-9-14**] 05:40AM BLOOD UreaN-22* Creat-1.2* Na-138 K-4.3 Cl-98
[**2119-9-13**] 04:13AM BLOOD Glucose-133* UreaN-25* Creat-1.1 Na-135
K-3.9 Cl-96 HCO3-30 AnGap-13
.
[**9-5**] EKG: STD in I, II, V4-V6, STE aVR: Left Cx vs prox Left
main vs gobal?
.
[**9-7**] 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 left ventricular
aneurysm. Overall left ventricular systolic function is
moderately depressed (LVEF = 35 %) secondary to severe
hypokinesis (with basal akinesis) of the inferior septum,
inferior free wall, and posterior wall. The apex is diffusely
hypokinetic with focal dyskinesis. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**1-9**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2119-9-13**] 8:47
AM
Final Report: As compared to the previous radiograph, there is
a slightly
increasing pleural effusion, as compared to a constant right
pleural effusion. Sternal wires in unchanged position. The
pre-existing small left apical pneumothorax is of unchanged
dimensions. No evidence of tension. Unchanged moderate
cardiomegaly without overt pulmonary edema.
Brief Hospital Course:
79 y/o with significant cardiac history including stent in [**2118**],
admitted for left hip surgery, then presented with CP, elevated
CKMB, elevated TnT, and EKG changes.
.
# LEFT HIP REPLACEMENT: Patient was admitted for left hip
replacement. Post-operative course was notable for failed left
acetabular cup. PACU xrays demonstrated interval change in cup
position as compared to intraop films as well as left hip
dislocation. Ms. [**Known lastname **] was re-consented and taken back to the
OR for revision of acetabulum. Post-operatively, she developed
cardiac complications. Orthopedic surgery continued to follow
the patient when she was transferred to the CCU and the CVICU.
Pain was controlled with oxycodone and morphine.
.
# CORONARY ARTERY DISEASE: Catheterization showed 99% stenosis
of the left main coronary artery, IABP was plaxced and the
patient was taken for CABG.
.
# ANEMIA: s/p 1U PRBC after surgery, Hct was 28 at discharge.
.
# UTI: UCx from [**9-5**] grew Enterococcus after Foley was placed.
The patient was treated with Zosyn to be continued until [**9-18**].
.
# ETOH ABUSE: Pt states her last drink was about 5mo ago when
starting physical rehab for left hip fracture. She was started
on CIWA scale in the CCU.
.
# DM2: As per patient, she was diagnosed 2mo ago and is on
metformin 500 [**Hospital1 **] at home. She was placed on ISS during her
hospitalization.
.
Patient tolerated coronary bypass opertion well. Her IABP was
weaned and removed on the morning of POD1. Sedation was then
weaned, she woke neurologically intact and was extubated. All
tubes lines and drains were removed per cardiac surgery protocol
w/o complication. She had several episodes of atrial
fibrillation and was started on Amiodarone and coumadin. She had
a supratherapeudic response to the coumadin and remained in the
ICU until because her INR was 8. She received vitamin K to
reverse INR. On POD3 she was transferred to the stepdown floor.
The remainder of her hospital stay was uneventful. She worked
with nursing and physical therapy to advance her ADL's and was
transferred to rehabilitation at [**Location (un) 1036**] in [**Location (un) 620**] on POD
6. All f/u appts were advised.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Losartan Potassium 50 mg PO DAILY
hold for SBP < 110, HR < 60
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
hold for SBP < 110, HR < 60
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Senna 1 TAB PO PRN constipation
8. Paroxetine 10 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. TraMADOL (Ultram) 100 mg PO Q8H:PRN pain
11. Calcium Carbonate 500 mg PO TID
12. Vitamin D 400 UNIT PO DAILY
13. Milk of Magnesia 30 mL PO PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
hold for SBP < 110, HR < 60
6. Losartan Potassium 50 mg PO DAILY
hold for SBP < 110, HR < 60
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Milk of Magnesia 30 mL PO PRN constipation
9. Paroxetine 10 mg PO DAILY
10. Senna 1 TAB PO PRN constipation
11. Simvastatin 40 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Acetaminophen 650 mg PO Q6H
standing dose
14. Amiodarone 400 mg PO DAILY
400mg QD x7days then 200mg QD
15. FoLIC Acid 1 mg PO DAILY
16. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
17. Furosemide 40 mg PO DAILY
18. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
19. Multivitamins 1 TAB PO DAILY
20. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 4 Days
21. Potassium Chloride 20 mEq PO DAILY
Hold for K+ > 4.5
22. 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.
23. Thiamine 100 mg PO DAILY
24. Warfarin MD to order daily dose PO DAILY afib
target INR 2-2.5
25. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
coronary artery disease s/p CABG
left hip non-[**Hospital1 **]
left hip failed acetabular cup
left hip dislocation
left posterior wall acetabular fx
PMH: HTN, type 2 DM, EtOH abuse([**1-10**] bottle vodka/day-?last drink
5 months ago), neuropathy d/t EtOH abuse, B12 deficiency, CAD,
s/p PCI-was on plavix, DVT(?[**2077**]) on coumadin, ?HIV+-no
testing-husband positive, L hip fracture-s/p screw placement and
non-[**Hospital1 **]/avascular necrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: TOUCHDOWN Weight bearing with walker or 2
crutches at all times for 2 MONTHS. Prone stretching.
Posterior precautions. No strenuous exercise or heavy lifting
until follow up appointment
Discharge Instructions:
1. Look at your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
2. Each morning you should weigh yourself and then in the
evening take your temperature.
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**
3. 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.
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. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) 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 rehab facility two weeks after
your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your coumdin for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to surgery, you may resume you
pre-operative dose while taking coumadin. [**Male First Name (un) **] STOCKINGS x 6
WEEKS.
10. 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 (4)
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 rehab
facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: TOUCHDOWN Weight bearing with walker or 2 crutches
at all times for 2 MONTHS. Prone stretching. Posterior
precautions. No strenuous exercise or heavy lifting until follow
up appointment. Mobilize frequently.
Followup Instructions:
You are scheduled for the following appointments:
Cardiac Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2119-10-19**] 1:00
Orthopedic Surgeon: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2119-10-5**] 2:15
Cardiologist: needs referral
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) 1730**] P. [**Telephone/Fax (1) 19980**] in [**4-13**] weeks
Labs: PT/INR for Coumadin ?????? Afib/DVT x3 mo
Goal INR 2-2.5
First draw [**9-15**]
**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:[**2119-9-14**]
|
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icd9cm
|
[
[
[]
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[
"36.12",
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icd9pcs
|
[
[
[]
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11728, 11805
|
7520, 9727
|
286, 465
|
12305, 12305
|
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15878, 16727
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,425
| 117,082
|
28372
|
Discharge summary
|
report
|
Admission Date: [**2158-2-27**] Discharge Date: [**2158-3-6**]
Date of Birth: [**2109-1-23**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Flexeril / Tricyclic Compounds
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 68459**] is a 49 year old female with history of Hep C
Cirrhosis, currently listed for transplant with history of
previous decompensation in way of encephalopathy and ascites
requiring TIPS, with additional med history pertinent for
secondary adrenal insufficiency, and DM who now presents from
her chronic care facility. The patient was found unresponsive
yesterday a.m. with fingerstick at that time of 8 and question
of seizure activity at that time. The patient was transported to
[**Hospital3 **] where a CT Head was performed without evidence of
bleed or acute intracranial pathology. The patient was
transferred to [**Hospital1 18**] for further care.
.
ED Course: In the ED vitals were 94.2 HR-81 BP- 110/55 RR: 20
O2: 100% NRB. The patient has labs performed revealing no
leukocytosis or bandemia. A CXR was performed revealing for new
RLL consolidation. A [**Name (NI) 5283**] sono and abdominal ultrasound was
performed revealing no ascites present. Fingerstick was 142. The
patient received Levo/Zosyn/Vanc and is now transferred to the
ICU for ongoing monitoring and care.
.
Patient being transferred to [**Doctor Last Name 3271**] [**Doctor Last Name **] service, upon
questioning patient is sleepy but arousable. She reports some
back pain which is her baseline but otherwise has little
complaints. On questioning she reports her breathing is
comfortable, has been coughing little more than usual green
sputum. She took 32 units of Glargine 2 nights ago per her usual
regimen, reports she ate meals that night. She does not recall
the exact events surrounding her event this a.m. and altered
mental status. She was put on vanc and unasyn for consideration
aspiration and ha-pna. Also put on stress dose steroids.
Baseline bp 100-110. Stress dose steroids initially 50 q6 and
decreased to 25 q6 currently.
.
On admit to the floor pt. near baseline mental status. Has NG
tube and getting lactulose--> stooling a lot. HD stable and
transferred to floor.
Past Medical History:
# HCV cirrhosis:
- complicated by encephalopathy, thrombocytopenia, ascites and
hydrothorax.
- s/p TIPS [**11-9**] for ascites
- currently On transplant list
#. Hyponatremia baseline 128-133
#. Secondary Adrenal insufficiency: should receive stress dosed
steroids when appropriate
- microadenoma on MRI, prolactin elevated
#. Asthma
#. DM
#. GERD
#. Anxiety
#. Recent ICU admission with intubation thought [**1-7**]
transfusion-related acute lung injury. Led to prolonged ICU stay
then rehab. Also treated for PNA
#. h/o UTIs
#. Hip fx and L4 compression fx on [**2157-11-6**] s/p ORIF of hip fx
Social History:
The patient is single with one child, she currently lives in a
chronic care facility, [**Hospital1 **] [**Hospital1 3894**] Nursing Facility in [**Location (un) 29158**]. She is currently on disability, formerly a waitress.
Illicits: Past IV drug use with needle sharing, last use 7 years
ago. Past drug-snorting.
Alcohol: Past alcohol use, last drink at age 46.
Tobacco: Past [**Location (un) 1818**] with 10 pack-year history
Family History:
Mother w/ DM2, HTN, and hyperlipidemia.
Father w/ COPD and EtOH cirrhosis
Physical Exam:
VITALS: 97.1 122/56 88 18 97% on RA
GEN: Patient is a middle aged female, appears older than stated
age, jaundiced skin. Patient is lethargic but arousable, answers
questions but need to keep awakening to hold attention. Oriented
to person place and year. Knows why she is here.
HEENT: NCAT, EOMI, sclera icteric. PERRL, OP clear, NGT in place
NECK: JVP wnl
LUNGS: Relatively clear anteriorly, bibasilar crackles
Cor: II/VI SEM loudest at apex
ABD: Obese, soft, nt/nd, bs+, live tip palpable just below
costal margin. spleen tip not palpable
EXT: 1+ LE non pitting edema to knees, mild diffuse erythema
likely secondary to venous stasis
Pertinent Results:
[**2-27**] CXR
IMPRESSION: AP chest compared to [**2-27**] and [**2157-11-10**]:
Moderate cardiomegaly has increased since [**Month (only) 1096**]. Elevation of
the left hemidiaphragm and ipsilateral basal atelectasis are
stable. Increased opacification at the right lung base could be
dependent edema but is concerning for pneumonia, unchanged since
[**59**]:07 a.m. Small right pleural effusion is probably present.
Nasogastric tube ends in the stomach, which is distended with
air.
--------------------
[**3-3**] CXR
FINDINGS: In comparison with the study of [**2-27**], the patient has
taken a somewhat better inspiration. Continued fullness of
pulmonary vessels is consistent with overhydration and increased
pulmonary venous pressure. There is increased opacification at
both bases, consistent with pleural fluid and atelectatic
change. The nasogastric tube has been removed.
[**3-5**] u/s
LEFT UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler
son[**Name (NI) 1417**] of the left internal jugular, subclavian, axillary,
brachial, and basilic veins was performed. The cephalic vein was
not visualized. In the visualized veins there was normal flow,
augmentation, compressibility, and waveforms demonstrated. No
intraluminal thrombus was identified.
IMPRESSION: No evidence of left upper extremity deep vein
thrombosis. Cephalic vein not seen.
d/c labs
[**2158-3-6**] 04:23AM BLOOD WBC-4.6 RBC-2.94* Hgb-10.2* Hct-30.0*
MCV-102* MCH-34.6* MCHC-33.9 RDW-19.3* Plt Ct-30*
[**2158-3-6**] 04:23AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-134
K-4.1 Cl-99 HCO3-31 AnGap-8
[**2158-3-6**] 04:23AM BLOOD ALT-36 AST-64* LD(LDH)-274* AlkPhos-214*
TotBili-6.4*
[**2158-3-6**] 04:23AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.5*
Brief Hospital Course:
A/P: 49 y/o F h/o HCV cirrhosis, currently on transplant list,
who presented with unresponsive episode and ? seizure episode 2
days prior in setting of hypoglycemia to 8, found to have RLL
consolidation identified on CXR c/w pneumonia. Currently
patient's mental status back at baseline.
.
# Altered mental status
Long h/o admissions for somnolence secondary to hepatic
encephalopathy although more likely etiology this admission
would be hypoglycemia given documented low blood sugar in
combination with underlying hepatic encephalopathy. Etiology for
hypoglycemia itself not clear given no change in meds, diet,
hepatic function. Possibly related to underlying pneumonia and
adrenal insufficiency. Her mental status was back to baseline at
time of discharge, alert and oriented times three. She is to
continue with lactulose and rifaximin for hepatic
encephalopathy.
.
#. DM
Patient was previously on Lantus 36 units. She was placed on
sliding scale to determine her insulin requirements. She had no
hypoglycemic episodes as an inpatient. Her dose of Lantus was 34
units at the time of discharge and her fingersticks were running
between 70-180. Of note she has been on a strict diabetic and
low sodium diet so her Lantus requirements may need to be
increased at her rehab facility. She is on a Humalog insulin
sliding scale.
.
# PNA
RLL consolidation, clinically afebrile without leukocytosis.
Given chronic illness and aspiration risk was treated with
Unasyn and Vancomycin given she came from a chronic care
facility. PICC line placed for full 10 day course. Urine
legionella negative, unable to provide sputum, blood cx NGTD.
She will need to complete 2 more days of antibiotics at rehab.
She should have a follow up CXR in 4 weeks to document
resolution.
.
# Depression and Chronic back pain
Psychiatry consulted to manage her depression related to
component of pain and long wait for her liver transplant. She
was started on venlafaxine. Chronic pain service evaluated her
and continued her oxycodone, started Neurontin 300 mg QHS
increase as tolerated every 5-7 days to 300mg TID. Continued
Lidoderm patches to low back area. PT for core strength and
endurance. Tizanidine for sleep and spasm Start at 1 mg po QHS.
Would benefit from Pain Psychologist/ Psychiatry follow up to
address depression and further psychological treatment options
as CBT and Biofeedback.
.
# HCV Cirrhosis
s/p TIPS [**11-9**] c/b hydrothorax, encephalopathy, ascites,
thrombocytopenia. On transplant list, placed back on diuretics
which were initally held. She was discharged on furosemide 40mg
[**Hospital1 **] and spironolactone 100mg daily. Her lactulose and rifaximin
were continued. Electrolytes should be checked in 3 days given
spironolactone was increased to 100mg daily at the time of
discharge. Weekly labs are to be drawn and faxed to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 697**] and should include CBC, [**Name (NI) 53324**], PT/INR, CHEM 7.
.
# Adrenal insufficiency
Received stress dose steroids and was tapered back to prednisone
5mg daily.
.
# Osteoporosis
Continued vitamin D and calcium citrate. History of fractures.
.
# Asthma
Continued Singulair, Albuterol/Ipratropium
.
# Code: Full, HCP Mother [**Name (NI) 2048**] [**Name (NI) 68659**] [**Telephone/Fax (1) 68660**]
Medications on Admission:
Lactulose 30 ml QID
Rifaximin 400 mg TID
Aldactone 25mg Daily
Lasix 40 mg [**Hospital1 **]
Lantus insulin 36 units qhs
Humulog sliding scale as needed
Singulair 10mg Daily
Fluticasone 1 puff [**Hospital1 **]
Albuterol 1-2 puffs q4
Combivent inhaler 2 puffs QID
Prednisone 5 mg Daily
Multivitamin 1 tab Daily
Folic acid 1 mg Daily
Protonix 40mg [**Hospital1 **]
Vitamin D 50,000 units qWk
Calcium citrate 950 mg TID
Morphine Sulfate 15 mg Daily
Oxycodone 5 mg q6h
Lidoderm 5% patch as needed
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO QID (4
times a day): titrate to 4 bm daily.
2. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
3. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
4. Insulin Glargine 100 unit/mL Cartridge [**Hospital1 **]: Twenty Four (24)
units Subcutaneous at bedtime.
5. Humalog 100 unit/mL Cartridge [**Hospital1 **]: One (1) Subcutaneous as
directed: sliding scale.
6. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) Inhalation Q6H (every 6 hours) as needed.
9. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation four times a day.
10. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
11. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
12. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1)
Capsule PO MONDAY AND WEDNESDAY ().
15. Calcium Citrate 950 mg Tablet [**Hospital1 **]: One (1) Tablet PO three
times a day.
16. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily).
19. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
20. Tizanidine 2 mg Tablet [**Hospital1 **]: 0.5 Tablet PO QHS (once a day
(at bedtime)).
21. Spironolactone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
22. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 2 days.
23. Ampicillin-Sulbactam 3 gram Recon Soln [**Hospital1 **]: One (1) Recon
Soln Injection Q8H (every 8 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehabilitation
Discharge Diagnosis:
[**Hospital **]
Hospital acquired pneumonia
HCV cirrhosis
Hepatic encephalopathy
Diabetes mellitus type II
Discharge Condition:
Stable, alert and oriented times 3
Discharge Instructions:
You were admitted with low sugar causing you to be confused. You
were treated for pneumonia. You were seen by psychiatry and the
pain service to help manage your pain and depression. You were
started on new medications to help with your depression and pain
(venlafaxine, gabapentine, tizanidine). You are neing discharged
to a rehab facility to regain your strength by working with
physical therapy.
You have follow up scheduled with Dr. [**Last Name (STitle) 497**].
You will need to have follow up with psychiatry and pain center.
The numbers to the clinics are in your discharge paper work.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2158-3-22**] 9:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2158-4-11**] 3:30
Provider: [**Name10 (NameIs) 21503**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2158-4-11**] 2:40
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2158-4-20**] 1:00
Call ([**Telephone/Fax (1) 24780**] to schedule a follow up appointment with
psychiatry, you were seen by Dr. [**Last Name (STitle) 16293**].
Call ([**Telephone/Fax (1) 30702**] to schedule a follow up with [**Doctor First Name **] P.
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Management Center
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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[
[]
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,814
| 128,089
|
12427
|
Discharge summary
|
report
|
Admission Date: [**2149-2-27**] Discharge Date: [**2149-3-4**]
Date of Birth: [**2083-11-22**] Sex: M
Service: MICU/Medicine
CHIEF COMPLAINT: Nausea, vomiting, diarrhea, urinary frequency.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
gentleman with a past medical history significant for coronary
artery disease status post coronary artery bypass graft times
four vessels 22 years ago, status post a recent admission to [**Hospital1 1444**] and discharged on [**2149-2-25**], at which time he had chest pain and dyspnea on exertion. At
that time, he ruled in for a myocardial infarction with a
troponin of 10 and a peak CK of 796. He had a cardiac
catheterization which showed two of the saphenous vein grafts had
been blocked but no intervention could be performed at that time.
He was ultimately discharged on Atenolol, Zestril, aspirin,
He did well until his day of admission on the 28th, when he
noticed some urinary frequency in the late evening. He was
eating dinner and he felt nauseated and vomited several times. He
subsequently had one episode of loose brown stool which he notes
no blood. He then went on to have rigors and went to the
Emergency Room at [**Hospital3 4298**]. There he was found to be
hypotensive and was placed on Dopamine after being given 1.5
liters of normal saline. Furthermore, a urinalysis showed
positive nitrites, two plus leukocyte esterase, 25 to 50 white
cells. He was transferred to [**Hospital1 188**] with the diagnosis of urosepsis and acute renal failure
with a BUN and creatinine of 31/2.1, baseline creatinine 0.9.
In the Emergency Department, blood pressure was 110/80 on 12.5 of
Dopamine. He was given a 200 cc. normal saline bolus and was
treated with Vancomycin and a dose of gentamicin due to a
questionable infection of his right groin where his cardiac
catheterization had been obtained.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post four-vessel coronary
artery bypass graft 22 years ago; status post recent myocardial
infarction with catheterization which revealed two occluded SVG
grafts, however, no intervention was performed.
2. Hypertension.
3. High cholesterol.
4. Peripheral vascular disease.
5. Benign prostatic hypertrophy.
MEDICINES AT HOME:
1. Atenolol 100 mg q. day.
2. Zestril 10 mg q. day.
3. Zocor 20 mg q. day.
4. Plavix 75 mg q. day.
5. Aspirin 325 q. day.
ALLERGIES: The patient is allergic to heparin with a history of
HIT.
SOCIAL HISTORY: He lives in [**Hospital3 4298**]. He is a former
chef. He has a history of tobacco, 47 pack years; quit 19 years
ago. Drinks alcohol socially at night. Denies any intravenous
drugs.
PHYSICAL EXAMINATION: Temperature 97.8 F.; pulse of 87;
blood pressure 110/84; saturation of 97% on three liters, 91%
on room air. In general, the patient is a mildly obese male
lying in bed, talkative, in no apparent distress. HEENT:
Pupils round and reactive to light. Anicteric sclerae.
Oropharynx was dry. No jugular venous distention
appreciated. Chest showed rales at the right base which did
not clear to cough. Cardiac examination: Regular rate, no
murmurs. Abdomen, obese, soft, nontender, positive bowel
sounds. Back examination revealed no costovertebral angle
tenderness. Extremities were thin and cool, slightly clammy.
Right groin was erythematous with a hematoma but was not warm
or tender.
LABORATORY: On admission, white blood cell count of 17.0,
hematocrit of 36.6, platelets of 579; 87% polys, 6% bands.
SMA-7 142 sodium, potassium 4.9, chloride 110, bicarbonate 16
with a gap of 16. BUN 33, creatinine 1.9, chloride 113. CK
198, MB 8, troponin 4.1.
Arterial blood gas on room air revealed 7.33, pCO2 of 28, pO2
of 57. Lactate of 1.8, INR of 1.4.
Urinalysis revealed 11 to 20 white cells, few bacteria.
EKG was normal sinus rhythm at 89, Q waves in II, III and
AVF, which is unchanged from [**2-23**].
Urine culture and blood cultures were pending.
Chest x-ray revealed mild heart failure.
HOSPITAL COURSE:
1. Urosepsis: The patient with a positive urinalysis,
hypotensive, symptoms of urinary tract infection, presumed
diagnosis of urosepsis. The patient was started on Vancomycin
and Gentamicin and Levaquin was added although most likely
pathogens were from genitourinary sources. Vancomycin was
continued given the question of a right groin infection. The
patient responded to antibiotics and intravenous fluids. The
patient's blood pressure improved as well. After blood cultures
were negative times 48 hours, Vancomycin was discontinued and the
patient was continued on Levaquin for urinary tract infection on
which the patient will be discharged to complete a 14 day course.
2. Cardiovascular: The patient was hypotensive on arrival.
Cardiac enzymes were cycles which were negative. Although
troponin was elevated, it was presumed from trending down from
the old myocardial infarction. The patient's blood pressure
responded to intravenous fluids in addition to the antibiotics.
Prior to the patient's discharge, the patient's blood pressure
medicines were restarted, including Zestril and Atenolol. The
patient will be discharged on Zestril and a reduced dose of
Atenolol to be further titrated up by his primary care physician.
3. Renal: The patient was admitted with acute renal failure
secondary to prerenal and plus/minus ATN. The patient's
creatinine improved with aggressive intravenous fluids and
returned to [**Location 213**] upon baseline.
4. Genitourinary: The patient with a history of urinary tract
infection one month ago. Given this is the second urinary tract
infection with a known diagnosis of benign prostatic hypertrophy,
the patient will need to follow-up with Urology for a possible
transurethral resection of prostate for treatment of his benign
prostatic hypertrophy.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Acute renal failure.
3. Benign prostatic hypertrophy.
4. Coronary artery disease status post four-vessel coronary
artery bypass graft 22 years ago; status post recent myocardial
infarction with catheterization which revealed two occluded SVG
grafts, however, no intervention was performed.
5. Hypertension.
6. High cholesterol.
7. Peripheral vascular disease.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with primary care doctor [**First Name (Titles) **]
[**Hospital3 4298**] to complete titration of his blood pressure
medicines.
2. The patient will need to follow-up with Urology for a
possible transurethral resection of prostate given his benign
prostatic hypertrophy and history of urinary tract infections.
DISCHARGE MEDICATIONS:
1. Atenolol 100 mg q. day.
2. Zestril 10 mg q. day.
3. Zocor 20 mg q. day.
4. Plavix 75 mg q. day.
5. Aspirin 325 q. day.
6. Addition of Nystatin Powder to his right groin.
7. Levaquin 500 mg q. day to complete a 14 day course.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2149-3-25**] 15:51
T: [**2149-3-25**] 19:35
JOB#: [**Job Number 38633**]
|
[
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] |
icd9cm
|
[
[
[]
]
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[
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] |
icd9pcs
|
[
[
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] |
5857, 6242
|
6666, 7129
|
4023, 5836
|
6300, 6643
|
2698, 4006
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159, 207
|
237, 1883
|
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|
6267, 6276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,683
| 175,145
|
43297
|
Discharge summary
|
report
|
Admission Date: [**2107-5-25**] Discharge Date: [**2107-6-7**]
Date of Birth: [**2069-10-8**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a otherwise
healthy 37 year-old male who had his wisdom teeth extracted
on [**2107-5-24**]. Postoperatively, the patient was
prescribed Amoxicillin and Percocet, which he first took at
13:00 on [**5-24**]. By 14:45 he felt nauseous and vomiting.
Around 18:00 took next dose of medications and again vomited
around 20:30 so violently that he "threw out his back." He
came to the Emergency Department at 21:30 where he received
morphine, Toradol and Compazine and was discharged with
Cyclobenzaprine and Compazine. He took Compazine at 6:45 and
Flexeril at 7:38. Shortly thereafter he felt antsy and "all
hopped up." Could not sit still and was sweating so he went
to his primary care physician's office at 13:00 and was sent
to the Emergency Department from there for evaluation. In
the Emergency Department the initially vital signs were heart
rate 170s, blood pressure 170/120 and temperature 97.8. He
received 12 mg of Adenosine to unmask his rhythm. Symptoms
though were consistent with a drug reaction, questionable
dystonic reaction and treated with Benadryl 50 intravenously,
Ativan and repeated doses of Lopressor totally 15 mg
intravenously and 50 mg po. Benadryl 25 intravenously given
again as there was no change in symptoms. Ceftriaxone and
Clindamycin were given empirically for systemic infection of
possible oral source after his temperature spiked to 102.4.
Toxicology was consulted and felt dystonic reaction not
neuroleptic malignant syndrome. He was treated with repeated
doses of intravenous Valium followed by Propanolol in case
thyroid storm was the cause with no effect after 25 mg.
Attempted Esmolol drip with good heart rate and blood
pressure control with a bolus. The patient subsequently
seized and was intubated and transferred to the MICU.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea.
2. Nephrolithiasis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Amoxicillin.
2. Percocet.
3. Flexeril.
4. Compazine.
SOCIAL HISTORY: Married, smokes one pack per week. Works as
an accountant.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 104.0. Blood pressure
205/150, heart rate in the 130s. The patient was diffusely
sweating, shaking, unable to sit still, very uncomfortable.
HEENT pupils are equal, round and reactive to light. No
nystagmus. No wound infection in the oropharynx noted.
Cardiovascular tachy without murmurs. Lungs were clear.
abdomen was soft. Extremities no edema.
LABORATORY: Serum and urine tox screen was negative. White
blood cell count was 22.9 with 90% neutrophils, hematocrit
45, platelets 262. CT of the head revealed a subtle
hyperdensity and a few sulci, which could indicate blood or
exudate, but otherwise was unremarkable.
HOSPITAL COURSE:
1. Possible drug reaction: It was felt that the patient's
presentation was most likely consistent with a severe
dystonic type drug reaction to a combination of Compazine and
Flexeril. Toxicology was on board from the start and
assisted in the care, which was largely supportive. In the
MICU the patient was rapidly weaned off the ventilator as
well as weaned off the Esmolol drip. An LP was attempted to
obtain cerebral spinal fluid to rule out a subarachnoid
hemorrhage as well as meningitis. Unfortunately the LP was
unsuccessful after numerous attempts including one IR guided
attempt, one attempt by neurology. It was therefore decided
to treat the patient with empiric antibiotics. He was
treated with 10 days of Ceftriaxone and Acyclovir. Since no
cerebral spinal fluid could be obtained an MRI with
gadolinium was performed to assess for possible meningeal
enhancement and thus the suggestion of meningitis. There was
an abnormal signal extending along the sulci of the occipital
parietal lobes that was nonenhancing, which was a nonspecific
finding and was read as possibly reflecting a subarachnoid
hemorrhage, pus or other pernicious material. The patient
continued to spike low grade fevers while on antibiotics and
also following the completed course of his antibiotics.
There was never another source or infection found. All
cultures were negative and a chest x-ray was negative as
well. Infectious disease was consulted. They recommended a
CT scan of the neck to rule out a retropharyngeal abscess
given the patient's recent dental work and this was negative.
It was eventually believed that the patient's mildly
elevated white blood cell count and persistent low grade
fevers were likely due to blood in the subarachnoid space as
will be discussed below.
2. Subarachnoid, subdural/epidural hematoma: The patient
had severe back pain following multiple LP attempts. He was
imaged with an MRI of the L spine, which revealed evidence of
an epidural and subdural hematoma. It was felt that his
blood was most likely due to the traumatic lumbar puncture
attempts. Neurosurgery was consulted to review the films and
this was the conclusion that they came to and they
recommended a repeat film in a few days to see if there was
resolution. A review of the MRI findings discussed in
problem number one was felt to be blood as well and most
likely tracking up from the lumbar spine blood. A repeat MR
of the L spine revealed basically no change. Neurosurgery
continued to emphasize that there was nothing to do except
follow with serial MRIs. An MRA of the brain was performed
to rule out an aneursym as the possible cause for the
subarachnoid blood. The MRI revealed spasm of the basal
artery, which was felt to be secondary to the subarachnoid
hemorrhage, but no aneurysm. Neurology who was following as
well felt there was once again nothing interventional to do
and that the patient should be followed clinically. At the
time of discharge the patient still had considerable low back
pain that was treated with pain medications and Valium and
was instructed to have a follow up MR of the head and MR of
the L spine in approximately one week.
3. Hyponatremia: The patient developed hyponatremia ranging
between 127 and 130. This was felt due to syndrome of
inappropriate antidiuretic hormone secondary to blood in the
brain and possibly secondary to pain. A fluid restriction
was put in place and the patient's sodium responded and was
132 at the time of discharge. The patient will have a follow
up sodium check by visiting nurse two days after discharge.
4. Hypertension: The patient was noted to be hypertensive
throughout his course. He was started on Amlodipine 10 mg a
day as this will also help treated the basal artery spasm
noted on MRA. He will have a blood pressure check by VNA and
will follow up with his outpatient doctor.
5. Hyperglycemia: The patient was noted to have occasional
random glucoses of greater then 200 and some glucosuria. It
was felt that this might represent type 2 diabetes as he has
a family history of that. He was recommended to follow up
with his primary care physician for workup of this. He did
have a hemoglobin A1C, which was within normal limits.
DISCHARGE CONDITION: The patient was discharged to home in
stable condition.
FINAL DIAGNOSIS:
1. Severe adverse drug reaction to Compazine and/or
Flexeril.
2. Subarachnoid hemorrhage and subdural epidural hematomas
in the L spine secondary to lumbar puncture.
3. Syndrome of inappropriate antidiuretic hormone.
4. Type 2 diabetes.
5. Hypertension.
FOLLOW UP: The patient is recommended to follow up with his
primary care physician within one week as well as to have a
repeat MRI of the head and L spine within seven to ten days.
DISCHARGE MEDICATIONS:
1. Ibuprofen 800 mg po q 8 hours prn pain.
2. Valium 5 mg po q 8 hours prn pain.
3. Morphine instant release 15 mg q 4 to 6 hours prn pain.
4. Norvasc 10 mg one po q day.
5. Tylenol 1 gram q 6 hours prn pain.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2107-6-7**] 05:17
T: [**2107-6-8**] 07:08
JOB#: [**Job Number 93257**]
|
[
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"780.39",
"401.9",
"253.6",
"780.57",
"998.12",
"E878.8",
"333.7",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"57.17",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7208, 7265
|
2244, 2262
|
7748, 8260
|
2943, 7186
|
7282, 7542
|
7554, 7725
|
2285, 2926
|
165, 1964
|
1986, 2149
|
2166, 2227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,601
| 130,980
|
8311
|
Discharge summary
|
report
|
Admission Date: [**2144-1-3**] Discharge Date: [**2144-1-9**]
Date of Birth: [**2088-2-4**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
anemia, renal failure
Major Surgical or Invasive Procedure:
EGD
endotracheal intubation
CVL placement
arterial line placement
paracentesis
History of Present Illness:
Mr. [**Known lastname 29436**] is a 55 y/o M w/ ESLD [**2-12**] EtOH cirrhosis c/b
ascites, SBP on ppx, portal HTN w/ portal HTN-ive gastropathy,
and hx chronic anemia requiring weekly transfusions, who
presented to ED after labs from [**Hospital3 2558**] rehab drawn
[**2144-1-2**] showed Hct 16 (baseline is 24) and Cr 2.0 (baseline
1.6). He c/o chronic BRBPR but denies hemoptysis,
lightheadedness, dizziness or tiredness. He was recently
admitted in [**2143-11-11**] for similar asymptomatic anemia (Hct
18.6) for which he received 3 units pRBCs and subsequently had
hematemesis, requiring admission to the ICU where he declined
EGD; he received 2 more units pRBCs. Since then, he has had
periodic labs and weekly transfusions. He most recently received
2 units on [**2143-12-31**].
.
In ED, vitals were T 96.8, HR 81, BP 90/48, RR 16, SaO2 100% RA.
He appeared pale and was guaiac positive. No EKG changes.
He was transfused 2u pRBCs and hepatology recommended 25gm
albumin for additional volume but he did not receive. In
addition, since he was due for surveillance RUQ u/s, this was
performed in the ER which showed ascites, splenomegaly and
patent umbilical vein.
.
Following presentation, patient received two units PRBCs. On
the floor this morning, patient reporting coughing up/vomiting
bright red blood with sputum. Patient has history of grade I
varices and portal hypertensive gastropathy. Received
pantoprazole and octreotide boluses, followed by drip, and one
unit of PRBCs was hung. NG lavage was done and continued to
bring back bloody lavage after 200 ccs of blood. Decision was
made to transfer patient to ICU for urgent EGD.
.
Upon arrival to the ICU, patient had no complaints. He denied
abdominal pain, fevers, chills. No nausea or vomiting following
episodes this morning. See below for results of EGD.
.
Review of sytems:
(+) Per HPI
.
Recent pRBC Transfusions:
first
[**2143-12-31**]: 2 units
[**2143-12-24**]: Hct 16.5, received 2 units
[**2143-12-17**]: 2 units
[**2143-12-13**]: 2 units
[**Date range (3) 29443**]: admitted for anemia, received 5 units
Past Medical History:
-ETOH Cirrhosis diagnosed [**12/2142**]: c/b portal hypertension,
jaundice,
hypertensive gastropathy, grade 1 esophageal varices, ascites,
SBP
-angioectasias of ileum/rectum (LGIB, [**Last Name (un) **] [**2143-4-9**], biopsy neg)
-HTN
-DJD of R hip
-Gout
-Bowel perforation: lap-assisted R colectomy [**5-18**] by Dr. [**Last Name (STitle) 1120**]
for cecal perforation while on steroids for gout flare
-Legally blind
.
Social History:
EtOH: used to drink [**6-17**] rum and cokes daily until [**10-19**] Tob: 8
pack years, quit 25 years ago Illicits: remote cocaine,
marijuana, and methamphetamines Home: He is divorced in [**2122**]
and has lived alone since, lives independently in "rehab"
facility in [**Location (un) **]. Occupation: He used to work as a taxi
driver for Redcab until he was forced to retire [**2-20**] because he
was declared legally blind.
Family History:
Grandmother with DM2.
Physical Exam:
VS: 97.1 100/54 77 14 100% RA
GEN: chronically ill-appearing frail M w/ temporal wasting and
marked limb muscle atrophy, appearing much older than his stated
age wearing baseball hat in NAD, comfortable, appropriate
HEENT: sclerae anicteric, EOMI, PERRLA
LUNGS: CTAB/L no wheeze or rales
CV: RRR nl S1 S2 no murmurs appreciated
ABD: +BS, markedly distended but soft w/ + fluid wave, tympanic
to percussion, non-tender no rebound/guarding. +umbilical hernia
EXT: 4+ pitting edema B/L LE, pedal edema to upper thigh,
massively edematous and unable to ambulate due to this, although
no UE edema, w/ diffuse UE muscle wasting. Cannot palpate distal
pulses.
SKIN: multiple scattered telangiectasias predominantly over
anterior surfaces of b/l LE
NEURO: A&Ox3, appropriate. (+) asterixis
Pertinent Results:
[**2144-1-3**] 11:55AM PT-18.9* PTT-38.6* INR(PT)-1.7*
[**2144-1-3**] 11:55AM PLT COUNT-144*
[**2144-1-3**] 11:55AM NEUTS-78.4* BANDS-0 LYMPHS-13.9* MONOS-6.1
EOS-1.3 BASOS-0.2
[**2144-1-3**] 11:55AM WBC-10.6# RBC-1.96* HGB-6.3* HCT-18.7* MCV-96
MCH-32.1* MCHC-33.5 RDW-20.7*
[**2144-1-3**] 11:55AM ALBUMIN-2.0*
[**2144-1-3**] 11:55AM LIPASE-18
[**2144-1-3**] 11:55AM ALT(SGPT)-13 AST(SGOT)-74* ALK PHOS-91 TOT
BILI-2.5*
[**2144-1-3**] 11:55AM estGFR-Using this
[**2144-1-3**] 11:55AM GLUCOSE-152* UREA N-70* CREAT-2.0* SODIUM-133
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12
[**2144-1-3**] 12:12PM HGB-6.5* calcHCT-20
[**2144-1-3**] 12:12PM K+-4.1
[**2144-1-3**] 02:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2144-1-3**] 02:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2144-1-3**] 02:40PM URINE GR HOLD-HOLD
[**2144-1-3**] 02:40PM URINE OSMOLAL-401
[**2144-1-3**] 02:40PM URINE HOURS-RANDOM
[**2144-1-3**] 02:40PM URINE HOURS-RANDOM UREA N-594 CREAT-105
SODIUM-<10 POTASSIUM-59 CHLORIDE-<10 PHOSPHATE-31.8
[**2144-1-3**] 05:44PM HGB-9.5* calcHCT-29
[**2144-1-3**] 11:34PM HCT-24.5*#
.
.
SINGLE SEMI-UPRIGHT PORTABLE CHEST RADIOGRAPH: The lung volumes
are slightly low, but there are no focal airspace
consolidations, pneumothorax or pleural effusions. The
cardiomediastinal silhouette, hilar contours and pulmonary
vasculature are normal. Mild vascular calcification is noted in
the aortic knob. Multilevel degenerative changes in the
visualized thoracolumbar spine are mild-to-moderate. Healed
fractures are again noted at the right 7th and 8th ribs.
.
Abdominal ultrasound: IMPRESSION:
1. Ascites secondary to cirrhosis with patent umbilical vein,
unchanged. Splenomegaly.
2. Hyperechoic focus in the region of the gallbladder neck may
represent a nonshadowing stone or polyp. Slight gallbladder wall
thickening is likely related to cirrhosis.
.
FINDINGS: As compared to the previous radiograph, the patient
has been intubated. The tip of the endotracheal tube is located
1.7 cm above the carina. No complications. No other relevant
changes.
.
IMPRESSION: Mild pulmonary artery systolic hypertension. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. Compared with the prior study
(images reviewed) of [**2143-8-2**], the cardiac findings are similar
(ascites and left pleural effusion are now seen).
.
CONCLUSION: Essentially normal non-contrast head CT.
.
.
Renal u/s
1. No evidence of hydronephrosis or renal mass.
2. Unremarkable Doppler examination of the kidneys, with no
findings to suggest renal artery stenosis
.
.
Technically successful diagnostic paracentesis, with a total of
1.8 L of yellow ascites removed.
.
CT torso:
1. Multiple bilateral nodular pulmonary opacities, concerning
for infection or aspiration. Enteric contrast above the ETT
balloon is presumably from gastroesophageal after from
tube-adminstration of contrast for CT.
2. Progressive bibasilar atelectasis, with near-complete right
lower lobe collapse.
3. Endotracheal tube just above the carina, please consider
retracting several cm.
4. Cirrhosis, borderline splenomegaly, and persistent
large-volume ascites.
5. Pancolonic edema, likely due to third spacing.
6. Atrophic kidneys.
7. Mildly displaced left subcapital femoral fracture.
.
Chest AP portable [**1-7**]:
Endotracheal tube has been advanced, now terminating in standard
placement approximately 3 cm above the carina. Previous
pulmonary edema has resolved and right perihilar consolidation
substantially decreased, probably a combination of clearing of
edema and atelectasis. I would recommend radiographic followup
in case the findings are due to aspiration, which would put the
patient at risk for pneumonia. Left lower lobe consolidation has
similarly improved, but warrants surveillance. Nasogastric tube
ends in the stomach. Mild cardiomegaly is stable. There is no
appreciable pleural effusion and no pneumothorax. Left internal
jugular line tip projects over the mid SVC. Nasogastric tube
ends in the stomach. No pneumothorax.
.
EGD:
Normal mucosa in the whole esophagus, without varices.
Friability, petechiae and mosaic appearance in the whole stomach
compatible with severe portal hypertensive gastropathy. Mass in
the antrum. Normal mucosa in the whole duodenum. (biopsy of
antral mass). Otherwise normal EGD to third part of the
duodenum.
Brief Hospital Course:
55 year old male with end-stage liver disease Alcoholic
cirrhosis complicated by ascites, gastrointestinal varicies,
portal hypertension with portal hypertensive gastropathy,
spontaneous bacterial peritonitis on ciprofloxacin for
prophylaxis, chronic gastrointestinal hemorrhage from
angiodysplasias, requiring frequent transfusions transferred
from rehab with asymptomatic anemia and acute on chronic renal
failure, now with hospital course complicated by upper
gastrointestinal bleed from portal hypertensive gastropathy.
.
1. Social work- prior to elective intubation for EGD, patient
had full capacity and gave ICU consent. Patient was asked about
health care proxy, and declined designation. Prior to
admission, his health care providers and insurance company
impressed upon him the importance of designating a HCP given his
advanced liver disease, to which he continually declined. Per
social work, patient has adamantly declined designating a health
care proxy. [**Name (NI) **] lives in [**Hospital **] health center; insurance
agency has also tried to help identify a health care proxy, but
has declinedAs patient was unable to be weaned from ventilation,
guardianship process was started. Given severity of patient's
illness (see below), guardianship process was deferred, as team
did not believe that patient would not survive the guardianship
process. Care was transitioned to no escalation of care on
[**2144-1-7**].
.
Mr. [**Known lastname 29436**] has shown no signs of recovery. His BP has worsened
and he became agitated off of sedation. Discussions were held
with liver and it was agreed that Mr. [**Known lastname 29436**] did not wish to
receive prolonged life support. Pastoral services will be
contact[**Name (NI) **] and following this his care will be transitioned to
comfort measures. All of his acquaintances were contact[**Name (NI) **] to
make them aware of his status.
.
Patient was made CMO on [**2144-1-8**]. Patient was placed on
fentanyl drip, pressors were turned off, and patient was
terminally extubated, and passed away on [**2144-1-8**].
.
2. Shock- suspect from hypovolemia- [**2-12**] UGIB from portal
hypertensive gastropathy. EGD showed portal hypertensive
gastropathy with active bleeding, and fungating mass in antrum
of stomach. Patient also noted to have grade 2 varices,
non-bleeding. Only evidence of infection at this time is
development of asterixis this morning, suggesting possible SBP,
although lactulose doses were missed overnight last night. If
patient develops fever, low threshold to perform diag para,
treat empirically for SBP. No suggestion of cardiopulmonary
etiology of shock. Underlying cirrhosis is also likely
contributing via low SVR. Continued IV PPI [**Hospital1 **], octreotide gtt.
Sucralfate 1g QID. Serial hematocrits monitored. Had 2 large
bore PIV's, CVL placed for more access. Following EGD, patient
continued to require two pressors, phenylephrine and
noriepinephrine, to maintain his blood pressure. A radial
a-line was placed. Cortisol was normal. Working diagnosis was
septic shock from spontaneous bacterial peritonitis. Broad
spectrum antibiotics were started, including vancomycin,
cefepime, and metronidazole. Patient was also resuscitated with
IVF to help maintain his BP, along with albumin. This worsened
long-standing hypervolemia, as patient was admitted with 4+
pitting edema in his lower extremities. IR-guided paracentesis
confirmed SBP. Received fresh frozen plasma peri-procedure.
.
3. Mechanical ventilation- electively intubated for EGD.
Required mechanical ventilaiton in setting of unstable upper GI
hemorrhage, and could not wean secondary to sedation and
worsening hypervolemia.
.
4. Acute on chronic kidney injury: most likely prerenal in the
setting of low blood volume. However, ischemic ATN is also
possible as pt was hypotensive in ED. Urine lytes were obtained
in ED, however pt is chronically on lasix so FeNa calculation
would not be accurate. FeUrea is 16.6% on admission, which would
be consistent w/ pre-renal azotemia. Hepatorenal syndrome also
on differential. Renal team was consulted, and microscopic
analysis suggested ATN as etiology of anuric renal failure.
Patient had made less than one liter of urine throughout five
day ICU course prior to transitioning care to CMO. Patient was
not a candidate for renal replacement therapy given unstable GI
bleed, and patient was not a transplant candidate given chronic
anemia and lack of psychosocial support (see below).
.
5. Alcoholic cirrhosis: Patient was never placed on transplant
list given chronic GI bleed and lack of psychosocial support.
MELD 22. Unable to provide nutrition in setting of UGIB. Held
nadolol given bleed, held lasix, held lactulose in setting of
GIB, GI irritant. Thiamine, vitamin b12 were continued.
.
6. Gout: stable. held uloric.
.
7. DJD of hip: stable
.
8. Depression. continued Mirtazipine.
.
9. FEN/GI- NPO for GIB, IVF: NS @ 100cc/hr, no bowel regimen
.
ACCESS: PIV's, CVL, a-line
.
PPX: DVT ppx with pneumoboots, lactulose for bowel regimen.
.
CODE: FULL
.
COMM: patient (no HCP listed).
.
Medications on Admission:
ATHLETIC SPORTS BRIEF - - 1 Brief
BLOODWORK - - Please check [**Hospital1 **]-weekly hematocrit, starting on
[**2143-9-21**], checked on Saturdays and Tuesdays. If Hematocrit is
less
than 23, please inform the Liver Center at [**Telephone/Fax (1) 2422**] and ask
t
CIPROFLOXACIN - (Prescribed by Other Provider) - 250 mg Tablet -
1 Tablet(s) by mouth
FEBUXOSTAT [ULORIC] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 [**1-12**] Tablet(s) by mouth daily
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth daily - No
Substitution
LACTULOSE - 10 gram/15 mL Solution - 30 mL by mouth twice a day
MIRTAZAPINE - (Prescribed by Other Provider) - 7.5 mg Tablet - 1
Tablet(s) by mouth at bedtime
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth once daily
OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth as needed for pain
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once daily
SUCRALFATE - (Prescribed by Other Provider) - 1 gram Tablet -
one Tablet(s) by mouth four times daily
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - one Capsule(s) by mouth daily
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a
day
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100
mg Capsule - one Capsule(s) by mouth twice daily
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg
Iron) Tablet - 1 Tablet(s) by mouth twice a day
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
.
Discharge Medications:
passed away on [**2144-1-8**]
Discharge Disposition:
Expired
Discharge Diagnosis:
passed away on [**2144-1-8**]
Discharge Condition:
passed away on [**2144-1-8**]
Discharge Instructions:
passed away on [**2144-1-8**]
Followup Instructions:
passed away on [**2144-1-8**]
|
[
"571.2",
"567.23",
"715.35",
"V11.3",
"537.89",
"572.3",
"263.9",
"995.92",
"572.2",
"518.81",
"276.52",
"287.49",
"584.5",
"369.4",
"274.9",
"585.3",
"403.90",
"293.0",
"280.0",
"785.52",
"V49.86",
"V49.87",
"285.1",
"V45.72",
"V15.82",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"45.16",
"96.71",
"54.91",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15771, 15780
|
8779, 13910
|
307, 387
|
15853, 15884
|
4257, 8756
|
15962, 15994
|
3416, 3439
|
15717, 15748
|
15801, 15832
|
13936, 15694
|
15908, 15939
|
3454, 4238
|
246, 269
|
2271, 2507
|
415, 2253
|
2529, 2952
|
2968, 3400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,275
| 146,688
|
34086+34087
|
Discharge summary
|
report+report
|
Admission Date: [**2106-4-5**] Discharge Date: [**2106-4-9**]
Date of Birth: [**2021-11-18**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Doctor First Name 2080**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84F with pmh lymphoblastic lymphoma and aplastic anemia
presenting from [**Hospital **] nursing home with anemia s/p a fall on
saturday. The patient has a history of colon cancer s/p
colostomy and she has reported seeing maroon stool in the
colostomy bag. She was been feeling lightheaded and weak. Labs
drawn at the nursing home [**Last Name (un) **] dplatelet count of 6 so given
the constellation of symptoms she was transferred to the [**Hospital1 18**]
ED.
.
In the ED, initial vs were: T 98.6 P110 BP 138/89 R22 O2 sat 99%
RA. Labs were notable for neutropenia, a platelet count of 7 ,
and a hematocrit of 18 fropm baseline 24. head CT was
significant for a subarachnoid hemorrhage. Neurosurgery was
contact[**Name (NI) **] and both they and the patient are declining
intervention. Patient was given 1L of NS, one unit of blood and
a unit of platelets are being hung prior to transfer. She went
into atrial fibrillation with rates to 120's while in the ED as
well.
.
On the floor, she is reported generalized weakness, worse in her
arms and legs.
.
Of note, she was recently discharged on [**3-31**] after being
hospitalized for pseudomonas sepsis and GI bleeding. She just
completed a course of cefepime and tobramycin today, [**4-4**].
Past Medical History:
Colon cancer [**2099**] s/p diverting colostomy reversed [**2100**], loop
colostomy for large bowel obstruction [**10-25**]
Lymphoplasmacytic lymphoma diagnosed [**10/2103**]
Aplastic anemia
Hypertension
Iron overload (heterozygous for hemochromatosis gene)
h/o C. diff colitis
h/o large bowel obstruction
s/p appendectomy
s/p tonsillectomy
s/p tubal ligation
s/p cholecystectomy
Social History:
Widow, has five children
Lives alone in [**Name (NI) 16843**], MA - son has been staying with her
recently
Denies tobacco, alcohol, or illicit drug use
Family History:
Father died of stroke at age 77
Mother had CAD and renal failure
No family history of malignancy or hematologic disorder
Physical Exam:
Vitals: T:98.6 BP:146/74 P:99 R: 18 O2: 100% 1.5L
General: Alert, oriented X3, no acute distress, pale
HEENT: Sclera anicteric, mucus membranes dry. lips with crusted
blood
Neck: supple, JVP not elevated, 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, non-tender, non-distended, colostomy on LLQ
draining maroon stool
GU: no foley
Ext: 1+ edema with scattered purpura.
Neuro: CN II-XII intact, moving all four extremities, [**4-21**]
strength in all 4 extremities
Pertinent Results:
[**2106-4-8**] 05:26AM BLOOD WBC-0.3* RBC-3.00* Hgb-9.0* Hct-25.8*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.3 Plt Ct-31*
[**2106-4-8**] 05:26AM BLOOD Neuts-64 Bands-0 Lymphs-32 Monos-0 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2106-4-8**] 05:26AM BLOOD Glucose-113* UreaN-29* Creat-0.7 Na-141
K-3.3 Cl-104 HCO3-31 AnGap-9
[**2106-4-8**] 05:26AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8
[**2106-4-5**] 04:41PM BLOOD Cyclspr-70*
[**2106-4-5**] 05:53PM BLOOD Lactate-0.8
.
[**2106-4-5**] 10:50 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
OF TWO COLONIAL MORPHOLOGIES.
Anaerobic Bottle Gram Stain (Final [**2106-4-6**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 29031**] [**2106-4-6**] 12:10PM.
.
CT Head [**4-5**]:
FINDINGS: There is a 6 x 6-mm new round hyperdense focus at the
right cranial vertex (2:26) concerning for acute hemorrhage.
There is no evidence of hemorrhage elsewhere, infarction, mass
effect, or edema. The [**Doctor Last Name 352**]-white matter differentiation is
elsewhere preserved. Age-appropriate prominence of ventricles
and sulci is consistent with diffuse parenchymal volume loss,
not significantly changed from prior. Subcortical and
periventricular white matter hyperdensity is consistent with
chronic small vessel ischemic disease. The visualized paranasal
sinuses and mastoid air cells are well aerated. No osseous
abnormality is identified. Globes are intact bilaterally.
IMPRESSION: New 6-mm hyperdense focus in right posterior frontal
vertex,
concerning for acute hemorrhage.
.
CT Head [**4-6**]:
FINDINGS: A small focal hyperdensity at the right posterior
vertex, most
likely intraaxial, is unchanged in size and configuration,
measuring 6 mm x 6 mm (2:24), without evidence of significant
mass effect or edema. There is no new intracranial hemorrhage.
The ventricles and cerebral sulci remain prominent, consistent
with diffuse parenchymal volume loss. Subcortical and
periventricular regions of hypoattenuation are consistent with
chronic small vessel ischemic disease, is unchanged. The
visualized paranasal sinuses and mastoid air cells remain
normally pneumatized and aerated. No fractures are identified.
IMPRESSION: Unchanged 6-mm right posterior vertex hematoma. No
new
intracranial hemorrhage.
Brief Hospital Course:
Acute Blood Loss Anemia/GI Bleed: The cause of the bleed was due
to missed transfusion of platelets. She was given transfusion
with good response and resolution of her bleed. Scoping was
deferred given this improvement. Her goal Hct is >25 for
symptomatic support.
.
Brain Hemorrhage: Low platelets were the likely cause. Will
platelet transfusion her bleed stabilized. Neurosurgery was
consulted. She did not have significant neurological deficitis.
Her goal platelet level should be 30-50. Neurosurgery
recommended repeat CT head in the beginning of may and follow up
with neurosurgery at that time.
.
Lymphoblastic Lymphoma/Transfusion dependend pancytopenia: She
remained neutropenic and transfusion dependent. Her filgrastim
and vitamins were continued, as was her cyclosporine,
deferoxamine. She will need TWICE WEEKLY blood and platelet
transfusions. Goal Hct >25, goal Plt >30K. The transfusions
should be performed at [**Hospital **] HOSPITAL. Please draw CBC with
diff 2-3 per week and arrange for transfusions from this
hospital.
.
Neutropenia: Stable without fever. She was continued on her
maintanance levofloxacin and acyclovir with good effect.
.
Atrial fibrillation with rapid response: Asymptomatic. Her
metoprolol was increased to 100 mg TID. She did require
intermittent IV metoprolol. She must NOT be anticoagulated.
Her metoprolol can be adjusted as needed to provide control.
Her HR was in the low 100s at discharge, occasionally going up
into the 120s
.
Hypertension, benign: Continued metoprolol and amlodipine and
HCTZ.
.
To do:
1. CBC with diff on [**2106-4-12**], then CBC 2-3 times per week
2. Platelet and Blood transfusions as [**Hospital 16844**] Hospital, goal Plt
>30, Goal Hct >25
3. PT/OT
4. CT Head in [**12-19**] weeks and Neurosurgery follow up at [**Hospital1 18**]
5. BMT follow up with Dr. [**Last Name (STitle) **]
6. Uptitrate metoprolol for afib, currently 100mg TID
Medications on Admission:
1. Metoprolol Tartrate 50 mg Tablet PO TID
2. Acyclovir 400 mg Tablet PO Q12H
3. Folic Acid 1 mg PO DAILY
4. Multivitamin Tablet PO DAILY
5. Deferoxamine 500 mg Recon Soln
Injection 2X/WEEK (WE,SA).
6. Calcium Carbonate 500 mg (1,250 mg)One (1)
Capsule PO four times a day.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection
Q24H
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.)PO once a day.
10. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule
PO Q12H.
11. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-19**]
Inhalation once a day.
14. Hydrochlorothiazide 25 mg PO once
a day.
Discharge Medications:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) injection
Injection Q24H (every 24 hours).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation DAILY (Daily).
8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule
PO Q12H (every 12 hours).
12. Deferoxamine 500 mg Recon Soln Sig: One (1) Recon Soln
Injection 2X/WEEK (WE,SA).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
14. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
15. Outpatient Lab Work
CBC with diff on [**2106-4-12**].
2-3 times weekly CBC with Diff thereafter.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Acute blood loss anemia/GI bleed
Pancytopenia, transfusion dependent
Lymphoblastic lymphoma
Atrial fibrillation with rapid ventricular response
Neutropenia
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:
Patient was admitted with GI bleeding due to a very low platelet
count. She was also found to have a right frontal brain
hemorrhage as well. She was transfused blood and platelets.
Heme/onc and Neurosurgery were consulted. With transfusion her
bleeding stopped and her brain hemorrhage was stable. No
further episodes of bleeding occurred.
.
She also had episodes of rapid afib. Her metoprolol was
increased. She had a contaminated blood culture, but no other
evidence of infection. She was continued on her prophylactic
antimicrobials.
.
Medication changes:
Metoprolol increased to 100 mg TID
.
Instructions:
1. Patient will REQUIRE twice weekly CBC and blood transfusion
and platelet transfusion. Her goal hematocrit is >25, and her
goal platelet is >30-50. Please check CBC on [**2106-4-12**], she will
needa platelet transfusion at that time.
2. Please continue the patient's Filgrastim, Levofloxacin, and
Acyclovir indefinitely
3. Patient will need repeat head CT in the beginning of [**Month (only) 116**] in
[**12-19**] weeks, and follow up with neurosurgery
4. Patient will need to follow up in our [**Hospital 3242**] clinic.
Followup Instructions:
PCP as soon as possible:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 75119**]
.
[**Last Name (LF) **],[**First Name3 (LF) **] E.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC as soon as possible
([**Telephone/Fax (1) 3936**]
.
Patient will need twice weekly blood and platelet transfusions
at [**Hospital **] HOSPITAL. Please arrange for this, and ask her son
with any questions.
.
Patients need HEAD CT in 10 days and neurosurgery follow up at
[**Hospital1 18**]
([**Telephone/Fax (1) 88**]
Admission Date: [**2106-4-9**] Discharge Date: [**2106-5-4**]
Date of Birth: [**2021-11-18**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
febrile neutropenia, respiratory distress, afib with RVR
Major Surgical or Invasive Procedure:
Peripherally Inserted Central Catheter
History of Present Illness:
The patient is a 84 y/o F with PMH of lymphoblastic lymphoma and
aplastic anemia, colons CA with recent admission for anemia s/p
fall, discharged today found to be febrile upon arrival to the
rehab had fever of 101.
.
Of note, the patient was admitted to [**Hospital1 18**] from [**Date range (1) **] s/p
fall with GI bleed and brain hemorrhage, all likely secondary to
thrombcytopenia. While here, she recieved 3units pRBCs and her
hct stabilized. Of note, the patient is transfusion dependent
with the aplastic anemia. Her head bleed stabilized with
platelets. She remained afebrile throughout that
hospitalization, with persistent neutropenia.
.
She was also admitted from [**Date range (3) 78633**] sepsis secondary to
Pseudomonas resistant to imipinem, quinolones an treated with
tobramycin and cefepime. (4/4 bottles positive). Completed 14
day course on [**4-4**]. At that time, she also had a GI bleed. The
patient has frequent admissions for GI bleeding in the setting
of thrombocytopenia. She also had history of groin abscesses.
.
In the ED, initial vitals were T 100.0, BP 150/89, HR 140, RR
16, O2 sat 99%. She recieved cefepime 2gm IV, vancomycin 1gm IV,
1gm tylenol and 5LNS. She recieved 5mg IV diltiazem x2.
.
On the floor, the patient is in respiratory distress, with
perioral cyanosis. She is put on a nonbreather. She is
tachypneic to the 30s. She reports difficulty breathing since
the morning. She has generalized weakness, no chills, no cough,
dysuea, abdominal pain, rhinorrhea, cold symptoms, n/v/d. She
does have some redness on her knee that she reports she noticed
several days ago. She denies chest pain.
.
Review of sytems:
(+) Per HPI
(-) Denies chest pain, abdominal pain.
Past Medical History:
Colon cancer [**2099**] s/p diverting colostomy reversed [**2100**],
loop colostomy for large bowel obstruction [**10-25**]
Lymphoplasmacytic lymphoma diagnosed [**10/2103**]
Aplastic anemia
Hypertension
Iron overload (heterozygous for hemochromatosis gene)
h/o C. diff colitis
h/o large bowel obstruction
s/p appendectomy
s/p tonsillectomy
s/p tubal ligation
s/p cholecystectomy
groin abscess
Social History:
Widow, has five children
Lives alone in [**Name (NI) 16843**], MA - son has been staying with her
recently
Denies tobacco, alcohol, or illicit drug use. One of patient's
sons is an alcoholic and has been belligerent with staff at
times.
Family History:
Father died of stroke at age 77
Mother had CAD and renal failure
No family history of malignancy or hematologic disorder
Physical Exam:
Vitals: T: 100.3 BP: 155/86 P: 136 R: 34 O2: 100% on 40%
facemask
General: Alert, but fatigued and short of breath, oriented to
place and person, intially cyanotic, improved with o2.
HEENT: Sclera anicteric, mucus membranes dry.
Neck: supple, EJ in place on right side
Lungs: decreased breath sounds at bases. crackles at bases.
CV: irregular heartbeat, no murmur
Abdomen: soft, non-tender, non-distended, colostomy on LLQ
draining non melanotic stool.
GU: foley
Ext: 3+ edema with scattered purpura.
Neuro: CN II-XII intact, moving all four extremities, [**4-21**]
strength in all 4 extremities.
Pertinent Results:
ADMISSION LABS:
[**2106-4-8**] 05:26AM BLOOD WBC-0.3* RBC-3.00* Hgb-9.0* Hct-25.8*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.3 Plt Ct-31*
[**2106-4-8**] 05:26AM BLOOD Neuts-64 Bands-0 Lymphs-32 Monos-0 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2106-4-9**] 09:10PM BLOOD ESR-68*
[**2106-4-8**] 05:26AM BLOOD Glucose-113* UreaN-29* Creat-0.7 Na-141
K-3.3 Cl-104 HCO3-31 AnGap-9
[**2106-4-8**] 05:26AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8
[**2106-4-9**] 09:07PM BLOOD Lactate-1.0
[**2106-4-9**] 09:10PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2106-4-9**] 09:10PM URINE Blood-TR Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
IMAGING/STUDIES:
.
CXR ON [**2106-4-22**]: SINGLE PORTABLE CHEST RADIOGRAPH:
Moderate-to-large bilateral pleural effusions with compressive
atelectasis are persistent, with increase in size on the right.
Upper lungs remain clear. Cardiac silhouette is partially
obscured. Mediastinal and hilar contours are unchanged. A
left-sided PICC is in stable position.
IMPRESSION: Persistent pleural effusions with increase on the
right.
.
CT OF CHEST/ABD AND PELVIS ON [**2106-4-13**]:
CT CHEST: Moderate bilateral pleural effusions have increased in
size since the previous examination. There is bilateral
compressive atelectasis. No focal parenchymal opacities are
present. Incidental note is made of an azygos lobe on the right.
There is tracheobronchomalacia. No pneumothorax is present.
There is no significant axillary, hilar, or mediastinal
lymphadenopathy. There are coronary artery vascular
calcifications and calcifications of the aortic arch. There is a
small pericardial effusion, unchanged.
There is calcification within the spleen (2:54) and an
incompletely evaluated hypodensity (2:53). Otherwise, the
splenic parenchyma appears normal. The adrenals are unremarkable
in appearance. The liver parenchyma appears unremarkable.
Cholecystectomy clips are present in the gallbladder fossa. The
kidneys enhance and excrete contrast symmetrically without
masses or hydronephrosis. The abdominal aorta and its branches
appear widely patent. Stomach and abdominal loops of small
bowel appear patent. There is a small-to-moderate amount of
intra-abdominal free fluid. Scattered non-pathologically
enlarged lymph nodes are present.
CT PELVIS: Patient is status post left colectomy with a right
abdominal wall ostomy containing a small amount of fluid
adjacent to the ostomy. Free fluid is present in the pelvis.
There are nonobstructed appearing loops of bowel. The sigmoid
colon, similar to the prior examination, is thickened with
diverticula. There is a fibroid uterus, with coarse
calcifications (2:100). The bladder is decompressed with a
Foley catheter in place. There is no pelvic adenopathy.
BONE AND SOFT TISSUE WINDOWS: There are degenerative changes of
the
thoracolumbar spine. There is soft tissue anasarca. No
suspicious sclerotic or lytic lesions are present.
IMPRESSION:
1. Bilateral pleural effusions, increased since prior
examination.
Atelectasis but no parenchymal opacities to suggest pneumonia.
2. Small-to-moderate amount of abdominal and pelvic ascites. No
loculated
fluid collections.
3. Decompressed thickened sigmoid may reflect diverticula. Mass
at this site
cannot be excluded and would recommend direct visualization if
not recently
performed.
4. Anasarca.
5. Nonobstructed loops of bowel with an ostomy in the left lower
quadrant.
6. Status post cholecystectomy.
7. Tracheobronchomalacia.
.
ECG ON [**2106-4-9**]:
Atrial fibrillation with rapid ventricular response. ST-T wave
abnormalities.
Since the previous tracing the rate is somewhat faster.
Otherwise, unchanged.
Rate PR QRS QT/QTc P QRS T
134 0 68 292/421 0 0 173
.
DISCHARGE LABS:
[**2106-5-4**] 00:45
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2106-5-4**] 00:45 4.0 2.90* 8.2* 24.7* 85 28.4 33.3
14.2 21*
Source: Line-PICC
DIFFERENTIAL Neuts 68% Bands 6% Lymphs 8* Monos 14* Eos 0
Baso 0 Atyps 2Metas 2 Myelos 0
Source: Line-PICC
BASIC COAGULATION: PT 13.8* PTT 29.2 INR(PT) 1.2*
ANC: 3063
CHEMISTRY:
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2106-5-4**] 00:45 111*1 29* 1.1 139 3.9 97 35* 11
ENZYMES & BILIRUBIN ALT AST LD(LDH) TotBili
[**2106-5-4**] 00:45 27 44* 176* 1.3
Calcium Phos Mg
[**2106-5-4**] 00:45 9.1 4.0 1.8
Source: Line-PICC
.
Cyclspr Trough: 213
[**2106-5-4**] 09:41
.
[**2106-4-16**] 10:07 am URINE Source: Catheter.
**FINAL REPORT [**2106-4-17**]**
URINE CULTURE (Final [**2106-4-17**]): NO GROWTH.
**FINAL REPORT [**2106-4-13**]**
URINE CULTURE (Final [**2106-4-13**]):
GRAM POSITIVE BACTERIA. ~1000/ML.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
Blood Culture, Routine (Final [**2106-4-18**]): NO GROWTH.
Blood Culture, Routine (Final [**2106-4-19**]):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
Tigecycline & Colistin SENSITIVITIES REQUESTED BY [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 78634**]
[**2106-4-12**]. SENT OUT TO [**Hospital3 **] FOR COLISTIN
SENSITIVITY.
UNASYN (AMPICILLIN/SULBACTAM) SENSITIVITY REQUESTED PER
DR [**Last Name (STitle) **]
[**2106-4-13**].
Tigecycline = 32 MCG/ML (NO INTERPRETATION).
Sensitivity testing performed by Etest.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism Results may not be
reliable
and must be interpreted with caution.
UNASYN (AMPICILLIN/SULBACTAM) = 6MM (NO ZONE, NO
INTERPRETATION).
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism Results may not be
reliable
and must be interpreted with caution.
COLISTIN = SENSITIVE, Sensitivities performed by [**Hospital1 **]
laboratories.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final [**2106-4-10**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 4617**] [**Last Name (NamePattern1) **] @ 2207 ON [**4-10**] -
[**Numeric Identifier 6026**].
GRAM NEGATIVE ROD(S).
[**2106-4-11**] 9:13 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2106-4-20**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-4-11**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 78635**] (4I) [**2106-4-11**] AT 1500.
CLOSTRIDIUM DIFFICILE.
Brief Hospital Course:
# Pseudomonas bacteremia - Blood cultures were positive for
multi drug resistant Pseudomonas aeruginosa. She received a 14
day course of IV tobramycin and meropenem, and was continued on
meropenem for the duration of her hospitalization. Infectious
disease was consulted and recommended indefinite treatment with
IV meropenem given her immunosupressed state.
.
# Clostridium difficile colitis - Stool was positive for C.
difficile antigen. She was started on vancomycin 125mg PO qid.
She experienced no abdominal pain or diarrhea. Infectious
recommended indefinite treatment with PO vancomycin.
.
# Respiratory Distress - Patient was noted to have perioral
cyanosis on arrival to the ER which resolved quickly with O2.
Imaging was consistent with volume overload, with bilateral
pleural effusions, and she had 3+ peripheral edema to the hip.
She was diuresed with IV lasix, and her weight came down from
194 Lbs on admission to 182.5 Lbs on discharge. She was given
40mg of IV lasix today since she received 1 unit of PRBCs. She
was discharged on 40mg of PO lasix with additional IV lasix
given with blood products.
.
#. Aplastic Anemia. Patient has baseline transfusion dependent
aplastic anemia. She was tranfused PRBC to Hct of 25, and
platelets of 10. She received one day of treatment with IVIG.
She was continued on neupogen 300 mcg sc daily. She was treated
with cyclosporine, and her dose was titrated to a therapeutic
serum level of ~200. She will need to continue to have the
cyclosporine levels checked during her oncology office visits.
Her last PRBCs transfusion was on [**2106-5-4**] for HCT of 24.7 and
plalet transfusion was on [**2106-5-2**] for Plats of 8,000 for which
she responded well. Platelet today 21,000. She will need to
continue to have CBC checked every 1-2 days with parameters for
transfusion as noted above and additional 40mg of IV lasix on
the day of transfusion. Please monitor I/os, creatine and
symptoms of fluid overload. Pt will follow-up with her
[**Date Range 5564**] on [**5-13**].
# AF with RVR - On admission she was in atrial fibrillation with
rapid ventricular rate in the 140s. This was initially treated
with boluses of IV metoprolol. She was continued on her home
dose of metoprolol 100 mg PO tid, and started on diltiazem 30mg
PO qid, with excellent rate control for the remainder of her
hospitalization.
.
# Lymphoplasmacytic lymphoma - CT torso showed no recurrance or
growth of her lymphoma.
# Recent Subarachnoid Bleed: In the setting of a fall 1 week
prior to admission. Bleed stable on CT scan after platelets.
Neurologic exam remained stable throughout her stay.
# Hypertension: Patient was continued on her home dose of
metoprolol 100mg tid and started on lasix as noted above. Her
home HCTZ and of amlodiopine 10mg daily were held. Her BP has
been under good control on current regimen and this will need to
be readress with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**].
# Iron overload: Patient is heterozygous for hemachromatosis
gene and requries frequent PRBC transfusions. She was continued
on deferoxamine 500 mg IV 2X/WEEK (WE,SA).
.
# Urinary incontinence: pt with urinary incontinence and her
skin was fragile due to immobility and anasarca. Foley catheter
was placed to protect her skin, and for close monitoring of
output while been diuresed. Please remove the foley as soon as
possible and monitor for skin breakdown.
Medications on Admission:
1. Acyclovir 400 mg PO Q12H
2. Folic Acid 1 mg PO DAILY
3. Multivitamin PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Filgrastim 480 mcg/1.6 mL - One Injection Q24H
6. Omeprazole 20 mg (E.C.) PO DAILY
7. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**12-19**]
Puffs Inhalation DAILY (Daily).
8. Hydrochlorothiazide 25 mg PO DAILY
9. Levofloxacin 500 mg PO Q24H
10. Acetaminophen 1000 mg Tablet PO TID
11. Cyclosporine Modified 75 mg PO Q12H
12. Deferoxamine 500 mg Recon Soln Sig: One (1) Recon Soln
Injection 2X/WEEK (WE,SA).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
14. Metoprolol Tartrate 100 mg PO TID
Discharge Medications:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours): Pt may refuse.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours): Pt
may refuse.
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain/and before blood products: You
should not exceed 4gm in 24hrs. If pt requiring continues amount
of tylenol for pain please notify MD, since tylenol may affect
liver function.
10. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
11. Deferoxamine 500 mg Recon Soln Sig: One (1) Recon Soln(s) IV
Injection 2X/WEEK (WE,SA): Please give over 4hours .
12. Cyclosporine Modified 25 mg Capsule Sig: Six (6) Capsule PO
Q24H (every 24 hours): At 22:00 daily.
13. Cyclosporine Modified 25 mg Capsule Sig: Five (5) Capsule PO
Q24H (every 24 hours): At 10:00 AM daily. .
14. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours): Continue Neupogen until she sees [**Month/Day (2) **] on
[**2106-5-13**].
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
16. Meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
18. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4HRS:PRN as needed for
shortness of breath or wheezing.
20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please
hold for SBP<100.
21. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for Pruritis/allergic reaction and before blood
products.
22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for Swish and swallow for oral
[**Female First Name (un) 564**].
23. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS:PRN as
needed for insomnia: Please hold for sedation and RR<12.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Aplastic Anemia
Pseudomonas aeruginosa bacteremia
Clostridium difficile colitis
Atrial Fibrillation
Fluid Overload
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 for fever. You were found to have a
bloodstream infection with the bacteria Pseudomonas bacteremia,
and an infection of your gut with Clostridum difficile. You
were treated for these infections with antibiotics. You were
also found to have excess fluid in your body, which was removed
with the medicine furosemide. Your atrial fibrillation was
controlled with medications.
Please note the following changes in your medications:
- Meropenem 1000mg IV daily
- Vancomycin 125mg by mouth, four times daily
- Started on lasix 40mg daily
- Stopped HCTZ
- Holding Amlodipine, until you further discuss with your
doctor. BP has been controlled on current regimen.
You will need to have blood work done daily to monitor your
blood counts and to have transfusion of PRBC for Hct less than
25 and plalets less than 10,000. You will also need to have
blood draws to monitor your electrolytes including magnesium and
potassium.
Followup Instructions:
You will need to follow-up as listed below.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD
Date/Time:[**2106-5-13**] 12:00,
[**Hospital1 **], [**Hospital Ward Name **] BUILDING LEVEL 9
Phone:[**Telephone/Fax (1) 3241**]
|
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"E888.9",
"287.5",
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"518.81",
"038.43",
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icd9cm
|
[
[
[]
]
] |
[
"99.14",
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
29155, 29226
|
22391, 25833
|
11935, 11976
|
29385, 29385
|
15153, 15153
|
30524, 30786
|
14398, 14520
|
26552, 29132
|
29247, 29364
|
25859, 26529
|
29561, 30501
|
18889, 22368
|
14535, 15134
|
3438, 5382
|
10400, 10979
|
11839, 11897
|
13658, 13710
|
12004, 13640
|
15169, 18873
|
29400, 29537
|
13732, 14127
|
14143, 14382
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,100
| 144,589
|
17869
|
Discharge summary
|
report
|
Admission Date: [**2184-1-23**] Discharge Date: [**2184-2-6**]
Date of Birth: [**2139-2-28**] Sex: F
Service: SURGERY
Allergies:
Zocor / Fosinopril
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
DM type 1
ESRD on HD
Major Surgical or Invasive Procedure:
renal and pancreas transplant [**2184-1-23**]
Past Medical History:
1. Type 1 DM (poorly controlled, last A1c 8.8)
2. Hypercholesterolemia
3. HTN
4. ESRD [**3-12**] DM
5. R eye blindness
6. Left leg weakness
7. Goiter s/p iodine ablation
8. Osteopenia/osteoporosis
9. Simultaneous renal and pancreas transplant [**2184-1-23**]
10.Cirrhosis, seen during OR [**2184-1-23**]
Social History:
Lives at home with her mother, stepfather and sister. Denies
tobacco, alcohol, and IVDU.
Family History:
Multiple family members on father's side with DM II. No family
history of premature CAD.
Physical Exam:
Vitals:95.9 79 159/68 20 100 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender.
Ext: No LE edema, LE warm and well perfused. RUE AVG with good
pulse, palpable thrill, audible bruit.
Laboratory:
All labs are pending at this time
Imaging:
None available at this time
Pertinent Results:
[**2184-2-6**] 05:43AM BLOOD WBC-9.6 RBC-2.90* Hgb-8.5* Hct-25.6*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.5 Plt Ct-153
[**2184-2-2**] 05:23AM BLOOD PT-12.8* PTT-26.2 INR(PT)-1.2*
[**2184-2-6**] 05:43AM BLOOD Glucose-117* UreaN-40* Creat-1.0 Na-141
K-5.2* Cl-116* HCO3-22 AnGap-8
[**2184-2-6**] 05:43AM BLOOD ALT-21 AST-18 AlkPhos-133* TotBili-0.5
[**2184-1-23**] 05:10AM BLOOD ALT-19 AST-28 LD(LDH)-293* AlkPhos-225*
Amylase-259* TotBili-0.3
[**2184-2-5**] 06:00AM BLOOD Lipase-65*
[**2184-2-5**] 06:00AM BLOOD Albumin-1.8* Calcium-8.9 Phos-2.8 Mg-1.8
[**2184-2-6**] 05:43AM BLOOD Albumin-2.7* Calcium-9.4 Phos-2.3* Mg-1.8
[**2184-1-23**] 05:10AM BLOOD Triglyc-102
[**2184-2-5**] 05:48PM BLOOD Ammonia-28
[**2184-2-5**] 06:00AM BLOOD tacroFK-12.5
Brief Hospital Course:
44 F with history of DM since age 18 and ESRD on HD was taken to
the OR on [**2184-1-23**] for simultaneous kidney-pancreas transplant.
Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Intraop findings were significant
for finding of cirrhosis (h/o prior w/u and liver biopsy with
concern for ? autoimmune hepatitis). A liver biopsy was obtained
and hepatologist consulted. Surgery proceeded to transplant.
Please refer to operative note for details. There was
significant abdominal swelling and abdomen was unable to be
closed primarily. Pressor support was required initially. Duplex
of kidney was done and vasculature was fine. She was taken back
to the OR on [**1-25**] for abdominal wall closure by Dr. [**First Name (STitle) **].
She was weaned off sedation and extubated without event in SICU.
Labetalol was restarted for elevated SBPs.
Postop, renal function was excellent with increased urine
production and decreased creatinine to 1.0. Pancreas function
was excellent with glucoses, amylase and lipase normalizing.
Daily aspirin was started as well as IV heparin drip to prevent
vascular thrombosis. Heparin was stopped on [**1-26**] for hct drop
to 25. 2 Units of PRBC were given with HCT increase to 37.
Hematocrits were stable and heparin was resumed. JP drain
continued to be sanguinous. Hct dropped again to 24 on [**1-29**] and
another 2 units of PRBC were administered. Heparin drip was
discontinued. Output became more serous then ascitic in
subsequent days. Hcts stabilized. JP fluid was sent for
creatinine and amylase. Findings were not indicative of urine or
pancreatic leak.
JP output was high with highest output of 1700ml/day decreasing
to 700ml/day. She required IV fluid replacement and albumin
administration on [**2-5**] for albumin level of 1.8. Albumin
increased to 2.7 on [**2-6**].
Abdominal incision was intact with staples. Incision continued
to have small amount of serosanguinous staining on dressing.
Incision was without redness. JP was removed on [**2-5**] and site
sutured.
Hepatology was consultd for cirrhosis and was felt to most
likely be due to NASH that had progressed. Biopsy had markedly
increased fibrosis, progressing to cirrhosis, and increased iron
deposition. The iron deposition pattern was atypical for a
primary iron storage disorder and requires further w/u.
Ursodiol and lipitor were recommended with every 6 month f/u AFP
and ultrasound check. EGD as outpatient was recommended to
evaluate for varices. Last EGD was done in [**2179**] and was normal.
Follow up appt was made with Dr. [**Last Name (STitle) **] from Hepatology. LFTs
remained stable. No asterixis was noted. Mental status was
alert, but slow with possible language barrier. TSH, T3 and T4
were checked and were pending at time of discharge.
Immunosuppression consisted of 5 doses of ATG (75mg each dose),
steroids ( tapered), cellcept and prograf. Cellcept was
initially 1 gram [**Hospital1 **], but switched to 500mg qid due to GI side
effects. Prograf dose was adjusted per trough levels. Level
became supra therapeutic twice while on 4mg [**Hospital1 **]. Dose was
decreased to 3mg [**Hospital1 **].
Diet was advanced and tolerated. However, caloric intake was
insufficient despite nutritional supplements. A post pyloric
feeding tube placement was attempted on [**2-5**], but was
unsuccessful in getting post pyloric. Tube was in stomach and
feedings started (Nepro continuous at 40cc/h).
Physical therapy evaluated and recommended a walker with
supervision. Rehab was pursued and a bed was available at [**Hospital1 **]
in [**Location (un) 86**]. She will transfer there.
Medications on Admission:
Sevelamer 800''', Lipitor 10', [**Last Name (un) **] Forte 500'', Cozaar 25',
Aspirin 81', Vit D 400 IU'', Colace 100'', Folic acid 1',
Insulin
: Lantus 5 units hs, Humalog sliding scale, labetalol 400''',
losartan 100', methimazole 5'
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
four times a day.
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
13. Outpatient Lab Work
Every Monday and Thursday with stat results
cbc, chem 10, ast, alt, alk phos t.bili, albumin trough prograf
level and UA
Fax results to [**Telephone/Fax (1) 697**] attention RN coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] in [**Location (un) 86**]
Discharge Diagnosis:
DM I
ESRD
Cirrhosis, NASH
Legally blind
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You will be transferring to [**Hospital **] Rehab in [**Location (un) 86**]
Please call the Transplant Service [**Telephone/Fax (1) 673**] if you have any
of the warning signs listed below.
You will need to have blood drawn every Monday and Thursday for
lab monitoring
Check your blood sugar twice daily prior to meals, call if
glucose 200 or greater
You may shower with soap and water. Rinse/pat dry. No tub baths
or swimming
Do not lift anything heavier than 10 pounds. No straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2184-2-12**] 2:40 ([**Hospital Ward Name **] Office Medical Building [**Last Name (NamePattern1) 12939**], [**Location (un) **], [**Location (un) 86**])
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17627**] [**2183-2-17**] at 11:30 [**Last Name (NamePattern1) 439**] , [**Location (un) 6749**] [**Hospital **] Medical Office Building
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2184-2-17**]
8:00
Completed by:[**2184-2-6**]
|
[
"272.0",
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"250.41",
"733.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
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icd9pcs
|
[
[
[]
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] |
7229, 7298
|
2064, 5712
|
298, 346
|
7395, 7395
|
1300, 2041
|
8087, 8729
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796, 886
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5999, 7206
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7319, 7374
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5738, 5976
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7578, 8064
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901, 1281
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238, 260
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368, 673
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689, 780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,267
| 155,611
|
32378
|
Discharge summary
|
report
|
Admission Date: [**2193-11-5**] Discharge Date: [**2193-11-11**]
Date of Birth: [**2135-4-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
hypertensive emergency
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
58 yo Spanish speaking male w/ a h/o refractory hypertension and
seizure disorder who was brought to ED today after presenting to
PCP's office w/ acute onset nausea and vomiting. This am,
patient had acute onset of nausea, vomiting and diarrhea. He ate
chicken and rice at a restaurant last night. He ate the same
meals as all other family members yesterday and no one else has
been ill. He had ~ 4 episodes of diarrhea and 4 episodes of
vomiting. He denies any blood in his vomit or stool. Around the
same time he also developed a headache. He was brought to [**Name8 (MD) **]
MD's office by his brother. In MD's office, he was confused and
complained of HA. His BP was 220/140 with HR in 140s. Patient
denied missing any of his regular medications but unclear if was
able to keep down with vomiting. His PCP called ambulance for
transport to the ED. On transport in the ambulance patient had 2
witnessed tonic-clonic seizures each lasting ~ 3 minutes. No
reported tongue biting or incontinence.
.
Upon arrival to the ED, VS showed T 99.7, BP 236/118, HR 141, RR
25, O2 95% RA. Patient was awake but oriented to person only. He
was thought to be post-icatal. Hoe received a CT head which was
negative for ICH. CXR was normal. ECG showed sinus tach but was
otherwise unremarkable. He received a labetolol bolus w/o
significant change in his BP so he was started on a labetolol
gtt w/ SBPs 240s --> 170s, HRs 140s --> 80s. His dilantin level
was checked and was 1.4 and he was loaded with 1000 mg of
dilantin. A lactate was checked and was 5.8, presumably
secondary to his seizure. Patient's mental status improved over
the course of his ED stay and was able to answer simple
questions in english. Once clear, he only complained of a mild
HA. His neuro exam was reportedly nonfocal and his abdomen was
benign. He had no further episodes of nausea or vomiting in the
ED and his stool was quiaic negative. Labetolol was weaned off
in ED w/ rebounding of BP and required restart. Patient
transferred to ICU for further management.
.
Upon arrival to the ICU, patient looks well. History confirmed
with the aid of an interpreter. He states he feels greatly
improved with only a mild residual HA. His initial HA was a [**6-4**]
and is currently a [**1-5**]. He denies any vision changes. He denies
any current abdominal pain. He does note mild nausea. He denies
and chest pain or shortness of breath. On ROS, he denies any
recent fevers, chills, sick contacts, cough, SOB, CP, HA, or any
other complaints in the recent past prior to today.
Past Medical History:
PMH:
# hypertension: x 20 years
- refractory to multiple meds as an outpatient
- per patient, has never been worked up for secondary
hypertension
# seizure disorder on dilantin and depakote
- first seizure in [**2170**] following EtOH abuse
- No further seizures until [**2185**]
- from [**2185**] until [**2192**] had ~ 1 seizure/year
- in last couple of months has had increasing frequency of
seizures now ~ every 2 wks
- multiple hospital admissions in PR for seizures and
hypertension
- typical seizure followed by arm and leg numbness and confusion
# DM: x 4 year. does not check blood sugars at home
# s/p cholecystectomy
# h/o EtOH abuse
Social History:
Moved from [**Male First Name (un) 1056**] 1 wk ago in search of medical help.
Currently unemployed. Used to work in the radio industry in PR.
Denies tobacco hx. Former heavy EtOH use x 16 years. Stopped [**12-29**]
years ago due to seizure disorder. H/o cocaine and marijuana
use. None recently
Family History:
No fam hx of hypertension or seizure disorders that he can
report
Physical Exam:
PE: T: 99.8 BP: 187/92 HR: 91 RR: 19 O2 95% RA
Gen: Pleasant, resting comfortably in bed, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, JVP ~10 cm H2O
CV: RRR. nl S1, S2. +S4. No murmurs
LUNGS: CTAB
ABD: NABS. Obese. Soft, NT, ND. No HSM. No abdominal bruits
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
Pertinent Results:
LABS:
[**2193-11-11**] 05:30AM BLOOD WBC-4.6 RBC-3.48* Hgb-11.3* Hct-33.3*
MCV-96 MCH-32.4* MCHC-33.8 RDW-14.1 Plt Ct-232
[**2193-11-6**] 05:25AM BLOOD Neuts-74.8* Lymphs-17.1* Monos-6.5
Eos-1.5 Baso-0.1
[**2193-11-6**] 05:25AM BLOOD PT-14.4* PTT-21.7* INR(PT)-1.3*
[**2193-11-11**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-1.4* Na-141
K-3.8 Cl-102 HCO3-29 AnGap-14
[**2193-11-5**] 08:05PM BLOOD ALT-27 AST-27 AlkPhos-54 Amylase-97
TotBili-0.4
[**2193-11-10**] 06:47AM BLOOD Lipase-22
[**2193-11-6**] 05:25AM BLOOD CK-MB-4 cTropnT-<0.01
[**2193-11-5**] 08:05PM BLOOD CK-MB-4 cTropnT-<0.01
[**2193-11-9**] 07:30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
[**2193-11-10**] 06:47AM BLOOD Albumin-3.7
[**2193-11-6**] 05:25AM BLOOD %HbA1c-6.1*
[**2193-11-6**] 05:25AM BLOOD TSH-1.1
[**2193-11-11**] 05:30AM BLOOD Phenyto-12.5
[**2193-11-5**] 08:05PM BLOOD Phenyto-1.4* Valproa-54
[**2193-11-5**] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-11-5**] 08:15PM BLOOD Lactate-5.8*
[**2193-11-7**] 03:28PM BLOOD ALDOSTERONE-PND
[**2193-11-7**] 03:28PM BLOOD RENIN-PND
[**2193-11-8**] 08:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2193-11-8**] 08:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2193-11-8**] 07:42PM URINE 24Creat-1470
[**2193-11-5**] 09:30PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2193-11-8**] 08:42PM URINE Hours-RANDOM Creat-125 TotProt-16
Prot/Cr-0.1
[**2193-11-8**] 07:42PM URINE METANEPHRINES-PND
.
Blood Culture, Routine (Final [**2193-11-11**]): NO GROWTH.
URINE CULTURE (Final [**2193-11-6**]): NO GROWTH.
.
.
STUDIES:
.
ECG [**11-5**]: sinus tach @ 135. LAD. QWs in III, aVF. LVH. Early RW
progression. ST depressions in V3-6.
.
repeat ECG: NSR @ 88. St depressions almost resolved. Otherwise
unchanged.
.
CXR [**11-5**]: The cardiomediastinal silhouette is unremarkable.
There is no effusion, airspace disease or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
.
CT head [**11-5**]: There is no evidence of intracranial hemorrhage,
hydrocephalus, shift of normally midline structures or edema.
Focal areas of hypoattenuation involving the right caudate and
right periventricular white matter are consistent with chornic
lacunar infarcts. Periventricular white matter hypoattenuation
is consistent with chronic small vessel ischemic changes. The
paranasal sinuses are well aerated.
IMPRESSION: No evidence of intracranial hemorrhage or edema.
.
[**2193-11-8**] MRA KIDNEYS:
IMPRESSION:
1. Small renal arteries bilaterally without evidence of renal
artery
stenosis.
2. Fusiform right internal iliac artery aneurysm with an
adjacent, 6.0 x 2.5
cm non-enhancing lesion with precontrast T1 hyperintensity,
could represent a
larger thrombosed aneurysm or hematoma. A dedicated pelvic MRI
with gadolinium
is recommended for further evaluation.
3. Bilateral simple renal cysts.
.
.
MRI PELVIS W/O & W/CONTRAST [**2193-11-10**] 4:22 PM (FINDINGS OF STUDY
POSTED AFTER PATIENT DISCHARGED)
FINDINGS: The abdominal aorta and common iliac arteries are
normal in caliber bilaterally. The right internal iliac artery
is dilated from its origin, measuring up to 11 mm in diameter.
Just distal to the takeoff of the first branch of the internal
iliac artery (iliolumbar artery; 100:34) there is a crescentic
area of signal abnormality and expansion of the vessel,
consistent with dissection. The dissection extends inferiorly
along the internal iliac artery and continues along a tortuous
branch which courses medially and anteriorly to the base of the
bladder, likely the superior vesical artery (100:26). At its
largest dimension, the diameter of the involved segment measures
2.9 cm. Hyperintensity on pre- contrast T1- weighted images is
consistent with thrombosis within the false lumen. Post-
contrast images show flow within the true lumen of the involved
vessel as well as within multiple branches of the internal iliac
artery. In particular, the obturator artery is patent, although
enveloped at its origin by the dissection, and the superior
gluteal artery is patent and does not display evidence of
dissection. More lateral and slightly anterior along the right
pelvic sidewall is an oval structure which shows partial
progressive enhancement measuring 1.8 x 1.0 cm (101A:79), likely
representing a partially thrombosed pseudoaneurysm of a pelvic
sidewall vessel.
The left internal iliac artery is normal in caliber with a focal
area of crescentic mural thickening and non-enhancement
(100:38), consistent with nonocclusive plaque. The bilateral
external iliac arteries and visualized portions of the common
femoral arteries, as well as the imaged portion of the abdominal
aorta, are patent and normal in caliber. The imaged portion of
the bladder, prostate and seminal vesicles, rectum and sigmoid
colon appear within normal limits as does the marrow signal.
Multiplanar reformations were essential in delineating the
above-described findings.
IMPRESSION:
1. Dissection and pseudoaneurysm (that appears completely
thrombosed) of the right internal iliac artery, extensively
involving the superior vesical artery and measuring up to 2.9 cm
in diameter.
2. 1.8 x 1.0 cm partially enhancing structure in the right
pelvic sidewall likely represents an additional thrombosed
vessel and pseudoaneurysm with flow within the non- thrombosed
portion of the lumen.
3. Nonocclusive plaque in the left internal iliac artery.
These results were discussed with [**Doctor First Name **] [**Doctor Last Name 21402**] on [**11-11**], [**2192**], at 12:30 p.m. via telephone message and at 4:50 p.m.
via telephone conversation. Findings of dissection and
pseudoaneurysm, and potential risk of rupture, were discussed.
Brief Hospital Course:
This is a 58 yoM w/ htn, seizure disorder who presented w/
nausea, vomiting, and seizures in the setting of severe
hypertension.
1) Hypertensive Emergency: He initially had MS changes, which
was evidence of hypertensive encephalopathy and was also noted
to have renal failure (baseline Cr unknown). No other evidence
of HTN emergency. Inciting event is unclear as patient states he
has not missed any medications - also baseline BP unknown. He
initially was started on a labetolol drip in the ED and was
quickly weaned off upon arrival to the MICU, with goal SBP 160,
DBP<100. He was restarted on po labetolol and HCTZ initially,
and his other home BP meds were held. Urine and serum tox
screens were negative. However, his BP continued to be labile
throughout the next day, ranging from 120's systolic - 200's
systolic, patient was asymptomatic. His po labetolol dose was
increased as well as the dose of lisinopril, and he was
restarted on clonidine, as there was concern that some part of
his HTN may be due to rebound HTN from the d/c of clonidine on
admission. TSH was normal. He had 3 sets of cardiac enzymes
which were normal. His ECG showed left ventricular hypertrophy
with lateral ST segment depressions, but as his BP was improved,
the depressions resolved on subsequent ECGs. He does not appear
to have had a prior work-up from secondary causes of HTN, so an
MRA of the kidneys were ordered to evaluate for RAS. Renin and
aldosterone levels were also sent. The patient was then
transferred to the floor for further control of his HTN. He was
maintained on Labetalol, Lisinopril, and Clonidine. He was
started on Amlodipine and HCTZ prior to discharge. He was
weaned down on the Clonidine to 0.1 mg [**Hospital1 **] prior to discharge.
His SBP ranged from 120-150 prior to discharge. He will have
followup with a PCP in [**Name9 (PRE) 12091**] Community Health Center this
Friday to determine further therapy. Our goal was to have him
weaned off Clonidine and to control his BP with other
medications which are less likely to cause rebound HTN. The MRA
of his kidneys were negative for renal artery stenosis, but did
show a lesion near the internal iliac artery that was better
assessed with MRI Pelvis. At the time of discharge, the MRI
pelvis read was pending. After discharge results were obtained
as above. These results were passed on to the [**Location (un) 12091**] Community
Health Center. The renin/aldosterone and urine metanephrines
were also pending at the time of discharge. We will followup
with the results and make an addendum to this discharge summary
so that his PCP will be aware of the results. This plan was
discussed with the patient through an interpreter, and he
understands his medication regimen and the need for close
followup. He has an appointment on [**11-15**] at the [**Hospital 12091**]
Community Health Center.
.
2) Seizure Disorder: In regards to his seizure disorder,
background information was not available. He was continued on
dilatin and depakote and neurology was consulted. Due to
subtherapeutic dilantin levels, he was loaded in the ED with 1
gm and with an additional doses throughout his ICU stay. At the
time of discharge, he was on Dilantin 200 mg [**Hospital1 **] and Depakote
500 mg [**Hospital1 **] with levels in the therapeutic range. Neurology was
informed, and the patient was made an appt to followup in
[**Hospital 875**] Clinic on [**2193-11-18**]. An EEG appointment could not be
made prior to discharge, so we have given the phone number to
the patient so that he can call the office in the morning to
schedule an EEG prior to his appointment with the Neurologist.
He also had a CT head on admission which was negative for
intracranial hemorrhage.
.
3) Acute Kidney Injury: The patient's baseline Cr was unknown,
but on admission was 1.7. This decreased to 1.4 after IVF.
Likely has renal disease secondary to long-standing HTN. He had
a protein/creatinine ratio of 0.1. His HbA1c was 6.1,
indicating good glycemic control. The patient likely has
underlying chronic kidney disease stage 3 with an eGFR of 55.
The patient will need f/u with his PCP to determine further
therapy if necessary and to followup his chem 7 at his next
appointment.
.
4) Diabetes: The patient's blood glucose levels were only
mildly elevated. He was continued on his metformin 500 mg [**Hospital1 **],
and had ISS coverage. His HbA1c of 6.1 suggest good glycemic
control. The patient will need close f/u of his creatinine to
determine if any changes need to be made to his metformin given
his baseline kidney disease. The patient is also on an ACE-I
for HTN and prevention of proteinuria secondary to diabetes.
.
5) Dispo: The patient has no PCP since he moved to the US. We
have set him up an appointment at [**Location (un) 12091**] Community Health
Center with Dr. [**Last Name (STitle) **] on [**11-15**]. The patient understands that he
needs close f/u of his HTN given his diabetes and risk for
seizure. Also, the patient was notified that he should not
drive for 6 months after his seizure episodes prior to
admission. The patient understands the risks involved with
driving when he just had recent seizures. He will have f/u with
neurology as well. We will send a copy of the discharge summary
with an addendum to include the pending lab values to his new
PCP. [**Name10 (NameIs) **] was all explained to the patient via an interpreter.
Medications on Admission:
dilantin 100 mg ?T ID
depakote 500 mg ? [**Hospital1 **]
hctz 50 mg Qday
doxazosin 2 mg Qday
Imdur 30 mg Qday
clonidine 0.4 mg TID
nifedipine XR 60 mg Qday
labetolol 200 mg [**Hospital1 **]
fluoxetine 20 mg Qday
metformin 500 mg [**Hospital1 **]
Discharge Medications:
1. Depakote 500 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*
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Phenytoin Sodium Extended 200 mg Capsule Sig: One (1) Capsule
PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypertensive Emergency
Secondary Diagnosis:
Diabetes Mellitus 2
Chronic Kidney Disease III
Dissection and pseudoaneurysm of the right internal iliac artery
Discharge Condition:
stable; BP controlled
Discharge Instructions:
You were admitted for very high blood pressure and altered
mental status. You were found to have some kidney disease as
well, likely from your high blood pressure. You were given IV
blood pressure medications, and then switched to an oral regimen
with good blood pressure control. You also had an MRI which
showed no disease in the arteries going to your kidneys.
.
Please take all medications as prescribed. Please go to all
scheduled appts.
.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pain, shortness of breath,
nausea, vomiting, fevers, chills, headaches, or visual losses.
Followup Instructions:
Appointment at [**Location (un) 12091**] [**Telephone/Fax (1) 3581**] on [**2193-11-15**] at 12:00 PM
.
Please call [**Telephone/Fax (1) 5285**] to schedule an EEG prior to your
appointment with Neurology on [**2193-11-18**].
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2193-11-18**] 9:00
|
[
"250.00",
"585.3",
"444.81",
"345.90",
"403.00",
"584.9",
"442.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17162, 17168
|
10339, 15772
|
338, 363
|
17387, 17411
|
4505, 10316
|
18099, 18456
|
3925, 3993
|
16069, 17139
|
17189, 17189
|
15798, 16046
|
17435, 18076
|
4008, 4486
|
276, 300
|
391, 2926
|
17252, 17366
|
17208, 17231
|
2948, 3596
|
3612, 3909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,707
| 186,045
|
5350+5351
|
Discharge summary
|
report+report
|
Admission Date: [**2153-9-22**] Discharge Date: [**2153-9-25**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
wrist pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 yo F c Mast Cell Degranulation, p/w recurrence in setting of
R wrist pain and swelling, with worsening airway edema
transferred from MICU on [**9-24**] admitted on [**9-22**]. Pt was admitted
to medicine in the morning on [**9-22**] with complaints of abdominal
pain, R arm pain and rash, SOB, nausea, itching, diarrhea and
low grade fevers for several days. She noted a rash with
purulence on her right wrist for which she took a course of
Keflex. She also c/o diarrhea and low grade fevers. She felt on
admission that these symptoms were similar to other "Mast Cell
Degranulation exacerbations."
.
On the floor her vanco was switched to keflex, she was given
benedryl 25mg iv x4, then 50mg iv x2, dilaudid 10mg iv, ativan
2mg iv, zofran 4mg x1, albuterol neb x1, and prednisone 40mg,
ranitidine 300mg po.
.
While on floor pt was noted to have worsening oral swelling and
concern for airway compromise. Anesthesia assessed her
oropharynx with bronchoscopy and though the vocal cords were not
edematous there was significant laryngeal edema. Pt was
intubated for airway protection. Additionally during this
episode she was given solumedrol 40mg iv, epinephrine (0.3mg sc)
x1, benedryl 50mg iv, famotidine 20mg iv. She was given dilaudid
1mg iv for chest pain and abdominal pain. Cardiac enzymes were
negative and the pt was transferred to the MICU.
.
Pt was extubated [**2153-9-23**]. Recent vitals: temp 98. Pulse 77. BP
122/63, rr 14. 92% RA. O2 sats are usually in the high 90's.
Right wrist does not appear erythematous or cellulitic so Keflex
was discontinued.
.
Past Medical History:
- mast cell degranulation syndrome as above- Followed by [**First Name8 (NamePattern2) 21734**]
[**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also
followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- ADHD
- depression/anxiety
- MI after given wrong dose of epi in anaphylaxis
- HTN
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports EGD demonstrated vegetable bezoar (?[**12-7**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
Pt divorced approx 2 [**Month/Day/Year 1686**] ago after 37 [**Month/Day/Year 1686**] of marriage. Husband
was doctor. [**First Name (Titles) **] [**Last Name (Titles) 21749**] as ED tech at [**Hospital 2436**] Hosp.
Reports that she was about to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2436**] Hosp for wrongful
termination as of [**6-10**] but then her PCP changed her status to
permanent disability which seemed to terminate the situation.
Son is HCP [**Telephone/Fax (1) 21738**].
Pt divorced approx 2 [**Telephone/Fax (1) 1686**] ago after 37 [**Telephone/Fax (1) 1686**] of marriage. Husband
was doctor. [**First Name (Titles) **] [**Last Name (Titles) 21749**] as ED tech at [**Hospital 2436**] Hosp.
Reports that she was about to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2436**] Hosp for wrongful
termination as of [**6-10**] but then her PCP changed her status to
permanent disability which seemed to terminate the situation.
Son is HCP [**Telephone/Fax (1) 21738**].
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
Vitals - T: 98.4 BP: 154/86 HR: 78 RR: 20 02 sat: 99% on RA
GENERAL: NAD, eating dinner, breathing comfortably on RA
HEENT: EOMI, OP clear, no JVD
CARDIAC: RRR no m/g/r
LUNG: b/l wheeze
ABDOMEN: soft, NT/ND 2+
EXT: warm, no C/C/E
NEURO: CN II-XII intact, symm strength and [**Last Name (un) 36**]
SKIN: mult skin tears, abrasions on UE
Pertinent Results:
[**2153-9-22**] 02:00AM BLOOD WBC-10.7 RBC-4.42 Hgb-12.8 Hct-38.5
MCV-87 MCH-29.1 MCHC-33.4 RDW-14.2 Plt Ct-304
[**2153-9-25**] 05:59AM BLOOD WBC-12.2* RBC-3.88* Hgb-10.9* Hct-33.5*
MCV-86 MCH-28.0 MCHC-32.4 RDW-14.0 Plt Ct-213
[**2153-9-22**] 02:00AM BLOOD Neuts-72.2* Lymphs-19.4 Monos-6.9 Eos-1.2
Baso-0.3
[**2153-9-25**] 05:59AM BLOOD Neuts-93.5* Lymphs-3.5* Monos-2.8 Eos-0
Baso-0
[**2153-9-22**] 02:00AM BLOOD Plt Ct-304
[**2153-9-23**] 03:38AM BLOOD PT-11.4 PTT-21.3* INR(PT)-0.9
[**2153-9-25**] 05:59AM BLOOD Plt Ct-213
[**2153-9-22**] 02:00AM BLOOD Glucose-148* UreaN-17 Creat-0.9 Na-140
K-4.0 Cl-105 HCO3-24 AnGap-15
[**2153-9-25**] 05:59AM BLOOD Glucose-185* UreaN-20 Creat-0.8 Na-144
K-3.7 Cl-107 HCO3-29 AnGap-12
[**2153-9-22**] 06:58AM BLOOD CK(CPK)-37
[**2153-9-23**] 03:38AM BLOOD ALT-26 AST-15 CK(CPK)-31 AlkPhos-91
Amylase-31 TotBili-0.2
[**2153-9-22**] 02:00AM BLOOD cTropnT-<0.01
[**2153-9-22**] 06:58AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2153-9-23**] 03:38AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2153-9-22**] 02:00AM BLOOD Lipase-31
[**2153-9-23**] 03:38AM BLOOD Lipase-21
[**2153-9-22**] 06:58AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
[**2153-9-23**] 03:38AM BLOOD Albumin-3.6 Calcium-8.1* Phos-2.2* Mg-2.4
[**2153-9-24**] 06:33AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.5
[**2153-9-25**] 05:59AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.6
[**2153-9-22**] 09:43PM BLOOD Type-ART pO2-444* pCO2-40 pH-7.39
calTCO2-25 Base XS-0
[**2153-9-23**] 05:59AM BLOOD Type-MIX pO2-52* pCO2-47* pH-7.36
calTCO2-28 Base XS-0
[**2153-9-25**] 05:14PM BLOOD TRYPTASE (BETA-SUBUNIT AND ALPHA/BETA
FRACTIONS)-PND
.
.
.
ECG Study Date of [**2153-9-22**] 1:47:54 AM
Sinus tachycardia. Borderline left axis deviation. RSR' pattern
in lead V1,
most likely a normal variant. Modest non-specific ST-T wave
changes which are
non-specific. Compared to the previous tracing of [**2153-8-31**] there
is no
significant diagnostic change.
.
.
CHEST (PORTABLE AP) Study Date of [**2153-9-22**] 2:31 AM
[**Last Name (LF) **],[**First Name3 (LF) 3347**] EU [**2153-9-22**] SCHED
CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVIC Clip #
[**Clip Number (Radiology) 21751**]
Reason: eval acute process
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with mast cell, cp after epi, sob
REASON FOR THIS EXAMINATION:
eval acute process
Final Report
HISTORY: 61-year-old female with chest pain, short of [**Hospital 1440**].
Evaluate for
acute process.
COMPARISON: [**2153-8-31**].
PORTABLE UPRIGHT CHEST, ONE VIEW: Venous access port tip
terminates in the
caval atrial junction. Lung volumes are low, with bibasilar
atelectasis. The
lungs are otherwise clear without consolidation or pulmonary
edema. There is
no pleural effusion or pneumothorax. Heart is normal in size.
Calcified lymph
nodes in the AP window are unchanged.
IMPRESSION: Low lung volumes with bibasilar atelectasis. No
pneumonia.
..
.
.
.
CHEST (PORTABLE AP) Study Date of [**2153-9-24**] 3:00 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MICU [**2153-9-24**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 21752**]
Reason: airway eval
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman intubated for mast cell degranulation
flare/airway
protection.
REASON FOR THIS EXAMINATION:
airway eval
Final Report
HISTORY: Intubation to protect airway, to evaluate airway.
FINDINGS: In comparison with study of [**9-22**], the endotracheal
tube has been
removed. Scattered bibasilar atelectatic change without acute
pneumonia.
.
.
.
.
Brief Hospital Course:
61 yo F with Mast Cell Degranulation presented with recurrence
of MCD in setting of R wrist pain and swelling, with worsening
airway edema. transferred from MICU on [**9-24**] admitted on [**9-22**].
.
# Mast Cell Degranulation:
The patient's symptoms were similar to prior episodes, some of
which have been associated with infections, but worse airway
edema than she normally had so she admitted first to the MICU
and was intubated for airway stabilization. Pt was extubated
successfully on [**2153-9-23**] and was able to breathe comfortably on
room air following that. Pt was initially on IV solumedrol and
was transitioned to a PO prednisone taper without incident. Her
home cromolyn was continued, as well as her home antihistaminic.
The pt described Mast Cell Degranulation attacks as always
treated with IV Dilaudid, Lorazepam and Benadryl and when these
medications were tapered to PO dosing the pt complained that her
pain was not being treated appropriately. At this time she
decided to leave the hospital AMA, and a night float house
officer was called. The night float house officer gave the pt IV
doses of the medications that had been converted to PO, but
despite that the pt decided to leave AMA.
.
# Please see discharge summary from [**2153-9-27**] for further details
of this hospitalization.
Medications on Admission:
Zolpidem 10 mg PO HS prn insomnia
Conjugated Estrogens 0.3 mg PO DAILY
Hydroxyzine HCl 25 mg PO QID
Ranitidine HCl 300 mg PO HS
Duloxetine 60 mg Capsule once a day
Hydroxychloroquine 200 mg PO BID
Fexofenadine 180 mg PO BID
Omeprazole 20 mg [**Hospital1 **]
Cromolyn 100 mg/5 mL Solution 600 mg PO QID
Diltiazem HCl Sustained Release 180 mg PO DAILY
Hydromorphone 4 mg every four 4 hours as needed for pain.
Amphetamine-Dextroamphetamine SR 15 mg once a day.
Lorazepam 0.5 mg PO every 6 hours as needed for anxiety.
Doxapine 50 mg [**Hospital1 **]
epi pen prn
Discharge Medications:
Pt left AMA and was discharged with her home medications and a
prednisone taper.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Mast Cell Degranulation Syndrome
.
Secondary: htn
Discharge Condition:
Fair.
Discharge Instructions:
Pt left AMA
Followup Instructions:
Pt left AMA
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Admission Date: [**2153-9-26**] Discharge Date: [**2153-9-27**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
61 yo F c Mast Cell Degranulation, p/w recurrence in setting of
R wrist pain and swelling, with worsening airway edema
transferred from MICU on [**9-24**] admitted on [**9-22**]. Pt was admitted
to medicine in the morning on [**9-22**] with complaints of abdominal
pain, R arm pain and rash, SOB, nausea, itching, diarrhea and
low grade fevers for several days. She noted a rash with
purulence on her right wrist for which she took a course of
Keflex. She also c/o diarrhea and low grade fevers. She felt on
admission that these symptoms were similar to other "Mast Cell
Degranulation exacerbations."
.
On the floor her vanco was switched to keflex, she was given
benedryl 25mg iv x4, then 50mg iv x2, dilaudid 10mg iv, ativan
2mg iv, zofran 4mg x1, albuterol neb x1, and prednisone 40mg,
ranitidine 300mg po.
.
While on floor pt was noted to have worsening oral swelling and
concern for airway compromise. Anesthesia assessed her
oropharynx with bronchoscopy and though the vocal cords were not
edematous there was significant laryngeal edema. Pt was
intubated for airway protection. Additionally during this
episode she was given solumedrol 40mg iv, epinephrine (0.3mg sc)
x1, benedryl 50mg iv, famotidine 20mg iv. She was given dilaudid
1mg iv for chest pain and abdominal pain. Cardiac enzymes were
negative and the pt was transferred to the MICU.
.
Pt was extubated yesterday. Recent vitals: temp 98. Pulse 77. BP
122/63, rr 14. 92% RA. O2 sats are usually in the high 90's.
Right wrist does not appear erythematous or cellulitic so Keflex
was discontinued.
.
The pt described Mast Cell Degranulation attacks as always
treated with IV Dilaudid, Lorazepam and Benadryl and when these
medications were tapered to PO dosing on [**2153-9-25**] the pt
complained that her
pain was not being treated appropriately. At this time she
decided to leave the hospital AMA, and a night float house
officer was called. The night float house officer gave the pt IV
doses of the medications that had been converted to PO, but
despite that the pt decided to leave AMA on [**2153-9-25**].
.
The pt then presented to the [**Hospital1 18**] ED later that evening c/o
chest pain consistent with the pain she had during her
hospitalization earlier that day. The pt was readmitted for pain
control.
Past Medical History:
- mast cell degranulation syndrome as above- Followed by [**First Name8 (NamePattern2) 21734**]
[**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also
followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- ADHD
- depression/anxiety
- MI after given wrong dose of epi in anaphylaxis
- HTN
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports EGD demonstrated vegetable bezoar (?[**12-7**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
Pt divorced approx 2 [**Month/Day/Year 1686**] ago after 37 [**Month/Day/Year 1686**] of marriage. Husband
was doctor. [**First Name (Titles) **] [**Last Name (Titles) 21749**] as ED tech at [**Hospital 2436**] Hosp.
Reports that she was about to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2436**] Hosp for wrongful
termination as of [**6-10**] but then her PCP changed her status to
permanent disability which seemed to terminate the situation.
Son is HCP [**Telephone/Fax (1) 21738**].
Pt divorced approx 2 [**Telephone/Fax (1) 1686**] ago after 37 [**Telephone/Fax (1) 1686**] of marriage. Husband
was doctor. [**First Name (Titles) **] [**Last Name (Titles) 21749**] as ED tech at [**Hospital 2436**] Hosp.
Reports that she was about to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2436**] Hosp for wrongful
termination as of [**6-10**] but then her PCP changed her status to
permanent disability which seemed to terminate the situation.
Son is HCP [**Telephone/Fax (1) 21738**].
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
Vitals - T: 98.4 BP: 154/86 HR: 78 RR: 20 02 sat: 99% on RA
GENERAL: NAD, coughing, breathing comfortably on RA
HEENT: EOMI, OP clear, no JVD
CARDIAC: RRR no m/g/r
LUNG: improved lung sounds, no rales, no wheeze, vigorous
coughing
ABDOMEN: soft, NT/ND 2+
EXT: warm, no C/C/E
NEURO: CN II-XII intact, symm strength and [**Last Name (un) 36**]
SKIN: mult skin tears, abrasions on UE
Pertinent Results:
[**2153-9-25**] 05:59AM BLOOD WBC-12.2* RBC-3.88* Hgb-10.9* Hct-33.5*
MCV-86 MCH-28.0 MCHC-32.4 RDW-14.0 Plt Ct-213
[**2153-9-27**] 05:30AM BLOOD WBC-10.6 RBC-3.66* Hgb-10.4* Hct-31.8*
MCV-87 MCH-28.5 MCHC-32.9 RDW-14.2 Plt Ct-210
[**2153-9-25**] 05:59AM BLOOD Neuts-93.5* Lymphs-3.5* Monos-2.8 Eos-0
Baso-0
[**2153-9-25**] 05:59AM BLOOD Plt Ct-213
[**2153-9-27**] 05:30AM BLOOD Plt Ct-210
[**2153-9-25**] 05:59AM BLOOD Glucose-185* UreaN-20 Creat-0.8 Na-144
K-3.7 Cl-107 HCO3-29 AnGap-12
[**2153-9-27**] 05:30AM BLOOD Glucose-122* UreaN-18 Creat-0.8 Na-139
K-3.4 Cl-104 HCO3-28 AnGap-10
[**2153-9-25**] 05:59AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.6
[**2153-9-27**] 05:30AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.4
[**2153-9-25**] 05:14PM BLOOD TRYPTASE (BETA-SUBUNIT AND ALPHA/BETA
FRACTIONS)-PND
[**2153-9-25**] 05:14PM BLOOD TRYPTASE-PND
.
.
CHEST (PORTABLE AP) Study Date of [**2153-9-26**] 12:10 AM
[**Last Name (LF) 21753**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2153-9-26**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 21754**]
Reason: eval for pna
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with mast cell crisis
REASON FOR THIS EXAMINATION:
eval for pna
Final Report
INDICATION: 61-year-old woman with mast cell crisis, please
evaluate for
pneumonia.
Comparison is made to the prior study of [**2153-9-4**].
PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The heart size is
normal. Calcified
nodes of the left hilum are unchanged. The mediastinal contour
is normal.
Left lung is clear. Mild residual opacification of the right
lower lobe is
noted. The patient is status post removal of the endotracheal
tube. The Port-
A-Cath distal tip projects at the expected location of the right
atrium. The
osseous structures of the thorax unremarkable
IMPRESSION: No acute intrathoracic pathology including no
pneumonia.
Brief Hospital Course:
61 yo F with Mast Cell Degranulation presented with recurrence
of MCD in setting of R wrist pain and swelling, with worsening
airway edema.
.
# Mast Cell Degranulation:
The patient's symptoms were similar to prior episodes, some of
which have been associated with infections, but worse airway
edema than she normally had so she admitted first to the MICU
and was intubated for airway stabilization. Pt was extubated
successfully on [**2153-9-23**] and was able to breathe comfortably on
room air following that. Pt was initially on IV solumedrol and
was transitioned to a PO prednisone taper without incident. Her
home cromolyn was continued, as well as her home antihistaminic.
The pt described Mast Cell Degranulation attacks as always
treated with IV Dilaudid, Lorazepam and Benadryl and when these
medications were tapered to PO dosing the pt complained that her
pain was not being treated appropriately. At this time she
decided to leave the hospital AMA, and a night float house
officer was called. The night float house officer gave the pt IV
doses of the medications that had been converted to PO, but
despite that the pt decided to leave AMA. The pt reports that
she was not able to drive herself home secondary to
chest/epigastric pain from Mast Cell crisis, so she re-presented
to the [**Hospital1 18**] ED and was readmitted. Repeat EKG and monitoring on
telemetry revealed no adnormalities, and since the chest pain
had been constant since prior admission, with normal cardiac
enzymes repeated 3 times, cardiac enzymes were not re-sent. She
was restarted on her IV medications including IV Ativan,
Dilaudid and Benadryl, and the prednisone taper was continued.
The pt was maintained on her prior home meds (mentioned above)
and on [**2153-9-27**] decided that she felt well enough to return home
on PO medications. Pt was advised not to drive while taking
Ativan, Dilaudid, or Benadryl.
.
# Right Wrist Cellulitis:
Pt did not have any additional complaints about her wrist and on
physical exam she had no signs of cellulitis. Blood cultures
sent on [**2153-9-22**] were negative.
.
# HTN:
Pt's diltiazem was re-started following extubation and it was
titrated up to her home dosage.
.
# Depression/anxiety:
A psychiatry consult was requested due to the concern that
psychosocial stressors were augmenting the pt's chest pain from
the Mast Cell Crisis. Psychiatry recommended speaking with pt's
care providers and ensuring close follow up. Psychiatry also
recommended that pt see a therapist in addition to the
psychiatrist who does her psychiatric medical management. The pt
was continued on her home dose of duloxetine and was discharged
with her home dose of ativan. On discharge pt was instructed to
resume taking her Adderall.
.
# Osteoarthritis:
Pt was continued on her home plaquenil.
Medications on Admission:
Zolpidem 10 mg PO HS prn insomnia
Conjugated Estrogens 0.3 mg PO DAILY
Hydroxyzine HCl 25 mg PO QID
Ranitidine HCl 300 mg PO HS
Duloxetine 60 mg Capsule once a day
Hydroxychloroquine 200 mg PO BID
Fexofenadine 180 mg PO BID
Omeprazole 20 mg [**Hospital1 **]
Cromolyn 100 mg/5 mL Solution 600 mg PO QID
Diltiazem HCl Sustained Release 180 mg PO DAILY
Hydromorphone 4 mg every four 4 hours as needed for pain.
Amphetamine-Dextroamphetamine SR 15 mg once a day.
Lorazepam 0.5 mg PO every 6 hours as needed for anxiety.
Doxapine 50 mg [**Hospital1 **]
epi pen prn
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
2. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
once a day.
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Cromolyn 100 mg/5 mL Solution Sig: Six (6) PO four times a
day.
7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice
a day.
8. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO q4h prn as
needed for pain.
11. Amphetamine-Dextroamphetamine 15 mg Capsule, Sust. Release
24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day.
12. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO daily prn as
needed for insomnia.
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q6h prn as
needed for anxiety.
14. Prednisone 10 mg Tablet Sig: see taper below Tablet PO once
a day for 3 days: On [**9-28**] take two tabs
On [**9-29**] take one tab
On [**9-30**] take one tab
[**10-1**] discontinue.
Disp:*4 Tablet(s)* Refills:*0*
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO tid prn as
needed for cough.
Disp:*60 ML(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Mast Cell Degranulation Syndrome
.
Secondary: Hypertension
Discharge Condition:
Good.
Discharge Instructions:
You were admitted with chest pain consistent with your prior
episodes of Mast Cell Degranulation Syndrome. You had an
unchanged EKG and you were monitored on telemetry with no events
noted. Your pain was controlled with IV medications and when you
felt improved you were discharged on your home medications.
.
You have the following follow up appointments listed below. It
is very important that you attend these follow up visits.
.
We have continued your home medications. Please continue to take
them as prescribed. We have added Prednisone, which you will
taper over the next four days. Please follow the prescription.
.
If you develop sudden chest pain, shortness of [**Month/Year (2) 1440**], nausea
and vomiting or leg pain, please call your primary care
physician or go to the emergency room.
Followup Instructions:
You have an appointment with your primary care doctor Dr.
[**First Name (STitle) **] at 1:30p on Friday, [**2153-9-28**] at his office in [**Location 21755**].
.
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2153-10-4**] 12:30
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2153-10-24**] 1:40
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,173
| 112,476
|
18911
|
Discharge summary
|
report
|
Admission Date: [**2182-3-9**] Discharge Date: [**2182-4-5**]
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory failure and hypotension; transferred from OSH
Major Surgical or Invasive Procedure:
CVL from OSH [**2182-3-8**]
PICC line placement
Tracheostomy placement
Intubation - [**2182-3-9**]; reintubation on [**2182-3-13**]; reintubation on
[**2182-3-30**]
Bronchoscopy [**2182-3-13**]
Arterial line placement
History of Present Illness:
86 yo M w/history of CVA, right hemiparesis, obtunded at
baseline, bilateral AKA presents with respiratory failure and
hypotension. The patient was sent to [**Hospital1 882**] after an apparent
aspiration even last night, with SaO2 87% on RA and coarse
breath sounds bilaterally. The patient had sats 87-94% on 4L and
was treated with Levo/Flagyl and nebs. At 4:30 pm the patient
was found with decreased responsiveness, diaphoretic with vitals
of 96.4, 110, 28, 63/41. The patient was placed on a NRB and
sent to the [**Hospital1 882**] for further evaluation. A chest x-ray
showed a multilobar pneumonia, for which he was given one dose
of Zosyn and Vancomycin. His pressure was noted be as low as
50/30, and a right subclavian line was placed. He wsa started on
levophed and dopamine and additionally received one 0.5mg dose
of Atropine for bradycardia. He was transferred to [**Hospital1 18**] for
further managment.
In the [**Hospital1 18**] ED, his pressures were maintained on both pressors
initially, but dopamine was discontinued due to HR 100-110. He
was found to have a multilobar pneumonia, and an initial lactate
of 4.5 (improved to 3.5 with IVF). WBC 28.6, 29% Bands. Blood
cultures were sent and vancomycin 1 g IV was given. Levaquin was
not used due to QTc 0.450. An EKG revealed ST elevations
laterally. Interventional cardiology was consulted, but the
patient was not felt to be an appropriate catheterization
candidate. The patient was also found to be strongly guaiac
positive, with a Hct 25.0 and therefore, no heparin was given.
He was transfused 1 unit PRBC. His urinalysis was grossly
positive. Additonal abnormal labs included: Na: 130, Cr: 1.5,
ALT: 55, AST: 97, LDH: 305, AP: 208, Tbili: 2.7, Albumin: 2.0,
INR 1.3.
Upon arrival to the ICU the patient is maintained on Levophed
only with MAP > 60. An a-line was placed in the patient's right
arm.
Past Medical History:
#. Aspiration pneumnonia
#. C. Diff complicated by sepsis [**2181-11-21**]
#. Multiple admissions for sepsis related to
UTI/pneumonia/sacral decubitus ulcers
#. s/p CVA with R hemiparesis (arms contracted)
#. PVD s/p bilateral AKA
#. Seizure Disorder
#. Dementia
#. Diabetes II
#. Anemia
#. MRSA colonization
#. Hypernatremia
#. cataracts
#. contracted hips
#. Stage IV Sacral decubitus ulcers
#. Fistula
#. ETOH
Social History:
Unobtainable
Family History:
Unobtainable
Physical Exam:
General: Patient is intubated, appears chronically ill.
Patient's lower extremities surgically missing, hips severely
flexed
HEENT: NCAT, EOMI, +ETT
Neck: right subclavian line
Chest: Lung sounds relatively [**Name2 (NI) **] with few course expiratory
breath sounds
Cor: Tachycardic, regular
Abdomen: thin, firm but not rigid. Patient flexes with deep
palpation of abdomen. + BS, hyperactive
Back: stage IV decubitus ulcer at sacrum/coccyx level, stage II
decubitus ulcer with several necrotic foci on right buttock,
Extremities: bilateral AKA
Pertinent Results:
[**2182-3-9**] 08:53PM
WBC-28.6* HGB-8.3* HCT-25.0* MCV-100* MCH-33.4* MCHC-33.3
RDW-14.9
NEUTS-62 BANDS-29* LYMPHS-5* MONOS-4 EOS-0 BASOS-0 ATYPS-0
METAS-0
MYELOS-0
PLT SMR-NORMAL PLT COUNT-248
PT-15.2* PTT-42.4* INR(PT)-1.3*
GLUCOSE-99 UREA N-61* CREAT-1.5* SODIUM-130* POTASSIUM-4.9
CHLORIDE-101 TOTAL CO2-15* ANION GAP-19
ALBUMIN-2.0* CALCIUM-7.1* PHOSPHATE-4.3 MAGNESIUM-2.1
ACETONE-NEG
cTropnT-0.37* CK-MB-25* MB INDX-3.0
LIPASE-17 ALT(SGPT)-55* AST(SGOT)-97* LD(LDH)-305* CK(CPK)-836*
ALK PHOS-
208* TOT BILI-2.7*
URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-
SM UROBILNGN-1 PH-5.0 LEUK-MOD
URINE RBC->50 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0
LACTATE-4.6*
TYPE-ART PO2-404* PCO2-37 PH-7.27* TOTAL CO2-18* BASE XS--8
INTUBATED-INTUBATED
CXR: 1. Bibasilar opacities likely representing a combination of
small effusions and passive atelectasis and/or pneumonia. 2.
Moderate central pulmonary arterial enlargement suggestive of
underlying pulmonary hypertension.
ECG: Sinus tachycardia with premature atrial contractions. ST
segment elevation in leads V3-V5 is non-specific. Clinical
correlation is suggested. Low QRS voltage in the limb leads. No
previous tracing available for comparison.
[**2182-3-30**]: CT chest
IMPRESSION:
1. Bilateral large layering nonhemorrhagic pleural effusion with
associated compressive atelectasis.
2. Diffuse patchy opacities involving both upper lobes could
represent infectious or inflammatory process.
3. Calcified pleural plaques.
4. Small liver hypodensity, too small to be fully characterized.
5. No evidence of cavitary lesion.
[**2182-4-3**]: Xray to confirm PICC line (prelim read):
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single-lumen Vaxcel PICC line placement via the left brachial
venous approach. Final internal length is 44 cm, with the tip
positioned in SVC. The line is ready to use.
ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50%). The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
A/P: 86 year old Male with history of aspiration pneumonia who
presents with respiratory failure and hypotension.
.
#. Hypoxic Respiratory failure: His respiratory failure was
thought most likely secondary to aspiration/hospital acquired
pneumonia. He received Zosyn at the OSH prior to transfer to
[**Hospital1 18**], in the [**Hospital1 **] ER he received vanc. Coverage was broadened
for potential multiple sources. Over his course of stay, he was
treated with Linezolid (VRE/MRSA), Cefepime (Pseudomonas), Cipro
(gram negative), Azithro, PO Vanc/IV Flagyl; as well as
transiently with Tobramycin for GNR based on sensitivities.
However, per ID recs, tailored down to course of Meropenem &
oral vancomycin (for history of C.diff). During his course, his
sputum grew GNRs and MSSA and blood cultures grew Klebsiella
pneumoniae. Legionella antigen was negative. He was extubated
on [**3-12**] and reintubated on [**3-13**] with increased work of
breathing. He continued antibiotic treatment and was diuresed
once blood pressure allowed. This allowed for successful
extubation on [**3-27**]. Patient was made DNR during this admission,
though per his HCP (niece) he was to be reintubated which he was
on [**2182-3-30**] for respiratory distress and increased work of
breathing. The patient also grew out multidrug resistant
Klebsiella from his sputum during his hospitalization. His
antibiotics were discontinued with the exception of his oral
vancomycin, which he should continue until [**2182-4-18**]
prophylactically for a history of C. Difficle sepsis.
.
#. Hypotension: Pt has multiple reasons for hypotension
requiring pressors. His hypotension was felt most likely
distributive secondary to sepsis given his elevated WBC and
bandemia with multiple potential sources including aspiration
pneumonia, UTI, sacral decubitus ulcer, C. Diff. Patient may
have also had contribution of cardiogenic shock given evolving
MI and was at risk for hypovolemia given guaiac+ stool with low
Hct. He was monitored with arterial line and pressors were
continued. He received aggressive fluid/pressor resuscitation
to maintain pressures. He had a total of 6 units of RBCs
throughout hospital course to maintain oxygen delivery. He
improved with treatment of sepsis and pressors were
discontinued.
.
#. STEMI: The patient was noted to have ST elevations in V3-V5.
He was seen by cardiology in ED, and thought not to be a cardiac
cath candidate. Given guaiac positive stool, a heparin gtt not
started. He has received ASA daily. Throughout his hospital
course, he has been transfused to maintain hematocrit in the
upper 20's. Troponin trended down from admit level of 0.37.
Echo was slightly poor quality, but with EF 50%, possible WMA,
1+ MR. Beta blocker started once hypotension improved.
.
#. Anemia: The patient was found to be guaiac positive in ED and
was originally transfused 1 unit of PRBC for his anemia. His
source is most likely GI, however given acute illness, overall
prognosis, and general stability he did not have endoscopy or
colonoscopy during this admission. His hematocrit was monitored
and he required a total of 6 units this admission with
appropriate bumps. At this point, the patient has transfusion
dependent anemia. He was transfused PRN throughout his course
to maintain a hematocrit greater than 24. B12 and folate levels
were checked, which were both within normal limits. Please
continue to monitor his hematocrit Q three days and transfuse as
needed.
.
#. Acute renal failure: The patient developed acute renal
failure in setting of acute illness, possible ATN. His
creatinine peaked at 2.4 and has prgressively trended down to
normal. His renal function improved with treatment of
underlying illness.
.
#. Decubitus ulcers with fistulization: Wound care was
consulted and recommendations followed for extensive wounds.
Please continue wound care recs per the page one.
.
#. s/p CVA with R hemiparesis (arms contracted): The patient
was continued on aspirin for stroke prevention.
.
#. Seizure Disorder: The patient was continued on his original
anti-epileptic medications. Please continue these medications
as prescribed.
.
#. Dementia: The patient is demented at baseline. His mental
status did not appear to change during his hospital course.
.
#. Diabetes II: The patient was continued on a sliding scale.
Please continue his sliding scale per the included sheet.
Medications on Admission:
Meds (on discharge from last hospitalization [**2181-11-23**])
1. omeprazole 40 mg po qd
2. folate 1 mg po qd
3. vitamin C 1 tab po bid
4. zinc 220 mg po qd
5. vitamin A 5000 units po qd
6. Magnesium oxide 400 mg po bid
7. Neurontin 200 mg po bid
8. Multivitamin 5 mL po qd
9. Neutra-phos one packet po bid
10. KCl 20 mEq po qd
11. Dilantin suspension 75 po tid
12. vancomycin 250 mg po qid x10 days (now discontinued)
13. chlorhexadine rinse 0.12% [**Hospital1 **]
-------
Meds from med list from Nursing Home
1. omeprazole 20 mg via g-tube qd
liquid antacid q6h prn GI upset
MOM 30 ml via g-tube for constipation
acetaminophen 325 2 tabs via g-tube q4hours
.
Allergies: Allopurinol
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): While pt is on mechanical
ventilation.
3. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. 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.
6. Morphine Sulfate 2 mg IV Q4H:PRN pain
for dressing changes
7. Furosemide 40 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
9. Phenytoin 100 mg/4 mL Suspension [**Last Name (STitle) **]: Seventy Five (75) mg PO
TID (3 times a day).
10. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-19**]
Drops Ophthalmic PRN (as needed).
12. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: Pls see
attached sheet Injection ASDIR (AS DIRECTED).
13. Vancomycin
Vancomycin Oral Liquid 125 mg PO Q6H until [**2182-4-18**], then
discontinue
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Multilobar pneumonia with respiratory failure requiring
tracheostomy
ST elevation myocardial infarction
Chronic anemia
Secondary:
s/p CVA with right sided hemiparesis
Stage IV sacral decubitus ulcers
Peripheral vascular disease s/p bilateral AKA
Seizure disorder NOS
Dementia
Type II Diabetes
Bilateral cataracts
Contracted hips
Fistula
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with respiratory failure and
low blood pressure. While you were in the hospital, you
required intubation to help you breath. Because you were unable
to be weaned off the ventilator, a tracheostomy was performed.
You were also treated with antibiotics for a pneumonia.
.
While you were in the hospital, you also had a heart attack.
Cardiology felt medical management was most appropriate so you
were treated with medications which were continued during your
hospitalization.
Followup Instructions:
You will be followed by physicians at the rehabilitation
facility.
You can also follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 5351**] at [**Telephone/Fax (1) 608**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"410.51",
"518.81",
"285.9",
"276.7",
"V49.76",
"785.52",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"38.93",
"33.24",
"96.72",
"96.6",
"96.71",
"96.04",
"31.1",
"99.04",
"00.14"
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icd9pcs
|
[
[
[]
]
] |
12722, 12803
|
6048, 10469
|
282, 502
|
13193, 13202
|
3485, 6025
|
13760, 14119
|
2891, 2905
|
11204, 12699
|
12824, 13172
|
10495, 11181
|
13226, 13737
|
2920, 3466
|
185, 244
|
530, 2408
|
2430, 2845
|
2861, 2875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,735
| 191,928
|
44150
|
Discharge summary
|
report
|
Admission Date: [**2157-1-30**] Discharge Date: [**2157-2-5**]
Date of Birth: [**2075-1-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Fever and dyspnea
Major Surgical or Invasive Procedure:
Intubation
Cardio-pulmonary resuscitation
History of Present Illness:
82 y/o F with PMHx of CAD s/p CABG & metastatic breast cancer on
navelbine who presented with fevers to 102 and dyspnea. Pt
reported 2 episodes of emesis at home and had loose stools in
the ED. She was otherwise denying cough and chest pain
.
Initial VS on arrival to ED: T 97.2 HR 66 BP 97/52 RR 16 Sats
94% RA. Pt was noted to have decreased breath sounds at Right
base but otherwise unremarkable exam. She received Cefepime on
arrival for presumed febrile neutropenia, but ANC was actually
1500. Due to elevated LFTs, pt underwent RUQ which showed
cholelithiasis but no signs of acute inflammation. CXR showed
RML opacity essentially unchanged from prior films. Pt went to
radiology for a CTA which showed bilateral PEs in the proximal
LUL, LLL & RUL.
.
Pt had returned from radiology and had undergone a stool guaic
with plan for heparin gtt when her son called out for help. Pt
was found unresponsive in pulseless polymorphic VT. CPR was
initiated for 1 minute, defibrillated and then became asystolic.
Pt received 1mg epi and then went into PEA. Pt was started on
Amiodarone, given another 1mg epi. Pt was intubated during the
7min code and the following rhythm was a sinus tachycardia. Of
note, pt was hypotensive with sbps in 80s and Levophed was
started. Amiodarone was stopped and BP improved to the 100-110
range.
.
CT head was performed and revealed new hyperdense lesions
suggestive of new mets, thus decision was made to avoid lysis.
Of note, EKGs post code were noted to have inferolateral ST
depressions. At the time of signout, pt was still requiring
Levophed and had RIJ line in place.
.
On arrival to the floor, pt was intubated and sedated. She was
reporting nausea and had some brown emesis that was gastroccult
positive.
Past Medical History:
ONCOLOGIC Hx: diagnosed with right breast cancer in [**2139**] for
which she underwent lumpectomy with axillary dissection and
radiation therapy followed by 5 years of tamoxifen. She
developed a local recurrence in 12/00, diagnosed by biopsy of a
palpable mass in the right breast. A right total mastectomy was
performed on [**2148-12-27**], with pathology revealing a 3 cm tumor,
grade II, with LVI, ER+ and HER2- by immunoperoxidase staining.
Due to a positive serratus muscle margin, a re-excision of the
right chest wall was performed on [**2149-2-28**]. She then began
adjuvant therapy with letrozole. In [**10-27**], she was found to have
extensive bony metastatic disease of the pelvis with additional
involvement of the liver, pleura, and mediastinal lymph nodes.
She was treated with zoledronic acid and fulvestrant followed by
15 months of liposomal doxorubicin, after which she was noted to
have a rise in her CEA and CA 27.29 tumor markers and increased
bony pain. She began treatment with capecitabine monotherapy in
[**6-28**] and has since remained clinically stable on this regimen,
with an excellent performance status. Of note, however, her most
recent CT scan of the torso, obtained on [**2155-6-18**], demonstrated
multiple new liver lesions and enlargement of the prior hepatic
metastasis, involvement of multiple new foci in the skeleton
with multiple new lytic and sclerotic lesions, and multiple new
pathologically enlarged retroperitoneal nodes. Her CA 27.29 was
266 on [**2156-8-19**], up from 138 on [**2156-6-18**]; CEA was 4.1, down from
4.6. She received capecitabine throughout [**2155**], and is now s/p 4
cycles of navelbine, most recently in late [**2156-12-23**].
.
ADDITIONAL MEDICAL HISTORY:
1. S/p cataract surgery [**12-27**]
2. Atherosclerotic coronary vascular disease
- S/p CABG in ([**2137**]) w/ no episodes of CP since
3. Hypertension
4. Tophaceous gout
5. Hyperlipidemia
6. History of tubular adenoma
Social History:
The patient is a widow who lives alone in [**Location (un) 50909**], [**Doctor Last Name **].
She denies smoking. Drinks 2-3 glasses of wine or beer daily.
She has 6 children and 10 grandchildren.
Family History:
Non-contributory.
Physical Exam:
VITAL SIGNS: T 97.7 HR 70 BP 100/66 RR 15 Sats 100%
General: NAD, tired, intubated
HEENT: Pupils are equal, round, and reactive to light. MM dry
LUNGS: clear to ausculation bilaterally, no w/r
HEART: Regular, prominent P2, no apprec murmur
ABDOMEN: Soft, mildly distended, NABS, NTTP, no rebound
EXTREMITIES: cool, distal pulses +2, left hand erythematous,
edematous and cool, radial pulse dopplerable
NEUROLOGIC: following commands and easily arousable
Pertinent Results:
[**2157-1-30**] 09:54PM TYPE-ART RATES-/14 TIDAL VOL-450 PEEP-5
O2-100 PO2-388* PCO2-33* PH-7.29* TOTAL CO2-17* BASE XS--9
AADO2-318 REQ O2-57 -ASSIST/CON INTUBATED-INTUBATED
[**2157-1-30**] 02:43PM COMMENTS-GREEN TOP
[**2157-1-30**] 02:43PM LACTATE-1.8
[**2157-1-30**] 02:35PM URINE HOURS-RANDOM
[**2157-1-30**] 02:35PM URINE GR HOLD-HOLD
[**2157-1-30**] 02:35PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2157-1-30**] 02:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2157-1-30**] 02:35PM URINE RBC-0-2 WBC-[**2-24**] BACTERIA-OCC YEAST-NONE
EPI-[**2-24**]
[**2157-1-30**] 02:33PM GLUCOSE-103 UREA N-25* CREAT-1.4* SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
[**2157-1-30**] 02:33PM estGFR-Using this
[**2157-1-30**] 02:33PM ALT(SGPT)-275* AST(SGOT)-400* CK(CPK)-1211*
ALK PHOS-528* TOT BILI-2.4*
[**2157-1-30**] 02:33PM LIPASE-30
[**2157-1-30**] 02:33PM cTropnT-1.91*
[**2157-1-30**] 02:33PM CK-MB-165* MB INDX-13.6*
[**2157-1-30**] 02:33PM ALBUMIN-3.4 CALCIUM-8.4 PHOSPHATE-3.4
MAGNESIUM-2.0
[**2157-1-30**] 02:33PM WBC-3.0*# RBC-3.21* HGB-10.2* HCT-29.9*
MCV-93 MCH-31.9 MCHC-34.3 RDW-18.2*
[**2157-1-30**] 02:33PM NEUTS-56.3 LYMPHS-35.3 MONOS-7.6 EOS-0.4
BASOS-0.4
[**2157-1-30**] 02:33PM PLT COUNT-298
[**2157-1-30**] 02:33PM PT-14.5* PTT-27.9 INR(PT)-1.3*
[**2156-1-30**] CTA Chest
IMPRESSION:
1. Acute pulmonary emboli involving the proximal left upper
lobe, left lower lobe, and right upper lobe. No CT findings to
suggest right ventricular strain.
2. Unchanged and likely metastatic mediastinal and hilar
lymphadenopathy,
resulting in compression and atelectasis of portions of the
right middle lobe and right lower lobe. Intraluminal secretions
and possibly soft tissue tumor invasion within the right- sided
bronchi are again noted as described above. New small right
pleural effusion is present.
3. Slight interval progression in the degree of predominantly
peripheral
right-sided opacities. While this may relate to progression of
presumed
lymphangitic disease (given interstital thickening), peripheral
regions of
infarction related to pulmonary embolism or superimposed
infection are also in the differential diagnosis.
4. Unchanged diffuse osseous metastatic disease.
[**2157-1-31**] ECHO
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
moderately depressed (LVEF= 30 %) with inferior, infero-lateral
and apical akinesis. There is no ventricular septal defect. with
mild global free wall hypokinesis. 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. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Brief Hospital Course:
82yo F with metastatic breast cancer on virorelbine since last
winter, presenting with fevers and dyspnea, s/p polymorphic
VT/PEA arrest in the setting of bilateral PEs.
.
MICU course:
# s/p PEA arrest: Pt with metastatic breast cancer who p/w fever
and found to have bilateral PEs, went into polymorphic VT/PEA
arrest, coded (CPR for 7 minutes) and converted to sinus tach.
Most likely etiology for arrest was PE and cardiac strain. Pt
was not a candidate for lysis given ? of hemorrhagic mets on
Head CT.
.
# Acute PE/Resp failure: Pt presented with fever & found to have
bilateral PEs, subsequently developed polymorphic VT/PEA arrest.
Lysis contra-indicated due to ? of hemorrhagic mets. Pt did
not have any respiratory distress on presentation. Pt intubated
peri-code and extubated without issue on [**2157-1-31**]. Pt maintained
on heparin gtt. UENIs and LENIs revealed R popliteal DVT.
.
# Fever: Etiology unclear, though may have been due to acute
PEs. CXR essentially unchanged, UA neg and Blood Cx sent. Given
recent chemo and neutropenia, pt received Cefepime and
Vancomycin for presumed neutropenic fever. On [**2157-2-1**] all
antibiotics were stopped as the pt did not have a leukocytosis,
was afebrile, did not have sputum and had an unremarkable CXR.
Sputum gram-stain negative and preliminary cultures did not show
any organisms.
.
# Elevated LFTs: Pt was noted to have new transaminitis and
worsening of obstructive pattern. RUQ u/s was negative for acute
cholecystitis. This may be due to worsening liver mets,
congestive hepatopathy and cardiac arrest.
.
# Metastatic breast cancer: Pt with known progression of her
disease on capecitabine, currently on navelbine, although recent
cycle was held for neutropenia. CT head revealed dural-based
metastatic disease. Primary onc Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**] to discuss with
pt options for chemo/XRT.
.
# Hypertension: Home meds were held s/p cardiac arrest.
.
# Hyperlipidemia: Holding home statin given acute transaminitis.
.
# Anemia: Stable anemia on chemotherapy, active type/cross
maintained.
.
# FEN: Pt transitioned to regular diet on [**2156-2-1**].
.
# Prophylaxis - Heparin gtt, PPI, bowel regimen.
.
Oncology Course: Patient intermittently required NRB for
oxygenation. Triggered twice for acute SOB and tachycardia (HR >
150). Etiology felt to be acute CHF decompensation, flash
pulmonary edema and possible worsening of PE load. Patient was
awake and alert and decided to be DNR/DNI. DNR/DNI was confirmed
with primary oncologist Dr. [**Last Name (STitle) 19**]. Patient was started on
standing lasix and cardiology was consulted (agreed with current
management). She was kept on telemetry due to patient's wishes
of not being alone when passes. [**2157-2-5**] overnight she had
difficult breathing and had long runs of wide complex tacycardia
to 150s. Family decided comfort measures only and patient was
made comfortable on morphine gtt and ativan. She expired
[**2157-2-5**].
Medications on Admission:
Allopurinol 200mg daily
Atenolol 50mg daily
Capecitabine cycled per hem/onc
Indapamide 1.25 daily
Ativan 0.5mg prn
Pravastatin 40 daily
Ramipril 5mg daily
ASA 325mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Breast Cancer
Cardiac arrest
NSTEMI
PE
Acute CHF
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2157-2-6**]
|
[
"198.5",
"428.0",
"E933.1",
"197.7",
"427.5",
"276.52",
"196.1",
"V10.3",
"410.71",
"428.21",
"198.3",
"415.19",
"401.9",
"197.2",
"518.81",
"288.03",
"V45.81",
"427.41",
"272.4",
"284.89",
"780.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.60",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11338, 11347
|
8073, 11085
|
298, 341
|
11451, 11460
|
4830, 8050
|
11516, 11553
|
4322, 4341
|
11306, 11315
|
11368, 11430
|
11111, 11283
|
11484, 11493
|
4356, 4811
|
241, 260
|
369, 2121
|
2143, 4091
|
4107, 4306
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,618
| 110,782
|
5317
|
Discharge summary
|
report
|
Admission Date: [**2157-4-13**] Discharge Date: [**2157-4-16**]
Service: ACOVE
CHIEF COMPLAINT: Chest pain.
HISTORY OF THE PRESENT ILLNESS: The patient is an
86-year-old male, Russian-speaking only, with history of
Parkinson's disease, depression, and colon cancer presenting
with new-onset left sided pleuritic chest pain, shortness of
breath, and new atrial fibrillation. The patient presented
to the emergency department with concern for pulmonary
embolism. He was started on heparin infusion. CT angiogram
was performed, which was negative. The patient was admitted
to the Cardiology Service, where the patient was found to be
in rapid ventricular rate and given 25 mg of Metoprolol. The
patient, shortly, thereafter, became hypotensive and
unresponsive. The patient was started on pressors and a head
CT was ordered. The head CT showed no evidence of
intracranial hemorrhage. The patient's mental status
improved while at the CT scan. The patient was rapidly
weaned off pressors and continued to do well in the ICU. He
was initially treated with antibiotics for presumed sepsis.
However, the patient's hypotension was thought to be more
likely secondary to Metoprolol with exaggerated response,
The patient also had an echocardiogram that revealed a
pericardial effusion. He was started on NSAIDS. There was
no evidence of tamponade physiology.
PAST MEDICAL HISTORY:
1. Parkinson's disease.
2. Benign prostatic hypertrophy
3. Depression with psychosis.
4. Gastroesophageal reflux disease.
5. Colon cancer status post hemicolectomy two years ago.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Sinemet 20/100, one p.o.q.i.d. and q.h.s.
2. Cardura 2 mg p.o.q.h.s.
3. Neurontin 600 mg p.o.t.i.d.
4. Flomax 0.4 mg p.o.q.h.s.
5. Seroquel 150 mg p.o.b.i.d.
SOCIAL HISTORY: The patient is Russian-speaking only. He is
a resident of [**Hospital1 5595**]. He ambulates with a walker. He is a
retired dentist. The patient notes remote cigarette smoking
approximately for twenty years.
FAMILY HISTORY: History is noncontributory.
PHYSICAL EXAMINATION: Examination revealed the temperature
of 96.6, blood pressure of 110/70, pulse 82, respiratory rate
20, and oxygen saturation of 97% on three liters. The
patient was then placed on room air, where he was saturating
95%. There was no evidence of pulsus paradoxus. GENERAL:
The patient was a fairly well appearing elderly male in no
acute distress. HEENT: Examination revealed EOMI, PERRLA,
slightly dry mucous membranes. NECK: Examination revealed
CVP of approximately 7 cm of water. There was no
lymphadenopathy. CARDIAC: Examination revealed irregularly
irregular rhythm with normal S1 and S2, no murmurs, rubs, or
gallops. PULMONARY: Examination revealed lung clear to
auscultation bilaterally. ABDOMEN: Examination revealed
belly soft, nontender, nondistended with normal bowel sounds.
EXTREMITY: Examination revealed no edema. Vascular
examination revealed good capillary refill. RECTAL:
Examination revealed good anal tone and guaiac negative.
LABORATORY DATA: Pertinent laboratory findings revealed the
following: The patient had a WBC of 7.4, hematocrit 28.4,
and platelet count of 172,000. Creatinine was 1.0. The
patient has a TSH of 0.36. Magnesium was 2.3 and phosphate
3.0. INR was 1.4. Urinalysis was unremarkable, except for
trace blood. The patient had initial CK of 50 with the
second CK of 135, third CK of 111, fourth CK of 134 with
negative indices. The patient did have troponin of 1.1 and
1.2.
Chest x-ray revealed no failure and left basilar atelectasis
that was improving.
Head CT: No acute intracranial pathologic process.
Chest CT: Bilateral small pleural effusions, pericardial
effusion, left lower lobe atelectasis, no PE.
On [**2157-4-14**], echocardiogram revealed left atrial
enlargement, right atrial enlargement, concentric LVH, EF
greater than 55%, RVH trace AR and trace MR, moderate
loculated pericardial effusion and no echocardiogram evidence
of tamponade.
HOSPITAL COURSE: The patient is an 86-year-old man with
history of depression, colon cancer, who presented with
new-onset chest pain and hypotension. The patient was found
to have pericardial effusion.
#1. CARDIOVASCULAR: The patient presented with chest pain
and hypotension. He was found to have a pericardial effusion
without evidence of tamponade. Apparently, the episode of
hypotension was felt to be secondary to an exaggerated
response to Metoprolol. The patient responded quickly to IV
fluids and pressors. The patient was easily weaned. He
ruled out for myocardial infarction. The patient developed
new atrial fibrillation thought to be secondary to his
pericarditis. He was not anticoagulated because of the
presence of a pericardial effusion. TSH was done and it was
on the low end of normal. He was started on NSAIDS for his
pericarditis. He was continued on aspirin. The patient's
atrial fibrillation with rapid ventricular response was
initially stable, but then he developed a rate into the 140s
to 160s. He was given 5 mg of Diltiazem IV push and 30 mg
p.o. Diltiazem with good response in his rate control. He
stabilized in the 80s to 90s. Repeat EKG was done, which
revealed atrial fibrillation in the 70s, leftward axis,
normal [**Doctor Last Name 1754**], intervals. ST segment elevation of 1-mm in
lead 2, biphasic T in V2, and T wave flattening in lead 3.
When compared to an earlier [**2157-4-14**] EKG, there were no
significant changes.
#2. GASTROESOPHAGEAL REFLUX DISEASE: The patient was
maintained on Protonix.
#3. GENITOURINARY: The patient has history of benign
prostatic hypertrophy, maintained on Flomax and Cardura.
#4. NEUROLOGIC: The patient has history of Parkinson's
disease maintained on Sinemet.
#5. PSYCHIATRIC: The patient has a history of depression
with psychosis, maintained on Seroquel.
#6. GASTROINTESTINAL: The patient has history of
constipation treated with Senna, Dulcolax, Fleet, and Colace.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged on the
following medications:
1. Aspirin 81 mg p.o.q.d.
2. Colace 100 mg p.o.b.i.d.
3. Sinemet 25/100, one p.o.q.i.d. and q.h.s.
4. Flomax 0.4 mg p.o.q.h.s.
5. Multivitamin, one p.o.q.d.
6. Seroquel 150 mg p.o.b.i.d.
7. Neurontin 600 mg p.o.t.i.d.
8. Motrin 600 mg p.o.t.i.d. with meals.
9. Heparin 7500 units subcutaneously b.i.d. until
ambulatory.
10. Senna, two tablets p.o.q.h.s.
11. Diltiazem 30 mg p.o.q.i.d. hold for SVP less than 90 or
heart rate less than 55.
12. Protonix 40 mg p.o.q.d.
13. Dulcolax 10 mg p.o.pr, q.d. p.r.n.
14. Fleet one pr, q.4h.p.r.n. constipation.
15. Tylenol 650 mg p.o.q.4h. to 6h p.r.n. pain.
The patient was discharged back to [**Hospital3 **]
Center.
DISCHARGE DIAGNOSES:
1. Pericardial effusion.
2. Atrial fibrillation with RVR.
3. Hypotension.
4. Parkinson's disease.
5. Benign prostatic hypertrophy.
6. Depression with psychosis.
7. Gastroesophageal reflux disease.
8. Colon cancer status post hemicolectomy two years ago.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], M.D. [**MD Number(1) 16133**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2157-4-15**] 13:22
T: [**2157-4-15**] 14:16
JOB#: [**Job Number 21682**]
cc:[**Last Name (STitle) 21683**]
|
[
"458.2",
"V10.05",
"332.0",
"530.81",
"423.9",
"427.31",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2079, 2108
|
6837, 7398
|
1665, 1832
|
4077, 6038
|
2131, 3656
|
109, 1378
|
3666, 4059
|
1400, 1639
|
1849, 2062
|
6063, 6816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,268
| 103,449
|
9108+9109
|
Discharge summary
|
report+report
|
Admission Date: [**2103-12-28**] Discharge Date:
Date of Birth: [**2064-2-21**] Sex: F
Service: MEDICINE SERVICE TO THE MICU ON [**First Name4 (NamePattern1) 640**] [**Last Name (NamePattern1) 31397**]
SERVICE AND THEN TRANSFERRED TO THE GENERAL MEDICINE SERVICE
WITH [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AS THE ATTENDING.
The patient was admitted on [**2103-12-28**], as a
transfer from [**Hospital3 3583**] for further management of
hypertension and respiratory failure.
HISTORY OF THE PRESENT ILLNESS: The patient, [**Known firstname 31398**]
[**Known lastname 17029**], is a 39-year-old woman who presented to [**Hospital3 6265**] Emergency Room on [**12-27**], in the afternoon
with a three-day history of back pain, which is chronic,
nausea, vomiting, and possibly diarrhea. The patient also
noted weakness and hand numbness, left greater than right.
The patient also has a rash over her right upper extremity,
shoulder, and axilla. Vital signs, on arrival to the
emergency room of the outside hospital, were the following:
temperature 104.2, blood pressure 83/50, heart rate 148,
respiratory rate 12. The patient was menstruating near the
end of her cycle and had a tampon in her vagina. The
patient's blood pressure decreased to 60 systolic and she was
started on fenethylline drip for hypotension. The tampon was
removed and the patient received 2-g IV oxacillin and 100 mg
IV gentamicin. While in the emergency room, the patient
apparently had a cyanotic episode and was intubated. The
patient was transferred to [**Hospital1 188**] Emergency Room via [**Location (un) **] on hospital day #2,
[**2103-12-28**]. In the [**Hospital1 188**] Emergency Room, the patient had a blood pressure of
90/palp on neosynephrine with a heart rate in the 140s.
Temperature was 37.9. She was ventilated. She received
Vancomycin 1-g IV, Ceftriaxone 2-g IV. She was also given
fentanyl and Ativan for sedation. A left femoral line was
inserted for central access and a right brachial artery line
was inserted for blood pressure monitoring. At that point,
the patient was transferred to the medical ICU.
PAST MEDICAL HISTORY:
1. L5 spinal surgery one year ago in [**2103-11-29**].
2. Splenectomy secondary to trauma.
MEDICATIONS: None.
ALLERGIES: The patient is allergic to ERYTHROMYCIN, CODEINE,
CORTISONE, AND SULFA; reactions are unknown to those
medications.
SOCIAL HISTORY: The patient's primary care physician is
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 31399**] in [**Location (un) 3320**], who is an OB-GYN physician. [**Name10 (NameIs) **]
patient lives in [**Location 3320**] with her sister and her own four
children. Her sister [**Name (NI) **] [**Name2 (NI) 31400**] phone # is:
[**0-0-**]. She is disabled and the patient is a former
nurses aid.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Physical examination on admission to
the medical ICU revealed the following: [**Known firstname 31398**] is an obese,
middle-aged woman, intubated, and sedated. Vital signs:
Temperature 99.1, blood pressure 84/52, on 340 mcg per minute
of neosynephrine. Heart rate was 100. She is on assist
control, tidal volume 800, respiratory rate 10, PEEP 5, FIO2
50%. HEENT: Conjunctivae are clear, no scleral icterus, no
mucosal ulcerations. NECK: Obese, neck veins not well
visualized. CHEST: Coarse breath sounds bilaterally with
occasional wheezes. CARDIOVASCULAR: Tachycardiac, regular,
no murmur appreciated. ABDOMEN: Examination was soft,
nontender, nondistended, bowel sounds present, midline
abdominal scar. EXTREMITIES: Warm with no edema. Back
examination revealed surgical scar over the lumbar spine.
NEUROLOGICAL: The patient is sedated and not responding to
painful stimuli. SKIN: Skin showed petechiae and pustules
over her left inner thigh and petechiae with erythema over
the right axilla and shoulder.
LABORATORY DATA: Laboratory data revealed the following:
ABG at the outside hospital on 100% nonrebreather 7.34, CO2
35, pO2 173. White count, at the outside hospital was 35.6,
hematocrit 43.5, platelet count 547,000. SMA 7 at the
outside hospital 131, 4.5, 96, 20, 32, 2.8, glucose 210,
anion gap 50. AST 125, ALT 124, alkaline phosphatase 91,
T-bilirubin 2.2, albumin 3.0, total protein 6.1, calcium 8.3.
Chest x-ray at the outside hospital showed right mainstem
intubation, low lung volume, no infiltrate. EKG at the
outside hospital showed sinus tachycardia with normal axis.
At [**Hospital1 69**] in the Emergency Room
the labs were as follows: white count 37.9, hematocrit 33.5,
platelet count 478,000, SMA 7 138, 4.1, 106, 19, 32.2,
glucose 161, anion gap 13. The PT was 20.8, PTT 39.0, INR
3.0. CK 604, troponin 0.9, alkaline phosphatase 68, lipase
3, phosphorus 4.3, magnesium 1.0. Urinalysis revealed
moderate blood, positive protein, trace ketones, 6 to 10
white cells, 6 to 10 epithelial cells, 0 to 2 granular casts,
6 to 10 hyaline casts.
MICROBIOLOGY DATA: Blood cultures and urine cultures are
pending. The ABG revealed pH of 7.22, carbon dioxide 33,
oxygen 364 with a bicarbonate 14.
IMPRESSION: This is a 39-year-old woman with hypertension,
fever, and multiorgan failure including DIC and renal failure
and metabolic acidosis. The patient is in septic shock
secondary to an unknown cause; likely causes include
toxic-shock syndrome, meningeal coxemia and gram-negative
sepsis. She has a history of back pain and spinal surgery,
also concerning, but no recent surgeries noted and no
inflammation or localizing signs on examination.
Other etiologies included [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] Spotted fever,
although that is thought to be less likely.
The patient was given oxacillin and Clindamycin for toxic
shock, Ceftriaxone for meningeal coxemia and gram-negative
sepsis. The patient was given Doxycycline for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**]
Spotted fever. The patient was given aggressive volume
resuscitation and pressors to maintain blood pressure with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] greater than 60. The patient was intubated and placed
on a ventilator. The patient's renal function will be
followed as will her urine output as it appears that the
patient is in acute tubular necrosis. A DIC panel was
checked on admission as the patient had elevated coagulation
panel.
On hospital day #2, the patient pressor was switched to
Levophed and the neosynephrine was discontinued. The patient
was started on an activated protein C. Oxacillin,
Clindamycin, Ceftriaxone were all continued. During her
entire time, the patient was given supportive care on the
ventilator and with fluids.
On hospital day #3, pressors were weaned to off. Cultures of
the tampon came back positive for Staphylococcus aureus,
which was Penicillin resistant, but methicillin sensitive.
Sedation was decreased with the goal of a spontaneous
breathing trial prior to extubation.
On hospital day #4, all cultures, urine and blood, have been
negative to date. The Clindamycin, Oxacillin, Ceftriaxone
and activated protein C were continued and stool was sent for
C-difficile analysis. The patient is still in nonoliguric
renal failure, likely acute tubular necrosis secondary to
ischemia. The original blood samples on the tampon from
[**Hospital3 3583**] were transferred to [**Hospital1 190**] and then sent on to the CDC for toxic shock
syndrome toxin #I and for antibodies to toxin #1.
Hospital day #5, the patient had right upper lobe and left
lower lobe infiltrates on chest x-ray. PICC line was placed.
On hospital day #6, antibiotics were changed to oxacillin and
Ciprofloxacin. The Ciprofloxacin was added to treat a
ventilator-associated pneumonia, presumptively. The other
antibiotics were discontinued. The Propofol was weaned to
off.
On hospital day #7, the patient continued to wean off the
ventilator support. On hospital day #8, the patient was
extubated. A new rash was noted and thought secondary to
antibiotics or other medications. Consequently, the
antibiotic were discontinued. The patient maintained good
urine output and the creatinine started to come down. On
hospital day #9 the patient was eating well and her
saturation was maintained on minimal oxygen.
On hospital day #10 the patient complained of weakness in her
hands, which she complained for three to four days prior to
the outside hospital emergency room. She also said that she
felt like she was breathing hard and she complained of her
usual chronic back pain. However, the patient was deemed
stable enough to be transferred to the floor. On transfer to
the floor team, current issues included pulmonary bilateral
infiltrates, ARDS versus ventilator-associated pneumonia.
The saturation was 87% on room air and 97% on three liters.
The patient complained subjectively of dyspnea.
INFECTIOUS DISEASE: The patient has all cultures negative.
The tampon grew out Staphylococcus aureus and the patient had
clinical criteria for toxic shock syndrome. The toxic shock
syndrome toxin #1 test and antibody are pending from the CDC
at this point in time. The patient is off all antibiotics.
HEMATOLOGICAL: The patient DIC has resolved and the
activated protein C was discontinued on [**1-3**],
hospital day #7. The hematocrit is stable at 25 and the
patient will not be transfused until the hematocrit drops
below 22. The patient is in post ATN diuresis phase with
high urine output and slowly decreasing creatinine.
GASTROINTESTINAL: The patient complained of mild abdominal
pain and cramping.
CARDIOVASCULAR: The patient has been cardiovascularly
stable, off pressors, for five to six days.
FLUIDS: The patient is making significant amounts of urine
and keeping herself 3-4 liters negative per day.
MUSCULOSKELETAL: The patient continues to complain of her
chronic low back pain and weakness of her hands bilaterally.
NEUROLOGICAL: The patient has sensory deficit to her elbow
bilaterally and weakness of her hands.
SKIN: The rash that the patient had on admission is now
resolved.
On hospital day #11, which was [**1-7**], stool was sent
for C. difficile and Flagyl was started empirically for loose
stool, crampy abdominal pain, and persistently elevated white
count to 22. The patient continued to improve in all areas.
On hospital day #12, the patient was weaned off oxygen to
room air. The patient continued to regain some function and
feeling in her hands bilaterally. The left one is
persistently worse than her right. The patient's abdominal
pain and cramping persisted with minimal p.o. intake. The
patient's creatinine continued to drop.
On hospital day #13, the patient's reported resolving loose
stool and decreased abdominal cramping and the patient was
able to take some POs. The patient also reported continued
improvement in her neurological symptoms of her hands
bilaterally.
On hospital day #14, [**1-10**], the patient regained her
voice. It had been hoarse previous to this. The patient
tolerated a full breakfast for the first time and having form
stool of two to three per day. The patient continues to take
the Flagyl 500 mg p.o. t.i.d.
The neurological deficits continued to resolved slowly. MRI
of the cervical spine was obtained to rule out any central
pathology. The results of the toxic shock syndrome toxin and
antibody test returned on Thursday, [**1-10**], or Friday,
[**1-11**]. The patient was screened for rehabilitation
on [**1-9**]. On [**1-10**], after tolerating a good
breakfast, the patient was deemed stable for discharge if the
patient could each a good lunch without any abdominal
cramping or loose stool.
The patient will be discharged on [**1-10**], in the
afternoon or possibly [**1-11**], early in the morning to
[**Hospital 46**] Rehabilitation, who should receive a copy of this stat
dictation summary.
After the patient tolerates good p.o. intake, the patient
will be discharged on the following medications:
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o.q.d.
2. Tums 1000 mg p.o.t.i.d.
3. Vitamin D 400 IU p.o.q.d.
4. Nystatin power to affected areas b.i.d. as needed.
5. Flagyl 500 mg p.o.t.i.d. until [**2104-1-18**].
6. Tylenol 650 mg p.o. q.4 to 6h.p.r.n.
7. Colace 100 mg p.o.b.i.d.
8. Serax 15 mg p.o.q.h.s. as needed on a regular diet.
The patient is in stable condition on discharge with the
diagnoses of the following:
1. Toxic shock syndrome.
2. Low back pain, chronic.
3. Neuropathy of upper extremities.
4. Acute tubular necrosis.
5. Adult respiratory distress syndrome, now resolved.
FOLLOW-UP CARE: The patient will followup with her OB-GYN
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31399**]. The patient will return to see the
[**Hospital 878**] Clinic here for followup.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-955
Dictated By:[**Last Name (NamePattern1) 31401**]
MEDQUIST36
D: [**2104-1-10**] 11:19
T: [**2104-1-10**] 11:20
JOB#: [**Job Number 31402**]
cc:[**Hospital1 31403**] Admission Date: [**2103-12-28**] Discharge Date: [**2104-1-11**]
Date of Birth: [**2064-2-21**] Sex: F
Service: Medicine
ADDENDUM: Toxic shock toxin number one came back positive
from the CDC.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-955
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2104-1-11**] 10:29
T: [**2104-1-11**] 10:44
JOB#: [**Job Number 10624**]
|
[
"040.89",
"584.5",
"486",
"401.9",
"286.6",
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"276.2",
"724.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2860, 2878
|
12080, 13594
|
2901, 12057
|
2182, 2426
|
2443, 2843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,872
| 179,230
|
28164+28165
|
Discharge summary
|
report+report
|
Admission Date: [**2141-9-26**] Discharge Date: [**2141-10-4**]
Service:
This is a [**Age over 90 **]-year-old female admitted to the Vascular service
on [**2141-9-19**] and discharged [**2141-10-4**].
CHIEF COMPLAINT: Right foot cellulitis and gangrenous
ischemic toes.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
hospitalized in [**Month (only) 216**] of this year for right foot ischemia,
who underwent a diagnostic arteriogram with Perclose groin
closure and right leg runoff for HIT induced thrombocytopenia
with right foot embolus. The study demonstrated right SFA
popliteal disease with single-vessel runoff via the peroneal
artery. The patient was seen in Dr.[**Name (NI) 1392**] clinic on
[**2141-9-19**] for right foot cellulitis. Since
discharge, last dialysis was on [**Month (only) **] __________. The
right foot and blood toes remained the same but in the last
48 hours there is increasing erythema, edema and drainage
from the wound. The patient denies any constitutional
symptoms. She is now admitted for IV antibiotics and
consideration for revascularization of the right lower
extremity.
ALLERGIES: Penicillin, manifestations not known; heparin,
HIT antibody positive.
MEDICATIONS: Include levothyroxine 75 mcg daily, Lopressor
XL 75 mg daily, __________ 10 mg daily, calcium 1000 mg
t.i.d., multivitamin capsule daily, Coumadin 2 mg Monday,
Wednesday, Friday, and 1 mg Tuesday, Tuesday, Saturday,
Sunday, aspirin 81 mg daily, Protonix 40 mg daily, senna
tablets 8.6 mg twice a day, Colace 100 mg b.i.d., oxycodone
2.5 mg q.8h. p.r.n. pain.
ILLNESSES: Include endstage renal disease, stage V, on
dialysis Tuesdays, Thursdays and Saturdays; status post right
IJ PermCath in [**2141-8-9**]; history of coronary artery
disease with a non-ST elevated MI; history of peripheral
vascular disease; history of hypertension; history of anemia
of renal disease; history of osteodystrophy; history of
hypothyroidism; history of gastroesophageal reflux disease.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
The patient is dialyzed at [**Location (un) **] Hemodialysis Center.
Their number is [**Telephone/Fax (1) 26161**]. Her nephrologist is Dr. [**Last Name (STitle) **].
[**Doctor Last Name 118**], his number is [**Telephone/Fax (1) 435**]. Cardiologist is [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 171**], office number [**Telephone/Fax (1) 1989**].
PHYSICAL EXAMINATION: Vital signs: 95.3 axillary, 104, 18,
blood pressure 111/85, O2 sats 97% on room air. HEENT exam:
There is no JVD or carotid bruits. Pulses are palpable 2+
bilaterally. Lungs are clear to auscultation bilaterally.
Heart is of regular rate and rhythm without murmur, gallop or
rub. Abdomen is mildly distended, nontender, with bowel
sounds x4. There are no abdominal bruits or masses.
Extremity exam shows left foot is pale, cool, without
lesions. The right foot is with 2 to 3+ edema, white toes
with erythema at the toes extending to the ankle. The foot
is cool. Pulse exam shows 2+ femoral pulses with 1+
popliteal, BP, and PT bilaterally. Neurological exam:
Oriented x person and place, nonfocal.
HOSPITAL COURSE: The patient was admitted to the Vascular
service. Wound cultures were obtained and she was begun on
triple antibiotic therapy of vancomycin, ciprofloxacin, and
Flagyl. Wound culture Gram stain showed no polys or
microorganisms. The wound culture was finalized as no
growth. Renal was consulted for hemodialysis and the patient
was continued on her preadmission schedule for Tuesdays,
Thursdays and Saturdays. The patient's INR on admission was
2.9. Epo was started at 22,000 units at dialysis. A long
discussion was held with the family, amputation versus
bypass, given the patient had poor outflow and questionable
graft patency, was presented to the family. They were
adamantly against amputation. The patient proceeded to
surgery after being evaluated by Cardiology who felt that
patient was at moderate risk for a perioperative event. Her
medications were adjusted to improve her blood pressure and
heart rate for a goal of systolic pressure of 120-140 and a
pulse rate of 60 or less. The cellulitis improved and edema
improved with antibiotics and bedrest. The patient underwent
on [**2141-9-26**], a right fem-DP bypass graft in situ
saphenous vein angioscopy. The patient tolerated the
procedure well and was extubated and transferred to the PACU
in stable condition. On arrival to the PACU, the foot was
cold, there was no signal in the graft. The patient returned
to the OR and underwent a thrombectomy of the right femoral
DP bypass x2. The patient was extubated and returned to the
PACU. The graft pulse was marginal after the second surgery
and decision was made if the graft failed that no further
surgical intervention would be attempted. The patient
remained intubated overnight and in the PACU. Postoperative
day 1 there were no overnight events. The patient was weaned
off Neo-Synephrine for systolic blood pressure control. The
patient was weaned off __________. She underwent
hemodialysis and then was attempted at extubation.
Postoperative day 2 there were no overnight events. The
patient was afebrile. The patient was extubated the day
prior and was transferred to the VICU for continued
monitoring of care. She was continued on triple antibiotics
with vanco, Cipro, and Flagyl. We will continue to follow
the patient for her hemodialysis needs. She was transfused 1
unit of packed red blood cells for a hematocrit of 26.
Postoperative day 3 overnight events: The patient experienced
chest pain with ST depressions. She was given aspirin and
nitroglycerin with relief of her symptoms. The patient
continued to do well from a cardiac standpoint. Arterial
studies were done on [**2141-10-2**] which showed on the
right foot 3 mm pressure wave tracings and on the left 2 mm.
Post transfusion hematocrit was 29.3. The patient remained
on argatroban for her history of heparin allergy. __________
was restarted on [**2141-10-1**] for regained Doppler
signals in the left foot that had been initially lost.
Physical therapy was requested through the patient for
evaluation for discharge planning. Case management was
consulted to assist in discharge planning needs. The patient
will be discharged when medically stable per PT's evaluation.
DISCHARGE MEDICATIONS: Include levothyroxine 75 mg daily,
__________ 10 mg daily, calcium carbonate 1000 mg t.i.d.,
Niferex capsule 1 daily, aspirin 81 mg daily, Colace 100 mg
b.i.d., oxycodone/acetaminophen 5/325 solution [**5-18**] mL q.4h.
p.r.n. for pain, Protonix 40 mg daily, senna tablets 8.6 mg
b.i.d., metoprolol 75 mg t.i.d., warfarin 2 mg Monday,
Wednesday and Friday, and 1 mg Sunday, Tuesday, Thursday and
Saturday, lisinopril was started for her systolic
hypertension at 5 mg daily.
DISCHARGE INSTRUCTIONS: She may ambulate essential
distances. She should wear an Ace from foot to knee on the
right side when ambulating. She should keep the right foot
and leg elevated in a chair. She should continue her
Coumadin for history of thrombus and heparin allergy and take
as directed. The goal INR is 2.0-3.0. She should follow up
with her primary care physician for monitoring of her INR and
adjustment of her Coumadin dosing as required. We have made
arrangements for her to see hematologist because of her
history of clotting problems, please keep that appointment.
Please call Dr.[**Name (NI) 1392**] office for the following reasons:
If you develop fever greater than 101.5, if the with wound
changes, becomes red, swollen or drainage, or there is any
increasing blue discoloration of the right toe or increasing
right foot pain. You may shower but no tub baths. Please
continue to take the stool softener, Colace, as directed
while you are taking pain medication since pain meds can
cause constipation.
DISCHARGE DIAGNOSES:
1. Right foot cellulitis with ischemic toes.
2. History of endstage renal disease, stage V, on dialysis
Tuesday, Thursday and Saturday.
3. History of hypertension, uncontrolled.
4. History of peripheral vascular disease.
5. History of anemia of renal disease.
6. History of renal osteodystrophy.
7. History of hypothyroidism.
8. History of gastric reflux.
9. History of coronary artery disease status post non-ST
myocardial infarction.
10.History of heparin-induced thrombocytopenia,
postoperative blood loss anemia, transfused.
MAJOR SURGICAL PROCEDURES: Right femoral-dorsalis pedis
bypass in situ saphenous vein with thrombectomy of the right
femoral-dorsalis pedis graft x2 on [**9-26**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2141-10-2**] 15:54:51
T: [**2141-10-2**] 23:17:22
Job#: [**Job Number 68452**]
Admission Date: [**2141-9-19**] Discharge Date: [**2141-10-5**]
Service: SURGERY
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
right foot ischemic and cellulitis
Major Surgical or Invasive Procedure:
rt. fem-dp bpg with insitu vein [**2141-9-26**]
thrombectomy of rt. fem-dp bpg [**9-26**]
History of Present Illness:
[**Age over 90 **]y/o female hospitalized [**8-15**] for blue toes rt. foot. s/p
angiogram diagnostic and right leg runoff with perclose femoral
artery closure. HIT antibody positive.discharged anticoagulated.
Seen in followup today. Now with rt. foot edema, erythema and
blue toes ( toe color stable). admitted for IV antibiotics,
bedrest.
Past Medical History:
PMH:
- Hypertension - Since [**2104**]'s
- Chronic Kidney Disease - Likely secondary to chronic htn,
complicated by anemia and renal osteodystrophy. Receives
dialysis Tue, Thr, Sat at [**Location (un) **] in So. [**Location (un) **]
- Hypothyroidism - Past 7 yrs
- GERD - Past 2 yrs. S/p normal upper/lower GI studies 1.5
years ago. Son does not regularly give omeprazole
Social History:
Lives in [**Location 10022**] with son. Pt is cared for 24/7 by three
children and is never left alone. She is a former town select
woman, and sold real estate. She never smoked or drank alcohol.
She eats a balanced diet without added salt, though with
decreased appetite in the past few yrs. She is able to walk
alone without a walker, except when feeling weak.
Family History:
Family history: Significant for no known kidney disease or
bleeding disorders in any family members. [**Name (NI) **] three children
are generally healthy.
Physical Exam:
VS:95.3 ax-104-18 O2 sat 97% room air,B/P 111/85
HEENT: no JVd, carotids 2=, no bruits
Lungs: cleqr to ausculation
Heart: RRR, no mumur,gallop or rub
ABd: moderatly distenderd, soft nontender BSx4 soft no bruits
EXT: left foot pale cool no ulcers. Rt. foot [**2-11**] + edema blue
toes with erythema toe to ankle.
Pulse: palpable femoral pulses bilaterally 2+, dital pulses 1
palpable bilaterally . no bruits
Neuro: Ox person, place
Pertinent Results:
[**2141-9-19**] 03:21PM GLUCOSE-150* UREA N-42* CREAT-7.1*#
SODIUM-135 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-22 ANION GAP-22*
[**2141-9-19**] 03:21PM estGFR-Using this
[**2141-9-19**] 03:21PM CALCIUM-8.4 PHOSPHATE-6.7*# MAGNESIUM-2.2
[**2141-9-19**] 03:21PM WBC-12.8*# RBC-3.74* HGB-10.7* HCT-35.1*
MCV-94 MCH-28.6 MCHC-30.5* RDW-18.0*
[**2141-9-19**] 03:21PM PLT COUNT-374#
[**2141-9-19**] 03:21PM PT-26.1* PTT-33.4 INR(PT)-2.7*
Brief Hospital Course:
[**9-19**] Admitted. Vanco dose@ hemodialysis 1Gm. cipro/flagyl
started. wound c/s obtained. Renal consulted for hemodialysis
need. Dialysed.
[**9-20**] Vein mapping to assess for graft conduit.
[**2141-9-26**] right fem-dp bpg, returned to surgery x2 for graft
thrombectomy, graft failed
[**Date range (1) 68453**] transfered to VICU postoperatively. Hemo dialyis
continued. IV antibioticscontinued. Fore- foot PVR demonstrated
3mm flow to rt. forefoot.No further surgery at this
time.postoperatively hospital course unremarkable. Assessed by
Physical Theraphy service not safe to be discharged to home.
Long discussions with son for the need of rehab prior to d/c to
home. Dialyized last [**2141-10-5**].Thransfer to rehab for continued
care stable.
Medications on Admission:
new meds to preadmission meds:
lopressor 75mgm tid
senna tabs 1 [**Hospital1 **] prn
Vancomycin 1 GM @ HD
cipro 250mgm qd
miconazole powder to affected area tid prn
bisacodyl 10 mg supp @HS prn
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
14. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 weeks.
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
give @HD when random level <15 for 2 weeks.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
rt foot cellulitis and ischemic toes
history of ESRD STage V on hemod8ialysis Tu,Thurs,Sat
history of hypertension,uncomtrolled
history of perpheral vascular disease
history of anemia of renal disease
history of renal osteodystrophy
history of hypothyroid
history of gastric reflux disease
history of coronary artery disease,s/pNSTEMI
history of HIT
postoperatvie blood loss anemia, transfused
Discharge Condition:
stable
Discharge Instructions:
may ambulate essential distances
ambulate with ace wrap from foot to knee on rt. side
keep rt. leg/foot elevated when in a chair
you are on coumadin for your history of thrombus and heparin
allergy, continue to take as directed
followup with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] your INR and
adjust your coumadin dosing as required and blood pressure, we
have adjusted your blood pressure medications
[**Last Name (Titles) **] cbc, random vanco while on antibiotics next two weeks
Vanco should be doses at HD.when random level <15
goal INR 2.0-3.0
We have arranged for you to see a hematologist because of your
clotting problems. please keep the appointment.
call Dr.[**Name (NI) 1392**] office for the following:
fever>101.5
wound changes of redness, swelling or drainage
or increasing blue discoloration of rt. toe or increasing rt.
foot pain
you may shower but no tub baths
continue to take a stool softner ( colace) as directed while you
are taking pain medication, since pain meds can cause
constipation
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**]. call for an appointment [**Telephone/Fax (1) 1393**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2141-10-13**] 10:30
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 17488**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2141-10-27**] 10:00
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2141-10-27**] 10:00
Completed by:[**2141-10-5**]
|
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"285.21",
"E878.2",
"585.5",
"244.9",
"530.81",
"403.91",
"996.74",
"285.1",
"682.7",
"412",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.49",
"39.95",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
14161, 14258
|
11552, 12305
|
9199, 9291
|
14697, 14706
|
11087, 11529
|
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|
10477, 10619
|
7949, 9108
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|
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|
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|
9125, 9161
|
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|
9683, 10058
|
10074, 10444
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,202
| 117,448
|
33839
|
Discharge summary
|
report
|
Admission Date: [**2125-8-4**] Discharge Date: [**2125-11-19**]
Date of Birth: [**2050-5-9**] Sex: M
Service: SURGERY
Allergies:
Vancomycin / Linezolid
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Sepsis and cellulitis
Major Surgical or Invasive Procedure:
angio [**2125-8-17**]
rt. pig tail chest catheter placement [**2125-8-28**]
left pigtail catheter placement [**2125-9-7**]
Mechanical ventilation
History of Present Illness:
75M with CAD s/p BMS, CHF, COPD, pleural effusions, PVD s/p
femeral endarterectomy and fem to posterior tibial bypass with
saphenous vein graft [**2125-5-28**] who was admitted [**8-4**] with a Right
Lower extremity MRSA surgical wound infection.
Past Medical History:
COPD (home O2)
CAD
Paroxysmal atrial fibrillation (anticoagulated)
PVD
H/O EtOH abuse
SIADH
Possible urinary retention
Coronary artery stenting, vessels unknown
Social History:
Lives at home with wife. The pt has been nearly immobilitezed
during his last 6 weeks at home with minmal ambulation.
Originally, pt was able to ambulate and take care of himself
before it became to painful to walk.
Smoker: [**12-20**] PPD x 60 years, quit 4 mos ago
H/o alcoholism, pt now admits to drinking 1 12oz beer per night.
Family History:
NC
Physical Exam:
On admittance
PE:
Gen: mild distress, diffuse erythema
HEENT: WNL
Chest: CTAB, A-fib
Abd: S/NT/ND
Ext: 5 cm open wound with purulent drainage on medial aspect of
right calf. blanching erythema from R toes to R thigh.
Skin: Red, dry, peeling sking; pt arrived with several small
stg. decubitis on both buttocks; dry brittle nails
Pulses: L R
Femoral Mono Mono
[**Doctor Last Name **] Mono
DP None None
PT None Mono
Graft - Dop
Radial Dop Palp
Pertinent Results:
[**2125-8-4**] 11:08PM
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 BLOOD-MOD
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-0-2 WBC-[**5-29**]* BACTERIA-FEW
YEAST-MOD EPI-0 HYALINE-0-2
[**2125-8-4**] 09:00PM
GLUCOSE-69* UREA N-31* CREAT-1.5* SODIUM-126* POTASSIUM-5.7*
CHLORIDE-95* TOTAL CO2-23 ANION GAP-14 CK(CPK)-314* proBNP-5151*
CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2125-8-4**] 09:00PM
WBC-16.8*# RBC-3.43* HGB-10.4* HCT-30.2* MCV-88 MCH-30.2
MCHC-34.3 RDW-14.8 NEUTS-80.9* LYMPHS-5.9* MONOS-3.7 EOS-9.4*
BASOS-0.1 PLT COUNT-441*# PT-39.8* PTT-38.1* INR(PT)-4.3*
[**2125-8-10**] TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) 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.
CT CHEST [**2125-8-27**]
IMPRESSION:
1. Moderate-to-large bilateral pleural effusions, new compared
to [**2125-5-22**].
2. Right [**Doctor Last Name **] lobe consolidation consistent with pneumonia.
3. Mild-to-moderate pulmonary edema superimposed over diffuse
emphysema.
4. Large solitary left paratracheal lymph node.
5. No evidence of abscess or osteomyelitis.
6. Extensive vascular calcifications including coronary arteries
and great
vessels (arteries), aorta, iliac arteries, common femoral
arteries. Minimal
arterial flow diffusely through out lower extremities.
8. Atrophy of the left leg.
9. Focal aneurysmal dilation of right common femoral artery
where in-situ
saphenous bypass arises.
CT CHEST [**2125-9-6**]
CT CHEST WITHOUT CONTRAST: Since the prior CT, there has been
placement of a
right posterior pleural pigtail catheter which terminates in the
major fissure
at the base of the right lung. There is a moderate pneumothorax
including a
basal component and smaller component along the anterior
junction line and the
pleural catheter courses through the largest air pocket. The
fluid component
is also moderate in size and is mostly unloculated, but the
attenuation of the
adjacent pleura is increased which can be seen in empyema. This
becomes a
further possibility as there is a large airspace consolidation
in the right
lower lobe consistent with pneumonia
On the left, there is a moderate partially loculated pleural
effusion which is
relatively unchanged with the prior, with associated
atelectasis. There is
severe emphysema of both lungs and severe anasarca of the soft
tissues.
There is no pericardial effusion. Multiple enlarged mediastinal
lymph nodes,
largest 22-mm left paratracheal (2:23), are very slightly
enlarged and likely
reactive. There are severe coronary artery calcifications and
severe aortic
valvular calcifications. An NG tube is located in the stomach.
The patient
is not intubated. Right PICC tip terminates in the lower SVC.
Study is not tailored for subdiaphragmatic evaluation, but no
abnormality is
noted except for high attenuation of a medullary pyramid in the
right upper
renal pole. No suspicious lesions are identified in the bones.
In the bones, there are multiple anterior wedge deformities of
T6, T7, T8, T9,
and L1, all stable from [**2125-8-27**].
IMPRESSION:
1. Moderate right hydropneumothorax with large right lower lobe
pneumonia.
The pleural effusion may be empyema.
2. Stable partially loculated moderate left pleural effusion
with underlying
atelectasis.
3. Stable enlarged mediastinal adenopathy, which may be
reactive.
4. Severe anasarca.
5. Severe coronary artery and aortic valvular calcifications.
VIDEO OROPHARYNGEAL SWALLOW STUDY [**2125-10-18**]
This study was performed in conjunction with speech pathology
department.
Continuous fluoroscopic observation was provided during
administration of
pudding and nectar-thick consistencies. During initial
nectar-thick
administration in a more recumbent position, there was marked
premature
spillover and frank aspiration, which remained silent. Cough
reflex was
inadequate in clearing the aspirated material. Subsequent
delivery of pudding
and nectar-thick consistency redemonstrated prolonged transit
times of the
oral phase and decreased epiglottic deflection. A
mild-to-moderate residue
was also again noted within the valleculae and piriform sinuses.
While no
laryngeal penetration or aspiration was identified during
swallow, there
appeared to be at least episodes of laryngeal penetration after
swallow from
leftover residue within the piriform sinus. Patient's O2
saturations were
noted to transiently decrease during these episodes.
IMPRESSION:
Episodes of laryngeal penetration and aspiration as described
above.
Technically suboptimal study.
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). 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 are moderately
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2125-8-10**],
right ventricular cavity size is smaller and the severity of
pulmonary artery systolic hypertension and tricuspid
regurgitation are reduced. Aortic regurgitation and mitral
regurgitation are not appreciated on the current study, but the
image quality is suboptimal and may not reflect a true change.
[**2125-11-8**]. RLE LENI.
IMPRESSION: Deep vein thrombosis of the right superficial
femoral vein.
[**2125-11-12**]. CT Chest.
IMPRESSION:
1. Abnormality on recent chest radiograph corresponds to an
enlarging
loculated left pleural effusion. There is no evidence of a
discrete lung
abscess in this region.
2. Persistent pneumonia in the right upper and right lower lobes
with likely necrotizing component in right lower lobe. Slight
improvement in right upper lobe since prior study.
3. New obstruction of airway proximal to the tracheostomy tube,
likely due to intraluminal secretions.
2. Mild hydrostatic edema superimposed on emphysema. Widespread
anasarca.
[**2125-10-6**] 10:00 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-10-8**]**
GRAM STAIN (Final [**2125-10-6**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2125-10-8**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78211**]
[**2125-10-3**].
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78211**]
[**2125-10-3**].
[**2125-10-3**] 7:54 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-10-8**]**
GRAM STAIN (Final [**2125-10-3**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2125-10-8**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
gram stain reviewed: 3+ (5-10 per 1000X FIELD): GRAM
NEGATIVE
ROD(S). were observed [**2125-10-5**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R 2 S
[**2125-9-24**] 1:15 pm BRONCHOALVEOLAR LAVAGE LLL SUPERIOR.
GRAM STAIN (Final [**2125-9-24**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2125-9-26**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII COMPLEX. >100,000
ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78212**]
([**9-24**]).
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78212**]
([**9-24**]).
FUNGAL CULTURE (Final [**2125-10-8**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2125-9-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2125-9-24**] 1:15 pm BRONCHIAL WASHINGS WASH RIGHT ( RLL ).
**FINAL REPORT [**2125-9-29**]**
GRAM STAIN (Final [**2125-9-24**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2125-9-29**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE
GROWTH.
AMIKACIN >32 MCG/ML.
CEFEPIME >16 MCG/ML.
LEVOFLOXACIN <=2.0 MCG/ML.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
NON-FERMENTER, NOT PSEUDOMO
| | |
AMIKACIN-------------- 16 S R
AMPICILLIN/SULBACTAM-- 8 S =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R R
CEFTAZIDIME----------- =>64 R =>64 R 4 S
CEFTRIAXONE----------- =>32 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R 1 S
GENTAMICIN------------ =>16 R =>16 R =>8 R
IMIPENEM-------------- 8 I 4 S
LEVOFLOXACIN---------- S
MEROPENEM------------- <=0.25 S 2 S
PIPERACILLIN---------- =>64 R
PIPERACILLIN/TAZO----- 8 S <=8 S
TOBRAMYCIN------------ 4 S =>16 R =>8 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R <=2 S
[**2125-9-19**] 4:38 pm PLEURAL FLUID
**FINAL REPORT [**2125-10-18**]**
GRAM STAIN (Final [**2125-9-19**]):
THIS IS A CORRECTED REPORT ([**2125-9-20**]).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78213**] @ 10:25 AM ON [**2125-9-20**].
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
.
PREVIOUSLY REPORTED AS.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS
([**2125-9-19**]).
FLUID CULTURE (Final [**2125-9-23**]):
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78214**]
([**2125-9-18**]).
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final [**2125-9-23**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2125-10-18**]): NO FUNGUS ISOLATED.
[**2125-9-18**] 1:27 pm PLEURAL FLUID
**FINAL REPORT [**2125-9-22**]**
GRAM STAIN (Final [**2125-9-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78215**] AT 1725 ON [**2125-9-18**].
FLUID CULTURE (Final [**2125-9-22**]):
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
GRAM NEGATIVE ROD #2. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78216**]
([**2125-9-19**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- 2 S
ANAEROBIC CULTURE (Final [**2125-9-22**]): NO ANAEROBES ISOLATED.
[**2125-9-7**] 2:11 am SWAB Source: CT site.
**FINAL REPORT [**2125-9-11**]**
WOUND CULTURE (Final [**2125-9-11**]):
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- 16 I =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- =>16 R
MEROPENEM------------- <=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I =>16 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
[**2125-8-5**] 5:03 am SWAB Source: r groin.
**FINAL REPORT [**2125-8-8**]**
WOUND CULTURE (Final [**2125-8-8**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
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 G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2125-9-6**] 11:37 am PLEURAL FLUID
**FINAL REPORT [**2125-10-5**]**
GRAM STAIN (Final [**2125-9-6**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) 3172**] [**2125-9-6**] @ 1552..
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI
(PROBABLE
BIPOLAR STAINING GRAM NEGATIVE RODS).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2125-9-17**]):
ACINETOBACTER BAUMANNII COMPLEX. HEAVY GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
AMIKACIN AND COLISTIN REQUESTED BY DR.[**Last Name (STitle) **].
SENT TO [**Hospital1 4534**] FOR COLISTIN SENSITIVITY.
AMIKACIN sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
COLISITIN = SENSITIVE AT <=2 MCG/ML , SENSITIVITIES
PERFORMED BY
[**Hospital1 4534**] LABORATORIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN------------ R
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2125-9-10**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2125-10-5**]): NO FUNGUS ISOLATED.
[**2125-10-18**] 04:39AM BLOOD WBC-13.5* RBC-3.42*# Hgb-10.6* Hct-31.9*#
MCV-93 MCH-30.9 MCHC-33.2 RDW-15.9* Plt Ct-804*
[**2125-8-4**] 09:00PM BLOOD WBC-16.8*# RBC-3.43* Hgb-10.4* Hct-30.2*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.8 Plt Ct-441*#
[**2125-10-18**] 04:39AM BLOOD Neuts-60.1 Lymphs-16.5* Monos-6.3
Eos-16.7* Baso-0.5
[**2125-9-27**] 04:15AM BLOOD Neuts-61.7 Lymphs-12.7* Monos-4.0
Eos-21.5* Baso-0.1
[**2125-10-18**] 04:39AM BLOOD PT-15.6* PTT-29.2 INR(PT)-1.4*
[**2125-8-14**] 09:30AM BLOOD PT-33.8* PTT-41.7* INR(PT)-3.5*
[**2125-9-24**] 07:17PM BLOOD Fibrino-312 D-Dimer-881*
[**2125-10-1**] 12:22AM BLOOD FDP-10-40*
[**2125-10-3**] 12:30AM BLOOD Ret Man-1.7*
[**2125-10-18**] 04:39AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-133
K-4.8 Cl-99 HCO3-28 AnGap-11
[**2125-8-4**] 09:00PM BLOOD Glucose-69* UreaN-31* Creat-1.5* Na-126*
K-5.7* Cl-95* HCO3-23 AnGap-14
[**2125-10-8**] 09:08AM BLOOD CK(CPK)-18*
[**2125-8-7**] 11:30AM BLOOD ALT-30 AST-73* LD(LDH)-394* AlkPhos-52
Amylase-20 TotBili-0.5
[**2125-8-4**] 09:00PM BLOOD proBNP-5151*
[**2125-8-9**] 12:51PM BLOOD CK-MB-16* MB Indx-6.3* cTropnT-0.09*
[**2125-8-10**] 10:39AM BLOOD CK-MB-13* MB Indx-3.3 cTropnT-0.12*
[**2125-8-11**] 03:26AM BLOOD CK-MB-12* MB Indx-2.9 cTropnT-0.13*
[**2125-10-8**] 05:41PM BLOOD CK-MB-3 cTropnT-0.16*
[**2125-10-8**] 09:08AM BLOOD CK(CPK)-18*
[**2125-10-17**] 03:50AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
[**2125-9-4**] 04:00AM BLOOD Ferritn-812*
[**2125-10-3**] 08:27PM BLOOD Hapto-222*
[**2125-8-7**] 08:55AM BLOOD TSH-3.3
[**2125-9-3**] 11:48AM BLOOD TSH-17*
[**2125-10-2**] 03:28AM BLOOD TSH-2.4
[**2125-10-2**] 03:28AM BLOOD T4-5.3
[**2125-9-13**] 04:32AM BLOOD T4-5.8 T3-52* calcTBG-0.96 TUptake-1.04
T4Index-6.0 Free T4-1.4
[**2125-10-7**] 05:25AM BLOOD Type-ART Temp-36.1 pO2-78* pCO2-49*
pH-7.47* calTCO2-37* Base XS-10
[**2125-10-5**] 04:31AM BLOOD Type-ART pO2-68* pCO2-61* pH-7.44
calTCO2-43* Base XS-13
[**2125-10-4**] 11:43AM BLOOD Type-ART Temp-35.9 FiO2-35 pO2-69*
pCO2-60* pH-7.40 calTCO2-39* Base XS-9 Intubat-INTUBATED
[**2125-10-4**] 04:13AM BLOOD Lactate-0.6
Brief Hospital Course:
In brief, this is a 75M with CAD s/p BMS, CHF, COPD, pleural
effusions, PVD s/p femeral endarterectomy and femoral to
posterior tibial bypass with saphenous vein graft [**2125-5-28**] who was
admitted [**8-4**] with a Right Lower extremity MRSA surgical wound
infection. He has had a complicated hospital course, summarized
as follows.
He was initially treated with Vancomycin, however, developed an
exfoliative rash to this medication. He completed a treatment
course with Linezolid and Unasyn. He developed pancytopenia
during this time. Hematology was consulted; it was thought to be
secondary to Linezolid. PF4Ab was negative for HIT. He also
developed acute renal failure and a NSTEMI during this time.
The patient developed increasing respiratory distress on [**8-26**];
eventually a respiratory code was called. He was found to be
unresponsive, with T = 92 degrees, BP 44/P, HR 82; he was
intubated. Nursing assessment at this time noted necrotic L
toes, necrotic calcaneous, as well as having thick bloody
secretions. His sputum ultimately grew Klebsiella. He was
treated initially with Daptomycin, Ceftazidime, and Fluconazole;
then Ceftriaxone alone from [**Date range (1) 78217**] then Meropenem started on
[**8-31**] (due to MIC levels) for a planned 10 day course (last day
planned as: [**9-6**]). A R pigtail chest tube was placed for his
pleural effusions. He was treated with stress dose steroids.
TFT's consistant with hypothyroid-- endocrine was consulted and
levothyroxine was started.
He was extubated on [**8-29**] and called out of the unit on [**8-30**]. He
was started on a heparin gtt on [**9-1**]. A L pigtail catheter
attempted but not able to be placed [**9-4**]; the R pigtail was
adjusted at that time.
On [**9-5**], the patient had an episode of respiratory distress with
hypertension to 190's/100's. He was reportedly "cyanotic" and
had blue fingertips, however, an O2 sat was unable to be
obtained. ABG around that time was 7.44/51/60/36. He was started
on a nonrebreather, given lasix/diamox and metoprolol. His
pigtail was TPA'd and put out several hundred cc's. His
respiratory status then improved and he was weaned to 2L NC. (Of
note, his I/Os were 1.6/.6 overnight). On [**9-6**] he developed
fever and hypotension and was transferred to the MICU.
The following issues were addressed during his MICU course:
1. Sepsis: He grew acinetobacter from his pleural fluid (right).
IP was consulted and a pigtail was placed on the left side; the
right pigtail continued to drain well. ID was consulted. He was
treated with Daptomycin/Meropenem. Unclear if acinetobacter was
a contaminant. Daptomycin was discontinued and he completed a
course of Meropenem to cover for Klebsiella Ventilator
Associated pneumonia. He then developed another Klebsiella &
Acinetobacter pneumonia, so was treated with Meropenem/Bactrim
which was switched to Mereopenem/Cefepime when his acinetobacter
was found to be resistant to Bactrim. He was on stress dose
steroids which were tapered and completed on [**11-13**]. He will
continue cefepime and meropenem until ???
2. Necrotic L foot: The patient requires a L AKA and a fem-fem
bypass.
Followed by vascular surgery and plan to take patient to OR when
medically clear. Cardiology saw patient and recommended stress
test prior to surgery. Plan is for patient to go to rehab to get
in better condition before undergoing vascular surgery. He will
eventually followup with Dr. [**Last Name (STitle) 1391**]. Plavix was held, but
patient was started on pentoxyphyline and continued on aspirin.
3.Nutrition: The patient was on tube feeds throughout his
hospital stay. He underwent several speech and swallow
evaluations and did not pass. Prior to discharge, he had an IR
guided PEG tube placed which is functioning well. He had an
ileus for approximately 5 days which prevented him from getting
tube feeds. He was started on an aggressive bowel regimen,
opioids were minimized, and patient was started on standing
reglan and hte ileus resolved.
4.Pain control: Patient was continuously experiencing intense
pain with any type of movement of his lower extremities. He was
treated with gabapentin, oxycodone, and a fentanyl patch to
achieve ideal pain control. He developed an ileus so pain
medications were weaned. He was resumed on ultram and around
the clock tylenol.
5.Respiratory Status: Patient had a continued and persistent
hypercarbic respiratory acidosis, likely from underlying COPD,
and several episodes of pneumonia. Tracheostomy was performed.
He was eventually weaned off the vent, with only intermittent
support on trach mask. Then over [**10-30**] developed
worsening infilatrates, reaccumulation of pleural fluid and
fever on Mereopenem/Cefepime.
6.Cellulitis: The patient developed a left knee cellulitis.
This was treated with daptomycin and ciprofloxacin for a total
of two weeks. Daptomycin was chosen because the patient had a
history of MRSA infection and he had an allergy to vancomycin.
His antibiotics were stopped on [**10-17**].
7.Mental Status: The patient went through several weeks of being
quite sedated and unarousable. This was evenually attributed to
the combination of high doses of tramadol and gabapentin. His
gabpentin dosing was decreased and his tramadol was
discontinued. The patient's mental status returned to him being
alert and interactive within two days of making these
interventions.
8.Congestive heart failure: The patient was total body fluid
overloaded. He had marginal blood pressures and so was placed
on a lasix drip. the patient diureses quite a bit, remaining on
the lasix drip for two weeks. It was eventually discontinued
once his fluid status was optimized. He still remains fluid
overloaded, but diuresis has not yet been initiated. Would
recommend diuresisi in the future.
9.NSTEMI: The patient was treated with metoprolol, aspirin.
Plavix was held due to coffee ground emesis from NGT.
10.Atrial Fibrilation: the patient was rate controlled with
metoprolol. He was initially placed on heparin gtt, but this
was discontinued as he began to bleed from a coccygeal ulcer.
His HR was in the 90s at discharge in A. fib.
11. RLE DVT. Patient was initiated on lovenox when he was
found to have a RLE DVT. He is currently getting bridged to
coumadin. Hematocrit has been stable.
12. Pleural effusion. Patient has bilateral pleural effusion.
He underwent several thoracenteses during hospital stay. A
thoracentesis on [**2125-11-12**] was suggestive of empyema
Upper GU bleed: [**11-4**] stablized on proton pump inhibitor.
Medications on Admission:
Coumadin 2.5 mg daily
lasix 40 mg daily
pravachol 40 mg daily
toprol xl 100 mg [**Hospital1 **]
cardizem 120 mg daily
Kcl 40 meq daily
flomax 0.4 mg daily
vitamin D
Advair 250/50 [**Hospital1 **]
xopenex
citracal
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital3 105**] Northeast-[**Location (un) 86**]
Discharge Diagnosis:
Death
Septic shock
Respiratory arrest
Peripheral vascular disease with critical limb
ischemia/necrosis.
right lower extremity cellulitis/wound infection
Ventilator associated/hospital acquired pneumonia
delerium with agitation, etology multifactorial,resolved
drug eruption,resolving with desqumation ? Bactrium ? Vanco,
improved
eosinophilia
Non ST elevation MI
left buttocks pressure decubitus Stg.[**12-20**],left heel decubitus
stage 1-2
history of MRSA
history of coronary artery disease, s/p PCI/stenting
atrial fibrillation
COPD
history of ETOH abuse
history of former tobacco use
history of hyponatremia-fluid restricted
acute blood loss anemia,on chronic, transfused
thrombocytopenia on linezolid with negative HIT
bone marrow suppression [**1-20**] linezolid
Urinary tract infection
bilateral pleural effusions
adrenal insuffiency- stress steroids
hypothyroid by thyroid function studies-synthroid
acute diastolic CHF
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2126-5-10**]
|
[
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"453.8",
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"453.40",
"584.9",
"995.92",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"34.04",
"33.23",
"96.72",
"38.91",
"38.93",
"00.14",
"34.91",
"43.11",
"31.1",
"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
31258, 31331
|
24387, 29427
|
303, 451
|
32304, 32314
|
1847, 11922
|
32366, 32400
|
1280, 1284
|
31230, 31235
|
31352, 32283
|
30993, 31207
|
32338, 32343
|
1299, 1828
|
11958, 24364
|
242, 265
|
479, 727
|
29442, 30967
|
749, 911
|
927, 1264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,329
| 136,744
|
45173
|
Discharge summary
|
report
|
Admission Date: [**2144-1-6**] Discharge Date: [**2144-1-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83F with hx of DM, CAD s/p CABG, CRI s/p recent admission for
urosepsis admitted [**1-6**] with mild left sided abd pain,
non-bloody emesis and bloody stool. Anoscopy showed hemorrhoids
and dried blood in vault and NG lavage was negative. An abd CT
showed wall thickening beginning in transverse colon and
extending throughout remainder of colon as well as evidence of
recurrent diverticulitis in the rectosigmoid. Given lactate 2.3,
sbp 90s, T 100.7 in ED MUST protocol was initiated. RIJ placed
and she received 7L NS in ED. Se was transiently on Levophed.
She received flagyl/cefepime/vanco for presumed colitis and
possible pneumonia given LLL infiltrate on CXR. She was briefly
on the SICU service, but was transferred to the MICU service on
the same day for further management. While in the MICU, she
received additional 4L NS and 1u PRBC for HCT 25. Given she
remains hemodynamically stable, she is being transferred to the
general medical service for further management.
Past Medical History:
* recent admission for urosepsis [**1-16**] pan-[**Last Name (un) 36**] E. coli s/p 14-day
course of amoxicillin
* DM type 2
* CAD s/p 2 vessel CABG and pci to lima-lad in '[**23**]
* Carotid stenosis s/p stent to left ica in '[**36**]
* Atrial septal defect
* TIA/CVA
* Chronic Kidney Disease, baseline cr 1.6-2.1
* Stroke Induced Seizures
* HTN
* Hyperlipidemia
* Cervical Spondylosis
* Lumbar Radiculopathy
* S/p cataract repair
* s/p LUE fx repair
* Depression
* h/o CHF: TTE [**7-17**] EF 20%, mildly dil LA, small ASD w/ L->R
flow, mild LVH, near akinesis distal [**1-17**] ventricle, mildly
hypokinetic basal anterior septal and inferolatral walls. Mild
global RV free wall hypokinesis. trace AR, 1+ MR, 3+ TR. Mild
mpulmonary artery systolic hypertension.
Social History:
Retired math professor [**First Name (Titles) **] [**Last Name (Titles) **], married, husband is health care
proxy. [**Name (NI) **] EtoH. Pt has 24h home health aid and ambulates with a
walker
Family History:
Non- contributory
Physical Exam:
Exam: Tc 97.9, Tm 99.4, pc 69, pr 64-80, bpc 125/62, bpr
101-135/40s-70s, resp 15, 98% 2L NC
Gen: elderly female, alert, oriented to person and place, NAD
HEENT: anicteric, pale conjunctiva, OMM slightly dry, OP clear,
neck supple, no LAD, JVP ~ 13 cm
Cardiac: RRR, soft S1/S2, II/VI SM at apex
Pulm: Scatterred wheezes bilaterally, bronchial breath sounds at
left base.
Abd: Moderately distended, NABS, soft, NT.
Ext: 1+ LE to mid calf bilaterally, warm, 2+ DP bilaterally
Pertinent Results:
[**2144-1-5**]
WBC-14.3*# RBC-4.51 HGB-13.6 HCT-39.1 MCV-87 MCH-30.2 MCHC-34.8
RDW-14.8
NEUTS-90.4* BANDS-0 LYMPHS-5.9* MONOS-3.1 EOS-0.3 BASOS-0.3 PLT
COUNT-304
PT-12.9 PTT-22.0 INR(PT)-1.1
GLUCOSE-228* UREA N-62* CREAT-2.2*# SODIUM-137 POTASSIUM-8.4
(hemolyzed) CHLORIDE-102 TOTAL CO2-22
CK(CPK)-94 CK-MB-2
EKG: NSR at 86bpm, nl axis, LAE, PRWP, TWI in I, aVL, V3-V6 (no
change from prior)
Micro:
ucx [**1-7**] (-), [**1-6**] 10-100k E. coli (levo [**Last Name (un) 36**])
bcx [**1-6**] NGTD
fecal cx [**1-6**] No salmonella/shigella/E. coli 0157:H7
C. diff [**1-9**] (-), [**1-6**] cancelled (mucus/blood contamination)
C. diff Toxin B [**1-6**] pending
Radiology:
CXR [**1-7**] increased LLL and lingular opacity
Head CT [**1-6**]: chronic microvascular changes atrophy
CT Abd [**1-6**]: Layering, dependent gallstones. No free air/fluid.
Thickening beginning in mid transverse colon and extending
distally, inflammation in rectosigmoid colon c/w recurrent
diverticulitis
Brief Hospital Course:
A: 83F with hx of CAD s/p CABG, CRF, DM admitted with abdominal
pain, BRBPR found to have extensive colitis (infectious vs
ischemic) and recurrent rectosigmoid diverticulitis.
1) Abdominal pain/BRBPR: This was most likely related to known
diverticulitis/colitis. Distal colitis was most likely secondary
to infectious etiologies. Ischemic colitis was felt to be less
likely, despite the patient's known cardiovascular disease,
given the distribution of inflammation on CT. Surgery was
consulted, who do not feel surgical intervention was required.
There was no indication for urgent colonoscopy, given acute
colitis/diverticulitis. The patient will require a colonoscopy
as an outpatient, once her acute illness has resolved. Her
abdominal exam was closely monitored, and remained benign at
time of discharge. Her diarrhea resolved prior to discharge.
Her hematocrit remained stable at 29 following transfusion 1
unit of PRBC in the ICU prior to transfer to the floor. E. coli,
Campylobactor, Salmonella, Shigella stool cultures were
negative. C. diff toxin was negative X 1 (unable to produce
additional stool samples), and C. diff toxin B assay was pending
at time of discharge. She was continued on
levofloxacin/metronidazole and will complete a 10 day course for
presumed infectious colitis. Her diet was advanced, and, at time
of discharge, she was tolerating a regular diet. If her diarrhea
resumes following completion of antibiotics, stool samples
should be obtained for C. diff testing.
2) Pneumonia: LLL/lingular infiltrate noted on CXR following
admission. This may have been related to aspiration in the
setting of nausea/vomiting prior to admission, although this may
also have represented a community-acquired pneumonia. As
mentioned above, she was continued on levofloxacin/metronidazole
and will complete a 10 day course, which will cover both
aspiration pneumonia and infectious colitis.
3) Blood loss anemia: The patient's hematocrit remained stable
at 29 following 1u PRBC transfusion [**1-7**] a.m. [**12-19**] iron studies
were not consistent with iron deficiency and vit B12/folate were
not deficient. The patient's hematocrit should be monitored as
an outpatient to ensure stability and, as mentioned above, she
will need an outpatient colonoscopy once her
diverticulitis/colitis has resolved
4) Hypotension: The patient's hypotension on admission was most
likely secondary to volume depletion given it rapidly
normalized with IV fluid resuscitation. Random cortisol obtain
in the ICU was 47, not suggestive of adrenal insufficiency. At
the time of discharge, the patient's blood pressure remained
stable on anti-hypertensives (required increase of lisinopril to
10 mg daily).
5) Acute on chronic renal failure: Creatinine improved to 0.9
from 2.2 on admission with hydration. The acute renal failure
was most likely related to volume depletion/dehydration in
setting of colitis, although the differential diagnosis includes
ATN in setting of hypotension.
6) Coronary artery disease: Initially held ASA in the setting of
GI bleed, however this was resumed at discharge. Her statin was
continued throughout hospital stay, and ACE inhibitor and
beta-blocker were resumed once she was hemodynamically stable.
There were no ischemic changes on EKG to suggest active
myocardial ischemia.
7) h/o congestive heart failure (EF20%): The patient was
euvolemic at time of discharge, and had been restarted on ACE
inhibitor and furosemide. Her fluid status will need to be
closely monitored as an outpatient to ensure stability, and she
should follow-up with cardiology as an outpatient at the
discretion of her PCP.
8) Type II diabetes: Her glyburide was intially held given poor
PO intake, however this, along with her home dose of 70/30 was
resumed at time of discharge
9) Stroke induced seizures: The patient was continued on her
home dose of Valproic acid.
10) Code: full
Medications on Admission:
1. Aspirin 81 mg qd
2. Atorvastatin 20 mg qd
3. Olanzapine 2.5 mg [**Hospital1 **] and qhs
4. Divalproex 125 mg [**Hospital1 **]
5. Atenolol 50 mg d
6. Lisinopril 5 mg qd
7. Glyburide 5 mg qd
8. 14 units 70/30 humulin qam
9. Lasix 20 mg qd
10. Prilosec 40 mg qd
Discharge Medications:
1. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-16**] puff Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
3. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 MDI* Refills:*2*
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 5 days.
Disp:*3 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed.
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. 70/30 humulin
14 units qAM
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: colitis, diverticulitis, pneumonia, blood loss anemia
Secondary: Urinary tract infection, Type II diabetes, coronary
artery disease, hypertension, hyperlipidemia,
Discharge Condition:
Good
Discharge Instructions:
Please follow-up with your primary care physician or go to the
emergency room if you develop recurrence of diarrhea, rectal
bleeding, abdominal pain, or other symptoms that concern you.
Your lisinopril has been increased to 10 mg daily, for better
control of your blood pressure. You will continue
levofloxacin/metronidazole for 5 more days to treat your
pneumonia and colitis
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
([**Telephone/Fax (1) 2936**]) [**2144-1-21**] at 3 p.m.
- if you have recurrent diarrhea following discontinuation of
antibiotics, you should be tested for C. diff colitis
- at time of discharge, C. diff toxin B is pending.
- your primary care physician may consider referral to
cardiology for further management of your coronary artery
disease and dilated cardiomyopathy
Completed by:[**2144-1-10**]
|
[
"585.9",
"562.12",
"397.0",
"424.0",
"438.89",
"745.5",
"401.9",
"584.9",
"276.50",
"285.1",
"250.00",
"272.4",
"V45.81",
"780.39",
"009.1",
"507.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9421, 9479
|
3836, 7736
|
275, 282
|
9695, 9702
|
2833, 3813
|
10128, 10641
|
2305, 2324
|
8048, 9398
|
9500, 9674
|
7762, 8025
|
9726, 10105
|
2339, 2814
|
221, 237
|
310, 1290
|
1312, 2078
|
2094, 2289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,673
| 106,483
|
26381
|
Discharge summary
|
report
|
Admission Date: [**2129-4-15**] Discharge Date: [**2129-4-25**]
Date of Birth: [**2058-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Syncope and Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained from daughter's translation from this Persian
speaking woman.
70-yo-woman w/ CAD, V tach w/ AICD, and severe COPD was brought
to ED by EMS after falling at home. The pt felt well until early
this AM, when she removed her PM BiPAP and O2 to walk to the
bathroom. On her way the bathroom, her "legs felt wobbly" and
she fell to the floor. Did not strike her head or lose
consciousness. There were no preceding dizziness,
lightheadedness, chest pain, palpitations, or confusion. There
was no bowel or bladder incontinence. No weakness, numbness, or
difficulty speaking/understanding are reported. After her fall,
she was unable to rise from the floor and became increasing
short of breath as she struggled to rise. She called her
Lifeline, who dispatched EMS to her home. ROS further
demonstrates no fever, chills, abd pain, dysuria, melena,
hematochezia, back pain, prior muscle weakness. She did fall
last night as well, though she was able to rise herself and was
not evaluated.
On EMS arrival, pt was dyspnic and hypoxic, w/ O2 sat 80's. She
was brought to the ED, where her initial O2 sat was 83% on 4L/m
O2 by NC.
Past Medical History:
1. CAD: s/p 4-vessel CABG [**2119**]
2. CHF: ECHO [**1-3**] w/ 1+ MR, minimal AS, EF 40% w/ regional wall
motion abnormalities
3. DM Type 2
4. HTN
5. COPD: on home O2 3.5L/m, BIPAP (settings 14/8) with multiple
past admissions w/ pCO2 in the 70-80 range
6. Schizophrenia: initially symptomatic w/ paranoia and
hallucinations, well controlled w/ meds
7. L3 fracture: [**2127**]
8. Symptomatic VT: s/p ICD in [**1-2**]
Social History:
SH: lives alone in [**Hospital3 **] apartment; has home health
aide daily; meals are prepared by the pt's daughter; walks
independently but sometimes uses walker; uses home O2 at all
times and BiPAP at night; smoked 60 pack-years but quit in [**2123**];
no alcohol, IVDU, or cocaine use.
Family History:
1. CAD: mother died of MI at unknown age
Physical Exam:
PE: T 100.4, HR 82, BP 100/43, RR 23, O2 sat 92% on BiPAP 14/8
Gen: obese woman lying flat in bed wearing BiPAP, lethargic but
rousable, mild resp distress.
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD visible
in obese neck
CV: reg s1/s2, + 2/6 systolic murmur loudest at LLSB, no s3/s4/r
Pulm: mild crackles in bases B/L w/ scattered wheezes over
bases, poor air movement throughout
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B/L, no edema
Neuro: a/o x 3, CN 2-12 intact, strength 3/5 throughout LE B/L,
though unsure that pt is awake and understanding of exam
Pertinent Results:
[**2129-4-15**] 06:36PM TYPE-ART PO2-82* PCO2-65* PH-7.35 TOTAL
CO2-37* BASE XS-6
[**2129-4-15**] 06:36PM O2 SAT-96
[**2129-4-15**] 04:25PM TYPE-ART PO2-120* PCO2-76* PH-7.31* TOTAL
CO2-40* BASE XS-8
[**2129-4-15**] 04:25PM O2 SAT-98
[**2129-4-15**] 02:14PM CK(CPK)-36
[**2129-4-15**] 02:14PM CK-MB-NotDone cTropnT-<0.01
[**2129-4-15**] 02:14PM TSH-0.51
[**2129-4-15**] 02:14PM VALPROATE-12*
[**2129-4-15**] 01:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2129-4-15**] 01:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-4-15**] 01:43PM URINE RBC-0-2 WBC-[**7-9**]* BACTERIA-MOD
YEAST-NONE EPI-[**4-3**]
[**2129-4-15**] 01:43PM URINE HYALINE->50
[**2129-4-15**] 12:31PM TYPE-ART PO2-65* PCO2-73* PH-7.28* TOTAL
CO2-36* BASE XS-4
[**2129-4-15**] 06:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2129-4-15**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2129-4-15**] 06:00AM URINE RBC-0-2 WBC-[**12-19**]* BACTERIA-FEW
YEAST-NONE EPI-0
[**2129-4-15**] 05:36AM TYPE-ART PO2-100 PCO2-52* PH-7.33* TOTAL
CO2-29 BASE XS-0
[**2129-4-15**] 04:58AM LACTATE-2.5*
[**2129-4-15**] 04:45AM GLUCOSE-186* UREA N-22* CREAT-0.9 SODIUM-142
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-32 ANION GAP-12
[**2129-4-15**] 04:45AM CK(CPK)-37
[**2129-4-15**] 04:45AM cTropnT-<0.01
[**2129-4-15**] 04:45AM CK-MB-NotDone proBNP-690*
[**2129-4-15**] 04:45AM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.3
[**2129-4-15**] 04:45AM WBC-11.6* RBC-3.54* HGB-10.4* HCT-30.8*
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.6*
[**2129-4-15**] 04:45AM NEUTS-90* BANDS-1 LYMPHS-5* MONOS-2 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2129-4-15**] 04:45AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ STIPPLED-1+
[**2129-4-15**] 04:45AM PLT COUNT-187
[**2129-4-15**] 04:45AM PLT COUNT-187
[**2129-4-15**] 04:45AM PT-12.0 PTT-20.6* INR(PT)-1.0
*
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS Intubat Comment
[**2129-4-22**] 01:41AM ART 67* 67*1 7.39 42*2 11 NOT
INTUBA3
1 VERIFIED BY REPLICATE ANALYSIS
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
3 NOT INTUBATED
[**2129-4-21**] 04:40PM ART 97 62*1 7.42 42*2 12
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-21**] 03:29PM ART 55*1 65*1 7.39 41*2 10
NOT INTUBA3
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
3 NOT INTUBATED
[**2129-4-21**] 02:29PM ART 60* 65*1 7.38 40* 9
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-20**] 12:39PM ART 71* 72*1 7.38 44*2 13
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-20**] 11:28AM ART 59*1 70*1 7.37 42*2 11
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-19**] 02:01PM ART 84* 64*1 7.41 42*1 12 NOT
INTUBA2
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NOT INTUBATED
[**2129-4-19**] 10:44AM ART 84* 76*1 7.35 44*2 11 NOT
INTUBA3
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
3 NOT INTUBATED
[**2129-4-19**] 10:15AM ART 80* 75*1 7.33* 41*1 9
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-17**] 10:53PM ART 36.1 66* 68*1 7.32* 37* 5
NOT INTUBA2
1 PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 NOT INTUBATED
[**2129-4-17**] 07:47AM ART 36.1 62* 67*1 7.36 39* 8
1 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-17**] 05:53AM ART 36.7 66* 71*1 7.35 41*1 9
NOT INTUBA2 VENTIMASK
1 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NOT INTUBATED
[**2129-4-17**] 02:51AM ART 36.7 53*1 63*1 7.38 39* 8
NOT INTUBA2 [**Hospital1 **] PAP 31 3
1 PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 NOT INTUBATED
3 [**Hospital1 **] PAP 31 ..NP
[**2129-4-16**] 10:52PM ART 36.1 59*1 78*1 7.33* 43*1
10 NOT INTUBA2
1 PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 NOT INTUBATED
[**2129-4-16**] 05:12AM ART 170* 68*1 7.34* 38* 8
1 VERIFIED BY REPLICATE ANALYSIS
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-15**] 06:36PM ART 82* 65*1 7.35 37* 6
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-15**] 04:25PM ART 120* 76*1 7.31* 40* 8
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-15**] 12:31PM ART 65* 73*1 7.28* 36* 4
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-15**] 05:36AM ART 100 52* 7.33* 29 0
%
DIABETES MONITORING %HbA1c [Hgb] [A1c]
[**2129-4-16**] 05:24PM 6.5*1 DONE DONE
Admission Chest X ray
Mild cardiac failure and bilateral lower lobe atelectasis
*
[**2129-4-19**]
Chest AP:
Moderate-to-severe cardiomegaly is unchanged. Lungs grossly
clear. There is no pleural effusion or pneumothorax. Transvenous
pacer defibrillator lead projects over the expected course to
the floor of the right ventricle. Mild fullness in the upper
mediastinum with slight leftward deviation of the trachea at the
thoracic inlet is probably due to tortuous or enlarged head and
neck vessels or right lobe of the thyroid.
*
CTA of abdomen and lungs [**2129-4-19**]
IMPRESSION:
1. No evidence of pulmonary embolus or aortic dissection.
2. Diffuse emphysematous changes within the lungs with bilateral
small pleural effusions.
3. Diffuse coronary artery and aortic calcifications.
4. Calcified fibroid uterus.
5. Hypo attenuating lesion in segment VII of the liver which is
too small to characterize.
*
[**2129-4-17**]
ECG:
Sinus bradycardia and atrial ectopy. Diffuse ST-T wave
abnormalities, less
prominent as compared to the previous tracing of [**2129-4-15**]. In
addition, the rate
has slowed. Otherwise, no diagnostic interim change.
Brief Hospital Course:
A/P: 70-yo-woman w/ CAD, CHF, DM2, HTN, COPD on home O2, and
schizophrenia s/p fall, admitted to the MICU w/ and somnolence.
.
1. Hypoxia/respiratory distress:
This was thought to be copd exacerbation (The patient is on 4L
O2 NC at home at rest.) in the setting of a URI worsened by lack
of O2 after fall and complicated by a CHF exacerbation given
initial appearance of pulm edema on CXR. She ruled out for an MI
and interrogation of ICD showed no SVT or VT. She was treated
with a five daz course of azithromycin and a prednisone taper.
She had a nasal congestion which originally may have been
secondary to her URI but was exacerbated by her self medication
with Afrin nasal spray even after her medication was
discontinued. Upon discovery of this the patient agreed to avoid
its use. She developed these episodes of desaturation to 68%
while on her nasal Bipap mask which was thought to be secondary
to a central sleep apnea along with some question of her not
being able to tolerate the nasal bipap mask secondary to her
nasal congestion. When she desated her O2 sats were restored by
placing the patient on a 24% Venturi mask and 6L of O2. She was
seen by pulmonary who recommended incresaing her nocturnal bipap
for obstructive sleep apnea to 14/12 (from 14/8) and
continuation of progresterone for respiratory stimulation. She
was continued on bipap as above (and encouraged to use it during
the day as well as she is suspected of having OSA during day
time during naps). She was also diuresed with IV lasix with good
effect. She was also continued on standing albuterol and
atrovent nebulizers.
.
2. Lethargy:
With initiation of bipap lethargy improved. She was seen by
psychiatry while in the hospital who did not think that her
somnolence was secondary to her medications. It was felt that
this was due to her hypercarbia. Her family thought that she was
close to her baseline and she was cleared for discharge by
psychiatry.
.
3. CAD: h/o 4v CABG in [**2119**], w/ no subsequent symptoms. No
active issues during this hospitalization. She ruled out for
myocardial ischemia with serial negative cardiac enzymes. She
was continued on ASA 325mg daily, lipitor and toprol XL.
.
4. CHF:
She has CHF with an EF 40% secondary to ischemic cardiomyopathy.
She was volume overloaded on admission and was succesfully
diuresed. She was continued on an ACEI for afterload reduction.
.
5. Anemia:
Iron studies c/w Fe deficency. The epogen level was wnl at 25.9.
She was started on iron supplementation. We recommend further
follow up of this as an outpatient.
.
6. Fall:
This appeared to be mechanical without syncope. ICD
interrogation showed no arrhythmia. We suspected that her
unsteadiness might have been secondary to visual problems in
dark - pinpoint pupils from psych meds preventing accomodation.
Her UTI may have also contributed to her instability. Her mental
status cleared without focal neuro deficit.
.
7. UTI:
U/A demonstrated small leukocyte esterase, WBcs and moderate
bacteria. She was initially started on ceftriaxone while in the
ICU and upon discharge to the floor her repeat U/A was negative
and the ceftriaxone was discontinued. Her urine culture was also
negative.
.
8. DM type 2:
Her glyburide was increased to 10 mg [**Hospital1 **] and she was started
metformin 500 [**Hospital1 **]
.
9. HTN:
Her blood pressure was well controlled on her outpatient dose of
Toprol XL.
.
10. FEN: [**Doctor First Name **]/low sodium diet. 1.5 L fluid restriction.
.
11. Proph: heparin sc, PPI.
.
12. Code Status: DNI/DNR: confirmed w/ pt and daughter
.
13. In light of her continued improvement the patient was
discharged to pulmonary rehab.
Medications on Admission:
ASA 81 daily
Toprol 25 daily
Lipitor 10 daily
Lasix 40 daily
Digoxin 0.25 daily
Glyburide 5 [**Hospital1 **]
L-thyrox 125 daily
Medroxyprogesterone 10 qAM
Zoloft 100 qAM
Abilify 40 QHS
Risperdal 2 QHS
Depakote 125 [**Hospital1 **]
Restoril 7.5 QHS prn for sleep
Duo Neb qid
Flovent 4 puffs [**Hospital1 **]
Beconase AQ 2 puffs Nasal [**Hospital1 **]
Folate 1mg daily
PhosLo 2 tabs with meals
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: [**1-31**] Inhalation Q2H
(every 2 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: [**1-31**] NEB Inhalation
Q6H (every 6 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
Two (2) Spray Nasal [**Hospital1 **] (2 times a day).
18. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO QHS (once
a day (at bedtime)).
19. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 1
doses.
21. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 1
doses.
22. Insulin Lispro (Human) 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED) for AS DIRECTED ON SHEET
ATTACHED weeks.
23. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed for constipation.
24. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
25. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
QID (4 times a day) as needed.
26. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
27. Albuterol Sulfate 0.083 % Solution Sig: [**1-31**] NEBS Inhalation
Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Chronic obstructive pulmonary disease- on home O2 3.5L/m, BIPAP
qhs(settings 14/8) -baseline pCO2 = 60-70
Obstructive sleep apnea
Congestive Heart Failure
Inability to void- requiring foley catherization
Secondary
3. DM Type 2
4. HTN
Schizophrenia: initially symptomatic w/ paranoia and
hallucinations, well controlled w/ meds
L3 fracture: [**2127**]
Symptomatic VT: s/p ICD in [**1-2**]
Discharge Condition:
Good, stable on bipap and supplemental O2.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500 mL
*
Please take all of your medications as prescribed.
*
Your dose of glyburide has been increased. You have been
started on a new medication metformin.
*
Please seek urgent medical attention should you develop
shortness of breath, chest pain, severe nausea or vomiting or
fevers or chills or other symptoms that concern you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2129-5-4**] 8:45
Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2129-6-6**] 7:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2129-6-7**] 9:00
*
Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) 8741**] [**Telephone/Fax (1) 2936**]
within one week of discharge.
*
Please follow up with your cardiologist [**First Name5 (NamePattern1) 65250**] [**Last Name (NamePattern1) 65251**] at [**Telephone/Fax (1) 65252**] within one week of discharge.
*
Please follow up with your psychiatrist Dr. [**Last Name (STitle) 12696**] at [**Telephone/Fax (1) 65253**] within one week of discharge.
|
[
"424.0",
"780.57",
"250.00",
"V45.02",
"428.0",
"491.21",
"280.9",
"401.9",
"V45.81",
"414.8",
"518.84",
"599.0",
"295.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15887, 15958
|
9367, 13036
|
335, 341
|
16399, 16444
|
2922, 9344
|
16943, 17775
|
2267, 2309
|
13479, 15864
|
15979, 16378
|
13062, 13456
|
16468, 16920
|
2324, 2903
|
276, 297
|
369, 1505
|
1527, 1946
|
1962, 2251
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,274
| 114,340
|
44277
|
Discharge summary
|
report
|
Admission Date: [**2183-3-24**] Discharge Date: [**2183-3-28**]
Date of Birth: [**2124-11-17**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Pneumonia, sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 55406**] is a 58M with asplenia, anxiety/depression, s/p
[**Country **] dissection and L hemiparesis, who presents with 2-3 days
worsening productive cough, fever, and fatiuge. The patient was
in his usual state of health until the weekend when he noted
chest congestion, increasing productive cough, SOB and fatigue.
He denies any [**Last Name (LF) **], [**First Name3 (LF) **], sinus congestion, overt CP, n/v/d, rash,
or dysuria. He was so fatigued he tripped on his cat and fell,
without LOC. On sunday, he spiked a fever to 102. He denies sick
contacts or recent travel. He received his flu shot this year.
.
In the ED, VS T 103, HR 70, BP 108/52, RR 18, 95%NRB, 80s on RA.
The patient subsequently became tachy to 120s with BP 80s-90s.
Given 6L NS without improvement. RIJ was placed and started on
Levophed 0.06mcg/kg/min. ? PNA so given Levaquin but had
reaction. Changed to CTX/Azithro, and Vanco.
Past Medical History:
1. Asplenia secondary to trauma incurred during Vietman, [**2144**],
pneumococcal vaccine given in [**2176**]. Does not remember if he
received H flu or meningococcus.
2. PTSD
3. ADHD
4. Depression/Anxiety
5. h/o Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by
[**Doctor Last Name 1327**]
8. Diverticulitis, now status post partial colectomy
9. Multiple sharpnel injuries while in Vietmam, [**2142**] - NO MRI!!
10. Scrtoal Hematoma s/p R radical orchiectomy [**3-7**] with phantom
pain syndrome
11. Traumatic [**Country **] dissection with L hemiparesis [**11/2180**]
Social History:
Married. 2 biologic and 1 adopted child. Works as a real estate
broker. Quit smoking a few years ago, former 1ppd. History of
alcohol abuse but no EtOH for 4 yrs. No drug use.
Family History:
adopted
Physical Exam:
VS: T 98.8, 132/70, HR 104, RR 22, 97% NRB
Gen: Awake and alert but fatigued, talking in full sent over
mask
HEENT: EOMI, PERRL, anicteric sclera, MMM
Neck: supple, RIJ line intact, no LAD
Heart: Tachy ,regular, nl S1 S2 no m/r/g
Lungs: Coarse crackles heard bilat at bases
Abd: soft NT/ND +BS no rebound or guarding
Ext: warm well perfused,
Skin: R arm with scattered wheal, no bruising or ecchymoses
Neuro: CN II-XII intact, [**5-5**] strengh on R, [**3-5**] in L upper ext,
[**1-4**] in L lower ext, decreased sensation on L, preserved on R
Pertinent Results:
[**2183-3-24**] 09:50AM BLOOD WBC-7.9 RBC-4.68 Hgb-13.6* Hct-40.5
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.2 Plt Ct-366
[**2183-3-27**] 05:50AM BLOOD WBC-16.0* RBC-4.39* Hgb-12.8* Hct-37.6*
MCV-86 MCH-29.2 MCHC-34.2 RDW-13.1 Plt Ct-426
[**2183-3-28**] 05:40AM BLOOD WBC-9.0 RBC-4.61 Hgb-13.4* Hct-39.6*
MCV-86 MCH-29.1 MCHC-33.9 RDW-13.4 Plt Ct-535*
[**2183-3-24**] 09:50AM BLOOD Glucose-159* UreaN-39* Creat-2.6*# Na-138
K-4.8 Cl-101 HCO3-23 AnGap-19
[**2183-3-28**] 05:40AM BLOOD Glucose-104 UreaN-9 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-23 AnGap-15
[**2183-3-24**] 03:42PM BLOOD Type-ART pO2-181* pCO2-47* pH-7.28*
calTCO2-23 Base XS--4
[**2183-3-24**] 08:35PM BLOOD Type-ART pO2-52* pCO2-44 pH-7.32*
calTCO2-24 Base XS--3 Intubat-NOT INTUBA
CXR ([**3-27**]): FINDINGS: AP and lateral chest views were obtained
with patient in sitting upright position. The heart size is
normal, and no pulmonary vascular congestion is present. Again
demonstrated is a parenchymal density in the left lower lobe
posterior segment, similar in appearance as described on the
next preceding AP single chest view of [**3-26**]. Additional new
findings consist of some small fluffy poorly identified
parenchymal abnormalities suspected in the lateral portion of
the right upper lobe as well as in the mid left lung field. As
the technical differences of the two studies to be appreciated,
the latter findings are somewhat insecure. Considering, however,
the patient's sepsis status, a followup chest examination with
short interval is recommended.
IMPRESSION: Persistent left lower lobe pneumonic infiltrate,
suspicion for new small disseminated pulmonary parenchymal
densities. Follow up recommended.
Chest CT ([**3-27**]): IMPRESSION:
1. Ground-glass opacities as well as centrilobular nodules in
the lower lobes, these findings are all consistent with
multifocal atypical infection.
2. Small bilateral pleural effusions.
3. Mediastinal lymphadenopathy as described above may be
reactive.
Followup imaging after treatment is recommended to ensure
resolution of these findings.
Brief Hospital Course:
Sepsis. : On admission, patients symptoms consistent with
sepsis, with hypotension, fever, and tachycardia. His pressures
were supported with levophed, and patient was admitted to the
MICU. The etiology of the patient's infection was attributed to
likely pneumonia, given hypoxia, cough, and concerning chest XR.
He was initially started on vanc/levo, but due to drug induced
hives reaction, patient was switched to vanc/CTX/azithromycin.
Sputum culture grew out MSSA, and patient was switched to
nafcillin then diclocicilian on discharge. Patients chest XR
showed developing disseminated pulmonary parencymal densities.
A chest CT was obtained, which showed ground glass opacitieis in
RUL and LML c/w multifocal atypical infection. Given the
patients complaints of shortness of breath and URI type symptoms
in the 2-3 weeks prior to presentation, i is felt that the
patient had an atypical pneumonia then developed a secondary
superinfection with a staph pneumonia. The patient was
afebrile, had a resolving WBC count, and normal vital signs
prior to discharge. He was sent home on a twenty-one day course
of diclox as well as azythromycin to complete a 7 day course for
atypical pneumona. The patient will follow up with his PCP [**Last Name (NamePattern4) **]
[**1-1**] weeks. Follow up chest XR should be optained to evaluate
for resultuion of disseminated pumonary parencymal densities'
resolution.
.
ARF: The patient with a baseline Cr of 1, which was elevated to
2.6 on admission. The patient's renal function resolved after
IVF resuscitation.
.
Asplenia: Underwent splenectomy in [**2144**] due to injury in
[**Country **]. Has not had severe infection in the past. Our records
indicate recent pneumo vax, flu shot, but no evidence of H. flu
or meningoccal vaccine. On follow up with is his PCP, [**Name10 (NameIs) **]
patient should receivie these vaccinations for encapsulated
organisms. Additionally, we would recommend consideration of
providing patient with prophylatic antibiotic to take of
immediate health care in not accessible.
.
s/p CVA: Occurred due to traumatic [**Country **] dissection s/p tPA. Had
subsequent anuerysm thought healing related change. Has L
hemiparesis as result. Not on anticoagulation anymore, hypercoag
work up neg
- Monitor clinically
.
Depresion/Anxiety: Continued outpatient Buproprion,
Nortriptyline.
.
Pain syndrome: Diagnosed with a phantom pain syndrome in the
setting of his orchiectomy. Has been seen by pain. Continued
patients neuronti, oxycodone, nortiptyline, and MS contin.
.
HTN: Patient admitted with hypotension, and anti-hypertensives
were held. Upon resolution, his outpatient BP meds were
restarted to good effect.
Medications on Admission:
Amlodipine 2.5 mg Daily
Bupropion 200 mg qAM, 100mg qPM
Disulfiram 250 mg Daily
Gabapentin 600 mg qAM, 600mg qPM, 1200mg qHS
Ibuprofen 800 mg TID:PRN
Lisinopril 40 mg Daily
Methylphenidate 20 mg [**Hospital1 **]
Morphine [MS Contin] 30 mg [**Hospital1 **]
Nortriptyline 25-50 mg qHS:PRN
Oxycodone 5-10 mg q4-6 PRN
Aspirin 325 mg Daily
Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: [**1-1**] Capsules PO HS (at
bedtime) as needed.
2. Disulfiram 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
4. Methylphenidate 20 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
5. Bupropion 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
6. Bupropion 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
10. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 17 days.
[**Month/Day (2) **]:*68 Capsule(s)* Refills:*0*
14. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: start morning of [**3-29**].
[**Date Range **]:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dx:
Sepsis
Staphalococcous Pneumonia
Atypical Pneumonia
Secondary Dx:
Acute Renal Failure
Hyptertension
Asplenia
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission
for sepsis. The etilogy of your infection is believed to be due
to a bacterial pneumonia. You were started on antibiotics, and
should ocmplete the course as an outpatient.
If you develop fevers, worsening shortness of breath,
cough, or any other concerning symptoms, you should call your
PCP. [**Name10 (NameIs) **] should follow up with you PCP at the below listed time
for follow.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule a follow up
appointment in the next 1-2 weeks.
|
[
"309.81",
"482.41",
"584.9",
"995.92",
"300.4",
"401.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9132, 9138
|
4772, 7464
|
288, 295
|
9304, 9313
|
2690, 4749
|
9816, 9951
|
2101, 2110
|
7849, 9109
|
9159, 9283
|
7490, 7826
|
9342, 9793
|
2125, 2671
|
231, 250
|
323, 1254
|
1276, 1892
|
1908, 2085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,728
| 100,061
|
27081
|
Discharge summary
|
report
|
Admission Date: [**2178-12-25**] Discharge Date: [**2178-12-27**]
Date of Birth: [**2116-2-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transfer from [**Hospital3 **] where she was admitted for
atypical chest pain and SOB
Major Surgical or Invasive Procedure:
-Central venous line insertion into R IJ
-Multiple attempts at securing arterial access
History of Present Illness:
62F with hx of severe of pulm HTN, CAD s/p DES to Lcx/LAD in
[**10/2177**], prior CVA s/p b/l CEA's, PVD, and COPD who was admitted
to OSH [**12-23**] for atypical chest pain and SOB. She ruled out for
ACS with by enzymes (MB 8 -> 7 -> 5; Trop 0.06 -> 0.07 -> 0.06)
and EKG without acute ischemic changes but was found to have a
BNP of 11K on admission. She was assessed as having severe
decompensated R-sided CHF and was diuresed with 40mg IV lasix in
the ED but later that day experienced [**9-9**] back pain with desat
to the 50's and was transferred to the CCU for close monitoring
with HR in the 60's and BP's in the 90's. She had ECHO on [**12-24**]
which showed severe pulmonary hypertension, RV pressure
overload, modestly depressed RV function, and LVEF of 55-65%.
.
Here in the CCU she describes feeling gradually more short of
breath over the past 2 months which has become acutely worse in
the past 1-2 weeks. Interestingly, about 1 month ago she was
started on sildenafil for treatment of her pulm htn but felt she
became more short of breath when taking that medication and
stopped taking it about 2 weeks ago when she started feeling
acutely more short of breath. She states that she has only
gained about 2-3lbs in the past two weeks but noticed increased
ankle swelling, increasing need for oxygen (she is usually at
88-92 on 3LNC at home but prior to these past 2 weeks she has
only used oxygen at night). She has 2 pillow orthopnea, but
denies PND. She denies dietary indiscretion, recent illnesses,
fevers, chills, cough, sputum production, or other symptoms.
According to her family she has never had low back pain as a
problem before but the patient states her back pain gets better
with positional changes and rubbing. Also, her baseline daily
function has decreased as she is normally able to move around
the rooms of house but has not been able to walk more than 10
feet due to shortness of breath in addition to her basleine
vascular claudication.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: CAD s/p LAD cypher stenting
- CABG: n/a
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
-Occult SBE with aortic valve vegetation
-Severe pHTN
-Severe PVD s/p multiple vascular surgeries
-Rt Fem-[**Doctor Last Name **] bypass
-Rt CEA following CVA prior to [**2173**]
-Lt CEA following TIA [**2173**]
-Stenting of LCx DPromus [**Name Prefix (Prefixes) **]
-[**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent
Social History:
Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies
Family History:
Father had MI in his 50's and stroke in his 60's. Siblings with
DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=96.7 BP=103/66 HR=72 RR=10 O2 sat= 93% non-rebreather
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to the earlobes
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, loud S2. No m/r/g. S3 at apex. No thrills,
lifts.
LUNGS: Rales halfway up bases
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting to mid shin, several old scars from
prior vascular surgery procedures. No femoral bruits.
SKIN: Mild stasis dermatitis changes.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable, PT
dopplerable
.
DISCHARGE PHYSICAL EXAM:
Patient expired.
Pertinent Results:
ADMISSION LABS:
.
[**2178-12-25**] 06:24PM BLOOD WBC-12.5* RBC-4.46 Hgb-11.4* Hct-35.8*
MCV-80* MCH-25.5* MCHC-31.7 RDW-17.5* Plt Ct-348
[**2178-12-25**] 06:24PM BLOOD Neuts-77* Bands-0 Lymphs-18 Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2178-12-25**] 06:24PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Burr-2+
[**2178-12-25**] 06:24PM BLOOD PT-17.0* PTT-34.3 INR(PT)-1.5*
[**2178-12-25**] 06:24PM BLOOD Glucose-40* UreaN-45* Creat-1.8* Na-131*
K-3.6 Cl-93* HCO3-22 AnGap-20
[**2178-12-25**] 06:24PM BLOOD CK(CPK)-180
[**2178-12-26**] 05:17AM BLOOD ALT-81* AST-65* LD(LDH)-365* CK(CPK)-149
AlkPhos-88 TotBili-1.2
[**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37*
[**2178-12-25**] 06:24PM BLOOD Calcium-8.7 Phos-5.6* Mg-1.4*
.
PERTINENT LABS:
.
[**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37*
[**2178-12-26**] 05:17AM BLOOD CK-MB-11* MB Indx-7.4* cTropnT-0.31*
[**2178-12-26**] 08:54PM BLOOD CK-MB-9 cTropnT-0.35*
[**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00*
[**2178-12-27**] 04:23AM BLOOD Cortsol-32.8*
[**2178-12-27**] 04:23AM BLOOD TSH-2.1
[**2178-12-26**] 05:41AM BLOOD Lactate-1.7
[**2178-12-26**] 03:52PM BLOOD Lactate-2.5*
[**2178-12-26**] 11:26PM BLOOD Lactate-7.5*
[**2178-12-27**] 01:50AM BLOOD Lactate-8.7*
[**2178-12-27**] 04:24AM BLOOD Lactate-11.1*
[**2178-12-27**] 05:05AM BLOOD Lactate-10.3*
[**2178-12-27**] 11:38AM BLOOD Lactate-5.1*
[**2178-12-26**] 03:52PM BLOOD Type-ART pO2-52* pCO2-35 pH-7.42
calTCO2-23 Base XS
[**2178-12-27**] 01:50AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-69* pH-7.02*
calTCO2-19* Base XS--15
[**2178-12-27**] 04:24AM BLOOD Type-CENTRAL VE pO2-53* pCO2-60* pH-7.10*
calTCO2-20* Base XS--11
[**2178-12-27**] 05:05AM BLOOD Type-CENTRAL VE pO2-52* pCO2-58* pH-7.16*
calTCO2-22 Base XS--8
[**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20*
calTCO2-30 Base XS--1
.
DISCHARGE LABS:
.
[**2178-12-27**] 11:16AM BLOOD WBC-26.6*# RBC-4.37 Hgb-11.3* Hct-36.8
MCV-84 MCH-25.8* MCHC-30.6* RDW-16.9* Plt Ct-335
[**2178-12-27**] 04:23AM BLOOD Glucose-506* UreaN-41* Creat-1.8* Na-131*
K-4.2 Cl-89* HCO3-19* AnGap-27*
[**2178-12-27**] 04:23AM BLOOD ALT-226* AST-262* LD(LDH)-905*
CK(CPK)-288* AlkPhos-89 TotBili-1.7*
[**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00*
[**2178-12-27**] 04:23AM BLOOD Albumin-3.4* Calcium-8.1* Phos-7.3*#
Mg-2.5
[**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20*
calTCO2-30 Base XS--1
[**2178-12-27**] 11:38AM BLOOD Lactate-5.1*
.
MICRO/PATH:
.
Blood Cultures x 2: Pending
MRSA Screen: Pending
.
IMAGING/STUDIES:
.
CXR Portable [**12-25**]:
IMPRESSION: Mild interstitial pulmonary edema is present, along
with a very small right pleural effusion, decreased since [**9-5**]. Heart size is top normal, and the main pulmonary artery is
substantially dilated, as before indicating persistent pulmonary
arterial hypertension. Previous mediastinal adenopathy
documented on the chest CT in [**Month (only) 216**] is difficult to assess but
probably has not worsened. No pneumothorax.
.
Aorta/Branches U/S [**12-25**]:
IMPRESSION: No evidence of abdominal aortic aneurysm.
Atherosclerosis.
.
CXR Portable [**12-25**]:
Tip of the new right internal jugular line ends in the region of
the superior cavoatrial junction. No pneumothorax or increase in
small right pleural effusion. Interval increase in mediastinal
caliber due to vascular
engorgement, and due to elevated central venous pressure,
probably a function of biventricular heart failure, reflected
mild increase in the heart size, moderate increase in pulmonary
edema. Severe pulmonary atrial enlargement, an indication of
marked pulmonary arterial hypertension, aortic valvular
calcification, which could be hemodynamically significant
(particularly in setting of decreased LV filling), and severe,
global coronary calcification were shown on a Chest CT in [**Month (only) 216**]
[**2178**], discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30814**] at the time of dictation.
.
R LENI [**12-26**]:
IMPRESSION: Limited assessment of the right lower extremity due
to early
termination of the examination. No DVT seen in the examined
veins.
.
CXR Portable [**12-27**]:
FINDINGS: In comparison with the study of [**12-25**], there has been
placement of an endotracheal tube with its tip at the upper
clavicular level, approximately 6.5 cm above the carina.
Nasogastric tube extends into the upper stomach, though the side
hole is within the lower portion of the esophagus. Continued
enlargement of the cardiac silhouette with substantial pulmonary
arterial enlargement consistent with pulmonary artery
hypertension. There is moderate pulmonary edema as well.
.
TTE [**12-27**]:The left atrium is mildly dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis. The basal inferolateral wall
contracts best (LVEF = 25%). The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis.
[Intrinisic right ventricular systolic function is more
depressed given the severity of tricuspid regurgitation.] There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
are mildly thickened (?#). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with extensive systolic dysfunction c/w diffuse
process (multivessel CAD, toxin, metabolic, etc.). Marked right
ventricular cavity dilation with free wall hypokinesis and
abnormal septal motion c/w marked pulmonary artery hypertension
(not quantified). Moderate to severe tricuspid regurgitation.
Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2178-10-16**],
biventricular systolic function has deteriorated and the heart
rate is much higher. Biventricular cavity size is similar.
Brief Hospital Course:
62F with hx of severe of pulm HTN, CAD s/p DES to Lcx/LAD in
[**10/2177**], prior CVA s/p b/l CEA's, PVD, and [**Hospital 2182**] transferred from
OSH for evaluation and management of right-sided diastolic CHF
exacerbation with background of severe pulmonary hypertension
who rapidly decompensated and passed away despite maximal
medical therapy.
.
ACTIVE DIAGNOSES:
.
# Right-sided Diastolic CHF Exacerbation: Pt with clinical
evidence of rales halfway up lung fields, JVD, and peripheral
edema on admission with CXR evidence of pulmonary edema and BNP
11,000 at OSH, and ECHO demonstrating fluid overloaded RV with
S3 gallop on exam. She was ruled out for ACS at OSH with
negative enzymes and non-ischemic EKG's and was transferred on
dopamine drip for pressure support with max O2 on venturi mask
in moderate respiratory distress satting in the low 90's. On
arrival to the CCU, R IJ was placed without complications and
she was started on sildenafil 20mg QID with the hope that
pressor support and vasodilatation of the pulmonary vasculature
would increase cardiac output and allow for gentle diuresis.
Unfortunately she was found to be anuric despite these measures
with a Cr of 1.8 on transfer up from 0.8-0.9 the days prior at
OSH. In the late morning the day following transfer, dobutamine
was added in an attempt to improve ionotropy but after this
medication was started her BP began to drop and over the next
few hours norepinephrine had to be added to maintain MAPs >65.
These medications were up and down titrated to try to achieve a
stable blood pressure but this kept ranging from 70/40-140/50.
No stability could be reached. At the same time her HR was
between 100-130's. The CCU team (including the CCU attending)
attempted to place an arterial line for better BP monitoring
given very severe peripheral vascular disease but this was
unsuccesful via the radial aproach. Anesthesia was contact[**Name (NI) **] to
attempt an axial arterial line but this was not deemed feasible.
The anesthesia attending attempted to obtain a L femoral
arterial line without success. The right side was not attempted
given her previous Fem-[**Doctor Last Name **] bypass. Through all of this her
oxygenation was worsening and she had to be switched to 100%
non-rebreather. At around 1600 dobutamine was stopped as this
was felt to be contributing to her persistently low BP's. She
remained stable until around 2100 when her BP again began to
decrease. A 250 mL NS bolus was given without response and
phenylephrine was started at this point. Also at around this
time her oxygen saturation began to drop and BiPAP was started.
At this point the patient was on dopamine, norepinephrine and
phenylephrine for BP support and BiPAP for respiratory support
with BP in the 79/55-101/57 and O2 sat of 90%. At 2300 (after ~3
hrs on BiPAP) given her tenious state with persistently low BP,
persistnently low O2 sat and tachypnea a discussion was held
with the patient and the family regarding endotracheal
intubation. Given her worseining cardiopulmonary status the CCU
team recommended intubation to try to achieve better
oxygenation, prevent respiratory colapse and to allow us to
manage her worsening heart failure while maintaing a patent
airway with adequate oxygenation. Anesthesia was called at 0000
for non-emergent intubation. This was performed succesfully and
the patient tolerated it well. At ~0030, milrinone was added in
an attempt to improve ionotropy. At this point the anesthesia
attending was asked for assistance in placing an arterial line
given the need for better blood pressure and oxygenation
parameters. Right radial was attempted as well as left femoral
without success. At around 0100-0130 her BP began to drop,
milrinone was stopped and vasopressin added. Despite these 4
pressors her BP continued to drop. At this point she was given
4 amps of bicarb, 1 mg epinephrine and 1 amp of calcium
carbonate. Her family was updated of her condition. Despite
all of these additions her BP continued to drop and at this
point a bicarb drip and an epinephrine drip were started. After
this she stabilized at around 0200 and remained with HR
120-130's and SBP 80-100's for the next several hours. At
around 0500 the ventilator began alarming due to high
peak/plateau pressures. This was thought to be due to pulmonary
edema as repeated succitioning brought up frothy fluid. She was
continued on max doses of 5 pressors throughout the day with
maximal respiratory settings for the sake of oxygenation. Her
condition continued to deteriorate despite maximal medical
support. Her family was made aware of her grave circumstances
and started to carefully consider her code status. She coded in
the later morning 2 days following transfer for pulseless
electrical activity and was coded briefly until resuscitative
efforts were halted per family request. The cause of her rapid
decline was unclear but hypothesis of the team included possibly
a PE (with suboptimal LENI which was negative). She has an
abdominal ultrasound to look for possible ruptured AAA given
report of acute onset low back pain at OSH but this was
negative.
.
# Anuric Acute Kidney Injury: Cr 1.8 on admission with
oliguria/near anuria, 0.6-0.7 at baseline. Was 0.9 yesterday at
OSH and making urine. Thought to be due to her brief hypotensive
episode after receiving bolus of 40mg IV lasix at OSH.
# Severe Chronic Pulmonary Hypertension/Cor Pulmonale: Unclear
etiology. Perhaps related to her mild-moderate COPD on CT
(although re-assuring spirometry in records) or possibly
recurrent embolic phenomena. She was treated aggressively as
above but unfortunately had a poor outcome.
.
CHRONIC DIAGNOSES:
.
# COPD/Hypoxia: PT with mild-moderate COPD changes on most
recent CT chest but with essentially normal PFT's. She requires
3LNC at home often worn during sleep but more recently during
the day and even when at rest. Has a 20-40 pack-year smoking
history. Not on any home COPD medications. She ended up
ventilated for respiratory support as above.
.
# CAD: Pt with severe 3VD with prior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LCx and LAD in
8/[**2177**]. Non-ischemic EKG here on admission and at OSH. Enzymes
unimpressive x 3. No chest pain or discomfort. She was continued
on aspirin, plavix, and a statin.
.
# HLD: Stable. Continued on her statin.
.
# Severe PVD: Stable. Continued on her statin.
.
# NIDDM Complicated by Neuropathy: Stable. Managed on HISS while
in-house as well as lyrica and gabapentin prior to her
hemodynamic compromise.
.
TRANSITIONAL ISSUES:
-To the deep regret of the CCU team, Mrs. [**Known lastname **] did very poorly
over her hospital course. Her team took solace in the fact that
she was surrounded by her large, loving family and hopefully
felt little pain or suffering in her final hours.
Medications on Admission:
- Plavix 75mg PO daily
- Gabapentin 200mg PO QHS
- Aspirin 81mg PO daily
- Metoprolol succinate 100mg PO daily
- Ativan 1mg PO TID PRN
- Metformin 100mg PO BID
- Glyburide 2.5mg PO daily
- Lisinopril 2.5mg PO daily
- Torsemide 40mg PO daily
- Lyrica 100mg PO BID
- Tylenol PM 1 tab QHS
- Simvastatin 40mg PO daily
- Prilosec 20mg PO daily
- Niacin 500mg PO BID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
-Severe Pulmonary Hypertension/Cor Pulmonale
-Biventricular diastolic congestive heart failure
-Severe peripheral vascular disease
-Chronic obstructive pulmonary disease
Discharge Condition:
Deceased
Discharge Instructions:
Patient was transferred from OSH for acute decompensated
biventricular heart failure complicated by severe pulmonary
hypertension. She was managed aggressively with pressors (5 at
max doses) with the goal to optimize her cardiac function with
the hope of inducing diuresis. Unfortunately her hemodynamics
declined rapidly. Code was called for PEA with initiation of
chest compressions and epi x 1 at which time code was called off
per family preference.
Followup Instructions:
N/A
Completed by:[**2178-12-28**]
|
[
"584.9",
"V45.82",
"443.9",
"496",
"428.33",
"357.2",
"V12.54",
"416.0",
"428.0",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
18295, 18304
|
11015, 11364
|
392, 482
|
18518, 18529
|
4677, 4677
|
19031, 19067
|
3668, 3739
|
18267, 18272
|
18325, 18497
|
17882, 18244
|
18553, 19008
|
6684, 10992
|
3779, 4615
|
3040, 3137
|
17600, 17856
|
267, 354
|
510, 2930
|
4693, 5509
|
5525, 6668
|
3168, 3499
|
11382, 17579
|
2952, 3020
|
3515, 3652
|
4640, 4658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,978
| 140,394
|
31734
|
Discharge summary
|
report
|
Admission Date: [**2184-9-30**] Discharge Date: [**2184-10-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
transfer from OSH for cath
Major Surgical or Invasive Procedure:
cardiac catheterization
Intra-aortic balloon pump
hemodialysis
Pulmonary Artery catheter placement
History of Present Illness:
This is an 87-year-old male with a history of hypertension,
diabetes, CRI and moderate aortic stenosis who was seen in his
cardiologists office on [**9-23**] with complaints of shortness of
breath and chest discomfort. He actually reports that the
shortness of breath and chest pain had started approx 1 week
prior to this but since he had a pcp appt soon, he decided not
to go to the Dr. [**Last Name (STitle) **] pain is described as substernal pressure
that would occur at rest and wake him from sleep. It radiated to
his left arm and is very similar to previous MI. It would
improve on its own and was intermittent over the last week.
.
OSH course:
He was transferred to the [**Hospital1 1474**] ED where he was found to have
a heart rate in the 30-40's. On EKG he was found to be have a
high grade AV block. He was admitted to the unit and his heart
rate dropped to the 20's thought secondary to beta-blocker
toxicity. Beta blockers had been discontinued, but bradycardia
persisted with dyspnea. The patient ruled in for a NSTEMI and he
was referred for cardiac catheterization but refused as he also
has a history of CRI. His heart rate increased to the 60's and
he was transferred to the telemetry unit in a 2:1 block on
[**2184-9-27**]. He underwent implantation of a pacemaker on
[**2184-9-29**] and immediately post procedure developed shortness of
breath, chest discomfort and decreased his blood pressure. He
was bolused with fluid and started on a Neo drip which his is
currently on at 20 mcg. He had a triple lumen catheter in the
RIJ and was transferred to the CCU. He has been pain free but
very short of breath on a venti mask at 40% which they have been
unable to wean. He has received repeated doses of IV lasix with
little effect.
.
Patient has agreed to cardiac catheterization at this time.
Patient was given Lasix 40 mg at 7:30, 40 mg at 10:50, 120 mg
given at 1200, mucomust 300 mg po prior to transfer. Troponin
from 9 am today 30.4
.
Patient was transported directly to the cath lab. Where the RCA
and prox LAD was intervened upon with BMS. He was given
additional lasix, IABP was placed and the patient had
improvement in urine output. Dopamine was started with
tachycardia and thus was transitioned to dobutamine for low
cardiac output.
.
Currently he denies chest pain, has mild dyspnea, otherwise is
asymptomatic.
Past Medical History:
glaucoma
Chronic renal insufficiency
diabetes type II
angina
moderate Aortic stenosis
Hypertension
Appendectomy at age 10
hyperlipidemia
Social History:
History of ~60 pack years stopped approx 10 years ago. History
of alcohol use, none in 10 years.
Family History:
There is family history of premature coronary artery disease
(father at age 42 had MI and angina)
Physical Exam:
Vitals:
T: 97.9
HR: 91
RR: 27
O2: 97%
GEN: Elderly man with labored breathing, hard of hearing but
able to engage questioner in conversation; tends to use short
sentences and has more labored breathing after talking.
HEENT: Anicteric. No lesions of the oropharynx; tongue slightly
dry; moist mucus membranes.
COR: Regular rate and rhythm, III/VI systolic murmur
PULM: Unable to sit up; on anterior exam, good air movement
bilaterally, no clear rales/crackles
ABD: BS+, NT. Distended but tympanic only at small area of
highest elevation of belly. Mildly taut.
EXT: 2+ pitting edema bilaterally. White, pale, slightly clammy
legs without mottling or petichiae; no palpable pulses, likely
concealed by edema.
Pertinent Results:
[**2184-9-30**] ADMISSION LABS:
CBC:
WBC-14.9* RBC-3.11* Hgb-9.6* Hct-27.9* MCV-90 MCH-30.8 MCHC-34.2
RDW-14.9 Plt Ct-143* Neuts-86.0* Lymphs-7.1* Monos-6.7 Eos-0.1
Baso-0.1
.
COAGS:
PT-33.7* PTT-150* INR(PT)-3.6*
.
CHEMISTRY:
Glucose-194* UreaN-79* Creat-3.1* Na-141 K-4.4 Cl-110* HCO3-17*
AnGap-18
Calcium-8.1* Phos-5.9* Mg-2.6
.
CARDIAC ENZYMES:
[**2184-9-30**] 10:00PM CK(CPK)-2202* CK-MB-GREATER THAN 500
cTropnT-6.87*
[**2184-10-1**] 03:57AM CK(CPK)-2219* CK-MB-482* MB Indx-21.7*
[**2184-10-1**] 02:10PM CK(CPK)-1534* CK-MB-261* MB Indx-17.0*
cTropnT-9.74*
.
LFTs:
ALT-36 AST-321* LD(LDH)-861* Albumin-2.8* Mg-2.5
.
DIABETES MONITORING:
%HbA1c-6.4*
.
TFTs:
TSH-4.8*
Free T4-1.2
.
ADRENAL FUNCTION:
[**2184-10-10**] 05:09AM BLOOD Cortsol-19.8
[**2184-10-10**] 11:13AM BLOOD Cortsol-53.3*
.
COMPLEMENT LEVELS:
C3-98 C4-26
Brief Hospital Course:
87 yo M with history of CAD, HTN, bradycardia s/p pacemaker and
NSTEMI now s/p PCI with 2 BMS (LAD, RCA) and IABP placement.
.
#) Cardiogenic shock: On admission with low cardiac output and
index, thus started on dobutamine and IABP. Swan placed on [**10-2**]
due to unclear etiology of shock. Picture initially thought to
be consistent with cardiogenic shock with elevated filling
pressures. Started on hydral for afterload reduction. However
persistently hypotensive, and thus swan placed again on [**10-12**].
Hemodynamics at this time consistent with mixed picture with
increased filling pressures, but elevated cardiac output and
decreased SVR. Due to persistent WBC and question of infiltrate
started on vanc, zosyn for nosocomial pneumonia and treated for
a 7 day course. On [**10-16**], pt wished to go home with home
hospice.
.
#) CAD/NSTEMI: Patient with severe 3VD and s/p 2 vessel
stenting. Patient initially reticent to have intervention and
thus had prolonged ischemia/infarction. Per cath report may
need further intervention in future of left circumflex.
Continued on aspirin, plavix, statin. BB and ACE-i held due to
continued hypotension.
.
#) Hypoxia/Tachypnea: patient with persistent 02 requirement
likely secondary to volume overload. Hemodynamics c/w
cardiogenic shock with elevated filling pressures. Due to
oliguric acute renal failure, started on CVVHD.
.
#) Acute on chronic renal failure: Oliguric renal failure
secondary to poor perfusion. Renal consulted. CVVHD initiated.
.
------
After much discussion, patient opted to be made CMO. He was
discharged to home with comort measures and hospice care.
Recommendations were as per the palliative care team who saw the
patient prior to discharge and discussed his care. Prior to
discharge all invasive lines were removed except tunnelled
dialysis catheter which was deemed to invasive to remove with
causing the patient further discomfort.
Medications on Admission:
Medications on transfer from OSH:
Protonix 40 mg dialy
Heparin gtt
Cefazolin 1 gram IV q8 today last dose
Neosynephrine gtt at 20 mcg/min
Alphgan gtt right eye daily
Regular insulin sliding scale
Aspirin 325 mg dialy
Plavix 75 mg daily
Lipitor 80 mg daily
Zetia 10 mg daily
Percocet 1-2 tabs q6 prn
lnaprost gtt both eyes qhs
Ntg prn
Lasix 120 mg given at 1200, mucomust 600 mg po
Na Bicarb gtt
.
Home medications: Vytorin 10/40 mg daily
Lisinopril 10 mg dialy
Atenolol 100 mg daily
Lasix 40 mg daily
Doxasozin 8 ? mg po dialy
ntg prn
alphgan gtt
xalatan gtt
asa 81 mg daily
glipizide 5 mg daily
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
Disp:*1 container* Refills:*2*
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*1 container* Refills:*2*
3. Ativan 0.5 mg Tablet Sig: 1-4 Tablets PO q2hrs as needed for
anxiety.
Disp:*60 Tablet(s)* Refills:*0*
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
Disp:*100 ml* Refills:*0*
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
q 3 days as needed for resp secretions: use only if levsin is
not effective in controlling secretions.
Disp:*10 patches* Refills:*0*
6. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg PO q1hr
as needed for dyspnea.
Disp:*200 ml* Refills:*0*
9. Haloperidol Lactate 2 mg/mL Concentrate Sig: 0.5-2mg PO q2hr
as needed for agitation.
Disp:*200 ml* Refills:*0*
10. Levsin/SL 0.125 mg Tablet, Sublingual Sig: [**12-30**] Sublingual
every four (4) hours as needed for secretions.
Disp:*180 tabs* Refills:*0*
11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for fever or pain.
Disp:*180 Tablet(s)* Refills:*0*
12. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-30**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*120 doses* Refills:*0*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: [**12-30**]
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*120 doses* Refills:*0*
14. Nebulizer Device Sig: One (1) device Miscellaneous once
a day.
Disp:*1 1* Refills:*2*
15. Oxygen
Please dispense 2-4 liters continuous flow.
16. [**Hospital 74529**] hospital bed
1 bed
17. Overlay Mattress
1 egg crate mattress
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary
NSTEMI
Acute on chronic renal failure
Congestive Heart Failure
Atrial fibrillation
Secondary
Hypertension
Aortic Stenosis
Hyperlipidemia
Discharge Condition:
O2 requirement, renal failure
Discharge Instructions:
You were transferred from an outside hospital with chest pain
and difficulty breathing. You underwent a cardiac
catheterization and were found to have a narrowing of two of
your coronary arteries. You had stents placed to these
arteries. Throughout your hospitalization you had decreased
blood pressure requiring multiple medications. You also had an
intra-aortic balloon placed to maintain your blood pressure.
You also had a catheter placed in your pulmonary artery to
further evaluate your blood pressure. You also had worsening
renal failure which required dialysis during this
hospitalization. You continued to have worsening renal
function.
.
You are being dicharged home with hospice.
Followup Instructions:
You are going home with hospice.
|
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icd9cm
|
[
[
[]
]
] |
[
"89.64",
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icd9pcs
|
[
[
[]
]
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9301, 9356
|
4745, 6680
|
290, 390
|
9545, 9577
|
3893, 3909
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10323, 10359
|
3053, 3152
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7327, 9278
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4243, 4722
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224, 252
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418, 2763
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3925, 4226
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2785, 2923
|
2939, 3037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,633
| 102,523
|
36706
|
Discharge summary
|
report
|
Admission Date: [**2107-2-3**] Discharge Date: [**2107-2-15**]
Date of Birth: [**2045-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
"Some ADHD medicine"
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2107-2-3**] Cardiac cath
[**2107-2-7**] Urgent off-pump coronary artery bypass graft x3 -- left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal and diagonal arteries
History of Present Illness:
61 year old male with a history of asthma and mild sleep apnea
describes many years of chest discomfort that have progressed in
frequency and duration. Currently he has daily episodes of
exertional chest discomfort. He reports that the discomfort
begins in the neck and spreads down to the chest. It typically
will resolve with rest but there was one time that he required
SL nitroglycerin to get relief of his discomfort. He has
undergone stress testing through the years. A myoview study was
negative in [**2101**]. Non imaging ETT in [**2106-5-26**] was positive for
chest pain but negative for ischemic EKG changes. He was
referred for cardiac catheterization to further evaluate. He was
found to have coronary artery disease and is now being referred
to cardiac surgery for revascularization.
Past Medical History:
Asthma
ADHD
Mild sleep apnea (CPAP)
GERD
Hx of vasovagal syncope (after coughing or vomiting)
Paratracheal cyst noted on CT s/p mediastinal thorascopy:
benign,
? recurrence
Anemia
Vitamin D deficiency
Psoriasis
Hard of hearing
Hypothyroidism (not on any meds)
ADHD
Mini strokes (per pt not TIAs)
Tonsillectomy
Appendectomy
Jaw abscess s/p I&D
Varicocelectomy
s/p mediastinal thorascopy: benign, ? recurrence
Social History:
Race:Caucasian
Last Dental Exam: <1 year ago
Lives with:Wife
Contact: [**Name (NI) 83013**] [**Name (NI) 83014**] (wife) Phone# [**Telephone/Fax (1) 83015**]
Occupation:Self employed artist
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-1**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Both parents died at young ages from cancer. No family history
of premature CAD.
Physical Exam:
Admission:
Pulse:64 Resp:16 O2 sat:100/RA
B/P Right:126/76 Left:125/76
Height:5'[**05**]" Weight:220 lbs
General:
Skin: Dry [x] intact [x] Psoriasis bilateral knees, elbows, feet
HEENT: PERRLA [x] EOMI [x] Glasses
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Obese, umbilical hernia, well healed appy incision
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: Left calf
Neuro: Grossly intact [x]
Pulses:
Femoral Right:cath site Left: 2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Discharge:
VS 98.3 90 110/68 18 98%-2LNP
Gen- NAD
Neuro- A&O x3, nonfocal
CV- RRR, no Murmur. Sternum stable- incision CDI
Pulm- CTA-bilat
Abdm- soft, NT/ND/+BS
Ext- warm, well perfused 1+ bilat edema
Pertinent Results:
[**2107-2-3**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system demonstrated left main and three vessel
disease. The LMCA had an eccentric 80% lesion distally near the
bifurcation. The LAD had a 90% stenosis both before and after
D1. The proximal aspect of D1 itself also had a 90% lesion. The
LCx had an ostial 90% lesion. The RCA was notable for an 80%
stenosis in the mid-PDA. 2. Limited resting hemodynamics
revealed normal systemic systolic arterial pressures, with a
central aortic pressure of 137/77, mean 93 mmHg.
.
[**2107-2-4**] Carotid U/S: Right ICA no stenosis. Left ICA <40%
stenosis.
.
[**2107-2-7**] Echo: 1. The left atrium is normal in size. 2. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). 3. Right ventricular
chamber size and free wall motion are normal. 4. There are
simple atheroma in the aortic root. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. 5. The aortic valve leaflets (3) appear
structurallynormal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. 6. The mitral valve appears
structurally normal with trivial mitral regurgitation. 7. There
is a small pericardial effusion.
Post myocardial revascularization: The patient is on no
inotropes. The patient is atrially paced. Biventricular function
is unchanged. Mitral regurgitation is unchanged. The aorta is
intact after partial cross-clamping.
.
[**2107-2-10**] Chest X-ray: The patient was extubated with removal of
supporting tubes and lines. Bibasilar atelectasis and small
amount of pleural effusion is seen. Small left apical
pneumothorax is present. No right pneumothorax is seen.
.
[**2107-2-12**] Hct-25.8*
[**2107-2-11**] WBC-7.3 RBC-2.84* Hgb-8.6* Hct-25.8* Plt Ct-158
[**2107-2-3**] WBC-5.1 RBC-4.17* Hgb-12.2* Hct-36.4 Plt Ct-142*
[**2107-2-12**] UreaN-35* Creat-1.4* Na-138 K-4.6 Cl-100
[**2107-2-11**] Glucose-108* UreaN-28* Creat-1.1 Na-137 K-4.3 Cl-101
HCO3-25
[**2107-2-3**] Glucose-98 UreaN-27* Creat-1.2 Na-139 K-4.3 Cl-105
HCO3-28
[**2107-2-12**] Mg-2.2
[**2107-2-3**] %HbA1c-5.8 eAG-120
[**2107-2-15**] 05:50AM BLOOD Hct-29.7*
[**2107-2-15**] 05:50AM BLOOD PT-17.2* INR(PT)-1.6*
[**2107-2-15**] 05:50AM BLOOD Glucose-105* UreaN-26* Creat-1.3* Na-137
K-4.5 Cl-98 HCO3-31 AnGap-13
Brief Hospital Course:
Mr [**Known lastname 83016**] was admitted to the cardiology service with angina on
exertion for planned cardiac catheterization. On [**2-3**] he was
brought to the cath lab, it revealed left main and 3 vessel
disease. The patient was then referred to cardiac surgery for
surgical revascularization. He had the usual pre-op screen
including vein mapping, carotid ultrasound, labs, CXR, and MSSA
screen.
He was brought to the operating room by Dr [**Last Name (STitle) 7772**] on [**2-7**]
for coronary artery bypass grafting. Please see the operative
report for details. In summary he had:
1. Urgent off-pump coronary artery bypass graft x3 -left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal and
diagonal arteries. 2. Endoscopic harvesting of the long
saphenous vein.
He tolerated the operation well and post operatively was
transferred tot he cardiac surgery ICU in stable condition. In
the immediate post-op period he was stable, woke neurologically
intact and extubated. On [**2-8**] he transferred to the stepdown
floor.
Respiratory: aggressive pulmonary toilet nebs and ambulation he
titrated off oxygen with saturations of 97%. Inhalers, singular
and home CPAP were continued.
Cardiac: low-dose beta-blockers were started. On postoperative
day 3 had intermittent atrial fibrillation 70-90's. Amiodarone
PO was started and he converted to sinus rhythm 60-70's. A 3
months course of Plavix was started immediately postoperative
for off-Pump CABG. His heart rate became bradycardic into the
30s. Electrophysiology was consulted. Amio was discontinued. He
remains on beta-blocker with a stable HR in the 80s. Paroxysmal
AF continued and he was started on anticoagulation with
Coumadin. He remained hemodynamically stable 110-130's. Low
dose aspirin and statin were continued.
GI: benign. Tolerated a regular diet
Renal: He was gently diuresed toward his preop weight of 100 kg.
Renal function CRE peaked to 1.4 base 0.9-1.2. His diuretic was
decreased. He continued to have good urine output. Electrolytes
were closely monitored and repleted as needed. Foley reinserted
for failure to void. Flomax was restarted and voiding trial with
good results.
Endocrine: well controlled with insulin sliding scale.
Disposition: he was seen by physical therapy who recommended
rehab. He was discharged on POD# 8 to [**Hospital 83017**] Nursing and Rehab
in [**Location (un) 1456**]. All follow up appointments were advised.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - PRN
SYMBICORT 160 mcg-4.5 mcg/actuation HFA Aerosol - 2 puffs [**Hospital1 **]
WELLBUTRIN XL 300 mg Daily
CYCLOBENZAPRINE 10 mg PRN
FLUTICASONE 50 mcg- 2 sprays each nostril daily
METOPROLOL TARTRATE 25 mg [**Hospital1 **]
SINGULAIR 10 mg Daily
NITROGLYCERIN 0.4 mg [**Hospital1 8426**], Sublingual - 1 [**Hospital1 8426**] sublingually
every five minutes for chest discomfort. Call 911 if pain
persists longer than 15 minutes
OMEPRAZOLE 20 mg Daily
ASPIRIN 325 mg Daily
CALCIUM CARBONATE Dosage uncertain
VITAMIN D3 1,000 unit Daily
CLARITIN Dosage uncertain
VITAMIN B COMPLEX Dosage uncertain
Discharge Medications:
1. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(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. pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 [**Hospital1 8426**](s)* Refills:*0*
5. bupropion HCl 150 mg [**Hospital1 8426**] Extended Release Sig: Two (2)
[**Hospital1 8426**] Extended Release PO QAM (once a day (in the morning)).
Disp:*60 [**Hospital1 8426**] Extended Release(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. atorvastatin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
8. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO BID (2
times a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
9. clopidogrel 75 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily)
for 6 months.
Disp:*30 [**Hospital1 8426**](s)* Refills:*0*
10. cholecalciferol (vitamin D3) 1,000 unit [**Hospital1 8426**] Sig: One (1)
[**Hospital1 8426**] PO DAILY (Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
11. montelukast 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
12. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
13. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO BID (2 times a day).
Disp:*120 [**Hospital1 8426**] Extended Release(s)* Refills:*2*
14. warfarin 1 mg [**Hospital1 8426**] Sig: Three (3) [**Hospital1 8426**] PO ONCE (Once)
for 1 doses.
Disp:*1 [**Hospital1 8426**](s)* Refills:*0*
15. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name6 (MD) **] [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day.
Disp:*qs [**Last Name (Titles) 8426**](s)* Refills:*2*
16. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*qs * Refills:*2*
17. acetaminophen 325 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO Q4H
(every 4 hours) as needed for fever/pain.
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Skilled Nursing Center - [**Location (un) 1456**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Asthma
ADHD
Mild sleep apnea (CPAP)
GERD
Hx of vasovagal syncope (after coughing or vomiting)
Paratracheal cyst noted on CT s/p mediastinal thorascopy:
benign,
? recurrence
Anemia
Vitamin D deficiency
Psoriasis
Hard of hearing
Hypothyroidism (not on any meds)
ADHD
Mini strokes (per pt not TIAs)
Tonsillectomy
Appendectomy
Jaw abscess s/p I&D
Varicocelectomy
s/p mediastinal thorascopy: benign, ? recurrence
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
WOUND CARE CLINIC: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2107-2-22**] 11:00
Surgeon:Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2107-3-15**] 1:15
Cardiologist: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] X. [**Telephone/Fax (1) 45578**]: [**2107-3-2**] at
9:00a (inform patient appt for [**2107-2-16**] is canceled)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 79695**] in [**3-31**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2107-2-15**]
|
[
"997.1",
"268.9",
"427.32",
"327.23",
"414.01",
"530.81",
"493.90",
"413.9",
"427.89",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"36.12",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11751, 11860
|
5698, 8185
|
296, 522
|
12394, 12623
|
3259, 5675
|
13425, 14329
|
2154, 2236
|
8878, 11728
|
11881, 11942
|
8211, 8855
|
12647, 13402
|
2251, 3240
|
246, 258
|
550, 1349
|
11964, 12373
|
1796, 2138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,822
| 105,274
|
8713
|
Discharge summary
|
report
|
Admission Date: [**2105-1-1**] Discharge Date: [**2105-1-23**]
Date of Birth: [**2051-6-5**] Sex: F
Service: SURGERY
Allergies:
Cellcept / Ampicillin / Penicillins
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
53 yo woman w/ h/o kidney transplant [**2076**], pancreas transplant
[**2-1**], w/ rejection [**6-3**].
DX: cmv pneumonitis
respiratory distress
Secondary DX: HTN, Left foot 4th metatarsal fx
Major Surgical or Invasive Procedure:
[**2105-1-9**] Bronchoalvelar lavage
[**2105-1-16**] NG tube placement
[**2105-1-21**] Picc line insertion
History of Present Illness:
52F s/p pancreas [**2-1**], and LRRT ('[**76**]), with fevers, N/V & ARF
(Creat 3.4) Pateint reports hx of sick contacts and prior
episode in [**7-/2104**] which resolved in house (pt had unrevealing
colonoscopy at the time).
Past Medical History:
Diabetes, hypertension.
Kidney transplant in [**2076**].
Pancreas after kidney transplant [**2104-1-29**],
chronic anemia
legally blind,
pancreas rejection [**2104-4-30**] treated with ATG,
left foot fracture [**2104-4-30**].
Pancreas transplant was done in [**State **].
PAST SURGICAL HISTORY: Ovarian cystectomy, bilateral nipple
duct resection, multiple rotator cuff surgical tears as well
as the pancreas after kidney [**2104-1-29**] and liver-related
kidney transplant in [**2076**].
Allergies:Penicillin, ampicillin, CellCept and MSG.
Social History:
Patient lives with her husband. She has 2 children and one
granchildren.
Family History:
Unremarkable
Physical Exam:
General: Patient in no apparent distress.
HEENT: Neck supple. legally blind. No adenopathies, oropharinx
clear
Lungs: Clear to Auscultation bilaterally
Cardiovascular: Regular rhythm, s1-s2 normal, sistolyc ejection
murmur mainly audible in 2 RParasternal border, no radiated to
the neck
Abdomen: BS + , soft, no distended,
Extremities: no edema, + pulses bilaterally, left foot banded
Neurological: legally blind, alert, oriented, non focal,
movilizes 4 extremities spontaneusly.
Lymphoid exam: No cervical, supraclavicular axillary or inguinal
adenopathy, no palpable spleen.
Pertinent Results:
[**2105-1-22**] 05:35AM BLOOD WBC-4.6 RBC-2.74* Hgb-8.6* Hct-25.6*
MCV-93 MCH-31.2 MCHC-33.4 RDW-19.8* Plt Ct-322
[**2105-1-21**] 04:45AM BLOOD WBC-4.4 RBC-2.77* Hgb-8.7* Hct-25.8*
MCV-93 MCH-31.2 MCHC-33.6 RDW-19.7* Plt Ct-226
[**2105-1-19**] 06:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2105-1-19**] 06:55PM URINE Blood-SM Nitrite-NEG Protein-500
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2105-1-13**] 12:15 pm URINE
**FINAL REPORT [**2105-1-14**]**
URINE CULTURE (Final [**2105-1-14**]):
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
53 year old female with DM (s/p renal and pancreatic transplant,
on immunosuppression, blindness in both eyes) who presented on
[**2105-1-1**] with nuasea, vomiting, diarrhea, headache and fevers.
Fever work was initiated including Blood, urine, and stool
cultures along with CMV viral load were all sent. Abd US, CXR,
CT sinuses, abd, pelvis all negative. Pateint remain febrile
despite all initial culture returning negative except CMV viral
load of 58,000 copies. On hospital day patient was transferred
to SICU for shortness of breath, tachypneaa nd hypoxemia.
Pateint was subsequqnetly started on albuterol nebullizer,
continous face mask and serial CXR. An [**2105-1-7**] echocardiagram
showed left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). A [**2105-1-7**] portable CXR
showed mild interstitial edema with moderate cardiomegaly has
increased as has mediastinal vascular engorgement indicating
elevated central venous volume. A repeat on [**1-8**] showed
satisfactory nasogastric tube position, worsening congestive
heart failure and persistent left lower lobe atelectasis. A
[**2105-1-9**] bronchoavleaolar lavage showed increased secretions but
no other significant findings.
A [**1-9**] CT chest showed
1.Mild-to-moderate CHF with cardiomegaly and bilateral pleural
effusions with bibasilar patchy atelectasis.
2. Small pericardial effusion.
3. Somewhat nodular appearance within the ground glass opacity
consistent
with CMV pneumonitis. Radiographically, fungal infections and
miliary
tuberculosis are in the differential diagnosis.
4. Left lower lobe pneumonia.
On [**2105-1-11**] urine culture was positive for yeast and antifungal
treatement was started. [**1-12**] repeat CMV viral load [**Numeric Identifier 30501**]. Repeat
urine culture along with sputum on [**2105-1-13**] showed yeast.
After a ten day course in ICU pt returned to floor [**2105-1-17**].
Antifungal where discontinued per ID recommendation after [**1-19**]
urine culture showed no evidence of yeast. [**1-16**] CMV viral load
was 10,600. Patient pertinent issue on the floor was ongoing
nausea which improved after several days of adjusting tube feeds
and antiemetics treatment. After stable course on floor patient
was prepared for discharge rehab with appropiate followup
schedule.
Today on [**2105-1-23**], patient feels cofortable and
awaiting rehab.Patient is a febrile, VSS. Patient will leave
with a foley, TFs . Please make sure patient is on a ConAir bed
for sensitivity of skin, and increase risk for break down skin.
Discharge Medications:
1Prednisone 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
3. Therapeutic Multivitamin Liquid [**Year (4 digits) **]: Five (5) ML PO DAILY
(Daily).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Year (4 digits) **]: [**12-1**]
Tablets PO 3X/WEEK (MO,WE,FR).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Fluconazole 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
10. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Tacrolimus 1 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day) for 2 doses.
12. Sirolimus 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Hydrochlorothiazide 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
14. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: 2.5 Tablets PO TID (3
times a day).
15. Ganciclovir Sodium 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous DAILY (Daily) for 5 days: 150mg iv q day.
16. Metoclopramide 10 mg IV Q6H:PRN
17. Insulin SS Insulin SC Sliding Scale Breakfast Lunch Dinner
Bedtime Regular Regular Regular Regular Glucose Insulin Dose
Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL [**12-1**] amp D50
[**12-1**] amp D50 [**12-1**] amp D50 [**12-1**] amp D50 61-120 mg/dL 0 Units 0 Units
0 Units 0 Units 121-160 mg/dL 3 Units 3 Units 3 Units 1 Units
161-200 mg/dL 5 Units 5 Units 5 Units 3 Units 201-240 mg/dL 7
Units 7 Units 7 Units 5 Units 241-280 mg/dL 9 Units 9 Units 9
Units 6 Units 281-320 mg/dL 11 Units 11 Units 11 Units 8 Units
321-360 mg/dL 13 Units 13 Units 13 Units 10 Units > 360 mg/dL
18. Hydralazine 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q 6HRS PRN
().
19. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
53 yo woman w/ h/o kidney transplant [**2076**], pancreas transplant
[**2-1**], w/ rejection [**6-3**].
DX: cmv pneumonitis
respiratory distress
Discharge Condition:
good
Discharge Instructions:
Patient is to call Transplant surgery immediately at
[**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting, increase
abdominal pain. Patient or caregiver should call immediately if
any change in mental status, increase in abdominal girth, any
increase diarrhea
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2105-2-2**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2105-2-5**] 1:30
F/u with Dr. [**Last Name (STitle) 12636**] from Podiatry in clinic in 4weeks. Please
call [**Telephone/Fax (1) 543**]
Completed by:[**2105-1-23**]
|
[
"428.0",
"276.51",
"518.81",
"250.50",
"V54.19",
"484.1",
"E878.0",
"584.9",
"008.69",
"276.2",
"369.01",
"401.9",
"V42.83",
"112.2",
"078.5",
"996.81",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"96.6",
"96.04",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7863, 7942
|
2793, 5420
|
487, 596
|
8136, 8143
|
2154, 2770
|
8467, 8908
|
1525, 1539
|
5443, 7840
|
7963, 8115
|
8167, 8444
|
1169, 1418
|
1554, 2135
|
254, 449
|
624, 851
|
873, 1146
|
1434, 1509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,053
| 111,696
|
41136
|
Discharge summary
|
report
|
Admission Date: [**2153-3-19**] Discharge Date: [**2153-3-29**]
Date of Birth: [**2089-5-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
GU bleed
Major Surgical or Invasive Procedure:
Hemodialysis with temporary line
Paracentesis
Kidney Biopsy
History of Present Illness:
63-year-old male with hep C cirrhosis and HCC who was admitted
for new ARF (creatinine 11.9 up from 1.1 on [**3-8**], K max on day
of admission was 6.2) after recently moving to [**Location (un) 86**]. He
started HD yesterday which he tolerated well and then underwent
left renal biopsy today at 11:30. He got DDAVP for plts of 65
in setting of liver failure. He then began having hematuria.
From discussion with nursing over the course of the afternoon he
may have had up to 660cc of frank looking blood out his foley.
He never became tachycardic. He was seen by urology who began
CBI. He was having bladder pain. He also received 200cc IVF
with the plan to have it taken off by HD at a later time.
During HD he dropped his SBP to 70s and HD was discontinued for
labile pressures. Yesterday during dialysis his SBP were only
as low as 80s. He lives at a SBP of 90s per the patient. He
never was tachycardic today. HCT this AM 39.8 this am and was
25.5 this afternoon. HCT was 39.6 on arrival to the hospital but
likely baseline is 30. He received the beginning of a blood
transfusion on the floor but became hypothermic and developed
rigors. Blood transfusion was stopped. Pt states blood always
needs to be specially prepared for him. HCT on arrival to the
unit was 20.4. INR today was 1.4.
.
He has HCC [**2-14**] hepatitis C complicated by esophageal varices s/p
banding, anemia requiring transfusion, portal gastropathy, and
ascites requiring intermittent paracenteses. His most recent
chemotherapy was from was sorafenib between the dates of [**2153-1-22**]
and [**2153-3-6**]. He had stopped his chemo at that time due to an
admission for a GI bleed. He had banding of a non actively
bleeding variceal bleed at that time.
.
On arrival to the ICU vitals were T95.8 SBP98/50 HR66 RR14 100%
RA. The pt reported he was feeling much better. All bladder
discomfort and rigors has resolved.
Past Medical History:
Onc Hx:
-[**2150-11-19**]: resection of 4x4x3.8cm liver lesion in segment 5.
Pathology consistent with HCC. No lymphovascular invasion
-[**2151-5-20**]: resection of 1.8cm lesion in segment 5
-[**2152-2-14**]: chemoembolization of a branch of right hepatic artery
with taxotere and embospheres for two right lobe lesions
measuring 1.5 and 0.5 cm along with microwave ablation of the
1.5cm lesion
-had been on transplant list when MRI [**2152-8-11**] showed 2.4 x 4.3cm
lesion in segment 8 and thrombosis of a portal vein branch.
Underwent biopsy of the lesion which revealed a moderately
differentiated hepatocellular carcinoma with tumor embolus in
the portal vein branch. AFP started rising, 232ng/mL. Delisted
from transplant list.
-attempt to enroll in SEARCH trial. However, pt had anemia
(despite d/c-ing internferon and ribavarin), making him
ineligible from study
-began radiation in [**11/2152**] and finished 01/[**2153**]. Since [**2153-1-22**]
he has been on sorafenib 400mg [**Hospital1 **]. AFP steadily increasing over
last 5 months to 3000s.
-required large volume paracentesis twice [**2-/2153**] (7.6L and
7.8L). Episodes of anemia secondary to GI bleeding. EGD and
colonoscopy performed, revealing esophageal varices, hemorrhoids
and mild portal gastropathy.
-hospital admission [**2153-3-5**] for drop in Hct for which he
received PRBCs. No site of bleeding identified.
.
Other Past Medical History:
HTN
? CHF
Social History:
Recently moved from [**State 531**] to [**Location (un) 86**] to be near his son. Lives
alone but son lives ten minutes away. Worked in the past as
sheet metal worker but now retired. Denies hx of smoking, EtOH
or illicit drug use, including IV drugs.
Family History:
Father: cirrhosis, EtOH
Physical Exam:
EXAM ON ADMISSION:
VS: 95.5 88/50 60 20 100%RA
GEN: AOx3, NAD
HEENT: PERRL. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, distended, moderate ascites, NT, no rebound/guarding,
liver enlarged to 2cm below costal margin, no [**Doctor Last Name 515**] sign
Extremities: wwp. 3+ b/l edema, L > R, left calf pain, DPs, PTs
2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. no
asterixis
EXAM ON DISCHARGE:
VS: 98.2 120/64 66 16 97%RA
GEN: AOx3, NAD
HEENT: PERRL. MMM. no LAD. no JVD. no [**Doctor First Name **].
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, distended, moderate ascites, NT, no rebound/guarding,
liver enlarged 2cm below costal margin
Extremities: wwp. 2+ b/l edema, L > R
Skin: no rashes or bruising, anicteric
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. no
asterixis.
Pertinent Results:
ADMISSION LABS:
[**2153-3-19**] 11:00AM BLOOD WBC-11.6* RBC-3.94* Hgb-12.4* Hct-39.6*
MCV-100* MCH-31.5 MCHC-31.4 RDW-19.0* Plt Ct-113*
[**2153-3-19**] 11:00AM BLOOD PT-17.6* INR(PT)-1.6*
[**2153-3-19**] 11:00AM BLOOD Gran Ct-8810*
[**2153-3-19**] 11:00AM BLOOD UreaN-141* Creat-11.9* Na-134 K-5.2*
Cl-101 HCO3-16* AnGap-22*
[**2153-3-19**] 11:00AM BLOOD ALT-30 AST-65* LD(LDH)-170 AlkPhos-244*
TotBili-1.3 DirBili-0.8* IndBili-0.5
[**2153-3-19**] 11:00AM BLOOD TotProt-7.7 Albumin-2.6* Globuln-5.1*
Calcium-8.2* Phos-11.8* Mg-2.0
[**2153-3-19**] 11:00AM BLOOD AFP-2802*
[**2153-3-19**] 06:15PM BLOOD C3-83* C4-15
[**2153-3-20**] 07:10AM BLOOD HCV Ab-POSITIVE*
DISCHARGE LABS:
[**2153-3-29**] 07:02AM BLOOD WBC-6.4 RBC-2.98* Hgb-9.4* Hct-29.0*
MCV-97 MCH-31.5 MCHC-32.4 RDW-19.4* Plt Ct-95*
[**2153-3-29**] 07:02AM BLOOD PT-13.5* PTT-30.8 INR(PT)-1.2*
[**2153-3-25**] 05:50AM BLOOD Lupus-NEG
[**2153-3-25**] 05:50AM BLOOD ACA IgG-PND ACA IgM-PND
[**2153-3-29**] 07:02AM BLOOD Glucose-92 UreaN-74* Creat-2.9* Na-135
K-4.2 Cl-99 HCO3-29 AnGap-11
[**2153-3-24**] 06:00AM BLOOD ALT-24 AST-64* LD(LDH)-155 AlkPhos-183*
TotBili-1.5
[**2153-3-29**] 07:02AM BLOOD Albumin-2.5* Calcium-8.9 Phos-4.6* Mg-1.8
[**2153-3-21**] 06:00AM BLOOD Hapto-120
[**2153-3-19**] 06:38PM BLOOD Cryoglb-POSITIVE *
[**2153-3-20**] 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2153-3-19**] 06:15PM BLOOD ANCA-NEGATIVE B
[**2153-3-19**] 06:15PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:640
[**2153-3-19**] 06:15PM BLOOD RheuFac-<3
[**2153-3-19**] 11:00AM BLOOD AFP-2802*
[**2153-3-19**] 06:15PM BLOOD PEP-POLYCLONAL
[**2153-3-28**] 10:36AM BLOOD C3-97 C4-17
[**2153-3-27**] 06:44PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-PND
[**2153-3-19**] 02:19PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
Osmolal-378
[**2153-3-19**] 02:19PM URINE Hours-RANDOM Creat-198 Na-40 K-31 Cl-14
TotProt-44 Prot/Cr-0.2
[**2153-3-26**] 03:53PM ASCITES WBC-50* RBC-52* Polys-11* Lymphs-13*
Monos-68* Mesothe-8*
[**2153-3-26**] 03:53PM ASCITES TotPro-0.9 Glucose-125 LD(LDH)-27
Albumin-LESS THAN
MICROBIOLOGY:
URINE CULTURE (Final [**2153-3-20**]): NO GROWTH.
Blood Culture, Routine (Final [**2153-3-25**]): NO GROWTH.
Blood Culture, Routine (Final [**2153-3-27**]): NO GROWTH.
MRSA SCREEN (Final [**2153-3-24**]): No MRSA isolated.
[**2153-3-26**] 3:53 pm PERITONEAL FLUID
GRAM STAIN (Final [**2153-3-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-3-29**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
STUDIES:
[**2153-3-19**] GU U/S:
IMPRESSION:
1. Normal kidneys.
2. Enlarged prostate gland with calculated volume of 37.4cc.
3. Large volume intra-abdominal ascites.
[**2153-3-20**] Bilateral LENIs:
IMPRESSION:
Bilateral normal lower extremity US. Negative for above-knee DVT
bilaterally.
[**2153-3-22**] CT abdomen/pelvis:
IMPRESSION:
1. Mild perinephric stranding adjacent to the left kidney, most
likely from recent percutaneous biopsy. A small hyperdense focus
in the posterior aspect of the left kidney likely represents a
tiny hematoma.
2. Hyperdense blood within the left collecting system, including
the proximal ureter, with no evidence of obstruction. There is a
large amount of blood and clot within the bladder. There is no
large hematoma outside of the collecting system.
3. Massive abdominal ascites.
4. Multiple irregular hypodensities within the liver,
incompletely
characterized on this non-contrast enhanced study, compatible
with multifocal HCC, better seen on prior reference imaging
studies.
5. Mediastinal and porta hepatis lymphadenopathy.
6. Colonic diverticulosis.
[**2153-3-21**] Kidney biopsy:
ULTRASOUND GUIDANCE FOR RENAL BIOPSY BY NEPHROLOGIST: Ultrasound
examination of the kidneys was performed. The lower pole of the
left kidney was identified and the position was marked on the
patient's back for renal biopsy to be performed by the
nephrologist.
[**2153-3-21**] CXR:
Opacification in infrahilar right lung is probably atelectasis,
unchanged. There are no findings to suggest current pneumonia.
Heart size is normal. No pleural abnormality. Right jugular line
ends in the region of the superior cavoatrial junction.
[**2153-3-26**] Peritoneal Fluid:
NEGATIVE FOR MALIGNANT CELLS.
[**2153-3-26**] Paracentesis:
IMPRESSION: Successful ultrasound-guided diagnostic and
therapeutic
paracentesis of 3 liters of serous fluid.
[**2153-3-27**] CT abdomen/pelvis:
IMPRESSION:
1. Unchanged hyperdense focus in the posterior left kidney,
consistent with a small subcapsular hematoma.
2. Decreased amount of hyperdense blood and clot both within the
proximal
left collecting system and the bladder. No hematoma is seen
outside of the
collecting system.
3. Large amount of abdominal ascites.
4. Incompletely characterized irregular hypodensities within the
liver
consistent with the patient's known multifocal HCC.
Brief Hospital Course:
63-year-old male with hep C cirrhosis and HCC with new onset
acute renal failure and transferred to the unit for GU bleed
after left renal biopsy.
# Acute renal failure: Cr was elevated on admission to 11.9 from
baseline 0.9. Renal was consulted and advised dialysis as well
as a kidney biopsy. He received several sessions of bedside
hemodialysis; two sessions were prematurely stopped as his blood
pressure did not tolerate it. Cr came down to 4.2 following
dialysis and further trended down to 2.9 prior to discharge.
His lasix was held given his acute renal failure and
hypotension. His other antihypertensives, amlodipine and
aldactone, were also held. Renal ultrasound showed enlarged
prostate and large amount of ascites but normal kidneys.
Initially, it was felt that his acute renal failure was
secondary to sorafenib induced nephrotoxicity. However, the
kidney biopsy light microscopy showed mesangial proliferative
GN. Immunofluorescence showed 2+ IgG and 2+ lambda mesangial
deposition. There were no thrombi in the microvasculature to
make deifinite diagnosis of a TMA to implicate the sorafenib.
SPEP showed polyclonal hypergammaglobulinemia and UPEP showed no
monoclonal IG and was negative for bence [**Doctor Last Name 49**] proteins. The
serum free light chain assay was pending on discharge. [**Country 7018**]
Red was negative for amyloid. His [**Doctor First Name **] was also positive at
1:640, lupus anticoagulant was negative, and anti-cardiolipin
IgG/M were pending at discharge. Preliminary biopsy results
were suspicious for fibrillary glomerulonephritis. He was
discharged with follow-up at nephrology clinic for further
evaluation as outpatient. He was discharged on sevelamer for
hyerphosphatemia. He was also restarted on his lasix as Cr
stabilized.
# GU bleed s/p kidney biopsy: Pt underwent kidney biopsy on
[**2153-3-21**] that was complicated by gross hematuria. He was seen by
urology and put on CBI. His hematuria led to drop in Hct from
high 20s to low 20s and a drop in blood pressure to systolic
70s. He was transferred to the ICU for the hypotension. CT
abdomen showed perinephric stranding adjacent to the left
kidney, most likely from
recent percutaneous biopsy, a small hematoma in left kidney, and
blood in the collecting system and bladder. He required a total
of 5 units PRBCs and 1 bag platelets throughout hospital
admission. Hct was stable at baseline in high 20s by time of
discharge. Repeat CT abdomen showed that small hematoma in
kidney was stable. He no longer had hematuria at discharge and
was able to urinate without a foley.
# ?Transfusion reaction: Of note, pt exhibited rigors during his
first transfusion. He was not febrile. Per transfusion
medicine, this was likely not a febrile non-hemoltyic
transfusion reaction given the short duration of his symptoms,
no subsequent fever and that leukoreduction significantly
decreases the risk of these reactions. He experienced no
adverse reactions from his subsequent transfusions.
# Hypotension: BP at admission was systolic 80s. He was given
IV fluids and his antihypertensives and diuretics were held
(with the exception of nadolol). He later became hypotensive to
systolic 70s following hematuria after a kidney biopsy and
hemodialysis. Pt also with mild hyperthermia to 95 concerning
also for infection on admission. He was pan-cultured, with
negative urine and blood cultures. Patient started on CTX 2gm
Q24hrs x2 days for possible SBP, but was dicscontinued [**3-23**] as
likelihood of SBP felt to be very small with no abdominal pain,
normal WBC and no fevers. Peritoneal fluid showed no signs of
infection. Following transfusion of PRBCs and IV fluids, BP
stabilized in systolic 100s-120s throughout remainder of
admission.
# LE edema: Pt presented with LE edema, left worse than right.
On admission he endorsed some calf pain as well. B/l LENIs were
obtained, which were negative for DVT. Pain resolved and pt was
able to ambulate without difficulty. He was discharged back on
his lasix.
# Hepatocellular carcinoma: Pt was s/p sorafenib [**2153-1-22**] to
[**2153-3-6**]. He has recently transferred his onc care here. He was
continued on nadolol at admission but this was briefly held in
the ICU when GI bleed was being ruled out for drop in Hct. He
underwent a therapeutic paracentesis on [**2153-3-26**]; peritoneal
fluid was benign and 3L were removed from abdomen. He will
discuss with his outpatient oncologist whether sorafenib can be
restarted once kidney function stabilizes.
Medications on Admission:
1. oxycodone 5mg po q4h prn
2. aldactone 100mg po daily
3. lasix 40mg po daily
4. nadolol 20mg daily
5. protonix 40mg daily
6. amlodipine/benzapril 10/40
7. Nexavar (on hold)
8. levaquin 500mg po x 1 week
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute renal failure
Secondary:
Hepatocellular carcinoma
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 in the hospital. You were
admitted with acute kidney failure. The severity of your kidney
failure required several sessions of hemodialysis. Your kidney
function improved with the hemodialysis. You were evaluated by
our renal consult team who performed a kidney biopsy. This was
complicated by bleeding that caused your blood counts to drop
and your blood pressure to drop. You were transferred to the
intensive care unit briefly because of this and were transfused
with blood products. Your blood pressure recovered and the
bleeding in the urine stopped.
Your kidney biopsy showed a rare condition called fibrillary
glomerulonephritis. It is very important that you have regular
follow-ups at the [**Hospital 10701**] Clinic for frequent monitoring of
your kidney function and possibly further testing.
The following medications were changed:
1) STOP amlodipine/benzapril unless one of your outpatient
doctors wants to restart. Your blood pressure was extremely good
in the hospital so you didn't need it on discharge.
2) STOP aldactone. Ask your outpatient doctors when [**Name5 (PTitle) **] [**Name5 (PTitle) **]
restart this medication.
3) STOP levaquin
4) STOP nexavar
5) START sevelemar 800mg three times a day with meals to lower
your phosphorous levels
Followup Instructions:
You have the following appointments scheduled for you. You will
need to come to the [**Hospital 2793**] Clinic on the [**Location (un) 448**] of the [**Hospital Ward Name 121**]
building ([**Hospital Ward Name **]) on Monday [**2153-4-2**] to get your labs drawn.
Please come between the hours of 9am and 2pm and bring with you
the lab order slip.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2153-4-6**] at 3:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2153-4-4**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2153-3-29**]
|
[
"789.59",
"584.9",
"572.3",
"401.9",
"275.3",
"458.9",
"070.54",
"583.9",
"E879.8",
"155.0",
"998.11",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23",
"54.91",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15413, 15419
|
10132, 14677
|
313, 375
|
15529, 15529
|
5184, 5184
|
17011, 18064
|
4047, 4072
|
14932, 15390
|
15440, 15508
|
14703, 14909
|
15680, 16988
|
5862, 7715
|
4087, 4092
|
265, 275
|
403, 2308
|
4688, 5165
|
5200, 5846
|
4106, 4669
|
7751, 10109
|
15544, 15656
|
3750, 3762
|
3778, 4031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,794
| 131,087
|
19434
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 52821**]
Admission Date: [**2107-1-25**]
Discharge Date: [**2107-2-3**]
Date of Birth:
Sex:
Service:
CHIEF COMPLAINT: To transfer from floor after polymorphic
ventricular tachycardia arrest.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old female
with unclear history of prior CAD, with history of a mass
encapsulating right middle lobe and right lower lobe bronchi
with no liver metastasis, presumed to be a possible
malignancy, unclear brain mets (though noncontrast head CT
showed no hemorrhage or midline shift), who was initially
transferred from an outside hospital for concerns of an aorta
dissection. By MRI at [**Hospital1 **], she was found to have aneurysmal
thoracic and abdominal aorta with penetrating ulcers, but no
evidence of a clear dissection. Evaluation on the outside
had revealed elevated CKs to around 2200 with troponin T at
peak 24. The outside hospital ECG had shown atrial
fibrillation, rapid ventricular response up to 150s with ST
depressions. At the [**Hospital1 **], on [**2107-1-25**], the patient was in
sinus rhythm without clear ischemia. However, until the a.m.
of transfer on [**2107-1-26**], the patient had an episode of
polymorphic ventricular tachycardia degenerating into
ventricular fibrillation, ultimately requiring DCCV,
lidocaine, and amiodarone drip. The patient was intubated,
placed on dopamine for pressure support and then staged with
propofol and transferred to the CCU for further evaluation.
PAST MEDICAL HISTORY: Breast cancer, diagnosed eight years
ago, status post mastectomy.
Triple aorta repair approximately 5 to 10 years ago.
History of CAD with MI in the 80s.
Hyperlipidemia.
Presumed COPD.
Question of psychiatric disorder.
MEDICATIONS: Synthroid unclear dose, also alternative
medications. At the time of transfer, the patient was on
amiodarone drip, dopamine of 13, aspirin, and propofol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lived with retarded daughter and son.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: Vital signs: Afebrile, temperature
97.9, blood pressure in the systolic 110s/70s, actually in
the 70s, heart rates in the 120s, respiratory of 20, on AC
600, saturating 100 percent. General: The patient was
intubated and sedated. Cardiovascular: She was tachycardic,
irregular with a [**3-12**] holosystolic murmur at the apex.
Abdomen exam: Benign. Extremities: The patient has 2+
lower extremity edema.
LABORATORY DATA: From [**2107-1-26**] show a CBC of 13.2,
hematocrit 34.9, and platelets of 36,000. Chemistries,
sodium 144, potassium 3.6, chloride 109, bicarbonate 29.5,
BUN 31, creatinine 0.8, glucose 129, lactate of 13.7, down to
6.3, coagulations 13.4, 28, 1.2; ALT 118, AST 319, alkaline
phosphatase 131, total bilirubin 0.7, troponin is 8 down from
24. CPK has been 2240, 1649, and 566 last.
Echocardiogram shows an ejection fraction of 25% with global
hypokinesis, 1 plus MR, mild aortic stenosis, negative for an
effusion.
HOSPITAL COURSE: Review of systems:
CAD; the patient was admitted from an outside hospital with
elevated CK and troponin in the setting of rapid atrial
fibrillation. She also has an unknown history of CAD. Given
her CKs and troponin, the patient was treated with aspirin,
statin, and Plavix. She was not heparinized in the setting
of a known malignancy with possible invasions to the brain. She
was not placed on beta blockers given her hemodynamic
instability. Her enzymes were trended down throughout her
hospital course.
Hypotension; the etiology of the patient's hypotension
remains somewhat unclear during the [**Hospital 228**] hospital
course. Initially, she was transferred from the floor on
dopamine following a polymorphic ventricular tachycardia,
degenerative ventricular fibrillation arrest. The patient
initially was treated for a possible cardiogenic insult. She
was continued on dopamine. However, the patient also has
fevers and there was a concern that the patient having
possible pneumonia. As such, it was unclear if the patient's
hypotension was secondary to cardiogenic versus septic shock.
Subsequently, during her hospital course, the patient had
Swan placed, which showed a RA pressure of 10, RV pressure of
30/7, PA pressure of 35/25, and a wedge of 15 with a cardiac
index of 2.9, and SVR of 10.20. Ultimately, secondary to
episodes of rapid atrial fibrillation and also episodes of
nonsustained ventricular tachycardia, the patient was
transitioned from dopamine to levofed. She did continue to
have episodes of hypotension that appeared to be fluid
responsive. As such, it was felt that the sepsis may then
play a large role on the patient's hypotension. Ultimately
she remained pressor dependent, until her death on [**2107-2-3**],
at which point pressors had been discontinued for CMO
status.
CHF; the patient had an echocardiogram from admission showing
an ejection fraction of only 25%, in the setting of presumed
cardiac ischemia. As mentioned above, she was initially
thought to have a component of cardiogenic shock. However,
her PA catheter numbers did not indicate cardiogenic shock.
She actually did receive a questionable amount of fluid later
in her hospital course for episodes of hypotension. It was
felt later on the patient was grossly fluid overloaded, but
still is exhibiting septic physiology. Ultimately, she was
gently diuresed to help improve oxygenation with bilateral
pleural effusions. This therapy continued until decision is
to make the patient CMO.
Rhythm; the patient transferred to the CCU after following an
episode of polymorphic ventricular tachycardia, degenerative
ventricular fibrillation arrest requiring DC cardioversion,
and in addition, IV amiodarone, lidocaine, epinephrine and
bicarbonate. Throughout the patient's CCU course, she
remained extremely dependent upon both IV amiodarone and
lidocaine. Initially, the patient was transitioned to p.o.
amiodarone and was attempted to have weaned off of lidocaine.
However, the patient developed several episodes of rapid
atrial fibrillation and also was felt to have some episodes
of sustained ventricular tachycardia. Ultimately, lidocaine
was continued until the patient's family had desired to
change the patient's status to CMO, at which point, lidocaine
was discontinued.
Pulmonary: Initially, the patient was transferred to the CCU
intubated following her ventricular tachycardia/ventricular
fibrillation arrest. She remained intubated in her entire
course until her death on the 29th. The patient ended up
spiking fevers throughout her hospital course. Her sputum
was positive for methicillin-sensitive Staphylococcus. She
was initially treated empirically with Levaquin and
clindamycin for possible postobstructive pneumonia given her
history of presumed lung cancer. Later on, vancomycin was
added when staph was found in her sputum. Meanwhile, the
patient actually oxygenated reasonably well during much of
her hospital course. Later on, however, the patient
developed increased oxygen requirements, as she became
progressively more over fluid overloaded, secondary to the
amounts of fluids she is requiring for hemodynamics.
ID; as I mentioned above, the patient spiked fevers
throughout her CCU course. Initially, she was treated with
Levaquin and clindamycin for presumed postobstructive
pneumonia. Vancomycin was added later on when sputum was
found to be positive for staph. In addition, there was
concern about possible line sepsis, so vancomycin was
continued for possible line-type sepsis. She continued on
antibiotics until the day of her death at which point she was
changed to be CMO. Of note, blood cultures remained negative
throughout her hospital course.
Oncology; the patient with history of breast cancer, status
post mastectomy. Upon transfer to the hospital with having
findings of her mass increasing in the right middle lobe,
right lower bronchi. The patient had an abdominal CT, which
also showed lesions in liver consistent with metastatic
disease. The etiology of the patient's masses presumed to be
malignant of unclear etiology. The patient did have a follow
up head CT, which was negative for any intracranial
malignancy, but did show diffuse mets throughout her skull.
No further intervention was made at this point. However,
given the patient's presumed metastatic disease, this was a
key point in discussions with the patient's family given the
patient's poor clinical progress in CCU.
Hematology; the patient's hematocrit was stable during the
hospital course. Her platelets remained under 100 and was
felt to be stable possibly secondary to underlying
malignancy.
Renal; the patient's renal function remained stable during
her hospital course. As mentioned above, she ultimately
found to be grossly fluid overloaded secondary to massive
amounts of fluid required to maintain her blood pressure.
DISPOSITION: CCU team had underwent multiple discussions
with the patient 's family during her hospital course in the
CCU. Ultimately, given the patient's presumed metastatic
malignancy, her ongoing arrhythmias requiring a persistent
lidocaine drips, her recent MI, and prolonged hypotension
with essential hypertension, and possible anoxic brain
injury, it was decided to change the patient's code status
from full code to eventually DNR/DNI and to ultimately CMO.
At 07:10 p.m., on [**2107-2-3**], the patient became asystolic and
hypertensive. She was found to be dead at 07:10 p.m. Family
was at the bedside. No request for autopsy.
DISCHARGE DIAGNOSES: Presumed metastatic malignancy.
Status post polymorphic ventricular tachycardia/ventricular
fibrillation arrest.
Coronary artery disease, status post myocardial infarction.
Fevers secondary to presumed pneumonia and questionable line
sepsis.
DISCHARGE CONDITION: Dead.
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2107-9-15**] 15:24:14
T: [**2107-9-17**] 10:20:43
Job#: [**Job Number 52822**]
cc:[**Name8 (MD) 52823**]
|
[
"486",
"496",
"197.7",
"427.31",
"427.41",
"162.8",
"410.11",
"427.1",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.93",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9843, 10184
|
2021, 2031
|
9575, 9821
|
3023, 3023
|
2054, 3005
|
3042, 9553
|
153, 227
|
256, 1492
|
1515, 1948
|
1965, 2004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,156
| 103,568
|
52854
|
Discharge summary
|
report
|
Admission Date: [**2167-2-19**] Discharge Date: [**2167-3-12**]
Date of Birth: [**2098-3-27**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Betalactams / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 68 year-old female with CLL, HTN, CAD, CHF (EF
65% 1/08), hyperlipdemia, hypothyroid, CKD (baseline creatinine
1.3), DM2, anemia, and gout referred in by the oncologist from
[**Hospital1 **] for AMS. Per record, on arrival to onc clinic she was
obtunded, somnolent, drifting to sleep and snoring with BP
readings in the 90 to 105, which is unusually low for her.
Patient was recently diagnosed with a UTI and started on
macrodantin on [**2-17**] for culture positive UTI. She also was
started on oxycontin day prior to presentation for tooth pain.
She was also noted to have worsening renal failure with increase
in creatinine from 2 to 2.8, and worsening thrombocytopenia
requiring a bag of platelets.
In the ED patient had a head CT which was negative for
hemorrhage or mass effect and a CXR which was unremarkable. She
received 1 gram of Vancomycin and 400 mg of IV Cipro, one amp of
D50, and tylenol.
On arrival to the floor, patient is sleeping deeply and awakens,
startled, speaking in Spanish. She is initially disoriented but
is soon oriented to person, place, date, and time. She does not
know why she is here other than "[her] doctor wanted [her] to
come." With prompting from reviewing the record, she says that
she's been feeling tired for a couple days. Denies any pain,
recent diarrhea or constipation. Her only complaint is mouth
pain including her tongue and teeth.
Past Medical History:
-CLL: Dx in [**12-16**] by periph blood flow cytometry. CT scan showed
abdominal & cervical LAD, and large right pelvic mass.
Excisional biopsy of left supraclavicular node pathology and
immunohistochemistry c/w CLL. BM Bx [**12-16**] revealed extensive
infiltration, with 40% marrow cellularity. Pt was asympt &
deferred Tx until F/sweats in [**1-17**] & Tx was started
w/fludarabine ([**2164-1-24**]). Rituxan was added to 2nd cycle.
However her chemotherapy course was complicated by febrile
neutropenia. After two cycles of fludarabine this was changed to
single [**Doctor Last Name 360**] Rituxan, and she completed four weeks of
consolidation. Her post-chemotherapy course was complicated by
febrile neutropenia and pancytopenia. Her bone marrow was again
assessed in [**8-/2162**] and was consistent with treated CLL. She
remained thrombocytopenic following this without a response to
steroids and only minimal response to IVIG. Rituxan weekly was
given from [**2164-10-10**] through [**2164-11-2**] and platelets recovered
to about 30,000. Bone marrow biopsy on [**10/2164**] suggested a
sustained response to chemotherapy on the megakaryocytes. She
began maintenance Rituxan on [**4-/2165**], but her course was
complicated by diffuse arthralgias. Due to increasing painful
lymphadenopathy and IVC compression seen on CT, she was treated
with chlorambucil from [**2166-2-24**] through [**2166-4-3**]. This was
then stopped due to thrombocytopenia. Chlorambucil was restarted
at 4mg dose on [**2166-8-29**] when she progressed with painful
adenopathy. This was given concurrently with prednisone to treat
ITP. The chlorambucil was discontinued on [**2166-10-2**]. A second
course was again started on [**2166-11-20**].
- HTN with multiple admissions for hypertensive urgency. Most
recent admission with neurological complaints that resolved on
outpatient regimen
- CAD: diffuse multi-vessel disease. LAD stent [**12-17**]
- CHF
- High cholesterol
- Hypothyroid
- Chronic renal insufficiency with baseline Cr about 1.3
- Anemia
- gout
- DM 2
Social History:
From [**Male First Name (un) 1056**]. Married. Works as cashier. Denies T/A/D
Family History:
The patient notes a mother with a myocardial infarction at the
age of 71. A sister with a myocardial infarction at the age of
47. Otherwise, denies any further family history.
Physical Exam:
VS: T: 98.0 BP: 123/68 P: 90 RR: 22 O2 sat: 99% 2L
GEN: sleepy, NAD, + anasarca
HEENT: AT, NC, EOMI, no conjuctival injection, anicteric,
yellow-brown coating on tongue with foul odor, multiple
scattered petichial lesions on tongue, poor dentition, MMM, neck
supple,
CV: RRR, nl s1, s2, no m/r/g
PULM: Crackles [**1-15**] way up BL with good air movement throughout
ABD: soft, NT, ND, + BS, scattered eccymoses
EXT: warm, dry, distal pulses BL, no femoral bruits
NEURO: alert & oriented, CN II-XII grossly intact, limited
attention span, unable to recall [**3-16**] items, 5/5 strength
throughout. No sensory deficits to light touch appreciated. +
asterixis, no pronator drift, intact FNF
Pertinent Results:
LABS ON ADMISSION:
[**2167-2-19**] 03:29PM GLUCOSE-70 LACTATE-1.1
[**2167-2-19**] 03:30PM WBC-2.5*# RBC-2.59* HGB-7.9* HCT-24.2* MCV-93
MCH-30.5 MCHC-32.6 RDW-18.3*
[**2167-2-19**] 03:30PM CK-MB-NotDone cTropnT-0.03* proBNP-1678*
[**2167-2-19**] 03:30PM GLUCOSE-75 UREA N-113* CREAT-2.7* SODIUM-138
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-31 ANION GAP-13
[**2167-2-19**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2167-3-4**] 10:06AM BLOOD TSH-3.9
[**2167-3-4**] 10:06AM BLOOD Free T4-1.5
.
LABS ON DISCHARGE:
[**2167-3-10**] 08:22AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEG
[**2167-3-12**] 12:00AM BLOOD WBC-3.7* RBC-2.57* Hgb-8.0* Hct-23.6*
MCV-92 MCH-31.0 MCHC-33.8 RDW-18.1* Plt Ct-28*
[**2167-3-10**] 02:30PM BLOOD Neuts-25* Bands-0 Lymphs-63* Monos-8
Eos-1 Baso-0 Atyps-1* Metas-2* Myelos-0
[**2167-3-12**] 12:00AM BLOOD Glucose-145* UreaN-11 Creat-0.9 Na-141
K-3.5 Cl-99 HCO3-35* AnGap-11
.
[**2167-2-19**] HEAD CT: FINDINGS: There is no hemorrhage, edema, mass
effect, hydrocephalus or acute territorial infarct. Since the
previous study, the patient has been extubated. No soft tissue
abnormalities are appreciated. Visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: No evidence of hemorrhage or mass effect.
.
[**2167-2-19**] CXR (AP PORT): IMPRESSION: No acute cardiopulmonary
process.
.
[**2167-2-19**] EKG: Atrial fibrillation with moderate ventricular
response. Modest inferolateral ST-T wave changes which are
non-specific. Compared to the previous tracing of [**2167-1-27**] there
is no significant diagnostic change.
.
[**2167-2-22**] LUE US: IMPRESSION: PICC line in the left brachial vein
without evidence of deep venous thrombosis in the left upper
extremity.
.
[**2167-2-23**] NECK US: IMPRESSION:
1. No evidence of internal jugular deep vein thrombosis.
2. No abscess.
3. Multiple enlarged lymph nodes consistent with history of CLL.
.
[**2167-2-23**] CXR (PA & LAT): IMPRESSION:
1. New vascular engorgement and perihilar haziness likely due to
fluid overload or CHF. Coexistent pulmonary infection cannot be
excluded.
2. Small bilateral pleural effusions.
.
[**2167-2-23**] Echo: The left atrium is dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension.
.
[**2167-3-1**] CXR (PORT): IMPRESSION: Worsening CHF with now moderate
pulmonary edema.
.
[**2167-3-2**] CXR: There has been continued worsening in pulmonary
edema with increased consolidation in the left upper lobe.
Cardiomegaly is unchanged. There is no pneumothorax. Small right
pleural effusion is stable.
.
[**2167-3-3**] CT HEAD: IMPRESSION: No evidence of hemorrhage, mass
effect, or significant interval change.
.
[**2167-3-5**] ECHO: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%) and regional function is normal.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue
velocity imaging are consistent with Grade II (moderate) LV
diastolic dysfunction. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Compared with the prior study (images reviewed) of [**2167-2-23**],
findings are similar except patient now in sinur rhythm.
.
[**2167-3-6**] RUE US: IMPRESSION: No evidence of deep vein thrombosis
of the right upper extremity.
.
[**2167-3-6**] CXR (AP PORT): IMPRESSION: AP chest compared to
[**Month (only) 956**]. Predominantly perihilar consolidation in both lungs
with a smaller region of abnormality at the right base laterally
has worsened since [**3-4**], probably unchanged since the
21st. Severe cardiomegaly, mediastinal vascular engorgement are
other indications of cardiac decompensation. Left PIC catheter
tip projects over the junction of brachiocephalic veins.
Small-to-moderate right pleural effusion is stable. No
pneumothorax.
.
MICRO:
[**2167-2-19**] UCX neg
[**2167-2-19**] BCX neg x 2
[**2167-2-23**] BCX neg x 2
[**2167-2-23**] UCX: Ecoi
URINE CULTURE (Final [**2167-2-27**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ESCHERICHIA COLI. ~8OOO/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 4 S =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- R R
CEFTAZIDIME----------- R R
CEFTRIAXONE----------- =>64 R =>64 R
CEFUROXIME------------ =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 4 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
.
[**2167-3-3**] UCX neg
[**2167-3-4**] UCX: Ecoi
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2167-3-4**] BCX neg
[**2167-3-5**] BCX neg
Brief Hospital Course:
The patient is a 68 year-old female with PMH of CLL, HTN, CAD,
chronic stable diastolic CHF (EF >60%), hyperlipdemia,
hypothyroid, CKD (baseline creatinine 1.3), DM2, anemia, a-fib,
and gout admitted with AMS, UTI, and renal failure.
.
HOSPITAL COURSE BY PROBLEM:
.
#) AMS. Etiology was likely multifactorial. The patient p/w
known UTI and recent neutropenia, and was recently started on
oxycontin for pain. She was also on gabapentin while in acute on
chronic renal failure. Review of her meds show multiple sedating
agents. Head CT on admission was negative. Patient's mental
status returned to baseline shortly after admission; however,
she was noted to occasionally sundown. She responded well to
0.5mg haldol for this. Blood cultures were negative. She
received treatemnt for her UTI, as below. The patient should
avoid medications such as oxycontin, lorazepam, diphenhydramine,
gabapentin.
.
#) UTI. Patient was being treated for reported "pan-sensitive"
E. coli with nitrofurantoin at rehab. Per rehab, she also did
receive imipenem. On admission she was started on IV
ciprofloxacin for coverage, which was changed to Bactrim for
10-day course given sensitivities. This was again changed to
nitrofurantoin when cultures returned as bactrim-resistent
strain. 10 day course will be completed on [**2167-3-15**].
.
#) Febrile neutropenia: The patient had febrile neutropenia
(GRAN count 80 on [**2-20**])during admission without clear source. CXR
was negative for consolidation, blood cultures were negative.
Sites of previous biopsy showed no e/o abscess (though
+fluctuance on exam). Other possible sites included sacral wound
and tooth decay. The patient has lactam allergy and received
imipenem at rehab, which could also be considered a cause of her
neutropenia. The patient was started on broad antibiotic
coverage -- aztreonam for gram negatives, vanco for gram
positives, and clindamycin for anaerobes (mouth flora in
presence of oral sores) which was narrowed to flaygl (stomach
upset with clinda) for mouth flora and bactrim (changed to
nitrofurantoin based on sensitivities) for UTI. The patient
quickly defervesced and GRAN count increased steadily to 930 by
[**3-4**].
.
#) SOB/HYPOXIA: Had occasional O2 requirement this
hospitalization w/ significant SOB [**3-2**] overnight in setting of
transfusions. TRALI was considered, but the patient improved
quickly with diuresis and nebulizer treatments. On [**2167-3-4**], the
patient had an acute episode of hypoxia which necessitated ICU
transfer. The patient had SOB and hypoxia in setting of HTN and
tachycardia (afib with RVR) consistent with flash pulmonary
edema. CXR showed volume overload and echo showed mild diastolic
dysfunction with preserved EF. CEs were cycled frequently and
were negative. She was aggressively diuresed and continued on
nebs ATC, supplemental O2 PRN, and continued on rate control
with diltiazem and carvedilol. She was seen by the heart failure
team to titrate her regimen, and is scheduled for follow-up with
Dr. [**First Name (STitle) 437**] as an outpatient.
.
#) Atrial Fibrillation w/ RVR: Likely triggered by hypoxia in
setting of flash edema ([**2-14**] HTN). She was continued on
carvedilol and diltiazem with good rate control. Rhythm was
mostly in sinus for duration of hospital course. With cardiology
input, she was determined not to be a candidate for
anticoagulation secondary to chronic low platelets.
.
#) Hypertension: Patient has history of malignant hypertension
in prior admissions with symptoms of headache and
epigastric/left sided chest pain. Patient is now on a fairly
extensive med regimen including lisinopril, BB, nitrate,
clonidine patch, and diltiazem which should be continued as an
outpatient.
.
#) CAD: The patient was continued on ASA, beta-blocker,
ACE-inhibitor, nitrate. Cardiac enzymes are negative on
admisison, recycled [**3-2**]. ECG w/o new ST-T changes. The patient
did have significant chest pain with her rapid a-fib and
received nitroglycerin with good effect.
.
#) ARF: The patient had a creatinine of 2.8 from baseline ~ 1.3
This trended back to baseline with diuresis and antibiotics.
Creatinine on discharge was 0.9.
.
#) Pancytopenia. Patient has CLL and chronically has low counts;
however, her white count on admission was very low compared to
her usual baseline. Marrow infiltration vs. medication effect
were considered; however, recent bone marrow biopsy on [**12-20**] was
not suggestive of a clear explanation to account for
pancytopenia. Retic count inappropriately low. Smear not very
impressive but confirms pancytopenia, also some larger RBCs.
Etiology was most likely felt to be c/w medication-effect as the
patient did receive imipenem at rehab and has history of
leukopenia w/ beta-lactam antibiotics. Her ANC returned to
baseline but platelets remained low. She required a total of 3
platelet transfusions (on [**2-23**], -18, and -25) and 4 PRBC
transfusions ([**2-21**] x 2, -17, and -21) during her hospital course.
.
#) CLL. Further management per Dr. [**Last Name (STitle) **]. The patient will
follow-up with Dr. [**Last Name (STitle) **] in [**2-15**] weeks from discharge.
.
#) Thrush/dental pain: Continued nystatin swish, peridex. The
patient had panorex x-ray and was seen by the dental team who
recommended extraction when medically stable. The patient
completed a 10 day course of flagyl for mouth sores.
.
#) Yeast infection. The patient was started on 3 day course of
miconazole for yeast infection on [**3-12**].
.
#) Diabetes. on HISS in house with no acute issues.
.
#) Hypothyroidism. The patient was continued levothyroxine 75mcg
daily.
.
#) Communication. HCP son [**Name (NI) **] [**Telephone/Fax (1) 108998**]; [**Name2 (NI) 4906**] [**Name (NI) **]
[**Telephone/Fax (1) **]
.
#) Code Status. Full Code -- confirmed with patient and HCP, but
patient would not want "heroic measures".
.
#) The patient was discharged to rehab on [**3-12**] in good
condition, VSS, ambulating well with walker, with good O2
saturations on 2L NC.
Medications on Admission:
Per last d/c summary dated [**2167-2-2**]
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID (4
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
15. Gabapentin 400 mg Tablet Sig: One (1) Tablet PO at bedtime.
16. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO Q
8H (Every 8 Hours).
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Maalox 200-200-20 mg/5 mL Suspension Sig: Fifteen (15) ML PO
TID (3 times a day) as needed for heartburn.
19. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for
wheezing.
21. Insulin
Humalog Insulin Sliding Scale
22. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for anxiety.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest Pain.
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
12. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
13. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
16. Miconazole Nitrate 200-2 mg-% (9 g) Combo Pack Sig: One (1)
Combo Pack Vaginal HS (at bedtime) for 3 days: day 1 = [**3-12**], to
complete 3 days.
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 3 days: 10 day course to end
[**3-15**] .
20. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold for SBP < 100.
21. Humulog insulin sliding scale
Gluc Breakfast Lunch Dinner HS
0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
51-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Delirium
2. Urinary Tract Infection
3. Atrial Fibrillation with Rapid Ventricular Rate
4. Pulmonary Edema
5. Acute Diastolic Congestive Heart Failure
6. CLL
7. Hypertension
8. Coronary Artery Disease
9. Type 2 Diabetes Mellitus
.
SECONDARY DIAGNOSIS:
1. Hypercholesterolemia
2. Hypothyroidism
3. Chronic renal insufficiency with baseline Cr about 1.3
4. Anemia
5. Gout
Discharge Condition:
Stable. Patient can ambulate 80 feet of flat distance with
assistance, tolerates 2L of oxygen.
Discharge Instructions:
You were admitted to the hospital with confusion due to a
urinary tract infection and renal failure. While you were here,
you also developed very high blood pressure, rapid and irregular
heart rate, and difficulty breathing. These have all improved
significantly during treatment in the hospital.
.
We have treated your urinary tract infection with an antibiotic
called bactrim for seven days. We have also started you on
another antibiotic called nitrofurantoin, which should be
completed on [**2167-3-15**].
.
You also developed severe shortness of breath due to your rapid
and irregular heart rate, heart failure, and elevated blood
pressure. Your breathing improved significantly with duiretics
(water pills) and blood pressure medicines. It will be important
for you to follow-up with the heart failure doctor, Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 437**].
.
Please continue to take your medications on the list provided.
(Please note that there have been several changes so you should
follow the updated list.)
.
If you experience any fevers > 100.5, chills, confusion,
shortness of breath, chest pain, palpitations, chest pain, or
any other concerning symptoms please call your PCP or go to the
ER for further evaluation.
Followup Instructions:
- Please follow-up with your cardiologist DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at
your appointment on [**2167-3-16**] 10:30. If you need to reschedule,
please call his office at [**Telephone/Fax (1) 3512**].
.
- Please follow up with your Oncologist, Dr. [**Last Name (STitle) **], within [**2-15**]
weeks of discharge. We are trying to arrange an appointment for
you on Thursday [**2167-3-26**], but you should call the clinic to
confirm this. Phone: ([**Telephone/Fax (1) 15328**].
.
Please also follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 2 weeks
of discharge. Phone [**Telephone/Fax (1) 14918**].
|
[
"244.9",
"274.9",
"041.4",
"584.9",
"599.0",
"284.1",
"427.31",
"780.6",
"428.33",
"403.90",
"585.9",
"250.00",
"272.4",
"112.0",
"942.09",
"E879.2",
"288.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
22362, 22435
|
12090, 12326
|
315, 321
|
22870, 22967
|
4853, 4858
|
24275, 24952
|
3947, 4127
|
19946, 22339
|
22456, 22456
|
18133, 19923
|
22991, 24252
|
4142, 4834
|
272, 277
|
5411, 5814
|
12354, 18107
|
349, 1759
|
8325, 12067
|
22729, 22849
|
5823, 8316
|
22475, 22708
|
4872, 5392
|
1781, 3832
|
3848, 3931
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,048
| 187,721
|
11303+11304+56227
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2169-9-19**] Discharge Date: [**2169-9-23**]
Date of Birth: [**2115-9-18**] Sex: F
Service: medicine
HISTORY OF PRESENT ILLNESS: This is a 54 year-old female
with a long history of schizophrenia, bipolar disorder and
alcohol use who was transferred from [**Hospital **] Hospital after she
was admitted for an acute psychotic episode after self
discontinuing her psychiatric medications around the 12th of
Hospital before being transferred to [**Hospital1 **] on
the [**9-19**]. On the [**9-19**] she
presented to the Emergency Room where she was found to be
noncommunicative on admission. In addition, she had a
temperature of 102.8, pulse of 120 and a systolic blood
pressure of 130 to 140 with a respiratory rate of 30. In
addition, the patient was noted to have gross tremors at
In the Emergency Room the patient was given Levofloxacin for
presumed community acquired pneumonia. Psychiatry Service
was consulted to work her up for neuroleptic malignant
syndrome, because of her high fever and also because her CK
was found to be 928 on admission with no MB and no
significant electrocardiogram changes. In the Emergency Room
she was given Ativan and then transferred to the MICU for
stabilization.
In the MICU she was noted to have a high sodium (160) and she
was started on D5 half normal saline.
HOSPITAL COURSE: The patient was admitted to the MICU for
observation of her cardiac enzymes and also to complete her
infectious disease workup and to help her defervesce. The
patient as previously stated was started on Levofloxacin
although her chest x-ray on the day of admission was negative
for any infiltrate. The patient's urinalysis done on
hospital day number one showed 100 protein, trace glucose, 3
red blood cells, 3 white blood cells, no bacteria and 4 epis.
The urine culture was negative for infection. Multiple
attempts were made to do an LP at the bedside, however, the
LP ultimately had to be done under fluoroscopy. The LP done
on hospital day number two was negative for evidence of
meningitis or any other infection. The patient defervesced
on hospital day number two and was transferred to the regular
medicine floor. Her sodium at that time was still elevated
at 156. The patient on the floor was continued on aggressive
hydration with D5 half normal saline at 175 cc an hour. In
addition with serial chemistry laboratories drawn. In
addition the patient's CK was followed throughout the course
of the admission. Throughout the hospitalization the patient
was maintained off of psychotropic medications and was given
only hydration as per the recommendation by psychiatry.
On physical examination the patient continued to have
stiffness in all extremities and a gross resting tremor.
However, by hospital day number three she was able to follow
simple commands. Over the course of the hospitalization the
patient's CK continued to drop and gradually cam eto normal
levels. In
addition, the patient's sodium level continued to normalize
over the course of the hospitalization and her sodium on the
day of discharge to psychiatry is 141. The patient's H&H
remained stable over the course of the hospitalization. On
hospital day number three her hematocrit was 41.8. The
belief was that the patient on admission was extremely dry. On
hospital day number
three, because of the patient's increased agitated state a
one to one sitter was needed and put in to place. The
patient has since then been relatively cooperative and
spending most of her days lying in bed. The patient and had
evidence of significant delirium with lethargy, slurred speech
and disorientation that lasted for subsequent week. She had
periods of agitation requiring ativan. over time we were able to
taper down the ativan and her mental status steadily improved. At
the time of transfer to psychiatry on [**2169-10-3**] pt was taking
adequate Pos, using the bathroom. She knew she was in the
hospital and what her name was but did not know other details
of current events. She had evidence of tardive dyskinesia with
contiued oral buccal movements and constant picking/hand and
finger movements. The patient will be discharged to an inpatient
psychiatric
floor here at the [**Hospital1 **].
[**First Name (Titles) **] [**Last Name (Titles) **] issue: enterococcal UTI- treated with d/c of foley and
amoxicillin. diarrhea- marked during initial part of hospital
stay. her family reports that she chronically has diarrhea.
Abdominal exam benign. labs remarkable for mild LFT
abnormalities. hepatitis serologies neg. stool sent for culture
and c. diff were neg. She should have outpatient eval of this.
In house put on immodium with good effect.
Discharge meds: Ativan 0.5 mg PO bid and 0.5 prn, immodium prn,
amoxicillin 250 tid to complete 1 week cours.
Discharge diagnoses: neuroleptic malignant syndrome, delirium,
hypernatremia, enterococcal UTI, chronic diarrhea, chronic
schizophrenia
Outpatient Psychiatrist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- [**Location (un) 86**] St. [**Location (un) **]
phone-[**Telephone/Fax (1) 36267**]
Outpatient PCP- [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1124**] [**Telephone/Fax (1) 36268**]
Pt transferred to inpatient psychiatry at [**Hospital1 18**] on [**2169-10-3**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 4872**]
MEDQUIST36
D: [**2169-9-23**] 12:32
T: [**2169-9-27**] 10:14
JOB#: [**Job Number **]
Admission Date: [**2169-9-19**] Discharge Date: [**2169-9-29**]
Date of Birth: [**2115-9-18**] Sex: F
ADDENDUM: This is an addendum. The patient was not
discharged on [**2169-9-23**], due to the fact that
Psychiatry felt that she was not ready to go and felt that
she had not undergone a subsequent thorough delirium workup.
1. NEUROLOGY: The patient had a normal TSH. The patient
was found to have negative CT scan for any evidence of bleed
or pathology. The patient was RPR nonreactive. The patient
had a normal folate level and vitamin B12 level and was found
to be cleared in terms of her metabolic causes of delirium.
The patient was maintained on Ativan, and due to increase
The patient's creatine kinases continued to be monitored due
to the fact that she had neuroleptic malignant syndrome, and
on the day of discharge her creatine kinase was at 232.
2. GASTROINTESTINAL: The patient was found to have had
increased motility of stool with numerous diarrhea episodes
from the dates of [**9-23**] to [**9-27**]. She
underwent a stool culture which was found to be negative, and
Clostridium difficile culture which was found to be negative.
The patient was subsequently placed on Imodium with
subsequent resolution of frequent bowel movements. The
patient had undergone some skin breakdown due to the frequent
bowel movements and Nystatin cream and ....................
ointment were applied to the buttocks with improvement of
area erythema and irritation.
3. GENITOURINARY: The patient had Foley catheter due to the
fact that she was unable to inform personnel when she had to
void. Her urine was cultured and was found to be positive
with enterococcus greater than 100,000. She was subsequently
placed on amoxicillin 250 mg p.o. t.i.d.
4. RENAL: The patient had elevated AST and ALT of 52
and 83, respectively. This was most likely thought secondary
to muscle breakdown. However, a hepatitis panel was run and
was found to be negative for hepatitis B and hepatitis C.
However, hepatitis A results were still pending upon
discharge; although, the patient was afebrile without any
abdominal pain or tenderness.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient was on
intravenous fluid hydration just due to decreased p.o.
intake. However, her electrolytes remained normal. Her
sodium was 145 upon discharge, and her potassium was 3.8.
However, the patient did have increased p.o. intake upon
discharge with encouragement. A Nutrition consultation was
sought during this stay, and the patient was advised to be on
Boost shakes.
DISCHARGE STATUS: The patient was subsequently discharged
to a Medical Psychiatric Unit in order for the initiation of
psychiatric medications.
************** See other discharge summary for discharge
diagnoses and medications and f/u plans**************
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 31245**]
MEDQUIST36
D: [**2169-9-29**] 14:20
T: [**2169-9-29**] 15:11
JOB#: [**Job Number 30734**]
Name: [**Known lastname 6465**], [**Known firstname 4193**] Unit No: [**Numeric Identifier 6466**]
Admission Date: [**2169-9-19**] Discharge Date: [**2169-10-3**]
Date of Birth: [**2115-9-18**] Sex: F
Service: [**Doctor Last Name 633**]
ADDENDUM: This is an addendum to a previously dictated
Discharge Summary.
The patient is a 54-year-old female with a history of
schizophrenia who was admitted to [**Hospital1 4242**] with a diagnosis of neuroleptic malignant
syndrome and was subsequently placed on intravenous fluid
hydration and had a negative Infectious Disease workup with a
negative chest x-ray, and lumbar puncture, and blood
cultures. However, the patient was found to have a positive
urinalysis with enterococcus and was treated with amoxicillin
for a 10-day course.
The patient was subsequently discharged to an inhouse
psychiatric facility for treatment of her schizophrenia due
to the fact that all of her medical issues had resolved. She
had a normal creatine kinase upon discharge with a value of
191 and a normal BUN and creatinine with a value of 8/0.6.
DISCHARGE DISPOSITION: Her condition upon discharge revealed
the patient was eating, ambulating, and urinating, and
defecating spontaneously without assistance. The patient was
able to converse. However, the patient still had some
evidence of delirium and would subsequently be transferred to
an inpatient psychiatric unit for initiation of antipsychotic
medication and monitoring for improvement and clearing of
post neuroleptic malignant syndrome delirium.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3258**], M.D. [**MD Number(1) 3259**]
Dictated By:[**Name8 (MD) 5443**]
MEDQUIST36
D: [**2169-10-3**] 13:20
T: [**2169-10-5**] 11:51
JOB#: [**Job Number 6467**]
|
[
"295.60",
"293.0",
"E941.1",
"276.0",
"333.92",
"276.5",
"599.0",
"E939.3",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9855, 10557
|
4825, 9831
|
1362, 4804
|
164, 1344
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,968
| 173,725
|
873+874
|
Discharge summary
|
report+report
|
Admission Date: [**2182-2-5**] Discharge Date: [**2182-2-6**]
Date of Birth: Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient was an 84-year-old man,
who had a fall at home after a bad headache with positive
loss of consciousness. 911 was called and he was brought to
the Emergency Room awake and alert. Initial CAT scan of the
head did show a small right subdural hematoma as well as left
temporal contusions with ventricular blood. He was scheduled
for a MRI of the brain when his mental status deteriorated.
Repeat CAT scan of the head showed a larger subdural hematoma
on the left side as well as increased contusions in the left
temporal region and blood in the fourth ventricle, which was
increased.
He was emergently taken to the OR for left craniotomy and
evacuation of a subdural hematoma.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post MI in [**2153**].
2. CABG x4 in [**2169**].
3. Non-insulin dependent-diabetes mellitus.
4. GERD.
5. Cataracts.
6. Glaucoma.
7. Hypertension.
8. Osteoarthritis.
9. Prostate cancer status post TURP in [**2170**].
10. Status post colon resection for adenoma.
MEDICATIONS AT TIME OF ADMISSION:
1. Isosorbide.
2. Lasix.
3. Procardia.
4. Naprosyn.
5. Diazepam.
6. Chlorpropamide.
SOCIAL HISTORY: He was not a smoker. Did not drink alcohol.
ALLERGIES: He has allergies to dye and shellfish.
HOSPITAL COURSE: Postoperatively, he remained intubated.
His vital signs were stable. His left pupil was nonreactive
at 6 mm and the right was 2 mm and nonreactive. He had no
corneal reflexes, no gag response or cough. He had bloody
drainage from the ventricular drain. He had a poor
prognosis.
On [**2182-2-6**] he had a cold caloric test, which was
negative, had no response. He continued to be managed in the
Intensive Care Unit. With discussion initially with his wife
and daughter and later with a nephew, and after much
discussion, the family opted to withdraw care.
On [**2182-2-6**] at 3:20 p.m., the patient expired.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 5996**]
MEDQUIST36
D: [**2182-4-8**] 12:04
T: [**2182-4-9**] 07:27
JOB#: [**Job Number 5997**]
Admission Date: [**2182-2-5**] Discharge Date: [**2182-2-6**]
Date of Birth: Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient was an 84-year-old man,
who had a fall at home after a bad headache with positive
loss of consciousness. 911 was called and he was brought to
the Emergency Room awake and alert. Initial CAT scan of the
head did show a small right subdural hematoma as well as left
temporal contusions with ventricular blood. He was scheduled
for a MRI of the brain when his mental status deteriorated.
Repeat CAT scan of the head showed a larger subdural hematoma
on the left side as well as increased contusions in the left
temporal region and blood in the fourth ventricle, which was
increased.
He was emergently taken to the OR for left craniotomy and
evacuation of a subdural hematoma.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post MI in [**2153**].
2. CABG x4 in [**2169**].
3. Non-insulin dependent-diabetes mellitus.
4. GERD.
5. Cataracts.
6. Glaucoma.
7. Hypertension.
8. Osteoarthritis.
9. Prostate cancer status post TURP in [**2170**].
10. Status post colon resection for adenoma.
MEDICATIONS AT TIME OF ADMISSION:
1. Isosorbide.
2. Lasix.
3. Procardia.
4. Naprosyn.
5. Diazepam.
6. Chlorpropamide.
SOCIAL HISTORY: He was not a smoker. Did not drink alcohol.
ALLERGIES: He has allergies to dye and shellfish.
HOSPITAL COURSE: Postoperatively, he remained intubated.
His vital signs were stable. His left pupil was nonreactive
at 6 mm and the right was 2 mm and nonreactive. He had no
corneal reflexes, no gag response or cough. He had bloody
drainage from the ventricular drain. He had a poor
prognosis.
On [**2182-2-6**] he had a cold caloric test, which was
negative, had no response. He continued to be managed in the
Intensive Care Unit. With discussion initially with his wife
and daughter and later with a nephew, and after much
discussion, the family opted to withdraw care.
On [**2182-2-6**] at 3:20 p.m., the patient expired.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 5996**]
MEDQUIST36
D: [**2182-4-8**] 12:04
T: [**2182-4-9**] 07:27
JOB#: [**Job Number 5997**]
|
[
"250.00",
"578.0",
"801.12",
"E880.9",
"286.6",
"401.9",
"V45.81",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.31",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3696, 4551
|
2439, 3126
|
3148, 3563
|
3580, 3678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,386
| 189,427
|
41916
|
Discharge summary
|
report
|
Admission Date: [**2119-10-22**] Discharge Date: [**2119-10-24**]
Date of Birth: [**2089-1-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 30 year-old woman with h/o [**First Name3 (LF) 31217**]-dependent
diabetes mellitus, with poor [**First Name3 (LF) 31217**] compliance [**1-18**] needle
phobia and h/o multiple hospitalizations for DKA, who presented
with nausea, vomiting, abdominal pain, and hyperglycemia.
Patient did not take any of her short acting [**Month/Day (2) 31217**] yesterday
because she was not eating. She reports that she frequently
misses meals so that she can miss [**First Name (Titles) **] [**Last Name (Titles) 31217**] dosing (she thinks
she does not have to take [**Last Name (Titles) 31217**] if she doesn't eat) because of
her needle phobia. Patient reports taking her home dose of
lantus last night. This morning she found that her FS was 410
and took 20 units of humalog. She developed nausea, vomiting
this morning with mild RLQ abdominal pain. No fevers, chills,
dysura. Patient does report recent staph groin infection (not
MRSA) for which she was treated with keflex. This has resolved
and she finished her antibiotic on [**2119-10-19**]. Furthermore, the
patient reports cough productive of clear sputum. No fevers,
chills.
In the ED initial vitals were: 97.4 131 125/91 16 100% RA. She
was noted to have to have initial FS of 410. Labs were
significant for bicarb of 5, anion gap of 29, blood glucose of
410. UA showed 150 ketones. No evidence of UTI and HCG
negative. CXR did not show evidence of pneumonia. Patient
received 7 units of regular [**Date Range 31217**] and was started on [**Date Range 31217**]
gtt at 7 units per hour. She received 3L IVF. She was very
anxious for IV placement and blood draws and recived 3 mg IV
ativan x1.
On arrival to the MICU, patient feels tired, but she has
improved from earlier. No fevers, chills. Mild cough. No
nausea/vomiting. Mild LLQ abdominal pain. No dysuria, hematuria.
Patient does report palpitations.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness. Denies shortness of breath,
or wheezing. Denies chest pain, chest pressure, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Type 1 Diabetes Mellitus, diagnosed at age 25
Needle Phobia, recently started seeing psychiatrist at [**Last Name (un) **]
Inguinal hernia
Social History:
- Tobacco: None
- Alcohol: Rare, has not had any drinks over past week
- Illicits: None
Lives with parents, works as hostess at a restaurant.
Family History:
Noncontributory
Physical Exam:
General: Sleeping, but easliy arousable, tearful at times, in no
acute distress
HEENT: Erythema over nasal bridge and cheeks, PERRLA, EOMI,
slightly dry mucus membranes
Neck: supple, JVP not elevated, no LAD
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild RLQ tenderness to palpation, non-distended,
bowel sounds present, no organomegaly
GU: no foley, healed left-sided scab in groin at prior site of
infection
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Physical Exam:
Vitals: T: 97.7, BP: 94/60, P: 101, R: 18, O2: 98% RA
General: well appearing female, resting in bed, no apparent
distress
HEENT: Erythema over nasal bridge and cheeks, dry MM
Neck: supple, JVP not elevated
CV: RR, tachy to 100, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, nontender, nondistended, +BS
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2119-10-22**] 08:30AM BLOOD WBC-12.9* RBC-5.05 Hgb-15.5 Hct-48.2*
MCV-96 MCH-30.8 MCHC-32.2 RDW-13.7 Plt Ct-446*
[**2119-10-23**] 06:15PM BLOOD WBC-4.8 RBC-4.05* Hgb-12.6 Hct-36.1
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.8 Plt Ct-262
[**2119-10-22**] 08:30AM BLOOD Neuts-89.5* Lymphs-8.7* Monos-1.5* Eos-0
Baso-0.3
[**2119-10-22**] 12:45PM BLOOD PT-11.9 PTT-26.8 INR(PT)-1.0
[**2119-10-22**] 08:30AM BLOOD Glucose-410* UreaN-15 Creat-0.9 Na-139
K-3.7 Cl-105 HCO3-5* AnGap-33*
[**2119-10-23**] 06:15PM BLOOD Glucose-290* UreaN-9 Creat-0.4 Na-136
K-3.8 Cl-104 HCO3-23 AnGap-13
[**2119-10-23**] 06:15PM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0
[**2119-10-22**] 12:54PM BLOOD Type-MIX pO2-196* pCO2-25* pH-7.26*
calTCO2-12* Base XS--13 Comment-GREEN TOP
[**2119-10-22**] 12:54PM BLOOD Glucose-148* Lactate-1.1 Na-144 K-3.4
Cl-121* calHCO3-12*
[**2119-10-22**] 10:50AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2119-10-22**] 10:50AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
PORTABLE AP CHEST RADIOGRAPH: The cardiac, mediastinal and hilar
contours are unremarkable. Both lungs appear clear with no focal
consolidation, pleural effusion or pneumothorax. IMPRESSION: No
acute cardiopulmonary process.
Brief Hospital Course:
1. Diabetic ketoacidosis with type I diabetes: The patient has
had multiple admissions for DKA. The likely etiology is that the
patient was not taking her [**Month/Day/Year 31217**] for a few days prior to
admission. She does state that she was taking lantus. She notes
that she often does not take [**Month/Day/Year 31217**] and will often avoid meals
due to needle phobia. No evidence of infection in blood, CXR or
UA. She was started on [**Month/Day/Year 31217**] gtt and IVF. She had rapid
closure of her gap and was switched to SC [**Month/Day/Year 31217**] lantus (40u)
and humalog ISS. She was transferred to the floor. On the floor
she noted she was at her baseline and was on a stable [**Month/Day/Year 31217**]
regimen. [**Last Name (un) **] consulted and agree with the regimen. She was
discharged with a psychiatry appointment at [**Last Name (un) **]. [**Last Name (un) **] will
contact her with a diabetes appointment. She noted the
importance of eating and taking [**Last Name (un) 31217**] regularly.
2. Anemia, NOS: Her hematocrit initially dropped from 48-34.
This was likely dilutional. It was stable upon discharge without
evidence of bleed on history or exam.
3. Anxiety: She has significant anxiety, especially related with
needles. She was given ativan prn for blood draws. She was
continued on her prozac. She will be followed by [**Last Name (un) **]
psychiatry.
Transitional issues:
Blood sugar: titration of [**Last Name (un) 31217**] regimen
Anxiety: needs better control of needle phobia
Medications on Admission:
Prozac 20 mg daily
Ativan 0.5 mg TID (patient reports taking at least 4 tabs at a
time)
Ambien 5 mg qHS PRN
Humalog [**Last Name (un) **] (carb counting, 1 unit of [**Last Name (un) 31217**]: 5 gram of
carbs)
Lantus 40 units qHS
Discharge Medications:
1. ethyl chloride Topical
2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
4. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. [**Last Name (un) 31217**] glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: please see attached sheet.
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 91012**],
You were admitted for DKA. This likely was because of you
[**Known lastname 31217**] management. It is essential that you eat everyday and
take both your short and long acting [**Known lastname 31217**] and prescribed. You
will need to be followed by your primary care physician and
[**Name9 (PRE) 91013**] diabetes doctor in the near future.
Please see the attached [**Name9 (PRE) 31217**] sliding scale for changes in
your [**Name9 (PRE) 31217**] regimen. If your blood sugars are consistantly over
300 please contact your primary care physician or [**Name9 (PRE) 387**]
diabetes doctor [**First Name (Titles) **] [**Last Name (Titles) 7219**] on how to adjust your
[**Last Name (Titles) 31217**]. If you develop symptoms of DKA please present to a
hospital as soon as possible.
You should likely continue to see a psychiatrist for your needle
phobia. Being compliant with your [**Last Name (Titles) 31217**] regimen is essential
for keeping you out of the hospital and healthy.
Followup Instructions:
Please follow up with your [**Last Name (un) **] psychiatry appointment.
[**Last Name (un) **] will contact you by telephone to set up an appointment
with your diabetes doctor.
Please set up an appointment with [**First Name9 (NamePattern2) 91014**] [**Doctor Last Name 12838**] for the next
1-2 weeks.
|
[
"V58.67",
"300.00",
"285.9",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7831, 7837
|
5524, 6915
|
308, 315
|
7885, 7885
|
4232, 5501
|
9080, 9388
|
2979, 2996
|
7326, 7808
|
7858, 7864
|
7072, 7303
|
8036, 9057
|
3011, 3734
|
6936, 7046
|
2247, 2639
|
265, 270
|
343, 2228
|
7900, 8012
|
2661, 2801
|
2817, 2963
|
3759, 4213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,931
| 145,283
|
31425
|
Discharge summary
|
report
|
Admission Date: [**2106-8-11**] Discharge Date: [**2106-9-15**]
Service: CARDIOTHORACIC
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2106-8-13**] CABG x 5 (LIMA->LAD, SVG->OM3, SVG->OM1->OM2, SVG->PDA)
[**2106-8-31**] Trach and PEG
History of Present Illness:
82 yo M with h/o CAD, presented to OSH with 48 hours of chest
pain. Cath showed 20-30% LM, 90% LAD, 90% Lcx, RCA 90%.
Transferred to [**Hospital1 18**] for CABG.
Past Medical History:
MI [**2071**], CHF, Afib (currently NSR), lipids, HTN, BLE vein
surgery [**2041**], bilat knee surgery.
Social History:
retired
lives with wife at [**Name (NI) 74005**] Place
quit tobacco 15 years ago, 30 pack year history
occasional etoh
Family History:
NC
Physical Exam:
Admission:
NAD, pain free on NTG gtt
Lungs CTAB ant/lat
RRR, no M/R/G
Abd soft/NT/ND
Extrem cool, no edema. BLE stasis changes. Well healed scars
bilat knees. Extensive UE ecchymosis
Some varicose veins
Discharge:
VS: T98.7 HR82AF BP122/63 RR22 O2sat 97% 50% trach collar
Gen: NAD
Neuro: Awake, responsive to verbal stimuli, occaisionally
follows commands
Pulm: Course rhonchi, trach in place
CV: Irreg/irreg. Sternum stable. Incision CDI
Abdm: soft, NT, +BS, Gtube in place, site CDI
Ext: warm, EVH site healing. 1+ pedal edema
Pertinent Results:
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2106-9-10**] 7:56 AM
CHEST (PORTABLE AP)
Reason: s/p ? aspiration-r/o infiltrate
[**Hospital 93**] MEDICAL CONDITION:
83 year old man s/p urgent cabg x5 remains intubated.
REASON FOR THIS EXAMINATION:
s/p ? aspiration-r/o infiltrate
INDICATION: Aspiration, recent CABG.
Comparison is made to films dating back to [**2106-8-12**], the
most recent being [**2106-9-7**].
PORTABLE UPRIGHT VIEW OF THE CHEST AT 8:10 A.M.: The
tracheostomy tube and right subclavian catheter remain in
unchanged and adequate position. There has been interval
improvement in left hazy opacity indicating improved pulmonary
edema. The left pleural effusion is slightly smaller. The right
lower lobe consolidation persists and may represent aspiration
pneumonia. The persistent retrocardiac opacity likely represents
atelectasis associated with the left pleural effusion, but may
also reflect a component of consolidation.
IMPRESSION: Interval improvement in pulmonary edema. Unchanged
right lower lobe pneumonia, likely aspiration. Left lower lobe
atelectasis versus additional focus of pneumonia.
DR. [**First Name (STitle) 2671**] [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Cardiology Report ECHO Study Date of [**2106-8-16**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Mitral valve disease.
Height: (in) 70
Weight (lb): 161
BSA (m2): 1.91 m2
BP (mm Hg): 97/49
HR (bpm): 68
Status: Inpatient
Date/Time: [**2106-8-16**] at 12:28
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
INTERPRETATION:
Findings:
Patient was intubated and sedated on a propofol drip as per CSRU
orders.
This study was compared to the prior study of [**2106-8-13**].
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Severely depressed LVEF.
RIGHT VENTRICLE: RV function depressed.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. No atheroma in ascending aorta. Simple atheroma in
aortic arch. Complex (>4mm) atheroma in the aortic arch. Simple
atheroma in descending aorta. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP.
Mild to
moderate ([**1-5**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**1-5**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). No TEE related complications. The rhythm
appears to be atrial fibrillation. Emergency study performed by
notified of the echocardiographic results by e-mail.
Echocardiographic results were reviewed with the houseofficer
caring for the patient. Left pleural effusion.
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
left ventricular systolic function is severely and globally
depressed (LVEF= 25-30 %). Right ventricular systolic function
appears depressed. There are simple and complex (>4mm)
nonmobile atheroma in the aortic arch and descending thoracic
aorta. There is spontaneous echo contrast in the descending
aorta and arch consistent with a low cardiac output state. The
aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is mild posterior leaflet mitral valve
prolapse. Mild to moderate ([**1-5**]+) mitral regurgitation is seen.
IMPRESSION: Posterior mitral leaflet systolic prolapse with mild
to moderate mitral regurgitation. Severely depressed left
ventricular systolic function. Depressed right ventricular
function. Mild aortic regurgitation. Compared with the prior
study (images reviewed) of [**2106-8-13**], findings are similar.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2106-8-16**]
19:46.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2106-9-13**] 02:54AM 9.1 3.25* 10.3* 31.8* 98 31.8 32.5 19.6*
191
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2106-9-13**] 02:54AM 191
Source: Line-R subclavian
[**2106-9-13**] 02:54AM 18.8* 26.1 1.8
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2106-9-13**] 02:54AM 55* 77* 1.4* 145 4.0 111* 27 11
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2106-9-10**] 02:37AM 74* 113* 201* 1.3
Source: Line-rsc
OTHER ENZYMES & BILIRUBINS Lipase
[**2106-8-29**] 06:35AM 123*
[**2106-8-11**] 04:36PM GLUCOSE-105 UREA N-15 CREAT-1.1 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2106-8-11**] 04:36PM ALT(SGPT)-36 AST(SGOT)-30 ALK PHOS-35*
AMYLASE-51 TOT BILI-1.0
[**2106-8-11**] 04:36PM LIPASE-33
[**2106-8-11**] 04:36PM %HbA1c-6.1*
[**2106-8-11**] 04:36PM DIGOXIN-0.6*
[**2106-8-11**] 04:36PM WBC-7.8 RBC-4.21* HGB-13.3* HCT-38.0* MCV-90
MCH-31.5 MCHC-34.9 RDW-13.5
[**2106-8-11**] 04:36PM PLT COUNT-153
[**2106-8-11**] 04:36PM PT-11.4 PTT-23.1 INR(PT)-1.0
Brief Hospital Course:
Mr. [**Known lastname 74006**] NTG gtt was weaned and he subsequently had chest
pain. The NTG was restarted, he was started on a heparin drip.
He underwent preop testing including vein mapping and carotid
ultrasound. He was taken to the operating room on [**8-13**]. On
induction of anesthesia he arrested, he then underwent an
emergent CABG x 5. He was transferred to the ICU in critical but
stable condition on epinephrine, milrinone, insulin, propofol,
and phenylephrine. He was started on levofloxacin for
pneumonia. He had atrial fibrillation for which he underwent TEE
and was unsuccesfully cardioverted. He was started on
cisatracurium. He was seen by wound care for groin and foot
wounds. He remained intubated on pressors in cardiogenic shock.
He was changed to zosyn and flagyl on [**8-21**]. His pressors were
slowly weaned and he was off all pressors on [**8-22**]. On [**8-30**] he
had a large retroperitoneal bleed which required 7 UPRBCs. On
[**8-31**] he had a percutaneous trach and PEG and tolerated the
procedure well. He coninued to improve but was neurologically
withdrawn and was evaluated by neurology and they thought it was
metabolic. He was started on Zoloft and became a little more
responsive. He continue to wean slowly from the ventilator and
on [**9-15**]
he was discharged to rehabilitation to progress with ventilator
weaning, and physical therapy.
Medications on Admission:
coreg, lasix, lisinopril, digoxin, fluvastatin
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Ten (10)
Subcutaneous once a day.
2. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection four times a day.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin 1 mg Tablet Sig: target INR 1.5-2.0 Tablets PO DAILY
(Daily).
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO DAILY
(Daily).
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Metoclopramide 5 mg/mL Solution Sig: Five (5) mg Injection
Q6 Hrs/PRN as needed for nausea/vomiting.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
CAD
s/p MI [**2071**]
CHF
Afib
Hyperlipidemia
HTN
Discharge Condition:
Stable.
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call with fevers, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) 5017**] 2 weeks after discharge from rehab
Dr. [**Last Name (STitle) 1884**] 2 weeks after dischrge from rehab
Dr. [**First Name (STitle) **] 4 weeks after discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2106-9-15**]
|
[
"518.5",
"414.01",
"785.51",
"997.1",
"428.0",
"413.9",
"427.31",
"998.12",
"486",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"31.1",
"96.71",
"88.42",
"88.48",
"36.15",
"96.6",
"36.14",
"38.93",
"88.72",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
10381, 10451
|
7754, 9143
|
240, 344
|
10545, 10555
|
1387, 1523
|
10824, 11149
|
814, 818
|
9240, 10358
|
1560, 1614
|
10472, 10524
|
9169, 9217
|
10579, 10801
|
2762, 6483
|
833, 1368
|
190, 202
|
1643, 2736
|
372, 535
|
6515, 7731
|
557, 662
|
678, 798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,929
| 143,559
|
51150
|
Discharge summary
|
report
|
Admission Date: [**2114-2-12**] Discharge Date: [**2114-2-27**]
Date of Birth: [**2032-5-30**] Sex: F
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
back pain, weakness
Major Surgical or Invasive Procedure:
subclavian central line
peripherally inserted central catheter
History of Present Illness:
81F with h/o lumbar stenosis, DJD, chornic back pain on epidural
injections, cervical spondylosis, parkinsonism, B12 neuropathy,
and AF on flecainide, who presents with worsening back pain, RLE
weakness and fever. She reports that she had been in USOH until
[**2-11**], when she woke up with increasingly severe LBP, worse with
movement, and she found it difficult to ambulate. In the ER,
exam showed R leg weakness. She was also found to be febrile to
102. L-spine MRI demonstrated increased T2 signal in L4-5
without enhancement, c/w DJD or discitis. Repeat MRI with STIR
images again showed no enhancement, suggesting DJD.
.
She was admitted, and found to have high grade bacteremia in [**7-18**]
bottles, which grew MSSA. She was started on vancomycin/CTX, and
switched to nafcillin once speciation and sensitivies were
complete. Gentamicin was held due to renal insufficiency. Having
had a recent toe surgery, she underwent a foot xray, which
showed no evidence of osteomyelitis. Pelvis film showed no
evidence of SI joint infection. Given high-grade bacteremia, TTE
was performed which showed no evidence of vegetation, but TEE
revealed a sub-cm aortic valve vegetation wihtout evidence of
peri-valvular abscess. She has had negative blood cultures since
[**2-12**] on nafcillin.
.
Due to worsening pain, she had a C-spine and T-spine MRI, which
demonstrated a fluid collection posterior to L2-3, extending
inferiorly beyond the T-spine cuts, which had not been noted
previously. Neurosurgery was consulted, who recommended a repeat
dedicated lumbar MRI. This was performed in the ICU after
elective intubation [**3-16**] patient agitation and showed new large
epidural abscess extending from the T11 to the L5 levels causing
severe canal stenosis. After a long discussion with the family,
it was decided to attempt conservative treatment with
antibiotics and re-image in 1 week given likely high
peri-operative mortality. Given her agitation and confusion, a
brain MR was done which showed enhancement of the sulci,
suggesting meningeal irritation or infection. Her mental status
appeared to remain stable and she was transferred to the floor
for further management.
Past Medical History:
Lumbar stenosis/disc disease, CLBP with DJD - gets epidural
injections at [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center
Likely cervical stenosis
Hammertoe repairs recently
Afib
HTN
PVD with stents in legs
Parkinsonism
Anemia
Neuropathy thought related to B12
Gastritis
Gout
Social History:
Married,lives with husband, non [**Name2 (NI) 1818**], occ beer. Walks with
cane at baseline.
Family History:
Positive fmily history of CAD, father died at age 63 of CAD.
Physical Exam:
On admission:
Tm 102.8 Tc 97.8 HR 64(64-76) BP 156/72(140-156/68-75) RR
16-20 sat 99%RA
General appearance: well appearing elderly woman, with mild pain
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: diminished breath sounds bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Back: point tenderness over vertebral body at L1 or L2
Rectal: normal tone, guaiac neg stool per ED
Neuro: CN II-XII in tact, + rigidity in arms and cogwheeling at
the wrists bilat. Rest tremor bilat. 5/5 strength in RLE, [**5-17**]
in LLE. No sacral anaesthesia to PP.
.
On transfer:
T: 98.4 BP: 140/62 HR: 70 RR: 16 SaO2: 98% RA
General appearance: elderly woman, confused, follows commands
but poor concentration
HEENT: PERRL, EOMi, oropharynx clear, dentures
Neck: supple, no bruits
Heart: [**Last Name (un) **] [**Last Name (un) 3526**], 2/6 SEM LUSB, no JVD
Lungs: CTAB
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused, 1+ bilat LE edema
Back: point tenderness over vertebral body at L2
Rectal: normal tone (per ICU team)
Neuro: Alert but closes eyes frequently, disoriented. CNII-XII
intact. Speech soft, logical. Tongue midline. +dysmetria
bilaterally. Strength 5/5 throughout. Sensation intact to light
touch. 2+ DTRs [**Name (NI) **] bilat, 1+ patellars, absent ankle jerks.
Downgoing toes bilat.
Pertinent Results:
Hematology:
[**2114-2-12**] 05:45AM WBC-9.7# RBC-3.27* HGB-9.5* HCT-28.3* MCV-87
MCH-29.2 MCHC-33.7 RDW-15.7*
[**2114-2-12**] 05:45AM NEUTS-92* BANDS-0 LYMPHS-4* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2114-2-12**] 05:45AM PLT COUNT-165
[**2114-2-12**] 05:41AM LACTATE-1.2
.
Chemistry:
[**2114-2-12**] 05:45AM GLUCOSE-116* UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2114-2-12**] 05:45AM CALCIUM-8.9 PHOSPHATE-2.2* MAGNESIUM-1.5*
.
Urine:
[**2114-2-12**] 10:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-2-12**] 10:11PM URINE RBC-[**1-1**]* WBC-[**4-16**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2114-2-12**] 08:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
Admission CXR: There is mild cardiomegaly. There is
mild perihilar haziness, right greater than left, likely
indicating edema. There are scattered nodular opacities in both
lung fields, though these are not as prominent when compared to
the prior examination. Osseous structures are unremarkable.
.
MR [**Name13 (STitle) **] ([**2-26**]): Multilevel discitis extending from L1 through
L5-S1 levels with new areas of increased T2 signal along the
disc spaces of L1-L2 and L3-L4 levels. There is however
decrease involving the overall size of the epidural abscess
detected on the previous examination which still extends from
T11-T12 through L5-S1 levels. The largest loculation is seen at
the L4-L5 level resulting in significant narrowing of the canal.
A paraspinal phlegmon is also identified at L4-L5 level.
Further followup is suggested.
.
SUPINE & UPRIGHT KUB ([**2-20**]): The bowel gas pattern is
non-obstructive. There is a normal amount of stool. There is
no evidence of free intra-abdominal air. Visualized portions of
the lungs are grossly clear. There are severe degenerative
changes of the lower lumbar spine. There is a right common
iliac stent. A rectal tube appears to be in place.
IMPRESSION: No evidence of obstruction or free air.
.
TEE ([**2-19**]):
The left atrium is top normal in size. Mild spontaneous echo
contrast is seen in the body of the left atrium and left atrial
appendage. Mild spontaneous echo contrast is present in the left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. There are simple (<4mm, non-mobile) atheroma in the
aortic arch and descending thoracic aorta. There aortic valve
leaflets (3) are moderately thickened. A 5x7mm, highly mobile
echodensity is seen on the aortic side of the left coronary
leaflet c/w a vegetation. No aortic valve abscess is seen. There
is trivial aortic regurgitation. The mitral valve leaflets are
moderately thickened with minimally increased gradient/stenosis.
No mass or vegetation is seen on the mitral valve. Mild (1+)
mitral
regurgitation is seen.
IMPRESSION: Small to moderate sized mobile echodensity on the
aortic side of the aortic valve consistent with a vegetation
(though atypical in location). Minimal mitral stenosis. Mild
mitral regurgitation.
.
Renal U/S ([**2-18**]):
FINDINGS: The right kidney measures 10.1 cm in length. The
left kidney measures 10.3 cm in length. There is no
hydronephrosis or nephrolithiasis. Both kidneys are echogenic,
suggestive of renal parenchymal disease. Within the mid pole of
the right kidney again seen is a 1.3-cm simple cyst. The
previously seen left upper lobe cyst is not well demonstrated on
the today's study secondary to technique and patient's body
habitus. No renal masses or perirenal fluid collections are
seen. The resistive indices within the renal parenchyma and
renal arteries are elevated bilaterally. The RIs in the
parenchyma of the right kidney range from 0.78 to 0.81. The RIs
in the parenchyma of the left kidney range from 0.79 to 0.86.
The RI in the right renal artery is 0.86. The RI in the left
renal artery is 0.90.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Echogenic kidneys consistent with renal parenchymal disease.
3. Elevated RIs in the renal parenchyma and renal arteries
bilaterally.
.
CT chest/abdomen/pelvis ([**2-17**]):
1. Interval decrease in now trace bilateral pleural effusions
with continued ground-glass opacities with vague nodular
opacities predominantly in the upper lobes. Findings may
suggest hydrostatic, pulmonary edema.
2. New patchy opacities in the lower lobes and posterior lungs
bilaterally consistent with atelectasis or infiltrate.
3. New small pericardial effusion.
4. No evidence of bowel inflammation or intraabdominal abscess.
5. Mildly distended gallbladder wall edema with apparent
layering sludge. Correlate clinically.
6. Small hiatal hernia.
7. Bilateral hypodense renal lesions, incompletely
characterized without IV contrast.
8. Body wall edema consistent with anasarca.
9. Stable right upper lobe nodule (series 2, image 24).
.
MR [**Name13 (STitle) **] ([**2-17**]):
1. Since [**2114-2-12**], new large epidural abscess extending from
the T11 to the L5 levels causing severe canal stenosis. This
process has increased in size compared to the MR of the thoracic
spine from [**2114-2-14**].
2. Worsening spondylodiscitis at the L4/5 level. Possible new
spondylodiscitis at L5/S1 level.
3. Possible focus of diskitis at L2-3.
.
MR [**Name13 (STitle) **] ([**2-16**]):
The study is limited due to patient motion artifact. However,
the FLAIR images demonstrate increased signal throughout all the
sulci of the brain as well as within the subdural space. These
findings are highly concerning for meningitis given the history
of bacteremia and possible epidural abscess. There may be
pachymeningeal enhancement noted on the post-gadolinium images,
which are limited due to patient motion artifact. These
findings were telephoned to Dr. [**Last Name (STitle) **] at the time of dictation.
There is no midline shift, mass effect, or hydrocephalus. There
is mucosal thickening with a large air-fluid level in right
maxillary sinus with a moderate-sized air-fluid level in left
maxillary sinus. Mucosal thickening is also noted throughout
the ethmoid, left frontal and right sphenoid sinuses. There is a
small amount of fluid in both mastoid air cells.
IMPRESSION: Findings are most consistent with meningitis with
abnormal CSF signal in the sulci and subdural space. There
appears to be pachymeningeal enhancement, also consistent with
this diagnosis.
.
MR C-,T- spine ([**2-14**]):
Posterior to the L2 and 3 vertebral bodies and extending
inferiorly, there appears to be a heterogeneous fluid collection
present. This does not appear to enhance, but is only partially
imaged. Direct comparison with the [**2114-2-12**] lumbar spine
MRI demonstrates posterior displacement of the nerve roots but
no fluid collection is appreciated. A repeat lumbar spine MRI
with gadolinium should be performed to better characterize this
collection. No axial images were obtained through this level on
the thoracic spine MRI.
.
TTE ([**2-14**]): EF > 55%
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. There is no
valvular aortic stenosis. The increased transaortic gradient is
likely related to high cardiac output. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2114-1-31**], the estimated pulmonary artery
systolic pressure is lower. No discrete vegetation identified
with similar vlavular regurgitation.
Brief Hospital Course:
81F h/o chronic LBP on epidural injections, cervical stenosis,
parkinsonism, Afib, HTN, PVD, Anemia and B12-related neruopathy
p/w back pain, LE weakness, fever found to have epidural
abscess, aortic-valve endocarditis, and acute-on-chronic renal
failure.
.
# Epidural abscess: Likely [**3-16**] outpatient epidural injections.
Dorsal, extending from T11 to L5 on most recent L-spine MRI,
impinging 50% of cauda equina. MSSA positive bacteremia at
presentation 6/6 bottles, but negative cultures since [**2114-2-13**]
after starting on IV nafcillin. Gentamycin was not started given
renal failure. Serial neuro exams have been stable. Briefly
intubated (for 2 days) for imaging studies. Neurosurgery decided
not to operate given high risk mortality. Repeat imaging on [**2-26**]
revealed improvement in abscess and plan is to continued
antibiotics for 6 weeks with Neurosurgery followup with Dr.
[**Last Name (STitle) 548**].
.
# Endocarditis: Given high grade bacteremia at presentation, the
patient underwent evaluation for possible endocarditis. TTE was
negative but TEE demonstrated 5-7mm mobile vegetation on aortic
cusp with no evidence of root abscess. Presumed MSSA positive,
likely seeded from epidural abscess. Daily ECGs revealed no
evidence of conduction abnormalities. She was monitored on
telemetry with no events noted. ID was consulted and recommended
continuing nafcillin to complete 8 week course (started on [**2-12**]).
She will followup with ID (Dr. [**First Name (STitle) **] per d/c instructions. The
patient will need weekly LFT checks while taking nafcillin.
.
# MSSA bacteremia: Likely [**3-16**] epidural abscess but also possible
from recent toe surgery. Blood Cx (-) since [**2114-2-12**], sensitive to
nafcillin. No perinephric abscess on U/S. The patient will
continue antibiotic treatment per above.
.
# Acute on chronic renal failure: Baseline Cre 1.5. Renal team
was consulted. U/S demonstrated increased echogenicity,
suggesting intrinsive renal disease. C3 and C4 normal; urine Eos
negative. PTH was 42. Etiology of acute renal failure thought
most likely embolic disease from endocarditis, however urine
lytes support underlying pre-renal component and her renal
function has improved with fluids (Cre 1.8 at discharge).
Continue to encourage PO intake. Medications should continue to
be renally dosed.
.
# Mental status: The patient had intermittent altered mental
status thought to be [**3-16**] delerium on baseline dementia from
underlying infection. She is A&Ox1 at baseline and stable at
discharge. Sedating pain medications have been held and her pain
instead has been well controlled with tylenol.
.
# Parkinsonism: Continued carbidopa/levodopa, [**Month/Day (2) 85471**] per outpt
regimen.
.
# HTN: Increased metoprolol dose given elevated BPs. [**Month (only) 116**] need to
be readjusted after underlying infection is further treated.
.
# Afib: Continued flecainide and metoprolol. Coumadin was held
initially for supratherapeutic INR (see below) and INR
normalized after administration of vitamin K. A heparin gtt
bridge was considered but given initial concern for septic
emboli the risk for hemorrhagic conversion was thought to be
high and outweigh benefit. Prior to discharge, however, given
the patient's improvment coumadin was restarted at 2.5 mg po qd.
She will need to have an INR check on [**3-1**].
.
# Anemia: Normocytic. Iron studies during admission c/w ACD. Hct
was low but stable. She received 1 unit pRBC with appropriate
increase. Epogen 1000 units qMoWeFr was started per Renal
consult team. The patient will need outpatient monitoring of her
hematocrit.
.
# PVD with LE stents: Continued lipitor, BB, ASA
.
# Coagulopathy: Both PT and PTT were elevated initially, but
then resolved with vitamin K. There was no laboratory evidence
of DIC and therefore the etiology was most likely [**3-16**] coumadin
use in context of antibiotics. An inhibitor screen was negative.
She was restarted on reduced dose coumadin prior to discharge
(see above).
Medications on Admission:
Sinemet 25/100 1.5tabs 4x/d
B12 500 mcg
Vit C 250 mg
Vit D 400 u
Lisinopril 20 mg
Metoprolol 50 mg [**Hospital1 **]
Flecainide 50 mg [**Hospital1 **]
Lipitor 40 mg
Coumadin 5 mg/2.5 mg
ASA 81 mg
Tums
Tramadol 50 mg PRN
MoM
[**Name (NI) **] 50 mg tid
Tylenol 500 mg prn pain
Discharge Medications:
1. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-13**] PO BID (2 times a
day).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
7. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
sliding scale qid Subcutaneous ASDIR (AS DIRECTED).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Epoetin Alfa 2,000 unit/mL Solution Sig: 1000 (1000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. 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.
14. Nafcillin 2 g Recon Soln Sig: Two (2) grams Intravenous
every four (4) hours for 6 weeks.
15. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Epidural abscess
Endocarditis
Acute renal failure secondary to septic emboli
Acute blood-loss anemia
Discharge Condition:
Stable, tolerating POs
Discharge Instructions:
You will need to have weekly liver function tests measured. You
will also need to have your INR level checked on [**3-1**] as you
have been restarted on coumadin. Finally, you will need to have
a repeat MRI/MRA of your L-spine in 6 weeks.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2114-4-9**] 2:15.
Please attend this appointment for followup of your epidural
abscess. You will need to have a repeat MRI/MRA of your L-spine
in 6 weeks.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2114-4-5**] 11:30. Please follow up with your infectious
disease doctor for your epidural abscess.
.
Cardiology Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2114-7-19**] 9:40
.
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-9-11**]
11:00
|
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"999.3",
"799.02",
"403.91",
"584.9",
"293.0",
"285.1",
"721.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"88.72",
"38.93",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
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|
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|
308, 372
|
18617, 18642
|
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|
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|
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|
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|
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|
2923, 3019
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,079
| 133,195
|
33313
|
Discharge summary
|
report
|
Admission Date: [**2126-5-22**] Discharge Date: [**2126-5-27**]
Date of Birth: [**2044-6-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zestril / Pravachol / Zocor / Mevacor / Crestor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2126-5-22**] Urgent Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG
to OM, SVG to Diag, SVG to PDA)
History of Present Illness:
81 y/o male who was c/o chest pressure x 1 month with activity.
Cardiac cath was initially declined by him but when his BNP and
CXR showed mild vascular congestion he agreed. Cath revealed a
95% left main lesion along with three vessel coronary artery
disease. He was then transferred to [**Hospital1 18**] for urgent/emergent
bypass surgery.
Past Medical History:
Gastroesophageal Reflux Disease, Hypertension,
Hypercholesterolemia, Sick Sinus Syndrome s/p [**Company 1543**] PPM,
Peripheral Neuropathy, Restless leg Syndrome, Chronic Renal
Insufficiency, Prostate Cancer
PSH: Radical Prostatectomy, Bilateral Carpal Tunnel Release,
Squamous cell removal, Bilateral Cataract Surgery
Social History:
Quit smoking greater than 40 years ago. Drinks approximately 2
ETOH beverages/day.
Family History:
Brother with CABG at age 85.
Physical Exam:
VS: 64 20 147/70 5'7" 175#
Gen: 81 y/o male lying in bed in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD, -Carotid Bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x3, MAE, non-focal
Pertinent Results:
[**2126-5-26**] 06:10AM BLOOD WBC-7.4 RBC-2.73* Hgb-8.3* Hct-24.0*
MCV-88 MCH-30.5 MCHC-34.8 RDW-14.1 Plt Ct-226
[**2126-5-24**] 05:35AM BLOOD WBC-9.9 RBC-2.32* Hgb-7.2* Hct-21.4*
MCV-92 MCH-31.0 MCHC-33.5 RDW-13.1 Plt Ct-191
[**2126-5-22**] 12:25PM BLOOD WBC-5.1 RBC-3.70* Hgb-11.2* Hct-32.6*
MCV-88 MCH-30.2 MCHC-34.3 RDW-12.6 Plt Ct-274
[**2126-5-26**] 06:10AM BLOOD Plt Ct-226
[**2126-5-22**] 12:25PM BLOOD PT-14.8* PTT-97.2* INR(PT)-1.3*
[**2126-5-22**] 08:47PM BLOOD Fibrino-206
[**2126-5-26**] 06:10AM BLOOD Glucose-103 UreaN-44* Creat-1.6* Na-141
K-4.3 Cl-104 HCO3-28 AnGap-13
[**2126-5-24**] 05:35AM BLOOD Glucose-155* UreaN-46* Creat-2.1* Na-138
K-4.9 Cl-104 HCO3-28 AnGap-11
[**2126-5-26**] 06:10AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.5
[**2126-5-22**] 12:25PM BLOOD %HbA1c-6.3*
CHEST (PA & LAT) [**2126-5-26**] 10:26 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with
REASON FOR THIS EXAMINATION:
r/o inf, eff
HISTORY: Rule out infiltrate or effusion.
CHEST, TWO VIEWS.
The lungs are hyperinflated and diaphragms are flattened,
consistent with COPD. There is eventration of the right
hemidiaphragm. The patient is status post sternotomy, with
cardiomegaly including prominence of the left main pulmonary
artery versus left hilum. There is a left-sided pacemaker with
lead tips over right atrium and right ventricle. There is a
small amount of pleural fluid and/or thickening bilaterally. No
CHF or focal infiltrate is identified. Minimal atelectasis is
present bilaterally. Compared with [**2126-5-24**], inspiratory volumes
have improved somewhat. The small pleural effusions are more
easily identified, but not clearly different.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77318**], [**Known firstname 412**] [**Hospital1 18**] [**Numeric Identifier 77319**] (Complete)
Done [**2126-5-22**] at 5:40:17 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: [**2044-6-2**]
Age (years): 81 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for Off pump CABG
ICD-9 Codes: 402.90, 786.51, 440.0
Test Information
Date/Time: [**2126-5-22**] at 17:40 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.8 cm <= 2.5 cm
Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.2 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo
contrast in the body of the LA. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity. All four pulmonary veins identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Mild regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Mildly dilated descending aorta. Simple
atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
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. No TEE related complications. The rhythm appears
to be A-V paced. Results were personally reviewed with the MD
caring for the patient.
Conclusions
Prebypass:
The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. 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. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
apical akinesis and distal anterior hypokinesis.. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. 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. Physiologic
mitral regurgitation is seen (within normal limits). Dr.
[**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the procedure..
Postbypass:
Normal Rv systolic function.
Thoracic aortic contour is intact.
Minimal MR.
Improved LV systolic function in ptrbioudly hypokinretic areas.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2126-5-23**] 01:16
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from [**Hospital6 1109**]
following cardiac catherization that showed severe left main and
three vessel disease. Upon admission to the CVICU, he was
continued on IV Heparin and appropriately worked-up. He was
taken to the operating shortly thereafter where he underwent a
coronary artery bypass graft x 4. Please see operative report
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was started on beta
blockers and diuretics and gently diuresed towards his pre-op
weight. Also on this day his chest tubes were removed and he was
transferred to the telemetry floor for further care. On post-op
day two his epicardial pacing wires were removed and his was
transfused several units of blood secondary to low HCT (21). His
HCT improved post transfusion. He continued to improve and beta
blockers were titrated up. Physical therapy worked with him for
strength and mobility. He was ready for discharge home with
services on POD 5.
Medications on Admission:
Atenolol 25mg qd, Cozaar 100mg qd, Klonopin 0.5mg qhs, Aspirin
81mg qd, Gemfibrozil 600mg [**Hospital1 **], Zantac 150mg [**Hospital1 **] prn, Prilosec
20mg qd, Neurontin
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
Coronary Artery Disease s/p Urgent Coronary Artery Bypass Graft
x 4
PMH: Gastroesophageal Reflux Disease, Hypertension,
Hypercholesterolemia, Sick Sinus Syndrome s/p [**Company 1543**] PPM,
Peripheral Neuropathy, Restless leg Syndrome, Chronic Renal
Insufficiency, Prostate Cancer
PSH: Radical Prostatectomy, Bilateral Carpal Tunnel Release,
Squamous cell removal, Bilateral Cataract Surgery
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 for redness or drainage from surgical wounds
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:
Please call to schedule appointments
[**Hospital Ward Name 121**] 6 for wound check in 2 weeks
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) 1075**] in [**3-17**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2126-5-27**]
|
[
"355.8",
"403.90",
"285.1",
"530.81",
"585.9",
"333.94",
"272.0",
"V10.83",
"V10.46",
"414.01",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10995, 11051
|
8042, 9194
|
323, 430
|
11486, 11492
|
1618, 2490
|
11815, 12129
|
1261, 1291
|
9415, 10972
|
2527, 2548
|
11072, 11465
|
9220, 9392
|
11516, 11792
|
1306, 1599
|
273, 285
|
2577, 8019
|
458, 802
|
824, 1145
|
1161, 1245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,948
| 195,852
|
43403
|
Discharge summary
|
report
|
Admission Date: [**2175-8-8**] Discharge Date: [**2175-8-13**]
Date of Birth: [**2116-10-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillin V / Metformin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
acidosis, respiratory failure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname 2816**] is a 58 year old man with a history of type II
diabetes mellitus, and chronic toe infections who first
presented to [**Hospital 5871**] Hospital with bradycardia and hypotension.
His wife notes that he was feeling episodes of lightheadedness
about a week ago. Around that time he was started on
ciprofloxacin for a toe infection by his podiatrist. She noticed
he was more quiet than usual today, and then at 11:30am, she was
called by a co-worker at [**Company 7546**] that he was pale and
diaphoretic and did not want to come to the hospital. The
coworker eventually helped him home and at 2:30pm his wife found
him at the front steps. At that time EMS was activated and he
was brought to [**Hospital3 **]. EMS noted sinus brady in the
40's and BP 82/40. Initial ABG was 7.01/46/332 and when repeated
was 7.14/39/370. AG was 14. Lactate was 6.2. Glucose was 508,
potassium was 7.2. A femoral TLC was placed, calcium gluconate,
insulin and kayexalate were given. Lasix was also given for "low
urine output." while his pressure was 84/41. In the ED there,
his HR dropped to the 20's with wide-complexes. He became
unresponsive and was intubated after getting etomidate/succinyl
choline. He got two amps of atropine, two amps of epi, lidocaine
100mg, vecuronium (at 3:35pm). He was hypotensive and
bradycardic for about 15 minutes.
.
In the ED here it was noted that his pupils were "fixed and
dilated 6mm". A head ct was performed and he was further
hydrated.
Past Medical History:
DM for 11 years on oral agents. Does not check his BS regularly
at all.
HTN
hypercholesterolemia
myocardial infarction- his PCP told him he had one after his
ECHO.
Toe infections
First digit on bilateral feet operated on in past.
Social History:
smokes 1ppd for 30 years, drinks 3 drinks/week, denies drug use.
Lives with wife and 13 [**Name2 (NI) **] son. works at [**Company 7546**].
Family History:
DM, Cancer (bladder, prostate, lung), heart disease
Physical Exam:
VS: T HR BP RR Sat
Gen: Intubated, sedated, making some myoclonic movements of
arms, legs. Access: +ETT, +Foley +femoral TLC
HEENT: MMM, pupils sluggish but reactive 6mm->5mm. Sclerae
anicteric.
Neck: Trachea midline
CV: Nl s1/s2, III/VI HSM at apex. RRR
Pul: CTA bilaterally
Abd: Obese, no rebound or guarding
Ext: cool but 2+ DP , 2+ RP bilaterally
Neuro: sedated, myoclonic jerking, withdraws to pain, moving all
four extremities. Off of sedation, neuro exam improved w/o
myoclonus, although he has upgoing toes.
Pertinent Results:
[**2175-8-8**] 06:45PM BLOOD WBC-11.8* RBC-3.31* Hgb-10.9*# Hct-32.1*
MCV-97 MCH-33.0* MCHC-34.0 RDW-13.8 Plt Ct-151
[**2175-8-8**] 06:45PM BLOOD Neuts-84* Bands-1 Lymphs-2* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2175-8-12**] 06:05AM BLOOD WBC-4.5 RBC-2.64* Hgb-8.6* Hct-24.6*
MCV-93 MCH-32.8* MCHC-35.2* RDW-13.8 Plt Ct-131*
[**2175-8-8**] 06:45PM BLOOD PT-15.1* PTT-29.5 INR(PT)-1.4*
[**2175-8-10**] 03:26AM BLOOD PT-13.8* PTT-27.6 INR(PT)-1.2*
[**2175-8-8**] 06:45PM BLOOD Glucose-386* UreaN-35* Creat-2.1* Na-136
K-5.9* Cl-106 HCO3-18* AnGap-18
[**2175-8-12**] 06:05AM BLOOD Glucose-143* UreaN-15 Creat-1.0 Na-140
K-3.2* Cl-103 HCO3-25 AnGap-15
[**2175-8-8**] 10:30PM BLOOD ALT-938* AST-766* LD(LDH)-1495*
CK(CPK)-116 AlkPhos-44 Amylase-57 TotBili-0.4
[**2175-8-11**] 05:45AM BLOOD ALT-360* AST-56* AlkPhos-41 TotBili-0.4
[**2175-8-12**] 06:05AM BLOOD LD(LDH)-212
[**2175-8-8**] 10:30PM BLOOD Lipase-73*
[**2175-8-10**] 03:26AM BLOOD Lipase-71*
[**2175-8-8**] 06:45PM BLOOD cTropnT-<0.01
[**2175-8-8**] 06:45PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.8
[**2175-8-12**] 06:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.6 Cholest-168
[**2175-8-11**] 05:45AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.3* Iron-42*
[**2175-8-10**] 03:26AM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.4 Mg-1.6
[**2175-8-11**] 05:45AM BLOOD calTIBC-299 Ferritn-305 TRF-230
[**2175-8-12**] 06:05AM BLOOD Hapto-171
[**2175-8-11**] 05:45AM BLOOD %HbA1c-8.9* [Hgb]-DONE [A1c]-DONE
[**2175-8-12**] 06:05AM BLOOD Triglyc-275* HDL-28 CHOL/HD-6.0
LDLcalc-85
[**2175-8-10**] 03:26AM BLOOD TSH-0.76
[**2175-8-9**] 05:15AM BLOOD Free T4-1.5
[**2175-8-8**] 06:57PM BLOOD pO2-354* pCO2-41 pH-7.25* calTCO2-19*
Base XS--8
[**2175-8-8**] 10:52PM BLOOD Type-ART Temp-35.9 Rates-18/4 Tidal V-700
PEEP-5 FiO2-50 pO2-62* pCO2-49* pH-7.29* calTCO2-25 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2175-8-9**] 01:50AM BLOOD Type-ART Temp-36.4 Rates-28/ Tidal V-600
PEEP-5 FiO2-60 pO2-98 pCO2-33* pH-7.44 calTCO2-23 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2175-8-9**] 08:19AM BLOOD Type-ART Temp-37.6 Rates-/22 PEEP-5
FiO2-50 pO2-88 pCO2-32* pH-7.42 calTCO2-21 Base XS--2
Intubat-INTUBATED Vent-SPONTANEOU
[**2175-8-8**] 10:52PM BLOOD freeCa-1.17
.
.
STUDIES:
[**2175-8-8**] CXR: IMPRESSION: No intracranial hemorrhage or mass
effect. Prominent atherosclerotic carotid and vertebral artery
calcifications are noteworthy in a patient of this age.
.
[**2175-8-8**] CXR: IMPRESSION:
1. ET tube is positioned in the mid trachea, in satisfactory
position.
2. NG tube tip is positioned a short distance beyond the GE
junction, and the side hole is not definitely visualized.
Consider advancement of the tube to ensure that the sidehole is
positioned beyond the GE junction.
3. Mild prominence of pulmonary vasculature - while this may
represent mild interstitial edema, the contribution of crowding
of pulmonary vessels from low lung volumes is uncertain.
4. There is a rounded ill-defined opacity in the right upper
lung zone of uncertain etiology. Further evaluation with
dedicated PA and lateral chest radiographs, or a CT scan, should
be considered.
.
[**2175-8-8**] EKG: Sinus rhythm. First degree A-V delay. Probable left
atrial abnormality. Modest
non-specific ST-T wave changes. No previous tracing available
for comparison.
TRACING #1
.
[**2175-8-8**] EKG:
Sinus rhythm. First degree A-V delay. Probable left atrial
abnormality. Modest
non-specific ST-T wave changes. Since the previous tracing of
[**2175-8-8**] no
significant change.
TRACING #2
.
[**2175-8-9**] CXR: FINDINGS:
Since the prior study, the patient has been extubated and the NG
tube removed.
Lung volumes are maintained. There is mild left basilar opacity
which has a linear configuration that suggests atelectasis,
though aspiration is a consideration. No pulmonary edema. Heart
size is normal.
Redemonstrated is the 1.8-cm round nodule within the right upper
lung that has mildly coarse calcifications. This nodule remains
indeterminant and a CT scan without contrast or quality PA and
lateral chest x-ray are recommended to characterize further.
.
[**2175-8-12**] CXR: IMPRESSION:
1. 2.3 cm nodular density within the right upper lobe containing
some coarse calcifications. Further evaluation with CT scan is
recommended as malignancy cannot be excluded.
2. No signs for acute cardiopulmonary process.
Brief Hospital Course:
58 year old man with type II diabetes mellitus presenting with
renal failure, hyperkalemia and altered mental status, intubated
during for bradycardic arrest at an OSH and transferred to [**Hospital1 18**]
for further management. Pt presented with rising LFT's,
unresponsiveness and myoclonic jerking. He recovered from his
acidosis and his brief hospital course is described below:
.
# Acidosis: patient presented on [**2175-8-9**] with a BS in the 500's
and was believed to have hyperglycemic hyperosmolar acidosis.
He was in an altered mental state and was started on an insulin
gtt with D5 and bicarb. He had frequent ABGs performed until
his acidosis reversed. Initially, he presented with a wide
complex brady arrythmia likely secondary to his hyperkalemia on
admission. An echo at the OSH was unremarkable. His EKG
improved as the hyperkalemia improved. On admission to [**Hospital1 18**] he
was noted to have fixed pupils but CT scan showed no mass effect
or ICH. He initially had some myoclonus which was likely due to
his metabolic derrangements and resolved shock. This
dissappated as the patient improved. He was extubated on
[**2175-8-9**] and transfered to the medical floor the next day. He
also had a shock liver pattern with rising transaminases thought
to be secondary to a shock liver from his initial bradycardia at
the outside hospital. Throughout the course of his
hospitalization, his LFTs improved.
.
# ARF: This was likely due to CRI from DM, and dehydration from
metabolic acidosis (max Cr 2.1). He was aggressively hydrated
and slowly his renal function returned to a basline Cr of 1.0.
An FeUrea suggested a pre-renal cause for his ARF.
.
# Diabetes: During his hospitalization, he was treated with
insulin as it was unclear whether his oral agents might have
contributed to his acidosis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] diabetes consult was
called and they felt he became acidotic secondary to the
following pattern of events: metformin plus cipro for foot
infection caused hyperglycemia. Created osmotic diuresis which
caused ARF. This led to metformin toxicity and metabolic
acidosis. His A1C was 8.9. He was told to NOT take the
metformine, but to restart his avandia and to increase his
glipizide to 10mg [**Hospital1 **]. He was asked to check his BS before
meals and at bedtime and record them in a journal. He had a
follow up appointment with Dr. [**First Name (STitle) **], endocrinology, in
[**Last Name (un) 5869**] closer to his home, and was told to contact them sooner
if his BS were consistently above 200 for insulin therapy.
.
# HTN: His blood pressure medications changed due to low blood
pressure. He was instructed not take the verapamil until he has
follow up with his PCP. [**Name10 (NameIs) **], his atenolol was cut in half (to
50mg a day) and lisinopril in half (to 20mg a day).
.
# PPX: PPI, heparin sq.
.
Code status: full
Medications on Admission:
Lisinopril 40mg daily
ASA 81mg daily
Glipizide 10mg daily
Viagra 100mg prn
Metformin 1000mg twice daily
Avandia 8mg daily
Buproprion 150mg twice daily
Verapamil 360mg twice daily
Rhinocort prn
Gemfibrozil 600mg twice daily
Atenolol 100mg qhs
Ranitidine 300mg daily
Discharge Medications:
1. One Touch Ultra System Kit Kit Sig: One (1) kit Miscell.
as directed.
Disp:*1 kit* Refills:*2*
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. One Touch Test Strip Sig: to be used with kit as directed
Miscell. four times a day.
Disp:*100 strips* Refills:*2*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Lab Work
Please have your liver function tests (ALT, AST, alk phos,
bilirubin), BUN, creatinine checked this week and Dr. [**Last Name (STitle) 58**]
will follow this up.
9. One Touch UltraSoft Lancets Misc Sig: to be used with kit
as directed Miscell. four times a day.
Disp:*100 lancets* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Infected foot ulcer
2. Hyperosmolar nonketotic coma
3. Hypotension
4. Acute renal failure
5. Shock Liver
6. Lactic acidosis
7. Hyperkalemia
8. Bradycardic arrest
Secondary Diagnosis:
1. Diabetes
2. Hypertension
3. Hyperlipidemia
Discharge Condition:
good, oxygenating well on room air, blood sugars controlled
Discharge Instructions:
You likely had an infection in your foot which led to elevated
blood sugars and dehydration/low blood volume which led to
kidney failure and liver failure. All of these problems are
improving now.
-We have resumed all your prior diabetes medications except the
metformin. We have also increased your glipizide to 10mg twice
a day.
Please check your sugars before all meals and at bedtime and
record them in a journal. If your sugars are consistently above
200, you should call the [**Last Name (un) **] and be seen so they can start
insulin therapy. The number for [**Last Name (un) **] is [**Telephone/Fax (1) 2378**].
.
-We have changed some of your blood pressure medications due to
low blood pressure. Do not take the verapamil until directed by
your PCP. [**Name10 (NameIs) **], we have cut your atenolol in half (to 50mg a
day) and lisinopril in half (to 20mg a day). You should follow
up with your PCP and he will increase these as needed.
Please call your PCP or go to the ER if you experience any of
the following symptoms: fevers, chills, confusion, dizziness,
increased thirst, increased urination, abdominal pain, nausea,
vomiting, diarrhea.
Followup Instructions:
Please call Dr. [**First Name (STitle) **] in [**Location (un) 620**] to make a diabetes
appointment. His phone number is ([**Telephone/Fax (1) 54400**]. He can also
set you up with a nutritionist to help you eat a better diabetic
diet.
Also, please call [**Telephone/Fax (1) 3329**] to make an appointment to see
your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**], or one of his nurses
ni the next week. At this time, your blood pressure should be
checked along with some labs.
Completed by:[**2175-8-16**]
|
[
"583.81",
"250.42",
"584.9",
"518.81",
"401.9",
"570",
"272.0",
"276.51",
"707.15",
"427.5",
"427.89",
"276.7",
"276.2",
"585.9",
"250.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11387, 11393
|
7224, 10158
|
314, 327
|
11689, 11751
|
2878, 7201
|
12962, 13515
|
2273, 2326
|
10474, 11364
|
11414, 11414
|
10184, 10451
|
11775, 12939
|
2341, 2859
|
245, 276
|
355, 1846
|
11620, 11668
|
11433, 11599
|
1868, 2100
|
2116, 2257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,005
| 158,487
|
47464
|
Discharge summary
|
report
|
Admission Date: [**2147-10-6**] Discharge Date: [**2147-10-14**]
Date of Birth: [**2079-11-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hemoptysis/hematemesis and Altered mental status
Major Surgical or Invasive Procedure:
Interventional Radiology - Embolisation
Intubation
History of Present Illness:
67yo M with CAD(s/p distant MI), HLD, gout, OSA was called in
to MICU after being bronched (which identified oozing blood in
Left Upper Lobe. He was found to be altered, and as per
Thoracics he had altered mental status prior to the procedure,
but unclear for how long before that.
He was recently ([**2147-8-30**]) admitted to [**Hospital1 18**] for massive
hemotpysis
underwent bronchoscopy and bronchial artery embolization with
interventional radiology. However, when he was d/c home, he
continued to cough up dark clots and small streaks of blood. He
is followed as an outpt by Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]. He presented
this time with
SOB and dysphagia, which started this afternoon occuring
mutliple times per hour.
He initially presented to his primary care physician who sent
him
to the ED for evaluation. There are no factors that exacerbate
or
relieve his symptoms. He is able to eat and drink without
problem, but he intermittently experiences shortness of breath
and inability to swallow which resolves in a few seconds without
intervention. He reports no fevers, chills, nausea or
vomitting,
lightheadedness or weakness.
.
On the floor, he was responsive to voice commands, opened eyes
spontaneously, moved extremities, but was somnolent and would
not answer questions directly at times.
.
Review of systems: unobtanable.
.
Past Medical History:
-CAD s/p Inferior MI [**2122**]
-Ischemic cardiomyopathy: Last TTE [**2142**] EF 35%, Moderate
regional LV systolic dysfunction with evidence of an extensive
inferior infarction
-Hypercholesterolemia
-Hypertension
-Gout
-Internal Hemorrhoids
Social History:
TOB: quit: 2yrs, previous 40 pack-yrs
ETOH: heavy use per wife until recent hospitalization then none
Occupation: accountant
Marital Status: Married. Lives w/ family
Family History:
Family History: Mother had MI in 50's and died in 80's of
unknown cause. Father died in 80's of unknown cause. No cancer
family history
Physical Exam:
General: disoriented, trying to get out of bed, responds to name
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds on the left
CV: Tachycardic, normal S1 + S2,no discernable murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Cranial nerves intact, hard to asses mental status as it
was waxing and [**Doctor Last Name 688**], oriented to name only.
Pertinent Results:
[**2147-10-5**] 09:41PM PT-12.1 PTT-25.1 INR(PT)-1.0
[**2147-10-5**] 09:41PM PLT COUNT-233
[**2147-10-5**] 09:41PM NEUTS-82.6* LYMPHS-10.3* MONOS-4.7 EOS-1.8
BASOS-0.6
[**2147-10-5**] 09:41PM WBC-8.8 RBC-3.56* HGB-10.5* HCT-32.0* MCV-90
MCH-29.6 MCHC-32.9 RDW-17.0*
[**2147-10-5**] 09:41PM GLUCOSE-93 UREA N-38* CREAT-1.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
[**2147-10-5**] 09:41PM GLUCOSE-93 UREA N-38* CREAT-1.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
[**2147-10-5**] 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2147-10-5**] 10:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2147-10-6**] 03:31PM PT-12.7 PTT-23.2 INR(PT)-1.1
[**2147-10-6**] 03:31PM PLT COUNT-211
[**2147-10-6**] 03:31PM WBC-7.5 RBC-2.89* HGB-8.8* HCT-26.1* MCV-90
MCH-30.3 MCHC-33.5 RDW-17.1*
[**2147-10-6**] 03:31PM HAPTOGLOB-70
[**2147-10-6**] 03:31PM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.6
MAGNESIUM-2.1
[**2147-10-6**] 03:31PM LIPASE-45
[**2147-10-6**] 03:31PM ALT(SGPT)-20 AST(SGOT)-33 LD(LDH)-327* ALK
PHOS-87 AMYLASE-94 TOT BILI-0.5
[**2147-10-6**] 03:31PM GLUCOSE-111* UREA N-33* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-25 ANION GAP-11
[**2147-10-6**] 05:55PM O2 SAT-79 CARBOXYHB-1
[**2147-10-6**] 05:55PM LACTATE-1.5
[**2147-10-6**] 05:55PM TYPE-ART PO2-46* PCO2-29* PH-7.48* TOTAL
CO2-22 BASE XS-0 INTUBATED-NOT INTUBA
[**2147-10-6**] 06:43PM PLT COUNT-173
[**2147-10-6**] 06:43PM WBC-9.3 RBC-2.81* HGB-8.4* HCT-25.2* MCV-90
MCH-29.9 MCHC-33.4 RDW-17.1*
[**2147-10-6**] 06:43PM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
[**2147-10-6**] 06:43PM CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-1.8
[**2147-10-6**] 06:43PM GLUCOSE-106* UREA N-32* CREAT-0.9 SODIUM-141
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2147-10-6**] 06:52PM HGB-8.1* calcHCT-24 O2 SAT-53 CARBOXYHB-1 MET
HGB-1
[**2147-10-6**] 06:52PM LACTATE-2.1* NA+-136 CL--105
[**2147-10-6**] 06:52PM TYPE-[**Last Name (un) **] PO2-32* PCO2-38 PH-7.42 TOTAL CO2-25
BASE XS--1 INTUBATED-NOT INTUBA
CXR: [**10-6**] In comparison with the study of [**10-5**], there is
continued
opacification in the anterior portion of the left upper lobe.
Given the clinical history of bronchial artery embolization and
hemoptysis, this most likely represents pulmonary hemorrhage.
However, the possibility of supervening pneumonia can certainly
not be excluded.
CT BIOPSY Study Date of [**2147-10-10**] 11:25 AM:. Successful CT-guided
core biopsy of largest inferior right hepatic segment V mass. 2.
Successful CT-guided core biopsy of large presumed right adrenal
metastasis.
CT HEAD:There are multiple large supra- and infratentorial
masses with a
hyperdense rim and associated surrounding edema. The largest
mass is in the right temporal lobe measuring approximately 2.7 x
2.6 cm (2:10). Hyperdensity may represent enhancement related to
recent administration of contrast;
however, intralesional hemorrhage cannot be excluded. Ventricles
and sulci
are normal in size and appearance. The basilar cisterns are
preserved. There is mucosal thickening in the bilateral ethmoid,
right greater than left, and sphenoid sinuses. The remainder of
the visualized paranasal sinuses and mastoid air cells are well
aerated. No osseous abnormality is identified.
IMPRESSION: Multiple supra- and infratentorial masses with a
hyperdense rim, which could represent enhancement, but
underlying intralesional hemorrhage cannot be excluded.
Differential diagnosis includes metastatic disease or infection.
Findings were discussed with Dr. [**First Name8 (NamePattern2) 7306**] [**Last Name (NamePattern1) 805**] at 2:10 a.m. on
[**2147-10-7**].
Procedure date Tissue received Report Date Diagnosed by
[**2147-10-10**] [**2147-10-10**] [**2147-10-12**] DR. [**Last Name (STitle) **]. BROWN/aas??????
DIAGNOSIS: A. Liver, needle core biopsy:Hepatic parenchyma and
necrotic material. No viable cells are present for evaluation
in the necrotic area.
Multiple levels have been examined.
B. Adrenal biopsy:Poorly differentiated carcinoma, the tumor
cells are large with abundant cytoplasm. No features of small
cell carcinoma are seen. Tumor cells stain strongly for CK7 and
do not stain for CK20. This pattern is not specific, but is
typical in lung carcinoma. Tumor cells do not stain for TTF-1,
but large cell lung carcinomas typically do not stain with this
marker.
Brief Hospital Course:
Mr [**Known lastname 12166**] was admitted to the MICU with altered mental status
following bronchoscopy by thoracics. While in the MICU he was
intubated for airway protection and he continued to have
hemoptysis into the tube. He was emergently sent for IR
embolization of the arteries, which appeared to be in the same
region as the ones previously (Left upper lobe). Given acute
changes in his mental status we did an extensive workup for
possible offending agents and infectious causes, as well as
obtained a CT of his head, which showed large number of masses
most consistent with metastatic disease. A CT of his chest was
performed and showed possible primary lung pathology as well as
extensive metastatic disease in hte liver as well as adrenal
glands.
Biopsies under CT guidance were obtained from liver and the
adrenal gland. Pathology of these came back as poorly
differentiated carcinoma, the tumor cells are large with
abundant cytoplasm.No features of small cell carcinoma were
seen.Tumor cells stained strongly for CK7 and do not stain for
CK20. This pattern is not specific, but is typical in lung
carcinoma. Tumor cells did not stain for TTF-1, but large cell
lung carcinomas typically do not stain with this marker.
The patient had recurrent hemoptysis on the morning of [**2147-10-14**].
He was unable to obtain adequate oxygen saturations despite
maximal ventilation settings. The patient died at 11:27am on
[**2147-10-14**].
Medications on Admission:
ALLOPURINOL 100 mg by mouth daily
ATENOLOL 25 mg Tablet by mouth daily
EZETIMIBE [ZETIA] 10 mg - 1 Tablet(s) by mouth daily
VENLAFAXINE 100 mg three times a day
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Hemoptysis
Respiratory failure
Metastatic nonsmall cell carcinoma
Discharge Condition:
Died
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"274.9",
"787.20",
"198.7",
"198.3",
"428.0",
"162.8",
"327.23",
"782.5",
"303.90",
"412",
"785.6",
"285.1",
"348.5",
"197.1",
"486",
"197.7",
"414.8",
"414.01",
"518.81",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97",
"99.29",
"96.71",
"07.11",
"50.11",
"96.72",
"38.91",
"33.22",
"88.43"
] |
icd9pcs
|
[
[
[]
]
] |
9277, 9286
|
7588, 9036
|
373, 426
|
9395, 9401
|
3044, 5781
|
9454, 9597
|
2311, 2432
|
9248, 9254
|
9307, 9374
|
9062, 9225
|
9425, 9431
|
2447, 3025
|
1810, 1827
|
285, 335
|
454, 1790
|
5789, 7565
|
1849, 2093
|
2109, 2278
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,785
| 123,882
|
42768
|
Discharge summary
|
report
|
Admission Date: [**2201-3-6**] Discharge Date: [**2201-3-27**]
Date of Birth: [**2164-8-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 36-year-old woman with a pmhx. significant for ESRD
(from hypertensive nephropathy) on HD (MWF) who is admitted from
[**Hospital 4199**] Hospital with hemoptysis. According to patient and OSH
records, patient began experiencing hemoptysis the day prior to
admission (once at 8am and then at 9pm); she went to [**Hospital 4199**]
Hospital that night where she was evaluated and sent home. The
following day she went to HD where she coughed up 30cc of
rube-red blood in clots. She was sent to [**Hospital 4199**] Hospital where
she had a CTA, which showed PEs in the lower lobe pulmonary
artery branches bilaterally. The RV LV ratio was 1.01 and there
was no septal bowing. Ms. [**Known lastname 55366**] was subsequently transferred
to [**Hospital1 18**] for further evaluation.
.
At the [**Hospital1 18**] ED, initial vitals were: HR 70, 98/54, 12, 100%RA.
Patient was guaic negative and she was started on a heparin.
She was given vanc and levaquin for GGO on CT scan and question
of HCAP. After heparin drip was started, patient passed about
100cc of frank hemoptysis. However, she remained
hemodynamically stable and maintained her airway. On admission
to the MICU, vitals were: 97.8, 68, 97/59, 97% on RA.
Past Medical History:
--HTN
--Anemia
--GERD
--ESRD on Dialysis
--Secondary hyperparathyroidism
Social History:
Patient came from [**Country 2045**] 1.5 years ago. She was not on HD there,
but only started in the US. Does not smoke cigarettes or drink
ETOH. She works at [**Company **]' Donuts. She is married and has an
11-year-old child.
Family History:
No family history of kidney failure. No clotting or bleeding
disorders.
Physical Exam:
Vitals: 97.8, 68, 97/59, 97% on RA
HEENT: EOMI, mucous membranes dry
CHEST: Dullness at both bases, good air movement throughout
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMTIES: No edema, erythema, or cords bilaterally
NEURO: Alert and oriented x3
RECTAL: Guaic negative
Pertinent Results:
[**2201-3-7**] 03:51AM BLOOD WBC-6.9 RBC-3.22* Hgb-10.0* Hct-31.0*
MCV-96 MCH-31.0 MCHC-32.2 RDW-13.7 Plt Ct-158
[**2201-3-6**] 08:11PM BLOOD Neuts-43.9* Lymphs-45.0* Monos-4.5
Eos-5.8* Baso-0.7
[**2201-3-7**] 12:20PM BLOOD PT-10.6 PTT-29.0 INR(PT)-1.0
[**2201-3-7**] 03:51AM BLOOD Glucose-85 UreaN-62* Creat-10.0*# Na-140
K-5.9* Cl-108 HCO3-22 AnGap-16
[**2201-3-6**] 11:40PM BLOOD ALT-14 AST-10 LD(LDH)-106 AlkPhos-71
TotBili-0.1
[**2201-3-7**] 03:51AM BLOOD Calcium-8.5 Phos-4.9*# Mg-3.1*
[**2201-3-7**] 03:51AM BLOOD HCG-<5
[**2201-3-6**] 08:30PM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-48* pCO2-52*
pH-7.38 calTCO2-32* Base XS-3 Intubat-NOT INTUBA
.
ECHO [**2201-3-7**]: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
.
IMPRESSION: Normal global and regional biventricular systolic
function. Normal estimated pulmonary pressures.
.
DISCHARGE LABS
[**2201-3-27**] 06:20AM BLOOD WBC-10.3 RBC-2.78* Hgb-8.8* Hct-27.2*
MCV-98 MCH-31.7 MCHC-32.3 RDW-15.4 Plt Ct-311
[**2201-3-25**] 06:45AM BLOOD Neuts-58.9 Lymphs-29.7 Monos-4.8 Eos-5.6*
Baso-0.9
[**2201-3-27**] 06:20AM BLOOD PT-21.2* PTT-95.9* INR(PT)-2.0*
[**2201-3-7**] 12:20PM BLOOD AT-100 ProtCFn-101 ProtSFn-106
[**2201-3-7**] 12:20PM BLOOD ACA IgG-6.2 ACA IgM-4.5
[**2201-3-27**] 06:20AM BLOOD Glucose-82 UreaN-54* Creat-10.5*# Na-139
K-5.0 Cl-105 HCO3-23 AnGap-16
[**2201-3-6**] 11:40PM BLOOD ALT-14 AST-10 LD(LDH)-106 AlkPhos-71
TotBili-0.1
[**2201-3-6**] 03:11PM BLOOD Lipase-106*
[**2201-3-27**] 06:20AM BLOOD Calcium-9.5 Phos-5.5* Mg-2.8*
[**2201-3-19**] 06:00AM BLOOD calTIBC-212* Ferritn-971* TRF-163*
[**2201-3-7**] 03:51AM BLOOD HCG-<5
[**2201-3-7**] 12:20PM BLOOD ANCA-NEGATIVE B
[**2201-3-7**] 12:20PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2201-3-7**] 12:20PM BLOOD ANTI-GBM-Test
[**2201-3-9**] 04:23AM BLOOD METHYLENETETRAHYDROFOLATE REDUCTASE
(C677T)-
Brief Hospital Course:
HOSPITAL COURSE
This is a 36-year-old woman with a pmhx significant for ESRD on
dialysis, HTN, and anemia who is admitted to the MICU with
bilateral PEs and hemoptysis. Hospital course prolonged by
repair of fistular prior to starting coumadin. Fistula repair
complicated by hematoma. The patient was ultimately discharged
witha functioning fistula on coumadin for management of
pulmonary emboli.
.
# HEMOPTYSIS: Likely in the setting of bilateral PEs. She was
initially sent to the MICU. There she remained hemodynamically
stable. She was started on a heparin gtt for the pulmonary
emboli, and hemoptysis resolved after 24 hours.
.
# BILATERAL PULMONARY EMBOLI: Unclear etiology of
hypercoagulable state however, there is no clear reversible risk
factor. Patient denies any long plane rides or periods of
immobility, and she does not take birth control. Patient denies
any family history or personal history of blood clots. No known
history of frequent miscarriages. Bilateral upper and lower
extremity ultrasound negative for clots. MRV pelvis showed no
evidence of proximal clots. Hypercoagulable studies showed were
unrevealing for etiology (ANCA, [**Doctor First Name **], Protein c and s, ACA Ig and
IgM, lupus anticoagulant, antithrombin, anti-GBM,
methylenetetrahydrofolate). Coumadin was not started immediately
secondary to an effort to revise her prior fistula prior to
initiation of coumadin. After successful revision of her left
sided fistula, coumadin was started requiring several days of
7.5mg to maintain INR goal [**3-20**]. Her Primary care physician was
notified of the hospitalization, aware of initiation of coumadin
and follow-up scheduled for initiation of coumadin clinic.
.
# ESRD ON HD: As per dialysis center, patient is on HD because
of hypertensive nephropathy, however ultimate etiology unclear.
She is dialyzed MWF. However, she is not all that hypertensive,
and TTE shows no evidence of hypertensive changes, calling that
diagnosis into question. A work-up as part of her
hypercoagulability work-up as outlined above was initiated. A
biopsy was not pursued given duration on HD. Her phosphorous
was persistently elevated on calcium high normal. Calcitriol
was discontinued and sevelamer was started. Nephrocaps were
continued.
.
# FISTULA REPAIR: Given hospitalization and initiation of HD,
repair of her clotted, non functioning fistula was performed.
Transplant surgery was consulted, venous mapping was performed
and a synthetic graft was placed at the site of her prior
fistula. Fistula repair was complicated by evolution of a
hematoma at the repair site. Several ccs of blood were aspirated
and her pain was controlled with tylenol and oxycodone. No
prescription pain medications were required at the time of
discharge.
.
# HYPERTENSION: Held lisinopril in setting of bleed. She
continued to be hypotensive throughout her hospitalization with
blood pressures in the 90-100s. Lisinopril was held on discharge
to be restarted in the outpatient setting as tolerated.
.
# ANEMIA: Iron studies confirmed anemia of chronic disease.
Ferrous sulfate was discontinued.
.
TRANSITIONAL ISSUES
- INR check on the Monday following admission, with PCP
[**Name9 (PRE) 702**] of labs. PCP office aware of INR check- she will have
lab draw at the office.
- start coumadin and sevelamer, discontinue ferrous sulfate,
lisinopril and calcitriol
- follow-up primary care for initiation of [**Hospital 3052**]
- follow-up transplant surgery for fistula
- code: full
Medications on Admission:
--Vitamin D
--Ferrous sulfate 1 tab daily
--Senna
--Bcomplex vitamins
--Calcitriol
--Colace
--Lisinopril 20mg QD
Discharge Medications:
1. Outpatient Lab Work
Please check INR on [**2201-3-30**] and fax these results to Dr.
[**Last Name (STitle) 92409**] at fax# [**Telephone/Fax (1) 92410**] (phone # [**Telephone/Fax (1) 25050**])
2. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
7. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*360 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. pulmonary embolism
2. end stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for coughing up blood and were found to have
blood clots in your lungs (pulmonary embolisms). It is unclear
why you developed these blood clots developed. Your primary care
physician may consider [**Name Initial (PRE) **] formal evaluation to better understand
why this occurred. Typically when people develop deep vein
thrombosis (blood clots in larger veins) or pulmonary embolisms,
they require at least 3-6 months of anticoagulation with a blood
thinner as treatment. You were started on a blood thinner
called heparin that was through your IV. A pill form of
anticoagulation (coumadin) was also started which takes longer
to have effect. While awaiting for the coumadin to work, you
were continued on heparin. While hospitalized our surgeons were
able to fix your fistula.
.
You will need careful monitoring of your blood while on coumadin
for the next 3-6 months. Your primary care physician is aware
of your hospitalization and will manage your coumadin.
.
The following medication changes were made:
1. START coumadin 5mg daily
2. START Sevelamer three times a day with meals
3. DISCONTIUE lisinopril unless otherwise indicated
4. DISCONTINUE ferrous sulfate unless otherwise indicated
5. DISCONTINUE calcitriol unless otherwise indicated
You will need to have your blood drawn on Monday to assess your
INR to see if your coumadin is therapeutic. Please go to your
primary care physicians office to have this blood drawn. They
are expecting you. You have a primary care visit scheduled
Wednesday after dialysis.
Followup Instructions:
Department: Primary Care
When: Wednesday [**4-1**] at 3:30 PM
With: [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 92409**]
Location: [**Street Address(2) 92411**], [**Hospital1 8**] [**Numeric Identifier 92412**]
Department: [**Location (un) 3786**] Family Medicine
Phone [**Telephone/Fax (1) 25050**]
.
Department: TRANSPLANT CENTER
Date/Time: [**2201-4-16**] 2:15
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"996.73",
"588.81",
"289.81",
"585.6",
"V58.83",
"276.7",
"V58.61",
"E878.2",
"444.21",
"458.9",
"415.19",
"285.21",
"998.13",
"403.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"39.95",
"86.01",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
9219, 9225
|
4749, 8256
|
313, 319
|
9318, 9318
|
2351, 4726
|
11039, 11689
|
1936, 2010
|
8420, 9196
|
9246, 9297
|
8282, 8397
|
9469, 11016
|
2025, 2332
|
263, 275
|
347, 1575
|
9333, 9445
|
1597, 1671
|
1687, 1920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,546
| 160,464
|
52940+59486
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-12-2**] Discharge Date: [**2137-12-8**]
Date of Birth: [**2076-12-15**] Sex: M
Service: ICU
CHIEF COMPLAINT: Sepsis/respiratory distress.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant 60
year old gentleman who has an extensive past medical history
consisting of cerebrovascular accident, hypertension,
depression, who was recently discharged from the [**Hospital1 346**] on [**2137-11-9**], after presenting here
with rhabdomyolysis, status post fall at home. The patient
was sent to the [**Hospital3 537**] on discharge with his CKs
trending down and his renal function improving. On the
morning of admission, the patient was found on the floor at
the [**Hospital3 537**] and was sent immediately to the Emergency
Department where he was found to be in respiratory distress.
From the notes, it could be gathered that the patient did
present with some earlier shortness of breath and acute
mental status change the day prior to admission but had
improved with nebulizers on the day of admission. The
patient's symptoms worsened and the patient was found
questionably unresponsive on the floor and so was immediately
brought into the Emergency Department. In the Emergency
Department, his oxygen saturation was found to be 70% in room
air and it only improved to 78 to 80% on four liters nasal
cannula. The patient was immediately intubated and sepsis
protocol was initiated given the white blood cell count was
23.4 and lactate was 9.1. In addition, a chest x-ray was
also obtained that showed bilateral alveolar opacities, right
side worse than the left, and so was given Ceftriaxone and
Clindamycin for concern of aspiration pneumonia. The patient
also was found to have elevated potassium and in acute renal
failure and so received Kayexalate, insulin, dextrose and was
transfused with two liters of intravenous fluids and
transferred to the [**Hospital Ward Name 332**] Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident - three times.
2. Hypertension.
3. Depression.
4. History of alcohol abuse with withdrawal seizures.
5. Osteoarthritis.
6. Hypercholesterolemia.
7. Status post appendectomy.
8. Status post tonsillectomy.
ALLERGIES: Questionable Percodan.
MEDICATIONS ON ADMISSION:
1. Phenytoin 350 mg p.o. q.a.m.
2. Aspirin 325 mg p.o. once daily.
3. Protonix 40 mg p.o. once daily.
4. Celexa 20 mg p.o. once daily.
5. Percocet one to two tablets p.o. q4-6hours p.r.n.
6. Plavix 75 mg p.o. once daily.
7. Ativan 0.5 to 1.0 mg p.o. q4-6hours p.r.n.
8. Atenolol 25 mg p.o. once daily.
SOCIAL HISTORY: The patient used to live by himself but
after most recent admission for rhabdomyolysis, the patient
was sent to the [**Hospital3 537**] and comes in today from the
[**Hospital3 537**]. He has a twenty pack year smoking history.
He used to drink but has had nothing for the past three
years. He denies any intravenous drug abuse.
PHYSICAL EXAMINATION: Vital signs revealed temperature
101.4, pulse 89, blood pressure 78/26, respiratory rate 18,
intubated, AC 400 times 18, FIO2 100%. In general,
comfortable, intubated. Head, eyes, ears, nose and throat
examination - dry mucous membranes. Lungs revealed decreased
breath sounds with crackles at the right lower bases. The
heart shows S1 and S2, regular rate and rhythm, distant heart
sounds. Abdomen reveals decreased bowel sounds,
nondistended, nontender. Neurologically, intubated.
Extremities no cyanosis, clubbing or edema, warm, good
pulses.
LABORATORY DATA: On admission, white blood cell count 23.4,
hematocrit 26.5, platelet count 803,000, neutrophils 49,
bands 19, lymphocytes 25, monocytes 5. Sodium 143, potassium
4.5, chloride 113, bicarbonate 18, blood urea nitrogen 81,
creatinine 3.2, glucose 251, calcium 9.5, magnesium 2.8,
phosphorus 4.6.
Electrocardiogram showed rate in the 90s, normal sinus
rhythm, normal axis, nonspecific ST-T wave changes.
Urinalysis and urine culture were negative.
HOSPITAL COURSE:
1. Hypoxic respiratory failure - The patient was intubated
secondary to respiratory distress. The initial working
diagnosis was community acquired pneumonia versus aspiration
pneumonia versus adult respiratory distress syndrome and so
the patient was started on Levofloxacin and Flagyl to cover
for aspiration pneumonia. The patient's ventilation setting
also adjusted for concern for adult respiratory distress
syndrome. The patient initially was placed on assist control
and seemed to have done well. The patient was switched over
to pressure support of 10 and 5 and started bringing up a lot
of secretions. The sputum was sent for culture and stain and
was found to be positive for Methicillin resistant
Staphylococcus aureus. Hence, the patient was started on
Vancomycin to cover for Methicillin resistant Staphylococcus
aureus pneumonia. An attempt was made for spontaneous
breathing trial in which it was found that the patient began
to work very hard and was over breathing the vent. The
patient was kept on pressure support of 10 and 5 at the time
of this dictation. At the time of this dictation, the
patient had already received seven days of Levofloxacin 500
mg once daily, seven days of Flagyl 500 mg p.o. three times a
day, and four days of Vancomycin one gram twice a day.
2. Sepsis - The patient was admitted on the sepsis protocol
since he was tachycardic, hypertensive, febrile, elevated
white blood cell count, elevated lactate. The patient was
aggressively fluid resuscitated in the first 24 hours to keep
a CVP of greater than 8.0. The patient was also started on
stress dose steroids, Hydrocortisone 100 mg intravenously
three times a day which he continued for four days but then
was stopped because of growing [**Female First Name (un) 564**] in his sputum. The
patient's blood pressure remained stable and urine output was
adequate and the patient did not require any pressors. At
the time of this dictation, the patient was on three
antibiotics consisting of Vancomycin, Levofloxacin, and
Flagyl. There is some concern that if the patient's
pneumonia does not improve and the secretions continue, maybe
a bronchoscopy should be considered to rule out any [**Female First Name (un) 564**]
infection in the lung tissue.
3. Renal - The patient presented to the hospital with acute
renal failure and a creatinine of 3.2. This is most likely
in the setting of hyperperfusion from him being in sepsis.
The patient was aggressively fluid resuscitated and his
creatinine improved from 3.2 to 0.8 at the time of this
dictation. The patient's creatinine continued to be checked
and his medications were adjusted based on the creatinine
clearance.
4. Cardiology - The patient does have a history of
hyperlipidemia at home but was not on any medication. On
presentation, the patient's antihypertensive medications were
held but they were restarted when the patient's blood
pressure was stable. In addition, the patient did rule in
with CKs in the 1000 and a troponin I peaking at 1.5. It was
unclear whether this troponin leak was from demand ischemia
versus non ST elevation myocardial infarction versus his
renal failure, however, an echocardiogram was obtained that
showed an ejection fraction of greater than 55% with no wall
motion abnormalities, but this was a poor quality
echocardiogram and a repeat study was going to be performed.
The patient's CK and troponin peak continued to trend down
throughout the hospital course.
5. Endocrine - The patient initially was critically ill and
was started on an insulin drip, however, on day five or six,
the patient's insulin drip was stopped and was switched over
to regular sliding scale insulin.
6. Gastrointestinal - The patient initially was NPO and was
getting aggressive intravenous fluids. The patient had an
episode of coffee ground emesis and there was a drop in his
hematocrit which was concerning and so the gastroenterology
team was consulted who performed an
esophagogastroduodenoscopy. Esophagogastroduodenoscopy was
unremarkable except for a small erythema found along the
fundic region. The patient's hematocrit continued to remain
stable. The patient was started on tube feeds.
7. Hematology - The patient presented with a low hematocrit
in the setting of septic shock and so the patient was
transfused with a total of six units of packed red blood
cells to help both with his hematocrit and also with volume
resuscitation. The patient's hematocrit continued to remain
stable since then.
8. Neurology - The patient has a history of seizures and was
on Phenytoin. There was some concern whether the patient
being found unresponsive on the floor was from a seizure or
not and so a head CT was obtained that ruled out any bleed.
A free Dilantin level was checked which was found to be 2.0
which was therapeutic and so the patient was continued on 100
mg p.o. suspension twice a day. The patient also has a
history of prior cerebrovascular accidents and Plavix and
Aspirin were to be continued.
9. Psychiatry - The patient has a history of depression and
anxiety. The patient is getting Ativan p.r.n. and is on
Celexa 20 mg p.o. once daily.
10. Code - The patient is full code.
Please note that this discharge summary describes the
hospital course events from [**2137-12-2**], up to and including
[**2137-12-8**]. For the remainder of the hospital course, please
see subsequent discharge summary.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 14914**]
MEDQUIST36
D: [**2137-12-8**] 13:26
T: [**2137-12-8**] 14:29
JOB#: [**Job Number 109133**]
Name: [**Known lastname **], [**Known firstname **] B Unit No: [**Numeric Identifier 17897**]
Admission Date: [**2137-12-2**] Discharge Date: [**2137-12-24**]
Date of Birth: [**2076-12-15**] Sex: M
Service: [**Company 112**]
ADDENDUM: This is an addendum to a previous Discharge
Summary on this patient covering his hospital course from
[**2137-12-2**] until [**2137-12-8**]. This summary will cover events
after [**2137-12-8**] until the time of discharge.
HOSPITAL COURSE:
1. HYPOXIC RESPIRATORY FAILURE: The patient was
successfully extubated on [**2137-12-9**], after several days of
gentle diuresis with Lasix and completion of a spontaneous
breathing trial. He completed a ten day course of
Levofloxacin and Flagyl for aspiration pneumonia.
Additionally, he completed a fourteen day course of
Vancomycin as a result of a sputum culture that was positive
for methicillin resistant Staphylococcus aureus.
For the remainder of his hospital course, he denied any
shortness of breath. Breathing by examination was easy,
unlabored. Oxygen saturation remained in the high 90s on
room air.
2. RENAL: The patient's acute renal failure was likely
secondary to hyperperfusion in the setting of sepsis. His
creatinine peaked at 3.2. Status post fluid resuscitation,
his creatinine improved and remained back to his baseline of
0.5 to 0.6 upon discharge.
3. CARDIOLOGY: The patient had a history of hyperlipidemia
in the past according to his medical records but was not on
any medication. Fasting lipid profile demonstrated LDL 46,
HDL 32, triglycerides 75 with a total cholesterol of 93. In
light of these values, the decision was made not to initiate
any lipid lowering agents as part of his medication regimen.
Additionally, the patient had a history of hypertension.
Throughout his hospital course, after discharge from the
Intensive Care Unit, his beta blocker medication was
aggressively titrated. At the time of discharge, he was
stable on a regimen of Atenolol 100 mg p.o. q. day.
4. GASTROINTESTINAL: While in the Intensive Care Unit, the
patient had an episode of coffee ground emesis along with a
decline in his hematocrit value. This was concerning for
acute bleed and so the Gastroenterology Service was
consulted. An esophagogastroduodenoscopy was performed on
[**2137-12-4**]; it was unremarkable except for a small area of
erythema found along the fundus. Status post transfusions,
the patient's hematocrit remained stable without any evidence
of further bleeding, however, he likely warrants a
colonoscopy as an outpatient. This should be followed up on
by the patient's primary care physician.
Iron studies were sent additionally in light of his anemia.
Along with the obvious source of anemia secondary to his
acute coffee ground emesis and gastrointestinal bleed, iron
studies were also indicative of chronic inflammation
secondary to chronic disease. In addition, the patient
demonstrated evidence of aspiration on a video swallowing
evaluation. This warranted placement of a percutaneous PEG
feeding tube. The PEG was placed on [**2137-12-17**]. The patient
tolerated this procedure well. At the time of discharge, he
was receiving tube feeds at goal.
5. NEUROLOGY: On arrival to the Floor from the Intensive
Care Unit, the patient's repeat Dilantin levels were found to
be sub-therapeutic on his regimen of 100 mg twice a day.
Therefore, the regimen was increased to 300 mg per
nasogastric tube / PEG tube twice a day. This resulted in
therapeutic total phenytoin level drawn at trough.
Additionally, the patient had a history of stroke in the
past.
He was continued on aspirin and Plavix for secondary stroke
prevention. He did have his doses of these medications held
for several days in the setting of PEG tube placement to
decrease the risk of bleeding. Aspirin and Plavix were
re-instituted four to five days after PEG tube placement and
should be continued after discharge from hospital.
6. FLUIDS, ELECTROLYTES AND NUTRITION: The patient
underwent a video Speech and Swallow evaluation which
demonstrated aspiration of foods of all consistencies. Per
the Speech and Swallow team, the patient had a history of
chronic aspiration dating back several years. This was
unlikely to be affected as a result of the issues
complicating this hospital course or any of his current
medical problems.
Therefore, it was not felt to be something that was amenable
to improvement as the issues of his current hospital
admission improved. In light of his aspiration, the patient
was kept strictly nothing per os. He did receive several
days of nutrition via a nasogastric tube. Ultimately, he
underwent PEG tube placement on [**2137-12-17**].
At the time of discharge, he was tolerating tube feeds at
goal. The patient is to remain upright for all feeds in
order to decrease his aspiration risk.
7. INFECTIOUS DISEASE: On further review, the patient's
level of muscle wasting seemed out of proportion to his
history of stroke. This resulted in a question of possible
diagnosis of HIV or syphilis. Review of his old laboratory
data demonstrated that the patient had a reactive rapid
plasma reagent test in 04/98, with a ratio of 1:2. He also
had positive FTA antibodies in 04/98.
In light of the patient's history of stroke, it appears that
part of his neurological work-up involved a lumbar puncture
in [**2133**]. Review of culture data from the patient's
cerebrospinal fluid from the [**2133**] lumbar puncture
demonstrated a negative VDRL with positive FTA antibodies and
elevated protein. This was concerning for possible
neuro-syphilis.
Further review of the [**Hospital 1325**] medical records and
discussions with him made it unclear whether the patient had
received any prior therapy for syphilis in the past. Also
complicating the picture, the patient had a history of HIV
antibody test in [**9-/2133**] which was equivocal with a
nonreactive [**Doctor First Name **] test. At that time, the patient was
instructed to repeat the test in six months but this was not
followed up on.
In light of these issues, the Infectious Disease Service was
consulted. They recommended a repeat lumbar puncture.
Repeat lumbar puncture was performed on [**2137-12-18**], and the
patient tolerated the procedure well. Cerebrospinal fluid
from repeat puncture demonstrated a negative Gram stain with
fluid culture pending at the time of this dictation. Also
concerning was that the cerebrospinal fluid again
demonstrated the elevated protein at the level of 53.
Infectious Disease further recommended the patient's serum
and cerebrospinal fluid be tested for VDRL and FTA
antibodies. At the time of this dictation, the patient's
serum RPR was reactive with the quantitative RPR level
pending as well as the serum FTA antibodies pending. Also
pending involved the cerebrospinal fluid studies including
VDRL and FTA. If the cerebrospinal fluid studies return
positive, the patient will likely need high dose benzocaine
penicillin therapy.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9307**], a fellow in the Department of Infectious
Disease, will follow-up on the patient's outstanding culture
data. Should culture data return positive necessitating
intravenous antibiotic therapy, Dr. [**Last Name (STitle) 9307**] will contact
[**Name (NI) 14404**] [**Name (NI) **], who is the head of Nursing at the [**Hospital3 10159**] Extended Care Rehabilitation facility in order to
establish a treatment plan including intravenous access as
well as initiation of penicillin therapy if warranted.
In addition to the above studies necessary to determine if
the patient in fact has tertiary syphilis, a repeat HIV
antibody test was also ordered and was pending at the time of
this dictation.
8. DISPOSITION: The patient received Physical Therapy and
Occupational Therapy while hospitalized. In light of his
continued weakness it was felt that he would continue to
benefit from rehabilitation in an acute facility. He will be
discharged back to [**Hospital3 474**].
CONDITION ON DISCHARGE: Fair: Tolerating feeds at goal via
PEG. The patient was to be strict n.p.o. in light of
aspiration risk, failed swallow evaluation.
DISCHARGE STATUS: The patient was discharged to [**Hospital3 10159**] extended care facility.
DISCHARGE DIAGNOSES:
1. Pneumonia due to Methicillin resistant Staphylococcus
aureus complicated by sepsis.
2. Acute renal failure.
3. History of cerebrovascular accident.
4. Hypertension.
5. Anemia due to blood loss.
6. Seizure disorder.
7. Hyperlipidemia.
8. Osteoarthritis.
9. Depression.
10. Gender dysmorphic disorder.
11. Possible neurosyphilis, culture data pending at time of
discharge.
DISCHARGE MEDICATIONS:
1. Tylenol 160 mg / 5 ml elixir, one to two p.o. q. four to
six hours as needed for fever or pain.
2. Phenytoin suspension 300 ml p.o. twice a day.
3. Nystatin swish and swallow suspension, 5 ml p.o. four
times a day.
4. Zinc oxide / cod-liver oil, 40% ointment, one application
topically twice a day as needed.
5. Lansoprazole 30 mg p.o. q. day.
6. Zinc sulfate 220 mg p.o. q. day.
7. Ascorbic acid 500 mg p.o. twice a day.
8. Citalopram 20 mg p.o. q. day.
9. Colace 100 mg p.o. twice a day.
10. Dulcolax 10 mg p.o. q. day as needed for constipation.
11. Nystatin Ointment, one application topically twice a day.
12. Heparin 5000 units subcutaneously q. eight hours.
13. Ativan 0.5 mg, one to two tablets p.o. q. four to six
hours as needed for anxiety.
14. Aspirin 325 mg p.o. q. day.
15. Plavix 75 mg p.o. q. day.
16. Tramadol 50 mg one tablet p.o. q. four to six hours as
needed for pain.
17. Atenolol 100 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to contact [**Name (NI) **] [**Name2 (NI) 17898**] office at
[**Telephone/Fax (1) 17899**] for a follow-up appointment within the seven to
ten days.
2. Additionally, he has scheduled appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 9307**], a fellow in the Department of Infectious Disease on
[**1-16**] at 09:30 in the [**Hospital 9023**] Medical Office Building,
[**Last Name (NamePattern1) 17900**]. Dr. [**Last Name (STitle) 9307**] will follow-up on
the patient's outstanding culture data. Should culture data
return positive necessitating intravenous antibiotic therapy,
Dr. [**Last Name (STitle) 9307**] will contact the head of nursing at [**Hospital3 10159**] in order to initiate a treatment plan including the
possibility of longer term intravenous access and intravenous
antibiotic therapy.
[**First Name8 (NamePattern2) 46**] [**Doctor First Name 258**], M.D. [**MD Number(1) 259**]
Dictated By:[**Last Name (NamePattern1) 3083**]
MEDQUIST36
D: [**2137-12-23**] 22:05
T: [**2137-12-23**] 22:34
JOB#: [**Job Number 17901**]
|
[
"285.1",
"584.9",
"038.9",
"780.39",
"578.0",
"276.7",
"507.0",
"482.41",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"03.31",
"99.07",
"38.93",
"43.11",
"45.13",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
18065, 18449
|
18472, 19408
|
2284, 2595
|
10211, 17786
|
19432, 20559
|
2967, 3985
|
155, 185
|
214, 1959
|
1981, 2258
|
2612, 2944
|
17812, 18044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,103
| 145,408
|
9470
|
Discharge summary
|
report
|
Admission Date: [**2113-2-23**] Discharge Date: [**2113-2-28**]
Date of Birth: [**2053-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
[**2113-2-24**] Coronary bypass graft x6 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery,
second diagonal artery and reverse saphenous vein, Y graft to
the first, second and third obtuse marginal artery.
History of Present Illness:
This 59 year old Brazilian male with known coronary artery
disease is s/p stents in [**2103**]. The patient was lost to follow
up in the meantime. He has had DOE over the past [**1-21**] mos. He
developed neck pain on [**2113-2-17**]. On presentation to his
chiropractor, he was found to be hypertensive with SBP>200mmHg.
He was advised to go to the ED. He was admitted and ruled out
for an infarction. A stress test was abnormal and the patient
underwent cardiac catheterization which revealed severe
multi-vessel disease. He was transferred for cardiac surgical
evaluation.
Past Medical History:
hypertension
hyperlipidemia
coronary artery disease - s/p stents
to LAD and LCx in [**2103**]
Social History:
Race: Hispanic
Last Dental Exam: many years ago
Lives with: wife and children
Occupation:
Tobacco: never
ETOH: occasionally, up to 4beers/week
Family History:
father-hypertension and coronary disease
Physical Exam:
Admission:
Pulse: 68sr Resp: 18 O2 sat: 99%RA
B/P Right: Left: 137/68
Height: 5'9" Weight:63kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] no edema or varicosities
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2113-2-23**] 05:17PM BLOOD WBC-8.0 RBC-4.89 Hgb-12.8* Hct-38.3*
MCV-78* MCH-26.2* MCHC-33.4 RDW-13.5 Plt Ct-191
[**2113-2-25**] 02:08AM BLOOD WBC-9.9 RBC-3.71* Hgb-9.7* Hct-28.8*
MCV-78* MCH-26.2* MCHC-33.9 RDW-13.3 Plt Ct-169
[**2113-2-23**] 05:17PM BLOOD Glucose-203* UreaN-17 Creat-1.0 Na-139
K-3.9 Cl-103 HCO3-29 AnGap-11
[**2113-2-25**] 02:08AM BLOOD Glucose-55* UreaN-15 Creat-1.1 Na-137
K-5.0 Cl-109* HCO3-25 AnGap-8
[**2113-2-28**] 05:35AM BLOOD WBC-11.8* RBC-3.19* Hgb-8.6* Hct-25.3*
MCV-79* MCH-26.8* MCHC-33.8 RDW-13.6 Plt Ct-274
[**2113-2-28**] 05:35AM BLOOD Glucose-108* UreaN-19 Creat-1.1 Na-134
K-5.6* Cl-103 HCO3-28 AnGap-9
[**2113-2-28**] 05:35AM BLOOD Mg-2.3
Prebypass
The left atrial appendage emptying velocity is depressed
(<0.2m/s). No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2113-2-24**] at 930am.
Post bypass
Patient is AV paced receiving an infusion of phenylephrine and
epinephrine. Biventricular systolic function is unchanged. Mild
mitral regurgitation persists. Aorta intact post decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2113-2-23**] as a transfer
from [**Hospital6 1109**] for surgical management of his
coronary artery disease. He was worked up in the usual
preoperative manner.
On [**2113-2-24**], he was taken to the Operating Room where he underwent
coronary artery bypass grafting to six vessels. Please see
operative note for details. he weaned from bypass on Neo
Synephrine, Epinephrine, Propofol and Insulin infusions.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next 24 hours, he awoke neurologically
intact and was extubated.
His CTs were removed on POD 1, beta blockade and lasix were
begun. He was transferred to the floor. Physical Therapy was
consulted for strength and mobility assistance. He was diuresed
towards his preoperative weight, and beta blockade was
initiated. The temporary pacing wires and chest tubes were
removed per protocol. Adequate analgesia was obtained with
Ketorolac and Percocet. Postoperative course was uneventful and
the patient was discharged home in good condition on POD 4 with
follow up instructions.
Medications on Admission:
ASA 81 mg daily
Lisinopril 40 mg daily
Amlodipine 5mg daily
Atorvastatin 80mg daily
lopressor 75mg TID
Ambien 5 mg prn
Ativan 0.5-1 mg prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypertension
hyperlipidemia
s/p coronary stents
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with percocet
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] (for Dr [**Last Name (STitle) **] at [**Hospital1 **] Heart Center
([**Telephone/Fax (2) 6256**]) - Thrusday [**2113-3-16**] at 9am
Cardiologist [**Hospital1 **] heart center ([**Telephone/Fax (2) 6256**]) - Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32255**] [**2113-3-20**] at 9am
****
[**Hospital 778**] health center - [**First Name8 (NamePattern2) 32256**] [**Location (un) 86**], [**Numeric Identifier 718**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Thrusday [**2113-3-2**] at 12:10- please
arrive by 11:30 am to fill out paperwork and please bring
identification with you
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 780**] - Financial Services 2 nd floor - Thrusday
[**2113-3-2**] at 3:45pm
Wound check appointment - RN will schedule [**Telephone/Fax (1) 3071**]
Completed by:[**2113-2-28**]
|
[
"285.9",
"414.01",
"V45.82",
"272.4",
"250.00",
"401.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.14",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6053, 6112
|
3868, 5033
|
346, 641
|
6262, 6355
|
2285, 3845
|
6896, 7803
|
1548, 1590
|
5223, 6030
|
6133, 6241
|
5059, 5200
|
6379, 6873
|
1605, 2266
|
283, 308
|
669, 1253
|
1275, 1371
|
1387, 1532
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,307
| 194,146
|
53923
|
Discharge summary
|
report
|
Admission Date: [**2125-8-9**] Discharge Date: [**2125-8-22**]
Date of Birth: [**2052-2-27**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Penicillins
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a 73 yo R-handed woman with CAD, GERD,
sinusitis, emphesema who presented with HA to the ED on [**8-9**] and
was admitted to Medicine service [**8-9**] for sinusitis.
[**6-19**], the patient presented to the ED with a severe headache.
At that time, a CT head was normal and the patient refused an
LP.
At follow up she did "complain of stuffy nose and pain behind
her
right eye like an ice pick. She states that she also has a
pressure in her sinuses bilaterally." At that point (early [**Month (only) **])
she was given a 10 day course of Augmentin, and her symptoms
improved somewhat. They did never completely resolve. She did
have photo- and phonophobia at that time, no muscle aches. She
had some neckpain (does not remember the details).
She returned to the ED [**8-9**] as her headache had been getting
worse over about 2 weeks. She said the onset was sudden, though
that may not fit with the story that her headache never really
went away. The headache became progressively worse. She was
evaluated in the ED and a CT head was normal except for
sinusitis
involving the sphenoid sinus (maxillary sinuses not in view).
She
was started on CTX and Unasyn. The patient refused an LP in the
ED. Neurology was not consulted and she was admitted to
Medicine.
The Medicine attending persuaded her to undergo an LP, which had
increased WBC (Lymphocytic predominant). She was emperically
started on vanco, ampicillin, CTX and acyclovir.
She has been having night sweats, and a chronic cough. No
weightloss. No rash or itching. No insect bites. No jaw
claudication, but does remember scalp tenderness upon touch. No
transient visual loss. This morning she noted some neckpain at
the right. She also noted that she would say the wrong words
occasionally and that she had difficulties thinking smoothly
(this morning). Also some nausea this morning.
About 10 years ago, she had similar headaches, fever and was
diagnosed with sinusitis. Followed by ENT, but last time she was
seen was 2.5 years ago.
ROS:
denies any hearing changes, vomiting, dysphagia, weakness,
tingling, numbness, bowel-bladder dysfunction, chest pain,
shortness of breath, abdominal pain, dysuria, hematuria, or
bright red blood per rectum.
Past Medical History:
-COPD, emphesema
-CAD
-anxiety
-GERD
-hyperlipidemia
-sinusitis
-head trauma, MVC in '[**08**]: since that time she has a tremor of
her
head and her hands
Social History:
Occupation: currently does not work (stopped in '[**97**], not able to
get clear reason)
Smoking: [**1-22**] ppd; EthOH: occasional; drug abuse: no
Married, 2 children
Family History:
- siblings are healthy
-CAD
-grandma has something, but she cannot remember what
Physical Exam:
EXAM ON ADMISSION
VITALS: T99.2 Tm 100.9 HR88 BP150/70 RR20 sO2 95 on 1L; 87 on
RA
GEN: NAD, in bed
HEENT: mmm; no rash
NECK: no LAD; no carotid bruits; neck supple, no brudzinski;
palpation a bit tender R-paraspinally
LUNGS: bilateral wheezing
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: some clubbing, no cyanosis, ecchymosis, or edema
MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect, very slow
thinking.
Oriented to place, month, day, and date, person.
Attention: MOYbw: unable; DOWbw slow but accurate
Memory: Registration: [**2-23**] items; Recall [**1-23**] at 5 min.
Language: fluent; repetition: intact; Naming: mistakes with low
frequency objects (cactus/hammock); Comprehension intact; mild
dysarthria, paraphasic errors: substitues wrong words (will
realize it). [**Location (un) **]: intact; Prosody: normal. 3D-construction:
poor clock, could not draw handles; did not want to proceed with
copying; No Apraxia. No Neglect.
CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round
and reactive to light both directly and consensually, 3-->2 mm
bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus.
Fixation and saccades are normal. No ptosis.
V: Facial sensation intact to light touch and pinprick.
VII: Facial movement symmetrical; R-nasiolabial fold somewhat
flat. Lev palp strong.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
MOTOR SYSTEM: Normal bulk and tone bilaterally in UE. Increased
tone in LE more on the R than the L. No adventitious movements,
no tremor, no asterixis.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 4+5 5 5 5 5 5- 5 5 [**5-25**] 5 5 5
Left 5 4+5 5 5 5 4+ 5- 5 5 4+5 5 5 5
No pronator drift. No rebound.
SENSORY SYSTEM: Sensation intact to light touch. No extinction
to
DSS.
Temperature (cold), vibration, and proprioception unreliable:
not
able to tell movement, not even in bigger joints; did say she
felt vibration everywhere
REFLEXES:
B T Br Pa Pl
Right 2 2 2 3 2
Left 2 2 2 3 2 crossed adductor
Toes: downgoing bilaterally.
COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. No dysmetria or
pastpointing.
However, slight action tremor bilaterally in UE. HTS slow.
GAIT: deferred
EXAM ON DISCHARGE: Unchanged, no neck tenderness, thinking
clear.
Pertinent Results:
Lactate:0.8
137 98 8 103 AGap=15
-----------<
3.9 28 0.8
ALT: 32 AP: 86 Tbili: 0.3 Alb: 3.9
AST: 42 LDH: Dbili: TProt:
[**Doctor First Name **]: 54 Lip: 31
WBC8.2 PLT309 Hct40.3
N:68.8 L:22.3 M:6.0 E:1.6 Bas:1.2
PT: 11.3 PTT: 22.8 INR: 0.9
ESR 68 (not c/w temporal arteritis), RF wnl, SPEP negative
UA, Ucx: negative
Bcx: negative
CSF #1 ([**8-11**]): 63 wbc, lymphocyte predominant(WBC 93, RBC 9,
Poly 0, Lymph 88, Mono 12), protein 33 glucose 70 , GS negative,
culture negative, fungal culture negative, RPR negative, crypto
ag negative, Lyme AB negative, HSV [**1-22**] PCR negative, ACE, VZV
pcr negative. TB .
Cytology #2 and 3:Hypercellular specimen.
Polymorphous population of lymphocytes and monocytes
consistent with a reactive process.
[**2125-8-9**] 08:19PM CEREBROSPINAL FLUID (CSF) TotProt-63*
Glucose-56
[**2125-8-9**] 08:19PM CEREBROSPINAL FLUID (CSF) WBC-66 RBC-19*
Polys-0 Lymphs-90 Monos-10
[**2125-8-11**] 05:35PM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-70
[**2125-8-11**] 05:35PM CEREBROSPINAL FLUID (CSF) WBC-75 RBC-460*
Polys-0 Lymphs-93 Monos-7
[**2125-8-11**] 05:35PM CEREBROSPINAL FLUID (CSF) WBC-93 RBC-9* Polys-0
Lymphs-88 Monos-12
[**2125-8-16**] 02:33AM CEREBROSPINAL FLUID (CSF) TotProt-31 Glucose-59
[**2125-8-16**] 02:33AM CEREBROSPINAL FLUID (CSF) WBC-51 RBC-23*
Polys-0 Lymphs-95 Monos-5
[**2125-8-16**] 02:33AM CEREBROSPINAL FLUID (CSF) WBC-40 RBC-6* Polys-0
Lymphs-96 Monos-4
[**2125-8-17**] 01:17PM CEREBROSPINAL FLUID (CSF) TotProt-32 Glucose-71
[**2125-8-17**] 01:17PM CEREBROSPINAL FLUID (CSF) WBC-76 RBC-18*
Polys-0 Lymphs-93 Monos-7
[**2125-8-17**] 01:17PM CEREBROSPINAL FLUID (CSF) WBC-63 RBC-2* Polys-0
Lymphs-97 Monos-3
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda
and CD antigens 5, 19, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Majority of the cells are in the cell debris/lysed cell area.
A limited panel is performed to determine B cell clonality.
In the viable lymphoid gate, CD19 positive B-cells are extremely
scant (less than 1% of lymphoid gated events ) and clonality
cannot be reliably assessed.
CD5 positive T cells comprise 82% of lymphoid gate.
INTERPRETATION
Non-specific T cell dominant lymphoid profile.
B-cell clonality could not be reliably assessed due to scant
numbers.
Correlation with clinical findings and morphology is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas due to topography, sampling or artifacts of sample
preparation.
MR OF THE LUMBAR SPINE: The lumbar spine is imaged from T12
through L5. The vertebral body heights are normal and marrow
signal intensity values are within normal limits. There is
diffuse disc desiccation without evidence of disc bulge, spinal
stenosis, or foraminal narrowing. The signal intensity values of
the pre- and paravertebral soft tissues are within normal
limits. There is no evidence of abnormal signal within the conus
or cauda and no evidence of abnormal epidural collection. No
areas of abnormal enhancement are identified on post-gadolinium
images.
IMPRESSION: No evidence of epidural abscess. Multilevel
degenerative disc desiccation. Otherwise, normal MRI of the
lumbar spine.
MR [**Name13 (STitle) **]: FINDINGS: There is increased T2 signal on the FLAIR
sequence within the subdural space as well as pachymeningeal
enhancement. These findings could be due to a recent
intervention such as lumbar puncture, intracranial hypotension,
or meningitis. However, there is no evidence of intraaxial
enhancement. There is no midline shift, mass effect, or
hydrocephalus. There are multiple foci of increased T2 signal
within the periventricular and subcortical white matter of both
cerebral hemispheres consistent with chronic microvascular
infarcts. The size and shape of the lateral ventricles is
unchanged from [**2125-8-10**], the prior MRI. There are no areas
of significantly abnormal magnetic susceptibility. There is no
slow diffusion to indicate an acute infarct.
IMPRESSION: Bilateral increased T2 signal within the subdural
space with pachymeningeal enhancement is new from the prior
examination of [**2125-8-10**]. These findings could represent a
recent intervention such as a lumbar puncture. Intracranial
hypotension or meningitis could also give a similar appearance.
There is no evidence of an intraaxial enhancing lesion. There is
no acute infarct.
MRV negative
Hip x-ray: There are some mild degenerative changes with medial
joint space narrowing seen bilaterally and some osteophytes, but
no fractures identified.
Brief Hospital Course:
The patient is a 73 yo R-handed woman with CAD, GERD, sinusitis,
and emphesema who presented with HA to the ED on [**8-9**] for a
severe headache. Her LP (63 wbc, lymphocyte predominant, high
protein, low glucose, GS negative) has shown lymphocytic
pleocytosis and is overall suggestive of an aseptic meningitis.
She was initially covered with CTX/vanco/amp(tolerated augmentin
as outpatient)/acyclovir and dexamethasone. The dexamethasone
was discontinued on [**8-10**] given the low suspicion for a bacterial
process. The antibiotics were discontinued after the lab results
returned and were negative for bacteria and HSV. All studies
have returned negative, including gram stain, bacterial and
fungal cultures, RPR, crypto Ag, Lyme Ab, HSV [**1-22**] PCR, ACE, VZV,
and TB. Cytology showed a hypercellular specimen, most likely
reactive. Though her course was initially complicated by
increased encephalopathy over the [**8-13**] to [**8-15**], she improved and
was clear by discharge. Notable events in her course include
intubation for LP. She was also noted to have hip pain but x-ray
was negative other than degenerative disease. She is discharged
to rehab with neurology follow up.
Medications on Admission:
-ADVAIR DISKUS
-ALBUTEROL
-ASPIRIN
-FLONASE
-FLOVENT
-IBUPROFEN
-LIPITOR
-NEXIUM
-NITROGLYCERIN
-SUDAFED
-TOPROL XL
-ZYRTEC
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Aseptic meningitis
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Please attend your scheduled appointments.
Call your doctor or go to the emergency room if you have any
worsening headache, any fevers, chills, neck pain, change in
vision, weakness, numbness, tingling, change in bowel or bladder
function, change in thinking, unresponsiveness, or any other
concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2125-9-27**] 2:25
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2125-9-27**] 2:45
Please follow up with Dr. [**Last Name (STitle) 7994**] in the neurology clinic
[**2125-10-5**] at 4:30 in [**Hospital Ward Name 23**]. Please call [**Telephone/Fax (1) 541**]
prior to your appointment.
|
[
"272.4",
"492.8",
"047.9",
"530.81",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12910, 12982
|
10353, 11545
|
291, 309
|
13045, 13054
|
5684, 10330
|
13453, 13922
|
2945, 3027
|
11719, 12887
|
13003, 13024
|
11571, 11696
|
13078, 13430
|
3042, 3492
|
243, 253
|
337, 2564
|
4128, 5598
|
5617, 5665
|
3507, 4112
|
2586, 2743
|
2759, 2929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,338
| 145,012
|
9334
|
Discharge summary
|
report
|
Admission Date: [**2158-12-15**] Discharge Date: [**2158-12-22**]
Date of Birth: [**2097-9-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 yo male, h/o 5V CABG, CHF, BIV ICD/PPM, who found by his
wife, sitting in chair with heated blanket, looking pale and
with difficulty speaking. He then appeared not to be breathing.
She called EMS, CPR briefly initiated(1-2 min) No tonic-clonic
movements, but + incontinence of urine. EMS reported a weak
pulse, but could not get a good BP. Got small amount fluid in
the field and then improved.
.
In the ED, initial vital: T 100 rectal, HR 95, BP 113/83, RR 13,
100% NRB. He was noted to be confused with poor short term
memory. CT head negative for acute process. Labs notable for WBC
of 15K, no left shift, TropT 0.04, INR 1.5. Digoxin 1.8, Lactate
1.8. ECG V-paced. Urine and serum tox screens negative, U/A
negative. Got 2L NS, 1gm CTX and 1 gm vancomycin emperically.
Had swelling of LLE> [**Last Name (LF) **], [**First Name3 (LF) **] CTA performed which was negative.
Later, family reported that this is his baseline. He was seen by
neuro who found he had inability to form new short term
memories, consistent with b/l hippocampi injury, possibly from
anoxic injury. It was felt that the situation was more
consistent with a cardiac event, and he was admitted to the ICU
for monitoring and work up. Vitals upon transfer: T 98.8, HR 83,
BP 104/90, RR 17, 100% 2L.
Past Medical History:
CAD s/p CABG
Anterior MI [**2144**]
h/o massive UGIB in [**2154**] [**1-1**] gastritis [**1-1**] NSAIDs and
coumadin(intubated, c/b MRSA VAP, had tracheostomy)
CHF (EF 25% by last echo) with BiV pacer and ICD placement
L hip arthritis
Hyperlipidimia
Hypothyroidism
h/o Afib in past (not currently on coumadin)
Social History:
Married > 25 years. Has three adult children. Lives with his
wife. Used to work in computers but on disability for health
reasons. Denies tobacco, occasional etoh. No illicits.
Family History:
FH: Father died of MI at age 52
Physical Exam:
PE
VS: T 98.5, BP 84/55, HR 63, RR 16, 97% 2L
GEN: awake, conversant
HEENT: PERRL, adentulous
LUNGS: Bibasilar crackles, no wheezes
HEART: RRR, nl S1S2
ABD: +BS, soft, ND/NT
EXT: LLE warm with erythema, dry scaly skin, and warmth. Left
foot with open wound on plantar aspect, draining purulent
material
NEURO: AAOx3, strength 5/5 throughout, some difficulty with [**Doctor First Name **],
FNF intact
Pertinent Results:
HEME:
[**2158-12-15**] 07:20PM BLOOD WBC-15.2* RBC-4.35* Hgb-14.0 Hct-40.0
MCV-92 MCH-32.1* MCHC-35.0 RDW-15.0 Plt Ct-388
[**2158-12-16**] 04:18AM BLOOD WBC-14.5* RBC-3.81* Hgb-12.5* Hct-34.4*
MCV-90 MCH-32.8* MCHC-36.3* RDW-15.1 Plt Ct-307
.
COAGS:
[**2158-12-15**] 07:20PM BLOOD PT-17.0* PTT-25.5 INR(PT)-1.5*
[**2158-12-16**] 04:18AM BLOOD PT-15.2* PTT-25.4 INR(PT)-1.3*
.
CHEM:
[**2158-12-15**] 07:20PM BLOOD Glucose-163* UreaN-27* Creat-1.2 Na-134
K-4.1 Cl-93* HCO3-27 AnGap-18
[**2158-12-16**] 04:18AM BLOOD Glucose-102 UreaN-24* Creat-1.0 Na-136
K-3.9 Cl-98 HCO3-28 AnGap-14
[**2158-12-15**] 07:42PM BLOOD Lactate-1.8
.
LFTs:
[**2158-12-16**] 04:18AM BLOOD ALT-27 AST-34 LD(LDH)-166 AlkPhos-91
TotBili-0.2
.
CARDIAC:
[**2158-12-15**] 07:20PM BLOOD cTropnT-0.04*
[**2158-12-16**] 04:18AM BLOOD CK(CPK)-110 CK-MB-5 cTropnT-0.08*
[**2158-12-15**] 07:20PM BLOOD Digoxin-1.8
.
MICRO:
[**2158-12-20**] URINE URINE CULTURE-NO GROWTH
[**2158-12-16**] FOOT CULTURE WOUND CULTURE-FINAL {STAPH AUREUS COAG
+, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)}
[**2158-12-16**] BLOOD CULTURE Blood Culture, NO GROWTH
[**2158-12-16**] URINE URINE CULTURE, NO GROWTH
[**2158-12-15**] BLOOD CULTURE Blood Culture, NO GROWTH
.
STUDIES:
[**2158-12-15**] - CT HEAD -IMPRESSION: No acute intracranial process.
.
[**2158-12-15**] - CTA CHEST
IMPRESSION:
1. No pulmonary embolism.
2. Marked cardiomegaly, with evidence of prior myocardial
infarction in the left ventricular apex, with likely areas of
scarring, and aneurysm formation at the apex. Evaluation is
limited on this non-gated study, but a dedicated cardiac CT
could be performed if clinically indicated to further evaluate
this region.
3. Small bilateral pleural effusions and bibasilar atelectasis.
4. Cholelithiasis without evidence of cholecystitis.
5. Pulmonary artery enlargement, concerning for pulmonary
arterial
hypertension.
.
[**2158-12-16**] - ECHOCARDIOGRAM
Conclusions
The left atrium is markedly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 20 %) secondary to muliple areas of severe
hypokinesis and akinesis (see figure), with posterobasal
dyskinesis. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade III/IV
(severe) LV diastolic dysfunction. Right ventricular chamber
size is normal. with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2155-3-17**], the tricuspid
regurgitation is probably increased. Left ventricular
contractile function remains profoundly depressed.
.
[**2158-12-16**] - Left Foot
Three views of the left foot were brought to our review. There
is
irregularity and thickening of the distal portion of the fifth
metatarsal that might represent chronic old fracture. There is
additional irregularity and potential old healed fracture of the
distal second metatarsal.
There is lysis/fracture of the distal part of the proximal third
phalanx with potentially some degree of the subcutaneous air. In
the absence of prior studies for comparison, the chronicity of
these findings cannot be determined.
There is dislocation of the third metatarsophalangeal joint,
chronicity is
also undetermined. If clinically warranted, further evaluation
with MR, more sensitive study for osteomyelitis.
.
[**2158-12-18**] - ART EXT (REST ONLY)
IMPRESSION: No evidence of right lower extremity ischemia at
rest. Mild left lower extremity peripheral [**Month/Day/Year 1106**] disease with
predominant SFA/tibial location.
.
[**2158-12-20**] - VENOUS ULTRASOUND (MAP)
IMPRESSION: Patent right greater saphenous and bilateral lesser
saphenous
veins with reasonable diameters for bypass.
Brief Hospital Course:
# Unresponsiveness/VTACH - 61 y.o. man with significant cardiac
history who became acutely unresponsive at home. CPR initiated,
had BP and pulse by the time EMS arrived. Confused in ED, CT
scan of the head was unrevealing. Neuro consulted in the ED and
they felt unlikely to be primary neuro issue. No PE or
pneumothorax on CTA. The patient was ROMI. The patient was
admitted to MICU for hypotension and monitoring overnight. The
EP Cardiology team was consulted and they found 6 minutes of
spontaneous VT occurring precisely at 7PM on the night of
admission after interrogating his pacer. His device was not
programmed to fire for this particular arrhythmia. His device
was reprogrammed. The patient had no further significant
arrhythmic events during this admission. He was noted to have
anterograde amnesia after his arrest which most likely related
to transient ischemia in the brain. The patient will require
follow up with behavioral neurology.
.
# Osteomyelitis - The patient had a chronic left LE ulceration
related to a hospitalization several years ago. It looked
erythematous and had purulent drainage on admission. Podiatry
was consulted for deep tracking foot ulcer on left plantar
surface. Podiatry ecommended broad spectrum antibiotics. A foot
xray was consistent with osteomyelitis. Non-invasive arterial
studies were obtained to evaluate the blood flow to his LE prior
to an debridement. The patient had poor arterial blood flow in
his left LE and [**Month/Day/Year 1106**] surgery was consulted and they
recommended
angiography and possible revascularization procedure in the next
week. He was discharged on Linezolid and Ciprofloxacin. He has
close follow up arranged with his PCP, [**Name10 (NameIs) 1106**] surgery and
podiatry.
.
# CHF, systolic. His last EF 25%. He appeared clinically
euvolemic. His digoxin and sotalol were continued. His
diuretics (lasix and spironolactone) were restarted at lower
doses given the patient's renal function. Echocardiogram was
preformed during this admission.
.
# Renal Function - The patient's creatinine began to rise during
this admission most which was felt to be secondary to vancomycin
toxicity. The patients diuretics were held. He was not
pre-renal by labs or volume-depleted on exam. There was not
evidence of AIN, ATN or renal obstruction. His creatinine
improved after the vancomycin was discontinued.
.
# The patient's stable medical issues include: Hypothyroidism,
Hyperlipidemi, Anxiety, Insomnia,
.
# CODE: FULL
Medications on Admission:
Spironolactone 25mg po BID
Sotalol 120mg PO BID
Bupropion 100mg [**Hospital1 **]
Levothyroxine 25mcg daily
Clonazepam 0.5mg [**Hospital1 **]
Simvastatin 40mg Daily
Digoxin 125 QAM, 250 QPM
Midodrine 5mg TID
Zolpidem 10mg QHS
Furosemide 80mg Daily
Lorazepam 3-4mg QHS
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Lorazepam 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
12. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for
14 days.
Disp:*28 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
Please check a CBC, BMP (Lytes, BUN/Cr, Glucose) and Digoxin
level checked on Monday [**2158-12-25**]. Please have the lab results
sent to both Dr. [**Last Name (STitle) 31925**], phone ([**Telephone/Fax (1) 2037**] and to Dr. [**First Name (STitle) **]
[**Name (STitle) 5404**] ([**Telephone/Fax (1) 30799**].
14. Outpatient Lab Work
Please have a CBC checked on Monday [**2159-1-1**]. Please have the
results sent to Dr. [**First Name (STitle) **] [**Name (STitle) 5404**] [**Telephone/Fax (1) **].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Syncope from Ventricular Tachycardia
Osteomyelitis
Anterograde Amnesia
Secondary Diagnosis:
Coronary Artery Disease
Chronic Systolic Heart Failure
Hypothyroidism
Hyperlipidemia
Depression
Insomnia
Discharge Condition:
stable
Discharge Instructions:
You were admitted after an episode of syncope (loss of
consciousness). The cause of your syncope was an arrhythmia
called Ventricular Tachycardia. Your pacemaker was reprogrammed
so that it would fire for this particular heart rhythm. You did
not have any more repeat episodes of syncope. You were found to
have difficulties with short term memory after this incident and
will need follow up with Behavioral Neurology.
.
You were found to have an infection in the skin and bone of your
left foot. You will need to take antibiotics for at least the
next 2 weeks. You will need to follow up with [**Hospital 1106**] surgery
to revasularize your leg prior to having more a surgery to
remove the infected tissue in your foot. The antibiotic you are
taking for your foot infection, linezolid, can cause your white
blood cell count to be low. You will need weekly blood draws
while you are on it to check your cell count.
.
You had some worsening renal function likely secondary to
vancomycin an antibiotic you were taking for your infection.
You will need to have your blood drawn on Monday [**12-25**] to have
your renal function checked.
.
We made the following changes to your medication regimen
We decreased the dose of your digxoin, lasix and spironolactone.
You will be given new prescriptions for those medications. If
you become more short of breath or notice increased weight or
lower extremity swelling, please call your cardiologist.
We added Ciprofloxacin and Linezolid, 2 antibiotics for your
foot infection, you should take twice daily.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: none
Followup Instructions:
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**], the [**Last Name (NamePattern1) **]
Surgeon to be seen next Wednesday [**2158-12-27**] at 9:15am. He will
likely arrange angiography within the following week.
We recommend that you contact your Podiatrist, Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) 31926**], and make a follow up appointment in the next [**12-1**]
weeks. His telephone number is ([**Telephone/Fax (1) 31927**].
Please make an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 5404**], for
follow up in the next [**12-1**] week. His telephone number is ([**Telephone/Fax (1) 31928**]. He will need to follow up on your infection in your
foot.
You have the following appointment with your Cardiologist:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-1-1**]
2:30pm
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2159-1-1**] 2:40pm
We have arranged the following appointment for you with with Dr.
[**First Name (STitle) **] in Behavioral Neurology to follow up on your memory
difficulities.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD
Phone: [**Telephone/Fax (1) 1690**]
Date/Time: [**2159-1-22**] 10:30
.
We recommend that you follow up with your Psychiatrist regarding
your depression.
Completed by:[**2159-2-7**]
|
[
"V45.01",
"348.1",
"427.31",
"244.9",
"E930.8",
"584.9",
"682.7",
"780.2",
"730.27",
"428.23",
"305.1",
"427.1",
"412",
"459.81",
"428.0",
"272.4",
"696.1",
"V45.02",
"V12.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45"
] |
icd9pcs
|
[
[
[]
]
] |
11580, 11638
|
7210, 9719
|
287, 294
|
11880, 11889
|
2612, 7187
|
13620, 15163
|
2142, 2176
|
10037, 11557
|
11659, 11731
|
9745, 10014
|
11913, 13597
|
2191, 2593
|
235, 249
|
322, 1598
|
11752, 11859
|
1620, 1931
|
1947, 2126
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,934
| 162,313
|
41009
|
Discharge summary
|
report
|
Admission Date: [**2196-7-27**] Discharge Date: [**2196-8-1**]
Date of Birth: [**2136-7-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2196-7-27**]
1. Replacement of ascending aorta and hemiarch using a 28-
mm Dacron tube graft and deep hypothermic circulatory
arrest. The graft data is the following. It is a
Vascutek Gelweave graft, catalog number [**Numeric Identifier 31950**], lot
number [**Telephone/Fax (3) 89446**], serial number [**Serial Number 89447**].
2. CorMatrix reconstruction of the pericardium.
3. Epiaortic duplex scanning.
History of Present Illness:
This is a 59 year old female well
known to our service who first presented in [**2196-3-8**] with
diagnosis of ascending aortic aneurysm. Aneurysm repair was
delayed at that time due to a colovesicular fistula causing
chronic urinary tract infections. In [**2196-4-8**] she underwent
placement of left-sided ureteral stent, sigmoid colectomy,
takedown of colovesicular fistula, mobilization of splenic
flexure and diverting loop ileostomy. In [**2196-5-8**] she underwent
successful ileostomy takedown. She is now recovering nicely from
surgery without recurrent urinary tract infections, and presents
again for surgical evaluation. Currently, she remains very
functional and denies chest and back pain, dyspnea on exertion,
orthopnea, PND, palpitations, pedal edema, and cough.
Past Medical History:
Aortic Aneurysm
Hypertension
Dyslipidemia
Colonic polyps
Renal Insufficiency 1.45
History of ischemic CVA [**2191**](transient visual disturbance)
COPD/Asthma
Uterine cancer
Right Lung Nodule, likely carcinoma
Giant Cell Arteritis/Polymyalgia Rheumatica (tx with steroids-
currently on Prednisone 5mg daily)
Obesity
Elevated HgbA1c (while on steroids)
Hypothyroidism
History of + PPD
Elevated CRP
Colovesicular fistula and Diverticulitis
Past Surgical History:
s/p Total Abd Hysterectomy
s/p Temporal artery biopsy
s/p Tonsillectomy
s/p Placement of left-sided ureteral stent, sigmoid colectomy,
takedown of colovesicular fistula, mobilization of splenic
flexure and diverting loop ileostomy
s/p Ileostomy takedown
Social History:
Lives with: Alone
Occupation: Clinical social worker, directs an inpt detox unit
Tobacco: Recently quit in [**2195-12-9**]. 40yrs, approx [**1-10**] ppd
ETOH: None since [**2195-12-9**]; previously [**2-11**] drinks per day
Family History:
Mother with abd aortic aneurysm. Both parents
with CVAs
Physical Exam:
Pulse: 71 Resp: 16 O2 sat: 98% BP: 128/84
Height: 237 lbs Weight: 66 inches
General: obese female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] anicteric sclera;OP unremarkable
Neck: Supple [X] Full ROM []no JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur-none
Abdomen: Soft [] non-distended [] non-tender []
bowel sounds + [];npo HSM, obese
Extremities: Warm [X], well-perfused [X] Edema-none
Varicosities: mild B spider veins
Neuro: Grossly intact; nonfocal exam; MAE [**5-12**] strengths
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2196-7-27**]
Conclusions
PRE-BYPASS: Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is severely dilated.
The sinotubular junction is intact without effacement. The
descending thoracic aorta is moderately dilated. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no pericardial effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolic function
2. Unchanged valvular structure and function
3. Tube graft visualized in ascending aortic position.
4. Intact descending thoracic aorta
[**2196-7-31**] 06:30AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.2* Hct-27.2*
MCV-90 MCH-30.6 MCHC-33.9 RDW-16.3* Plt Ct-250
[**2196-7-30**] 05:00AM BLOOD WBC-10.0 RBC-2.86* Hgb-9.0* Hct-26.4*
MCV-92 MCH-31.3 MCHC-33.9 RDW-16.8* Plt Ct-199
[**2196-7-31**] 06:30AM BLOOD Glucose-129* UreaN-39* Creat-1.2* Na-132*
K-4.0 Cl-93* HCO3-26 AnGap-17
[**2196-7-30**] 05:00AM BLOOD Glucose-113* UreaN-37* Creat-1.2* Na-134
K-4.3 Cl-98 HCO3-26 AnGap-14
[**2196-7-31**] 06:30AM BLOOD Mg-2.1
[**2196-7-30**] 05:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
Brief Hospital Course:
The patient was brought to the Operating Room on [**2196-7-27**] where
the patient underwent ascending aorta and hemiarch replacement.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
She returned to the CVICU overnight for hypotension and
oliguria. This improved with hydration, and she returned to the
telemetry floor. Cipro was started for positive urinalysis,
urine culture returned negative and antibiotics were
discontinued. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
Albuterol MDI prn, Atenolol 50mg daily, Buproprion 150
twice daily, Prozac 40mg daily, Flovent 110 2P twice daily, HCTZ
25mg daily, Avapro 300mg daily, Levothyroxine 250 daily,
Prednisone 5mg daily, Spiriva 18 daily, Aspirin 325 mg daily, MV
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
14. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Aneurysm
Hypertension
Dyslipidemia
Colonic polyps
Renal Insufficiency 1.45
History of ischemic CVA [**2191**](transient visual disturbance)
COPD/Asthma
Uterine cancer
Right Lung Nodule, likely carcinoma
Giant Cell Arteritis/Polymyalgia Rheumatica (tx with steroids-
currently on Prednisone 5mg daily)
Obesity
Elevated HgbA1c (while on steroids)
Hypothyroidism
History of + PPD
Elevated CRP
Colovesicular fistula and Diverticulitis
Past Surgical History:
s/p Total Abd Hysterectomy
s/p Temporal artery biopsy
s/p Tonsillectomy
s/p Placement of left-sided ureteral stent, sigmoid colectomy,
takedown of colovesicular fistula, mobilization of splenic
flexure and diverting loop ileostomy
s/p Ileostomy takedown
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2196-8-2**] at
11:30
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**8-23**] at 2:45pm
Cardiologist: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2920**] on [**8-3**] at 3:10pm in [**Name (NI) **] (pt
already had this appointment
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] K. [**Telephone/Fax (1) 17794**] in [**4-12**] 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:[**2196-8-1**]
|
[
"585.9",
"272.4",
"788.5",
"458.29",
"V12.54",
"441.2",
"V12.72",
"V58.65",
"244.9",
"725",
"584.9",
"V10.42",
"403.90",
"518.89",
"278.00",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7779, 7828
|
4752, 6062
|
291, 721
|
8587, 8752
|
3366, 3994
|
9624, 10403
|
2524, 2582
|
6355, 7756
|
7849, 8287
|
6088, 6332
|
8776, 9601
|
8310, 8566
|
2597, 3347
|
235, 253
|
749, 1529
|
1551, 1989
|
2283, 2508
|
4005, 4729
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,878
| 173,430
|
9078
|
Discharge summary
|
report
|
Admission Date: [**2189-9-5**] Discharge Date: [**2189-9-10**]
Date of Birth: [**2112-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77-year-old female with hx type 2 diabetes, seropositive
nonerosive rheumatoid arthritis, hypothyroidism, osteoporosis,
and glaucoma who presented with weakness and fever, found be to
hypotensive.
Per the records, the patient has a recent history of sacral
decub ulcer. On [**7-22**] the pt was initially evaluated and found to
have "dime sized portion is pinkish white without obvious
discharge at this time. The surrounding skin is indurated and
erythematous without warmth" and does occasionally drain
yellowish fluid. She was seen by the wound care RN on [**8-20**] at
which point it was described as "Large area 5 x 4 cm irregular
with intact blanchable erythema, along with distant satellite
lesions related to increase moisture on skin from UI, along with
non-breathable depends." She was started on Critic aid clear
antifungal skin barrier ointment. On [**8-27**] f/u the pt's ulcerated
area was felt to be healed, with continued erythema and signs of
pressure. To aid in healing, the pt's humira was being held
since [**2189-7-24**] and has not been restarted. Subsequent to this the
pt's daughters note increased joint pain ([**Name (NI) 31346**], elbows, knees,
ankles, shoulders) and decreased mobility, which they have been
treating with tylenol.
On [**2189-8-27**] the pt was seen in [**Hospital **] clinic and complained of
increased urinary frequency and her daughters noted malodorous
urine and decreased appetite. UCx showed E. coli >100k CFU. She
was prescribed Bactrim DS for 3 days however after the first
dose of Bactrim she developed generalized weakness, excessive
sleepiness, poor oral intake, and more difficulty with her
mobility to the point that her daughter had to carry her to and
from the bathroom. Therefore no subsequent doses were given.
They returned to [**Hospital **] clinic [**2189-9-3**] and requested change of abx
at which point the pt was started on Ciprofloxacin 500mg PO BID
x3 days. Again she received one dose and the family felt she
developed a rash, increased saliva and continued
lethargy/fatigue so they gave no subsequent doses.
Per the daughters, the pt has had chills and weakness, and had a
T 101.5 at 820pm last night. She did have a HA x1 yesterday but
both daughters felt she was not altered. She also had diarrhea
x2 days with 3-4bm/day which were yellow and liquidy. They deny
blood in the stool or black tarry stools.
Of note, the pt's daughter states that she has had very limited
PO intake since [**8-31**] when she took her dose of bactrim. She was
also instructed to hold her glimepiride given decreased PO
intake, so it has been held since [**2189-9-4**]. They have been unable
to check FSG [**3-5**] broken glucometer. Also, on examination of the
pt's medications, she had two pill bottles with MMF, one was
marked as "Vitamina D" by the pharmacist, so the pt has been
receiving 1g q12h of MMF for the last few days rather than her
regular 500mg q12h.
In the ED the pt was found to have VS: 99.2 (101.8) 88/36 101 16
98%RA. She triggered for hypotension at triage and nadired at
79/41. A central line was placed and she was given a total of 4L
of IVF with CVP going from 4 to [**10-12**]. She was also started on
norepi and given hydrocort 100mg IV. Labs showed Na 118, WBC
22.9, HCT 32.2. The pt received CTX 1g IV and vanc 1g IV. LP was
attempted x2 "given no source" but failed. Vitals on transfer
99.1 67 19 117/55 98%RA.
On arrival to the MICU, patient's VS 97.4 76 124/67 (on norepi)
98%RA. She was lethargic, sleeping but arousable. She denied
pain but did endorse TTP at [**Month/Year (2) 31346**], elbows, shoulders and spine.
Repeat Na 136, WBC 20.8, HCT 29.7.
Past Medical History:
-DMII ([**7-13**] HbgA1c 6.6%)
-Seropositive Non-erosive Rheumatoid Arthritis (recent d/c of
humira)
-Hypothyroidism
-Osteoporosis
-glaucoma with blindness in left eye
-allergic rhinitis
-interstitial lung disease
-sacral decubitus ulcer
Social History:
The patient does not smoke or drink alcohol.
She has been a housewife all her life. Living with her
daughter,
[**Name (NI) 4014**]. Originally from [**Location (un) **].
Family History:
noncontributory
Physical Exam:
Admission PE
General: Emaciated female, fatigued, sleeping, but responsive to
loud voice, complains of pain with movement
HEENT: Sclera anicteric, dry edentulouse mucous membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD, TTP over c-spine
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: scattered crackles anteriorly
Abdomen: soft, thin, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: responds to questions, moving all extremities, did not
participate with exam
Skin: purpura on bilateral forearms
.
Discharge PE
As above. Dry crackles at lung bases. No joint swelling.
Conversant with her family.
Pertinent Results:
[**2189-9-5**] CXR
IMPRESSION:
Unchanged diffuse interstitial lung disease. No acute
intrathoracic process.
.
[**2189-8-27**] 12:00 pm URINE
**FINAL REPORT [**2189-8-29**]**
URINE CULTURE (Final [**2189-8-29**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Labs on Discharge:
[**2189-9-8**] 11:15AM BLOOD WBC-8.0 RBC-4.14* Hgb-11.5* Hct-34.8*
MCV-84 MCH-27.8 MCHC-33.0 RDW-16.1* Plt Ct-481*
[**2189-9-8**] 11:15AM BLOOD Glucose-98 UreaN-10 Creat-0.4 Na-136
K-4.4 Cl-101 HCO3-28 AnGap-11
Brief Hospital Course:
This is a 77 yo F with a PMHx of RA previously on humira but
discontinued due to worsening sacral decubitus ulcers, who was
recently diagnosed with a UTI but was unable to toelrate
outpatient antibiotics who presentes with urosepsis
.
# Sepsis: Pt presented with SIRS criteria (WBC 22, T 101.8),
hypotension and recent UTI with e.coli concerning for sepsis.
Regarging the hypotension, the pt with baseline SBP 90-120 (not
on antiHTN) presented to the ED with SBP 88 nadired at 79 and
subsequently given 4L NS, hydrocort and started on levophed. A
central line was placed. The hypotension was thought to be
multifactorial [**3-5**] decreased PO intake c/b infection. Infectious
source likely e.coli urinary tract infection; while urine
sterile from this hospitalization UC from [**2189-8-27**] showed
pansensitive e. coli. This may have been because patient had
received one dose of bactrim and one dose of cipro, which likely
confounded labs. For this, she was treated with ceftriaxone.
There was also concern for c.diff with a recent history of
diarrhea, but c.diff toxin was negative. Overnight, the patient
pulled out the central line without any residual complication.
In the ICU, she was found to have SBPs in 120s, and levophed was
quickly weaned off. Patient remained hemodynamically stable for
remainder of MICU course and was transfered to the floor. On
the floor she did well and was transitioned to Cefpodoxime. She
will require an additional 1.5 days of antibiotics at discharge.
# Hyponatremia: Pt with hyponatremia to 118 on presentation,
down from 133 ([**8-7**]). Improved to 136 with 4L NS. This was
thought to be secondary to hypovolemia.
# Stage I Sacral Decub Ulcer: Pt with sacral decub since [**Month (only) **]
for which she has seen wound care and hsa been using barrier
cream. Based on report appears improved though still stage I.
Importance of frequent repositioning discussed with family.
# "Rash": Pt's family reported development of rash after cipro.
However on exam, pt appeared to have purpura on upper
extremities likely [**3-5**] poor skin integrity from chronic pred and
nutritional deficiencies. Pt without thrombocytopenia. She was
monitored for rash, with no complication.
# Rheumatoid arthritis: Pt with chronic RA with +RF and +CCP.
Has been on multiple medications, most recently prednisone, MMF
and humira. Humira was held due to ongoing infection, decubs
with noticable worsening in pain and functional status. Of note,
patient also accidentally received double dose of MMF in recent
history. MMF and prednisone were continued. Patient's primary
rheumatologist was contact[**Name (NI) **]. Inpatient rheumatology consult was
recommended by him. The inpatient Rheumatology team recommended
continuing the current regimen until her antibiotic course was
completed, and then re-starting Humira. A follow-up appointment
with Dr.[**Last Name (STitle) **] was scheduled within one week of the end date of
her antibiotics.
# Weight loss and malnutrition
The patient family was very concerned about the patient's 30 lbs
weight loss in the last several months. The patients albumin
was checked and was 2.9. Nutrition was consulted and
recommended supplements. The patient ate well while in the
hospital, but per her family requires significant coaxing to eat
at home. It was recommended that they continue to discuss this
with the patient's primary care physician.
# Type 2 diabetes: Held home glimepiride and put on insulin
sliding scale while in-house. Glimepiride was re-started at
discharge.
# Transitional Issues
-follow up with Rheumatology to discuss re-starting Humira
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver[**Name (NI) 581**].
1. Alendronate Sodium 70 mg PO QWEEK
2. Lumigan *NF* (bimatoprost) 0.03 % OU qhs
3. Azopt *NF* (brinzolamide) 1 % OU TID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. glimepiride *NF* 1 mg Oral daily
6. Levobunolol 0.5% 1 DROP BOTH EYES [**Hospital1 **]
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Mycophenolate Mofetil 500 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 150 mg PO BID
11. Acetaminophen 1000 mg PO Q12H:PRN pain, fever
12. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral [**Hospital1 **]
13. Cyanocobalamin 500 mcg PO QOD
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Azopt *NF* (brinzolamide) 1 % OU TID
3. Cyanocobalamin 500 mcg PO QOD
4. Levobunolol 0.5% 1 DROP BOTH EYES [**Hospital1 **]
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Lumigan *NF* (bimatoprost) 0.03 % OU qhs
7. Mycophenolate Mofetil 500 mg PO BID
8. PredniSONE 5 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Alendronate Sodium 70 mg PO QWEEK
11. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral [**Hospital1 **]
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. glimepiride *NF* 1 mg Oral daily
14. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth q12 Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Pansensitive E. coli UTI with Urosepsis
RA
Malnutrition
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with low blood pressure and fevers.
These were likely caused by a urinary tract infection. You were
given IV antibiotics and IV fluids and you improved. You were
evaluated by a physical therapist who recommended Rehab. You
will complete your course of antibiotics as an outpatient. After
your antibiotics are completed you will see Dr.[**Last Name (STitle) **] to discuss
re-starting your Humira.
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] G.
Location: [**Hospital1 18**]-DIVISION OF GERONTOLOGY
Address: [**Doctor First Name **], 1B, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 719**]
Department: RHEUMATOLOGY
When: WEDNESDAY [**2189-9-16**] at 3:00 PM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"038.42",
"366.9",
"729.1",
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"707.22",
"263.9",
"285.29",
"995.91",
"250.00",
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icd9cm
|
[
[
[]
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[
"03.31",
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icd9pcs
|
[
[
[]
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11685, 11784
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6575, 10200
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283, 289
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11883, 12005
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5270, 6321
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12020, 12043
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3985, 4224
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4240, 4414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,062
| 168,583
|
52861
|
Discharge summary
|
report
|
Admission Date: [**2171-3-31**] Discharge Date: [**2171-4-12**]
Date of Birth: [**2110-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
bioprosthetic mitral regurgitation, tricuspid regurgitation
Major Surgical or Invasive Procedure:
[**2171-4-2**] Redo sternotomy,redo Mitral Valve Replacement(29mm St.
[**Male First Name (un) 923**] mechanical),redo Tricuspid Valve repair (28mm ring)
History of Present Illness:
This 60 year old black female underwent tissue mitral
replacement and tricuspid banding in [**2168**] at [**Hospital3 **]. She has had progressive valve dysfunction with
regurgitation of both valve. Workup has been completed and she
was referred for reoperation. She was admitted now for Heparin
bridging prior to reoperation.
Past Medical History:
End stage renal disease
Hypertension
Asthma
Atrial Fibrillation
Congestive heart failure
Peripheral vascular disease
s/p Mitral valve replacement and tricuspid valve repair
s/p Left arm AV fistula
s/p Renal transplant right iliac fossa [**12/2170**] [**Hospital1 18**]
s/p mitral valve replacement,tricuspid annuloplasty
Social History:
Her stated height and weight are 5'8" and 168 lbs. She does not
drink alcohol. non smoker
Family History:
adopted- FH unknown
Physical Exam:
Pulse:56 Resp:18 O2 sat:91/RA
B/P 91/59
Height:68" Weight:80.8 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade VI/VI, mid
diastolic click
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], incision c/d/i
Extremities: Warm [x], well-perfused [x] Edema [] _____
Left Arm Fistula Good Bruit and Thrill
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+ no bruit
DP Right: Doppler Left: Doppler
PT [**Name (NI) 167**]: Doppler Left: Doppler
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2171-4-5**] 05:40AM BLOOD WBC-5.3 RBC-3.22* Hgb-8.7* Hct-28.6*
MCV-89 MCH-27.0 MCHC-30.3* RDW-16.0* Plt Ct-108*
[**2171-3-31**] 05:24PM BLOOD WBC-3.8* RBC-3.66* Hgb-9.8* Hct-32.8*
MCV-90 MCH-26.6* MCHC-29.7* RDW-15.9* Plt Ct-182
[**2171-4-6**] 04:07AM BLOOD PT-16.9* PTT-54.4* INR(PT)-1.6*
[**2171-4-5**] 05:40AM BLOOD PT-14.4* PTT-28.2 INR(PT)-1.3*
[**2171-4-4**] 10:29AM BLOOD PT-13.4* PTT-33.6 INR(PT)-1.2*
[**2171-4-1**] 07:21PM BLOOD Glucose-117* UreaN-27* Creat-2.2* Na-142
K-4.0 Cl-103 HCO3-30 AnGap-13
[**2171-4-6**] 04:07AM BLOOD UreaN-26* Creat-1.7* Na-137 K-4.3 Cl-105
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 109007**] (Complete) Done
[**2171-4-2**] at 11:47:35 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2110-5-1**]
Age (years): 60 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Left ventricular function. Mitral valve disease.
Preoperative assessment. Prosthetic valve function. Pulmonary
hypertension. Shortness of breath. Valvular heart disease.
ICD-9 Codes: 424.0, 424.2
Test Information
Date/Time: [**2171-4-2**] at 11:47 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 #: 2012AW3-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.8 cm <= 2.5 cm
Mitral Valve - Peak Velocity: 2.4 m/sec
Mitral Valve - Mean Gradient: 10 mm Hg
Mitral Valve - Pressure Half Time: 354 ms
Mitral Valve - MVA (P [**1-14**] T): 0.6 cm2
Tricuspid Valve - Peak Velocity: 3.6 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Normal regional LV systolic function. Overall normal
LVEF (>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global
RV free wall hypokinesis.
AORTA: Mildly dilated ascending aorta. Mildly dilated descending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Thickened MVR leaflets.. Increased MVR gradient.
Severe valvular MS (MVA <1.0cm2). Mild to moderate ([**1-14**]+) MR.
TRICUSPID VALVE: Tricuspid valve annuloplasty ring. Moderate to
severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
prosthetic mitral valve leaflets are thickened and have markedly
limited opening.. The gradients are higher than expected for
this type of prosthesis. There is severe valvular mitral
stenosis (area 0.6-0.7cm2). Mild to moderate ([**1-14**]+) mitral
regurgitation is seen. A tricuspid valve annuloplasty ring is
present. Moderate to severe [3+] tricuspid regurgitation is
seen.
POSTBYPASS
LV systolic function remains normal. RV systolic function
remains moderately impaired. There is a well seated, well
functioning, bileaflet mechanical prosthesis in the mitral
position. Valvular MR is present which is normal in quantity and
location for this type of prosthesis. A anulloplasty ring is
visualized in the tricuspid position. TR is now trace. The
remaining study is unchanged from the prebypass study.
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) **] [**2171-4-2**] 15:45
?????? [**2162**] CareGroup IS. All rights reserved.
[**2171-4-11**] 03:57AM BLOOD WBC-4.4 RBC-3.04* Hgb-7.8* Hct-27.3*
MCV-90 MCH-25.8* MCHC-28.7* RDW-15.1 Plt Ct-256
[**2171-4-11**] 03:57AM BLOOD PT-21.4* PTT-76.0* INR(PT)-2.0*
[**2171-4-11**] 03:57AM BLOOD UreaN-21* Creat-1.8* Na-134 K-4.2 Cl-104
[**2171-4-12**] 04:05AM BLOOD Hct-27.0*
[**2171-4-12**] 04:05AM BLOOD PT-27.2* PTT-150* INR(PT)-2.6*
[**2171-4-11**] 12:00PM BLOOD PT-23.4* INR(PT)-2.2*
[**2171-4-12**] 04:05AM BLOOD Glucose-98 UreaN-21* Creat-1.9* Na-132*
K-4.3 Cl-102 HCO3-21* AnGap-13
Brief Hospital Course:
Heparin was started on admission. On [**4-2**] she went to the
Operating Room where redo sternotomy, redo mitral valve
replacement and tricuspid annuloplasties were undertaken. Please
see operative report for further details. Cardiopulmonary Bypass
Time: 152 minutes. Cross Clamp Time: 131 minutes. She weaned
from bypass on Neo Synephrine and remained stable. She was
transferred intubated and sedated. She awoke neurologically
intact and extubated the night of surgery.
Pressor support was weaned off. She had a junctional rhythm
postoperatively and remained in the CVICU for close observation
until POD#2 when she transferred to the step down unit for
further recovery. CTs were removed without incident.
Heparin was started on POD 3. Atrial wires did not work and
were removed on POD 3. V wires were retained. On POD 4 she had
Wenckebach and Type II block as well as atrial fibrillation.
The ventricular rate fell as low as 40, but the pacer failed to
sense or pace reliably. She remained asymptomatic. An
Electrophysiology consult was obtained and a formal study
recommended to determine the need for a permanent pacemaker.
Ultimately her rhythm returned to sinus and then her preop rate
controlled atrial fibrillation. EP recommended low dose
Beta-blocker initiated. She has tolerated it well. Coumadin was
reinstated. Her V wires were removed.
Physical Therapy consulted for evaluation of strength and
mobility. She continued to progress and on POD# 10 she was
discharged to home with VNA. Coumadin follow up to resume at
[**Hospital6 **]. All follow up appointments were
advised.
Medications on Admission:
Aspirin 81 mg daily
Cinacalcet 60 mg daily
Metoprolol Succinate 25 mg daily
Midodrine 2.5 mg tid
Mycophenolate Mofetil 500 mg daily (dose change [**3-29**]/transplant)
Simvastatin 10 mg daily
Sulfamethoxazole-trimethoprim 400 mg-80 mg daily
Tacrolimus 6 mg [**Hospital1 **] (dose change [**3-29**]/transplant)
Torsemide 50 mg daily
Warfarin 5/7.5 mg daily (Warfarin management by [**Hospital6 109008**])Last dose 3/14
Discharge Medications:
1. mycophenolate mofetil 500 mg [**Hospital6 8426**] Sig: One (1) [**Hospital6 8426**] PO
BID (2 times a day).
2. sulfamethoxazole-trimethoprim 400-80 mg [**Hospital6 8426**] Sig: One (1)
[**Hospital6 8426**] PO DAILY (Daily).
3. ranitidine HCl 150 mg [**Hospital6 8426**] Sig: One (1) [**Hospital6 8426**] PO DAILY
(Daily).
4. acetaminophen 325 mg [**Hospital6 8426**] Sig: Two (2) [**Hospital6 8426**] PO Q4H (every
4 hours) as needed for fever, pain.
5. aspirin 81 mg [**Hospital6 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital6 8426**], Delayed Release (E.C.) PO DAILY (Daily).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed for constipation.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. oxycodone-acetaminophen 5-325 mg [**Hospital6 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 [**Hospital6 8426**](s)* Refills:*0*
10. metoprolol tartrate 25 mg [**Hospital6 8426**] Sig: 0.5 [**Hospital6 8426**] PO BID (2
times a day).
Disp:*30 [**Hospital6 8426**](s)* Refills:*2*
11. tacrolimus 1 mg Capsule Sig: Seven (7) Capsule PO Q12H
(every 12 hours).
Disp:*420 Capsule(s)* Refills:*2*
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
Disp:*qs 1* Refills:*0*
13. warfarin 2.5 mg [**Hospital6 8426**] Sig: daily [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a
day.
Disp:*125 [**Last Name (Titles) 8426**](s)* Refills:*2*
14. Outpatient Lab Work
serial PT/INR for prosthetic mitral valve
goal INR 2.5-3.5
Results to [**Hospital6 12736**] [**Hospital **] clinic
[**Telephone/Fax (1) 109009**]
15. Outpatient Lab Work
BUN/Cr on [**2171-4-18**]
Results to Dr. [**Last Name (STitle) **] fax: [**Telephone/Fax (1) 21335**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral Regurgitation-prosthetic
Tricuspid Regurgitation
end stage renal disease
s/p renal transplant
Hypertension
Asthma
Atrial Fibrillation
Congestive heart failure
Peripheral vascular disease
s/p Mitral valve replacement/tricuspid valve repair
s/p Left arm AV fistula
s/p Renal transplant right iliac fossa [**12/2170**] [**Hospital1 18**]
s/p mitral valve replacement/tricuspid annuloplasty [**2168-10-19**]
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
cardiac surgeon:Dr [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2171-5-8**] at 1:45pm
cardiology: Dr.[**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]([**Telephone/Fax (1) 62**]) on [**2171-4-16**] at
3:00
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2171-4-16**] 10:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2171-5-6**] 2:40
please schedule the following appointments:
Dr.[**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) 61068**] (PCP) ([**Telephone/Fax (1) 31372**]) in [**4-18**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (EP) in [**3-17**] weeks [**Telephone/Fax (1) 62**]
Coumadin followup with: [**Hospital6 12736**]
[**Hospital 2786**] clinic
Indications: mechanical mitral valve: INR goal: 2.5-3.5
next blood draw on: [**2171-4-14**]
phone results to: [**Telephone/Fax (1) 109009**]
Completed by:[**2171-4-12**]
|
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"458.29",
"V43.3",
"428.0",
"424.0",
"V42.0",
"585.3",
"285.1",
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"V58.61",
"584.9",
"424.2",
"427.31",
"426.13",
"428.32",
"791.9",
"403.90"
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icd9cm
|
[
[
[]
]
] |
[
"35.14",
"39.61",
"38.97",
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icd9pcs
|
[
[
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12247, 12305
|
8165, 9762
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2145, 5718
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13800, 14827
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1349, 1370
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5763, 8142
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1385, 2126
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270, 331
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552, 882
|
904, 1226
|
1242, 1333
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16,273
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Discharge summary
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report
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Admission Date: [**2123-5-15**] Discharge Date: [**2123-5-20**]
Date of Birth: [**2073-11-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 yo male, s/p motorcycle crash vs SUV, helmeted, +LOC and upon
awakening was perseverating and disoriented. He was taken to an
area hospital and was later transferred to [**Hospital1 18**] for continued
trauma care.
Past Medical History:
Chronic Pain
Depression
Hep C
GERD
"Neck" Surgery
Social History:
Substance abuse issues
Chronic pain on narcotics
Married
+h/o tobacco
Family History:
Noncontributory
Pertinent Results:
[**2123-5-15**] 01:15PM GLUCOSE-141* UREA N-11 CREAT-0.7 SODIUM-140
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2123-5-15**] 01:15PM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-1.6
[**2123-5-15**] 01:15PM WBC-11.8* RBC-3.70* HGB-11.8* HCT-31.5*
MCV-85 MCH-31.9 MCHC-37.4* RDW-13.2
[**2123-5-15**] 01:15PM PLT COUNT-245
[**2123-5-14**] 10:27PM HGB-14.0 calcHCT-42
[**2123-5-14**] 07:34PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2123-5-14**] 07:26PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-5-14**] 07:26PM PLT COUNT-288
[**2123-5-14**] 07:26PM PT-11.9 PTT-23.2 INR(PT)-1.0
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2123-5-14**] 7:32 PM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: eval for orbital floor fracture / blood behind left eye
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with proptosis of left eye / lac
REASON FOR THIS EXAMINATION:
eval for orbital floor fracture / blood behind left eye
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Evaluate for orbital floor fracture, blood behind
the eye.
COMPARISON: None.
TECHNIQUE: Axial non-contrast images of the facial bones were
obtained. Coronal and sagittal reformatted images were also
displayed.
FINDINGS: Fractures are seen within the lateral left orbital
wall, the left sphenoid, and left zygoma. Orbital floor appears
intact. There is evidence of high-density material consistent
with hematoma posterior to the left orbit. Air-fluid levels are
noted within the sphenoid air spaces bilaterally. There is
mucosal thickening within the ethmoid sinuses. Again seen is a
punctate high- density focus within the left frontal scalp, and
high density material over the left orbit concerning for foreign
body.
IMPRESSION:
1. Fractures of the left lateral orbital wall, the left zygoma,
left sphenoid.
2. High-density material consistent with extra-conal hematoma
seen superiorly in the left orbit.
3. Suspicion for foreign body within the soft tissues.
4. Air-fluid levels within the sphenoid air spaces and mucosal
thickening within the ethmoid sinuses.
Findings were discussed with the surgical team and relayed to
the ED dashboard immediately following completion of the study.
CT HEAD W/O CONTRAST [**2123-5-14**] 7:17 PM
CT HEAD W/O CONTRAST
Reason: r/o bleed
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with MCC versus SUV
REASON FOR THIS EXAMINATION:
r/o bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: MVC, evaluate for bleed.
COMPARISON: Comparison is made to the films provided from the
outside hospital..
TECHNIQUE: Noncontrast head CT scan (patient was scanned at
outside hospital and did receive IV contrast for body CT at that
time).
FINDINGS: There is high density material seen along the sulci of
the right temporal region, consistent with subarachnoid
hemorrhage. There is also evidence of high density material
within the area of the right tentorium consistent with subdural
hematoma. A more focal area of increased density is seen in the
left temporal region consistent with contusion. There appears to
be mild mass effect on the right lateral ventricles and possible
slight leftward shift of normally midline structures. High
density material is seen posterior to the left orbit. Air-fluid
levels are seen within the sphenoid sinuses bilaterally.
Fractures are seen in the left lateral orbital wall, left
sphenoid, and left zygoma. There is evidence of subcutaneous air
in these regions consistent with fracture. High density focus is
seen. A punctate hyperdensity is seen in the left frontal scalp
as well as over the left orbit concerning for foreign body.
Large hematoma is seen in the left parietal scalp.
IMPRESSION:
1. Evidence of right subarachnoid and subdural hematoma and left
temporal contusion. Mild mass effect on right lateral ventricles
and slight leftward shift.
2. Left retro-orbital hematoma.
3. Facial fractures as described, better assessed on CT of the
facial bones.
4. Air-fluid levels in the sphenoid air spaces.
5. Large left parietal scalp contusion with suspicion for
foreign bodies within the soft tissue as described.
Findings were discussed with the surgical team and relayed to
the ED dashboard immediately, at the conclusion of the study.
CT HEAD W/O CONTRAST [**2123-5-15**] 2:42 PM
CT HEAD W/O CONTRAST
Reason: Please perform at 2pm; r/o interval change in CTH
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with MCC vs SUV
REASON FOR THIS EXAMINATION:
Please perform at 2pm; r/o interval change in CTH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 49-year-old male with _____ injury.
COMPARISON: Prior studies from earlier the same date at 01:50
hours.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no short-term interval change in appearance
of the brain. The previously identified right subdural
hemorrhage measures approximately 6 mm. A small extra-axial
collection in the right frontal lobe remains unchanged in size.
Mild leftward subfalcine herniation is unchanged. There is no
evidence of hydrocephalus. The basal cisterns are not effaced.
Again identified is a 5 mm focus of parenchymal hemorrhage
within the left temporal lobe. High density material tracking
along the right tentorium consistent with subdural hematoma and
stable. Hemorrhage within the sphenoid air cells and above the
left orbit is stable in size and appearance. There is a large
left subgaleal hematoma.
IMPRESSION: Stable appearance of subarachnoid, subdural, and
intraparenchymal hemorrhage as described above. There is no
change in mild subfalcine herniation.
CT HEAD W/O CONTRAST [**2123-5-16**] 10:11 AM
CT HEAD W/O CONTRAST
Reason: interval change?
[**Hospital 93**] MEDICAL CONDITION:
49 year old man s/p motorcycle accident w/ intracranial bleed.
REASON FOR THIS EXAMINATION:
interval change?
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE HEAD ON [**5-16**].
CLINICAL HISTORY: Motorcycle accident. Hemorrhage. Followup.
TECHNIQUE: Contiguous scans were obtained from the skull base to
the vertex.
FINDINGS:
There is a small right-sided subdural hematoma primarily
overlying the right temporal lobe. A thin component extends over
the right tentorium. There are at least 3 peripheral focal areas
of hemorrhage in the right temporal lobe, unchanged. These may
represent hemorrhagic contusions with surrounding edema.
Vague high attenuation is seen in the region of the inferior
aspect of the left sylvian fissure perhaps representing a small
amount of subarachnoid blood. A shear type injury might have a
similar appearance. This is not visible on the preceding day's
study.
There is right-sided mass effect. The right lateral ventricle
and the sulci are smaller than the left, without change. There
is no shift of normally midline structures. There is a large
left parietal scalp hematoma. Subgaleal low attenuation fluid is
now seen on the right.
There is a left sided orbital hematoma with proptosis. There are
air, blood levels in the sphenoid sinus.
IMPRESSION:
1. There is no significant change from [**5-16**].
2. There is relatively thin but extensive right-sided subdural
hematoma with mass effect on the lateral ventricles and sulci.
There is no shift of normally midline structures.
3. There are two peripheral areas of hemorrhage in the right
temporal region probably hemorrhagic contusions. Another is seen
in the posterior left temporal lobe, near the petrous ridge.
4. There is new vague high attenuation in the dependent aspect
of the left sylvian fissure likely a small amount of
subarachnoid hemorrhage.
5. There is a large left orbital hematoma, unchanged.
6. Blood is seen in the sphenoid sinus and there is a large left
parietal scalp subgaleal hematoma. There is new subgaleal
low-attenuation fluid, on the right.
ELBOW (AP, LAT & OBLIQUE) LEFT [**2123-5-15**] 12:00 AM
ELBOW (AP, LAT & OBLIQUE) LEFT
Reason: eval trauma
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with mvc
REASON FOR THIS EXAMINATION:
eval trauma
INDICATION: Motorcycle versus SUV.
LEFT ELBOW, THREE VIEWS: No comparisons are available. There is
a small osseous fragment adjacent to the medial epicondyle,
which could represent an avulsion fracture. Overlying
intravenous tubing limits assessments. No other fractures are
identified. There is no elbow joint effusion seen. The joint
spaces appear well preserved. Soft tissue swelling raises the
possiblility of bursal hematoma.
IMPRESSION:
1. Fracture of the medial epicondyle. No evidence of intra-
articular fracture.
2. Question bursal hematoma.
CLAVICLE LEFT [**2123-5-14**] 11:51 PM
CLAVICLE LEFT
Reason: r/o fx
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with mcc vr suv
REASON FOR THIS EXAMINATION:
r/o fx
INDICATION: Motorcycle versus SUV, assess for clavicular
fracture.
LEFT CLAVICLE, TWO VIEWS: There is a minimally displaced
fracture of the one-third of the left clavicle. No other
fracture is identified. There is cervical spinal hardware seen.
The visualized lung appears clear.
IMPRESSION: Minimally displaced fracture of the mid third of the
left clavicle.
CLAVICLE LEFT [**2123-5-14**] 11:51 PM
CLAVICLE LEFT
Reason: r/o fx
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with mcc vr suv
REASON FOR THIS EXAMINATION:
r/o fx
INDICATION: Motorcycle versus SUV, assess for clavicular
fracture.
LEFT CLAVICLE, TWO VIEWS: There is a minimally displaced
fracture of the one-third of the left clavicle. No other
fracture is identified. There is cervical spinal hardware seen.
The visualized lung appears clear.
IMPRESSION: Minimally displaced fracture of the mid third of the
left clavicle.
Psychiatry Evaluation
IDENTIFYING DATA AND REASON FOR ADMISSION: 49yo man with history
of cervical injury on Oxycontin as an outpt admitted on [**5-14**] for
treatment of a SAH who became agitated and threatening to his
nurse when he felt she was not giving him sufficient Oxycontin
causing a code purple to be called.
SOURCES OF INFORMATION (ESTIMATE RELIABILITY):
-Patient (somewhat reliable)
-Pt's nurse, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67647**], (reliable)
-OMR (reliable)
LEGAL STATUS: N/A
CHIEF COMPLAINT: "I want to go to the [**Hospital1 756**]"
HISTORY OF PRESENT ILLNESS: 49yo man with history of cervical
injury on Oxycontin as an outpt admitted on [**5-14**] for treatment
of
a SAH who became agitated and threatening to his nurse when he
felt she was not giving him sufficient Oxycontin causing a code
purple to be called. The pt was originally admitted to [**Hospital 1474**]
Hospital after a motorcycle accident, and found to have a SAH on
CT and therefore transferred to BIMDC. He was admitted to the
SICU on arrival here for close monitoring. While in the ICU pt
became agitated, the team attempted to treat this with Haldol
and
Ativan, but he continued to be agitated. Per the chart a
decision
was made to selectively intubate the pt on [**5-15**] for safety and
in
order to be able to get a CT scan. The pt was maintained
intubated until [**5-18**] when he was extubated and remained calm and
appropriate for transfer. At 8pm tonight pt became agitated
because he felt the nurse working with him had given him less
pain medications than he should receive. Per the nurse the pt
reported to her that he is used to taking Oxycontin 480mg PO a
day, and that when he is home he tends to either chew or snort
his Oxy's because they give him a buzz that way. The pt also
reported to the nurse, per her report, that he chewed the
Oxycontin he got here. He reported her that if she would not
give
him more meds he would call an ambulance to transport him to the
[**Hospital6 1708**].
When I arrived pt was saying to the nurse, "All my doctors are
at [**Name5 (PTitle) 112**], and I want to go there. There I will get the pain meds I
need." He was very angry that security and extra personnel were
on the scene, and kept making angry references to the situation.
He reported to me that he has a history of neck fracture and has
been on Oxycontin for 6 years, he stated, "I am the first to
admit that I am a major addict, but that means that just giving
me what I get at home when I am having additional pain is not
going to work." He felt that the staff at the [**Hospital1 **] do not
understand how much pain medication he needs, and that they are
not responding to his needs. When the surgical intern, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], M.D., arrived on the floor the patient explained to him
that he needed more pain meds. Dr. [**Last Name (STitle) 68119**] told the pt he would
give him more. The patient explained he needed at least three
more Oxycontin 80mg pills tonight and more Oxycodone for in
between the doses. Dr. [**First Name (STitle) **] reported to the pt that he would
look into how much the pt could get, and add something for
breakthrough. Pt became very angry that Dr. [**First Name (STitle) **] did not know
exactly how much pain medication he could get and that he was
limited by what the pharmacy would release. He continued to
threaten to leave the hospital, but ultimately agreed to stay
and
take medications overnight. Dr. [**First Name (STitle) **] suggested to the that he
could speak with the am team about the situation, and if he
continues unhappy a transfer could be considered. I attempted to
complete psych eval, but pt refused further interview because he
was in too much pain. He also refused to allow other family
members to be contact[**Name (NI) **]. After pt got medicated he was willing
to briefly review his history, which is detailed below. He
denied
current SI or HI. He denied current depression, hallucinations
of
any form or paranoia.
PSYCHIATRIC HISTORY:
*Diagnosis: OMR reports that pt has a history of depression, but
he reports he has a history of anxiety and not depression. He
also denied prior history of psychosis or mania. He does confirm
his dependence on opiates which he reported earlier.
*Prior Hospitalizations: Pt denies any.
*Medication Trials: Pt reports he has used Klonopin, Xanax, and
Valium for his anxiety in the past. He is not currently
prescribed these.
*SIB/SI/SA: Pt denies a history of these.
*Legal: Pt denies
*Psychiatrist: Pt denies current psychiatrist or therapist.
PAST MEDICAL HISTORY:
-hepatitis C
-R inguinal hernia repair
-GERD
-atypical chest pain
-s/p cervical spine fusion
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. at [**Hospital1 112**]
ALLERGIES: NKDA
MEDICATIONS ON ADMISSION: Oxycodone 480mg po daily (per pt)
SUBSTANCE ABUSE HISTORY:
EtOH: Pt denies EtOH abuse, he did had no EtOH in his blood;
Tobacco: Pt does smoke approx 1ppd, has been on the patch with
good effect here.
Caffeine: Unknown
Illicits: Pt reports he overuses his Oxycontin at home, he chews
it and snorts it while he is home. He reports has been using
opiates for 6 years since he sustained a neck injury and was
placed on them for pain.
SOCIAL HISTORY: Pt lives in [**Hospital1 1474**] with his fianc . He has a
daughter in her twenties who lives in the area and is very
involved in his life. He is a mechanic.
FAMILY PSYCHIATRIC HISTORY: Pt denies any.
Physical Exam:
VS T 99.8 HR 91 BP 113/81 RR 18 SaO2 99% RA
Physical exam completed by ED physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
reports pt is medically stable.
LAB DATA:
CBC: WBC 12.2 (H), Hct 28.6 (L), Plt 210;
BMP: Na 145, K 3.2 (L), Cl 111, HCO3 23, BUN 6, Cr 0.6, Ca 7.6,
Phos 2.8, Mag 1.8;
Phenytoin Level: 5.5 (L)
Serum Tox: Negative;
Urine Tox: + Opiates;
U/A: Unremarkable;
Head CT ([**5-16**]): IMPRESSION: 1. There is no significant change
from [**5-16**]. 2. There is relatively thin but extensive right-sided
subdural hematoma with mass effect on the lateral ventricles and
sulci. There is no shift of normally midline structures. 3.
There
are two peripheral areas of hemorrhage in the right temporal
region probably hemorrhagic contusions. Another is seen in the
posterior left temporal lobe, near the petrous ridge. 4. There
is
new vague high attenuation in the dependent aspect of the left
sylvian fissure likely a small amount of subarachnoid
hemorrhage.
5. There is a large left orbital hematoma, unchanged. 6. Blood
is
seen in the sphenoid sinus and there is a large left parietal
scalp subgaleal hematoma. There is new subgaleal low-attenuation
fluid, on the right. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MENTAL STATUS EXAM:
APPEARANCE & FACIAL EXPRESSION: Disheveled middle aged man with
multiple scars on face, nose and bruising on his shoulder area
dressed in hospital gown with ripped jeans;
POSTURE: Standing by his room door, in NAD
BEHAVIOR: Some PMA initially, later calmer; good eye contact;
ATTITUDE: Ucooperative with interview;
SPEECH: Nl rate, increased volume and nl prosody, no increase
response latency;
MOOD: "Pissed-off"
AFFECT: Irritable, labile;
THOUGHT FORM: Linear, goal oriented answers;
THOUGHT CONTENT: No PI or delusions noted; Focused on his need
for opiates and unable to reason with physicians until this was
provided to him;
ABNORMAL PERCEPTIONS: Pt denies any AVH currently or in the ICU;
SUICIDALITY/HOMICIDALITY: Pt denies SI or HI;
INSIGHT AND JUDGMENT: Poor/Poor;
COGNITIVE ASSESSMENT:
SENSORIUM: Alert
ORIENTATION: A and O x 3, "[**Hospital3 **]" "[**2123-5-18**]"
ATTENTION: Unwilling to do months or spell world; he was
attentive during his interview with me and with Dr. [**First Name (STitle) **].
MEMORY: Was able to register and remember who I was when I
returned to re-interview him 30 minutes after our initial
meeting;
CALCULATIONS: Was able to calculate how much Oxycontin, to
multiply and divide doses as they were explained to him;
FUND OF KNOWLEDGE: Average;
PROVERB INTERPRETATION: Unable to assess;
SIMILARITIES/ANALOGIES: Unable to assess;
STRENGTHS: Pt is employed, has involved significant other and
daughter;
ASSESSMENT & FORMULATION: 49yo man with history of cervical
injury on Oxycontin as an outpt admitted on [**5-14**] for treatment
of
a SAH who became agitated and threatening to his nurse when he
felt she was not giving him sufficient Oxycontin causing a code
purple to be called. Pt was difficult to redirect until he was
promised additional opiates, but very volatile and easily became
angry and abusive. Pt did not appear delirious, he knew exactly
where he was and what the time was, understood that he was next
door to the [**Hospital1 112**], and was able to attend to interview. It does
appear that during his stay in the ICU he was somewhat delirious
and this lead to his being electively intubated for his
protection. Pt was calm earlier today on transfer, but after
careful review of the medical record with his nurse we realized
that pt had been getting Oxycontin 120mg po TID with additional
Morphine 20mg IV in prns on [**5-17**]. It does appear that on
transfer
to the floor the Morphine orders were dropped, and pt was likely
suffering from some breakthrough pain exacerbated by the fact
that he is chewing his Oxycontin and therefore it is no longer
sustained release. Some of his behavior could also be explained
by his recent brain injury and time on the ICU which appear to
have lead to some disinhibition. Other parts of this behavior is
likely tied to an opiate dependence, which he reports has been
going on for the past 6 years. As, I have not been able to
contact his family I can't speak to whether this is chronic. At
this time pt is calm and cooperative as he has gotten additional
narcotics. When pt's regular team is in house again, would
recommend full review of record and discussion with the pt about
pain medication regimen he will be on. Also, pt needs to be
further counseled on proper use of Oxycontin and the
inappropriateness of chewing or sniffing his meds at home. I did
intiate counseling on Oxycontin, but pt was not interested in
hearing more.
DIAGNOSIS:
AXIS I: Opiate Dependence, Delerium, resolved
AXIS II: Deferred
AXIS III: Hep C, R inguinal hernia repair, GERD, atypical chest
pain, s/p cervical spine fusion, recent SAH
Rec's:
1. Recommend full narcotic dose eval and plan by am team
2. In light of pt's use of opiates at home, and thus high level
of opiate requirement here would consider pain consult for
management of his pain
3. Would discuss to pt what the plan is with nurses, intern and
resident present to avoid confusion in the team and blaming of
particular team members
4. Recommend consulting addictions service for their input as
well where additional counseling about his habit of chewing and
snorting Oxycontin could be discussed.
5. Would add Ativan 1-2mg IV prn agitation, for the nurse to use
if pt becomes belligerent again along with his existing Haldol
5mg IV prn;
6. Would not give access to Ativan prn above to pt for simple
anxiety
7. Would contact pt's PCP to discuss the events of this
hospitalization, and to make sure she is aware of how pt is
utilizing the narcotics that she is prescribing him
8. Psychiatry Consult team will see pt in the am, and follow
with
you
9. Please feel free to page [**Numeric Identifier 68120**] with any further questions
10. These recommendations relayed to Dr. [**First Name (STitle) **]
Brief Hospital Course:
Patient admitted to the trauma service. In the trauma bay
patient became increasingly agitated and disoriented and was
subsequently intubated for airway protection. Neurosurgery was
immediately consulted because of his head injuries; he was
treated non operatively; loaded with Dilantin and will continue
on this for the next 3 months until follow up with Dr. [**Last Name (STitle) **];
he will have repeat head imaging at that time. His Dilantin
level will need to be checked weekly while taking this
medication.
Ophthalmology was consulted because of left retrobulbar
hematoma; no compartment syndrome identified. He is on
erythromycin ointment which will need to continue for at least
10 days.
Orthopedics was consulted because of left clavicle fracture;
this was treated non operatively. He will need to follow up in 2
weeks with Dr. [**Last Name (STitle) 1005**].
Psychiatry was consulted because of behavioral issues; patient
requesting to leave hospital against medical advice. It was
determined that patient did not lack capacity. Social work was
consulted as well because of his addictions issue.
Patient on long acting narcotics at baseline; his dose of
Oxycontin was increased slightly because of his injuries.
Physical and Occupational therapy were consulted; patient with
poor balance and is in need of continued therapy. He will need
ongoing cognitive training because of his head injuries.
Medications on Admission:
Klonopin
Flovent
Oxycontin 240'
Nicorette
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, headache.
2. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
3. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
5. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day for 3 months.
6. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for breakthrough pain.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-30**] Tablet,
Delayed Release (E.C.)s PO twice a day as needed for
constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motorcycle Crash
Subdural Hematoma
Subarachnoid hemorrhage
Left Clavicle fracture
Retrobulbar hematoma
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Orthopedics in 2 weeks for your left clavicle
fracture.
Follow up with Neurosurgery in 3 months. You must continue your
Dilantin until that time over the next 3 months.
You will need to have your Dilantin blood levels monitored over
the next 3 months at least 1x/week.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for an appointment to be seen in 2 weeks with
Dr. [**Last Name (STitle) 1005**], Orthopedics.
Call [**Telephone/Fax (1) 1669**] for an appointment to be seen in [**Hospital 4695**]
clinic in 3 months with Dr. [**Last Name (STitle) **]. Infrom the office that you
will need a repeat head CT scan for this appointment.
Follow up with your primary doctor, Dr. [**Last Name (STitle) **] for monitoring
your Dilantin levels over the next 3 months.
Completed by:[**2123-6-2**]
|
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|
15149, 15392
|
15867, 16071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,821
| 133,734
|
17799
|
Discharge summary
|
report
|
Admission Date: [**2153-3-23**] Discharge Date: [**2153-3-26**]
Date of Birth: [**2078-6-20**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
woman with a history of coil aneurysm two months ago at [**Hospital 14852**]. The patient had a myocardial
infarction perioperatively, had a routine angiogram done on
the 12th at the [**Hospital3 **] for re-evaluation of the
aneurysm. The follow-up angiogram showed the presence of
recanalization of the previously coiled aneurysm and therefore
the patient underwent recoiling of the remnant using Bioactive
Matrix GDC coils. The patient had no bleeding prior to or
postcoiling, and patient had a normal neurological examination
prior coiling.
The patient was admitted to the Intensive Care Unit
postprocedure for monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Myocardial infarction.
4. Status post stent placement.
PAST SURGICAL HISTORY:
1. Left hip replacement.
2. Cholecystectomy.
MEDICATIONS ON ADMISSION:
1. Nitroglycerin.
2. Zocor.
3. Atenolol.
4. Protonix.
5. Folic acid.
6. Vitamin E.
ALLERGIES: Morphine which causes nausea and vomiting.
PHYSICAL EXAMINATION: On physical exam, temperature was
97.6, heart rate 60, blood pressure 158/67, respiratory rate
16, and sat is 97% on face mask. In general, the patient was
in no acute distress responding appropriately. HEENT:
Pupils are equal, round, and reactive to light. Extraocular
movements are full, no jugular venous distention. Heart
regular, rate, and rhythm, no murmurs, rubs, or gallops.
Lungs are clear to auscultation. Abdomen: Positive bowel
sounds, soft, nontender, nondistended. Extremities are warm
and well perfused. Palpable pulses. Neurologically:
Cranial nerves II through XII intact. Strength was [**4-16**] in
all extremities. She was awake, alert, and oriented times
three.
She was monitored in the Intensive Care Unit overnight,
transferred to the regular floor. On postprocedure day #1,
she also had a MRA which shows good coiling of the aneurysm.
She tolerated the procedure well. She was discharged home on
[**2153-3-26**] with followup with Dr. [**Last Name (STitle) 1132**] in six months for a
repeat angiogram.
DISCHARGE MEDICATIONS:
1. Simvastatin 40 mg po q day.
2. Atenolol 25 po q day.
3. Protonix 40 mg po q day.
4. Folic acid 1 mg po q day.
5. Aspirin 81 mg po q day.
6. Percocet 1-2 tablets po q4h prn for pain.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2153-3-26**] 10:13
T: [**2153-3-26**] 10:26
JOB#: [**Job Number 49416**]
|
[
"437.3",
"V45.82",
"412",
"414.00",
"511.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2281, 2467
|
1054, 1194
|
982, 1028
|
1217, 2258
|
174, 833
|
855, 959
|
2492, 2756
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,566
| 184,839
|
36904
|
Discharge summary
|
report
|
Admission Date: [**2160-8-5**] Discharge Date: [**2160-8-10**]
Date of Birth: [**2106-2-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Known PFO, with history of stroke/transient ischemic attack
Major Surgical or Invasive Procedure:
[**2160-8-5**] Minimally Invasive Closure of PFO
History of Present Illness:
This is a 54 year old female with history of stroke/transient
ischemic attack dating back to age 23. PMH notable for active
smoker, COPD and dyslipidemia. Her stroke has left her with left
sided weakness and lack of coordination. First told of having a
"hole in heart" at age 31 during the birth of her first child.
Since that time, she has had no further neurological
complications. She has undergone occasional echocardiograms
which reportedly have conflicting results about the presence of
a PFO. She was referred by Dr. [**Name (NI) **] for consideration
of surgical repair.
Past Medical History:
Patent Foramen Ovale
Transient Ischemic Attack, Cerebrovascular Accident at age 23
Chronic Obstructive Pulmonary Disease
Dyslipidemia
Hypothyroidism
Cervical Spondylosis
Past Surgical History:
Cesarean Section
Cervical Fusion
Social History:
Occupation: Recently laid off
Lives with: son
[**Name (NI) **]: caucasian
Tobacco: active smoker, currently [**2-1**] PPD. at least a 30 pack
year history
ETOH: occasional, no history of abuse
Other: admits to occasional marijuana, last smoke 2 days ago
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 88 Resp: 20
B/P Right: 120/70 Left:
General: Middle age female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: left thigh GSV with minor varicosities
Neuro: alert and oriented, CN 2-12 gorssly intact, left sided
weakness, slightly unsteady gait and balance
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2160-8-5**] Intraop TEE:
Pre Bypass: The left atrium is mildly dilated. A left-to-right
shunt across the interatrial septum is seen at rest. A secundum
type atrial septal defect is present. 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. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
Post Bypass: Patient is in sinus rhythm on no pressors.
Preserved biventricular function, LVEF >55%. The atrial septum
appears thickened post repair. There is turbulent flow around
the seputm without flow visible across by color doppler. Aortic
contours intact. Remaining exam is unchanged. All findings
discussed with surgeon at the time of the exam.
[**2160-8-5**] 11:25AM BLOOD WBC-8.6# RBC-2.67*# Hgb-8.4*# Hct-25.1*#
MCV-94 MCH-31.6 MCHC-33.7 RDW-13.4 Plt Ct-155
[**2160-8-6**] 03:26AM BLOOD WBC-7.5 RBC-3.16* Hgb-10.0* Hct-29.4*
MCV-93 MCH-31.7 MCHC-34.1 RDW-13.3 Plt Ct-188
[**2160-8-8**] 05:50AM BLOOD WBC-6.8 RBC-2.87* Hgb-9.1* Hct-27.1*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.2 Plt Ct-198
[**2160-8-6**] 03:26AM BLOOD Glucose-116* UreaN-12 Creat-0.5 Na-137
K-4.3 Cl-109* HCO3-24 AnGap-8
[**2160-8-8**] 05:50AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
[**2160-8-8**] 05:50AM BLOOD Mg-1.7
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent minimally invasive
closure of her patent foramen ovale.Cardiopulmonary Bypass
time=74 minutes.Please refer to DR[**Doctor Last Name 14333**] operative
report for further surgical details.She tolerated the procedure
well and was extubated in the operating room prior to transfer
to the CVICU for invasive monitoring. Preoperative medications
were resumed. She maintained stable hemodynamics and transferred
to the SDU on postoperative day one. She remained in a normal
sinus rhythm. She had adequate pain control with Ultram and
Toradol. On post-op day four she complained of dizziness and her
lasix was discontinued since her weight was only slightly about
her pre-operative weight and her blood pressure was systolically
running from the high 90s to low 100s. She felt better by the
end of the day and was discharged to home.
Medications on Admission:
Synthroid 100 qd
Simvastatin 10 qd
Plavix 75 qd - stopped [**2160-7-28**]
Aspirin 81 qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety or nausea: please see your PCP if
you need refills of this medication.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Patent Foramen Ovale, s/p Minimally Invasive Closure
Transient Ischemic Attack, Cerebrovascular Accident at age 23
Chronic Obstructive Pulmonary Disease
Dyslipidemia
Hypothyroidism
Cervical Spondylosis
Discharge Condition:
Good
Discharge Instructions:
1)No driving while on narcotics
2)Please shower daily. Wash surgical incisions with soap and
water only.
3)Do not apply lotions, creams or ointments to any surgical
incision.
4)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
5)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**First Name (STitle) **] in [**5-4**] weeks, call for appt; [**Telephone/Fax (1) **]
Dr. [**Last Name (STitle) 7659**] in [**3-4**] weeks, call for appt
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2160-8-9**]
|
[
"305.1",
"728.89",
"438.89",
"244.9",
"272.4",
"745.5",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.71"
] |
icd9pcs
|
[
[
[]
]
] |
5989, 6008
|
3938, 4821
|
379, 430
|
6254, 6261
|
2383, 3915
|
6733, 7013
|
1577, 1620
|
4960, 5966
|
6029, 6233
|
4847, 4937
|
6285, 6710
|
1254, 1289
|
1635, 2364
|
280, 341
|
458, 1039
|
1061, 1231
|
1305, 1561
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,860
| 156,644
|
49315
|
Discharge summary
|
report
|
Admission Date: [**2119-11-21**] Discharge Date: [**2119-12-7**]
Date of Birth: [**2062-11-22**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
code stroke
minimally responsive
Major Surgical or Invasive Procedure:
-PEG tube placement
-intubation x2
History of Present Illness:
The patient is a 57 yo woman with a negative previous medical
history, obesity, who presents [**2119-11-21**] after being found in the
parking lot with R hemiparesis.
The patient was in her usual state of health, with her sister on
the morning of presentation. The ED neurology resident was able
to talk with her sister over the phone. Patient had left for
work in the morning and was seen normal at 3.15PM. At that time
she went out to her car for lunch. Time passed and at 4.30PM or
so her coworkers decided to go out and look for her. She was
found in the drivers seat, car off, with emesis, not following
commands. EMS was called and the patient was found not moving
the right side, still not following commands, with pupils
reactive, FSG 233, BP 184/120. Her speech was slurred and she
was able to do a weak grip with the left hand. There was no
movement on the right side. There were no meds in her purse.
Sister was able to tell us over the phone that she has no known
HTN, no HL, no meds, no OCP, no smoking/ETOH or drugs.
On arrival at 5/25pm NIHSS score 23:
1. 0,2,NA
2. 2
3. 2
4. 2
5. 4
6. 4
7. x
8. 2
9. 3
10. x
11. 2
12. C
Past Medical History:
No known history to patient or family
Social History:
Lives alone, works in health care administration. No tob, no
etoh.
Family History:
HTN and high cholesterol in family; however, sister admits that
nobody in her family goes to doctor.
Physical Exam:
VS: T: BP: hard to measure - then 170 to 260 over palp
P: 120's RR: O2 sat: 80's to 70's RA
General: patient actively vomiting and airway being protected by
primary team. Moving towards intubation at time of arrival at
5.25pm. Appears overwght, well perfused, with no spontaneous
movemnts on the right.
MS: not answering any questions, no discernible speech, even
when
not having emesis, looks at my facewhen I am on the left side of
bed for a second to command, but she also has a L gaze
preference, so it is not entirely clear if she is following my
command. Able to squeeze L hand for a second to command. No
midline commands. CN exam with PERRLB 3.5->3mm bilaterally and
right facial droop. Remainder of exam limited by precipitous
intubation.
.
Exam in ICU on propofol - very limited. Corneals present,
pupils above, w/d to noxious stimuli on left, minimal vs
extensor posturing to stimuli on right UE.
.
Exam upon discharge:
awake, alert, following simple commands, non-verbal, but seems
to understand well
PERL, limited tracking, R-facial droop, severe dysphagia
Dense R-hemiplegia; able to move L side spontaneously
Sensory exam intact to noxious (localized on L; withdraws some
on R)
Pertinent Results:
[**2119-11-21**] 05:40PM PLT COUNT-315
[**2119-11-21**] 05:40PM PT-12.0 PTT-18.5* INR(PT)-0.9
[**2119-11-21**] 05:40PM WBC-13.1* RBC-5.18 HGB-15.2 HCT-43.0 MCV-83
MCH-29.3 MCHC-35.3* RDW-13.5
[**2119-11-21**] 05:40PM WBC-13.1* RBC-5.18 HGB-15.2 HCT-43.0 MCV-83
MCH-29.3 MCHC-35.3* RDW-13.5
[**2119-11-21**] 05:40PM ALBUMIN-4.4
[**2119-11-21**] 05:40PM CK-MB-3 cTropnT-<0.01
[**2119-11-21**] 05:40PM ALT(SGPT)-36 AST(SGOT)-33 CK(CPK)-121 ALK
PHOS-81
[**2119-11-21**] 05:40PM GLUCOSE-268* UREA N-13 CREAT-0.9 SODIUM-136
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
[**2119-11-21**] 09:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2119-11-21**] 09:45PM URINE HOURS-RANDOM
.
CXR [**11-20**]:
An endotracheal tube is seen with its tip at the lower margin of
the clavicles. There is diffuse bilateral alveolar airspace
opacification. There is no pneumothorax. An NG tube is seen
extending below the diaphragm with its coursing off the edge of
this radiograph. Osseous structures are unremarkable.
IMPRESSION:
ET tube at level of the inferior clavicle. Diffuse bilateral
airspace opacification may represent edema, infection, or ARDS.
.
Initial CT [**11-20**]:
FINDINGS: There is a large area of intraparenchymal hemorrhage
centered in the left basal ganglia which measures 6.2 x 2.5 cm.
There is also blood within the bilateral lateral ventricles and
also a small amount of blood within the third ventricle. There
is no evidence of hydrocephalus and the ventricles are of normal
size. There is minimal shift of the midline structures to the
right side. There is no evidence of uncal herniation or
herniation of the tonsils. There is calcification of the right
vertebral artery. Examination of the bone windows demonstrates
normal aeration of the visualized portions of the mastoid air
cells and paranasal sinuses.
IMPRESSION:
1. Large intraparenchymal hemorrhage in the region of the left
basal ganglia, with intraventricular extension.
.
MRI/A BRAIN [**11-23**]:
FINDINGS: Again seen is a large acute hemorrhage likely centered
in the left lentiform nucleus with effacement of the left
lateral ventricle and minimal shift of normally midline
structures to the right. No nodular enhancement is identified
around the hemorrhage. Of note, there is a linear focus of
hemorrhage in the left anterior temporal lobe consistent with a
developmental venous anomaly. Susceptibility images are
remarkable for innumerable foci of susceptibility in the
cerebral and especially cerebellar hemispheres. While some of
these foci likely represent subarachnoid blood, many foci appear
intraparenchymal. Surrounding osseous and soft tissue structures
are unremarkable.
TECHNIQUE: 3D time-of-flight imaging with multiplanar
reconstructions.
FINDINGS: The major tributaries of the circle of [**Location (un) 431**] are
patent. No aneurysms are identified and no area of significant
stenosis is seen.
IMPRESSION: Large acute intraparenchymal hemorrhage likely
centered in the left lentiform nucleus. Numerous foci of
susceptibility, especially in the cerebral hemispheres,
consistent with micro-hemorrhages. Overall, these findings are
suggestive of a hypertensive etiology. However, given the
presence of a developmental venous anomaly in the left temporal
lobe adjacent to the intraparenchymal hemorrhage, the presence
of multiple cavernous malformations is a consideration.
.
ECHO [**11-28**]:
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
difficult to assess but is probably low normal.
.
CXR [**12-4**]:
1. Improved pulmonary edema.
2. Worsening bibasilar opacities, most likely due to a
combination of atelectasis and effusion.
.
Brief Hospital Course:
The patient is a 56 year old woman with "no past medical
history" because she had not seen a doctor in years, presented
with L subcortical ICH. She had gone to lunch around 3pm, and
was found in her car about an hour later with emesis and right
sided weakness. She was admitted to the Neurology service.
.
ICU course:
Dilantin was loaded for ?shaking in ED, intubated at time
(preintubation NIHSS score was 22). She was initially very
hypertensive "220s/palp", started on labetolol gtt and then
later propofol. Then in the ICU around 10pm she became
hypotensive to 60's -> 90's with IVF and head down; started
pressors. At the time, her exam demonstrated: pupils 1.5->1mm
bilat, + corneals, no dolls, postures right arm, triple flex
right leg, withdraws on the left. Repeat head CT showed slight
worsening of L-ICH. Drop in pressure was either sepsis-related
(with aspiration pna) or related to damage of insula and
autonomic instability. EKG was sinus tach. PE not considered
likely given good sats (later dropped sats but responded to
suctioning.) On [**11-21**], BP had stabilized and the pt was off
pressors; CXR had demonstrated pulmonary edema, widened
mediastinum thought related to volume overload/hilar
infiltrates. Some suspicion of ARDS. Neurologically, exam was
unchanged. She was on propofol for sedation with vigorous
spontaneous mvmt on left. On [**11-23**] she underwent MRI/MRA of the
brain which revealed many microhemorrhages on susceptibility;
there was the question of a developmental venous anomaly in L
anterior temporal lobe adjacent to the hemorrhage, as well as
the question of multiple cavernous malformations. A fasting
lipid panel was checked which was within goal limits: TC 134 TG
74 HDL 65 LDL 54. She had been improving both medically and
neurologically and was extubated. Cr had initially bumped up to
1.7 from 0.9 on admission, but had been resolving since then.
On the night of [**2119-11-27**], cardiac telemetry demonstrated that the
patient was in rapid atrial fibrillation for hours that did not
respond to IV lopressor, diltiazem drip, amiodarone, or esmolol.
With respiratory distress, RAF was thought potentially related
to pulmonary edema versus pneumonia. Cardiology was consulted
and recommended treating the underlying cause. To decrease work
of breathing and aid diuresis, she was reintubated. Electric
cardioversion was attempted the following day but was not
successful. Over the next 24-48 hours, as she diuresed (and
after being digoxin loaded), her heart rate returned to sinus,
in the 80s. By [**12-1**], she was still intubated and on a lasix drip
for diuresis. Heart rate was improved and neurological exam was
stable. She was started on linezolid for VRE positivity and
spiking temps, wbc ct 14.5, and for pus at the site of one of
her lines (which was replaced). She slowly improved and was
extubated.
.
.
Floor:
The patient was transfered to the floor in the evening of [**12-4**].
Her neurological exam was stable: she was awake, alert, able to
follow simple commands, R-hemiplegia, and she was non-verbal
(but able to understand some).
.
Her respiratory status improved slowly. She was continued on
linezolid for VRE-PNA (day 7 on [**12-7**]; needs to finish a total
course of 2 weeks) and albuterol was given PRN. She remained
afebrile. Given her history of pulmonary edema, i/o should be
monitored closely and she should be diuresed if needed.
Supplementary oxygen to keep sO2 above 94%.
.
Cardiovascularly, amiodarone was being titrated down to a goal
of 200mg daily (see medication instructions). Metoprolol was
continued at a dose of 50mg TID. Lisinopril was started at a
dose of 2.5mg dialy to further manage her bloodpressure. This
should be titrated up only if her renal function allows.
.
The patient was continued on ISS and NPH (40BID). This regimen
will need further adjustement based on FSBS.
.
A PEG tube was placed on [**12-6**] as the patient continued to have
severe dysphagia.
Tubefeeds were resumed and fluid boluses were given to treat a
hypernatremia (but watch out for pulmonary edema). Sodium on the
day of discharge: 147. Please keep K above 4 and Mg above 2.
.
For prophylaxis, a bowelregimen, heparin sc, and lansoprazole
were given.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: [**11-27**] Suppositorys Rectal
Q4-6H (every 4 to 6 hours) as needed for fever .
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) 30mg PO DAILY (Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days: decrease dose to 200mg daily after 5 days.
Tablet(s)
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Insulin Glargine 100 unit/mL Solution Sig: Two (2) units
Subcutaneous per sliding scale.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
15. HydrALAZINE HCl 10 mg IV Q6H sbp>160
16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours). Continue for 7 more days until [**12-14**].
17. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. L-subcortical hemorrhage
2. pulmonary edema
3. atrial fibrillation with rapid ventricular response
4. insulin dependent diabetes mellitus
5. hypertension
Discharge Condition:
-stable: awake, alert, following simple commands, R-hemiplegia,
non-verbal, severe dysphagia
Discharge Instructions:
Please administer medications as instructed.
Monitor i/o's; oxygen to keep sO2 above 94%. Please monitor Na,
and keep K above K and Mg above 2.
Followup Instructions:
Please follow up at the [**Hospital 4038**] Clinic:
Please call [**Telephone/Fax (1) 1694**] to update your demographics and make an
appointment with Dr. [**Last Name (STitle) **].
Completed by:[**2119-12-7**]
|
[
"432.9",
"482.39",
"514",
"507.0",
"342.90",
"427.31",
"V09.80",
"401.9",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.71",
"44.32",
"96.6",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12874, 12944
|
6976, 11226
|
351, 388
|
13145, 13240
|
3076, 6953
|
13434, 13646
|
1723, 1825
|
11282, 12851
|
12965, 13124
|
11252, 11259
|
13264, 13411
|
1840, 2773
|
279, 313
|
416, 1562
|
1584, 1623
|
1639, 1707
|
2794, 3057
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,864
| 148,805
|
40442
|
Discharge summary
|
report
|
Admission Date: [**2173-7-13**] Discharge Date: [**2173-7-16**]
Date of Birth: [**2105-4-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year-old woman with recent hemorrhagic stroke secondary to
amyloid angiopathy s/p emergent left craniectomy and evacuation
of hematoma on [**2173-5-16**], seizures on dilantin and keppra,
respiratory failure s/p tracheostomy placement on [**2173-5-21**], also
with large gastric ulcer on endoscopy that prevented PEG tube
placement with gastric mucormycosis infection, currently
ventilator dependent, directly admitted to the MICU for
persistent fevers, presumed to be secondary to MSSA pneumonia in
addition to follow-up neurosurgery evaluation by Dr.[**Name (NI) 9034**]
team.
She was recently admitted on [**2173-6-25**] for repeat endoscopic
evaluation for treatment response after ambisome therapy for her
gastric mucormycosis infection. EGD showed known ulcer in the
stomach body, and an NJ tube was placed by GI and verified on
imaging to be in the 4th portion of the duodenum. Infectious
disease was contact[**Name (NI) **] during this admission and recommended no
change in therapy with plan to continue ambisome daily as
previously prescribed until further ID evaluation. She had an
isolated temperature of 100.3 during the admission with negative
blood and urine cultures.
ID was contact[**Name (NI) **] on [**6-30**] regarding antimicrobial regimen. Dr.
[**Last Name (STitle) **] had reported intermittent fevers, and she received a
course of vancomycin and zosyn empirically with removal of PICC
line. Dr. [**Last Name (STitle) **] was concerned that amphotericin was causing
fevers and stopped it. She was afebrile at that time and off
antibiotics. It was suggested that she start posaconazole 200 mg
QID at this point with a lipid-[**Doctor First Name **] diet.
She spiked again to 102.6F on Thursday [**2173-7-8**] with WBC 21 at
which time it appears she was started empirically on cefazolin
and Vancomycin. Midline was placed Friday [**2173-7-9**]. Antibiotics
were narrowed to nafcillin on Saturday [**2173-7-10**] when sputum
culture grew MSSA. She was also noted to be having very loose
stools but has been C Diff negative x4.
Her hematocrit was noted to be 22.8 (decreased from baseline of
27) over the weekend, for which she received 1 unit pRBCs with
post-transfusion Hct of 25.1.
She also has had issues with vent weaning and
tachycardia/hypertension. Her mental status has remained
altered.
On arrival to the MICU, patient was agitated.
Review of systems: unable to obtain
Past Medical History:
s/p Hemorrhagic Stroke [**5-/2173**]
- Large left occipital IPH with intraventricular extension
- s/p left craniectomy and evacuation of hematoma
Gastric Mucormycosis
- s/p several weeks of amphotericin treatment, stopped in
setting of intermittent fevers of unclear etiology
[**2173-5-16**]: Left craniectomy and evacuation of hematoma
[**2173-5-21**]: Trach placement
[**2173-5-25**]: EGD w/ gastric biopsy
- Seasonal allergies
Social History:
Was previously living with husband normally in [**Name (NI) 108**] but camps
each summer in [**Location (un) **] in a trailer which she was prior to
hospitalization for intracranial hemorrhage. No tobacco.
Currently at [**Hospital 100**] Rehab. Sister is HCP.
Family History:
CVA in mother, father, and grandmother.
Physical Exam:
Admission Physical Exam:
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Not assessed, Movement: Not assessed, Tone: Not
assessed
.
Discharge Physical Exam:
Pertinent Results:
[**2173-7-13**] 09:50AM BLOOD WBC-16.1* RBC-3.31* Hgb-9.1* Hct-27.4*
MCV-83 MCH-27.4 MCHC-33.1 RDW-15.8* Plt Ct-502*
[**2173-7-14**] 04:03AM BLOOD WBC-16.3* RBC-3.12* Hgb-8.4* Hct-26.0*
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.6* Plt Ct-420
[**2173-7-14**] 07:03PM BLOOD WBC-19.0* RBC-3.13* Hgb-8.5* Hct-25.9*
MCV-83 MCH-27.2 MCHC-33.0 RDW-15.9* Plt Ct-492*
[**2173-7-15**] 03:06AM BLOOD WBC-19.1* RBC-3.04* Hgb-8.3* Hct-24.9*
MCV-82 MCH-27.2 MCHC-33.2 RDW-16.0* Plt Ct-457*
[**2173-7-13**] 09:50AM BLOOD Glucose-119* UreaN-16 Creat-0.8 Na-137
K-3.3 Cl-96 HCO3-30 AnGap-14
[**2173-7-14**] 04:03AM BLOOD Glucose-141* UreaN-19 Creat-1.1 Na-135
K-3.6 Cl-95* HCO3-27 AnGap-17
[**2173-7-14**] 07:03PM BLOOD Glucose-138* UreaN-23* Creat-1.4* Na-133
K-3.0* Cl-92* HCO3-26 AnGap-18
[**2173-7-15**] 03:06AM BLOOD Glucose-158* UreaN-23* Creat-1.4* Na-134
K-3.3 Cl-93* HCO3-27 AnGap-17
[**2173-7-13**] 09:50AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.8
[**2173-7-13**] 10:36AM BLOOD Albumin-3.0*
[**2173-7-14**] 04:03AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.8
[**2173-7-14**] 07:03PM BLOOD Calcium-8.8 Phos-4.2 Mg-1.7
[**2173-7-15**] 03:06AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.4
[**2173-7-13**] 10:36AM BLOOD VitB12-1106*
[**2173-7-13**] 10:36AM BLOOD TSH-2.5
[**2173-7-13**] 10:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2173-7-15**] 12:33AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2173-7-13**] 10:47AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2173-7-15**] 12:33AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2173-7-13**] 10:47AM URINE RBC-12* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
[**2173-7-15**] 12:33AM URINE RBC-12* WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
[**2173-7-15**] 12:33AM URINE CastHy-34*
URINE CULTURE (Final [**2173-7-14**]): NO GROWTH.
Brief Hospital Course:
68F with recent hemorrhagic stroke secondary to amyloid
angiopathy s/p emergent left craniectomy and evacuation of
hematoma on [**2173-5-16**] complicated by seizures, continuing
respiratory failure s/p tracheostomy on [**2173-5-21**], large gastric
ulcer with mucormycosis presents for repeat
neuroimaging/neurosurgery evaluation; also with MSSA pneumonia.
# ICH secondary to amyloid angiopathy s/p left craniectomy and
hematoma evacuation complicated by seizure: The patient
underwent MR [**First Name (Titles) **] [**Last Name (Titles) **] imaging of her head. The imaging showed
expected changes with continued swelling and no new hemorrhage.
The neurosurgery service was satisfied with the imaging and
plans for a repeat non-contrast head CT in [**7-23**] weeks, and for
reconstruction of her skull sometime in [**Month (only) **].
# Fever
Patient being treated for VAP, sputum culture positive for MSSA
pneumonia. She is ventilator dependent, but sputum cultures have
allowed for narrowing antibiotic regimen to nafcillin. Patient
does have persistent loose stools with negative stool studies as
above. She also has history of mucormycosis of the GI tract and
has been treated with ambisome for several weeks, recently
switched to posaconazole. No other sources of infection
identified. Her last dose of nafcillin will be [**2173-7-19**].
# Respiratory Failure
Patient has been ventilator dependent since hemorrhagic stroke
in [**5-/2173**], currently at [**Hospital 100**] Rehab with unsucessful weaning.
By the end of her ICU stay she was able to tolerate pressure
support ventilation of [**11-15**] with an FiO2 of 0.4.
# Pulmonary Edema
CXR with pulmonary edema, which appears to be consistent problem
on prior CXR. It is not entirely clear if this is cardiogenic
or non-cardiogenic pulmonary edema. The elevated BNP suggests a
cardiac cause, but her echocardiogram showed essentially normal
cardiac function with a LVEF of 55%. She was easier to diurese
with IV furosemide, so it may be worth considering IV rather
than PO diuretics.
# Diarrhea
Patient with diarrhea likely secondary to medication side effect
or high-lipid tube feeds. Multiple stool c diff toxin assays
have been negative. She was started on loperamide since the
diarrhea seemed to be causing perineal irritation.
# Chronic toxic-metabolic encephalopathy
Patient intermittently agitated as she has been at rehab. Likely
multifactorial from central process, pulmonary infection,
medication side effect such as levetiracetam. However,
neurosurgery states that she was in her current state before
starting on levetiracetam, making it an unlikely cause of her
condition. TSH, B12, and RPR were normal. There was no
suggestion of encephalitis on her MR.
# Agitation
She was continually agitated throughout her MICU stay, except
when sedated with propofol for imaging studies. The level of
agitation is unchanged from her baseline at rehab. She will
continue on her prior quetiapine dose.
# Atrial fibrillation
During her ICU stay the patient developed atrial fibrillation
with rapid ventricular response. Attempts at rate control were
not successful and so she was started on amiodarone, which
converted her to sinus rhythm. She was transitioned to
amiodarone per tube, with a plan for 400 mg TID until [**2173-7-19**] to
finish 10g loading dose. Then, discontinue amiodarone and
re-evaluate the need for rhythm control.
# Tachycardia/Hypertension
Hemodynamics have been variable at rehab with BP 140-170 and
persistent tachycardia in 100s. Excepting the atrial
fibrillation noted above, she has been in sinus tachycardia.
During her ICU stay, her home diltiazem and metoprolol were held
in the setting of hypotension and initiating amiodarone therapy,
but metoprolol was restarted at low doses before discharge. The
plan will be to restart her prior metoprolol dose of 100 mg TID.
Continue to hold diltiazem.
# Gastric Ulcer with mucormycosis colonization
Patient with known gastric ulcer, H. pylori negative. EGD showed
very broad ulcer with hyphal forms seen on biopsy recognized as
zygomycosis with negative culture. Etiology of ulcer is not
known definitely. Repeat biopsy for culture did not grow any
organisms. She was continued on posaconazole per infectious
disease's original recommendations. Follow up with infectious
disease to clarify duration of posaconazole therapy.
# Anemia
Etiology likely multifactorial. Stool guiaic has been negative.
Her hemoglobin fell from 9.1 to 8.3 over the course of her ICU
stay with no obvious source of bleeding. She was transfused one
unit of packed red blood cells, after which her urine output
improved modestly.
# Code status
The patient was full code throughout her hospital course and
will remain so after discharge.
Medications on Admission:
From rehab list
- levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: [**2161**] ([**2161**]) mg PO BID
per NG tube.
- metoprolol tartrate 100 mg Tablet TID
- Nafcillin 2mg Q4hours IV - started [**7-10**]
- nystatin 100,000 unit/mL Suspension - 5ml PO TID after meals.
- omeprazole 40mg daily
- posaconazole 200mg QID
- KCL po elixir 20 meq daily
- Vancomcyin 250mg po TID
- quetiapine fumarate 6.25mg daily oral
- quetiapine fumarate 12.5mg QHS
- albuterol/ipratrop inhaler - 6 puffs q4hrs
- chlorhexidine gluconate - 15ml QID swish and spit
- cholestyramine 4grams
- diltiazem 30mg q6 hours per G tube (total 45mg q6hrs)
- diltiazem 15mg q6hrs per G-tube (total 45mg q6hrs)
- furosemide 20mg po (by NG tube)
- lidocaine jelly q6hrs topical
- zinc oxide q8h topical
- prn acetaminophen 650mg q4h
- prn dextrose oral gel
- prn glucagon 1mg IM
- prn ondansetron 4mg Q8h
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Methicillin-sensitive Staphylococcus aureus pneumonia
Intracranial hemorrhage, status post craniectomy
Discharge Condition:
Mental Status: Confused - always. Has a tracheostomy but does
not attempt to respond verbally to speech or stimuli. Does not
follow commands. Not purposefully interactive.
Level of Consciousness: Awake but not attentive. Opens eyes
spontaneously. Moves all extremities spontaneously and
continuously.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you had a pneumonia,
and you had a scheduled follow up with Dr. [**Last Name (STitle) **], your
neurosurgeon. You were continued on antibiotics for your
pneumonia, which is improving. You were seen by the
neurosurgeon, Dr. [**Last Name (STitle) **], who was very pleased with your
progress. While you were in the hospital, we also started a new
medication to help control an abnormal rhythm that your heart
went into. We also were able to change your ventilator settings
after getting a little extra fluid out of your lungs.
The following changes were made to your medications:
- please START amiodarone 400 mg PO TID x 2 more days, then STOP
- please STOP diltiazem home dose for now.
This medication can be restarted and uptitrated as necessary
in the rehabilitation facility.
- please continue Nafcillin IV 2gm Q4 hours for 2 more days (for
total of 10 day course of antibiotics), then STOP.
- please STOP PO Vancomycin
- [**Month (only) 116**] START loperamide as needed for loose stool
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) **] and the Neurosurgery
team in [**7-23**] weeks for repeat head imaging. Dr. [**Last Name (STitle) **] plans to
reconstruct your skull in [**Month (only) **].
Completed by:[**2173-7-16**]
|
[
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
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|
6171, 10945
|
276, 282
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4249, 6148
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4230, 4230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,210
| 152,616
|
49438
|
Discharge summary
|
report
|
Admission Date: [**2115-10-3**] Discharge Date: [**2115-10-9**]
Service: MEDICINE
Allergies:
Lipitor / Ativan
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Pt is a [**Age over 90 **] y/o male w/h/o dementia (A&Ox2 at baseline), chronic
AFib, CAD s/p single-vessel CABG in [**2093**], and pseudogout who is
sent in from his PCPs office w/ acute mental status changes in
the setting of worsening productive cough and hypoxia. His two
daughters found him quite confused last night and this morning
in his independent apartment at [**Location (un) **]. When they went to
see him this afternoon he was in his pajamas, confused and
agitated beyond his baseline.
Over the past few days, they had noted that he had developed a
cough with a small amount of sputum production.
Of note he recently had an episode of pseudogout, which was
treated by his rheumatologist, Dr. [**Last Name (STitle) 1839**], at the [**Hospital1 3372**] with colchicine.
In Dr. [**Last Name (STitle) **] office he was found to be hypoxic on presentation
(91% RA), with a productive cough, and diminished mental status
(A&Ox1).
In the ED initial vitals: 98, HR 97, BP 110/55, RR 16, O2Sat
91% RA and work-up was initiated with CXR, head CT, u/a,
chemistry and CBC. EKG was interpretted as AFib, LAD, NI, no
s/o ischemia and unchanged from prior. Labs were impressive for
an INR of 18.0 and hct drop from 43 in [**Month (only) **] to 25 today. On
further history taking it was discovered that the patient's INR
hasn't been checked "in months." Rectal exam revealed guaiac
positive melanotic stool in the vault. He was ordered for 4
units of FFP, 2 units of blood and 10mg of IV vitamin K and GI
was consulted. He only received 1 unit of FFP prior to
transfer.
A Head CT was checked and ICH was r/o'd. Given his elevated
WBC, he was given ceftriaxone and azithromycin.
On the floor he is without complaint, though nauseated in rapid
AFIB.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Coronary heart disease.
4. Atrial fibrillation.
5. Memory loss or early dementia.
6. Spinal stenosis.
7. Pseudogout.
8. Status post laparoscopic cholecystectomy.
Social History:
The patient is a retired civil engineer. He has 3 children. he
quit tobacco in the 70's (30 pack years) and denies drugs.
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse, though patient has
one drink per night.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died at 95 of stroke and father lived to
91.
Physical Exam:
ADMISSION EXAM:
Vitals: T: BP:92/55 P:112 R:22 O2:100%
General: Alert, no acute distress, very hard of hearing
HEENT: pale conjunctiva, dry MM, oropharynx clear with dentures
Neck: supple, JVP below clavicle, bounding carotids, no LAD
Lungs: Diffuse rhonchi, no obvious crackles
CV: Irregular, tachycardic, ?flow murmur s2s2
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: diffuse psoriasis
DISCHARGE EXAM:
VS: Tm 97.4, 100-135/50-, 72-90, 92-97% RA
General: elderly male resting comfortably in bed, NAD, very hard
of hearing
Lungs: CTAB, no wheezes/crackles/rhonchi
CV: irregularly irregular, no r/m/g appreciated
Abdomen: +BS, soft, NT/ND
Ext: warm, well perfused, 1+ edema of lower extremities
Pertinent Results:
Admission Labs:
[**2115-10-3**] 05:25PM BLOOD WBC-22.1*# RBC-2.60*# Hgb-8.4*#
Hct-25.0*# MCV-96 MCH-32.4* MCHC-33.7 RDW-14.6 Plt Ct-360
[**2115-10-3**] 05:25PM BLOOD PT-141.6* PTT-50.5* INR(PT)-18.0*
[**2115-10-3**] 05:25PM BLOOD Glucose-232* UreaN-72* Creat-1.4* Na-139
K-4.5 Cl-103 HCO3-21* AnGap-20
[**2115-10-3**] 11:27PM BLOOD Calcium-8.3* Phos-4.3# Mg-2.3
EGD:
Impression: Erythema in the gastroesophageal junction
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings do not account for the symptoms.
Consideration should be given to repeat colonoscopy. Will need
to discuss with patient and faimly.
Additional notes: The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss = zero. No specimens were taken for
pathology
COLONOSCOPY:
Grade 3 internal and external hemmorhoids
Diverticulosis of whole colon
polyps in the distal descending colon
polyp at 35 cm in the sigmoid sent for biopsy, endoclip place
Otherwise normal
Discharge labs:
[**2115-10-9**] 06:33AM BLOOD WBC-14.1* RBC-2.88* Hgb-9.1* Hct-27.3*
MCV-95 MCH-31.4 MCHC-33.2 RDW-18.8* Plt Ct-242
[**2115-10-9**] 06:33AM BLOOD PT-14.2* PTT-27.7 INR(PT)-1.2*
[**2115-10-9**] 06:33AM BLOOD Glucose-104* UreaN-38* Creat-1.3* Na-138
K-4.1 Cl-106 HCO3-20* AnGap-16
Brief Hospital Course:
[**Age over 90 **]M on coumadin for AFIB coming in with greatly supertherapeutic
INR, AMS, hypoxia, and GI bleeding with HCT drop.
Diagnoses:
# GIB: He presented with a supratherapeutic INR of 18 and was
given 3 units of FFP with improvement in his INR to 1.6.
Spontaneous gastritis in the setting of the coagulopathy was the
most likely source. EGD was performed and he did not show any
signs of active bleeding or oozing. Colonoscopy was performed
and showed diverticulosis and two polyps the largest of which
was removed. He received 2 units of PRBCs with an appropriate
bump in his hematocrit. His bumex, lisinopril, metoprolol,
aspirin, and warfarin were initially held. He was restarted on a
diet and tolerated food. An IV PPI was initially started and
then he was transitioned to PO. His metoprolol was restarted but
his bumex and lisinopril were held due to low blood pressure.
# AMS: Thought to be secondary to acute illness in the setting
of a GIB coupled with sundowning. Frequent orientation was
helpful, and small doses of antipsychotics.
# Hypoxia: He had mild hypoxia in the setting of a white count
and dry cough. His chest x-ray was unremarkable, however he did
have unilateral crackles. He was treated for a CAP with
azithromycin initially but this treatment was stopped later in
his hospitalization. Exact etiology was not determined.
# Coagulopathy: This may be secondary to a drug-drug
interaction between his coumadin and colchicine. More likely
this was [**3-13**] either patient error administering his own
medication or the fact that he gets his INR checked relatively
infrequently (monthly) He was aggressively corrected. His
colchicine was discontinued after discussion with his
rheumatologist.
# AFIB: HIs metoprolol was initially held but he had several
episodes of AFib with RVR. He was treated with 5 mg IV
Metoprolol with resolution of these episodes. His Metoprolol was
restarted and was titrated up to 25 mg TID. This was converted
to metoprolol succinate on discharge. His warfarin was planned
to be restarted the day after discharge. He was also planned to
take enoxaparin unitl his INR was therapeutic.
# CAD: Aspirin held during coagulopathy.
Transitional Issues:
Anticoagulation: Mr [**Known lastname 103486**] warfarin was held in the setting
of his GIB and elevated INR. His INR at discharge was 1.2. His
warfarin will need to be restarted and his dose will need to be
titrated up to his goal INR of [**3-14**]. While he is subtherapeutic
he should be treated with enoxaparin which should be renally
dosed. Aspirin held at discharge. Decision about re-starting
aspirin can be addressed as outpatient once HCT known to be
stable with therapeutic INR.
Follow-up: Patient needs a follow up appointment with Dr. [**First Name (STitle) 1022**]
after discharge from the rehabilitation facility.
Medications on Admission:
Medications:
BUMETANIDE - 0.5 mg Tablet daily
DONEPEZIL - 10 mg Tablet daily
LISINOPRIL - 5 mg Tablet daily
MECLIZINE - 25 mg Tablet as needed for vertigo attack
MEMANTINE [NAMENDA] - 10 mg Tablet [**Hospital1 **]
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr
SIMVASTATIN - 20 mg Tablet Tablet(s) by mouth
WARFARIN
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet
FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 (One) Tablet(s) by
mouth once a day
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 2
(Two) Tablet(s) by mouth once a day
Discharge Medications:
1. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for rash.
3. memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY PRN as
needed for Agitation.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
9. Outpatient Lab Work
Please check CBC Thursday [**2115-10-10**]
Please check INR Saturday [**2115-10-12**]
Please Fax results to :
Name: [**Doctor Last Name 1022**], [**Name6 (MD) **] [**Name8 (MD) **] MD
Address: [**Doctor First Name **],STE 1B, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 719**]
Fax: [**Telephone/Fax (1) 716**]
Email: [**University/College 103487**]
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on Thursday, [**2115-10-10**].
11. enoxaparin 100 mg/mL Syringe Sig: One (1) 90 Subcutaneous
once a day for Until INR 2-3 days: Please start Thursday
[**2115-10-10**].
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Gastrointestinal Bleed
Altered Mental Status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 16417**],
You were admitted to the hospital with changes in your mental
status. While you were here we also discovered that you had a
bleed in your GI tract and that your warfarin level was very
high. Initially you were admitted to the Intensive Care Unit
but you were then transferred to the floor because you were
stable. You underwent an upper and lower bowel endoscopy. The
upper endoscopy did not show evidence of bleeding. The lower
endoscopy showed a small growth that may have caused the
bleeding. This growth was removed. We also stopped the warfarin
to bring your level back to normal which helped stop the
bleeding. We also started a medication [**Doctor Last Name **] pantoprazole which
decreases the acid in your stomach which may also help stop
bleeding. You will need to restart the warfarin Thursday
[**2115-10-10**]. Because the warfarin was stopped you will need to take
a medicine called enoxaparin for a couple days before the
warfarin will be effective again. We also stopped your
bumetanide and lisinopril because your blood pressure was low.
Medication Changes Summary:
Please START warfarin 2mg per day on Thursday
Please START enoxaparin 90mg daily (renal dosing)
Please START Ferrous sulfate (iron) 300mg twice a day
Please start pantoprazole 40 MG twice a day
Please STOP Bumetanide
Please STOP Lisinopril
Please Increase Metoprolol succinate to 75mg daily
Please continue all other medications
Thank you for allowing us to participate in your care. We wish
you a speedy recovery.
Followup Instructions:
Department: GERONTOLOGY
When: FRIDAY [**2115-10-18**] at 2:30 PM
With: [**Last Name (un) 3895**] [**First Name8 (NamePattern2) 3896**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"45.42",
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icd9pcs
|
[
[
[]
]
] |
9915, 9988
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4954, 7153
|
247, 252
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10077, 10077
|
3599, 3599
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8432, 9892
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10262, 11807
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7174, 7804
|
185, 209
|
280, 2046
|
3615, 4635
|
10092, 10238
|
2068, 2280
|
2296, 2567
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,114
| 115,233
|
36128
|
Discharge summary
|
report
|
Admission Date: [**2128-1-22**] Discharge Date: [**2128-1-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
PEG tube placement, trach tube replacement
History of Present Illness:
[**Age over 90 **]yo M w/ h/o endstage alzheimer's, afib, esophageal stricture
s/p 3 diliataions, and recurrent aspiration who presented from
nursing home for lethargy, and cough w/sputum over last couple
days. Wife says 1 wk ago pt (?partially)pulled out his g-tube,
and nurse put back in place. Pt was looking more emaciated and
his feeds were increased from 12h to continuous over 24h, which
is when she thinks pt started to decline, and may have been
aspirating. Over the last couple days pt became more
unresponsive and also developed a cough w/ sputum. Pt was on
levoflox for pna as outpt.
Of note pt was discharged on [**2127-11-27**] with asp pna, treated with
vanco/cipro/zosyn. During that admission pt failed extubation
twice due to mucous pluging and tracheostomy was placed. J-tube
and G-tube were placed to prevent aspiration. (Also had C5-6
fusion then)
Required bag masking at NH, hemodynamically stable, then
transported to [**Location (un) **], cxr showed pna, no ivf, then transferred
to [**Hospital1 18**].
In [**Hospital1 18**] ED, t99.8, 136/91, 104, 22, 99%ra, cachectic,
non-responsive, rhonchi at R base, suctioning pus from lungs,
abd soft, IVF initiated - given 1.5L, ceftaz, vanco, and azithro
initiated. HR 88, sats 50% 15L, rr26, 149/94, T 100.8 on
transfer.
Past Medical History:
Esophageal stricture ? s/p [**Hospital 81947**]
Hiatal hernia
Hypertension
S/p aortic valve replacement 3 years ago bovine per wife
Hip fracture s/p repair
H/o aspiration pneumonia, ? recurrent aspiration
H pylori gastritis
Dementia
Social History:
Patient is a retired ENT surgeon per out side hospital report.
He lives at home with his wife. Independent ADLs until last
summer
Family History:
non contributory
Physical Exam:
GENERAL: late-stage alzheimer's - nonresponsive
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRL 2mm->1mm. MMM. OP clear.
NECK: trach present. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=flat
LUNGS: course rhonchi, and rales throughout
ABDOMEN: +BS Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Pt non-responsive to commands. Somnolent.
Pertinent Results:
[**2128-1-27**] 04:06AM BLOOD WBC-7.6 RBC-3.87* Hgb-11.3* Hct-33.5*
MCV-87 MCH-29.3 MCHC-33.8 RDW-15.8* Plt Ct-373
[**2128-1-22**] 02:30PM BLOOD Neuts-85.0* Lymphs-10.6* Monos-4.0
Eos-0.2 Baso-0.2
[**2128-1-23**] 04:00PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2*
[**2128-1-27**] 04:06AM BLOOD Glucose-115* UreaN-19 Creat-0.7 Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
[**2128-1-22**] 02:30PM BLOOD CK(CPK)-16*
[**2128-1-22**] 02:30PM BLOOD cTropnT-0.01
[**2128-1-27**] 04:06AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.2
[**2128-1-22**] 03:30PM BLOOD Lactate-1.9
[**2128-1-27**] 04:49AM URINE Color-Pink Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2128-1-27**] 04:49AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2128-1-27**] 04:49AM URINE RBC-756* WBC-87* Bacteri-FEW Yeast-NONE
Epi-0
Sputum culture: MRSA
Urine and blood cultures: neg
[**2128-1-22**] CXR: 1. Patchy opacity in the right lower lobe concerning
for pneumonia. 2. Dense retrocardiac opacity, which could
represent second area of pneumonia or atelectasis.
[**2128-1-26**] Replacement of G/J tube: Uncomplicated placement of
gastrojejunostomy tube through the patient's existing tract. The
tube may be used immediately.
Brief Hospital Course:
[**Age over 90 **]yoM htn, afib, esophageal stricture transferred from nursing
home with lethary and fever, diagnosed at OSH ED with pna,
transferred to [**Hospital1 18**], diagnosed with pna, admitted to [**Hospital Unit Name 153**] for
tx of aspiration pna/HAP.
# [**Name (NI) 10227**] Pt has had recurrent pneumonia. Pt had aspiration
pneumonia on this admission. It is possible that pt had
aspiration with increasing his feeds from 12h to continuous 24h.
His trach was also replaced with one with a cuff to further
prevent aspiration risk. He was treated w/ Vancomycin and Zosyn.
Cipro was not started during this admission as there is no
recorded Pseudomonas infection on cultures. Pt required frequent
suctioning initially q1h, which is now improved. Pt is now
afebrile and wbc is coming down. He showed moderate growth of
STAPH AUREUS COAG +, and his zosyn was discontinued. Pt needs
Vanc 1g IV q24 (as only coag + SA on cx data) x8 days ([**4-26**]) for
two more days.
# Hypernatremia - Pt's Na was 158, and improved with free water
replacement. Now resovled at 141.
# 1st degree AV block - overnight once, now resolved in sinus
60-80s HR
#. H/o Atrial Fibrillation - currently not in afib, but rate
controlled.
#. Hypertension- currently controlled, will moniter
#. UTI- UA with neg nitrates but pos leukocytes, few bacteria,
WBC 21-50, 90 on repeat, Urine Culture with minimal yeast and
GNR. Treated while pt was on Zosyn
#. Hiatal hernia- gave home omezprazole
Medications on Admission:
Lasix 40 [**Hospital1 **]
Aricept 10 QD
ASA 81
Omep 40 QD
KCl suspension 20 [**Hospital1 **]
Levaquin 250 x9d
Ativan 0.5mg q6 prn
Twocal HN continuous @ 50ml/h via g-tube
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Aspiration Pneumonia, MRSA
Secondary: Alzheimers dementia
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted with fevers, increased secretions thought to
be due to an aspiration pneumonia. We treated you with
antibiotics to cover the bacteria which grew from your cultures.
Followup Instructions:
please follow up with your PCP as necessary
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2128-1-27**]
|
[
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icd9cm
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[
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icd9pcs
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[
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3941, 5425
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280, 325
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5825, 5844
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6076, 6287
|
2066, 2084
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5734, 5804
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5451, 5624
|
5868, 6053
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2099, 2668
|
230, 242
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353, 1645
|
1667, 1902
|
1918, 2050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,279
| 149,302
|
6281
|
Discharge summary
|
report
|
Admission Date: [**2179-7-11**] Discharge Date: [**2179-7-21**]
Date of Birth: [**2132-9-2**] Sex: M
Service: MEDICINE
Allergies:
Protonix / Mercaptopurine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
weakness, slurred speech and rectal pain
Major Surgical or Invasive Procedure:
Right femoral central venous line
PICC line
History of Present Illness:
46 year old male with history of multiple sclerosis, [**First Name3 (LF) **]'s
disease, PUD s/p multiple bowel resection and partial
gastrectomy who presented from home to OSH with weakness,
slurred speech and rectal pain; he was found to be hypotensive,
hypokalemic, and was transferred to [**Hospital1 18**] for further
evaluation.
.
At the OSH, he complained of increased rectal pain, but could
not tell for how long. He denied previous peri-rectal abscesses.
He has not had a change in his bowel habits, with frequent
diarrhea [**1-13**] bowel resections. A CT torso was reportedly normal.
He was hypotensive and received 7 liters of NS and was started
on norepinephrine after a femoral CVL was placed. He was given
unasyn and gentamycin and was then transferred to [**Hospital1 18**] for
continued management. In the [**Hospital1 **] ED, he was given vanc and
continued on norepi.
.
He was admitted to the surgical ICU given concern for a
peri-rectal abscess and sepsis as the cause of his hypotension.
He was found to have a RLE DVT, provoked from the R CVL placed
at the OSH and was started on a heparin drip. R femoral CVL was
d/c'ed and L IJ CVL was placed. He was also started empirically
on vancomycin, cipro, and metronidazole. He was transfused 2U
PRBCs for Hct 24 -> 28.
.
He was evaluated by neurology given his episode of slurred
speech. TTE with bubble study identified a PFO. MRI identified a
possible subacute stroke in the left parietal region. Given the
DVT, it was thought that this represented a paradoxical embolic
stroke (acute vs. sub acute) and recommended anticoagulation
with coumadin. Neurology also recommended outpatient follow up
for MS.
.
Norepinephrine was weaned off on [**2179-7-13**]. Vascular surgery was
consulted for consideration of IVC filter placement given need
for possible intra-operative drainage of peri-rectal abscess,
who did not feel that it was indicated. Ultimately it was
decided not to I&D the abscess. Overall, peri-rectal abscess is
3 x 1.5 cm, non-operative, likely old per attg, within rectum,
not amenable to drainage.
.
The patient was then transferred out of the ICU. He triggered
[**2179-7-17**] for SBP in the 70s. Blood and stool cultures for C. diff
were sent, and have been negative to date. He recevied 500 cc of
LR and one unit of PRBCs. Vancomycin was discontinued on [**2179-7-14**],
cipro and metronidazole have been continued.
.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Multiple sclerosis dx roughly 2 years go per family which has
been rapidly progressive ? PPMS vs SPMS and previously failed
Copaxone which was the only disease modifying therapy used -
patient is followed by Dr [**Last Name (STitle) **] at [**Location (un) 14840**]. Currently
bedbound
and last was able to walk roughly 1 year ago."
- [**Location (un) **]'s Diease s/p multiple small bowel resections has been
off
medications since [**2174**] lost to GI follow up
- Peptic Ulcer disease with gastrectomy an Billroth II
reanastomosis
PSH:
Multiple small bowel resections (at least 3), partial
gastrectomy
with B2 reconstruction
Social History:
Lives with mother/brother and dependent for all [**Name (NI) **]/ADLs
Family History:
NC
Physical Exam:
DISCHARGE PHYSICAL EXAM
VS: 97.7, 98/66, 86, 16, 97 RA
Gen: cachectic, sleeping comfortably in bed, arousable to voice,
then appeared restless
HEENT: EOMI, PERRL, MMM, OP clear
Neck: no JVD, no LAD
CV: regular rate and rhythm, no murmurs
Resp: CTAB, no wheezes or crackles
GI: soft nt/nd +bs no HSM, no stigmata of chronic liver disease
Ext: no c/c/e, +pneumoboots
Neuro: CNII- CNXII intact, dysarthria, right side contracted and
weaker than left
Psych: A&OX3, appropriate
Pertinent Results:
LABS ON ADMISSION
[**2179-7-11**] 06:15AM BLOOD WBC-9.3 RBC-2.89*# Hgb-8.3*# Hct-24.2*#
MCV-84# MCH-28.7# MCHC-34.3 RDW-16.2* Plt Ct-773*
[**2179-7-11**] 06:15AM BLOOD Neuts-82.7* Lymphs-12.4* Monos-4.4
Eos-0.3 Baso-0.2
[**2179-7-11**] 06:15AM BLOOD Plt Ct-773*
[**2179-7-11**] 09:50AM BLOOD PT-14.5* PTT-30.8 INR(PT)-1.2*
[**2179-7-11**] 06:15AM BLOOD Glucose-82 UreaN-13 Creat-0.3* Na-140
K-2.2* Cl-113* HCO3-20* AnGap-9
[**2179-7-11**] 06:15AM BLOOD Calcium-5.7* Phos-2.9 Mg-1.3*
[**2179-7-12**] 06:00PM BLOOD calTIBC-72* Ferritn-331 TRF-55*
[**2179-7-13**] 02:22PM BLOOD VitB12-904*
[**2179-7-13**] 02:22PM BLOOD %HbA1c-5.2 eAG-103
[**2179-7-13**] 02:22PM BLOOD Triglyc-32 HDL-30 CHOL/HD-1.7 LDLcalc-14
.
LABS ON DISCHARGE
[**2179-7-20**] 04:03AM BLOOD WBC-7.7 RBC-2.93* Hgb-8.7* Hct-26.5*
MCV-90 MCH-29.7 MCHC-32.9 RDW-16.7* Plt Ct-374
[**2179-7-21**] 04:38AM BLOOD PT-14.6* INR(PT)-1.3*
[**2179-7-21**] 04:38AM BLOOD Plt Ct-201
[**2179-7-21**] 04:38AM BLOOD Glucose-109* UreaN-14 Creat-0.3* Na-138
K-4.0 Cl-113* HCO3-23 AnGap-6*
[**2179-7-21**] 04:38AM BLOOD ALT-9 AST-12 LD(LDH)-124 AlkPhos-165*
TotBili-0.2
[**2179-7-21**] 04:38AM BLOOD Albumin-1.5* Calcium-6.9* Phos-2.2*
Mg-1.7
.
Imaging:
TTE [**2179-7-13**]:
The left atrium is normal in size. A patent foramen ovale is
present with right-to-left shunt across the interatrial septum
is seen at rest (using agitated saline contrast). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The 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. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
.
CT A/P: [**2179-7-11**]
1. 3.6 x 1.6 cm perirectal abscess.
2. Evidence of bowel wall thickening and mucosal enhancement at
the junction
of the small and large bowel in the right lower quadrant is
likely
representative of acute inflammation, consistent with active
[**Month/Day/Year **]'s flare.
3. Right hydrocele with no evidence of Fournier's gangrene.
.
MRI Brain [**2179-7-12**]:
1. A focal area of high signal intensity demonstrated in the
left
parietal lobe medially, suggesting subacute ischemic changes
versus
demyelination, there is no evidence of mass effect or abnormal
enhancement in the region.
.
2. Subtle areas of high signal intensity are visualized in the
subcortical white matter associated with cortical volume loss
and likely representing sequela of chronic MS changes. These
areas are involving both cerebral hemispheres, right cerebellar
hemisphere and the left medulla oblongata.
Brief Hospital Course:
46 y/o male with hx of untreated MS [**First Name (Titles) **] [**Last Name (Titles) **]'s, chronic
diarrhea, chronic perirectal abscess, and hx of GIB presented to
OSH with weakness, slurred speech, and hypotension. Found to be
severely hypokalemic, hypocalcemic, hypomagnesemic and anemic as
well, and found to have a RLE DVT. Transferred to [**Hospital1 18**] for
further evaluation and treatment. A right groin CVL was placed
at the OSH and this was removed and sent for culture which was
negative. He was admitted to the SICU where he was fluid
resuscitated and started on levophed for hypotension and a left
IJ CVL was placed. His electrolytes were repleted and was
transfused 2 units PRBCs for HCT of 24.2. He was started on a
Heparin drip for the DVT.
.
# ALTERED MENTAL STATUS/SUBACUTE STROKE:
Neurology was consulted for altered mental status and a HCT was
performed showing no acute intracranial hemorrhage or mass
effect with a hypodense area noted in the left frontal lobe
likely relate to volume averaging. A follow up MRI demonstrated
a focal area of increased signal intensity in the L parietal
lobe suggesting subacute ischemic changes vs. chronic
demyelination. Also, there are subtle areas of high signal
intensity in the subcortical white matter likely representing
sequelae of chronic MS changes. Further workup for causes of
stroke included an ECHO with bubble study which revealed a PFO.
Cardiology was consulted who recommend outpatient management of
the PFO. In addition, a CTA of head/neck was without vascular
occlusion, stenosis, aneurysm formation or other vascular
abnormality. Given his DVT and PFO, this was thought that he had
paradoxical embolus resulting in subacute vs. chronic stroke and
should be anticoagulated with recommended follow up with MS [**First Name (Titles) **] [**Last Name (Titles) 24391**]e specialists as an outpatient.
.
# DVT/ANTICOAGULATION:
A heparin gtt was started for RLE DVT and initially coumadin 2mg
was given. His INR returned supratherapeutic at 4.3 and his
coumadin was held allowing him to drift downwards, likely a
result of Vit. K depletion [**1-13**] chronic diarrhea. His coumadin
was resumed, and goal INR is [**1-14**] on discharge. Would consider
extended course in setting of PFO, unless this is closed sooner.
.
# [**Month/Day (3) **]'S/CHRONIC DIARRHEA/SHORT GUT/PERI-RECTAL ABSCESS:
GI was consulted for hx of [**Month/Day (3) **]'s disease and chronic diarrhea.
The patient was followed at [**Hospital1 18**] by Dr. [**Last Name (STitle) 2305**] and was
receiving Remicade but has not been seen at this facility since
2/[**2174**]. C. diff Ag x3 were sent which returned as negative.
Stool cultures were sent and were all negative. Etiology for
chronic diarrhea is felt to be short gut syndrome from his
numerous prior bowel surgeries. Antibiotics were initially
started, but discontinued when no infectious source was found.
Loperamide, cholestyramine, and psyllium were initiated for
management of chronic diarrhea. TPN was initiated for management
of nutrition, as his albumin was < 1.5 on presentation. Per
surgery, patient will require improved nutrition and wound
healing prior to correction of his peri-rectal abscess. Per GI,
peri-rectal abscess would need drainage prior to initiating
effective [**Year (4 digits) **]'s therapy (budesonide vs.
prednisone vs. infliximab); however, patient is currently
reluctant for future treatments of [**Year (4 digits) **]'s.
.
# DECONDITIONING/NUTRITION
Deconditioning has been a major issue for him as well. He has
been mostly bed bound for the past year. He lives at home with
family and they report having a difficult time turning the
patient and cleaning him after his frequent stooling. PT and OT
have been working with him and they recommend rehab after
discharge. He had significant skin breakdown from incontinence
and WOCN has been involved with recommendations for skin
treatments. During family meeting, patient and family agree that
rehab for improved nutrition and wound healing are important
goals, with the ultimate goal of returning home for improved
quality of life. Wound care recommendations are noted below
separately. He was initiated on TPN via PICC line, to continue
on discharge.
.
# WOUND CARE
Recommendations: Continue pressure relief measures per pressure
ulcer guidelines.
Turn and reposition every 1-2 hours and prn side to side
Heels off bed surface at all times
Waffle Boots to B/L LE's
.
Moisturize B/L LE's and feet [**Hospital1 **] with Aloe Vesta Moisture
Barrier Ointment
.
Gentle cleansing of back tissue with Foam cleanser
Pat the tissue dry.
Apply Aloe Vesta Moisture barrier ointment to the peri wound
tissue
Apply Xeroform Gauze to the ulcerated sites-right trochanter,
right flank, midline
Cover with large Sofsorb sponges
No tape-just lay in place
Change dressing daily and prn
.
Apply antifungal critic Aid clear moisture barrier Ointment to
the penile shaft and scrotal tissue daily and prn or every 3rd
cleansing. Obtain securing device for indwelling Foley catheter.
.
Apply antifungal Critic Aid Clear Moisture Barrier Ointment to
the perianal
tissue daily and prn or every 3rd cleansing to protect perianal
tissue from stool irritation. Place xeroform around the FSM at
the insertion site.
.
Nutrition has also been a major issue for him. He did pass a
bedside speech and swallow and was placed on regular diet with
Ensure supplements and protein supplements. His albumin came
back at 1.2. Nutrition was consulted to perform calorie counts
([**Date range (1) 24392**]) which are pending. If he doesn't meet needs they
recommend enteral feeds however, with multiple bowel resections
and chronic diarrhea TPN may be a better option for him. He does
have R IJ placed in the SICU since PICC can't be placed in the
setting of elevated INR. Family have been very involved and they
are currently working with the MS society about attempting to
get PCA and PT for home when the patient is discharged from
rehab.
.
# TRANSITIONAL ISSUES
- please consult GI physicians at LTAC for any questions
regarding management of chronic diarrhea
- please continue TPN, wound care, rectal tube
- patient to follow-up with Dr. [**First Name (STitle) 2405**] (PCP), Dr. [**Last Name (STitle) **].
[**Doctor Last Name **] (surgery), and Dr. [**Last Name (STitle) 1940**] (GI) after being discharged
from acute care rehab. Also to see primary care doctor to
establish care with a neurologist and cardiologist for stroke
and patent foramen ovale.
Medications on Admission:
None
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
5. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
TID (3 times a day).
6. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: titrated to INR [**1-14**].
7. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
8. HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN pain
9. 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.
10. Humalog 100 unit/mL Cartridge Sig: as per sliding scale
units Subcutaneous three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]
Discharge Diagnosis:
PRIMARY:
1. Chronic diarrhea from short gut syndrome
2. Untreated [**Hospital1 **]'s disease
3. Untreated multiple sclerosis
4. Chronic malnutrition
5. Chronic deconditioning
6. Peri-rectal abscess
7. Sacral decubitus ulcer
8. Deep venous thrombosis
9. Subacute stroke from patent foramen ovale
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were transferred to [**Hospital3 **] for management of your
chronic diarrhea, low blood pressure, peri-rectal abscess,
change in speech, and blood clot. Your electrolytes were
corrected and you were treated aggressively for shock with
fluids and antibiotics. You met with the neurology team, who
felt that you suffered from a subacute stroke. You were found to
have a patent foramen ovale, which may be the cause for your
stroke. Cardiology felt that this can be managed with surgery in
the future, if you would like. Fortunately, your speech
continued to improve. You will need to stay on coumadin for the
blood clot and the stroke.
.
With regard to your chronic diarrhea, a thorough infectious
work-up did not reveal an infectious cause. The GI doctors [**Name5 (PTitle) 2985**]
that the cause may be related to short gut syndrome from your
numerous prior bowel surgeries. It was noted that you have not
had treatment for your MS [**First Name (Titles) **] [**Last Name (Titles) **]'s since [**2174**], and it will be
important to re-establish care with your previous doctors after [**Name5 (PTitle) 17773**] are discharged from rehab.
.
With regard to your peri-rectal abscess, the surgery team felt
that this was not amenable to drainage or correction right now,
but that in the future, with improved nutrition, you may be able
to undergo correction of this. For nutrition, you were started
on TPN. For wound healing in the rectal area and management of
the chronic diarrhea, you are continuing with the rectal tube,
which was placed by surgery.
.
Prior to your discharge, a family meeting occurred and you
agreed that going to rehab to become stronger was a good option,
with the ultimate goal of going home. For any questions in the
future, please feel free to contact Dr. [**Last Name (STitle) **] (surgery) or
Dr. [**Last Name (STitle) 1940**] (GI).
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) 2405**] (PCP), Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]
(surgery), and Dr. [**Last Name (STitle) 1940**] (GI) after being discharged from
acute care rehab. Please have your primary care doctor establish
care with a neurologist and cardiologist for your stroke and
patent foramen ovale.
Completed by:[**2179-7-21**]
|
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45,126
| 131,346
|
41098
|
Discharge summary
|
report
|
Admission Date: [**2157-6-3**] Discharge Date: [**2157-6-4**]
Date of Birth: [**2090-10-23**] Sex: M
Service: EMERGENCY
Allergies:
plasma
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Abdominal pain, hypotension --> GI perforation, peritonitis,
sepsis
Major Surgical or Invasive Procedure:
Bipap (Non-invasive Ventilation)
Central Venous Line (RIJ)
History of Present Illness:
66 yo male with history of alcohol cirrhosis (?c/b ascites/SBP,
varices, encephalopathy), with care at [**Hospital 1474**] Hospital, who
presented to Liver Clinic this morning to establish care (?TIPS
vs. transplant work-up). Complained of abdominal pain (RUQ) and
was found hypotensive to SBP60s. The patient endorsed feeling
weak for the last 1-2 days, may have fallen yesterday. The
patient's wife states he has been more confused recently, with
poor memory but mentating/ conversant. Denies melena or bright
red blood per rectum; denies hematemesis. Of note, the patient
has been taking immodium as he really dislikes lactulose;
reportedly has been having bowel movements fairly regularly.
.
In [**Month (only) **], patient had been admitted to [**Hospital 1474**] Hospital for
a GI bleed. Reportedly, EGD at the time documented varices, the
patient was transfused and had paracenteses. In mid-[**Month (only) 404**], the
patient had a repeat paracentesis. [**2157-3-15**] the patient was
admitted to [**Hospital 1474**] Hospital for variceal bleeding, which was
banded and he was transfused. Also received IV PPI and another
paracentesis. In early [**Month (only) 116**], paracentesis "milky," ?chylous
ascites.
.
In the [**Hospital1 18**] ED, initial VS were: T90.0, BP74/29. Patient was
placed on Bear Hugger and volume resuscitated with 3L normal
saline. CXR not suggestive of PNA. Labs showed mild leukocytosis
10.9 w/ bandemia (32%), lactate 6.4, INR 1.9, mild hyponatremia
132, mild hyperkalemia with renal failure Cr 4.5. Paracentesis
with 12,000 WBC and he received Ceftriaxone. With persistent
hypotension, the patient was broadened to Vancomycin and Zosyn.
Given stress dose steroids, home levothyroxine and three more
liters normal saline. Also received octreotide and protonix IV
for concern of GI bleed initially. RIJ placed and levophed
started. The patient was trace guaiac positive and started on
octreotide, IV PPI. Patient intially mentioning that he would
not want to be intubated. On transfer, T33.8, HR77, BP97/48,
RR20, 97% on NRB.
.
ROS: Patient denies shortness of breath, endorses mild pain and
distension in upper abdomen, urinary urgency. Otherwise denies
cough, fevers, diarrhea.
Past Medical History:
* Alcohol cirrhosis c/b ascites/SBP, varices w/ bleeding,
encephalopthy
* COPD
* Hypertension
* Hypothyroidism
* Prostate Cancer
* L1/L2 fracture, multiple thoracic fractures
* Rib fractures
* Prostatectomy
* Ventral hernia repair
Social History:
Lives with wife (former nurse), has daughters in [**Name (NI) 3914**].
T - Quit [**2147-9-26**], unclear pack years
A - 1 pint vodka/day X 13 years, quit [**2156-11-15**].
Family History:
Unknown
Physical Exam:
VS: Temp: 91.4 BP: 102/52 HR: 88 RR: 20 O2sat 99% on BiPap,
alert and oriented X1-2 (name, +/- hospital)
GEN: Pleasant, comfortable but sleepy, ill appearing
HEENT: PERRL, EOMI, dry mucus membranes, op without lesions, no
JVD
RESP: CTA b/l with moderate air movement throughout, bibasilar
crackles at bases.
CV: RR, S1 and S2 wnl, no m/r/g, spider angiomas
ABD: Distended abdomen, minimal bowel sounds, soft with + fluid
waves, no masses palpable, mildly TP (RUQ)
EXT: no cyanosis/ecchymosis/edema but +palmar erythema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx1-2. Cranial nerves and strength/sensation grossly
intact.
Pertinent Results:
[**2157-6-3**] 10:20AM WBC-10.9 RBC-3.65* HGB-12.1* HCT-38.1*
MCV-104* MCH-33.2* MCHC-31.8 RDW-16.8*
[**2157-6-3**] 10:20AM PLT SMR-LOW PLT COUNT-115*
[**2157-6-3**] 10:20AM PT-20.4* PTT-42.1* INR(PT)-1.9*
[**2157-6-3**] 10:20AM TSH-1.6
[**2157-6-3**] 10:20AM GLUCOSE-60* UREA N-67* CREAT-4.5* SODIUM-132*
POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-18* ANION GAP-22*
[**2157-6-3**] 10:20AM CALCIUM-8.3* PHOSPHATE-8.9* MAGNESIUM-3.3*
[**2157-6-3**] 10:20AM ALT(SGPT)-26 AST(SGOT)-52* ALK PHOS-114 TOT
BILI-0.9
[**2157-6-3**] 10:20AM LIPASE-10
[**2157-6-3**] 10:24AM LACTATE-6.4*
.
Paracentesis:
ASCITES TOT PROT-1.7 GLUCOSE-11 LD(LDH)-420 ALBUMIN-LESS THAN
ASCITES WBC-[**Numeric Identifier 89579**]* RBC-417* POLYS-93* LYMPHS-0 MONOS-7*
Gram stain: 3+ polys, 1+ rods, 1+ cocci in pairs
.
EKG: Normal sinus rhythm, HR 63, normal axis, QTc 491, biphasic
STs in V3-V6, poor baseline.
.
CXR: Consistent with the given history, a right internal jugular
approach central venous catheter has been placed in the
interval. The distal tip projects over the right heart and takes
the expected course through the superior vena cava. No
pneumothorax is evident. Lung volumes remain markedly diminished
with predominantly linear hazy opacity at the left lung base and
blunting of the left costophrenic angle. Old rib fractures are
identified at multiple levels in the left hemithorax.
.
CT head: No evidence of hemorrhage, large vascular territory
infarction or skull fracture. Essentially normal head CT with
age appropriate atrophy.
.
CT torso:
1. Free air and fluid seen throughout the abdomen. There is a
region of
cecum seen with with possible pneumatosis and abnormal bowel
wall which could represent the source of perforation due to
ischemic colon however the bowel wall cannot be truly
characterized without contrast. It is also possible that this
free air is from duodenal ulcer or alternative bowel
perforation. It is less likely a duodenal ulcer due to the lack
of significant free air seen surrounding the duodenum.
2. There is simple fluid throughout the abdomen. The liver is
cirrhotic thus it is impossible to discern whether the fluid
seen interdigitating throughout the loops of bowel is ascites
from liver failure or fluid from the bowel perforation.
3. Fluid seen distending the esophagus as well as several
ground-glass
opacities within the lung which could be worrisome for
aspiration.
4. Multiple bilateral healed rib fractures with callus
suggesting chronicity. There are multiple compression fractures
noted throughout the thoracolumbar spine whose acuity is age
indeterminate without prior imaging, though morphology suggests
chronicity.
Brief Hospital Course:
66 year old male with history of alcoholic cirrhosis c/b
SBP/varices/encephalopathy, hypertension, hypothyroidism, COPD,
prostate cancer who presents with RUQ abdominal pain,
hypotension, found to have acute abdomen secondary to
perforation (?ischemic colon and duodenal ulcer).
.
#. Hypotension: With hypothermia, altered mental status and poor
urine output most likely sepsis. Known perforation, with
surgical abdomen/peritonitis. In discussions with Transplant
Surgery and Hepatology, the patient and wife (and daughters),
the decision was to not pursue surgery. With a MELD of 27 and
Childs-[**Doctor Last Name 14477**] C score he has a very poor prognosis
peri-operatively. Also has extremely poor prognosis without
surgery. On the first day of hospitalization, antibiotics,
levophed and volume resuscitation (with normal saline and
albumin 25%) were continued. The plan was for no escalation of
care (additional pressors, surgery). The patient was DNR/DNI
with goal of comfort. The patient was switched to face mask from
BiPap for oxygen and his pain controlled with morphine. The
patient's daughters, sisters and other family members visited
him throughout the day. On hospital day 2, the patient's wife
discussed with the family and decision was made to withdraw
care. Antibiotics, levophed were discontinued. The patient was
started on low-dose morphine gtt and ativan boluses PRN for
anxiety, comfort. He became progressively hypotensive,
bradycardic, hypothermic, no urine output. The patient expired
at 2:35pm, two hours afterwards, with family at the bedside.
Autopsy was declined.
.
#. Renal failure: Unclear prior baseline but has known elevated
creatinine as of [**Month (only) 958**]. [**Month (only) 116**] be chronic kidney disease from
hypertension vs. preprenal from current sepsis/peritonitis vs.
hepatorenal from cirrhosis. Anuric throughout hospitalization,
?abdominal compartment syndrome or ongoing sepsis. Urine lytes
were not ordered and further work-up not pursued, given goals of
care.
.
#. Hyponatremia: Cirrhosis and acute illness are both potential
precipitators. Serum sodium only mildly low. The patient
received normal saline and albumin 25% for volume resuscitation
early in admission.
.
#. Alcoholic cirrhosis: Childs-[**Doctor Last Name 14477**] C and MELD 27. Coagulopathic
given INR, significant ascites, renal failure possible prerenal
vs. hepatorenal. The patient was also encephalopathic and
critically ill. Of note, the patient has prolonged QTc possibly
due to cipro for SBP prophylaxis. Repeat EKG with normal QTc
450s. All his medications (nadolol, lactulose, lasix,
spironolactone, cipro) were held.
.
#. Rib fractures: Appear chronic on CT although patient did
possibly sustain a fall yesterday. Patient may be splinting,
contributing to low O2 sats but no signs of flail chest etc.
Patient likely has osteoporosis given significant vertebral
compression fractures also. Vitamin D, calcitonin, citrucel were
held in critical illness setting.
.
# Hypothyroidism: Stable, received stress dose steroids in ED
also for adrenal insult of acute illness. The patient was
initially continued on levothyroxine 50mcg IV which was then
discontinued.
.
# Hypertension: Home antihypertensives were held given
peritonitis
.
# Prostate Cancer: s/p prostatectomy, currently stable
.
Contact: [**Name (NI) **] [**Name (NI) 28272**] (wife, HCP - signed in chart)
[**Telephone/Fax (1) 89580**]
Code: DNR/DNI --> CMO
Medications on Admission:
* Magnesium 100mg daily
* Nadolol 20mg daily
* Multivitamin daily
* Lasix 40mg daily
* Cipro 500mg daily
* Spironolactone 100mg daily
* Protonix 40mg daily
* Levothyroxine 75 mcg daily
* Vitamin D 1000 daily
* Calcitonin 200 unit nasal spray
* Citrucel 1000 daily
* Lactulose 30mL twice daily
* Immodium twice daily
* Albuterol sulfate 90 mcg every 4-6 hours PRN
.
Allergies: FFP causes hives, premedicate with benadryl okay
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Sepsis, peritonitis, GI perforation, liver failure
Secondary: Alcoholic cirrhosis c/b ascites, SBP, encephalopathy,
varices, COPD,
hypothyroidism, L1/L2 fracture, multiple thoracic compression
fractures, rib fractures
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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28,902
| 128,345
|
13271
|
Discharge summary
|
report
|
Admission Date: [**2185-7-5**] Discharge Date: [**2185-7-7**]
Date of Birth: [**2121-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
SOB, diaphoresis
Major Surgical or Invasive Procedure:
Diagnostic Cardiac Catheterization
History of Present Illness:
This is a 64yo gentleman with recent discharge for h/o 3vCAD s/p
DES x2 to LAD in [**2185-6-27**], ESRD on HD, and DMI who presented with
shortness of breath and diaphoresis since his recent discharge
from [**Hospital1 18**] on [**2185-7-2**].
.
In the ED, his presenting vitals were T98.8 BP 157/83 HR90 sat
94%RA. EKG revealed increased ST elevations in V1-V3 similar to
EKG changes when he presented for his [**6-27**] admission. Pt
received antiplatelet products and the cath lab was activated.
During cardiac catheterization, he had hypertensive urgency with
a peak SBP in the 200s. He had flash pulmonary edema and
tachycardia necessitating intubation. He was started on the
nitro gtt in the cath lab. He also received heparin IV,
integrillin, and lasix 80mg IV x1.
.
In the cath lab, he was found to have stable 3 vessel disease
with patent LAD stents.
Past Medical History:
CAD--h/o 3 vessel disease (LAD and LCx), s/p multiple DES in
[**6-21**] and [**3-22**], D1: 80% stenosis, Lcx: 80% proximal stenosis,
RCA: 60% ostial stenosis
ESRD on HD--secondary to diabetic nephropathy, also has h/o
dye-induced nephropathy. Started HD [**3-/2185**] and currently being
evaluated for transplant.
Chronic mild systolic heart failure with EF 40%
Dyslipidemia
Hypertension
PVD s/p bilateral lower extremity revascularization in [**2181**]
Diabetes mellitus c/b neuropathy, nephropathy and
retinopathy--A1C not available
Hypothyroidism
Hemorrhoids
Heard of Hearing
Social History:
Social history is significant for the absence of current tobacco
use; he smoked for 35-40 years but quit over 15 years ago.
There is no history of alcohol abuse. He works as a carpet
salesman and runs 3 miles a day. He is divorced with 4 adult
children.
Family History:
Mother DM, died at age 63 from colon cancer
Brother CAD age 55
Father CAD, died of MI at age 62
Physical Exam:
Exam on admission to ICU:
PHYSICAL EXAMINATION:
VS: T 95, BP 139/77, HR 78, RR 19, O2 100% on AC 100% 650/20
PEEP 5
Gen: intubated and sedated, shaking
HEENT: Intubated. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, unable to assess JVP due to pt lying flat
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: L chest with HD catheter, site w/o erythema, edema. No
chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. Coarse BS BL, no wheeze,
rhonchi.
Abd: Obese, soft, + mild distention, nontender, no
rebound/rigidity/guarding. No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. Right groin has access sheath
in place, no bleeding or hematoma, no bruit.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: follows verbal commands, moving all four extremities
.
Death exam:
Patient unresponsiveness.
Did not respond to physical stimuli including chest
compressions.
Absent heart sounds, peripheral pulses, and no spontaneous
respirations.
Pupils fixed and dilated.
Pertinent Results:
Labs on admission:
[**2185-7-5**] 10:35AM BLOOD WBC-11.5*# RBC-4.06* Hgb-11.5* Hct-34.9*
MCV-86 MCH-28.2 MCHC-32.8 RDW-16.4* Plt Ct-495*
[**2185-7-5**] 10:35AM BLOOD PT-20.3* PTT-29.8 INR(PT)-1.9*
[**2185-7-5**] 10:35AM BLOOD Glucose-124* UreaN-58* Creat-6.1*# Na-137
K-4.8 Cl-99 HCO3-22 AnGap-21*
[**2185-7-5**] 08:25PM BLOOD Calcium-8.9 Phos-2.9# Mg-1.5*
[**2185-7-5**] 11:20AM BLOOD Glucose-167* Lactate-2.9* Na-137 K-5.2
Cl-98*
[**2185-7-5**] 11:20AM BLOOD Type-ART pO2-49* pCO2-68* pH-7.18*
calTCO2-27 Base XS--4
.
Cardiac enzymes:
[**2185-7-5**] 10:35AM BLOOD CK(CPK)-89
[**2185-7-5**] 05:14PM BLOOD CK(CPK)-102
[**2185-7-5**] 08:25PM BLOOD CK(CPK)-103
[**2185-7-6**] 04:10AM BLOOD CK(CPK)-79
[**2185-7-6**] 03:30PM BLOOD CK(CPK)-79
[**2185-7-7**] 01:17PM BLOOD CK(CPK)-40
[**2185-7-5**] 05:14PM BLOOD CK-MB-6 cTropnT-1.65*
[**2185-7-5**] 08:25PM BLOOD CK-MB-5 cTropnT-1.75*
[**2185-7-6**] 09:15AM BLOOD CK-MB-NotDone cTropnT-1.82*
[**2185-7-6**] 03:30PM BLOOD CK-MB-NotDone cTropnT-1.71*
.
Labs on AM prior to code:
[**2185-7-7**] 05:05AM BLOOD WBC-13.1* RBC-3.48* Hgb-9.7* Hct-30.3*
MCV-87 MCH-28.0 MCHC-32.2 RDW-15.6* Plt Ct-328
[**2185-7-7**] 05:05AM BLOOD PT-23.6* PTT-58.4* INR(PT)-2.3*
[**2185-7-7**] 05:05AM BLOOD Glucose-205* UreaN-42* Creat-5.3*# Na-138
K-4.6 Cl-99 HCO3-23 AnGap-21*
[**2185-7-7**] 05:05AM BLOOD ALT-15 AST-17 LD(LDH)-200 AlkPhos-120*
Amylase-23 TotBili-0.3
[**2185-7-7**] 05:05AM BLOOD Lipase-9
[**2185-7-7**] 05:05AM BLOOD Albumin-3.1* Calcium-8.9 Phos-5.4*#
Mg-2.2
.
Labs during code:
[**2185-7-7**] 01:17PM BLOOD WBC-11.1* RBC-2.95* Hgb-8.4* Hct-26.9*
MCV-91 MCH-28.6 MCHC-31.4 RDW-16.5* Plt Ct-246
[**2185-7-7**] 01:17PM BLOOD Glucose-412* UreaN-39* Creat-4.6* Na-141
K-3.3 Cl-106 HCO3-21* AnGap-17
[**2185-7-7**] 01:17PM BLOOD Calcium-10.2 Phos-5.0* Mg-2.0
[**2185-7-7**] 01:33PM BLOOD Type-ART pO2-60* pCO2-54* pH-7.27*
calTCO2-26 Base XS--2
[**2185-7-7**] 01:33PM BLOOD Lactate-8.9* K-4.5
[**2185-7-7**] 01:33PM BLOOD O2 Sat-83
.
Brief Hospital Course:
ASSESSMENT AND PLAN:
This is a 64yo male with known 3vD who was admitted for SOB and
angina. His EKG showed anteroseptal ischemia and his troponin
was positive. On cardiac catheterization he had stable 3VD with
a patent LAD stent. The patient was awaiting CABG pending
resolution of recent fevers and elevated INR. He developed Vtach
and the patient was coded and ultimately expired.
.
# CAD/Ischemia: The patient had 3 vessel disease with recurrent
episodes of ischemia. He had multiple stents in the LAD and
stenoses in D1, LCx, RCA. His EKG showed anteroseptal ischemia.
He was brought for cardiac catheterization, during it he had
hypertensive urgency with peak SBP in 200s. He had flash
pulmonary edema and tachycardia necessitating intubation. He was
started on nitro gtt in the cath lab and he also received
heparin IV, integrillin, and lasix 80mg IVx1. On cath, he was
found to have stable 3 vessel disease with patent LAD stents.
The patient's troponins were positive. During his
hospitalization he was kept on [**Month/Day/Year **], [**Month/Day/Year 4532**], metoprolol, a
statin, and imdur. The patient was seen by surgery who
suggested CABG pending resolution of fever and a normal INR.
The morning he expired, his telemetry was reviewed and it was
noted he had and increase in PVCs. Later that morning the
patient had two short runs of non-sustained Vtach. In the late
morning the patient developed pulseless Vtach and compressions
were started within seconds. He was coded for the next hour
with rhythms including pulseless vtach, v fib, and asystole.
During the code he received several doses of bicarbonate,
epinephrine, lidocaine, and amiodarone. Cardioversion was
attempted approximately 15 times. The attending asked for a
temporary internal pacer to be placed prior to calling the code.
Dr. [**First Name (STitle) **] (the attending) and the fellow both spoke with the
family. The on-call intern spoke with his son [**Name (NI) **] [**Name (NI) 4223**]
who declined an autopsy.
.
# Pump: The patient had an echo during his last admission that
revealed EF <20% and apical left ventricular aneurysm. Though he
does not appear significantly fluid overloaded, he had episode
of hypertensive urgency likely secondary to poor systolic
function and stiff ventricles. The patient did not tolerate a
balloon pump which was removed. A repeat echo during this
admission showed slightly improved LV systolic funciton with an
EF of 20-25%. The patient received HD during his
hospitalization.
.
# Respiratory failure: The patient was intubated in the setting
of hypertensive urgency and flash pulmonary edema. He later
received HD to help with fluid removal. In the morning prior to
being coded he was still requiring an FiO2 of 50% on the vent.
.
# HTN: The patient had SBP in the 200s during cath which
resolved with intubation and with a nitro gtt. The patient was
successfully weaned from the nitro drip. The plan was to restart
antihypertensives as tolerated as the patient was on imdur,
amlodipine, and hydralazine as an outpatient.
.
#Infection: The patient was having shaking chills early in his
admission and received a CT of the head without contrast which
showed no intracranial process. He was febrile and had
increased WBCs. The patient was started on Vancomycin and
Zosyn. His HD site was being followed as there was question as
to whether he had some puss at the site. For his fever, shaking
chills, and abdominal distension her received a RUQ u/s which
was unremarkable and without evidence of cholecystitis. In
addition his LFTs were all normal except for an alk phos of 120.
.
# ESRD: The patient had ESRD and was on HD. He was being
evaluated for renal transplant. He received HD during his
hospitalization and was continued on sevelamer.
.
# DM1: The patient is on a home insulin pump. During his
hospitalization he was on a insulin drip.
.
# Hypothyroidism: The patient was continued on his levothyroxine
during his hospitalization.
.
# Nutrition: The patient was receiving tube feeds.
.
# Prophylaxis: The patient received IV heparin IV and a PPI for
prophylaxis.
.
# Code: The patient was full code.
Medications on Admission:
[**Name (NI) **] 325mg PO daily
[**Name (NI) **] 75mg PO daily
Metoprolol Succinate 50mg PO daily
Amlodipine 5mg PO daily
Hydralazine 25mg PO QID
Imdur 39mg PO daily
Atorvastatin 80mg PO daily
Levothyroxine 200mcg PO daily
Pantoprazole 40mg PO daily
Warfarin 4mg PO daily
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulseless Vtach/Vfib/Asystole
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2185-9-5**]
|
[
"585.6",
"357.2",
"518.5",
"250.40",
"428.43",
"250.60",
"410.11",
"362.01",
"V45.82",
"428.0",
"426.3",
"427.1",
"244.9",
"V45.1",
"414.01",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.20",
"37.61",
"39.95",
"88.56",
"96.71",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
10098, 10107
|
5583, 9736
|
330, 366
|
10196, 10213
|
3588, 3593
|
10277, 10322
|
2153, 2251
|
10058, 10075
|
10128, 10175
|
9762, 10035
|
10237, 10254
|
2266, 2292
|
2314, 3569
|
4125, 5560
|
274, 292
|
394, 1259
|
3607, 4108
|
1281, 1863
|
1879, 2137
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,365
| 169,783
|
49217
|
Discharge summary
|
report
|
Admission Date: [**2178-9-2**] Discharge Date: [**2178-9-10**]
Date of Birth: [**2130-11-15**] Sex: F
Service: MED
Allergies:
Abacavir / Vancomycin / Ativan / Haldol
Attending:[**First Name3 (LF) 23753**]
Chief Complaint:
s/p TIPS procedure
Major Surgical or Invasive Procedure:
TIPS
History of Present Illness:
47 yo F w/HIV/AIDS, HCV cirrhosis c/b varices, encephalopathy
and ascites, DVT w/recurrent PEs s/p IVC filter admitted s/p
elective TIPS w/embolization/coiling of gastric varices x 2. Pt
admitted to [**Hospital1 18**] in [**7-12**] w/GIB [**2-9**] esophageal varices. Was
readmitted ~1 week later with DVT and PE requiring IVC filter.
Pt returned to hospital in [**8-12**] w/pleuritic CP and found to have
new PE. Repeat EGD during that admission showed grade 3
esophageal varices which were banded x 3. Pt had difficulties
tolerating procedure and did not want to have repeated bandings
in the future, and thus it was decided that given extent of
varices and need for mult EGDs, TIPS would be a viable
alternative. Was subsequently started on heparin and d/c'd on
lovenox with plans to return for TIPS [**2178-9-2**]. Pt states she did
well over the weekend with no complications.
Tolerated TIPS well with Hct stable. Post-procedure course
c/b fever to 101 and increase of LFT's and t.bili from 0.7 to
5.5. Was kept in the PACU overnight and vitals remained stable.
+c/o Nausea, pain controlled by IV morphine.
Past Medical History:
1. HCV/Cirrhosis, grade 2 esophageal varices, encephalopathy
2. HIV - last CD4 - 88, VL <50.
3. Asthma
4. IVDU on methadone
5. DVT/PE s/p filter, on lovenox (last dose 8/24)
6. depression
7. gastroparesis
8. h/o VZV
9. h/o intubation for EGD
10. chronic abd pain
Social History:
L/w boyfriend. IVDU/Heroin. Smokes - trying to quit.
Family History:
non-contrib.
Physical Exam:
99.7 140/90 60 20 91% RA
Gen: in NAD
HEENT: PERRLA, EOMI, no sceral icterus
Neck: supple, no lymphadenopathy. L IJ line in neck.
CV: RRR, II/VI systolic murmur heard best at LUSB. +some slight
substernal discomfort.
Lungs: Slight crackles R>L. [**Month (only) **] BS throughout.
Abd: Soft, diffusely tender, worst in RUQ. . +BS. +
splenomegaly, no hepatomegaly.
Ext: B pneumoboots in place. + 2+pitting edema B LE. +ecchymoses
and varicose veins on feet B. Pulses 2+ bilaterally DP/PT.
Neuro: A&Ox3. non-focal. Sensation in tact to light touch.
Pertinent Results:
[**2178-9-2**] 10:00PM ALT(SGPT)-38 AST(SGOT)-93* LD(LDH)-319* ALK
PHOS-128* TOT BILI-5.4*
[**2178-9-2**] 10:00PM HAPTOGLOB-<20*
[**2178-9-2**] 07:09PM GLUCOSE-157* UREA N-6 CREAT-0.5 SODIUM-140
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2178-9-2**] 07:09PM ALT(SGPT)-35 AST(SGOT)-94* ALK PHOS-131* TOT
BILI-5.5* DIR BILI-4.2* INDIR BIL-1.3
TIPS ([**2178-9-2**])
1) Successful transjugular intrahepatic portosystemic shunt
performed via the right internal jugular vein. The 10-mm x 94-mm
bare metal Wallstent extends from the main portal vein to the
distal right hepatic vein. Following deployment, the shunt was
sequentially dilated with a 10-mm balloon. The pre- TIPS hepatic
venous pressure gradient measured 23 mm Hg. The post-TIPS
hepatic venous pressure gradient measured 4 mm Hg.
2) Portal venography demonstrated significant variceal branches
from the left gastric vein. Two large variceal branches were
treated with absolute alcohol injection followed by microcoil
embolization. Post-embolization venography demonstrated
obliteration of the variceal branches.
Abd U/S ([**2178-9-3**]):
1) Patent TIPS with wall-to-wall flow.
2) Chronic cholecystitis.
3) Normal bile ducts.
Brief Hospital Course:
47 yo F with h/o HIV, HCV c/b cirrhosis and varices and 3 recent
admissions for GIB and 2 PE's respectively, now s/p TIPS
procedure with banding of varices.
1. HCV cirrhosis-Pt had a sucessful TIPS procedure. Post
procedure she had elevated LFTs, which was thought to be related
to post-TIPS and resolved over the course of the admission.
Unasyn started post procedure for fever spike, but later d/c. Pt
was called out of the unit after a 24 hour stay. U/S showed
patent TIPS. LFTS continued to decline while on the floor until
discharge. Pt D/c'd on lactulose
2. Fever- Post op fever covered with unasyn 3 gm IV q6 for
possible atelectasis. Pt became afevrile with negative urine and
blood culture.
3. PE/DVTs-s/p filter: Pts anticoagulation was held
periprocedure and restarted later in course due to a low Hct
(lowest was 26, recieved 2 units during stay) which responded
and remained stable. It was resarted on [**9-9**] with 10 mg coumadin
qd over two days, which brought her INR to 2.7, goal. She will
be D/c on coumadin 5 mg with INR check on Fri, and then every
few days, with results to be faxed to Dr [**Last Name (STitle) **]. 4. HIV/AIDS:
HAART therapy stopped as LFTs increased but restarted on [**9-8**].
Bactrim continued for HSV and PCP [**Name Initial (PRE) 1102**]. CD4 and viral
load draw before D/c.
5. Anemia: Hct was low on [**9-6**], prompting two overall
transfusion over 48 hours which she tolerated well.
6. Depression: Effexor and Trazodone continued.
7. Pain: Oxycodone and IV morphine prn for pain mgmt. D/c with
oxycodone, two weeks supply. Pt has fentanyl patched at home.
8. IVDU: Continued Methadone in [**Last Name (LF) 103192**], [**First Name3 (LF) **] recieve it with
gentiva as outpt.
9. Wheezing/Asthma: albuterol inhaler prn.
Pt was D/c in good condition after successful removal of central
line with good hemostasis and dressing. Pt will follow up with
Dr [**Last Name (STitle) **] later this month and Dr [**Last Name (STitle) 497**] in the future.
Medications on Admission:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
2. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
4. Venlafaxine HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once
a day).
5. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO bid ().
6. Stavudine 30 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Methadone HCl 40 mg Tablet, Soluble Sig: Two (2) Tablet,
Soluble PO QD (once a day).
10. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
14. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
15. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
17. Propranolol HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
18. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
19. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
20. Fentanyl 50 mcg/hr Patch 72HR Sig: [**1-9**] patches Transdermal
every seventy-two (72) hours as needed for pain.
Disp:*20 patches* Refills:*0*
Discharge Medications:
1. Propranolol HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO Q M,W,F ().
Disp:*30 Tablet(s)* Refills:*2*
3. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO QD (once a day).
Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
7. Stavudine 30 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs 1* Refills:*2*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 1* Refills:*2*
10. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
11. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. Methadone HCl 40 mg Tablet, Soluble Sig: Two (2) Tablet,
Soluble PO QD (once a day).
Disp:*60 Tablet, Soluble(s)* Refills:*2*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
15. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for 2 weeks.
Disp:*56 Tablet(s)* Refills:*1*
18. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*2*
20. Clotrimazole-Betamethasone 1-0.05 % Cream Sig: One (1) Appl
Topical HS (at bedtime) for 6 days.
Disp:*1 1* Refills:*0*
21. Warfarin Sodium 5 mg Tablet Sig: Five (5) Tablet PO once a
day: Readjust per Dr [**Last Name (STitle) **]. .
Disp:*30 Tablet(s)* Refills:*0*
22. Outpatient Lab Work
Please have INR rechecked on Friday, [**2178-9-11**]. Fax results to Dr
[**Last Name (STitle) **].
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Hepatitis C cirrhosis with varicies, s/p TIPS
2. Multiple pulmonary emobli
3. Anemia
Secondary:
1. HIV
2. Pain management
3. Asthma
4. Depression
5. Gastroparesis
Discharge Condition:
Good.
Discharge Instructions:
If you have shortness of breath, fever, nausea/vomiting, chest
pain, or bleeding, please call your PCP or come to the emergency
room.
Followup Instructions:
1. Dr. [**Last Name (STitle) **] on [**2178-9-30**] at 11:00 am
2. Dr. [**Last Name (STitle) 60707**] [**Name (STitle) 497**] in Liver Clinic on [**2178-12-11**] at
11:20 in [**Hospital Ward Name **] Bldg. ([**Last Name (NamePattern1) **].)([**Telephone/Fax (1) **])
3. VNA coumadin lab draws. Results to be faxed to Dr. [**Last Name (STitle) **] at
.
|
[
"070.41",
"304.01",
"415.19",
"518.0",
"571.5",
"286.7",
"042",
"456.8",
"575.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.29",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
10186, 10247
|
3664, 5661
|
315, 321
|
10466, 10473
|
2434, 3641
|
10655, 11010
|
1839, 1853
|
7488, 10163
|
10268, 10445
|
5687, 7465
|
10497, 10632
|
1868, 2415
|
257, 277
|
349, 1466
|
1488, 1753
|
1769, 1823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,887
| 195,060
|
2379
|
Discharge summary
|
report
|
Admission Date: [**2171-9-30**] Discharge Date: [**2171-10-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
as described in D/C summary
History of Present Illness:
89 y.o. male with past medical history of prostate cancer
(remoted), vascular dementia +/- coexistent Alzheimer's disease,
hypothyroidism, and gout who was brought in by ambulance from
his nursing home today after being lethargic and found to be
hypoxic. At best patient is intermittently recognizing family
and somewhat appropriate though also doing things like talking
to dolls and wandering. This behavior has dramatically worsened
over the past four months so that the patient is now in a [**Hospital1 1501**].
Recently, the family has noted several episodes recently of the
patient coughing and sputtering while eating, which raised
concern from them that the rehab was feeding him too fast.
Therefore, they hired a private individual to feed the patient.
That person has noted that the patient was much less responsive
and engaged today; the patient was unable to give any history.
Because of his dramatically reduced responsiveness the patient
was brought in to the ED where initial vitals revealed an O2 sat
of 86% on a nonrebreather. SBP dropped into the 50's so the
patient had a femoral CVL placed under emergent conditions and
he was intubated after being started on norepinephrine. Temp was
96.4 rectal with a lactate of >10. Imaging revealed a right
sided infiltrate, EKG w/ NSR w/ slightly peaked T's. The patient
received bicarb, calcium, and kayexalate through an orogastric
tube. He received pip-tazo and vancomycin for empiric antibiotic
coverage. After receiving 2 L of fluids the patient's temp was
96.7, P 100, BP 106/82, RR 30-35, and satting 90-100% on the
ventilator. ABG 7.28/35/330 and lactate was down to 5.8. CT head
was negative. He was sent to the ICU.
On arrival to the ICU the patient is intubated but was initially
responding to commands and squeezing fingers. ROS was
unobtainable but per family patient had been touching his lower
abdomen over the preceding days, which made them concerned for a
UTI.
Past Medical History:
-Vascular Dementia +/- vascular dementia
-Cervical spondylosis
-Gout
-BPH s/p prostatectomy
-? MDS
-Hypothyroidism
Social History:
He lives in [**Location 2251**] with his wife of 60 years. He does not have
pets. He does not drink alcohol. He quit smoking in [**2130**].
Family History:
His father died at age 84 of cancer of the throat related to
cigar smoking and on an older brother had hearing problems.
Physical Exam:
GEN: intubated, frail, elderly male
HEENT: anicteric, MM appear dry, op with dried white food on
tongue no jvd, no carotid bruits
RESP: crackles at bases bilaterally
CV: tachycardic, no M/R/G
ABD: tender to palpation, mildly distended, decreased bowel
sounds, no organomegaly or masses
EXT: no c/c/e, cool
SKIN: 7*3 cm nonstageable ulcer on right upper glut, few
vascular lesions on feet
NEURO: Initially opening eyes to voice and following simple
commands (squeeze hands)
RECTAL: Guiac + brown stool in ED
Pertinent Results:
Initial Labs:
[**2171-9-30**] 04:00PM WBC-28.8*# RBC-2.61*# HGB-7.4*# HCT-25.7*
MCV-99*# MCH-28.3# MCHC-28.7*# RDW-16.5*
[**2171-9-30**] 04:00PM NEUTS-80* BANDS-6* LYMPHS-7* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2171-9-30**] 04:00PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL
[**2171-9-30**] 04:00PM PLT SMR-NORMAL PLT COUNT-330#
[**2171-9-30**] 04:00PM PT-16.8* PTT-34.1 INR(PT)-1.5*
[**2171-9-30**] 04:00PM ALT(SGPT)-36 AST(SGOT)-38 ALK PHOS-118 TOT
BILI-0.4
[**2171-9-30**] 04:00PM cTropnT-0.29*
[**2171-9-30**] 04:00PM GLUCOSE-100 UREA N-130* CREAT-5.8*#
SODIUM-162* POTASSIUM-6.5* CHLORIDE-124* TOTAL CO2-13* ANION
GAP-32*
[**2171-9-30**] 04:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD
[**2171-9-30**] 04:30PM URINE RBC-[**11-2**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2171-9-30**] 04:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
Lactate trend:
[**2171-9-30**] 05:24PM LACTATE-10.4*
[**2171-9-30**] 05:37PM LACTATE-5.8*
[**2171-9-30**] 07:07PM LACTATE-5.7*
[**2171-9-30**] 08:12PM BLOOD Lactate-4.6*
[**2171-10-1**] 01:46AM BLOOD Lactate-2.6*
[**2171-10-1**] 01:19PM BLOOD Lactate-2.1*
Microbiology:
[**2171-9-30**] blood cx: GNR PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2171-9-30**] urine culture: > 100,000 CFU
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ 1 S
PENICILLIN G---------- 4 S
TETRACYCLINE---------- S
VANCOMYCIN------------ 2 S
[**2171-10-1**]: sputum cx
respiratory culture: BETA STREPTOCOCCI, NOT GROUP A. STAPH
AUREUS COAG + PROTEUS SPECIES (SPARSE GROWTH) PSEUDOMONAS
AERUGINOSA (SPARSE GROWTH)
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 1 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Imaging:
CT head w/o contrast: [**9-30**]
1. Some patient motion on inferior most images, making
evaluation in this
region suboptimal. Otherwise, no evidence of acute intracranial
process.
2. Age-related involution and small vessel ischemic disease.
CXR: [**9-30**]
Single AP supine portable view of the chest was obtained. There
is
an endotracheal tube, terminating approximately 4.2 cm above the
carina. A
nasogastric tube terminates in the distal esophagus/GE junction
and should be advanced so that it is well into the stomach.
Subtle retrocardiac lucency may be due to a hiatal hernia.
Prominence and indistinctness of the hila suggests fluid
overload. Right upper-to-mid lung airspace opacity is seen,
worrisome for pneumonia. An additional left base patchy opacity
is also seen, which may be due to aspiration/pneumonia. There is
bibasilar atelectasis. Trace right effusion may be present.
Renal U/S: [**9-30**]
1. Left hydronephrosis, appears slightly less severe as compared
to [**2168-4-12**].
2. Overall stable multiple right renal cysts, largest measuring
up to 8.5 cm. No evidence of right hydronephrosis.
Brief Hospital Course:
This is an 89 year old male with severe dementia,
hypothyroidism, and gout who presented with septic shock from
multiple sources and respiratory failure requiring intubation.
He had a prolonged 2 week ICU course with multiple infectious
complications culminating in a necrotizing VAP and inability to
wean from the vent. A family meeting was held with multiple
family members including his daughter [**Name (NI) 12334**] who was appointed as
the family spokesperson. It was decided that given his poor
overall prognosis and worsening respiratory failure, he would be
made CMO and terminally extubated. He was made comfortable on a
morphine drip and expired on [**2171-10-15**] at 7:40PM in the presence
of multiple family members.
The following is a brief problem based summary of his hospital
course prior to expiration:
1) Septic shock: Presented with septic physiology: hypotension,
hypothermia, elevated lactate and severe renal dysfunction.
Most likely etiologies were felt to be secondary to UTI given
oliguria/ pyuria vs PNA given pulmonary infiltrate. Upon
presentation, patient was aggressively rehydrated according to
the Rivers protocol with boluses of crystalloid and levophed gtt
to target MAP > 65, UOP > 50cc/hr and CVP of [**9-24**].
Additionally started on broad spectrum empiric antibiotics
including vancomycin/ cefepime/ ciprofloxacin and flagyl which
were subsequently narrowed to ciprofloxacin given pan-sensitive
enterococcus from urine culture and pansensitive proteus from
blood. Initially, the patient improved with decrease in lactate
from 10.4 to 2.0, decreasing pressor requirement and
defervescence. On [**10-5**], patient developped recurrent shock
physiology with fevers and hypotension that was attributed to
VAP based on sputum cultures that grew MRSA, psudomonas and
proteus. Antibiotics were broadened to vancomycin and cefepime.
Patient slowly improved and was able to weaned off levophed
again, when WBC count rose to 17.5K on [**10-5**]. Repeat blood and
urine cultures were sent, CVL was changed and antibiotics were
broadened to meropenem and ciprofloxacin for improved
pseudomonas coverage.
2) Hypoxic respiratory failure: Patient was intubated on arrival
to ED for hypoxic respiratory distress due to acute
bronchopneumonia in the setting of poor pulmonary reserve and
poor functional status. Patient had high minute ventilation
throughout hospital course and respiratory pattern characterized
by tachypnea with normal/ high tidal volumes. He initially
required little ventilatory response but with aggressive fluid
resuscitation/ persistent septic shock he developped bilateral
infiltrates from VAP with fluid overload vs ARDS. As stated
above, his antibiotic coverage was expanded based on sputum
culture results to vanc/ cefepime. Mechanical ventilation c/b
development of a small right apical pneumothorax that was
incidentally discovered on rountine CXR. Underwent placement of
chest tube by thoracic surgery with resultant resolution of PTX.
By the end of 14 days, patient still remained dependent on
mechanical ventilation. Given the risks of significant tracheal
stenosis, the patient's family was offerred tracheostomy but
refused.
3) Anuric renal failure: Admitted with oliguria and ARF with
creatinine of 5.8 from recent baseline of 1.8. Renal ultrasound
on admission had no evidence of worsened hydronephrosis or
obstructive nephropathy. Etiology of renal failure
multifactorial from prerenal ischemia in the context of free
water deficit/ dehydration and intrinsic renal injury from ATN
secondary to sepsis. Patient was aggressively rehydrated and
treated for septic shock with gradual improvement in creatinine.
Of note, he did develop postoliguric diuresis with persistent
electrolyte imbalances requiring aggressive repleteion
4) Hypernatremia: Present with Na of 162 in setting of severe
dehydration/ poor PO intake from acute illness and underlying
dementia. Initially fluid resusicated with boluses of NS to
correct underlying hypovolemia. Then switched to free water
repletion with goal of correcting Na by 0.5 / hr using D5W
infusion and free water flushes down NGT.
5) Atrial fibrillation: During course of severe illness and
pressor requirement developped atrial fibrillation with RVR.
Echo showed mild symmetric left ventrcular hypertrophy with
hyperdynamic global systolic function and mild pulmonary artery
systolic hypertension. Started on amiodarone via IV loading
protocol for rate control given relative contraindication to AV
nodal agents with hypotension
6) Troponin elevation: Likely simply demand in the context of
hypotension and metabolic abnormalities. Will trend.
7) Hypothyroidism: Continued on home levothyroxine
8) Ulcer: Large decub without signs of secondary infection.
Wound care recommended surgical debridement but this was
deferred until
9) Dementia: hold donezepil and memantine for now
Medications on Admission:
-DONEPEZIL 10 mg by mouth once a day with food
-LEVOTHYROXINE 88 mcg by mouth once a day
-MEMANTINE 10 mg by mouth twice a day
-FERROUS SULFATE 325 mg by mouth once a day
-MULTIVITAMIN,TX-MINERALS 1 Capsule(s) by mouth daily
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
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12542, 12551
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286, 315
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12602, 12611
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3262, 7331
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12572, 12581
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12292, 12519
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12635, 12644
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2734, 3243
|
225, 248
|
343, 2282
|
2304, 2421
|
2437, 2580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,474
| 161,783
|
6911
|
Discharge summary
|
report
|
Admission Date: [**2132-1-27**] Discharge Date: [**2132-3-13**]
Date of Birth: [**2063-7-29**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
found down, hypotension, hypothermia, lactic and ETOH/starvation
ketoacidosis acidosis, acute renal failure, elevated
transaminases, LDH and T.bili and macrocytic anemia, SBP
Major Surgical or Invasive Procedure:
[**2132-2-24**]: ex lap, sigmoid colectomy & end colostomy for abscess
and sigmoid diverticulitis.
Right internal jugular central line placement [**2132-1-27**]
Thoracentesis [**2132-1-28**]
Paracentesis [**2132-2-4**]
History of Present Illness:
68 year old male with no known prior medical care who was found
on the floor covered in feces, with bottle of vodka and
cigarettes scattered around him. Fell at 2:30 AM. Per EMS last
drink was at 3AM. Called 911 this morning. EMS noted that his
floor was covered in diarrhea. A section 12 was placed by EMS
which was subsequently lifted when he was found to be calm and
cooperative on arrival to the ED.
.
On admission he denies any trauma but states that he may have
fallen. He states he has not eaten in the past eight days noting
that he just didn't feel like eating. Has been drinking fluids
and vodka. No specific nausea, vomiting or abdominal pain. He
thinks he has lost a lot of weight from not eating although he
is not sure since he hasn't weighed himself. Across the past 8
days he has felt quite fatigued but he credits this to not
eating as well.
.
He denies chest pain, shortness of breath, abdominal pain,
nausea or vomiting. He states that he feels very weak and was
unable to walk this morning due to this but he denies any
specific lightheadedness or dizziness. Denies black or bloody
stools. He states he has never seen a doctor and is unaware of
any medical problems.
.
In the ED inital vitals were temp 95.9, hr 104, bp 103/71, rr
20, 99% on room air. A bear hugger was started due to
hypothermia. He was started on vanc/zosyn due to concern for
sepsis in the setting of hypothermia and a lactate of 12. Also
started on stress dose steroids as well as thiamine, folic acid,
calcium and magnesium. Guaic negative.
.
He was briefly hypotensive to SBPs of 60s-70s which was
confirmed manually. A right IJ line was placed. Started on
stress dose steroids. Received 2 units of packed RBCs and 3L of
NS. His lactate trended from 11.9 to 5.6. He did not require any
pressors. He has remained normotensive since. AOx3. Being
admitted to ICU for episode of hypotension and elevated lactate.
.
On arrival to the ICU he appeared comfortable and had no
specific complaints. He said that he wanted to go home and go to
sleep. He explained that his neighbor (the one who brings him
the vodka) had found him and called 911 because he was on the
floor and felt weak. He does not specifically remember falling
last night but thinks his last drink was about 2AM. Reports
loose stools for last few weeks with 3-4 bowel movements per
day. He denies any other recent symptoms.
.
He said that he has not left his house for the last month. He
mostly watches TV in his bedroom and walks between the bedroom
and the bathroom. He said that the kitchen is too far away so he
tries not to walk there unless he has to.
.
Review of OMR shows that he was seen in the ED almost a year ago
for a fall also in the setting of EtOH. Also of note he has lost
a significant amount of weight as compared to his driver's
license.
Past Medical History:
Unknown- patient does not see doctors
During admission:
Depression
ETOH Abuse
cirrhosis, SBP
Social History:
Never married, no children. Lives home alone. Neighbor who
supplies vodka and does his shopping. Sister lives in [**Name (NI) 13040**],
she notes he's had pretty significant personality change in the
last many (~8) months. Stays home most of the time and does not
walk much due to foot pain.
- Tobacco: 1 PPD since [**2080**]
- Alcohol: <1 quart daily, mostly vodka, which he has a neighbor
bring to him
- [**Name (NI) 3264**]: denies
Family History:
Mother and father both died of old age. No known family history
of DM, early CAD, or liver disease.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.9 BP:117/72 HR:104 RR:20 O2: 98%/2L
General: Dishevled, comfortable and cooperative with exam
HEENT: Icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diminished breath sounds bilaterally but otherwise clear,
no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Long toe nails.
Skin: mild jaundice
Neuro: CN2-12 intact, strength and sensation intact across upper
and lower extremities, no asterixes
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
136 / 87 / 31
------------------< 146
4.3 / 21 / 1.4
7.9
8.1 >------< 60
22.9
Ca: 7.3
Mg: 1.4
Ph: 3.3
iCa: 0.76
Osmolal: 292
ALT 19 AST 58 AlkP 100
CK 122 TBili 3.9
Lipase: 46
ABG [**1-27**] 11am 7.55/29/116/26
Lactate 11.9 -> 8.5 -> 5.6
UA: RBC 4 WBC 21 Epi few 76 hyaline casts
Tox Screen: negative for ASA Ethanol Acetmnp Bnzodzp Barbitr
Tricycl
Micro:
Urine culture [**2132-1-27**]: negative
Urine culture [**2132-1-28**]: negative
Urine Culture [**2132-2-3**]: negative
Blood culture x 2 [**2132-1-27**]: negative
Stool culture [**2132-1-28**]: C.difficile toxin A&B negative
Pleural fluid [**2132-1-28**]:
Protein: 0.8 Glucose: 142 LD(LDH): 58 Albumin: <1.0
WBC: 14 RBC: 41 Poly: 19 Lymph: 12 Mono: 0 Macro:
69
GRAM STAIN (Final [**2132-1-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
CULTURE: negative
[**2132-2-4**] 5:24 pm PERITONEAL FLUID
GRAM STAIN (Final [**2132-2-4**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2132-2-5**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2132-2-4**] ascites culture No Growth
[**2132-2-4**] stool cultures: No Growth (salmonella, shigella,
campylobacter, yersinia, giardia, O&P, vibrio, cryptosporidium)
[**2132-2-22**] ascites culture no growth
Paracentesis results:
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Macroph
[**2132-2-4**] 433* 22* 96* 0 0 4*
ASCITES TotPro Glucose LD(LDH) Amylase Albumin Cholest Triglyc
0.6 115 152 32 <1.0 15 217
[**2132-2-19**] 04:38PM ASCITES WBC-520* RBC-150* Polys-86* Lymphs-9*
Monos-5*
[**2132-2-19**] 05:01PM OTHER BODY FLUID TotProt-1.9 LD(LDH)-66
Albumin-1.4
[**2132-2-22**] 05:03PM ASCITES WBC-465* RBC-960* Polys-66* Lymphs-18*
Monos-0 Mesothe-3* Macroph-12* Other-1*
[**2132-2-22**] 05:03PM ASCITES Glucose-116 LD(LDH)-79 Albumin-1.6
Images:
[**2132-1-27**] EKG: sinus tach at 100, left axis deviation, right
bundle branch block, inferior Q waves, no prior
CXR [**2132-1-27**]: 1. Concern for small left-sided hydropneumothorax
of uncertain etiology. 2. 13 mm right lower lobe pulmonary
nodule. Differential includes nipple shadow, osseous lesion, or
pulmonary parenchymal nodule. Followup radiographs with oblique
projections and nipple markers could be considered.
Alternatively, CT of the chest could also be performed for
further characterization of the left-sided pleural process and
the right lower lobe nodule. 3. No confluent consolidation or
pulmonary edema.
CXR [**2132-1-28**]: Mild pulmonary edema is new. Opacification of the
base of the left lung, accompanied by elevation of the left
hemidiaphragm is substantially atelectasis, now accompanied by
small pleural effusion. Followup advised to exclude developing
pneumonia in this location from presumed aspiration. Heart size
is normal. No pneumothorax. Right jugular line ends in the SVC.
Abdominal ultrasound [**2132-1-28**]: The liver is diffusely echogenic
and difficult to penetrate. There is a moderate amount of
abdominal ascites. Hepatopetal flow is seen within the main
portal vein. The common bile duct is normal in caliber at 3 mm.
The pancreas is not well visualized due to overlying structures.
The gallbladder is not well demonstrated on this study, no
gallstones are seen. The right kidney measures 9.9 cm. There is
a prominent calix in the mid pole, though there is no frank
hydronephrosis, nor mass nor stones. The left kidney measures
10.1 cm, and is normal in appearance without masses,
hydronephrosis, or stones. The bladder contains a Foley catheter
and is collapsed. There is a moderate left pleural effusion. The
spleen is normal in size and measures 7 cm in the craniocaudal
dimension. IMPRESSION: 1. Limited study, demonstrating an
echogenic liver consistent with fatty liver. Other forms of
liver disease and more serious liver disease such as hepatic
cirrhosis/fibrosis are not excluded. There is moderate abdominal
ascites. 2. Normal-appearing kidneys bilaterally, without
hydronephrosis. The bladder contains a Foley catheter and is
collapsed.
CXR: [**1-29**]: Compared to the previous radiograph, there is mild
increase in extent of bilateral pleural effusions. As a
consequence, the retrocardiac atelectasis has also increased.
Subtle signs indicative of mild fluid overload. No evidence of
pneumonia. Unchanged right internal jugular vein catheter.
[**2132-1-30**] ECHO: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The aortic valve is
not well seen. There is no aortic valve stenosis. The mitral
valve leaflets are not well seen. The pulmonary artery systolic
pressure could not be determined.
IMPRESSION: Image quality is extremely suboptimal, making
assessment of ventricular and valvular function very difficult.
Left and right ventricular systolic function are probably
normal, a focal wall motion abnormality cannot be excluded.
[**2132-2-2**] CXR: Left pleural effusion appears to be unchanged
associated with small amount of right pleural effusion. Left
retrocardiac opacity most likely reflects atelectasis but
infectious process cannot be excluded as well as aspiration. The
rest of the lungs are clear. Heart size and mediastinal
silhouette are stable.
[**2132-2-4**] Renal US: The right and left kidneys measure 9.5 and
10.1 cm respectively. No hydronephrosis, stones, or renal
masses are seen. The urinary bladder is collapsed around a Foley
catheter. The urinary bladder likely has a small amount of
debris. Moderate amount of ascites is seen throughout the
abdomen. IMPRESSION: Normal kidneys, without evidence of
hydronephrosis.
CXR ([**2-20**]):
FINDINGS: As compared to the previous radiograph, the
pre-existing left pleural effusion has slightly increased in
extent. The effusion occupies approximately half of the left
hemithorax. There are relatively extensive areas of subsequent
atelectasis. The left-sided aspect of the cardiac silhouette can
no longer be visualized. On the right, there is an unchanged
area of atelectasis but no evidence of pleural effusion or
pneumonia.
CXR ([**2-22**]):
IMPRESSION: An AP chest compared to [**2132-2-10**] through
[**2132-2-20**]:
Left lower lobe collapse has improved. Moderate bilateral
pleural effusion is present, stable on the left, increased on
the right and there is a suggestion of new consolidation in the
right lower lobe that could be a large pneumonia. Confirmation
with conventional radiographs recommended when feasible.
CT Abdomen and Pelvis ([**2-23**]):
Within the pelvis, adjacent to the sigmoid colon, there are
locules of free air decreased in extent compared to the prior
study (2:65). It is difficult to ascertain the size of an
associated abscess given lack of IV contrast and adjacent
ascites, but it has likely decreased in size and the most
distinct component measures 3.4 x 1.6 cm (2:65) versus 4.5 x 1.6
cm previously. Note is made of an apparent rectal catheter.
There are bilateral fat containing uncomplicated inguinal
hernias.
IMPRESSION:
1. Decreased locules of air adjacent to the sigmoid colon with
associated small fluid collection which has mildly decreased in
size (although this is difficult to quantify given larges
ascites and lack of IV contrast) suggests abscess. Given the
presence of adjacent sigmoid diverticulosis, the possibility of
a contained diverticular perforation should be considered.
2. Mild increase in large volume ascites.
3. Unchanged small to moderate bilateral pleural effusions.
4. Tiny non-obstructing left lower pole renal calculus.
5. Moderate hiatal hernia, as before.
Brief Hospital Course:
68 year old man with ETOH abuse initially with hypotension and
hypothermia, now with resolved lactic and ETOH/starvation
ketoacidosis acidosis, found to have SBP with [**Last Name (un) **].
Medical Service Course:
# Hypotension with Concern for Sepsis: Patient briefly
hypotensive in ER and admitted to ICU, however resolved with
fluids. In setting of hypothermia, leukocytosis and elevated
lactate, concern was originally for sepsis, source initially
unclear. [**Name2 (NI) **] was treated broadly with vancomycin and zosyn,
which was narrowed to azithromycin and ceftriaxone to treat
possible community acquired pneumonia and/or urinary tract
infection (urine cultures negative). In addition, hypotension
may have been due to hypovolemia in the setting of poor oral
intake over a prolonged period. Lactate trended down with fluid
resuscitation. Pleural fluid was transudative. On transfer to
the floor, patient had paracentesis which showed impressive SBP.
Patient was given a course of ceftriaxone for 7 days. All
culture data has been negative, however much was drawn after
antibiotic administration. Throughout admission, systolic blood
pressure remained in the low 100s= high 90s. His blood pressure
remained stable until [**2132-2-17**] when he dropped to 78/doppler
overnight repeat Hct showed drop to 23 and then 6 hours later
dropped to 20.6. He had black melenic stool. One unit of pRBC
was ordered and he was sent to the unit for endoscopy.
Endoscopy showed showed blood and gastritis, no active bleeding
and no varices or ulcers. Repeat EGD [**2-20**] showed friable mucosa
in esophagus, but no blood. His blood pressures and hct remained
stable and he was transferred out of the MICU. Once on the
floor he had no recurrence of hypotension.
While in SICU, was persistently hypotensive. Unable to wean neo,
and was only withdrawn after pt's HCP made decision to make pt
[**Name (NI) 3225**].
.
# GI Bleed: His Hct was stable for most of the course of his
stay, but on [**2132-2-17**] he became relatively hypotensive and labs
revealed a rpt hct drop. There was concern for GI bleed and
plan was for endoscopy in the ICU. patient was transferred to
the unit and endoscopy showed showed blood and gastritis, no
active bleeding and no varices or ulcers. Repeat EGD [**2-20**] showed
friable mucosa in esophagus, but no blood. Hct and BP remained
stable and he was transferred out of the ICU after 3 days.
Once on the floor he showed no further hypotension or GI
bleeding.
.
# Oliguric [**Last Name (un) **]: Creatinine on admission 1.4 vs 0.8 one year ago,
improved with fluids. ATN likely initial cause, given muddy
brown casts in urine. Remained oliguric across ICU stay despite
aggressive volume resuscitation of ~10L. Abdominal ultrasound
showed no hydronephrosis or evidence of obstruction. Patient
developed edema shortly after transfer to the medicine floor,
given albumin trial, with minimal urine output. One dose of
lasix 20mg IV with good urine output but acutely worsened Cr to
1.5. Albumin was continued and renal and hepatology were
consulted for concern for HRS. Urine sediment continued to show
muddy brown casts, likely from resolving ATN. FeNa was < 1%.
Repeat US showed no hydronehprosis. Albumin was continued and
creatinine improved and stiabilized at 1.3. He was believed to
have acutely worsened creatinine [**3-20**] to cirrhosis and SBP
infection. He remained oliguric and continued to be challenged
with fluid and albumin. His creatinine settled out around 1.3
until [**2132-2-18**] when it rose to 1.5 in the setting of GI bleed.
His urine output also dropped off and he became anuric. Cr rose
to 3.9 by [**2-22**] with anuria, thought to be due to ATN.
Pt's kidney function did not improve. Remain anuric, and
required CVVH, which was withdrawn when pt made [**Month/Day (4) 3225**].
# SBP: Patient was diagnosed with SBP on [**2132-2-4**]. He had
already been on empiric treatment with ceftriaxone for 2 days.
He completed a 7 day course. Rpt para on [**2132-2-14**] showed
bacterial peritonitis. There was concern for secondary
bacterial peritonitis. Work up for secondary bacterial
peritonitis was negative, but started treatment with ceftazidine
on [**2132-2-14**] and flagyl on [**2132-2-15**]. Repeat paracentensis on [**2-19**]
continued to show leukocytosis with negative cultures,
vancomycin was added [**2-19**]. The patient remained febrile despite
this therapy. Paracentesis [**2-22**] showed continued leukocytosis of
the ascitic fluid, raising concern for an alternative source of
abdominal infection. Concern for abscess, perforation, or
collection led to CT abdomen on [**2-23**] despite worsening renal
function and ATN. This study showed the presence of a
rectovesciular abscess. This likely explained the persistent
leukoyctosis of the ascitic fluid. Antibiotics were continued.
Abx was discontinued when pt made [**Month/Day (4) 3225**].
.
# Abscess: CT performed [**2-23**] revealed the presence of a
rectovesicular abscess, likely a previously perforated
diverticula. The position of this abscess was such that IR
drainage was unlikely. Surgery was consulted for possible open
drainage. Vancomycin, Flagyl, and ceftazadime were continued.
Abx was discontinued when pt made [**Month/Day (4) 3225**].
.
# Altered mental status/Delerium: Patient waxed and waned during
his hospital course (A&Ox1-3). His delerium was likely the
result of a combination of influences: ICU time, infection
(SBP), baseline depression and ETOH abuse, [**Last Name (un) **], age, new
environment. SBP was treated and other infectious work up was
negative. Psychiatry was consulted and did not feel the patient
had capacity. On cognitive testing he has difficulty with
abstract thinking, some word finding, concentration, and memory.
He denies audio or visual hallucinations, says he is thinking
clearly. He seemed to be slowly improving and plan was to have
psych re-eval on [**2132-2-19**], however his worsening health delayed
this evaluation. Per his sister, he was independent and
functional in all ADLs prior to admission.
.
# Thrombocytopenia: Likely due to ETOH related BM toxicity. Also
has evidence of impaired hepatic synthetic dysfunction from
possible cirrhosis/NASH, could have splenic sequestration as
well. Given SC heparin as platelets were not <50.
With associated renal dysfunction and anemia initial concern for
TTP however hemolysis labs negative and no schistocytes on
smear. Platelets monitored and remained stable.
.
# Pleural effusion: Patient with left-sided pleural effusion
seen on CXR. Could be [**3-20**] cirrhosis. Given L-sided effusion,
and history of weight loss, concern for malignant effusion.
Diagnostic thoracentesis performed, and drained 660cc of serous
fluid, consistent with transudate. No malignant cells were seen
on cytology.
.
# PNA: The patient required oxygen support following EGD on
[**2-19**], although he was able to return to room air. CXR [**2-22**] showed
increased effusion and possible RLL PNA. He was already on
treated with antibiotics for SBP/abscess (see above), so no
additional treatment was provided. He continued to be
comfortable on room air despite clinical signs of consolidation
and effusion.
Abx was discontinued when pt made [**Month/Day (4) 3225**].
.
# Anemia, Macrocytic (MCV 100s-120s): Likely nutritional
deficiency [**3-20**] EtOH. Patient was transfused 2U PRBC in the ER
with good response. Hemolysis labs were negative and no
schistocytes were visualized on smear. Patient was given
thiamine and folate. B12 and folate level were both normal, but
patient was continued on thiamine and folate supplementation.
Stool guaiac was negative x 3 (multiple times over course of
admission). On [**2132-2-18**] had another hct drop and stool grossly
guaiac positive. See above for GI bleed.
.
# Transaminitis with bilirubinemia: Stable, likely secondary to
underlying ETOH liver injury (at least fatty liver, but may have
cirrhosis given elevated INR and low albumin as well) previously
worsened by hypotension and hypovolemia. Direct bilirubin
elevated in comparison to indirect bilirubin, suggesting hepatic
etiology, likely related to cirrhosis. Concern was high for
portal hypertension given patient's long term alcoholism. RUQ
ultrasound revealed evidence of fatty liver, could not rule out
more extensive liver disease, including cirrhosis. Ascites and
SBP also present, suggesting higher likelihood of cirrhosis/etoh
hepatitis. Bilirubin acutely worsened off antibiotic treatment,
however returned back to normal with treatment for SBP. His
nutritional status led to consideration of placing a feeding
tube, however given the EGD results that showed friable mucosa
in the esophagus and stomach, this was deferred to avoid future
GIB.
.
# Acidosis, Anion Gap: Likely combination of lactic acidosis
(lactate 11.9), starvation and alcoholic ketoacidosis. Lactate
trended down and returned to [**Location 213**] by HD 1 with fluid
resuscitation, with resolution of anion gap acidosis. Also had
mild respiratory alkalosis on admission which was trending down
on repeat ABG in the ICU.
.
# EtOH: As above, patient was given thiamine and folate. He was
monitored on a CIWA scale with prn valium however he was not
[**Doctor Last Name **] so this was discontinued. He has no known history of
withdrawal seizures or DTs. Social work, PT, OT, and psychiatry
were consulted and did not feel the patient had capacity to make
his own decisions. Additionally, they did not feel he was
capable of independent living.
.
# Depression: Patient denies feeling depressed, however his
sister states that he has had a significant personality change
in the last 8 months or so. She believes he is drinking much
more heavily and is very concerned for depression as the patient
is drinking heavily, sleeping a lot, not eating well, and not
leaving his house. Additionally, he was found in squalor, with
feces all over his home. Psychiatry was consulted and does not
feel he has capacity to make decisions. B12 normal, Folate
normal, TSH WNL. RPR negative. Psych requested CT to document
atrophy, but patient has refused study. Had CT in [**2-27**] showed
mild bihemispheric white matter hypoattenuation predominantly in
the occipital lobes, likely representing sequelae of small
vessel ischemic disease. Psychiatry, PT, OT, and social work do
not feel he is capable of independent living. Treatment of
depression was deferred during treatment for SBP, as there was
some thought that this could all be related to his infection.
.
# Diarrhea: Patient has persistent diarrhea, which he admits to
having even at home for quite a while. C.diff negative but could
have viral gastroenteritis or other community acquired bacterial
infection. However, timeline does not suggest an acute
infection. He states he has had diarrhea chronically. Stools are
formed but loose, now with blood streaks around the outside of
the stool, consistent with hemorhoids. Hct stable. Guaiac
negative, stool studies negative. Patient was kept hydrated when
possible and given loperamide for symptomati relief. Outpatient
PCP can consider work up for celiac disease or other causes of
chronic diarrhea. IBD is low on the differential. No clear
etiology was found, but his diarrhea self resolved.
.
Surgical Service Course:
CT scan performed [**2132-2-23**] demonstrated sigmoid diverticulosis as
well as an abscess adjacent to the sigmoid colon in the pelvis.
Due to his persistent elevated
cell count in his peritoneal fluid, his renal failure, and his
overall clinical decline surgical consultation was requested for
potential sigmoid colectomy. Risks and benefits of sigmoid
colectomy, end colostomy and Hartmann procedure were discussed
with the patient's sister who gave her consent to proceed. Pt
underwent operation on [**2132-2-24**], and was then transferred to SICU.
Was maintained on abx, CVVH, and pressors. Was unable to wean
pressors, no return of renal function, poor mental status, and
clinical status continued to decline. On [**2132-2-28**] family
meeting to discuss goals of care, sister made decision to pursue
comfort measures. Stopped all interventions including abx,
pressors, CVVH. Maintained pt on morphine and versed for
comfort. Sister wanted to continue ventilator support as well as
IVF. Sister continued to request pt remain on vent. Readdressed
goals of care with sister on [**2132-3-11**]. was extubated [**2132-3-11**],
transferred to floor [**2132-3-12**]. On floor maintained on morphine
gtt for comfort with intermittent ativan. Morning of [**2132-3-12**] at
8:40 AM pt expired. Sister was notified by Dr. [**Last Name (STitle) **]. Sister
declined post mortem.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Spontaneous Bacterial Peritonitis, Sigmoid diverticulitis, ESLD
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2132-3-13**]
|
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icd9cm
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[
[
[]
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[
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"96.6",
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icd9pcs
|
[
[
[]
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25635, 25644
|
12835, 25551
|
478, 700
|
25752, 25762
|
4992, 4992
|
25814, 25849
|
4124, 4225
|
25606, 25612
|
25665, 25731
|
25577, 25583
|
25786, 25791
|
4265, 4947
|
264, 440
|
728, 3539
|
5008, 6107
|
6189, 12812
|
3561, 3656
|
3672, 4108
|
6139, 6153
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4973, 4973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,301
| 123,486
|
20324+57141
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-2-25**] Discharge Date: [**2190-3-2**]
Date of Birth: [**2124-12-25**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
female with a history of sacral osteomyelitis, urosepsis, and
cerebrovascular accident, transferred from [**Hospital3 537**] with
unresponsiveness and blood pressure at 80/60.
The patient has multiple recent admissions to [**Hospital6 14430**] from [**1-26**] to [**2-5**] with MSSA, urosepsis,
NSTEMI, delirium, stage IV sacral ulcers, and from [**2-7**] to [**2-22**], with fever diagnosed with sacral
osteomyelitis.
Blood cultures, urine cultures, and sacral swabs were
negative on admission, but a bone scan was consistent with
sacral osteomyelitis.
The patient also had evidence of delirium with that admission
felt secondary to dementia, infection, and hypovolemia, in
the setting of acute renal failure and hypernatremia. The
patient also had anemia requiring 1 U packed red blood cells,
but the family had declined GI work-up.
The nurses at [**Hospital3 537**] reported that since admission
there, the patient had been lethargic, not oriented but
alert. She had increasing lethargy on the morning of
presentation and became unresponsive, and so she was
transferred to [**Hospital6 256**].
In the Emergency Room, the patient's blood pressure was as
low as 68/38. She was received 2 L intravenous fluids with
some blood pressure response to systolic in the 90s; however,
the patient in Emergency Room remained unresponsive.
The patient's family reported at baseline she is aphasic but
alert and can eat. They said at presentation, the patient
had similar characteristics to her presentation two weeks
prior at [**Hospital6 256**].
PAST MEDICAL HISTORY: 1. Cerebrovascular accident, left
MCA, tight left ICA residual global aphasia, right
hemiparesis, 2. Insulin-dependent diabetes mellitus. 3.
MSSA urosepsis. 4. Sacral osteomyelitis, stage IV. 5.
Gastroesophageal reflux disease. 6. Hyperkalemia secondary
to ACE inhibitor. 7. History of delirium. 8. Renal
insufficiency. 9. Dementia. 10. Osteomyelitis of the
sacrum. 11. Hypertension. 12. Myocardial infarction times
two. 13. Total abdominal hysterectomy. 14. History of
C-diff. 15. Iron deficiency anemia. 16. Seizures
secondary to cerebrovascular accident in [**2183**]. 17. History
of PEG tube in [**2183**], now removed. 18. Hypercholesterolemia.
19. History of increased T4.
ALLERGIES: ACE INHIBITOR, TAPAZOLE CAUSES NEUTROPENIA.
MEDICATIONS ON ADMISSION: Colace, Lovenox in transition to
Coumadin, Levofloxacin 250, q.d. regular Insulin sliding
scale, Multivitamin, Zinc 220 q.d., Zantac 150 q.d., Iron 325
q.d., Baclofen 15 b.i.d., Metformin 500 b.i.d., Lopid 600
b.i.d., Vitamin C 500 b.i.d., Tylenol #3 with dressing
changes, Propanolol 20 q.i.d., Isordil 5 t.i.d., Vancomycin 1
g q.24, Flagyl 500 t.i.d., Lactulose p.r.n., Dulcolax p.r.n.
SOCIAL HISTORY: The patient is from [**Hospital3 537**]. She is
dependent on all activities of daily living. Her healthcare
proxy is her daughter [**Name (NI) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 54528**].
PHYSICAL EXAMINATION: Vital signs: Temperature 99.8??????, blood
pressure 68/58, increased to 99/41, pulse 70, respirations
12, oxygen saturation 100% on room air. General: The
patient was unresponsive to voice, sternal rub, or painful
stimuli. HEENT: Pupils were pinpoint. Dry mucous
membranes. Cardiovascular: Regular, rate and rhythm. S1
and S2. No murmurs, rubs, or gallops. Lungs: Rhonchorous
at the right base, otherwise clear. Back: Exam showed deep
sacral decubitus ulcer with granulation tissue. No
surrounding erythema or drainage. Abdomen: Good bowel
sounds. Soft, nondistended, no masses. Extremities:
Bilateral contractures. Warm and well perfused. Right heel
with a stage I decubitus ulcer. Rectum: Exam was guaiac
negative per the Emergency Room.
LABORATORY DATA: White count 10.1, hematocrit 31.6; sodium
142, potassium 4.9, bicarb 16, BUN 33, creatinine 1.4,
lactate 2.2; urinalysis positive for nitrites, small amount
of leukocytes, 6-10 WBCs.
Electrocardiogram revealed sinus rhythm [**Company 36597**]-wave
inversions in V1-V3, V4 with biphasic T-wave.
Head CT showed a large chronic left MCA infarct.
Chest x-ray was with some right hilar fullness but no
evidence of congestive heart failure.
HOSPITAL COURSE: 1. Infectious disease: The patient was
with sepsis physiology on admission. Her blood pressure
improved with aggressive hydration and remained stable
throughout her hospitalization.
The most likely source of the sepsis was a urinary tract
infection, but also the possibility was raised for infection
due to her sacral osteomyelitis.
The patient's blood cultures remained negative at this
hospitalization. Her urine culture was consistent with
contamination. The patient's Foley was changed on admission.
The patient was treated empirically with Zosyn, and the
patient remained afebrile, and blood pressure was stable
throughout hospitalization.
Given her recent history of antibiotic use, the patient was
checked for C-diff; however, these were negative as well.
Per prior records from [**Hospital1 2177**], the patient had no positive wound
cultures at that hospital. She had negative C-diff dating
back to [**2-2**]. The only cultures that were positive at
that hospital were from [**1-26**] which were two blood
cultures and one urine culture, positive for methicillin
sensitive Staphylococcus aureus.
The patient had been discharged on broad coverage of
Levofloxacin, Vancomycin, and Flagyl for urosepsis and
possible sacral osteomyelitis, and very broad coverage,
although the only culture that they had obtained which was
positive was for MSSA.
Their plan had been to treat for six weeks with eventual
switch to Nafcillin during that course.
The plan will be to continue the patient's antibiotics for an
additional ten days, to finish a six-week course.
2. Acute mental status changes: The patient had a negative
head CT on admission revealing no evidence of acute bleed.
As the patient's infection was treated, she improved.
The patient was responsive to voice and commands and was
interactive with caregivers at the time of discharge.
Given her history of large embolic stroke, the patient was
continued on her Coumadin goal INR of 2.5.
3. Sacral decubitus and osteomyelitis: Plastic Surgery was
consulted for the patient's wounds. They recommended
wet-to-dry dressing changes b.i.d. with frequent bed turns.
They also guided the antibiotic use during this admission.
4. Coronary artery disease: The patient is with a recent
history of non-ST elevation myocardial infarction. She was
continued on an Aspirin and restarted on her beta-blocker as
her blood pressure allowed. The patient's hematocrit was
kept greater than 30 which required one blood transfusion
during this admission, as her hematocrit fell with aggressive
hydration. After this, the patient's hematocrit remained
stable.
5. Hypertension: The patient was restarted on her
beta-blocker, as her sepsis physiology resolved. The patient
may be restarted on Isordil at a later time should her blood
pressure require it.
6. Diabetes: The patient was continued on a regular Insulin
sliding scale. The patient was not restarted on her
Metformin, as her blood sugars remained in good control
without further intervention.
As an outpatient, the patient may be restarted on a
medication such as Glyburide to treat her diabetes.
Metformin may want to be avoided due to the potential for
lactic acidosis.
7. Iron deficiency anemia: The patient was restarted on
iron replacement, and so she began to take p.o.'s.
8. FEN: The patient underwent a speech and swallow exam
which she passed. They recommended soft solids and thin
liquids. The patient was able to take her p.o. pills without
difficulty.
9. Code status: The patient is DNR/DNI. Per family
discussion, this includes no pressors, no shocks, no CPR, and
no intubation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To long-term facility, [**Hospital3 537**].
DISCHARGE DIAGNOSIS:
1. Urosepsis.
2. Sacral decubitus.
3. Hypertension.
4. Delta MS.
5. Coronary artery disease status post recent myocardial
infarction.
6. Anemia.
7. Diabetes.
DISCHARGE MEDICATIONS: Colace 100 mg b.i.d., Coumadin 2.5
q.h.s. to be adjusted for goal INR of 2.5, regular Insulin
sliding scale, Multivitamin, Zinc 220 q.d., Zantac 150 q.d.,
Iron supplements, Baclofen 15 t.i.d., Lopid 600 b.i.d.,
Vitamin C 500 b.i.d., Propanolol 20 t.i.d., Lactulose p.r.n.,
Dulcolax p.r.n., Nafcillin for 10 additional days.
FOLLOW-UP: The patient will follow-up with the physicians at
[**Hospital3 537**] or with her primary care physician as needed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 12502**]
MEDQUIST36
D: [**2190-3-1**] 19:00
T: [**2190-3-1**] 19:07
JOB#: [**Job Number 54529**]
Name: [**Known lastname 2601**], [**Known firstname **] Unit No: [**Numeric Identifier 10158**]
Admission Date: [**2190-2-25**] Discharge Date: [**2190-3-2**]
Date of Birth: [**2116-12-25**] Sex: F
Service:
ADDENDUM TO DISCHARGE SUMMARY: The patient remained stable
throughout her remaining hospital course. The course of
antibiotics was reevaluated. Given the patient's positive
blood cultures on [**1-26**] at [**Hospital6 592**] with
MSSA the following set of negative blood cultures was on
[**2190-2-7**]. The six week course of antibiotics should
be dated from most recent negative blood culture following
positive blood culture. Given this the patient's six week
course will begin on [**2190-2-7**] and is scheduled to
end [**2190-3-21**]. The patient had a transesophageal
echocardiogram at [**Hospital1 4418**], which was negative for endocarditis,
however, she will receive a full six week treatment given her
evidence of osteomyelitis. The patient was continued on
Zosyn at the time of this discharge scheduled to end [**2190-3-21**] as she has been doing well on this antibiotic. It
will treat the MSSA.
In addition to this the patient was again seen by [**Hospital 6655**]
Clinic and they will follow up with her in one months time on
[**Hospital 3032**] clinic. The patient is stable for transfer to [**Hospital3 10159**] where she will have her INR followed, blood sugars
followed and be followed clinically.
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Name8 (MD) 2450**]
MEDQUIST36
D: [**2190-3-2**] 11:04
T: [**2190-3-2**] 11:11
JOB#: [**Job Number 10160**]
|
[
"730.28",
"584.9",
"276.0",
"995.91",
"285.9",
"599.0",
"707.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8404, 10853
|
8214, 8380
|
2576, 2965
|
4458, 8095
|
3219, 4440
|
179, 1756
|
1779, 2549
|
2982, 3196
|
8120, 8193
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,317
| 194,396
|
3113+55443
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-11-6**] Discharge Date: [**2139-1-2**]
Date of Birth: [**2060-10-15**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfonamides
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Low hematocrit
Major Surgical or Invasive Procedure:
Total hip replacement (right-sided)
Bronchoscopy
Thyroid aspirate biopsy
Bone marrow biopsy
History of Present Illness:
HPI: 78 yo F with sideroblastic anemia, sickle trait, G6PD
deficiency, h/o bilateral PEs presents from home after bloodwork
showed Hct 16. Covering PCP called patient and requested she
come to the ED which she was at first reluctant to do as she
felt okay. Last Hct was 24.9 in [**8-20**]. She denies any
hematuria, hematochezia, hematemesis, or melena. She states
that she has been off coumadin since her last admission in
[**Month (only) 462**]; it was supposed to be restarted but the prescription
had not been filled yet. She denies any tea-colored urine. She
did have a recent UTI that was treated with an unknown
antibiotic. She used to be on procrit shots but has not had one
since approx [**Month (only) 205**]. She states that she was discharged from the
[**Hospital1 **] approx 1 month ago and received 2 U pRBCs.
.
Ms [**Known lastname **] currently states that she feels fairly well other than
a recent dry "tickly" cough. She denies any fevers, chills,
nausea, post-tussive vomiting. She does endorse some fatigue
but denies light headedness, shortness of breath, chest pain. .
With regards to her TB history, she was dx with TB on her last
admission to the MICU in [**Month (only) 462**]. She has been receiving
multi-drug therapy and a special "TB nurse" has been coming to
give her her meds at home each day, including a medicine that
makes her urine "pink." She denies fevers, chills, night
sweats. She endorses a recent cough. CXR in the ED is
essentially negative.
Past Medical History:
1. Refractory anemia with ringed sideroblasts dx by BMB in '[**33**].
Baseline Hct 23 to 27.
2. Rheumatoid arthritis on Methotrexate and Remicaide infusions.
3. Left shoulder mass - ganglion vs. cyst by MRI report in [**2134**].
4. Low back pain.
5. Glucose 6-phosphate deficiency.
6. Sickle cell trait by Hgb Electrophoresis.
7. Recurrent otitis media.
8. Recurrent genital rash.
9. Allergic rhinitis.
10. Supraventricular tachycardia, likely atrial per cardiology
11. Bilateral PE, dx'd [**2135-8-15**] for w/u for pulmonary
HTN.
12. Tuberculosis in the setting of methotrexate and remicaid
treatment for RA. Diagnosed in [**7-20**]. Treated with DOT for
four months.
13. History of HSV 2 skin R thigh
14. Hepatitis B core Ab and surface Ab positive, surface Ag
negative in [**2121**]'s
Social History:
Originally from [**Location (un) 4708**]. Lives with her 13 year old
grandson. [**Name (NI) 6934**] with a walker. No smoking, ETOH or other drug
use.
Family History:
Significant for diabetes mellitus in her mother.
Daughter died at age 38 of "tongue cancer."
Physical Exam:
Admission Vitals:
Vitals: 98.1 67 98/48 12 98% on 2L n/c
Gen: well-appearing elderly woman in NAD. Frequently coughing.
HEENT: conjunctiva pale, non-icteric
NEck: flat neck veins; no masses
CV: RRR + II/VI holosystolic murmur heard best at LUSB
Pulm: crackles at L base, otherwise clear
Abd: s/nd/nt, no splenomegally or hepatomegally appreciable
Ext: no clubbing/edema/cyanosis.
.
EKG: NSR, no ST-T changes
Pertinent Results:
[**2138-11-6**] 11:40PM LD(LDH)-207 TOT BILI-1.9* DIR BILI-0.7* INDIR
BIL-1.2
[**2138-11-6**] 11:40PM IRON-125
[**2138-11-6**] 11:40PM calTIBC-124* VIT B12-1459* FOLATE-5.9
HAPTOGLOB-106 FERRITIN-GREATER TH TRF-95*
[**2138-11-6**] 11:40PM RET AUT-1.4
[**2138-11-6**] 11:40PM HCT-22.7*#
[**2138-11-6**] 05:25PM GLUCOSE-98 UREA N-12 CREAT-1.0 SODIUM-133
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-13
[**2138-11-6**] 05:25PM estGFR-Using this
[**2138-11-6**] 05:25PM ALT(SGPT)-22 AST(SGOT)-43* ALK PHOS-76 TOT
BILI-1.0
[**2138-11-6**] 05:25PM ALBUMIN-3.1*
[**2138-11-6**] 05:25PM WBC-3.6* RBC-1.81*# HGB-5.6*# HCT-16.0*#
MCV-88 MCH-30.8 MCHC-34.9 RDW-22.9*
[**2138-11-6**] 05:25PM NEUTS-54.8 LYMPHS-31.2 MONOS-6.0 EOS-7.4*
BASOS-0.5
[**2138-11-6**] 05:25PM ANISOCYT-3+ MACROCYT-2+ MICROCYT-1+
[**2138-11-6**] 05:25PM PLT COUNT-282#
[**2138-11-6**] 05:25PM PT-14.6* PTT-36.6* INR(PT)-1.3*
.
CHEST (PORTABLE AP) [**2138-11-6**] 5:39 PM
FINDINGS: AP upright radiograph was reviewed. The right
costophrenic angle is blunted, likely secondary to a small
pleural effusion. There is also likely a small left pleural
effusion. The lungs are otherwise clear. Micronodules previously
described in the right upper lobe are not as well evaluated on
this portable radiograph. The heart and mediastinal contours are
stable. The pulmonary vasculature is normal. Note is made of
mild S-shaped dextrolevoscoliosis.
IMPRESSION: Small bilateral pleural effusions.
.
HIP UNILAT MIN 2 VIEWS RIGHT [**2138-11-9**] 1:54 PM
Relatively stable examination demonstrating superior and lateral
subluxation of the right femoral head stable since at least
[**2138-7-30**]. There is significant sclerosis and cystic areas
of lucency in the subchondral region of the femoral head with
bony remodeling in the form of flattening. No definite depressed
fracture identified. Rapidly progressive osteoarthritis,
inflammatory arthropathy, or neuropathic joint remain diagnostic
considerations.
.
[**2138-11-12**]: Thyroid US
THYROID ULTRASOUND: At the level of the isthmus, the right
thyroid lobe measures 2.0 x 1.5 x 3.6 cm and the left lobe
measures 1.9 x 2.3 x 4.3 cm. Multiple colloid cysts and
spongy-appearing nodules are identified bilaterally. A dominant
nodule with solid cystic components in the mid left thyroid lobe
measures 2.9 x 1.9 x 1.0 cm. Several subcentimeter colloid cysts
are seen within the left lower and right mid thyroid lobes.
There is no cervical lymphadenopathy. The trachea is midline.
IMPRESSION: Multinodular thyroid gland. Dominant nodule in the
left lobe is amenable to ultrasound-guided biopsy
.
[**11-23**]: US of Spleen:
1. 2.2 x 1.6 x 1.7 cm cyst containing an incomplete septation at
the inferior pole of the spleen.
2. Two homogeneously hyperechoic lesions measuring approximately
2 cm, most likely represent hemangioma. However, the presence of
an abscess cannot be excluded. If there is persistent clinical
concern, a follow- up US is recommended.
.
[**2138-12-2**]: ECHO:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Tissue velocity imaging demonstrates an E/e' <8
suggesting a normal left ventricular filling pressure
(PCWP<12mmHg). 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. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is moderate estimated pulmonary
hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No evidence of endocarditis. Mild left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Moderate pulmonary hypertension.
.
[**2138-12-5**]: ECHO
Conclusions:
The interatrial septum is aneurysmal. 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%). Right ventricular chamber size and free wall
motion are normal. There are complex (>4mm, non-mobile) atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. There is no pericardial effusion.
.
[**2138-12-13**]: Chest CT with Contrast:
FINDINGS: The number and extent of the multiple small pulmonary
nodules appear stable. There has been a decrease in the size of
the small right-sided pleural effusion. There remain small areas
of atelectasis at the lung bases. The central airways remain
patent without endobronchial lesions. The pulmonary artery
prominence is stable. The heart and pericardium appear
unremarkable. The thoracic aorta is of normal caliber, with
calcifications seen of the arch.
No pathologically enlarged mediastinal, axillary, or hilar
lymphadenopathy is seen.In the upper abdomen, again noted are
multiple hypodensities within the spleen, unchanged.
OSSEOUS STRUCTURES: There is degenerative change of the spine,
but no concerning lytic or sclerotic lesions are identified.
IMPRESSION:
1. Stable appearance to the multiple small pulmonary nodules.
Decrease in the size of the right small pleural effusion.
2. Stable appearance of the multiple hypodensities within the
spleen.
.
[**2138-12-18**]: CT Abdomen and Pelvis:
CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images
demonstrate small bilateral pleural effusions, which are stable
in comparison with most recent study. The aorta demonstrates
coarse calcification along its wall, without any evidence of
aneurysmal dilatation. No pericardial effusions are seen. The
heart is stable in appearance. Small mediastinal lymph nodes are
noted, which do not meet CT criteria for enlargement.
Lung windows demonstrate multiple tiny nodules bilaterally,
consistent with a miliary distribution. This appears stable in
comparison to prior exam.
CT OF THE ABDOMEN WITH IV CONTRAST: Several hypodensities are
seen within the spleen, which are not well defined. One of these
appears to be a cyst (series 2, image 50). A second of these
appears more wedge-shaped than peripheral, and may reflect an
area of infarction (series 2, image 57). The liver, gallbladder,
adrenal glands, and kidneys are normal in appearance. There are
_____ calcifications noted. There are several small soft tissue
nodules noted within the anterior abdominal wall, likely
reflecting areas of subcutaneous injection. The bowel is normal
in appearance, without any evidence of bowel wall thickening or
dilatation. No fluid or free air is seen. No pathologically
enlarged lymphadenopathy is seen.
CT OF THE PELVIS WITH IV CONTRAST: A calcification is seen
within the uterus consistent with a calcified fibroid. No free
fluid is seen. The bladder and rectum are normal in appearance.
BONE WINDOWS: There is fluid within the right hip joint, and no
evidence of erosive irregularity and loss of joint space and
subarticular cystic change. These findings likely reflect the
patient's known history of rheumatoid arthritis. No other
suspicious lytic or sclerotic lesions are identified.
Specifically, no osseous lesions are identified within the
thoracic or lumbar spine. Degenerative changes seen at L1-L2,
and this _____ _____ anterolisthesis of L4 on L5.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating anatomy and pathology.
IMPRESSION:
1. Persistent appearance of miliary distribution of nodules
within the lungs consistent with known history miliary
tuberculosis.
2. Small bilateral pleural effusions, unchanged from prior exam.
3. Persistent areas of hypodensity within the spleen, which are
unchanged.
4. Right joint effusion and areas of irregularity seen within
the adjacent osseous structures. Findings would be consistent
with the patient's known history of rheumatoid arthritis and
active disease in this location.
.
[**2138-12-24**]: pMIBI:
IMPRESSION: There is a mild reversible perfusion defect
involving the
inferolateral wall towards the base. There is normal left
ventricular wall
motion and cavity size
.
[**2138-12-25**]: Hip Film:
Single AP view of the right hip. The patient is status post
right hip THR, in nominal alignment on this single view. There
is soft tissue swelling, subcutaneous emphysema, surgical
drains, and overlying skin staples, consistent with recent
surgery.
.
BIOPSIES:
R Middle Lobe Biopsy: [**2138-12-10**]
Transbronchial biopsies of right middle and lower lobes:
Bronchial and alveolar tissue with patchy acute and chronic
inflammation including eosinophils focally. No well defined
granulomas are identified. No evidence of malignancy. Special
stains for organisms will be reported in an addendum.
.
ADDENDUM: Special stains for bacteria, fungi and AFB are
negative with appropriate positive controls. This does not
exclude the possibility of infection.
.
HIP Biopsy (Synovium) - PENDING
[**12-11**]: Transfusion Reaction: Negative
Brief Hospital Course:
78 year old female with sideroblastic anemia, G6PD deficiency,
sickle trait, tuberculosis, who presented with hematocrit of 16
discovered on a routine lab check and low systolic blood
pressure to 80. Her hospital course was length and involved
treatment for Tuberculosis, fevers of unknown origin, a total R
hip replacement and the finding of a reversible defect on
pMIBI.
.
# Anemia. The initial concern was for hemolysis given history of
G6PD. However, there was no evidence of hemolysis by laboratory
parameters. Stool guaiac was negative and she was not taking
coumadin. In addition, the patient was completely asymptomatic
with Hct of 16 suggesting slow decrease in her Hct from baseline
around 25 rather than an acute drop. Hct was the only cell line
down from the baseline. Further history revealed that the
patient has not been getting her long-standing Procrit
injections for over a month, since the time she was discharged
from [**Hospital1 **]. The cause of her low Hct was felt to be secondary
to underproduction due to underlying MDS/refractory anemia with
ringed sideroblasts and her h/o not receiving epo. Retic count
was 1.4% (uncorrected). She was initially admitted to ICU and
transfused 3 units of PRBC with appropriate response (Hct
increased from 16 to 29). Her Hct remained stable until [**11-7**]
when she received an additional unit for crit 23.1. Pt continued
with slow HCT trend down during stay. She was transfused on
several occasions w/ goal to keep Hct above 21. She was
restarted on Epogen and continue on folic acid 3 grams per day,
Vit B12, B6. Bone marrow biopsy was repeated on this admission
to primarily re-evaluate for presence of AFB, but this was
negative for AFB and was sent for FISH, which was negative for
cytogenetic abberations.
.
As her hospitalization moved into [**Month (only) 404**], the patient required
intermittent blood trasnfusions. Prior to her R hip replacement,
she had a pMIBI which showed a small reversible defect. As such,
it was decided to ensure that her HCT should be maintained above
30 given her propensity for ischemia. In addition, her G6PD and
MDS also necessitated closer monitoring of her HCT. On
discharge, it was planned that she should follow up with HemeOnc
in two weeks.
.
# TB. The patient was initially placed on respiratory
precautions because of continuous cough productive of white
sputum. Induced sputum AFB smears x 3 were all negative. DOT and
medication doses were comfirmed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the
physician overseeing patient's TB therapy. Patient was adherent
to TB medication regimen. In the hospital, she was continued on
home regimen of INH, Rifampin, ethambutol, and Pyrazinamide. The
dispo planning was initiated. Dr. [**First Name (STitle) **] requested a routine
chest CT to be done prior to the patient's discharge, which
showed an increase in number and size of pulm nodules compared
with last CT on [**7-20**] and the repeat CT on this admission was
read as "miliary TB" by the radiology. The patient was initially
afebrile (although she was started on standing Tylenol on
admission because of hip pain), but then started spiking fevers
to over 103. She was asymptomatic from her fevers. ID and
pulmonary were consulted. Both consultant teams felt that
progression of active TB is extremely unlikely given
pan-sensitive organism, DOT, and duration of therapy she has
received. The possibility of worsening chest CT findings in the
setting of stopping remicade was entertained. Question of
possible brochoscopy vs surgical biopsy was discussed w/ pulm.
During the early part of admission, they felt that for the
relative invasiveness of not only the surgical bx but also the
bronchoscopy, and for the probable low yield of procedure, that
the procedure should not be done. Following a subsequent chest
CT, which showed stable disease, and with the patient still
spiking daily fevers, the decision was made to perform a
bronchoscopy, which was negative for organisms or malignancy or
TB. Of note, HIV testing was discussed w/ pt but the patient
refused the consent. The additional work up recommended by ID
and pulmonary is outlined under the FUO section. In [**Month (only) 1096**],
her regimen was changed from ETH/PZA to Levo/Strepto. In [**Month (only) 404**]
was reduced to INH/Rifampin on [**2138-12-17**]. Neither of these
alterations modified her fever spikes. On [**12-12**], a repeat chest
CT was done which showed unchanged size of pulm nodules (now at
4 months of rx). Her eosinophilia persisted. Out of concern for
a possible eosinophilic pneumonitis her regimen was changed to
INH/levofloxacin/ethambutol to see if her fevers and
eosinophilia would resolve. This regimen was started on
[**2139-1-2**]. She is to remain on this regimen for at least 4 more
months per the ID service.
.
# Fever of unknown origin. Pt was afebrile on admission but was
started on OTC tylenol for persistant R hip pain. Shortly after
admission, she began to spike fevers to around 102-103 while
still on OTC tylenol. Possible etiologies were PNA, UTI (Ecoli
in urine but UAs neg x 3), drug fever, adrenal insuff,
malignancy, right hip process, TB. Of note, when the patient
left the hospital on her previous admission in mid [**Month (only) **]
[**2137**] she was still febrile to 101. At that time, her fevers were
attributed to TB. On this admission, the extensive search for
source of her fevers was initiated. Diagnostic tests performed
including serum aspergillus galactomannan Ag, B-glucan,
histoplasma antibody and urine histoplasma antigen, CMV VL, HBV
viral load, c diff, stool Oand P were all negative. Adrenal
insuff testing was inconclusive. Multiple blood cultures
including mycolitic cultures on this admission have been
negative. Pt was started on Levo empirically given pulmonary
finding on CT, but continued to have fevers. She was then
started on 7-day course of meropenem for ESBL E.coli in urine,
but was still febrile after completing the course. Two
subsequent urine cultures were negative. Thyroid nodule was
aspirated and culture was negative. On [**11-28**], we changed her TB
meds for possible drug fever. ETH/PZA stopped and Levo/Strepto
started.
On [**12-1**] - more bottles positive for coag-neg staph; started 2
week course for presumed line-related bacteremia (although line
tip negative) with vanco. To further work this up, on [**12-5**] a
TEE demonstrated no vegetations.
.
Because of her eosinophilia in the setting of fevers, on [**12-6**],
she was treated empirically for strongyloides with 1 dose of
ivermectin.
.
To evaluate a potential oncologic contribution to the
fevers/eosinophilia, Heme/Onc repeated the bone marrow biopsy
which was consistent with her known diagnosis of MDS and AFB
stain was negative. Her bone marrow was also negative for
lymphoma. SPEP and UPEP were negative.
.
# Right hip pain. Patient has a history of rheumatoid arthritis
and evidence of rapidly progressive destructive arthropathy in
the right hip. Outpatient regimen had included methotrexate and
remicade which were stopped in [**2138-7-15**] when she was
diagnosed with TB. Patient continue to complain of severe pain
in the right hip. Patient was given oxycodone, lidocaine patch
and OTC tylenol for pain control. [**11-9**] the plain hip film was
performed and revealed no fracture but with a superior and
lateral subluxation of the right femoral head. Given the nature
of patient's fever and no obvioius source as described above, it
was considered that hip could be cause of fever as possible
extra pul TB infection although unlikey as the patients 2 prior
hip aspirations on last admission that were negative.
Rheumatology was consulted and synovial biopsy was suggested for
definitive diagnosis.
.
Ortho was consulted as request of other teams for possible
synovial bx/ hip aspirate to question the significance of R hip
pain and possibility again of extra pul TB manifestation causing
fever. Intially, ortho believed best approach would be for
scheduled outpt hip replacement/synovectomy since hip has far
advanced arthritis/capsule restriction, it would preclude
arthroscopic distension and distraction needed, so would need
open procedure. As her hospitalization progressed into [**Month (only) 404**]
and her fevers continued to persist, the issue of doing hip
surgery was revisited and agreed upon. This was the choice of
her primary team, as well as the various consultant services
involved. The patient was also agreeable to this procedure
because of her severly limited mobility [**1-16**] pain. Hence, she had
a pMIBI prior her her surgery which demonstrated a small
reversible defect. Certainly, this presented some mortal risk to
the patient. This was discussed with her and a plan was made to
ensure that she would be agressively treated to ensure that her
Hct did not drop below 30 or become hypotensive, with an eye
towards maintaining adequate perfusion to her heart. She had her
procedure under special OR settings because of the potential of
exposure to TB. She tolerated the procedure well. It was
estimated that there was 1L of blood loss. She thus received 3U
PRBC during the procedure as well as approximately 6-7L IVF
during/perioperatively. Her BP did not deviate below 90 during
the operation. Her post op pain was managed with narcotics. The
synovial and bone biopsies were negative for AFB and did not
demonstrate any signs of TB. TB PCR of both sample.
.
# Coagulase negative Staph infection. Blood cultures drawn on
[**11-9**] grew coagulase negative staph. Vancomycin was
started [**12-1**] and the patient's PICC line was removed. A
transthoracic echocardiogram was negative for endocarditis. A
transesophageal echocardiogram did not show evidence of
endocarditis. She was given 2 wks of Vancomycin
.
# Cough: Pt w/ cough and productive sputum of unclear etiology,
has been receiving active TB treatment and CXR on admission was
otherwise clear except for some mild b/l effusions. Original
sputum cultures were negative for AFB smears x 3 and w/ only
rare GNR growth. Was thought it could also be viral URI,
pertussis possible as pt without fevers on admission although on
high dose standing tylenol for R hip pain. The patient was put
on isolation/resp precautions for TB as diagnosed on previous
admission. ID/pulm/public health commission were following. We
restarted TB meds at home doses of rifampin, ethambutol, INH and
Pyrazinamide and gave her guaifenesin/codeine for a cough.
Levoflox started for empiric bacterial pna treatment. Pt still
with cough, appears not to be responding despite antibiotic
therapy. Pt now developing fevers, spiking to 102-103 despite
OTC tylenol, but again , asypmtomatic. Another sputum sent
approx 7 days later, again only showing rare GNR growth. Approx
a 2 week f/u CXR showed slightly more profuse pulmonary
nodularity and a new small right pleural effusion and a 2 week
f/u Chest CT was read as improvement in pulm nodules but both ID
and Pulm felt was unchanged. Given this data, and the patients
persistant fevers, the decision was made to perform a
bronchoscopy (see results and previous discussion).
.
# Thyroid nodule. CT also showed some heterogeneity in the left
lobe of the thyroid gland (present on CT back in [**2138-7-15**]).
Thyroid function tests were normal. A thyroid biopsy was
performed that was non-diagnosistic due to insufficient cellular
material but was had many hemosiderin-laden macrophages
consistent with cyst contents. Aspirate was sent for culture and
AFB both of which have been negative. Endocrinology was
curbsided, and they felt that given US read and FNA results
there was no need for further inpatient testing. She will
follow up as an outpatient.
.
# Hypotension. Resolved with hydration in ED. Continued
metoprolol, but held verapamil. Pt with borderline BP during
admission having to hold metoprolol on multiple occasions. Pt
asymptomatic during entire admission.
.
#Supraventricular Tachycardia. This was originally thought to be
AVNRT, noted on last admission, when the patient was started on
metoprolol, digoxin and verapamil. She was continued on
metoprolol. Pt's Dig and verapamil were originally discontinued,
given only one episode of previous SVT and concern for drug
fever. However, the patient developed several episodes of SVT
to the 160's, and therefore the metoprolol, verapamil and
digoxin were titrated up. The patient and already on
beta-blocker. Pt remained borderline sinus tachy around 90-110
during admission w/ no SOB, chest pain or palpitations ir
lightheadedness.
.
During the month of [**Month (only) 404**], the patient's rates were well
controlled with metoprolol, verapamil and digoxin. The digoxin
was held perioperatively given concerns for arrhythmogenicity
per cardiology attending. Digoxin was then discontinued as the
cardiology team questioned the diagnosis of AVNRT. On discharge,
her rates were well-controlled to 70-90 with verapamil 40mg PO
TID and metoprolol 50mg PO TID.
.
# h/o PE. Bilateral PE in [**2134**] on 1 + years of anticoagulation
with coumadin. Given massive PEs the plan was to continue
life-long anticoagulation with goal INR 1.5-1.9 Coumadin had
been held on last admit, for unclear reasons. Coumadin was held
throughout much of this admission, and enoxaparin was given.
After her surgery, she was bridged from enoxaparin to coumadin.
.
# CAD. H/o NSTEMI on last admission. Was never cathed but was
started on ASA. Statin was held due to history of transaminitis
and risk of hepatic toxicity from TB meds. Held aspirin until
sure pt is not having hemolysis [**1-16**] G6PD, patient also has
aspirin documented as allergy. Metoprolol was restarted.
.
pMIBI prior to ortho procedure showed mild reversible defect.
However, given the severe nature of the patient's longstanding
pain, it was agreed upon by the team and the patient that the
procedure should still be done. Post op, her hcts were checked
and maintained above 30 and troponins were flat post
operatively. EKG did not show any ischemic changes.
.
# Incontinence. H/o urge incontinence, continued on home
oxybutinin dosage.
.
# Eosinophilia: The patient had significant eosinophilia. The
differential was large and this finding was often considered in
the background of her fevers of unknown origin. Given her
multitude of drugs, this was considered as one possible source
of her eosinophilia. She was treated with 1 dose of ivermectin
for potential strongyloides (though her titre was negative).
Connective tissue diseases were also entertained, and she did
have an elevated [**Doctor First Name **], but of uncertain significance. Her
eosinophilia was reduced to normal levels for two days
post-operatively, but then rebounded back up to 7-10% of her
differential, where it remained on discharge.
Medications on Admission:
Cyanocobalamin 100 mcg PO DAILY
Pyridoxine 50 mg PO DAILY
Folic Acid 1 mg qday
colace/senna
?Oxycodone 5 mg po q8
?Aspirin 325 mg po qday
Ipratropium Bromide 17 mcg/ 2 puffs qid prn
Metoprolol Tartrate 25 mg po tid
Digoxin 125 mcg po qday
Oxybutynin Chloride 2.5mg po bid
Verapamil 240 mg po q24h
Rifampin 600mg po qday
Ethambutol 1200 mg po qday
Ferrous Sulfate 325 mg po qday
Isoniazid 300 mg PO DAILY
ambien 5mg po qhs prn
60,000 units of Epogen/week (has not gotten since prior to her
admission)
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical ONCE A DAY ().
6. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR ([**Doctor First Name 766**] -Wednesday-Friday).
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever >101.5.
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for cough.
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed
for pain.
17. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours). Tablet(s)
19. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
23. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
24. Lactulose 10 g/15 mL Solution Sig: Three Hundred (300) ML PO
ONCE (Once) as needed.
25. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
26. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-16**] Sprays Nasal
TID (3 times a day) as needed.
27. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours).
28. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
29. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
30. Ethambutol 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
31. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
32. Oxycodone 15 mg Tablet Sig: One (1) Tablet PO Once a day as
needed 15 minutes before PT as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary
Anemia
Fevers
Tuberculosis
Right hip joint destruction
.
Secondary
Supraventricular Tachycardia
Urinary tract infection
Anemia
Rheumatoid Arthritis
Incontinence
Pulmonary embolism
Discharge Condition:
Good
Discharge Instructions:
Please resume all of your prehospital medications including your
TB medications and Epo injections for your anemia. Please take
all of your new hospital medications as indicated.
Please call your PCP or return to the ED for worsening cough,
shortness of breath, chest pain, blurred vision, weakness.
You must have your labs, including CBC, Chem 10, and liver
function tests checked every day at the rehab hospital because
of your new tuberculosis medications. You should have your
coagulation tests, including PT, [**Name (NI) 14765**], and PTT per
Please call your PCP or return to the ED for worsening cough,
shortness of breath, chest pain, blurred vision, weakness.
Followup Instructions:
You have an appointment scheduled with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) 4223**], on [**Last Name (LF) 766**], [**1-5**], at 11am, at [**Location 14766**]. [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 12201**].
[**Telephone/Fax (1) 14767**]
.
You have a follow-up appointment scheduled with your orthopedic
physician [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], for Date/Time: [**Last Name (NamePattern4) 766**], [**2139-1-5**]
at 1:20pm. His office is at the [**Hospital1 18**], [**Location (un) 830**],
[**Hospital Ward Name 23**] 2, [**Location (un) 86**], [**Numeric Identifier 718**]. MD Phone:[**Telephone/Fax (1) 1228**]
.
You have an appointment scheduled with your tuberculosis
specialist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on Wednesday, [**1-21**], at the
[**Hospital6 2222**], [**Last Name (NamePattern1) **], [**Location (un) 538**], [**Numeric Identifier 14768**]. Phone ([**Telephone/Fax (1) 14769**].
.
You have a follow-up appointment scheduled with your
hematologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D., on Thursday, [**1-8**],
at 1:30pm. Address: [**Hospital1 18**], [**Last Name (LF) **], [**First Name3 (LF) **] 430,
[**Location (un) **],[**Numeric Identifier 718**]. Phone: [**Telephone/Fax (1) **]
.
You have a follow-up appointment scheduled with your
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at the [**Hospital1 18**] at [**Location (un) **]., [**Hospital Ward Name 23**] 7, [**Location (un) 86**], [**Numeric Identifier 718**], on Thursday, [**1-29**],
at 9am. Phone: [**Telephone/Fax (1) **]
.
You have a follow-up appointment scheduled with your
rheumatologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3057**], for [**3-9**] at 4:30pm.
His office is at [**Doctor First Name **], STE 4B, [**Location (un) **],[**Numeric Identifier 718**].
Phone: [**Telephone/Fax (1) **]
.
Completed by:[**2139-1-2**] Name: [**Known lastname 2343**],[**Known firstname **] M. Unit No: [**Numeric Identifier 2344**]
Admission Date: [**2138-11-6**] Discharge Date: [**2139-1-2**]
Date of Birth: [**2060-10-15**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfonamides
Attending:[**First Name3 (LF) 653**]
Addendum:
Patient also dc'd on Protonix 40 mg tablet Daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]
Completed by:[**2139-1-2**]
|
[
"427.89",
"282.2",
"790.7",
"238.72",
"715.95",
"V12.51",
"288.3",
"599.0",
"041.4",
"018.96",
"511.9",
"780.6",
"714.0",
"241.1",
"282.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"06.11",
"38.93",
"41.31",
"88.72",
"33.24",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
34699, 34905
|
12852, 27673
|
298, 392
|
31383, 31390
|
3459, 12829
|
32112, 34676
|
2920, 3014
|
28223, 31053
|
31152, 31362
|
27699, 28200
|
31414, 32089
|
3029, 3440
|
244, 260
|
420, 1920
|
1942, 2735
|
2751, 2904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,171
| 115,626
|
18784
|
Discharge summary
|
report
|
Admission Date: [**2172-2-26**] Discharge Date: [**2172-3-5**]
Date of Birth: [**2086-11-14**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
splenomegaly, ?metastatic disease
Major Surgical or Invasive Procedure:
1. Laparoscopically-assisted splenectomy.
2. Exploratory laparotomy, abdominal washout, crossclamp of the
aorta.
History of Present Illness:
The patient is a 85y/o gentleman who has a history of mild
splenomegaly that has been increasing slowly. He is thought to
perhaps have some disorder of myelodysplastic syndrome. Of note
is he also has had colon cancer and had a
metastasis to his liver. He was noted on recent scanning to
have some abnormalities in his spleen. The spleen is also
somewhat increased in size. It is unclear whether this
enlargement is due to his metastatic disease or progression of
his myelodysplastic syndrome.
Past Medical History:
PMH: AAA with expansion after EVAR, HTN, COPD,
hypercholesterolemia, metastatic colon CA s/p adjuvant
chemotherapy, +ETOH, MDS anemia
PSH: L colectomy, segment [**3-17**] liver resection for metastatic
colon CA/open CCY '[**63**], EVAR [**2163**], redo EVAR [**2166**]
Social History:
Significant EToH use including [**3-17**] cocktails daily. Prior
smoker, but quit 25 yrs ago.
Family History:
Non-contributory
Physical Exam:
On Discharge:
AVSS
GEN: NAD, more alert and oriented
CV: RRR
Lungs: CTAB, no r/w/r
ABD: Soft, NT/ND. Staples in place. Wound is clean, dry, and
intact.
EXT: warm, well perfused.
Pertinent Results:
[**2172-2-26**] 06:51PM BLOOD WBC-15.6*# RBC-3.45* Hgb-10.4* Hct-31.1*
MCV-90 MCH-30.2 MCHC-33.5 RDW-17.9* Plt Ct-352
[**2172-3-5**] 09:25AM BLOOD WBC-12.3* RBC-3.03* Hgb-9.2* Hct-27.3*
MCV-90 MCH-30.3 MCHC-33.5 RDW-15.4 Plt Ct-818*
[**2172-3-4**] 07:15AM BLOOD Glucose-119* UreaN-19 Creat-1.1 Na-139
K-3.9 Cl-101 HCO3-31 AnGap-11
LUE duplex [**2172-3-2**]: No evidence of pseudoaneurysm
LUE CTA [**2172-3-3**]: No evidence of pseudoaneurysm
ABD U/S [**2172-3-4**]: No evidence of splenic/portal vein thrombosis
ABD CT [**2172-3-5**]: No subdiaphragmatic collection. Small residual
hematoma in LUQ.
Brief Hospital Course:
The patient was admitted to the General surgery service on
[**2172-2-26**]. He underwent a laparoscopic assisted splenectomy.
(Please see the operative report for further details.) The
patient was extubated and taken to the recovery room in stable
condition. Upon arrival to the recovery area, patient was noted
to have a SBP in the 80s. His postoperative HCT was 23.1 down 8
units compared with pre-op. 2 units of PRBCs were given and
patient was bolused with IVF to help improve urine output. The
patient's epidural was split as well to improve vascular tone.
His BP actually improved to 100 systolic after these
interventions, but the patient soon became unresponsive. A
central line was placed in the L femoral vein, and patient began
to get hypotensive again to the 60s and was very pale and
tachycardic. He was bolused aggressively, and then taken back to
the OR emergently for re-exploration. (Please see operative note
for further details). Post-operatively, the patient was managed
in the ICU. He was HDS, but was still intubated and on pressors.
A left subclavian line was attempted on [**2-27**], but was
accidentally placed in the artery. This line was promptly
removed and pressure held for 55 min, with no evidence of
bleeding after. A Right SCL was subsequently placed
successfully. The patient was weaned off of respiratory support
and extubated on [**2-28**]. Epidural was restarted for pain control.
He was ultimately transferred to the floor in good condition on
[**2172-3-2**].
Neuro: The patient received epidural with good effect and
adequate pain control. This was discontinued on [**3-2**], and
patient was transitioned to oxycodone when tolerated oral
intake. The patient has history of significant EToH use at
baseline. As such, he was managed on CIWA scale during his
hospital stay. He became intermittently agitated the first few
days post-op and this was treated with small doses of ativan.
However, once he was transferred to the floor, his mental status
greatly improved. He was alert, oriented, and much less
confused. He did show any signs of severe alcohol withdrawal.
CV: Postoperatively, patient was initially on pressors, but this
was quickly weaned off on POD1. Due to h/o AAA, Vascular was
consulted and recommended keeping SBP between 100-140. As such,
patient was maintained on lopressor during his hospital course.
Pulmonary: The patient was weaned off of respiratory support and
extubated on [**2-28**]. The patient's was stable from a respiratory
standpoint after extubation. O2 was weaned as tolerated. Good
pulmonary toilet, ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Once extubated, the patient was started on sips and advanced to
regular diet as tolerated. Due to intermittent confusion and
agitation, patient did not take much po initially. However, this
improved during his hospital course. His diet was supplement
with ensure shakes. Prior to discharge, patient was eating
larger amounts of food and tolerating it well. An abdominal
ultrasound was performed on [**2172-3-4**] to rule out splenic/ portal
vein thrombosis and it showed no evidence of thrombosis. On
[**2172-3-5**] a CT scan was performed to evaluate for subdiaphragmatic
collection due to persistent hiccups. No collection was seen on
CT and patient's hiccups were improving upon discharge.
GU/FEN: The patient suffered acute renal insufficiency during
his hospital stay, likely from hypotension, possibly exacerbated
by cross clamp of aorta during re-exploration. His Cr
post-operatively was maximally elevated at 2.8. The patient was
kept well hydrated and serial Cr levels were measured. His Cr
came down appropriately and was 1.1 at time of discharge.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Post-operative, the patient was
several Kg above his baseline weight and was started on lasix
drip in the unit. Cxr's were followed that initially showed
pulmonary edema, but this improved greatly with the lasix. Lasix
was continued on the floor, but then discontinued when patient
was clinically improved. Electrolytes were routinely followed,
and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient's wound
remained clean, dry, and intact.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
HEME: The patient's complete blood count was examined routinely;
After initial operation, the patient's HCT dropped to 23, down 8
units from pre-op. He was given 2 units of PRBCs at that time.
He also received several more units of blood products when he
was taken back to the OR for re-exploration. Serial HCTs were
checked and on [**2172-3-1**], patient was noted to have a HCT of 22.3.
He was given 1 unit of PRBCs and his HCT improved to 26.4. For
the remainder his stay, the patient's HCT was stable. It was
27.3 at time of discharge. Patient was started on ASA 325 daily
due to rising platelet count. The patient was also started on
coumadin upon discharge for prophylaxis against splenic vein
thrombosis.
VASCULAR: The patient underwent a duplex of his L subclavian
artery on [**2172-2-28**] that showed a 1.9 cm linear tract arising from
the puncture site. Follow up duplex on [**2172-3-2**] showed no
pseudoaneurysm. A CTA was performed on [**2172-3-3**] that again showed
no evidence of pseudoaneurysm. The patient received
mucomyst/bicarb before and after CTA for kidney protection.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible. Physical therapy worked
with the patient and recommended short term rehab until patient
was back to baseline. He was begun on coumadin for prophylaxis
against splenic/ portal vein thrombosis, which is relatively
common followinf splenectomy in patients with myelodysplasia.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
amlodipine 5', atorvaststin 10', trandolapril 2', ASA 81', Vit D
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. trandolapril 2 mg Tablet Sig: One (1) Tablet PO once a day.
5. Coumadin 5 mg Tablet Sig: Five (5) Tablet PO once a day:
Please adjust dose for goal INR of [**1-16**].
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Splenomegaly- Myelodysplasia ? metastatic disease
[**Last Name (un) **] operative bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-21**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2172-3-12**]
9:45
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2172-3-23**]
1:30
Please call your [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8049**] (PCP) upon discharge from rehab to
follow up on INR and coumadin dosing as well as BP measurement.
([**Telephone/Fax (1) 14935**]
Completed by:[**2172-3-5**]
|
[
"443.9",
"998.11",
"238.75",
"V10.05",
"790.01",
"E878.6",
"272.4",
"441.4",
"401.9",
"E870.8",
"789.2",
"496",
"998.2",
"E849.7",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
9267, 9345
|
2258, 8642
|
337, 452
|
9480, 9480
|
1631, 2235
|
11783, 12316
|
1400, 1418
|
8757, 9244
|
9366, 9459
|
8668, 8734
|
9663, 10644
|
11270, 11760
|
1433, 1433
|
1447, 1612
|
10676, 11255
|
264, 299
|
480, 980
|
9495, 9639
|
1002, 1273
|
1289, 1384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,736
| 108,159
|
49171
|
Discharge summary
|
report
|
Admission Date: [**2152-5-3**] Discharge Date: [**2152-5-11**]
Date of Birth: [**2082-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
Chest Tube Placement complicated by subcutaneous emphysema
Bronchoscopy
History of Present Illness:
Briefly, 69 yo M with severe COPD on home O2 who orginally c/p
SOB x 24hrs in addition to L sided chest pain. He used nebs
without relief, did have a productive cough and was hypertensive
to 190s. EMS was called, and vitals on arrival were the
following: 190/90, HR 120, RR 24, O2 sat 90% with unclear amt of
oxygen.
.
At the [**Hospital1 18**] ED, his vitals were T99.0, P 136, BP 214/126, RR
35, and O2 sat 89% on unclr amt of O2. NIPV was tried, but did
not relieve resp distress. CXR showed L sided PTX. CT was placed
by ED, then was c/b kinking and SQ emphysema, the pt developed
extensive subcutaneous air over his chest, neck, and down into
his scrotum. He c/o increasing shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] the
decision was made to intubate him. Intubation was difficult and
c/b hypotension with sedation. IP replaced chest tube. The
patient was intubated and sedated and xferred to MICU For futher
care.
.
MICU course:
A line was placed. CT to suction was initiated, but IP not
following. Patient quickly weaned off the vent with tx for COPD
exacerbation and was extubated. He was maintained on steroids.
Hypotension resolved. L sided chest pain was controlled with
lidocaine patches and fentanyl. Original PTX thought to be due
to ruptured bleb due to patient's COPD. The patient maintained
Sats in the 90s on 6L nasal cannula. He maintained to have a
small amount of hemoptysis that was attributed to traumatic
intubation. Abx were continued empirically as well as
theophylline and inhalers as part of tx for COPD exacerbation.
Chest tube leaked persisted and there was a concern raised for
bronchopleural fistula
Past Medical History:
COPD [FEV1 of 0.67 liters, which is 27% of predicted]. is on
2-3L oxygen at home.
H/O treated TB
Hypertension
Glomerular nephritis
Hyperchol
Social History:
Positive tobacco history; he quit 15 years ago.
Worked in dowel manufacturing and was exposed to wood dust.
No alcohol or IV drug abuse.
Family History:
nc
Physical Exam:
Gen: comfortable, not tanchypneic
Skin: crepitus on L side from neck to scrotum
HEENT: NC in place, PERRLA, EOMI, no cervical LAD
Lungs: coarse [**First Name3 (LF) 1440**] sounds bilaterally, decreased BS and bases.
tenter at the chest tube site.
CV: RRR, no m/r/g
Abd: soft, nt/nd, +bs
Ext: no edema
+scrotal edema/SQ emphysema. Foley catheter is in.
Pertinent Results:
CHEST (PORTABLE AP)
The left chest tube has been repositioned and is now in the left
upper chest. The left lung appears better aerated and expanded.
An endotracheal tube is in place, approximately 7.5 cm above the
carina.
The endotracheal tube balloon cuff is overdistended, and should
be deflated slightly.
A massive amount of subcutaneous emphysema now covers both sides
of the chest wall and the neck, obscuring evaluation of the
underlying lung fields. Mediastinal air is also present.
.
CHEST (PORTABLE AP) [**2152-5-9**] 4:19 PM
INDICATION: Chest tube removal after pneumothorax.
CHEST, ONE VIEW: Comparison with [**2152-5-8**]. Left chest tube
has been removed. No residual pneumothorax is seen. Volume loss
on the left is slightly less in degree than the previous exam;
there is residual opacity over the left mid lung and left lower
lobe, which can represent consolidation, atelectasis, or
asymmetric edema. Right lung appears relatively clear, though
right lung basilar opacity is unchanged. Bilateral subcutaneous
emphysema is still present.
[**2152-5-11**] 06:05AM BLOOD WBC-9.8 RBC-3.36* Hgb-10.9* Hct-32.0*
MCV-95 MCH-32.6* MCHC-34.2 RDW-14.5 Plt Ct-194
[**2152-5-3**] 10:45AM BLOOD WBC-20.3*# RBC-4.35* Hgb-14.2 Hct-40.7
MCV-94 MCH-32.6* MCHC-34.9 RDW-14.0 Plt Ct-287
[**2152-5-3**] 10:45AM BLOOD Neuts-82.8* Lymphs-13.4* Monos-2.8
Eos-0.8 Baso-0.2
[**2152-5-10**] 06:55AM BLOOD Glucose-135* UreaN-24* Creat-0.8 Na-144
K-3.6 Cl-106 HCO3-29 AnGap-13
[**2152-5-4**] 01:06AM BLOOD CK-MB-22* MB Indx-0.9 cTropnT-0.04*
[**2152-5-6**] 06:44AM BLOOD CK-MB-5 cTropnT-<0.01
[**2152-5-8**] 10:50AM BLOOD Theophy-12.9
[**2152-5-5**] 09:24AM BLOOD Lactate-1.2
Brief Hospital Course:
Mr. [**Known lastname **] is a 69 year old gentleman with severe COPD who
presented with acute respiratory distress who was found to have
a large left sided pneumothorax. Chest tube was placed in the ED
complicated by subcutaneous empysema. He was intubated and later
extubated on [**2152-5-4**]. After transfer to the floor the patient
steadily improved, chest tube was removed without complication,
pt had significant hemoptysis and underwent bronchoscopy for
suctioning and diagnostic purposes, revealing bronchomalacea. Pt
should have an interval noncontrast chest CT for further eval as
an outpatient.
1) Respiratory failure:
Likely secondary to pneumothorax from ruptured bleb. Following
extubation the patient was quickly weaned to 6L by nasal
cannula, then 2-3L as his baseline O2 requirement. He was
treated empirically with cefpodoxime/azithromycin for 7 and 5
days respectively. Given IV solumedrol and later changed to
prednisone taper. Pt's subcutaneous emphysema steadily improved
over the course of the admission.
He will-follow up with Dr. [**First Name4 (NamePattern1) **] [**Known firstname **] in Pulmonary. Sutures
from the patients chest tube site should be removed in 10 days
following discharge on [**2152-5-11**].
2) Pneumothorax:
Likely secondary to ruptured bleb, complicated by chest tube
placement and subcutaneous emphysema (large amount). Chest to
suction during initial air leak, later resolved. Tube was
removed by interventional pulmonary [**2152-5-9**] without event.
Interval chest xray revealed resolution of pnemothrax with
persistent LLL collapse and volume loss. Pt went for
bronchoscopy as below for deep suction and diagnostic purposes.
3) hemoptysis:
likely secondary to intubation trauma vs multiple rupture blebs
in COPD. He has not had this prior to admission. Bronchoscopy
during this admission revealed bronchomalacia, follow up
noncontrast Chest CT should be performed in [**1-8**] weeks for
further elucidation of pt's lung disease.
.
4) tachycardia-
appearance of MAT by EKG. pt was stared on low dose diltiazem
for rate control. He may be weaned of this medication as an
outpatient beyond the acute phase of his illness.
.
5) Cardiovascular-
Tachycardia as above. Lasix was held in the setting of transient
rise in Creatinine clearance. He did not require re-introduction
of lasix during this admission. Close follow up as an outpatient
may require re-initiation of this medication. Aspirin therapy
was held in the setting of hemoptysis. Atorvastatin was
continued.
6) GERD-
Continued home dosing of protonix while inpatient.
Medications on Admission:
advair 250 mg 1 puff [**Hospital1 **]
combivent 2 puff four times / day
theophylline 200 mg [**Hospital1 **]
folate 1 mg daily
diovan 325 mg one tab daily
norvasc 5 mg daily
lipitor 60 mg daily
lasix 40 mg daliy
protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
9. Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
Disp:*60 Capsule, Sust. Release 12 hr(s)* Refills:*2*
10. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day
for 1 days: Take 20mg Friday, then 10mg Saturday, then 5mg
Sunday, then off.
Disp:*7 Tablet(s)* Refills:*0*
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
QID (4 times a day) as needed.
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY: Spontaneous Pneumothorax
SECONDARY:
Chronic Obstructive Pulmonary Disease
Hypertension
Glomerular nephritis
Hypercholesterolemia
History of Treated TB
Discharge Condition:
Stable 02 sats on [**1-8**] liters, req 4liters while ambulating.
Discharge Instructions:
You were admitted for difficulty breathing and found to have a
pneumothorax. You had a chest tube placed to drain the air from
around your lung and allow it to re-inflate. You required a
brief period of time on a mechanical ventilator. You underwent
bronchoscopy to help clear thick secretions and were found to
have bronchomalacia (thin airways).
.
Please take all of your medications as prescribed.
.
Call Dr. [**Last Name (STitle) 58**] or 911 if you have worsening shortness of
[**Last Name (STitle) 1440**], require more oxygen at home, worsening cough, fevers,
chills, chest pain, dizziness or any other concerning symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 58**] next week for follow up appointment.
.
Please have a non-contrast, high-resolution chest CT performed
as an outpatient for further evaluation of your lungs.
.
Please keep the following appointments:
PULMONARY BREATHING TEST Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2152-5-24**]
11:40
Provider [**Name9 (PRE) 1570**],[**Name9 (PRE) 2162**] [**Name9 (PRE) 1570**] INTEPRETATION BILLING
Date/Time:[**2152-5-24**] 12:00
Provider [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] NP/DR [**Known firstname **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2152-5-24**] 12:00
|
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icd9cm
|
[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,806
| 159,157
|
49039
|
Discharge summary
|
report
|
Admission Date: [**2123-2-22**] Discharge Date: [**2123-3-3**]
Date of Birth: [**2060-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Bradycardic arrest, found hypotensive.
Major Surgical or Invasive Procedure:
Endotracheal intubation
Right radial arterial Line
Temporary pacing wire (transvenous)
History of Present Illness:
Dr. [**Known lastname 102918**] is a 62-year-old psychiatrist (former
anesthesiologist) at [**Hospital1 **], with history of coronary
disease (on cath. no stents), poorly controlled diabetes, gout,
hypertension, dyslipidemia, who is admitted for treatment of
bradycardic arrest.
Dr. [**Known lastname 102918**] was feeling unwell at work on the morning of
admission when he developed sudden onset of chest pain. He had
been arguing with the Social Worker at [**Name2 (NI) **]. EMS was
called; patient was found to have bradycardia with rate of 30.
His blood pressure was undetectable.
Collateral history was obtained from a close friend and his
PCP (Dr. [**Last Name (STitle) **]. According to them both - patient is
non-compliant with medications. He was an anethetist and tends
to make his own decisions about medications. His friend (also a
physician) describes that he take occasional Lasix. His doctor
reports that his blood glucose is very poorly controlled and
that it has previously been in 600-700 range. He lives alone,
works at [**Hospital1 **].
In the ED, EKG was remarkable for complete AV nodal
dissociation with ventricular rate of 40. Patient was intubated;
he was given atropine and started on transthoracic pacing with
peripheral dopamine. A cordis was then placed with a transvenous
wire and he was started on temporary pacing. Dopamine was weaned
off. Labs in the emergency room were remarkable for potassium of
7.8 and blood sugar of 350 for which patient was given calcium
chloride and insulin. Repeat potassium was 7.3. Renal function
was noted to be normal. Patient was admitted to the CCU for
further management. Vitals at time of transfer were 86, 170/66,
14, 600, PEEP 5, FiO2 100%. In the ED, he was given 20 units of
humalog with continuing glucose above 600. Blood gas, utox, dig.
level were sent. Was given three amps of calcium chloride. No
Kayelexate given. OG, RIJCVL and cordic with transvenous pacing
wires placed. Seen by EP (confirmed wire placement, voltage and
hemodynamics) and Renal (no dialysis for now). Serum and urine
tox. sent. Currently patient on transvenous rate of 70. Access
is 2 peripheral IVs. Intubated. CXR confirmed tube and line. The
patient was also noted to not respond to atropine.
REVIEW OF SYSTEMS:
Although the patient was conscious upon arrival to the ED, he
was shortly after sedated and intubated. Per ED note: Patient
had chest pain. No fever, chills, diplopia, tinnitus, cough,
SOB, black/bloody stools, dysuria, frequency, back pain, rash,
headache.
Past Medical History:
1. Obesity
2. Hypertension
3. Diabetes, poorly controlled, HbA1c 11, est. av. glucose 280.
On oral agents at admission.
4. Chronic renal insufficiency (likely diabetic)
5. Hyperlipidemia, not clear that this was being treated.
6. History of smoking - remote, 20 pack years
7. Coronary artery disease s/p catheterization (at [**Hospital 2586**]). He had had a positive stress test and elective
cath. in [**2117**]: Anatomy: LAD 50-60% stenosis distally. RCA mid
100% stenosis. LCx and LM without lesions. Excellent left to
right collaterals. No stents placed. Last echo revealed LVEF of
55%, per [**Hospital3 **] Cath. report. No evidence of CABG
(although in ED note - no evidence of incision and no sternotomy
wires).
8. Obstructive sleep apnea
9. Hemorrhoids
10. Anxiety
11. Gridiron incision c/w past appendectomy.
12. Gout - fifth finger of right hand affected.
Social History:
Patient is physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 102919**], now
psychiatrist that works at [**Hospital1 **]. Is divorced and now lives
alone, bar his tuxedo cat. His close friend, [**Name (NI) 2951**], also tells
us that he has many good friends. [**Name (NI) 102920**] PCP (Dr. [**Last Name (STitle) **]
infrequently.
Ex-smoker, quit 30 years ago, and had a 20 pack year history.
Alcohol - nil. No recreational drugs. He has no children. Has
lots of friends. Only aunt and cousin in US. Has a cat at home.
Family History:
Mother died of pancreatic ca in her mid 80s, she also had type 2
DM.
Father died of stomach cancer aged 47.
Paternal aunt had type 2 DM.
Physical Exam:
GENERAL: Overweight man with good self-care and of generally
heathy constitution. Sedated, intubated, central lines,
restraints x2.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. Difficult to appreciate JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Examination at time of hand pain:
GEN: Obese man, looks stated age.
Neck: Thick, JVP not elevated.
Cardiovascular: R, normal S1 S2, no M/R/G
Respiratory: Clear to auscultation throughout, no wheeze,
rhonchi. Good air entry.
Gastrointestinal: Benign - soft, non-tender, non-distended, no
organomegaly.
Extremities: Rigth hand with rubor, calor, dolor, tumor, but in
glove distribution. Painful, without sensory changes, capillary
refil rapid, impression of pain-limited strength - not in
neurologic distribution (would need to be radial, ulnar and
median all at wrist, but paradoxically including extrinsic hand
muscles). Greatest pain over dorsum of wrist. Doppler of hand
reveals intact radial and ulnar arteries with good flow.
Neurological: Alert and oriented x 3. CNs II-XII intact. Gross
motor intact with pain limited extension and flexion of wrist
and movement of intrinsic AND extrinsic hand muscles on right.
Left hand WNLs. Gait normal base, rhythm.
Psychiatric: Beligerent and threatening. Agitated. Changes
subject to blaming hospital staff for sore hand when we describe
events leading to admission. Insight poor. Judgement poorer than
expected - came to nurses station to demand Neurology
consultation while writing note.
Skin: Erythema of right hand. Pressure ulcer(s): None.
Pertinent Results:
Lab Data at and near Admmission
[**2123-2-22**] 10:42AM BLOOD WBC-10.6 RBC-5.46 Hgb-15.2 Hct-44.4
MCV-81* MCH-27.9 MCHC-34.3 RDW-15.9* Plt Ct-374
[**2123-2-22**] 10:42AM BLOOD Neuts-69.8 Lymphs-20.2 Monos-5.0 Eos-3.9
Baso-1.1
[**2123-2-22**] 01:42PM BLOOD PT-10.4 PTT-17.1* INR(PT)-0.9
[**2123-2-24**] 02:24PM BLOOD Ret Aut-1.8
[**2123-2-22**] 10:42AM BLOOD Glucose-645* UreaN-44* Creat-0.7 Na-126*
K-7.8* Cl-95* HCO3-18* AnGap-21*
[**2123-2-22**] 10:42AM BLOOD ALT-36 AST-80* CK(CPK)-212 AlkPhos-73
TotBili-0.5
[**2123-2-22**] 10:42AM BLOOD Lipase-90*
[**2123-2-22**] 10:42AM BLOOD CK-MB-9 cTropnT-0.02*
[**2123-2-22**] 01:42PM BLOOD Albumin-3.6 Calcium-10.8* Phos-3.9 Mg-2.4
[**2123-2-23**] 06:23AM BLOOD calTIBC-205* Ferritn-89 TRF-158*
[**2123-2-22**] 04:00PM BLOOD %HbA1c-11.4* eAG-280*
[**2123-2-22**] 01:42PM BLOOD Osmolal-326*
[**2123-2-22**] 10:42AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-2-22**] 12:58PM BLOOD pO2-70* pCO2-50* pH-7.28* calTCO2-24 Base
XS--3
[**2123-2-22**] 01:51PM BLOOD freeCa-1.42*
Lab Data at or near Discharge
[**2123-3-3**] 06:50AM BLOOD WBC-7.2 RBC-4.46* Hgb-11.8* Hct-35.2*
MCV-79* MCH-26.5* MCHC-33.5 RDW-15.1 Plt Ct-297
[**2123-2-24**] 02:27AM BLOOD Neuts-78.2* Lymphs-10.7* Monos-8.9
Eos-2.0 Baso-0.2
[**2123-2-27**] 07:15AM BLOOD PT-11.2 PTT-21.5* INR(PT)-0.9
[**2123-3-3**] 06:50AM BLOOD Glucose-223* UreaN-36* Creat-1.2 Na-135
K-3.9 Cl-95* HCO3-29 AnGap-15
[**2123-2-25**] 09:45PM BLOOD ALT-33 AST-32 LD(LDH)-227 CK(CPK)-310
AlkPhos-73 TotBili-0.5
[**2123-2-25**] 09:45PM BLOOD Lipase-87*
[**2123-2-25**] 09:45PM BLOOD CK-MB-3
[**2123-3-1**] 06:20AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.0
Wrist Plain Films
IMPRESSION: Normal right wrist radiographs.
Neurology Consultation [**2123-3-2**]
Impression: With moderate edema and tenderness, the exam is
quite
limited, but as his sensation is nearly normal, I expect his
motor power is also probably fairly normal. I doubt he has
substantial injury to median nerve. Hopefully edema will resolve
soon, and he should follow up with Dr [**Last Name (STitle) 12332**] in 2 weeks if he
continues to have any motor or sensory concerns with his hand.
UENI US
IMPRESSION: Nonocclusive thrombus within the right basilic vein.
Brief Hospital Course:
Precis of Hospital Course
The ED course is described above. He was sedated, intubated
and paced on arrival on the floor. Wrist restraints were needed
because of the need to maintain endotracheal orogastric tubes
and central venous line with pacer wires. Sedation was weaned
and he was extubated the following day after correction of
hyperglycemia and hyperkalemia, which resulted in restoration of
sinus rhythm wihtout further bradycardia. He was delirius and
agitated after extubation, requiring low-dose antipsychotic
medication. With clearing of his mental state, pcyhotropics were
stopped. His mental state continued to improve during the
admission. Late in the hospitalization, right hand swelling and
pain was noted. Symptoms, signs and examination were not
consistent with a neurologic cause and it was attributed to
superficial venous thrombosis, confirmed on ultrasound. This was
likely provoked by slowed flow in vessels given arterial line
(artery is patent), intravenous line in outflow and wrist
restraint. Lovenox was started and analgesia given. He is
discharged to rehabilitation.
Hospital Course by Problem
Complete heart block.
Etiologies considered include infarctive, related to
electrolyte disturbance (hyponatremia, hyperkalemia), toxic
(accidental versus intentional). Infarction unlikely given
enzyems, atypical for electrolyte disturbance, more likely
toxic. Prolonged QRS could relate to either toxicity,
particularly with tricyclics, but may also results from
hyperkalemia. Patient takes metoprolol at home, is somewhat
erratic with medications and did not respond to atropine.
Concerning for beta-blocker overdose, toxic and ischemic -
negative by level. UTox and STox panels negative (including for
ASA). Attributed to hyperkalemia.
Diabetes/Non-ketotic hyperglycemic hyperkalemic hyperosmolar
state (326 mOsms)
Given insulin and kayelexate with resolution, later
supplementation with potassium containing fluids as potassium
fell below 5. This state was responsible for hyperkalemia and
bradycardia, hypotension and presentation. Cardiac rhythmicity
normal with correction of potassium and glucose. Secondary to
very poorly controlled hyperglycemia of diabetes II. [**Month (only) 116**] have
been elevated for some time, per PCP, [**Name10 (NameIs) **] now dramatic enough to
become symptomatic. Hemoglobin glycosylation is time dependent,
so A1c should reflect poor control and chronicity more than this
acute event and is 11, suggesting average glucose of 280 mg/dl.
Diabetes
Patient will be followed by [**Last Name (un) **], which will be very
important for his care. DM management will be critical to
prevent further bradycardic arrest and other complications.
Given A1c, likely glucose is about 280 on average (estimated).
He has been taking oral anti-hyperglycemics along with standing
70/30 (14 units [**Hospital1 **]) and sliding scale. This will need final
titration in rehab. Oral anti-hyperglycemics may be increased.
Hypertension
Hypotensive on arrival. Hypotension appeared somewhat out of
proportion to bradycardia. But became hypertensive (likely
baseline) with pacing. Aimed for SBP > 110, given risk of
cerebral hypoperfusion in this patient, while intubated and
sedated. Antihypertensives will need to be titrated.
Acute Renal Failure
Likely secondary to diabetes. Improved somewhat while here and
now likely at baseline. Would recommend tight glucose control
and following of urinary protein.
Hand Pain
Likely due to venous insufficiency, particularly given
swelling, pain, erythema. Neurologically intact, arteries intact
by Doppler. Non-occlusive thrombus in basilic vein. He can
follow-up with Neurology as an outpatient to charge improvement.
Coronary Artery Disease
Two vessel disease, likely without stents. Ischemic etiology
possible, particularly if sinus node infarcted. However, enzymes
are presently flat. LVEF 55% in [**2117**], but may be less now. No
intervention - inactive while here. Needs ASA and Cardiology
follow-up in future.
Medications on Admission:
Patient appears to have been taking (based on friend, PCP and
[**Hospital3 5097**] cath. report):
(per PCP from [**2121-8-27**])
Lisinopril 10mg daily
HCTZ 25mg daily
Gyburide 10mg [**Hospital1 **]
Glucophage 500mg [**Hospital1 **]
Gemfibrozil 600mg daily
Crestor 10mg daily
Allopurinol 100mg daily -- not compliant
Per PCP, [**Name10 (NameIs) **] not taking any of the following:
- Aspirin
- Lasix
- Metoprolol
PCP also thinks that he is writing some prescriptions for
himself
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day: check FS before meals and
at HS.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold SBP < 100.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Sixteen (16) units Subcutaneous twice a day: before
breakfast and dinner.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) **] nursing and rehab
Discharge Diagnosis:
Hyperosmolar non-ketotic hyperglycemic state
Hyponatremia
Complete Heart Block
Aspiration Pneumonia
Thrombocytopenia
Acute Renal Failure, Stage 3
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a bradycardic arrest from high potassium levels and high
glucose levels. A pacing wire was placed temporarily until your
heart rate improved after electrolyte correction and an insulin
drip. You had a fever which we think was from aspiration, you
received 7 days of antibiotics to treat this and had no fever or
leukocytosis today.
You have a painful right arm that we think is from the right
basilic clot and muscle soreness because of restraints and
agitation. We have prescribed warm compresses, ACE bandage,
elevation, Tramadol, Aspirin and Tylenol to treat this. This
should slowly improve.
.
Medication changes:
It is unclear what medicines you were taking before this
hospitalization. We recommend that you take medicines in
coordination with your primary care physician.
1. Start Colace and Senna as needed to prevent constipation
2. Start Metoprolol Succinate to keep your heart rate low and
control your blood pressure
3. Start Aspirin to prevent the basilix thrombus from
increasing.
4. Start Tramadol to treat the pain in your right wrist
5. Start 70/30 Insulin twice daily and Humalog sliding scale for
your diabetes. Your blood sugars have been too high to rely on
oral antihyperglycemics only
6. Decrease Lisinopril to 5 mg daily.
7. Start Pantoprazole to prevent irritation from the aspirin.
8. Start Tylenol every 8 hours to treat the pain in your wrist
9. Start Ferrous sulfate to treat your iron deficiency
10. Stop taking Propanolol, Verapamil, Avandia, Allopurinol and
Pravastatin.
11. continue Metformin at 500 mg twice daily
12. Start taking Hydrochlorothiazide for your blood pressure
13. Start Taking Lorazepam as needed for Anxiety
Followup Instructions:
Primary Care:
[**Doctor Last Name **],ZINAIDA Phone: [**Telephone/Fax (1) 7751**] Date/Time: Please make an appt
to see Dr. [**Last Name (STitle) **] when you get out of rehabilitation.
.
Endocrinology:
[**Hospital **] Clinic, [**Last Name (un) 3911**], [**Location (un) 86**] Phone: [**Telephone/Fax (1) 2378**]
Date/time: Tuesday [**3-9**] at 9:am with Dr [**Last Name (STitle) **]
.
Vascular:
Ultrasound right upper extremity, [**Hospital Ward Name 517**], [**Hospital1 7768**],
[**Location (un) 470**]. Phone: [**Telephone/Fax (1) 327**] Date/time: Friday [**3-12**] at
2:15pm.
.
Neurology:
Dr [**Last Name (STitle) **] and [**Doctor Last Name 12332**] Phone: [**Telephone/Fax (1) 541**] Date/time: Thursday
[**4-1**] at 4:30pm.
|
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3027, 3894
|
3912, 4437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,862
| 175,038
|
13425
|
Discharge summary
|
report
|
Admission Date: [**2191-8-31**] Discharge Date: [**2191-9-5**]
Date of Birth: [**2139-3-6**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
woman with diabetes for many years who uses an Insulin pump.
She reported dyspnea with activity over the past couple of
years without chest pain or pressure. She is from [**State 531**]
originally and had nuclear scan there which suggested normal
left ventricular function with mild anterior ischemia but no
infarction and was subsequently referred for catheterization
and possible intervention in [**State 531**].
Hemodynamically she was found to have left ventricular
pressure of 150 with an end diastolic pressure of 14 mmHg per
ventriculogram. Left ventricular pressure was 158 with an
end diastolic pressure of 17 mmHg post ventriculogram.
Aortic pressure was 156/67 with a mean of 98 mmHg. There
was no significant aortic valve gradient.
Left ventriculography showed that the patient had normal
contractility throughout. Ejection fraction was estimated to
be 65-70% with no mitral regurgitation seen.
Coronary angiography showed that the patient had right
dominant mildly diffuse calcification throughout her coronary
arteries. Her arteries were all relatively small in caliber.
Left anterior descending was a small vessel with severe
diffuse proximal to midvessel disease up to 90% stenosis.
The first diagonal branch was small with an 80% proximal
lesion.
She requested to be sent to [**Location (un) 86**] for her coronary artery
bypass grafting to be near where her diabetologist was. She
was thus admitted to [**Hospital6 256**] on
[**2191-8-31**], and referred for coronary artery bypass
grafting times two with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
PAST MEDICAL HISTORY: Diabetes mellitus; the patient uses an
Insulin pump. There is some question of asthma. Anemia.
Hypothyroidism. Chronic renal insufficiency.
ALLERGIES: SULFA, CAUSING TONGUE SWELLING.
FAMILY HISTORY: No significant family history.
SOCIAL HISTORY: Teacher. The patient lives with husband.
The patient quit tobacco 27 years ago. No alcohol. No
recreational drugs.
MEDICATIONS ON ADMISSION: Lisinopril 10 mg q.d., Naproxen
500 mg q.d., Synthroid 175 mcg q.d., Fluoxetine 20 mg q.d.,
Insulin pump, Calcium 1 g q.d., Vitamin B complex, Aspirin 81
mg, Imdur 30 mg q.d., Toprol XL 25 mg q.d., [**Doctor First Name **] D.
REVIEW OF SYSTEMS: The patient denied any recent illness.
She had no orthopnea. She has palpitations.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 114/60 on
admission, heart rate 59. Lungs: Clear. Cardiovascular:
Regular, rate and rhythm. Normal S1 and S2. There was a
1-2/6 systolic ejection murmur over the left sternal border.
Extremities: Mild edema. There were 2+ pulses bilaterally
throughout.
HOSPITAL COURSE: The patient was then taken to the Operating
Room on [**2191-8-31**], with the diagnosis f coronary
artery disease and had a coronary artery bypass grafting
times two with LIMA to left anterior descending and saphenous
vein graft to ramus intermedius under general endotracheal
anesthesia by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] and assistant [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 40734**].
Two chest tubes were placed, one mediastinal and one left
pleural. The patient was transferred to the unit on a
Propofol, Insulin, Neo-Synephrine and Nitroglycerin drip.
On postoperative day #1, the patient did extremely well, and
chest tubes were discontinued, and all drips were
discontinued except for Nitroglycerin drip for cardiac
protection.
[**Last Name (un) **] Diabetes continued to follow the patient for Insulin
pump management. The patient was started back on Imdur on
postoperative day #2, and all drips were discontinued.
Physical Therapy began to see the patient throughout the
hospital course until clearance for discharge. On
postoperative day #2, the patient was transferred to the
floor and did very well on the floor. The patient was
discharged on postoperative day #5 without event.
DISCHARGE MEDICATIONS: Colace 100 mg b.i.d., Aspirin 325 mg
q.d., Percocet [**12-9**] tab p.o. q.4-6 hours pain, Imdur 60 mg
p.o. q.d., Protonix 40 mg p.o. q.d., Lopressor 12.5 mg p.o.
b.i.d., Levoxyl 175 mcg p.o. q.d., Iron Complex, Vitamin C,
Multivitamin, Paxil 20 mg p.o. q.d., Lasix 20 mg q.d. x 1
week.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass grafting with incomplete revascularization.
2. Diabetes.
3. Chronic renal insufficiency.
FOLLOW-UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) 40735**], primary care physician, [**Last Name (NamePattern4) **] [**12-9**] weeks, and with the
cardiologist in [**1-10**] weeks, with Dr. [**Last Name (STitle) 1537**] in three weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 10197**]
MEDQUIST36
D: [**2191-9-5**] 09:33
T: [**2191-9-5**] 09:35
JOB#: [**Job Number 40736**]
|
[
"413.9",
"447.1",
"244.9",
"414.01",
"724.2",
"250.61",
"357.2",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
2051, 2083
|
4197, 4484
|
4566, 5273
|
2246, 2473
|
2909, 4173
|
2601, 2891
|
2493, 2578
|
182, 1822
|
1845, 2034
|
2100, 2219
|
4509, 4545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,004
| 173,573
|
1047
|
Discharge summary
|
report
|
Admission Date: [**2169-3-29**] Discharge Date: [**2169-3-31**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
infected left AV graft
Major Surgical or Invasive Procedure:
excision of infected left AV graft [**2169-3-29**]
History of Present Illness:
89 yo male who presented with chills at dialysis. He was noted
to have a fever to 102 at that time. While at dialysis, he was
noted to have a ulceration over his left AV graft site with
bleeding. He was transferred to [**Hospital1 18**] for further evaluation
and work-up of a likely infected left AV graft.
Past Medical History:
CKD-- stage IV disease, baseline ~3.8 in [**3-/2168**]; patient has one
kidney, per the family; lost to f/u with nephrology after
discharge from [**Hospital1 18**] in [**3-/2168**] for similar symptoms; family and
family refused dialysis at that time
2o hyperparathyroidism
2o anemia
HTN
Hyperlipidemia
Gout
Hernias s/p repair
Social History:
Greek-only speaking
Lives with daughter-in-law and son in JP
Substance abuse history unknown
Family History:
His parents lived to their 90s; no known cancer history.
Physical Exam:
Vitals: 102 110 220/110 19 96%RA
Gen: A+Ox3, mild distress
HEENT: NC/AT, no LAD, no bruits
CV: tachycardic, -MRG
Chest: CTAB
Abd: soft/NT/ND
Ext: bleeding from ulceration over left AV graft site with
likely associated infection, no edema
Pertinent Results:
[**2169-3-31**] 02:30AM BLOOD WBC-8.0# RBC-3.32* Hgb-10.6* Hct-32.2*
MCV-97 MCH-32.0 MCHC-33.1 RDW-15.1 Plt Ct-162
[**2169-3-30**] 02:41AM BLOOD WBC-16.2*# RBC-3.42* Hgb-10.9* Hct-32.8*
MCV-96 MCH-31.7 MCHC-33.1 RDW-15.3 Plt Ct-183
[**2169-3-29**] 06:30PM BLOOD WBC-9.4 RBC-3.96* Hgb-12.7* Hct-37.8*
MCV-96 MCH-32.1* MCHC-33.6 RDW-15.1 Plt Ct-208
[**2169-3-29**] 06:30PM BLOOD Neuts-90.2* Lymphs-5.5* Monos-3.2 Eos-0.8
Baso-0.3
[**2169-3-29**] 06:30PM BLOOD PT-13.9* PTT-150* INR(PT)-1.2*
[**2169-3-31**] 02:30AM BLOOD Glucose-93 UreaN-57* Creat-6.8*# Na-138
K-4.9 Cl-104 HCO3-20* AnGap-19
[**2169-3-30**] 02:41AM BLOOD Glucose-110* UreaN-42* Creat-5.5* Na-138
K-4.7 Cl-104 HCO3-20* AnGap-19
[**2169-3-29**] 06:30PM BLOOD Glucose-257* UreaN-36* Creat-4.9* Na-140
K-4.5 Cl-100 HCO3-23 AnGap-22*
[**2169-3-30**] 02:41AM BLOOD Vanco-5.5*
[**2169-3-30**] 02:58AM BLOOD Type-ART pO2-281* pCO2-28* pH-7.52*
calTCO2-24 Base XS-1
[**2169-3-29**] 10:22PM BLOOD Type-ART pO2-58* pCO2-45 pH-7.32*
calTCO2-24 Base XS--3
Brief Hospital Course:
After presentation the patient was taken to the operating room
where he underwent excision of his infected left AV graft.
Post-operatively he was taken to the ICU because of difficulty
weaning off the vent after the procedure. He was given
vancomycin and levofloxacin as well at that time. The following
day he was extubated without difficulty. His wound cultures
grew coag + staph aureus from the OR. The following day he was
given hemodialysis through his right sided tunnelled line. He
was transferred to the floor following dialysis and his foley
was discontinued. He was able to void after this was removed.
Wet to dry dressing changes were used over his infected wound
site. He was discharged home to continue dialysis with
vancomycin for 6 weeks and with VNA for continued wet to dry
dressing changes. He was discharged in good/stable condition.
Medications on Admission:
1. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Pantoprazole 40 mg PO QD
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Pantoprazole 40 mg PO QD
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
4. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
with dialysis for 6 weeks.
Disp:*18 grams* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
infected left AV graft
Discharge Condition:
good/stable
Discharge Instructions:
Please continue on all of your medications that you were on
prior to coming to the hospital and please take any new
medications as prescribed. Please continue on your regular
dialysis schedule at [**Location (un) **] dialysis ([**Telephone/Fax (1) 673**]). You
will be given vancomycin 1g IV (an antibiotic) with your
dialysis for your left arm wound for 6 weeks after discharge. A
home nurse will help you with your wet to dry dressing changes
on your left arm. Please follow-up as scheduled. If you
develop fevers, chills, nausea, vomitting, diarrhea, shortness
of breath, or chest pain please contact a physician [**Name Initial (PRE) 2227**].
If you have any questions or concerns regarding your dialysis
access please call [**Telephone/Fax (1) 673**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-4-6**]
8:00
|
[
"E878.2",
"285.21",
"272.0",
"996.62",
"274.9",
"588.81",
"585.6",
"403.91",
"V45.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.43",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3891, 3949
|
2517, 3379
|
284, 337
|
4016, 4030
|
1485, 2494
|
4841, 4996
|
1154, 1212
|
3588, 3868
|
3970, 3995
|
3405, 3565
|
4054, 4818
|
1227, 1466
|
222, 246
|
365, 677
|
699, 1027
|
1043, 1138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,793
| 111,708
|
41682
|
Discharge summary
|
report
|
Admission Date: [**2138-11-10**] Discharge Date: [**2138-11-16**]
Date of Birth: [**2070-4-24**] Sex: F
Service: SURGERY
Allergies:
Succinylcholine
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abd pain, abd wall abscess
Major Surgical or Invasive Procedure:
exlap, washout,R colectomy, CCY [**2138-11-11**]
History of Present Illness:
68F with morbid obesity, COPD and a recent admission for
cholecystitis most recently seen in [**Hospital 2536**] clinic on [**2138-10-14**] now
with five days of anorexia, RLQ pain and diarrhea. She notes
that pain is gradually worsening and does not radiate, though
she does feel a "heaviness" in her abdominal wall when walking.
She
denies recent fevers or sick contacts and has never had a
colonoscopy. She denies the presence of blood in her stool.
Past Medical History:
PMH: DM2, symptomatic cholelithiasis, spinal
stenosis,hypothyroidism, COPD, Depression, Anxiety,
Hyperlipidemia, hypertension, OSA
PSH: denies prior operations
Social History:
significant smoking history stopped 30 years ago. Denies alcohol
use.
Family History:
NC
Pertinent Results:
[**2138-11-10**] 05:00PM BLOOD WBC-14.3* RBC-3.68* Hgb-9.7* Hct-31.4*
MCV-85 MCH-26.4* MCHC-30.9* RDW-15.9* Plt Ct-325
[**2138-11-11**] 04:36AM BLOOD WBC-12.4* RBC-2.95* Hgb-7.8* Hct-24.8*
MCV-84 MCH-26.6* MCHC-31.5 RDW-15.6* Plt Ct-358
[**2138-11-12**] 02:05AM BLOOD WBC-9.1 RBC-3.15* Hgb-8.1* Hct-26.8*
MCV-85 MCH-25.7* MCHC-30.3* RDW-15.8* Plt Ct-337
[**2138-11-13**] 05:07AM BLOOD WBC-13.1* RBC-3.29* Hgb-8.9* Hct-28.8*
MCV-88 MCH-26.9* MCHC-30.8* RDW-16.3* Plt Ct-395
[**11-10**] CT abd pelvis (wet read): Area of circumferential
wall thickening of the proximal ascending colon, concerning for
malignancy. Abutting the abnormal colon is a large abscess
extending through the right lower anterior abdominal wall
measuring 11.8 (trv) x 11.3 (CC) x 9.2 cm (AP), presumably
caused
by perforation of the colon.
Brief Hospital Course:
The patient was admitted to the ACS surgery service on [**2138-11-11**]
and had a exlap, washout, R colectomy, CCY. The patient
tolerated the procedure well.
Neuro: Post-operatively, the patient received fentanyl IV. Once
extubated she was switched to a dilaudid PCA, with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient remained intubated on the night of POD 0,
she was successfully extubated on POD 1. The patient was stable
from a pulmonary standpoint; vital signs were routinely
monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced once bowel
function had returned. Foley was removed on POD#1. Intake and
output were closely monitored.
ID: Post-operatively, the patient was started on IV vancomycin
and zosyn. She may continue on vancomycin and zosyn until she
is seen in [**Hospital 2536**] clinic. The patient's temperature was closely
watched for signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD 6, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. Her pathology report returned a diagnosis of
colonic adenocarcinoma, pT3N2Mx, hence her discharge diagnosis
is perforated colonic adenocarcinoma.
Medications on Admission:
Gabapentin 300 mg Q AM, Hydrocodone-Acetaminophen 5-500 mg Oral
Tablet PRN, Doxepin 25 mg QHS, Levothyroxine 75 mcg Qday,
Lorazepam (ATIVAN) 0.5 mg [**Hospital1 **] PRN Sertraline (ZOLOFT) 100 mg
Qday, Glipizide 2.5 mg [**Hospital1 **], Metformin 1,000 mg [**Hospital1 **], Simvastatin
40 mg Qday, Albuterol Sulfate 90 mcg/Actuation Inhalation.
Q4-6hrs PRN, Tiotropium Bromide (SPIRIVA WITH HANDIHALER) 18 mcg
Inhalation Qday, Lisinopril 20 mg Qday, Hydrochlorothiazide 25
mg Qday
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sliding scale.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
COPD/SOB.
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain.
13. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
14. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
15. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Perforated colon adenocarcinoma pT3N2Mx
Abdominal wound debridement and washout with VAC placement
Discharge Condition:
At the time of discharge the patient was able to ambulate. She
was able to void and was tolerating a regular diet. Her pain
was well controlled and she had normal mental status.
Discharge Instructions:
You will go to an acute inpatient rehabilitation facility where
you will have VAC dressing changes to your abdominal wound every
three days. Additionally you will have ongoing care for your
incision site and your abdominal drain, which will remain in
place until you are seen in clinic.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Location (un) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medication. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
Followup Instructions:
Please follow up in the Acute Care Surgery clinic 5-10 days
after discharge. Call [**Telephone/Fax (1) 600**] upon discharge to schedule an
appointment. At this time she will have her staples removed and
her drain discontinued. Additionally, she should follow up with
Dr. [**Last Name (STitle) 28049**]. from oncology, who has indicated will be in touch to
schedule appropriate follow up appointments.
Completed by:[**2138-11-16**]
|
[
"153.9",
"244.9",
"311",
"574.20",
"196.2",
"300.00",
"278.01",
"593.9",
"401.9",
"250.00",
"327.23",
"567.22",
"569.83",
"569.81",
"272.4",
"682.2",
"496",
"V85.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"45.93",
"51.22",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
5715, 5792
|
1988, 3613
|
304, 354
|
5934, 6116
|
1151, 1965
|
10470, 10906
|
1128, 1132
|
4145, 5692
|
5813, 5913
|
3639, 4122
|
6140, 10447
|
238, 266
|
383, 839
|
861, 1024
|
1040, 1112
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,027
| 123,218
|
10235
|
Discharge summary
|
report
|
Admission Date: [**2150-11-6**] Discharge Date: [**2150-11-8**]
Date of Birth: [**2089-8-17**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Reglan
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 yo F with DM, CKD s/p renal tx in [**2148**], who presents with
lethargy. Her partner reports she was in her USOH until the
morning of admission, when she awoke with a left side headache
typical of her usual migraine. Pt took 2 Tylenol #3 tablets and
Ativan 2 mg. She slept throughout the rest of the day. At 4PM,
pt's partner reports helping her to the restroom and noting
confusion, and "unsteadiness" on her feet. He called her PCP
who referred them to the ED.
.
Pt presented to the ED with VS: 97.4 71 129/52 12 95%RA.
In the ED Head CT neg. ABG 7.46/62/70/45. Bicarb elevated to
43, Creat 1.9 (baseline 1.4). She received one dose of Narcan
for ?ativan overdose, w/o improvement. Admitted to [**Hospital Unit Name 153**] for
observation.
.
ROS: notable for +palpitations ~2d earlier, lasted for 5-10 min,
associated with coming down steps in her building, a/w
dizziness. no associated cp/sob/n/v. partner also notes pt has
been "sleeping a lot" recently. otherwise, ROS negative for
f/c/cp/sob/v/abd pain/changes in bowel or bladder habit/weight
changes/rash.
Past Medical History:
- s/p Left Living unrelated kidney transplant [**2148**] for diabetic
nephropathy
- DMI complicated by nephropathy, retinopathy and neuropathy
Never had dialysis - was pre-emptive in [**2148-5-7**] from husband.
- DM1 x 30 years, with retinopathy, nephropathy. Now legally
blind.
- Migraines
-GERD
- Aseptic meningitis ?secondary to amoxicillin
- Gout
- Hypothyroidsim
- Hyperlipidemia
- malignant hypertension
- gastroparesis
- s/p Lumpectomies (benign)
- History of urosepsis post-transplantation.
- Osteoporosis of the hip and spine by BMD [**2150-6-11**].
- History of skin transplant related to a ski accident in [**2144**]
in which patient had skin grafted from her right hip into her
left leg.
- Colonoscopy in [**2146**] showing hyperplastic polyp in the sigmoid
colon with recommend follow up in five years.
- History of depression.
Social History:
<5 years x 1 ppd tobbacco quit 30+ yr ago, [**1-12**] glasses
wine/week, denies IVDU. Patient lives in [**Location **] with her
partner of 16 years, [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) **].
Family History:
2 brothers, 1 sister. Father died early age from alcoholism.
Mother healthy. Brother and sister with diabetes.
Physical Exam:
PE: Tc 98.6 BP 122/60 HR 73 RR 11 95%RA
GEN: NAD, cachetic appearing female.
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD,
No JVD.
CV: regular, nl s1, s2, +3/6 systolic murmur, loudest LSB, no
r/g.
PULM: crackles at right base, no r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL, no edema B LE, ?chronic
venous changes of B LE.
NEURO: alert & oriented x 3, CN II-XII grossly intact. [**5-15**]
strength symmetric @ triceps, biceps, delts, hip flexion,
dorsoflexion, plantarflexion. sensation grossly intact.
Pertinent Results:
[**2150-11-5**] 07:10PM [**Month/Day/Year 3143**] Lactate-1.4
[**2150-11-5**] 09:51PM [**Month/Day/Year 3143**] Type-ART pO2-76* pCO2-62* pH-7.46*
calTCO2-45* Base XS-16
[**2150-11-5**] 07:10PM [**Month/Day/Year 3143**] ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2150-11-7**] 04:45AM [**Month/Day/Year 3143**] rapmycn-7.4
[**2150-11-5**] 07:10PM [**Month/Day/Year 3143**] TSH-2.3
[**2150-11-5**] 07:10PM [**Month/Day/Year 3143**] Glucose-201* UreaN-48* Creat-1.9* Na-138
K-3.1* Cl-89* HCO3-43* AnGap-9
[**2150-11-8**] 06:55AM [**Month/Day/Year 3143**] Glucose-76 UreaN-32* Creat-1.3* Na-143
K-4.3 Cl-108 HCO3-31 AnGap-8
[**2150-11-5**] 07:10PM [**Month/Day/Year 3143**] WBC-5.3# RBC-5.02 Hgb-12.3 Hct-37.0
MCV-74* MCH-24.4* MCHC-33.2 RDW-18.0* Plt Ct-181
[**2150-11-8**] 06:55AM [**Month/Day/Year 3143**] WBC-3.0* RBC-4.55 Hgb-11.5* Hct-34.2*
MCV-75* MCH-25.2* MCHC-33.6 RDW-18.5* Plt Ct-159
[**2150-11-5**] 09:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2150-11-5**] 09:30PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-11-5**] 09:30PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2150-11-5**] 10:16PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
CXR: 1. Left seventh rib posterior fracture with questionable
eighth rib fracture. 2. No acute cardiopulmonary processes.
.
CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is
identified. The ventricles are symmetric, and there is no shift
of normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. There are areas of low attenuation
in the right occipital region, consistent with an area of remote
infarct. Additionally, there is a low attenuation in the
periventricular and subcortical white matter, which is similar
in comparison to prior study, and likely represents areas of
chronic microvascular angiopathy. The soft tissue and osseous
structures are within normal limits. The paranasal sinuses are
well aerated.
.
IMPRESSION: No intracranial hemorrhage or mass effect is
identified. Chronic white matter changes and an area of remote
infarction in the right occipital region unchanged in comparison
to prior studies.
.
NOTE ADDED AT ATTENDING REVIEW: I agree that there have been no
acute changes. however, the ventricles appear enlarged out of
proportion to the sulci. This is a stable finding, but it raises
the possibility of chronic communicating hydrocephalus.
Brief Hospital Course:
Hospital Course, by Problem:
.
#lethargy - upon presentation pt was somewhat lethargic,
although appropriately conversive. Repeat ABG 7.46/56/84
revealed modest elevation in CO2 which was unchanged from
earlier. Her elevated C02 was likely from hypoventilation from
meds and compensatory from metabolic alkalosis. Mild
hypercalcemia may also have been contributing to altered mental
status as pt takes citrical. She received narcan in the ED
with modest benefit. Sedating medications were held, and pt's
mental status improved over her hospital stay, back to baseline
per partner.
.
#metabolic alkalosis - pt presented with a metabolic alkalosis
which resolved over the course of [**11-6**] with fluid hydration.
Etiology was likely multifactorial with component of milk alkali
syndome (given citrical intake and hypercalcemia), contraction
alkalosis from loop diuretic, and lasix induced hypokalemia
resulting in intracellular hydrogen shifts. Pt was rehydrated
with 2L NS, lasix was held, and her alkalosis improved. She was
instructed to hold her Lasix and Citrical until she follows up
with Dr. [**First Name (STitle) 805**].
.
#[**Doctor First Name 48**]/CRI - pt s/p renal transplant. her elevated Cr was most
likely prerenal azotemia. Pt was rehydrated with 2L IVF, and
cellcept levels were obtained. She was otherwise continued on
her transplant medication (cellcept, rapamune, prednisone) and
PCP prophylaxis with bactrim.
.
#Rib Fractures: unclear etiology. Patient asymptomatic, no
history of fall, trauma, etc. Have forwarded this report to
Endocrinologist, PCP and Nephrologist.
.
#?Chronic Communicating Hydrocephalus: per attending read of
Head CT. Patients partner notes several years of memory
problems. [**Name (NI) **] inform outpatient Neurologist.
Medications on Admission:
insulin lantus 11 units at bedtime.
ISS (conversion factor 1U = 50 mg/dl FSBS)
cellCept [**Pager number **] mg p.o. b.i.d.
rapamune 3 mg p.o. daily.
bactrim single Strength one tablet QMonWedFri
protonix 40 mg p.o. b.i.d.
levoxyl 50 mcg daily
procrit 4000 units every week.
venlafaxine 150 mg daily.
prednisone 4 mg po qdaily
citrical 600 mg qdaily ? takes 4 pills daily
actonel 35 mg every week.
lipitor 60 mg po qhs.
furosemide 40mg po qam, 20mg po qpm
metolazone (occasional use if edema does not resolve with lasix)
zetia 10 mg p.o. daily.
aspirin 81 mg po qdaily
folbee tablet
vit b complex 50 mg po qdaily
vit c time release 500 mg po qdialy
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
9. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*2*
13. Lantus
11 U qam with Insulin sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
1. Drug induced delerium
2. Metabolic Alkalosis secondary to contraction alkalosis and
?milk
alkali
3. Acute on Chronic Renal Insufficiency, resolved
4. ?Chronic Hydrochephalus, Head CT stable
5. L rib fractures, asx
Secondary Diagnoses:
- s/p Left Living unrelated kidney transplant [**2148**] for diabetic
nephropathy
- DMI complicated by nephropathy, retinopathy and neuropathy
- Migraines
- GERD
- Aseptic meningitis ?secondary to amoxicillin
- Gout
- Hypothyroidsim
- Hyperlipidemia
- h/o malignant hypertension
- h/o gastroparesis
- s/p Lumpectomies (benign)
- History of urosepsis post-transplantation.
- Osteoporosis of the hip and spine by BMD [**2150-6-11**].
- History of skin transplant related to a ski accident in [**2144**]
in which patient had skin grafted from her right hip into her
left leg.
- Colonoscopy in [**2146**] showing hyperplastic polyp in the sigmoid
colon with recommend follow up in five years.
- History of depression.
Discharge Condition:
stable, MS improved
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] or return to the emergency room with any
mental status changes, fevers, chills, sweats, chest pain,
shortness of breath, or any other concerns.
Do not take your Lasix or your Citrical until you follow up with
Dr. [**First Name (STitle) 805**] next week.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 805**] in one week.
Please make an appointment to follow up with Dr. [**Last Name (STitle) **].
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2150-12-7**] 10:50
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-3-24**] 1:15
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2151-3-24**] 2:30
|
[
"274.9",
"276.3",
"530.81",
"403.91",
"357.2",
"244.9",
"346.90",
"584.9",
"250.41",
"362.01",
"583.81",
"E878.0",
"536.3",
"250.61",
"996.81",
"292.81",
"250.51",
"585.6",
"275.42"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9822, 9828
|
5836, 7624
|
303, 310
|
10835, 10857
|
3253, 5813
|
11203, 11769
|
2545, 2659
|
8323, 9799
|
9849, 10076
|
7650, 8300
|
10881, 11180
|
2674, 3234
|
10097, 10814
|
242, 265
|
338, 1424
|
1446, 2291
|
2307, 2529
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,828
| 194,307
|
32005
|
Discharge summary
|
report
|
Admission Date: [**2112-8-16**] Discharge Date: [**2112-9-2**]
Date of Birth: [**2033-12-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal pain, nausea/vomiting and weight loss transferred to
[**Hospital1 18**] after undergoing a laparoscopic cholecystectomy
complicated by an unsuccessful cholangiogram where contrast was
seen flowing only into the distal common bile duct but no
duodenum was identified. Postoperatively, the patient developed
rising liver function tests.
for a bile duct injury was entertained. He was transferred to
[**Hospital1 18**] for ERCP.
Major Surgical or Invasive Procedure:
Exploratory laparotomy and evacuation of intraperitoneal
hematoma.
History of Present Illness:
78 M with nausea, vomiting and abdominal pain in setting of
weight loss presented to [**Hospital3 4107**]. RUQ u/s showed sludge
in gallbladder. HIDA scan showed normal EF and no cholecystits.
MRCP was negative for common duct stones. He underwent
laparoscopic cholecystectomy with intraoperative cholangiogram
that showed complete common bile duct obstruction without
obvious stones. He had dense adhesions and per report there was
no evidence of cancer. He was transferred to the [**Hospital1 18**] for ERCP
and further management.
Past Medical History:
Afib, htn, diabetes, anemia, pulmonary hypertension,
hyperlipidemia, BPH, s/p left nephrectomy, history of lung
cancer (squamous cell carcinoma).
Social History:
Lives alone. History of distant tobacco use.
Family History:
Non-contributory
Physical Exam:
Expired.
Pertinent Results:
[**2112-9-2**] 02:30AM BLOOD WBC-23.0* RBC-3.26* Hgb-10.6* Hct-31.4*
MCV-96 MCH-32.5* MCHC-33.8 RDW-23.9* Plt Ct-146*
[**2112-9-1**] 07:38AM BLOOD Hct-30.5*
[**2112-9-1**] 02:52AM BLOOD WBC-24.7* RBC-3.10* Hgb-10.1* Hct-29.0*
MCV-94 MCH-32.6* MCHC-34.9 RDW-23.8* Plt Ct-108*
[**2112-8-17**] 03:10AM BLOOD WBC-30.4* RBC-3.12* Hgb-9.7* Hct-28.9*
MCV-93 MCH-31.3 MCHC-33.7 RDW-17.4* Plt Ct-145*
[**2112-8-16**] 09:05PM BLOOD WBC-26.5* RBC-2.84* Hgb-9.0* Hct-26.1*
MCV-92 MCH-31.6 MCHC-34.3 RDW-18.2* Plt Ct-139*
[**2112-8-16**] 09:05PM BLOOD Neuts-86.0* Lymphs-7.6* Monos-5.4 Eos-0.7
Baso-0.2
[**2112-9-2**] 02:30AM BLOOD Plt Ct-146*
[**2112-9-2**] 02:30AM BLOOD PT-20.0* PTT-44.7* INR(PT)-1.9*
[**2112-8-16**] 09:05PM BLOOD Plt Ct-139*
[**2112-8-16**] 09:05PM BLOOD PT-15.4* PTT-47.8* INR(PT)-1.4*
[**2112-8-17**] 03:10AM BLOOD PT-16.5* PTT-50.4* INR(PT)-1.5*
[**2112-8-25**] 11:20AM BLOOD Fibrino-476*
[**2112-8-23**] 02:02AM BLOOD Thrombn-16.3
[**2112-9-2**] 09:12AM BLOOD Glucose-136* UreaN-25* Creat-0.5 Na-134
K-3.9 Cl-98 HCO3-17* AnGap-23*
[**2112-9-2**] 02:30AM BLOOD Glucose-126* UreaN-24* Creat-0.5 Na-133
K-3.8 Cl-97 HCO3-19* AnGap-21
[**2112-9-1**] 07:38AM BLOOD Glucose-113* UreaN-23* Creat-0.4* Na-132*
K-3.8 Cl-97 HCO3-20* AnGap-19
[**2112-8-17**] 03:10AM BLOOD Glucose-154* UreaN-66* Creat-2.7* Na-138
K-4.1 Cl-103 HCO3-21* AnGap-18
[**2112-8-16**] 09:05PM BLOOD Glucose-47* UreaN-69* Creat-2.9* Na-140
K-4.1 Cl-100 HCO3-29 AnGap-15
[**2112-9-2**] 02:30AM BLOOD ALT-242* AST-176* TotBili-34.2*
DirBili-27.6* IndBili-6.6
[**2112-9-1**] 02:52AM BLOOD ALT-247* AST-214* AlkPhos-268*
TotBili-32.9* DirBili-25.8* IndBili-7.1
[**2112-8-31**] 12:46AM BLOOD ALT-263* AST-266* AlkPhos-295*
TotBili-31.4* DirBili-26.0* IndBili-5.4
[**2112-8-30**] 04:36AM BLOOD ALT-247* AST-303* AlkPhos-266* Amylase-14
TotBili-29.1*
[**2112-8-27**] 02:07AM BLOOD ALT-263* AST-560* CK(CPK)-6202*
AlkPhos-280* TotBili-21.5* DirBili-16.0* IndBili-5.5
[**2112-8-26**] 09:41AM BLOOD CK(CPK)-8378*
[**2112-8-26**] 02:05AM BLOOD ALT-240* AST-698* CK(CPK)-9653*
AlkPhos-280* TotBili-21.0* DirBili-15.6* IndBili-5.4
[**2112-8-20**] 06:23AM BLOOD ALT-52* AST-229* AlkPhos-312*
Amylase-231* TotBili-6.0*
[**2112-8-18**] 11:45PM BLOOD ALT-47* AST-222* LD(LDH)-570*
AlkPhos-280* Amylase-334* TotBili-6.2*
[**2112-8-17**] 03:10AM BLOOD ALT-50* AST-238* CK(CPK)-1850*
AlkPhos-346* TotBili-5.6*
[**2112-8-24**] 02:18AM BLOOD Lipase-15
[**2112-8-26**] 09:41AM BLOOD CK-MB-50* MB Indx-0.6 cTropnT-0.30*
[**2112-8-26**] 02:05AM BLOOD CK-MB-48* MB Indx-0.5 cTropnT-0.29*
[**2112-9-2**] 09:12AM BLOOD Calcium-9.9 Phos-2.0* Mg-2.1
[**2112-9-2**] 02:30AM BLOOD Calcium-10.2 Phos-1.9* Mg-2.2
[**2112-8-17**] 05:42PM BLOOD Calcium-8.2* Phos-5.5* Mg-2.1
[**2112-8-17**] 03:10AM BLOOD Calcium-7.1* Phos-4.8* Mg-2.2
[**2112-8-16**] 09:05PM BLOOD Albumin-2.2* Calcium-8.0* Phos-4.5 Mg-2.6
Iron-35*
[**2112-9-2**] 09:41AM BLOOD Type-ART pH-7.40
[**2112-9-2**] 02:37AM BLOOD Type-ART pO2-173* pCO2-36 pH-7.40
calTCO2-23 Base XS--1
[**2112-9-1**] 02:20PM BLOOD Type-ART pH-7.38
[**2112-9-1**] 07:52AM BLOOD Type-ART pO2-179* pCO2-39 pH-7.38
calTCO2-24 Base XS--1
[**2112-9-1**] 03:15AM BLOOD Type-ART pO2-159* pCO2-35 pH-7.39
calTCO2-22 Base XS--2
[**2112-8-17**] 11:01AM BLOOD Type-ART Temp-37.3 Tidal V-450 PEEP-5
FiO2-40 pO2-48* pCO2-41 pH-7.26* calTCO2-19* Base XS--8
-ASSIST/CON Intubat-INTUBATED
[**2112-8-17**] 03:31AM BLOOD Type-MIX Comment-GREEN TOP
[**2112-9-2**] 02:37AM BLOOD Lactate-3.7*
[**2112-9-1**] 02:20PM BLOOD Glucose-140* Lactate-4.2*RADIOLOGY Final
Report
ABDOMINAL FLUORO WITHOUT RADIOLOGIST [**2112-8-16**] 11:40 PM
ABDOMEN (SUPINE ONLY); ABDOMINAL FLUORO WITHOUT RADIO
Reason: ERCP
Question cholangitis.
No prior comparison exams are available.
ERCP
Four spot fluoroscopic images were obtained by gastroenterology
without a radiologist present. Partial biliary and pancreatic
duct filling in single spot film. No evidence of stricture or
definite focal filling defects. Subsequently, a plastic biliary
stent was placed. Per ERCP report, no purulent drainage was
identified.[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74972**]Portable TTE
(Complete) Done [**2112-8-17**] at 10:32:41 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Doctor Last Name **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Pulmonary, Critical Care & [**Last Name (un) 9368**]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], [**Hospital Ward Name 23**] 8
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2043-12-6**]
Age (years): 68 M Hgt (in): 70
BP (mm Hg): 108/55 Wgt (lb): 180
HR (bpm): 130 BSA (m2): 2.00 m2
Indication: Left ventricular function.
ICD-9 Codes: 427.31, 424.0, 424.2
Test Information
Date/Time: [**2112-8-17**] at 10:32 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7749**]
Doppler: Full Doppler and color Doppler Test Location: East MICU
Contrast: None Tech Quality: Adequate
Tape #: 2007E000-0:00 Machine: Vivid i-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.32 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.8 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - E Wave deceleration time: *130 ms 140-250 ms
TR Gradient (+ RA = PASP): *37 to 47 mm Hg <= 25 mm Hg
Findings
The rhythm appears to be atrial fibrillation with a rapid
ventricular response.
LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by
TEE).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal descending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Calcified tips of papillary
muscles. Mild to moderate ([**11-24**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**11-24**]+] TR. Moderate PA systolic hypertension.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm
appears to be atrial fibrillation. Emergency study. Right
pleural effusion.
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**11-24**]+) mitral regurgitation is seen. There is mild to moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild-moderate mitral regurgitation. Pulmonary artery systolic
hypertension.
CLINICAL IMPLICATIONS:
Based on [**2111**] 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.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician
RADIOLOGY Final Report
CT ABDOMEN W/O CONTRAST [**2112-8-17**] 11:24 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: Bowel edema, evidence of toxic megacolon. Please give po
co
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with recent cholecystectomy and colonic dilation
on KUB.
REASON FOR THIS EXAMINATION:
Bowel edema, evidence of toxic megacolon. Please give po
contrast not IV contrast given his Acute Renal Failure.
CONTRAINDICATIONS for IV CONTRAST: ARF
INDICATION: 68-year-old man with cholecystectomy on [**2112-8-10**] at
an outside hospital. Now hypovolemic with increasing white count
and concern for toxic megacolon.
COMPARISON: Abdominal radiograph [**2112-8-17**].
TECHNIQUE: Multidetector helical scanning of the chest, abdomen
and pelvis was performed without IV contrast due to the
patient's acute renal failure. Oral contrast was administered
through an NG tube. Coronal and sagittal reformats were
displayed.
CT OF THE CHEST: There is diffuse anasarca in the soft tissues.
Endotracheal tube terminating in the mid trachea and left
subclavian catheter terminating in the distal SVC are noted. The
heart, pericardium, and great vessels are unremarkable on this
non-contrast scan. Dense atherosclerotic calcifications are
noted within the LAD and RCA. There is a large right pleural
effusion and moderate-sized left pleural effusion, both
measuring simple fluid density. There is significant relaxation
atelectasis, particularly in the right lower lobe. Additionally,
there are areas of ground-glass opacity with micronodules
throughout the right upper lobe which are concerning for
infection versus asymmetric edema. Streaky patches of
consolidation in the left upper lobe are more consistent with
atelectasis.
CT OF THE ABDOMEN: NG tube terminates within the body of the
stomach. Biliary drain follows the expected course of the common
bile duct. An additional [**Location (un) 1661**]-[**Location (un) 1662**] drain enters via the
right mid abdomen and terminates in the left upper quadrant. The
gallbladder has been removed and there is pneumobilia in the
left lobe of the liver, presumably related to the biliary stent.
No focal hepatic lesions are seen on this non-contrast scan.
Anterior and inferior to the liver is a large heterogeneous
fluid collection with areas of hyperattenuation, consistent with
an acute hematoma. This collection measures 12.6 x 8.2 cm in the
axial plane. The drain abuts the hematoma, coursing at the
lateral and superior aspect of it. There are additional regions
of hyperattenuating fluid surrounding the bowel loops in the
lower abdomen consistent with hemorrhagic ascites.
Oral contrast has reached the rectum, with no evidence of
obstruction. Bowel wall thickening is difficult to evaluate
given the amount of ascites. There are several areas of concern
including possible focal thickening of the ascending colon
(2:71), as well as the sigmoid colon (2:93). There are no
definite areas of wall thickening involving the small bowel,
though again evaluation is limited due to the ascites. There is
no evidence of pneumatosis, free air, or portal venous gas.
The left kidney is absent, possibly congenitally as there are no
surgical clips identified in the left renal fossa. The adrenal
glands, right kidney, spleen, fatty replaced pancreas, and
aortic caliber are normal. Scattered vascular calcifications are
seen throughout the aorta, celiac axis, and splenic artery.
CT OF THE PELVIS: Foley catheter is seen within the bladder. As
mentioned previously, there is probable mild wall thickening vs
nondistension of the sigmoid colon. Ascites extends into the
pelvis. No pathologic lymphadenopathy.
The bones are osteopenic, with a bone island noted in left S1,
and left iliac crest. No suspicious lytic or sclerotic lesions.
IMPRESSION:
1. Large acute peri- and infrahepatic hematoma measuring
approximately 12.5 x 8.2 x 8.8 cm. The intra-abdominal drain
abuts the hematoma, passing at its lateral and superior aspect.
2. Moderate amount of hyperattenuating fluid throughout the
abdomen consistent with hemoperitoneum.
3. Focal wall thickening of the ascending colon, likely edema
from compression by the hematoma, however, ischemia cannot be
excluded. There is no evidence of free air, pneumatosis, or
portal venous gas.
4. Additional possible wall thickening of the sigmoid colon
versus collapsed bowel, and again ischemia cannot be excluded.
5. Large right and moderate left pleural effusions with edema
versus infection involving the right lung.
5. Surgically absent gallbladder with biliary drain following
the expected course of the CBD.
6. Absent left kidney.
7. Diffuse anasarca.
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2112-8-24**] 3:21 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: r/o source of infection
Field of view: 40
[**Hospital 93**] MEDICAL CONDITION:
78 year old man s/p CCY now with increasing WBC
REASON FOR THIS EXAMINATION:
r/o source of infection
CONTRAINDICATIONS for IV CONTRAST: None.
CT TORSO
CLINICAL HISTORY: 78-year-old man status post CCI now with
increasing white blood cells. Evaluate for source of infection.
TECHNIQUE: MDCT acquired axial images were obtained following
administration of intravenous 130 cc of Optiray and oral
contrast. Coronal and sagittal reformatted images were also
obtained.
COMPARISON: [**2112-8-17**].
CT OF THE CHEST:
There is an endotracheal tube in place, in satisfactory
position. There is a left subclavian central line with its tip
in the right atrium. Coronary artery calcifications are noted.
The heart is borderline in size. There is no pericardial
effusion. There appears to be mild right atrial and right
ventricular enlargement. There are bilateral pleural effusions
with associated airspace disease that are not significantly
changed since the prior study. There is also a small loculated
pleural effusion in the region of the lingula. Evaluation of the
lung windows demonstrates patchy bilateral ground-glass
opacities involving both lungs (right greater than left)
suspicious for pneumonia and less likely asymmetric pulmonary
edema.
CT OF THE ABDOMEN WITH CONTRAST:
The liver is normal in size and contour. There is no
intrahepatic or extrahepatic biliary dilatation. Patient is
status post cholecystectomy. A common bile duct stent is in
place. There has been interval removal of the right percutaneous
drainage catheter. There has been marked improvement of
previously noted hemoperitoneum with some high-density inferior
edge of the liver as well as minimally hyperdense fluid in the
pelvis consistent with involving hematoma. There is moderate
amount of ascites. There is also a 4.5 x 3.0 cm fluid collection
adjacent to the caudate lobe. The right kidney demonstrates
homogeneous enhancement. Left kidney is not seen. The adrenal
glands are within normal limits. The spleen and pancreas are
unremarkable. There is diffuse anasarca in the subcutaneous soft
tissues. The celiac and superior mesenteric arteries are patent.
CT OF THE PELVIS:
There is large amount of fluid in the pelvis. A Foley catheter
is present in the urinary bladder.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Bilateral pleural effusions with atelectasis, unchanged.
Small loculated pleural effusion in the lingula region.
2. Patchy bilateral opacities involving predominantly upper
lobes may represent pneumonia and less likely pulmonary edema.
3. Large amount of fluid in the abdomen and pelvis just now
lower intensity consistent with involving hemoperitoneum. No new
foci of acute hemorrhage or active contrast extravasation are
identified.
4. Absence of the left kidney.
5. Diffuse anasarca.
RADIOLOGY Final Report
US ABD LIMIT, SINGLE ORGAN PORT [**2112-8-25**] 8:18 AM
US ABD LIMIT, SINGLE ORGAN POR
Reason: HX SEPTIC SHOCK W/ COLLECTION IN LIVER PLEASE ASSESS
COLLECTION
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with ARF, septic shock, s/p L nephrectomy, w/
collection in liver
REASON FOR THIS EXAMINATION:
please assess RUQ collection for possible drainage
INDICATION: 78-year-old man with recent cholecystectomy, abdomen
collection seen on recent CT, assess right upper quadrant
collection for possible drainage.
COMPARISON: Abdomen CT [**2112-8-24**].
FINDINGS: The liver shows no focal or textural abnormalities.
There is no biliary dilatation. The portal vein is patent with
hepatopetal flow. The hepatic veins and IVC are seen and are
patent. There is a right pleural effusion identified. Inferior
to the liver is a heterogeneous echogenic region consistent with
a complex hematoma in the gallbladder fossa. Since this area is
not well seen and because of its location it is not approachable
for drainage by ultrasound. Some ascites is identified within
the right and left lower quadrants.
IMPRESSION: Complex echogenic collection in the gallbladder
fossa is identified but is not approachable for drainage by
ultrasound guidance. Right pleural effusion. Ascites in lower
quadrants.
Brief Hospital Course:
Patient was transferred to the [**Hospital1 18**] for further work up. ERCP
was obtained : 1. Normal major papilla 2. Cannulation of the
pancreatic duct was successful and deep with a sphincterotome
using a free-hand technique. 3. A 7 cm by 5 Fr Zimmon single
pigtail pancreatic stent was placed successfully. 4. Cannulation
of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. This was done over a
pancreatic stent placed after the pancreatic cannulation. 5.
Normal CBD size with no obvious filling defects. 6. A 7 cm by 10
Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully using a
OASIS stent introducer kit. 7. A plastic stent was removed from
the main pancreatic duct successfully using a snare. CT scan of
the abdomen showed a large fluid collection consistent with
hematoma. He underwent an exploratory laparotomy with evacuation
of hematoma on [**8-17**]. He continued to have worsening liver
function with rising LFTs and bilirubin. Post-operatively
patient remained intubated.
By system: Neuro: Initially required sedatives while intubated.
These were subsequently stopped. However, given patients kidney
and liver failure, patient never recovered meaningful mental
recovery. Significantly encephalopathic.
Cardiovascular: Progressive hypotension requiring pressor
support. Initially good result with neosynephrine. Later during
hospital course required Pitressin to keep MAPs > 60. He did
not tolerate weaning of pressors
Pulmonary: Progressive respiratory failure requiring intubation
and ventilatory support. He subsequently developed findings
consistent with fluid overload and increasing FiO2 requirement
to keep PaO2 at an acceptable range.
GI: Progressive liver failure with Total bilirubin reaching 33.
Renal: Patient had a history of chronic renal insufficiency.
This was however complicated by his hospital course and he
developed frank renal failure requiring CVVH. Given his rising
pressor requirement, he did not tolerated any significant
diuresis.
ID: Patient was continued on broad spectrum antibiotics.
Cultures were positive for budding yeast from sputum only.
Repeated blood/urine/stool cultures were otherwise negative for
infection.
Despite all efforts, patients clinical status continued to
deteriorate. Multiple family meetings were held. The decision
was made that continuing with aggressive efforts would be
against the patient's and patient family's wishes. Pressors and
medications were stopped and patient expired shortly thereafter
on [**2112-9-3**].
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Multi-organ system failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2112-9-3**]
|
[
"998.12",
"287.5",
"998.11",
"427.31",
"511.9",
"995.92",
"038.9",
"585.9",
"280.0",
"584.9",
"428.0",
"403.90",
"250.00",
"998.59",
"785.52",
"414.01",
"576.1",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"51.87",
"96.72",
"97.56",
"51.85",
"52.93",
"54.19",
"38.93",
"34.04",
"96.6",
"87.54",
"97.55"
] |
icd9pcs
|
[
[
[]
]
] |
21932, 21941
|
19317, 21876
|
748, 816
|
22011, 22021
|
1688, 9860
|
22073, 22106
|
1626, 1644
|
21899, 21909
|
18196, 18278
|
21962, 21990
|
22045, 22050
|
1659, 1669
|
9883, 10438
|
273, 710
|
18307, 19294
|
844, 1379
|
1401, 1548
|
1564, 1610
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,578
| 115,245
|
7921
|
Discharge summary
|
report
|
Admission Date: [**2151-5-27**] Discharge Date: [**2151-5-31**]
Service: [**Last Name (un) **]
DATE OF DEATH: [**2151-5-31**], at 5:38 p.m.
CHIEF COMPLAINT: Status post fall.
HISTORY OF PRESENT ILLNESS: An 84-year-old female after a
fall from standing for unknown reason. The patient had
respiratory arrest and brief asystole. The patient was
intubated at the scene and brought to the emergency
department. The patient was found to be flaccid on initial
exam. The patient had a CT of the head and C-spine. C-spine
showed a comminuted type 2 dense fracture nearly 30 degrees
of leftward rotation of C1 on C2.
PAST MEDICAL HISTORY: Hypertension, history of multiple PEs,
interstitial lung disease on home O2, room air saturating
around 88% to 89%, diabetes, pulmonary artery hypertension,
DJD, history of stroke x2, the last one was [**2140**], without any
residual effect, status post cholecystectomy.
ALLERGIES: Vasotec.
MEDICATIONS: At home, Coumadin, metoprolol, Lasix,
glyburide, Protonix, Lipitor, Macrodantin.
PHYSICAL EXAMINATION: On physical examination, her
temperature was 98 degrees, heart rate was 43, blood pressure
was 117/47, respirations 12, saturating 100%. Her pupils were
2 mm and reactive. She was intubated. She was moving both
upper and lower extremities to pain. The patient had regular
rate and rhythm. The patient's lungs were clear. Abdomen was
soft, nontender, nondistended. The patient was guaiac
negative. Normal tone. There were no step-offs on the
examination of the spine. The patient had C-collar in place.
The patient had a CT of the C-spine and CT of the head that
showed no intracranial hemorrhage. CT of the C-spine showed
the comminuted type 2 dense fracture. CTA of the neck showed
no dissection. MR of the C-spine showed cord contusion at C2
and disruption of anterior ligaments. The patient's white
count was 8.9, hematocrit was 44. BUN was 18, creatinine was
1.3. UA was negative. Toxicology was negative.
HOSPITAL COURSE: The patient was admitted to the trauma
surgery service and was taken to the intensive care unit. The
patient was started on steroids with a bolus and a drip for
the concern for spinal cord injury. Cardiology was consulted
and recommended continuing supportive medical care. Ortho-
spine was consulted who recommended continuing the collar.
The patient had an elevated coag with 2.4 INR and that was
reversed and the patient was continued on ventilation. On
hospital day #2, the patient was continued on C-collar. The
patient had echocardiogram that showed significant pulmonary
artery hypertension with systolic around 80s with a very poor
right ventricular function. Per cardiology, recommend to
continue supportive care. The patient was kept NPO with a
Foley and the patient was slowly weaned from the ventilation.
On hospital day #3, the patient had acute change in ability
to move the upper extremity. The patient was given vitamin K
and FFP to reverse the coagulopathy for concern for possible
hemorrhage into the C-spinal canal. CT of the C-spine showed
a superior fragment of odontoid fracture, most posteriorly
displaced but not impinging on the cord. MR of the spinal
cord showed no cord compression but continued to have spinal
cord edema. CT of the head showed no acute process. The
patient also had acute respiratory decompensation where the
patient had CTA that initially showed no PE. The patient was
continued to be supported throughout. On hospital day #4,
the patient remained afebrile with stable vital signs and was
continued to be weaned from the propofol. The patient had
decreased movement of the upper extremity and only moved the
lower extremity with decreasing the vent support. The patient
was placed on Augmentin for Enterococcus urinary tract
infection. Approximately noon on hospital day #4, the patient
developed a significant respiratory and cardiac
decompensation. The patient was hypotensive, also tachycardic
to 150s, and urgent echocardiogram was obtained which showed
that the patient did not have a functioning right ventricle
and also the patient desaturated which were clinically
consistent with pulmonary emboli. At this time with her
injuries and also development of a new pulmonary emboli,
discussion was made with the family who made her DNR. The
patient was continuously supported with pressors and full
vent support and after subsequent discussion, the patient was
then made CMO. After the patient was CMO, the patient expired
at 5:38 p.m. on [**2151-5-31**].
CONDITION ON DISCHARGE: Death.
DISCHARGE STATUS: Death.
DISCHARGE DIAGNOSES:
1. Cervical spine fracture after a fall.
2. Pulmonary emboli.
3. Status post cholecystectomy.
4. Hypertension.
5. History of multiple pulmonary emboli.
6. Interstitial lung disease.
7. Diabetes.
8. Pulmonary artery hypertension.
9. Degenerative joint disease.
10. History of stroke.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2151-5-31**] 19:01:33
T: [**2151-5-31**] 20:07:36
Job#: [**Job Number 28464**]
|
[
"805.02",
"401.9",
"E885.9",
"415.19",
"276.8",
"416.8",
"515",
"250.00",
"276.0",
"599.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"99.07",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4580, 5136
|
1992, 4499
|
1062, 1974
|
172, 191
|
220, 626
|
649, 1039
|
4524, 4559
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,824
| 180,537
|
19275
|
Discharge summary
|
report
|
Admission Date: [**2115-4-4**] Discharge Date: [**2115-4-13**]
Date of Birth: [**2054-7-20**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Thrombocytopenia.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male status post liver transplant on [**2114-9-15**] complicated
by mild acute cellular rejection treated with Solu-Medrol. He
was seen yesterday in the clinic. He recently completed a
steroid taper, and liver biopsy was planned for a few weeks.
Labs drawn as an outpatient showed platelet count to be 35.
Previous platelet count was 44. The patient was called to the
come to the transplant center.
PAST MEDICAL HISTORY: Hepatitis C virus, alcohol cirrhosis,
ascites, hepatic artery stenosis, status post stent
placement, esophageal varices, umbilical hernia, inguinal
hernia repair, liver transplant in [**2114-9-15**], status post
umbilical and left inguinal hernia repair.
MEDICATIONS ON ADMISSION: Protonix 40 mg daily, Bactrim
single strength daily, vitamin D 400 IU daily, Lasix 20 mg
p.o. daily, calcium carbonate 500 mg p.o. q.i.d.,
dicloxacillin 100 mg p.o. daily, prednisone 15 mg p.o. daily,
Prograf 1.5 mg p.o. b.i.d., Rapamune 3 mg p.o. daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No habits. Nonsmoker. No alcohol.
PHYSICAL EXAMINATION: Vital signs: On admission T-max was
98.3, heart rate 84, blood pressure 138/77, respiratory rate
20, 97% on room air. General: No acute distress. Heart:
Regular rate and rhythm. Lungs: Clear bilaterally. Abdomen:
Soft, nontender, nondistended. Rectal: Normal tone. Guaiac
negative.
HOSPITAL COURSE: The patient was admitted to the transplant
service. Hepatitis C and CMV viral load were sent off. CMV
was not detected. Hepatitis C viral load was 23,100,000
IU/ml. Hematology consult was obtained. It was noted that the
patient had a bone marrow biopsy in late [**2113**] that showed no
evidence of overt myelodysplasia and maturing trilineage
erythropoiesis. Findings were consistent with peripheral
destruction of his hematopoietic cells.
It was felt to be likely exacerbated by drug-induced affects,
notably the calcineurin inhibitor was used for his
immunosuppression. Also suspected was Bactrim and
fluconazole. It was felt that the fluctuations in his
platelet count was reflective of medication changes.
Hepatitis C infection was also felt to be a positive factor
of the thrombocytopenia, as well as his liver dysfunction.
Heparin antibody were sent off. This was subsequently found
to be negative.
During his hospital course, vital signs remained stable.
White blood cell count ranged between 5.3 and 8.1. Hematocrit
on admission was 38.8. This trended down to 36.1. Platelet
count was 106 on admission, and this increased to 135,
subsequently decreasing to 100. Creatinine was stable at 1.0.
LFTs on admission showed an AST of 150, ALT 98, alkaline
phosphatase 222, total bilirubin 1.9, with an albumin of 4.8.
amylase and lipase were 77 and 18 respectively. INR was 1.2.
LFTs improved with an AST of 24, ALT 29, alkaline phosphatase
121, total bilirubin 0.9. He remained on Prograf 4 mg p.o.
b.i.d. Prograf levels were checked. These levels ranged
between 12.5 and 15.3.
Of note, he did complain of diarrhea. Stools were sent for C-
diff x 3. All were negative. Stool was also sent for O&P.
This was also negative. Given past history of hepatic artery
stricture with stent placement, a cardiac echocardiogram was
done. This demonstrated normal left ventricular cavity size,
left ventricular systolic function appeared depressed along
the posterior wall, which was hypokinetic. The right
ventricular systolic function also appeared depressed. Aortic
valve leaflets were mildly thickened. The mitral valve
leaflets were mildly thickened with 1+ mitral regurgitation
noted. There was no pericardial effusion.
On [**2115-4-8**], he underwent a transjugular liver biopsy.
He was given a bag of platelets pre-liver biopsy. Post
biopsy, he complained of some nausea and abdominal cramping.
Hematocrit post transjugular liver biopsy decreased to 25.7
from 27. He was transfused with 1 unit of packed red blood
cells.
CT scan was done to evaluate for hematoma. This demonstrated
a small subcapsular hematoma and a moderate amount of
hemorrhage within the abdomen and pelvis intermixed with a
large amount of ascites. He was transferred to the SICU for
monitoring.
Serial hematocrits were drawn. These were stable. He received
an additional 2 units of packed red blood cells and 2 units
of platelets. Hematocrit increased to 33.2 and a platelet
count of 94. Coags were 12.9 for PT, PTT were 25.7, and INR
was 1.1.
His liver biopsy tissue returned with changes consistent with
a recurrent viral hepatitis C, grade II inflammation.
Findings were indeterminate for acute cellular rejection.
He was transferred back to the medical surgical unit where
his hematocrit remained stable. Intravenous fluids was Hep-
Locked, and his diet was advanced to a regular diet. His
creatinine remained stable at 1.0. He remained on Prograf,
prednisone and Rapamune. Hematology followed throughout this
hospital course.
Rapamune was discontinued. Prograf continued at 2 mg p.o.
b.i.d. for a level of 9.6. Prednisone was continued. Vital
signs were stable. He was discharged home on [**2115-4-13**].
DISCHARGE MEDICATIONS: Prograf 2 mg p.o. b.i.d., Lasix 20 mg
p.o. daily, Bactrim was discontinued, Metoprolol 12.5 mg p.o.
b.i.d., Prednisone 15 mg p.o. daily, Protonix 40 mg p.o.
daily, doxycycline 100 mg p.o. b.i.d.
FOLLOW UP: The patient was scheduled to followup in the
outpatient clinic. He was instructed to call for a followup
appointment within 1 week.
DISCHARGE DIAGNOSIS:
1. Recurrent viral hepatitis C grade II inflammation.
2. Hepatitis C virus status post liver transplant.
3. Thrombocytopenia.
4. Subcapsular liver hematoma status post transjugular liver
biopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2115-4-22**] 14:07:17
T: [**2115-4-22**] 19:47:31
Job#: [**Job Number 52508**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"50.11"
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icd9pcs
|
[
[
[]
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5340, 5536
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5702, 6159
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1625, 5316
|
5548, 5681
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1324, 1607
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171, 190
|
219, 649
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672, 928
|
1266, 1301
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,875
| 161,923
|
28004+57548
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-6-12**] Discharge Date: [**2191-6-12**]
Date of Birth: [**2165-3-8**] Sex: M
Service: MEDICINE
Allergies:
Prozac / Haldol / thorazine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
altered mental status in setting of taking clonazepam and
[**First Name3 (LF) 21330**] for pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 26M w/PMHx significant for [**First Name3 (LF) 7344**] abuse and
multiple psych disorders was found altered by friend after
taking Clonazepam and [**Name (NI) **] for pain. Pt has had multiple
prior, recent hospitalizations related to drug abuse. Per prior
psych note on [**2191-5-17**] (time of prior ED eval for similar issues)
pt has multi axis diagnoses including Schizoaffective DO,
Borderline PD, Bipolar DO and heavy substance abuse and past med
hx of head injury, seizures and Hep C. Friends called EMS for
AMS and pt was brought to ED.
.
In the ED, initial vs were: 99.0 130 130/76 20 98%. Pt was
diaphoretic and tachy in the 130s. No clonus or hyperreflexia on
exam. Pupils 2mm-1 mm. Per report from friends, pt had taken a
large quantity of clonazepma and [**Date Range 21330**] (recently broke jaw for
which got [**Date Range 21330**] Rx). Agitated and wanted to leave; pt received
Haldol and Versed to calm him in addition to reportedly in 4pt
leather restraints. Tox screen showed tylenol level of 73
(unknown time of ingestion) and pt placed on NAC protocol for
tylenol: 150 mg/kg, then 12.5 mg/kg/hr over 4 hours, then 6.25
mg/kg/hr over 16 hours w/plan per Tox to check LFTs at 20 hours,
if not elevated stop NAC, if elevated continue; repeat tylenol
in 4hrs. EKG: SR@84 QRS 96 QTc 412. Pt wanted to leave, pulled
IV and during attempts to leave was tackled, sedated wtih 5
haldol + 2 mg of ativan + 5 of versed and placed in 4 point
restraints. Pt then fell asleep, w/VSS 70s 100% 3 l NC, RR 8, BP
112/71. Pt was admitted to the ICU for managment of extreme
agitation in setting of drug overdose and associated altered
mental status.
.
Of note, pt has history of SI/SA w/multiple psych
hospitalizations as well as admission for drug overdose/AMS or
injuries related to drug use. Also of note, pt historically
difficult to get concrete hx from.
.
.
On the floor, pt was sedated. Unable to relate hx. Rousable but
falls back asleep.
Past Medical History:
* multi axis diagnoses including Schizoaffective DO, Borderline
PD, Bipolar DO and heavy substance abuse
* [**Hospital1 1680**] HRI [**3-/2191**] and after care plans to f/u @ [**Location (un) 14221**]
Health with [**First Name8 (NamePattern2) 23368**] [**Last Name (NamePattern1) 1557**] [**Telephone/Fax (1) 68182**] on [**2191-4-13**] but did not
* no current treaters
* Pt reports mult diagnoses including ADHD dx @ 5 y/o, bipolar
do
* MDD, GAD and social anxiety, PTSD. Reports h/o hearing muffled
voices.
* Per BEST records, pt has h/o schizoaffective d/o and
depression
* and last admitted to [**Hospital1 1680**] in [**5-24**].
* Pt reports mult psychiatric admissions including [**Hospital1 **]
State x1 year @ age 20 for SA by jumping off bridge and
cutting wrists
* h/o SIB by cutting; h/o SI/SA.
* h/o DMH and case manager in [**Location (un) 1459**] , MA. no contact for
months
* Multiple med trials including quetiapine (felt tired),
wellbutrin, risperidal, clonazepam, effexor, trileptal,
Other PAST MEDICAL HISTORY:
* hx of grand mal seizures secondary to prior brain trauma and
alcohol
* craniotomy after a traumatic insult [**2184**]; ?reportedly hit by
bat
* prior stabbings to torso and back
* hepatic dysfunction
* HCV
* s/p assault on [**2191-1-21**] and seen @ [**Hospital1 18**] s/p Lt Zygomatic
arch fracture
Social History:
(per OMR, unable to get from pt)
[**Name (NI) **] abuse, EtOH abuse, tobacco use (>half ppd)
born and raised in [**Location (un) 86**]; left home at 16. Multiple arrests for
drinking in public and hx of serving 2 years in jail for armed
robbery, attempted manslaughter. Reportedly earned GED. ? of
works parttime at a bar in [**Location (un) 86**] where his "boyfriend" is the
manager but currently lives with his fiance' in her subsidized
apt in [**Location (un) 2973**] and she said she is pregnant with his child. Pt
parents live in [**Last Name (un) 68183**], MA., but he is estranged from them.
Family History:
Mother with depression and alcohol dependent
Physical Exam:
Vitals: T: 95.4 BP:110/59 P: 63 R: 12 O2: 97%
General: sedated but arousable, no acute distress, asking for
food but then falls asleep again
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated but limited exam
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, however pt sedated so exam
limited
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2191-6-12**] 03:35AM GLUCOSE-92 UREA N-17 CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
[**2191-6-12**] 03:35AM ALT(SGPT)-33 AST(SGOT)-97* LD(LDH)-358* ALK
PHOS-60 TOT BILI-0.7
[**2191-6-12**] 03:35AM CALCIUM-8.5 PHOSPHATE-3.6# MAGNESIUM-2.1
[**2191-6-12**] 03:35AM ACETMNPHN-13
[**2191-6-12**] 03:35AM WBC-3.3* RBC-4.64 HGB-14.2 HCT-43.5 MCV-94
MCH-30.5 MCHC-32.5 RDW-14.1
[**2191-6-12**] 03:35AM PT-15.3* PTT-28.0 INR(PT)-1.3*
[**2191-6-11**] 07:43PM GLUCOSE-101* UREA N-19 CREAT-1.3* SODIUM-137
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-21* ANION GAP-22*
[**2191-6-11**] 07:43PM ALT(SGPT)-33 AST(SGOT)-73* ALK PHOS-73 TOT
BILI-0.5
[**2191-6-11**] 07:43PM LIPASE-18
[**2191-6-11**] 07:43PM CALCIUM-9.8 PHOSPHATE-5.3*# MAGNESIUM-1.9
[**2191-6-11**] 07:43PM OSMOLAL-286
[**2191-6-11**] 07:43PM ASA-NEG ETHANOL-NEG ACETMNPHN-73*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2191-6-11**] 07:43PM WBC-5.9 RBC-4.90 HGB-15.4 HCT-45.1 MCV-92
MCH-31.4 MCHC-34.2 RDW-14.7
[**2191-6-11**] 07:43PM NEUTS-65.4 LYMPHS-21.5 MONOS-10.6 EOS-1.6
BASOS-1.0
[**2191-6-11**] 07:43PM PLT COUNT-184
[**2191-6-11**] 07:43PM PT-12.7 PTT-24.1 INR(PT)-1.1
Brief Hospital Course:
Pt is a 26M w/PMHx significant for [**Month/Day/Year 7344**] abuse and
multiple psych disorders admitted for overdose with tylenol
level 73, agitation
[**Hospital Unit Name 153**] course:
Tox consulted in [**Last Name (LF) **], [**First Name3 (LF) **] was put on NaC protocol, dc'ed in AM as
level decreased and LFTs wnl. Unclear if suicidal attempt or
not, but has had SI/SA in the past. Pt's fiancee pregnant and
this may have been a trigger. In ICU, he was hemodynamically
stable, had 1:1 sitter, and psych was consulted however patient
initally too somnolent for discussion with psych. He was
written for CIWA with valium considering his h/o EtOH abuse,
however did not require any. Continued home keppra and
neurontin. Initially patient with [**Last Name (un) **] with Cr elevated to 1.3,
resolved with IVF. Pt was able to tolerate PO in AM. Pt noted
to have leukopenia and low plts, HIV was considered, unable to
discuss with pt.
Transitional issues:
- psych recs
- SW
- HIV consent
Medications on Admission:
* Adderall 20mg [**Hospital1 **]
* Seroquel 200mg [**Hospital1 **]
* Keppra 250mg qam
* Neurontin 600mg qid
* Klonopin 2mg [**Hospital1 **]
* Celexa 20g [**Hospital1 **]
Discharge Medications:
1. quetiapine 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO BID (2 times a day).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Medication overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the intensive care unit for an overdose of pain
medications. It is dangerous to take medications, especially
pain medications such as [**Hospital1 21330**], which can cause dangerous side
effects including breathing problems, liver damage, and urinary
retention, among others. You also should not take medications
that are prescribed for other people as this can be unsafe.
Please follow up with your primary care doctor to treat your
pain as an outpatient. You should also consider a substance
abuse treatment program as you are using your medications not as
prescribed.
Changes to your medications:
No changes were made to your medications
Followup Instructions:
Please call to make an appointment with your primary care doctor
in [**1-16**] weeks.
Completed by:[**2191-6-12**] Name: [**Known lastname 11660**],[**Known firstname 168**] Unit No: [**Numeric Identifier 11661**]
Admission Date: [**2191-6-12**] Discharge Date: [**2191-6-12**]
Date of Birth: [**2165-3-8**] Sex: M
Service: MEDICINE
Allergies:
Prozac / Haldol / thorazine
Attending:[**First Name3 (LF) 10790**]
Addendum:
please see below for addendum to brief hospital course.
Brief Hospital Course:
Psychiatry service evaluated patient and concluded that overdose
was due to substance abuse and not related to suicidal ideation,
as the patient stated that he was in pain and was taking more
medications to try to relieve his pain. Medication abuse was
discussed with pt and it was recommended that he follow up with
his PCP regarding safe pain control and that he discuss
outpatient substance abuse treatment. Per psych, no psychiatric
barrier to discharge.
# Leukopenia: would consider HIV test as outpatient
Discharge Medications:
1. quetiapine 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO BID (2 times a day).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
[**Doctor First Name 3354**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 3353**] MD [**MD Number(2) 10791**]
Completed by:[**2191-6-12**]
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icd9cm
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45,317
| 103,029
|
42609
|
Discharge summary
|
report
|
Admission Date: [**2118-4-18**] Discharge Date: [**2118-7-5**]
Date of Birth: [**2054-9-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / meropenem / cefepime / vancomycin
Attending:[**First Name3 (LF) 38616**]
Chief Complaint:
Admission for allogenic stem cell transplant
Major Surgical or Invasive Procedure:
allogenic stem cell transplant
Right subclavian central venous line placement and removal
Right internal jugular cental venous line placement
bronchoscopy
Bone marrow biopsy
History of Present Illness:
63 year old woman with AML progressing out of MDS. She was
induced with 7+3 (daunorubicin and cytarabine) and achieved
remission. She has received 1 cycle of MiDAC for consolidation
on [**2118-2-28**].
She is admitted in CR1 for allogenic transplant on protocol
07-384. She reports feeling well, except for mild persistent
fatigue. She was examined today by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3236**], NP and Dr.
[**Last Name (STitle) **], who determined that she was OK to be admitted for
transplant today.
Past Medical History:
ONCOLOGY HISTORY:
- Panyctopenia noted on preop for excisional biopsy, CBC
revealed a white blood count of 2.2, hematocrit of 34.2,
platelet count of 116,000, and MCV of 101 at OSH.
- BM Bx at OSH on [**2117-12-7**] showed dyspoietic granulocytes and
13%
myeloblasts. There was no immunophenotypic evidence for
lymphoproliferative disorder and the findings were most
suggestive of a clonal myeloid neoplasm thought to be MDS with
excess blasts.
- Referred to [**Hospital1 18**], repeat BM bx on [**1-13**] showed 15% blasts on
aspirate and translocation between chromosome 6 at band 6p23 and
chromosome 9 at band 9q34
- s/p Idarubicin 7+3 induction Day 1: [**2118-1-21**] Cycle end:
[**2118-2-17**]. During her neutropenic period, she developed acute
fevers with focal erythroderm on her L forearm and distal L>R
leg. Prior to the hospitalization, she had a L parotidectomy for
what turned out to be parotiditis and sialadenitis with a large
retained duct stone. Ultimately, it became clear she had no
persistent infectious process in the parotid bed, but had
evolving carbapenem and cephalosporin erythroderm. Her rashes
improved dramatically with transition to from meropenem to
cefepime to aztreonam. Her course was further complicated by a
fever curve that had regular Tmax in the 101 range, resolving
while on vancomycin, aztreonam, clindamycin and micafungin, but
then recurred first low grade then becoming very hectic and high
grade to 104 without any focal findings. The vancomycin was
stopped and she defervesced after 72 hours. She soon thereafter
recovered her counts and all antibiotics were discontinued when
her ANC approached 500.
- [**2118-2-28**] - MiDAC Consolidation
OTHER PAST MEDICAL HISTORY:
-Osteoarthritis
-Left total knee replacement
-Remote cholecystectomy and appendectomy.
-Epilepsy with a history of grand mal seizures. Her last
seizure was four to five years ago. She is followed by a
neurologist in [**Hospital1 392**].
-Hypertension
-Anxiety.
Social History:
She has been married for 41 years. She is a retired post-office
worker. She has three daughters who all live locally. She is a
smoker who quit 26 years ago. She smoked one pack per week for
about 30 years. She does not drink any alcohol due to her
antiepileptic medications.
Family History:
Her mother died of heart complications. Her father died of
emphysema. She has a healthy brother. She has a daughter who was
diagnosed with colon cancer at age 29, currently in remission.
She has another daughter age 31 with a pituitary
tumor and she has a third daughter who is healthy.
Physical Exam:
Admission Physical Exam:
VS: 98.6 133/86 89 18 99%RA Weight: 276 Height 62 BMI:
50.5
Gen: WD/overnourished in NAD
HEENT: alopecia, anicteric, [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**], clear OP, supple neck,
no masses
Lungs: CTAB
CV: RRR NL S1,S2; no murmurs, rubs or gallops
Abd: Soft, obese, non-tender no HSM or masses
Skin: Reddish reticular flat pruritic rash on left side of back
Ext: without C/C/E; petechial and confluent rash on bilteral LE
resolved
Neuro: Non-focal and symmetric
.
Discharge Physical Exam
VS: tc 98.0, 142-158/72-78, 70, 18-20, 99% RA.
Gen: obese woman in NAD
HEENT: alopecia, anicteric, [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**], clear OP, supple neck,
no masses
Lungs: CTAB
CV: RRR NL S1,S2; no murmurs, rubs or gallops
Abd: Soft, obese, non-tender no HSM or masses
Skin: Reddish reticular flat pruritic rash on left side of back
Ext: without C/C/E; petechial and confluent rash on bilteral LE
resolved
Neuro: Non-focal and symmetric
Pertinent Results:
ADMISSION LABS:
[**2118-4-18**] 08:00AM BLOOD WBC-4.6 RBC-3.72* Hgb-12.6 Hct-37.8
MCV-102* MCH-33.9* MCHC-33.4 RDW-17.2* Plt Ct-211
[**2118-4-19**] 12:00AM BLOOD WBC-6.9 RBC-3.34* Hgb-11.4* Hct-33.3*
MCV-100* MCH-34.1* MCHC-34.1 RDW-17.1* Plt Ct-109*
[**2118-4-20**] 12:00AM BLOOD WBC-5.5 RBC-3.12* Hgb-10.8* Hct-31.3*
MCV-100* MCH-34.6* MCHC-34.5 RDW-16.8* Plt Ct-100*
[**2118-4-18**] 08:00AM BLOOD Neuts-53.6 Lymphs-24.1 Monos-10.2
Eos-10.4* Baso-1.7
[**2118-4-19**] 12:00AM BLOOD Neuts-94* Bands-2 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2118-4-20**] 12:00AM BLOOD Neuts-95.9* Lymphs-0.7* Monos-3.1 Eos-0
Baso-0.2
[**2118-4-19**] 12:00AM BLOOD Fibrino-211
[**2118-4-20**] 12:00AM BLOOD Fibrino-250
[**2118-4-21**] 12:20AM BLOOD Fibrino-234
[**2118-5-30**] 03:20PM BLOOD CD3%-89.1 CD3Abs-307 16/56%-9.9
16/56Ab-34
[**2118-4-23**] 12:00AM BLOOD Ret Aut-1.6
[**2118-5-30**] 03:20PM BLOOD WBC-4.3 Lymph-8* Abs [**Last Name (un) **]-344 CD3%-80 Abs
CD3-275* CD4%-39 Abs CD4-135* CD8%-38 Abs CD8-130* CD4/CD8-1.0
[**2118-4-18**] 09:15AM BLOOD UreaN-18 Creat-0.9 Na-140 K-4.8 Cl-103
HCO3-29 AnGap-13
[**2118-4-19**] 12:00AM BLOOD Glucose-174* UreaN-16 Creat-0.8 Na-137
K-4.3 Cl-101 HCO3-24 AnGap-16
[**2118-4-20**] 12:00AM BLOOD Glucose-178* UreaN-16 Creat-0.8 Na-133
K-4.3 Cl-99 HCO3-26 AnGap-12
[**2118-4-18**] 09:15AM BLOOD ALT-12 AST-18 LD(LDH)-189 AlkPhos-61
TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2118-4-21**] 12:20AM BLOOD LD(LDH)-175
[**2118-4-22**] 12:00AM BLOOD ALT-12 AST-11 LD(LDH)-163 AlkPhos-46
TotBili-0.2
[**2118-5-20**] 07:37AM BLOOD CK-MB-4 cTropnT-0.06*
[**2118-5-20**] 02:37PM BLOOD cTropnT-0.15*
[**2118-5-20**] 08:32PM BLOOD CK-MB-4 cTropnT-0.08*
[**2118-4-18**] 09:15AM BLOOD TotProt-6.6 Albumin-4.2 Globuln-2.4
Calcium-10.1 Phos-3.4 Mg-1.9 UricAcd-5.9*
[**2118-4-19**] 12:00AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.5*
[**2118-4-20**] 12:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
<31 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.1 <0.5
URINE:
CSF:
[**2118-5-23**] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-285*
Polys-33 Lymphs-10 Monos-0 Eos-2 Macroph-55
[**2118-5-23**] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-81* Polys-3
Lymphs-17 Monos-0 Macroph-80
[**2118-5-23**] 05:12PM CEREBROSPINAL FLUID (CSF) TotProt-31 Glucose-74
LD(LDH)-18
Test Result Reference
Range/Units
CMV DNA, QL PCR NOT DETECTED Not
Detected
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Virus 6 DNA, Qualitative Real-Time PCR
HHV-6 DNA Not Detected Not
Detected
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
[**Doctor Last Name 3271**] [**Doctor Last Name **] Virus DNA, Qualitative Real-Time PCR
EBV DNA, QL PCR Not Detected
Not Detected
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
---------------
Herpes Simplex Virus PCR
Specimen Source CSF
Result Negative Not
Applicable
MICRO:
WOUND CULTURE (Final [**2118-4-29**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
C. difficile DNA amplification assay (Final [**2118-5-1**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
Blood Culture, Routine (Final [**2118-5-9**]):
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 4 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2118-5-7**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN @ 0231 ON
[**2118-5-7**].
Aerobic Bottle Gram Stain (Final [**2118-5-7**]):
GRAM POSITIVE COCCI IN CLUSTERS.
WOUND CULTURE (LINE TIP) (Final [**2118-5-10**]):
STAPHYLOCOCCUS EPIDERMIDIS. <15 colonies.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Blood cultures ([**5-7**], [**5-14**], [**5-15**], [**5-17**], [**5-19**], [**5-20**], [**5-21**], [**5-22**],
[**5-24**], [**5-25**], [**5-26**]): no growth
Urine cultures ([**5-15**], [**5-17**], [**5-20**], [**5-22**], [**5-24**]): no growth
CMV Viral Load (Final [**2118-5-18**]):
1,040 copies/ml.
Respiratory Viral Culture (Final [**2118-5-19**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
[**2118-5-17**] 2:23 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
PLS R/O KLEBSIELLA. R/O CMV.
GRAM STAIN (Final [**2118-5-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2118-5-19**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2118-5-24**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2118-5-17**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2118-5-17**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2118-5-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Final [**2118-5-20**]):
TEST CANCELLED, PATIENT CREDITED.
FURTHER [**Location (un) **] OF THE CULTURE WILL BE PERFORMED ON
REQUEST ONLY.
Refer to CMV early antigen test result for further
information.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
CULTURE REQUESTED BY DR [**First Name (STitle) **].
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2118-5-20**]):
POSITIVE FOR CYTOMEGALOVIRUS.
Early antigen detected by immunofluorescence.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2118-5-20**]
11:10AM.
[**2118-5-17**] 2:23 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
PLS R/O KLEBSIELLA. R/O CMV.
GRAM STAIN (Final [**2118-5-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2118-5-19**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2118-5-24**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2118-5-17**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2118-5-17**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2118-5-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Final [**2118-5-20**]):
TEST CANCELLED, PATIENT CREDITED.
FURTHER [**Location (un) **] OF THE CULTURE WILL BE PERFORMED ON
REQUEST ONLY.
Refer to CMV early antigen test result for further
information.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
CULTURE REQUESTED BY DR [**First Name (STitle) **].
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2118-5-20**]):
POSITIVE FOR CYTOMEGALOVIRUS.
Early antigen detected by immunofluorescence.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2118-5-20**]
11:10AM.
Respiratory Viral Culture (Final [**2118-5-20**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2118-5-18**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
CMV Viral Load (Final [**2118-5-20**]):
9,380 copies/ml.
Performed by PCR
CMV Viral Load (Final [**2118-5-24**]):
1,470 copies/ml.
Performed by PCR.
CSF: CRYPTOCOCCAL ANTIGEN (Final [**2118-5-23**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
STUDIES:
ECG ([**4-18**]): rate 86. Sinus rhythm. Within normal limits.
EEG ([**4-20**]):
IMPRESSION: This is an abnormal EEG due to the presence of
moderate
diffuse background slowing and frequent generalized bursts of
high
amplitude slow waves. These findings are indicative of a
moderate
diffuse encephalopathy which suggests widespread cerebral
dysfunction
but is etiologically non-specific. There were no epileptiform
features.
ECG ([**4-23**]): Sinus rhythm. Non-specific inferior ST-T wave
flattening.
INVESTIGATION OF TRANSFUSION RXN ([**2118-4-29**]):
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mrs. [**Known lastname **]
experienced
chills and urticaria after receiving an infusion of
hematopoietic stem
cells. The laboratory work-up revealed no evidence of hemolysis.
Noncryopreserved allogeneic stem cell products are generally
well
tolerated. Approximately 2% of infusions will be complicated by
chills
likely resulting from recipient anti-HLA antibodies reacting
with donor
white blood cells. Additionally, recipient antibodies against
plasma
proteins present in the component may cause allergic type
reactions
characterized by urticaria. We recommend no changes in infusion
practice
in the patient at this time.
INVESTIGATION OF TRANSFUSION RXN ([**2118-5-4**]):
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mrs. [**Known lastname **]
experienced a
urticarial reaction after transfusion of an apheresis platelet
transfusion. Urticarial transfusion reactions are thought to be
triggered by exposure to soluble substances/antigens within the
donor
product that cause IgE mediated histamine release. Urticarial
reactions
complicate 1-3% of transfusions. The presence of one urticarial
transfusion reaction does not predict future reactions. We
recommend no
changes in standard transfusion practices in this patient at
this time.
CT Head noncon ([**2118-5-4**]):
1. No acute intracranial hemorrhage, edema or mass effect.
2. Highly symmetric confluent hypoattenuation in bihemispheric
white matter, unusual for typical sequelae of chronic small
vessel ischemic disease, and more characteristic of intrathecal
methotrexate or other treatment-effect, which should be
correlated with more detailed clinical information.
INVESTIGATION OF TRANSFUSION RXN ([**2118-5-13**]):
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname **] developed
an
urticarial reaction after receiving a bag of apheresis platelets
on
[**2118-5-13**]. Urticarial transfusion reactions are thought to be
triggered by
exposure to soluble substances/antigens within the donor product
that
cause IgE mediated histamine release. Urticarial reactions
complicate
1-3% of transfusions. The presence of occasional urticarial
transfusion
reactions does not typically predict future severe reactions. We
recommend no changes in transfusion practices in this patient at
this
time.
ct head noncontrast ([**5-13**]):
1. No acute intracranial process.
2. Stable periventricular and subcortical white matter
hypodensities may be
related to intrathecal methotrexate or other treatment effect
and less likely the sequela of chronic microvascular ischemic
disease.
3. Mild global atrophy.
ct chest non-con([**5-16**]):
1. Diffuse ground-glass opacities within the entire right lung.
These
findings are not typical of any one particular etiology. Given
that the
patient is status post bone marrow transplant prior to
engrafting, bacterial, viral, and fungal etiologies should all
be considered including infections such as toxoplasmosis or CMV.
2. Bilateral trace pleural effusions, right greater than left.
Echo ([**5-17**]):
The left atrium is mildly dilated. 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
diameters of aorta at the sinus, ascending and arch levels are
normal. No masses or vegetations are seen on the aortic valve.
There is no aortic valve stenosis. No aortic regurgitation is
seen. No mass or vegetation is seen on the mitral valve. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2118-3-29**], no
change.
renal u/s ([**5-17**]):
IMPRESSION: No hydronephrosis bilaterally.
cxr ([**5-18**]);
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The severity and extent of the pre-existing extensive
bilateral
parenchymal opacities is constant. Also constant is the absence
of pleural
effusions, the moderate cardiomegaly and the position of the
right internal
jugular vein catheter.
LENI ([**5-19**]):
1. No DVT to the popliteal veins bilaterally. Bilateral calf
veins not well
visualized.
2. Right popliteal [**Hospital Ward Name 4675**] cyst.
CXR ([**2118-5-21**]):
1. Right internal jugular central line has its tip in the distal
SVC,
unchanged. When compared to the most recent prior study, there
has been
slight interval improvement in the bilateral airspace process
suggestive of
moderate-to-severe pulmonary edema. However, there is still a
substantial
residual pulmonary edema present on the current examination.
Overall, cardiac and contours are likely unchanged. No evidence
of pneumothorax.
CT head noncon ([**5-21**]):
1. No acute intracranial process.
2. Stable periventricular and subcortical white matter
low-attenuating
regions may be related to treatment effect or the sequelae of
chronic small
vessel ischemic disease.
3. Mild age-related involutional changes.
EEG ([**5-22**]):
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of a diffuse encephalopathy manifest by a mild to moderate
background
slowing. Superimposed upon this is focal slowing in the left
central
temporal region with superimposed admixed paroxysmal
epileptiform
transients in the same region. No seizures were identified.
CXR ([**5-22**]);
There is a right central venous catheter with distal lead tip in
distal SVC.
Heart size is upper limits of normal. There are again seen
diffuse airspace
densities and more confluent areas of opacity within the left
lobe. These may represent pulmonary edema; however, superimposed
infection is not entirely excluded. A small left-sided pleural
effusion is also seen.
UENI ([**5-22**]):
IMPRESSION: No evidence of DVT in the right upper extremity.
EEG ([**5-23**]):
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of disorganized theta and delta background indicative of mild to
moderate diffuse encephalopathy. In addition, there is focal
slowing in
the left frontocentral region with superimposed epileptiform
discharges.
There were no electrographic seizures. Compared to the prior
day's
recording, there were no significant changes.
CSF ([**5-23**]):
Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Rare lymphocytes.
EEG ([**5-24**]):
MPRESSION: This is an abnormal continuous ICU monitoring study
because
of disorganized theta and delta background indicative of mild to
moderate diffuse encephalopathy. In addition, there is focal
slowing in
the left frontocentral region with superimposed epileptiform
discharges.
There were no electrographic seizures. Compared to the prior
day's
recording, there were no significant changes.
KUB ([**5-25**]):
IMPRESSION: Limited study. No evidence of obstruction.
CT Chest non-con ([**5-27**]):
IMPRESSION: Increased pulmonary ground-glass opacities and
interstitial
abnormality. New pleural and increased pericardial effusions.
Appearance is
most compatible with viral infection, such as CMV, or
Pneumocystis. Graft
versus host disease could also have this appearance, but should
also produce extrathoracic manifestations.
BMB [**2118-5-31**]:
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
normochromic and normocytic with slight anisopoikilocytosis
including rare teardrop microcytes and schistocytes seen. The
white blood cell count appears decreased. Platelet count
appears decreased; large forms are seen. Differential shows 72%
neutrophils, 4% monocytes, 10% lymphocytes, 4% eosinophils, 2%
basophils, 3% metamyelocytes.
Aspirate Smear:
The aspirate material is suboptimal for evaluation due to
paucity of spicules and hemodilution. M:E ratio is 5:1
(hemodilution). Erythroid precursors are relatively,
proportionately decreased in number and exhibit dyspoietic
maturation; forms with irregular nuclear contours are seen.
Myeloid precursors appear relatively increased in number.
Abnormal nuclear lobation and hypogranular forms are seen.
Megakaryocytes are not seen.
A 200 cell differential shows 4% Promyelocytes, 7% Myelocytes,
22% Metamyelocytes, 45% Bands/Neutrophils, 7% Lymphocytes, 15%
Erythroid.
Clot Section and Biopsy Slides:
The core biopsy material is suboptimal for evaluation, severely
limited by aspiration and crush artifact. It consists of a 0.8
cm core, trabecular marrow with a cellularity of 5%. Minimal
hematopoietic tissue is seen in one space. No excess of blasts.
Erythroid precursors are decreased in number and exhibit mildly
dyspoietic maturation. Myeloid precursors are decreased in
number with complete maturation to neutrophilic stage with left
shifted maturation with dyspoietic maturation. Blood clot is
non-contributory.
SKIN BIOPSY [**2118-6-2**]:
Skin, left inferior abdomen, biopsy (A-B):
Mild superficial perivascular lymphocytic infiltrate, with
occasional eosinophils, see note.
Note: Rare dyskeratotic keratinocyte are seen. The interface
changes are minimal, and although early graft versus host
disease cannot be entirely excluded, the findings are more in
favor of a drug hypersensitivity reaction. Clinical correlation
is recommended. Multiple levels examined.
MR HEAD [**2118-6-1**]:
1. No acute intracranial abnormality.
2. No pathologic focus of enhancement.
3. Extensive FLAIR-signal abnormality in bihemispheric
subcortical and
periventricular, as well as central pontine white matter.
Though this likely represents sequelae of chronic small vessel
ischemic disease, a contribution of treatment effect is a
consideration, and should be closely correlated with detailed
history (e.g. Is there any history of intrathecal methotrexate
or other chemotherapeutic [**Doctor Last Name 360**]?).
NCHCT [**2118-6-9**]:
There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. Periventricular and subcortical white matter
hypodensities are suggestive of chronic small vessel ischemic
disease. The ventricles and sulci are normal in size and
configuration. There is no fracture. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
Chest CT [**2118-6-17**]:
There is been marked improvement in the interstitial opacities
in
the lungs with mild residual or recurrent disease seen in the
right lower
lobe. Bilateral pleural effusions have resolved. A small
unchanged cyst is seen in the left upper lobe. Right internal
jugular catheter terminates in the distal SVC.
The thyroid is normal and symmetric in appearance. Normal three
vessel
branching aortic arch is seen with mild atherosclerotic
calcification. The heart appears normal with mitral and aortic
valvular calcifications and perhaps mild calcification of the
left main coronary artery. Small
pericardial effusion is unchanged or minimally more prominent
than the
previous examination. No pathologically enlarged axillary,
supraclavicular, mediastinal or hilar nodes are seen. The
esophagus is normal in appearance. The trachea and central
airways are patent to the segmental level.
Although this study is not tailored for subdiaphragmatic
evaluation imaged
upper abdomen reveals unchanged left adrenal lipoma. Rounded
low-attenuation structure in the pancreatic tail is likely
invaginated fat. Calcification is seen at the celiac and SMA
origins
[**2118-6-20**] Radiology MR HEAD W/O CONTRAST
IMPRESSION: 1. No evidence of acute infarct or hemorrhage. 2.
Stable bilateral subcortical and periventricular T2/FLAIR
hyperintensities likely representing microangiopathic ischemic
changes versus post-treatment changes.
[**2118-6-20**] Radiology CT ABD & PELVIS W/O CON .
IMPRESSION: 1. No evidence of PTLD on this non-contrast CT of
the abdomen. 2. Diverticulosis, without evidence of
diverticulitis. 3. Pericardial thickening, unchanged from
[**2118-1-23**]. 4. Nonspecific peribronchovascular ground-glass
opacity in the right lower lobe. 5. Hypodense blood pool,
consistent with anemia.
[**2118-6-21**] Neurophysiology EEG .
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of one electrographic seizure in the left temporal
region with spread to the left parasagittal area lasting 48
seconds. On video, patient's view is limited but there is no
obvious ictal clinical correlation; however, immediately in the
postictal phase, she has an arousal with purposeful movements.
In addition, there are frequent left temporal epileptiform
discharges and intermittent prominent slowing in this region.
These findings are indicative of an epileptogenic focus with
underlying subcortical dysfunction in the left temporal lobe.
Furthermore, the posterior dominant rhythm was poorly sustained
with further bursts of bifrontal intermittent rhythmic delta
(FIRDA) slowing indicative of mild to moderate diffuse cerebral
dysfunction. Potential causes include, but are not limited to,
medication effect, or metabolic, toxic, and infectious
disturbances.
[**2118-6-22**] Neurophysiology EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of occasional left temporal epileptiform discharges as
well as intermittent significant slowing in this region. These
findings are suggestive of a potentially epileptogenic focus in
the left temporal region with underlying subcortical
dysfunction. In addition, the posterior dominant rhythm was not
well-sustained and there were frequent bursts of bifrontal
intermittent rhythmic delta (FIRDA) slowing indicative of mild
to moderate diffuse cerebral dysfunction. Potential causes
include, but are not limited to, medication effect or metabolic,
toxic, and infectious disturbances. There are no electrographic
seizures. Compared to prior day's recording, this study shows
improvement due to less frequent left temporal epileptiform
discharges and the absence of electrographic seizures.
[**2118-6-23**] Neurophysiology EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of intermittent focal slowing and rare epileptiform
discharges in the left temporal region. These findings are
indicative of a potentially epileptogenic focus in the left
temporal region with underlying subcortical dysfunction. There
is also a poorly sustained alpha rhythm, excess diffuse admixed
theta and delta activity and rare bursts of frontal intermittent
rhythmic delta activity. These findings are indicative of mild
to moderate diffuse cerebral dysfunction which is etiologically
non-specific. There are no electrographic seizures. Compared to
the prior day's recording, there is less frequent and less
prominent left temporal slowing and epileptiform discharges have
also decreased in frequency.
Discharge labs:
[**2118-7-5**] 12:00AM BLOOD WBC-2.1* RBC-2.58* Hgb-7.9* Hct-24.0*
MCV-93 MCH-30.7 MCHC-33.0 RDW-19.1* Plt Ct-83*
[**2118-7-5**] 12:00AM BLOOD WBC-2.1* RBC-2.58* Hgb-7.9* Hct-24.0*
MCV-93 MCH-30.7 MCHC-33.0 RDW-19.1* Plt Ct-83*
[**2118-7-5**] 12:00AM BLOOD Neuts-67 Bands-1 Lymphs-21 Monos-4 Eos-6*
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2118-7-5**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) 833**]
[**Name (STitle) 4486**] Ellipto-OCCASIONAL
[**2118-7-5**] 12:00AM BLOOD Plt Ct-83*
[**2118-7-3**] 11:39PM BLOOD Gran Ct-2450
[**2118-6-30**] 01:43PM BLOOD WBC-1.4* Lymph-19 Abs [**Last Name (un) **]-266 CD3%-71
Abs CD3-188* CD4%-31 Abs CD4-84* CD8%-35 Abs CD8-93* CD4/CD8-0.9
[**2118-6-30**] 01:43PM BLOOD CD3%-79.2 CD3Abs-211 16/56%-19.0
16/56Ab-51
[**2118-7-5**] 12:00AM BLOOD Glucose-107* UreaN-24* Creat-1.7* Na-134
K-4.1 Cl-106 HCO3-20* AnGap-12
[**2118-7-5**] 12:00AM BLOOD ALT-7 AST-16 LD(LDH)-311* AlkPhos-65
TotBili-0.3
[**2118-7-5**] 12:00AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.6 Mg-2.0
[**2118-6-30**] 01:43PM BLOOD IgG-1471 IgA-222 IgM-122
[**2118-7-5**] 09:45AM BLOOD Cyclspr-PND
[**2118-7-3**] 09:43AM BLOOD Cyclspr-112
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
63 year old woman with AML progressing out of MDS who was
admitted in CR1 on [**2118-4-18**] for allogenic transplantation.
Admission complicated by bacteremia, hyponatremia/SIADH, mild
mucositis, CMV pneumonitis and altered mental status.
ISSUES:
# AML: s/p 7+3 (daunorubicin and cytarabine) and achieved
remission. She has received 1 cycle of MiDAC for consolidation
on [**2118-2-28**]. The patient was admitted for allogenic stem cell
transplant with conditioning regimen of TLI, ATG, and
clofarabine. Transplant on [**2118-4-29**]. She tolerated the transplant
well. She was provided zofran for nausea. The patient was on
acyclovir for prophylaxis. Fluconazole prophylaxis was not
initiated during admission secondary to medication interaction
with anti-epileptic medications, micafunfin was used instead.
Her counts started to recover near the beginning of [**Month (only) 116**], but
then decreased again. She needed support with intermittent blood
transfusions and injections of filgrastim. She had a repeat bone
marrow biopsy on [**2118-6-29**], which preliminarily showed hypoplastic
marrow consistent w/ suppression from medication (suspected to
be due to valgancyclovir, see below). Pt will need to have
continued follow-up for her continued neutropenia. For now, Pt
will need continued filgrastim 480 mcg sc on Mon and Thursday,
with 2x weekly CBC with differential. Pt was started on
cyclosporine and mycophenolate for graft-versus host
prophylaxis, which has been tapered to current dosage of
cyclosporine 50mg po q12h and mycophenolate mofetil 250mg po
bid. Pt will need continued cyclosporine levels weekly with
results faxed to primary oncologist Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 21962**].
# Bacteremia: Patient found to have staph epidermitis bacteremia
[**2-24**] line infection, complicated by fevers to 103 and severe
rigors. Fevers resolved and blood cultures cleared with addition
of Daptomycin and Aztreonam and replacement of her central line.
Other infectious sources, including UA and CXR remained normal.
# Hypoxia: Patient desaturated on night of [**5-20**] and was in
respiratory distress. Was in ICU for 5 days for respiratory
distress (likely caused by CMV pneumonitis and pulmonary edema).
CMV VL positive. Never required intubation. Now stable on 3-5L
NC, on meropenem, micafungin and gancyclovir. Received IVIG as
well. Of note, pt has many allergies, most notably antibiotic
allergies that have caused severe and painful body rashes.
Patient was desensitized of meropenem in ICU, and if pt comes
off of meropenem, would need to be desensitized again if want to
put it back on. Per ID, will continue meropenem through
Monday, [**5-30**], as low likelihood infection in lung is a bacterial
cause. Follow-up CT scan done [**5-27**] shows worsening of pulm
interstitial and ground glass, but patient clinically much
better. Patient has had no fevers since [**5-25**]. qMON CMV VL were
drawn. Patient also had pulmonary edema. Has already been
diuresed about 11L in ICU and a couple more slowly on floor.
Patient responded to PRN 40mg IV lasix doses.
.
# CMV PNEUMONITIS: patient was admitted to the ICU on [**5-20**] in
the setting of acute respiratory distress as above. At this
time a CMV viral load returned elevated at 9000. She was
initially treated with gancyclovir and anti-CMV IVIG starting on
[**5-18**]. Her over all clinical status improved and she was
gradually weaned from oxygen. On [**5-30**] her CMV VL again was
elevated to 22,000 raising concern for gancylcovir resistance
and she was switched to foscarnate on [**5-31**]. She continued to do
well clinically, but developed acute renal insufficency with a
gradual rise in her creatinine from 1.0 to 2.2 over the 2 weeks
she recieved foscarnate. Pt was switched to gancyclovir on [**6-11**]
and placed on maintenace dosing of 1.4 mg/kg on [**6-17**]. Interval
Chest CT on [**6-17**] showed dramatic improvement in her pulmonary
infiltrates. A CMV resistance genotype was sent and was
negative for any resistant mutations. Pt was switched to
valgancyclovir and on a dose of 450mg po daily after discussion
with ID attending and CMV viral load was not detectable x 4
after [**2118-6-6**], to be continued until 12 months after her
transplant ([**2119-4-29**]). Pt will need to have weekly CMV
viral loads. Given her continued need for valgancyclovir, Pt
will need filgrastim and 2x weekly CBC (see below).
# Hyponatremia. While undergoing conditioning for transplant,
the patient became hyponatremic to 129. Serum/Urine OSM
consistent with SIADH. The patient is chronically on
oxcarbamazepine, but no other new offending medications were
identified as the source of her hyponatremia. The patient was
started on a 1L fluid restriction, but continue to have
persistent hyponatremia. The patient was evaluated by the renal
team and was started on 1 salt tab TID. Sodium stabilized around
130. The patient was also on hypertonic saline for a brief
amount of time. While anti-epileptics changed in ICU, pt was
able to keep Na of low 130s w/ no need for hypertonic saline or
salt tabs, only fluid restriction. However, later during her
admission, Pt's sodium was still low but her hyponatremia was in
the setting of [**Doctor First Name 48**] and appropriately dilute urine (low osms).
Pt's hyponatremia was resolved and sodium was stable by
discharge at ~135, although pt continued to have mild diuresis.
Pt will need 2x weekly Chem 7 (Na, K, Cl, HCO3, BUN, Cr, Gluc).
# Back pain: Patient with low midline back pain that began when
getting onto a CT scanner table. Back pain-free at rest, but
present with movement. Back pain likely mechanical secondary to
strain. Pain improved with lidocaine patch.
.
# Esophagitis: While neutropenic, the patient experienced mild
symptoms of mucositis. However, she was able to tolerate food
by first eating something cold, such as a popsicle.
Breakthrough symptoms were controlled on oxycodone 5 mg PO and
resolved prior to discharge.
# Seizures : The patient's home regimen was: LeVETiracetam 500
mg [**Hospital1 **], Clonazepam 0.5 mg TID:PRN, Oxcarbazepine 900 mg PO BID.
Patient had 48hrs EEG w/out definitive seizures, but
seizure-like activity while in the ICU. neuro changed
anti-epileptics, and they are following. currently on keppra and
lacosamide. CT head on [**5-21**] had no acute intracranial changes.
Patient also had altered mental status in the ICU, unclear
whether etiology was seizures vs. ICU delirium. Patient's mental
status at baseline prior to discharge from the ICU. Begining the
week of [**6-16**] the patient was again noted to be slightly
lethargic and confused. Neurology was contact[**Name (NI) **] and agreed with
decreasing her dose of keppra in the setting of her renal
insufficency this change was made on [**6-18**]. Pt had more seizures,
as evidenced on EEG. Her keppra was increased back to 750mg po
bid as her renal function improved, and her seizure activity
lessened as viewed on EEG. Pt was discharged on levetiracetam
750mg po bid and Lacosamide 150 mg po bid for seizure
prophylaxis. She should see neurology for possible uptitration
of her medications as an outpatient since her latest EEG showed
some minor epileptiform activity, although she is currently
asymptomatic.
# acute renal insufficiency: Patient initially developed acute
renal insufficency on [**5-5**] in the setting of gancyclovir
administration and her acute clinical deterioration related to
CMV infection. She was maintained supportively and her
creatinine reached a max of 2.0 before returning to baseline of
1.0 on [**5-27**]. On [**6-1**] her creatinine was again noted to be
elevated in the setting of foscarnate administration for
refractory CMV infection as described above. This trend
continued before hitting a max of 2.4 on [**6-16**], nephrology was
again consulted and felt that her [**Doctor First Name 48**] was multifactoral from
several nephrotoxic medications. Micafungin and foscarnate were
discontinued and her renal function improved slightly but then
regressed. Renal service was reconsulted on [**2118-6-27**]. Urine only
had a few muddy brown casts, not really consistent with ATN or
AIN. Renal service is also unclear on etiology of [**Name (NI) 1094**] continued
diuresis or hyponatremia (see above). Renal feels that it may be
related to medications, including cyclosporin and suggested
lower dosing. Also felt that hypovolemia may be contributing and
mild response with fluids. Cyclosporin was decreased, with level
112 on [**2118-7-3**]. Pt's creatinine on discharge is 1.7. Pt will
need 2x weekly chemistry panels (see above).
.
# HYPERCALCEMIA: on [**6-14**] the patient's calcium was noted to be
elevated to 11.0 despite her hypoalbuminemia. A venous free
calcium was sent and returned elevated at 1.5 confirming
hypercalcemia. Initially her fluids were increased to promote
diuresis without effect. PTH was inappropriately elevated at 29,
but not felt to be the primary driving mechanism of her
hypercalcemia. Endocrinology was consulted and felt that her
elevated calcium and phosphate was the result of primary
hyperparathyroidism combined with secondary causes including
imobility. Various efforts to control her hypercalceima were
trialed including diuresis with lasix, calcitonin, phosphate
binders and promindronate none of which substantially reversed
her hypercalcemia which was felt to be driving her symptoms of
constipation, abdominal pain and lethargy. Her calcium was
finally controlled after receiving IV palmindronate. Her PTH
then increased further to 141, suggestive of primary
hyperparathyroidism. Endocrine service recommended outpatient
MIBI parathyroid scan for adenoma. Pt will need 2x weekly
calcium and albumin levels (to calculate corrected calcium). Pt
was started on vitamin d [**2106**] u daily per endocrine service.
# hypertension: previously on lisinopril, held due to [**Doctor First Name 48**]. Was
on labetalol, switched to nifedipine but back to labetalol 200mg
po bid on [**2118-6-25**]. [**Month (only) 116**] need to increase dose as BP has been
130s-140s/60s-80s.
# deconditioning: Pt has been hospitalized for over two months.
She is extremely weak and deconditioned from her stay and needs
intensive physical therapy. She occasionally suffers from
"buckling" of her knees and is currently a high fall risk.
# increased urinary frequency: Pt had increased urinary
frequency for the last 2 days of her admission, no fevers. UA on
[**2118-7-5**] showed WBC 85, RBC 33, no bacteria. Urine culture
pending at the time of discharge.
TRANSITIONAL ISSUES:
-needs 2x weekly complete blood count with differential
-needs weekly CMV viral load
-needs 2x weekly cyclosporine levels
-monitor 2x weekly chemistry panel, calcium and albumin for
sodium, Cr, Ca
-outpatient MIBI parathyroid scan
-outpatient neurology follow-up to further uptitrate
anti-epileptics / consider further seizure treatment as needed
-needs continued filgrastim 480mcg sc on Mondays and Thursdays
-urine culture from [**2118-7-5**] results still pending
Medications on Admission:
acyclovir 400 mg PO q8hrs
clonazpam 0.5 mg PO BID
levetiracetam 500 mg PO BID
lisinopril 20 mg PO daily
oxcarbazepine 900 mg PO BID
paroxetine 5 mg PO daily
docusate sodium 100 mg PO BID
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. lacosamide 150 mg Tablet Sig: One (1) Tablet PO twice a day.
4. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day for 10 months.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day: Pt may refuse if ambulating.
6. filgrastim 480 mcg/0.8 mL Syringe Sig: Four [**Age over 90 11578**]y
(480) mcg Injection q Mon and q Thurs.
7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
9. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. cyclosporine modified 50 mg Capsule Sig: One (1) Capsule PO
twice a day.
12. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): hold for sbp < 100 or hr < 60.
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stool.
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
-Myelodysplastic syndrome, with allogenic matched unrelated
donor stem cell transplant
-epilepsy
-acute renal insufficiency
-CMV pneumonitis / pneumonia
-hypercalcemia (likely primary hyperparathyroidism)
-hyponatremia (resolved)
Secondary:
-hypertension
-anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for an allogenic stem cell
transplant. You also were treated with antibiotics for an
infection with your bloodstream and a severe viral infection of
your lungs. You were also treated for low blood sodium,
reduction of your kidney function, and seizures.
We have made the following changes to your medications:
-STOP acyclovir
-STOP lisinopril
-STOP oxcarbazapine
-INCREASE your levetiracetam (Keppra) to 750mg tablets, 1 tab by
mouth twice daily
-START fluconazole 200mg tabs, 2 tabs by mouth daily
-START senna 8.6mg tabs, 1 tab by mouth twice daily
-START polyethylene glycol (miralax) 17g packet, 1 packet as
needed for constipation
-START mycophenolate 250mg tabs, 1 tab by mouth twice daily
-START cyclosporine 50mg tabs, 1 tab by mouth twice daily
-START labetalol 200mg tabs, 1 tab by mouth twice daily
-START lacosamide 150mg tabs, 1 tab by mouth twice daily
-START atovaquone liquid, 1500mg by mouth once daily
-START filgrastim 480 mcg subcutaneous injections every Monday
and Thursday
-START vitamin D 1,000 unit tabs, 2 tabs by mouth daily
-START valganciclovir 450mg tabs, 1 tab by mouth daily
Please continue to take your other medications as previously
prescribed. We have made an appointment for you to be seen by
your oncologist. Please have your rehab facility make
arrangements for your transportation to your appointment.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2118-7-7**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2118-7-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]
Completed by:[**2118-7-5**]
|
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icd9cm
|
[
[
[]
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[
"03.31",
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|
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[
[]
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,113
| 114,566
|
5534
|
Discharge summary
|
report
|
Admission Date: [**2105-4-4**] Discharge Date: [**2105-4-10**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
Intubation
Endoscopy
History of Present Illness:
88 year old female with hx of a. fib and right brachial artery
embolism on dabigatran, CAD, diastolic CHF, HTN, hypothyroidism
presenting with dysphagia. Pt was recently admitted
[**Date range (1) 22336**] for DOE and melenotic stools; Hct was found to
be 22 from baseline 40. She underwent extensive GI workup
including EGD, colonoscopy and capsule endoscopy that was
largely unrevealing for source of bleed. She was started on
omeprazole for gastritis. She received total of 4 units PRBCs
during admission with Hct in low 30s on discharge. She was
discharged on lower dose of dabigatran and lower dose of
atenolol. She was discharged to rehab where she had
difficulties with constipation and intermittent dysphagia. She
was discharged home approximately one week ago and has
complained of intermittent dysphagia. On day of admission, she
had difficulties even swallowing water. Reports vomiting twice.
In the ED, initial VS were: 96.6 50 167/69 16 94% RA. She was
evaluated by GI who plan to perform EGD tonight. Anesthesia was
called for intubation for MAC anesthesia. CXR was unremarkable.
CT chest showed fluid distention of the stomach and fluid
layering up to mid esophagus.
Past Medical History:
CAD s/p DES to LAD and OM1, [**2098**]
Mild biventricular systolic/diastolic CHF (compensated)
Reactive Airway Disease
Hypothyroidism
Hypertension
Hyperlipidemia
Osteoporosis
Previous pneumonia
Atrial Fibrillation, not anticoagulated [**1-8**] falls
Bilateral rotator cuff repair
Status post right hip repair [**2096**].
Social History:
quit smoking 9 years ago, glass wine per day.
Family History:
sister - deceased from CVA
Physical Exam:
ADMISSION PHYSICAL EXAM
96.6 50 167/69 16 94% RA.
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: bibasilar crackles, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
trace b/l edema
Neuro: CNII-XII intact, following commands, moving all
extremities
Discharge PE:
T97.8, HR 77, BP 133/60, RR 18, 94% RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular rhythm, normal S1 + S2, 2/6 systolic
murmur heard at R and L sternal border
Lungs: minimal bibasilar crackles, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
trace b/l edema at ankle
Neuro: CNII-XII intact, following commands, moving all
extremities
Pertinent Results:
ADMISSION LABS
[**2105-4-4**] 04:35PM BLOOD WBC-5.5# RBC-4.39# Hgb-10.5* Hct-35.5*
MCV-81* MCH-24.0*# MCHC-29.7* RDW-17.2* Plt Ct-123*
[**2105-4-4**] 04:35PM BLOOD Neuts-83.4* Lymphs-8.9* Monos-6.7 Eos-0.7
Baso-0.3
[**2105-4-4**] 04:35PM BLOOD PT-14.9* PTT-50.3* INR(PT)-1.4*
[**2105-4-4**] 04:35PM BLOOD Glucose-102* UreaN-23* Creat-1.0 Na-133
K-6.4* Cl-92* HCO3-28 AnGap-19
[**2105-4-4**] 04:35PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.3
[**2105-4-4**] 04:35PM BLOOD TSH-2.1
[**2105-4-4**] 04:35PM BLOOD Digoxin-0.7*
Discharge labs
[**2105-4-10**] 07:00AM BLOOD WBC-3.3* RBC-3.89* Hgb-9.1* Hct-31.1*
MCV-80* MCH-23.4* MCHC-29.3* RDW-17.3* Plt Ct-108*
[**2105-4-10**] 07:00AM BLOOD Glucose-101* UreaN-22* Creat-1.0 Na-137
K-3.9 Cl-99 HCO3-32 AnGap-10
IMAGING
CXR [**2105-4-4**]
FINDINGS: PA and lateral views of the chest were obtained.
Cardiomegaly is again noted with diffuse ground-glass opacity
concerning for pulmonary edema. Bilateral pleural effusions are
present, left greater than right with bibasilar consolidation,
likely representing compressive atelectasis. No pneumothorax is
seen. Aortic calcifications again noted. Bony structures are
demineralized.
IMPRESSION: Pulmonary edema, bilateral effusions and bibasilar
atelectasis, stable cardiomegaly.
CT CHEST [**4-4**]
1. Fluid distension of the esophagus suggesting dysmotility.
2. Left adrenal nodule is incompletely assessed. Elective
evaluation with
dedicated adrenal protocol CT may be performed as an outpatient.
EGD [**2105-4-4**]:
Impression:
Food in the whole Esophagus
Erythema and friability in the lower third of the esophagus
compatible with esophagitis
Retained fluids in stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations:
Trial clears with close monitoring. Continue PPI to allow
esophagitis to heal. F/u TSH. Barium swallow and esophageal
manometry should be done to evaluate motility within the
esophagus. Can consider further motility evaluation if it
becomes clear that the stomach as well as colon are involved as
well and if the above is unrevealing.
Barium Swallow [**2105-4-5**]
FINDINGS: The patient has mild esophageal dysmotility. The
primary stripping wave breaks in the mid to distal esophagus.
There is a moderate amount of residual contrast in the esophagus
after swallowing, even in the upright position. There is no
abnormal dilation, stricture, or evidence of achalasia. The
esophagus distends normally. The 13-mm tablet passes easily into
the stomach.
IMPRESSION: Mild esophageal dysmotility. No evidence of
achalasia.
Manometry [**2105-4-8**]: no signs of achalasia, final read pending
Brief Hospital Course:
Patient is a 88 year old female with hx of a. fib and right
brachial artery embolism on dabigatran, CAD, diastolic CHF, HTN,
hypothyroidism who presented with dysphagia and was found to
have esophagitis and food particles throughout the esophagus
without evidence of stricture on barium swallow. Manometry
showed no signs of achalasia.
Dysphagia: Patient presented with intermittent dysphagia. She
had a CT of the chest which showed large amounts of food in the
esophagus with air fluid levels. She was intubated for her EGD
given food seen on CT scan and concern for aspiration. Her EGD
showed large amounts of food in the esophagus as well as
esophagitis without evidence of strictures or malignancies. Food
was removed and she was extubated without incident. Barium
swallow showed no stricture. Manometry showed no signs of
achalasia. She was advanced to clear liquids then full liquids
and finally to a pureed diet which she tolerated. She was given
pantoprazole IV initially and then started on po omeprazole 40
mg po BID. She was discharged on pureed diet after the nutrition
specialist gave her diet education. Etiology of dysphagia
remains unclear. Gastroenterology thinks esophagitis likely is
contributing to esophageal dysmotility, though there is concern
for dysmotility elsewhere in the GI tract including in the colon
given constipation and the stomach as this was full of food. No
clear metabolic cause for this has been discovered, however.
Patient will be closely followed by GI to discuss further work
up as indicated.
Diastolic CHF: Torsemide dosing recently increased from 20mg to
40mg for worsening LE edema. She initially appeared euvolemic
on exam and torsemide was initially held. It was restarted when
she developed an O2 requirement on [**2105-4-6**]. She then was
oxygenating well on room air and had minimal LE edema. Her
torsemide dose was subsequently decreased from 40 mg to 20 mg
prior to discharge as she developed a contraction alkalosis and
appeared euvolemic to slightly dry. She was instructed to weigh
or if she developed lower extremity edema.
Intubation: Pt electively intubated with fentanyl/versed for MAC
anesthesia/EGD. She was extubated following the procedure
without complications.
Atrial fibrillation: Rate controlled on atenolol and digoxin. On
dabigatran on off-label dosing for afib and right brachial
artery embolism.
Hypothyroidism: TSH within normal limits. She was continued on
her home levothyroxine.
Anemia: Recent extensive workup for source of anemia was
unrevealing (pt is s/p EGD, colonoscopy, capsule endoscopy).
Hct remained at her baseline in low 30s. She will need a repeat
colonoscopy in 6 months as outpatient
Thrombocytopenia: Has long-standing thrombocytopenia. Platelet
count remained in her baseline range. She had no evidence of
active bleeding
# Transition issues:
1. Patient needs to be followed up on her dysphagia as
outpatient, and further work up should be discussed with GI
2. Patient needs to monitor her daily weight for appropriate
volume status
3. Patient needs a repeat colonoscopy in 6 months as outpatient
4. Patient needs to be followed up for thrombocytopenia and
leukopenia as outpatient with consideration of hematology follow
up if this fails to resolve
5. Patient complained of difficulty hearing, and found to have
bilateral ear wax impaction. Attempt to remove ear wax but
unsuccessful. She was given prescription for Carbamide Peroxide
to use as outpatient.
6. Left adrenal nodule found incidentally on CT chest, should
have adrenal protocol CT as outpatient to further assess
# Communication: [**Name (NI) **] [**Name (NI) 575**] (son, [**Name (NI) 382**] [**Telephone/Fax (1) 22335**];
[**Telephone/Fax (1) 22334**]
# Code: Full (confirmed with HCP)
Medications on Admission:
1. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day.
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (1-2 times a day).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. torsemide 40 mg Tablet daily(recently doubled)
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for c.
8. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
TID (3 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Dabigatran Etexilate 75 mg PO TID
2. Atenolol 25 mg PO DAILY
hold for sbp < 100 or hr < 60
3. Torsemide 20 mg PO DAILY
4. Carbamide Peroxide 6.5% 5-10 DROP AD [**Hospital1 **] Duration: 4 Days
RX *carbamide peroxide 6.5 % twice a day Disp #*1 Bottle
Refills:*0
5. Digoxin 0.0625 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg twice a day Disp #*60 Capsule Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
11. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary: Dysphagia
Secondary: diastolic heart failure, hypertension, atrial
fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with trouble and pain with
swallowing. You had an endoscopy to look at your esophagus and
food was found within your esophagus as well as irritation of
your esophagus called esophagitis. We also performed a barium
swallow study which did not show any strictures. A study called
esophageal manometry was performed and showed no evidence of
achalasia. You can further discuss the final result with your GI
doctor.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than [**1-9**] lbs.
Followup Instructions:
Please keep the following appointments:
Department: [**Hospital3 249**]
When: MONDAY [**2105-4-20**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2105-5-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
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|
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11244, 11244
|
3134, 5782
|
11970, 12736
|
1924, 1953
|
10421, 11020
|
11131, 11223
|
9599, 10398
|
11395, 11947
|
1968, 2518
|
2532, 3115
|
212, 223
|
312, 1499
|
11259, 11371
|
1521, 1844
|
1860, 1908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,431
| 194,042
|
35979
|
Discharge summary
|
report
|
Admission Date: [**2161-1-13**] Discharge Date: [**2161-1-23**]
Date of Birth: [**2086-4-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
ruptured TAA
Major Surgical or Invasive Procedure:
Endovascualr repair of TAA [**2161-1-14**]
Left VATS with Ct placement [**2161-1-14**]
Left Ct removal [**2161-1-22**]
U/S guided left pleural aspiration [**2161-1-20**]
PICC line placement [**2161-1-20**]
History of Present Illness:
74M with Parkinson's, chronic back pain s/p laminectomy several
years ago, hypertension and hypercholesterolemia who lives at
home and presented to an OSH on [**1-12**] with increased confusion
and fevers. He was found to have leukocytosis to 18K and a ? of
infiltrate on a CXR. He was started on ceftriaxone,
azithromycin
for pneumonia. The following day a chest CT was obtained for
odd
CXR which showed possible thoraco-abdominal junction aneurysmal
leak.
He was transferred to [**Hospital1 18**] where repeat CT scan revealed that
he
indeed had a contained rupture of a juxta-visceral aortic
aneurysm with hematoma surrounding the rupture as well as large
left pleural
Past Medical History:
- Parkinson's disease
- S/p laminectomy "several years ago per wife" for disc
herniation
- Implantable intrathecal (?) morphine pump - from our scans 'a
left lower quadrant device is seen with the tip of its lead in
the spinal
canal, likely representing a nerve stimulator."
- CAD s/p PCI in [**4-/2157**] and [**4-/2160**]
- HTN
- Hypercholesterolemia
- Idiopathic sensory motor neuropathy
.
Social History:
lives with wife at home. retired. several grandchildren.
Family History:
one son with hemachromatosis
Physical Exam:
T: 98.5 P:75 BP:140/60 97% on 2L NC
General: pleasant, non-toxic
HEENT: perrl, op dry
Neck: supple, no lad
Cardiovascular: RRR 2/6 SM best at LUSB. Non-crisp S2. ?
diastolic murmur
Respiratory:cta bilaterally w/out wheezes/rhonchi/rales; CT in
place draining serosang fluid
Back: no ST tenderness, no CVA tenderness. with evidence of
surgical scar at lumbar spine.
Gastrointestinal: non-distended, + BS, soft/non-tender, no
reb/guarding. surgical site at right groin intact, non-tender,
no induration.
Genitourinary: foley in place. scrotal edema.
Musculoskeletal: moving all extremities. resting tremor.
Skin:
-RIJ in place. erythema. non-tender.
-left foot with shallow ulcer to stage 2. surrounding erythema.
non-tender.
-right groin surgical site with staples in place. mild
erythema,
no purulence, no induration
Neurological: oriented to self and [**Location (un) **]. per family very far
from baseline.
Pertinent Results:
[**2161-1-13**] 01:15PM freeCa-1.02*
[**2161-1-13**] 01:15PM HGB-10.4* calcHCT-31 O2 SAT-98 CARBOXYHB-1
[**2161-1-13**] 01:15PM GLUCOSE-109* LACTATE-0.7 NA+-128* K+-3.5
CL--98*
[**2161-1-13**] 01:15PM TYPE-ART PO2-128* PCO2-37 PH-7.50* TOTAL
CO2-30 BASE XS-5 INTUBATED-NOT INTUBA
[**2161-1-13**] 02:44PM HGB-8.0* calcHCT-24
[**2161-1-13**] 02:44PM TEMP-36 PO2-275* PCO2-38 PH-7.45 TOTAL CO2-27
BASE XS-3 INTUBATED-INTUBATED
[**2161-1-13**] 03:54PM HGB-9.2* calcHCT-28 O2 SAT-96
[**2161-1-13**] 03:54PM GLUCOSE-135* LACTATE-1.2 NA+-126* K+-3.7
CL--100
[**2161-1-13**] 03:54PM TYPE-ART PO2-92 PCO2-46* PH-7.37 TOTAL CO2-28
BASE XS-0 INTUBATED-INTUBATED
[**2161-1-13**] 07:05PM PT-16.6* PTT-34.3 INR(PT)-1.5*
[**2161-1-13**] 07:05PM PLT COUNT-234
[**2161-1-13**] 07:05PM NEUTS-92.2* LYMPHS-3.1* MONOS-4.6 EOS-0.1
BASOS-0
[**2161-1-13**] 07:05PM WBC-20.0* RBC-3.39* HGB-10.5* HCT-29.4*
MCV-87 MCH-30.8 MCHC-35.6* RDW-13.4
[**2161-1-13**] 07:05PM ALT(SGPT)-66* AST(SGOT)-32 CK(CPK)-77 TOT
BILI-2.1*
[**2161-1-13**] 07:05PM estGFR-Using this
[**2161-1-13**] 07:05PM GLUCOSE-140* UREA N-15 CREAT-0.5 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-7*
[**2161-1-13**] 07:08PM freeCa-1.11*
[**2161-1-13**] 07:08PM O2 SAT-96
[**2161-1-13**] 07:08PM TYPE-ART PO2-89 PCO2-38 PH-7.41 TOTAL CO2-25
BASE XS-0
[**2161-1-13**] 11:17PM freeCa-1.14
[**2161-1-13**] 11:17PM O2 SAT-96
[**2161-1-13**] 11:17PM LACTATE-1.4 K+-3.8
[**2161-1-13**] 11:17PM TYPE-ART PO2-101 PCO2-37 PH-7.45 TOTAL CO2-27
BASE XS-1
ECHO:No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the descending thoracic
aorta. The assessed portion of the abdominal aortic graft is
without vegetations. 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. The pulmonic valve leaflets are
thickened. No Mass or vegetation is seen on the pulmonic valve.
There is no pericardial effusion.
Brief Hospital Course:
[**1-13**] Transfered from [**Location (un) **] Jacues,Patient went directaly to
surgery fro our ER and underwentEndovascular repair of a TAA
with left VATS for evacuation of hemothorax. patient was
transfered to ICU from surgery intubated.Extubated later in Pm.
[**2161-1-14**] POD#1 Speech and swallow evaluation post
extubation.Aspirates wit thin liquids. recommendations began
diet but with thickened liquids.epidosed of hypotension
requiring fluid resustation and blood transfusion with
resolution of
hemdynamic instablility.Post transfusion hct. 28.0
[**2161-1-15**] POD#2 No overnight events. transfered to VICU.Ct
remains in place and on water seal.Codris cath converted to CVl
over wire.POD#1 urine,blood, and pleural c/s + for MSSA.WBC
continue to be elevated. 20.0. Cardiac enzymes negative.gluteal
decubitus noted Stage 2, treatment began.Mild disorentation
improving.
[**2161-1-16**] POD#3 Chest tube placed on suction for small PTX.CT
postion readjusted, followup cxr unchanged . remains on
Suction.Speech and swallow foolowup thickened liquids and purees
continued with supervision with meals.Infectious disease
consulted for managment of MSSA in blood,sputum and pleural
fluid. Vanco,flagyl and cipro discontinued. Gentamycin and
nafcillin began. patient will require total of 5 days of gent.
and four weeks of nafcillin with life long antibiotic
suppression with rifimpin.Patient withknown intrathecal
catheter/morphine pump. MRI suggested.
[**2161-1-17**] POD#4 pleural tube contiues to drain., continous
suction continued.TEE done no intracardiac vegitations noted.
[**2161-1-18**] POD#5 continues with IV antibiotics., no change in
chest tube mangement. PT
working with patient.
[**2161-1-19**] POD#5 slow progress. chest tube to water seal.diet
advanced thin liquids and ground food. Supplement
added.Nutritional consult placed. recommendations were tube
feeds. Discussed with Dr. [**Last Name (STitle) 1391**], [**First Name3 (LF) **] defer tube placement
for concern of aspiration in this patient and continued to
encourage supplements.
[**2161-1-20**] POD# 6. MRI of back unremarkable for abcess at this
time. Will need followup he future/ID.Contiues to be followed by
PT.Left pleural thorcentesis for dyspena done, 5ml fluid
obtained.PIC line placed
[**Date range (1) 81676**] POD# [**7-22**] small apical
PTX on post thorocentesis xray. Ct remain in place on
waterseal.CT discontinued later that day [**1-22**].Wound care consult
for gluteal stg. 2 decubitus.
[**2161-1-23**] POD# 9 patient pulled out PICC line. line replace in
intervenional radology.
D/c to rehab. stable. Nafcillin to continue for total of four
weeks from start date fo [**2161-1-16**]. moniter CBC weekly, moniter
LFT's monthly. Rimfampin will will continued
indefinately.followup with Dr.[**Last Name (STitle) 81677**] and Dr. [**Last Name (STitle) **] of ID,
see appointments.
[**2161-1-20**] POD#6.
Medications on Admission:
same as d/c meds with the addition of atbx.
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. Memantine 5 mg Tablet Sig: One (1) Tablet PO daily ().
5. Galantamine 4 mg Tablet Sig: Six (6) Tablet PO daily ().
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QID
(4 times a day).
9. Entacapone 200 mg Tablet Sig: One (1) Tablet PO tid ().
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
12. Nafcillin 2 g IV Q4H
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
leaking thoroco-abdominal aa
left hemothoroax-CT by VATS
history of parkinsons
history of dementia
history of MSSA bacteremia
history of coronary artery disease s/p PCI 4/05,[**4-22**] ? vessel
history of dyslipdemia
history of idiopathic moter-sensory neuropathy
history of laminectomy with intrathecal morphine pump
pre/postoperative acute blood loss anemia, transfused, corrected
postoperative hypotension-fluid resustated
postoperative respiratory insuffiency-on vent
postoperative dysphagia with aspiration with thin liquids,
resolved
postoperative failure to thrive,supplements
postoperative sacral decubitus, stage 2
Discharge Condition:
stable
Discharge Instructions:
moniter CBC weekly while on IV atbx
moniter LFt's monthly while on rifampin
Followup Instructions:
[**Doctor Last Name 1391**], 2 weeks, call for an appointment. [**Telephone/Fax (1) 1393**]
[**Hospital **] clinic 2 weeks, call for an appointment [**Telephone/Fax (1) 457**],[**2161-2-24**]
@11:00-Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Completed by:[**2161-1-23**]
|
[
"447.4",
"511.89",
"414.01",
"518.5",
"997.79",
"458.29",
"401.9",
"338.29",
"356.8",
"715.90",
"441.6",
"707.05",
"724.2",
"783.7",
"790.7",
"041.11",
"787.20",
"V45.89",
"E878.2",
"272.0",
"285.1",
"707.22",
"294.10",
"331.82",
"453.2",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"88.72",
"38.93",
"88.42",
"88.73",
"39.73",
"34.04",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9456, 9503
|
5087, 7989
|
327, 535
|
10172, 10181
|
2748, 5064
|
10306, 10606
|
1750, 1780
|
8083, 9433
|
9524, 10151
|
8015, 8060
|
10205, 10283
|
1795, 2729
|
275, 289
|
563, 1241
|
1263, 1658
|
1674, 1734
|
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