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Discharge summary
|
report+addendum
|
Admission Date: [**2156-6-13**] Discharge Date: [**2156-7-2**]
Date of Birth: [**2089-12-21**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Clonazepam
Attending:[**Last Name (NamePattern1) 2499**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 W with poorly differentiated metastatic adenocarcinoma
(presumed breast primary given famililial BRCA1 mutation) on
chemo tx who has known mets to lungs, liver, omentum and bony
metastasis including vertebral mets who presents to the ED with
fevers x 1 day and 1-2 days of soft-tissue neck swelling. Per
patient's daughter, patient [**Name2 (NI) 58747**] her last round of chemo with
taxol and carboplatin. She was in her usual state of health
until Thursday, when she noted malaise and a vague sensation of
difficulty breathing. In clinic on Thursday she [**Name2 (NI) 58747**] 2 bags
of platelets and was started on steroid eye drops for her
lacrimal duct obstructions ([**2-12**] previous therapy with taxotere.)
The remained "about the same", although with persistent general
malaise until Saturday morning, when she awoke complaining of a
sore throat and was noted to have swelling around her neck,
"like a collar." She was still able to speak, although her
voice was very rough and raspy, and to take PO's without
difficulty. Her visiting nurse took her temp, which was noted
to be 99.9. In the setting of the neck swelling, patient's
family brought her in to the ED for evaluation.
Of note, patient has had thrush in the past involving her entire
esophagus, for which she still takes nystatin solution.
.
In the ED, patient was found to be neutropenic. A sepsis
protocol was started and patient was started on cefapime,
Vancomycin, and Clindamycin and [**Month/Day (2) 58747**] 6 liters of normal
saline. A CT scan was obtained of her chest and neck. Patient
began to experience difficulty breathing as was intubated.
.
ROS: negative
Past Medical History:
1. Metastatic CA of unknown origin (likely breast given BRCA
mutation): metastatic to liver, lungs, omentum, bones (see Onc
history below)
2. CAD: last cath [**10-14**] w/ 20% stenosis proximal RCA; LAD stent
patent; 90% osteal stenosis DIAG1; 40% proximal stenosis LCX
3. erythema multiforme
4. temporal arteritis
5. hypothyroidism
6.Hypertension
7.Zoster X 2, mild post herpetic neuralgia
8.Vaginal bleedingS/p D+C X 2
9. Osteopenia
PERTINENT CANCER HISTORY:
- A bone scan on [**2156-3-15**] showed multiple areas of increased
tracer uptake consistent with metastatic disease in L1, the
proximal right femur, bilateral sacroiliac joints, left ischium,
and bilateral scapula as well as the occiput.
- CT scanning revealed multiple liver lesions as well as
multiple small lung nodules primarily located in the right
middle and right lower lobe, as well as a subcarinal lymph node
measuring 1.2 cm. There was also some nodularity of the omentum
consistent with omental caking.
- Ms. [**Known lastname 58746**] [**Last Name (Titles) 1834**] a liver biopsy [**2156-3-30**] which
revealed metastatic adenocarcinoma poorly differentiated with
immunoassay positive for CK7, negative for CK20, negative for
Ttf-1 and estrogen receptor, chromogranin, synaptophysin,
progesterone receptor, and HER-2/neu. Her serum tumor markers
including a CEA were within normal limits. A CA-125 was only
slightly elevated at 56. However, her CA27.29 was significantly
elevated at 177.
- Bilateral breast MRIs have been negative. However, given +
BRCA1 mutation and family history, presumed primary tumor is
breast CA.
- Treatment history has included Zometa as well as one cycle of
Xeloda at 15 mg p.o. b.i.d. initiated on [**2156-4-2**]. She is
status post one dose of weekly Taxotere 25 mg/m2 on [**2156-4-20**].
She is status post palliative radiation to the right femur, low
back, and right shoulder at [**Hospital 1121**] Cancer Center, the last
treatment being on [**2156-4-24**]. Her most recent treatment has
included a combination chemotherapy of Taxotere and carboplatin.
She has finished cycle one on [**2156-5-14**].
Social History:
lives in [**Location 4047**] w/ her husband; has 2 daughters. Smoked 50-pack
years, but quit. No alcohol, cocaine, or IVDU.
Family History:
1. Breast CA: mother; both daughters dx in [**2150**]
2. Ovarian CA: cousin
3. Colon CA: brother dx at 44
Physical Exam:
VS: 123/68 126 18 96% on CPAP, PEEP 5, Ppeak 11
Gen: elderly woman, intubated, lying in bed in NAD
HEENT: scleral edema bilaterally, anicteric, MMM, no lesions but
difficult to assess entire airway [**2-12**] ET tube; neck tensely
swollen BL
CV: RRR , heart sounds distant, no murmurs
Lungs: scattered ronchi, decreased breath sounds at the bases,
no wheezing
Abd: soft, NT, ND, +BS, palpable liver edge 1 fingerbreath below
costal margin, no masses
Ext: no edema, + 2 DP pulses
Neuro: intubated and sedated
Skin: mild petechial rash on posterior forearms and shins
Pertinent Results:
[**2156-6-13**] 10:55PM TYPE-ART RATES-/18 PEEP-5 O2-100 PO2-534*
PCO2-28* PH-7.43 TOTAL CO2-19* BASE XS--3 AADO2-150 REQ O2-35
INTUBATED-INTUBATED
[**2156-6-13**] 10:55PM LACTATE-4.3*
[**2156-6-13**] 10:55PM O2 SAT-98
[**2156-6-13**] 10:55PM freeCa-0.98*
[**2156-6-13**] 08:40PM LACTATE-3.8*
[**2156-6-13**] 08:30PM GLUCOSE-141* UREA N-16 CREAT-0.5 SODIUM-134
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-17* ANION GAP-18
[**2156-6-13**] 08:30PM WBC-0.5* RBC-3.71* HGB-10.4* HCT-30.8* MCV-83
MCH-28.0 MCHC-33.7 RDW-22.2*
[**2156-6-13**] 08:30PM NEUTS-52 BANDS-36* LYMPHS-12* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-60*
[**2156-6-13**] 08:30PM PLT COUNT-52*
[**2156-6-13**] 06:24PM LACTATE-4.5*
[**2156-6-13**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2156-6-13**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-NEG
[**2156-6-13**] 04:22PM LACTATE-4.1*
[**2156-6-13**] 04:15PM GLUCOSE-121* UREA N-21* CREAT-0.6 SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19
[**2156-6-13**] 04:15PM ALT(SGPT)-49* AST(SGOT)-25 ALK PHOS-128*
AMYLASE-82 TOT BILI-1.0
[**2156-6-13**] 04:15PM LIPASE-21
[**2156-6-13**] 04:15PM CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-1.8
[**2156-6-13**] 04:15PM WBC-0.9*# RBC-4.26 HGB-12.1 HCT-34.7* MCV-81*
MCH-28.3 MCHC-34.8 RDW-22.4*
[**2156-6-13**] 04:15PM NEUTS-62 BANDS-14* LYMPHS-10* MONOS-8 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-4* NUC RBCS-32*
[**2156-6-13**] 04:15PM PLT SMR-VERY LOW PLT COUNT-68*
[**2156-6-13**] 04:15PM PT-11.3 PTT-20.4* INR(PT)-0.9
*
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2156-6-26**] 11:17 AM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: PROGRESSIVE SOB, BREAST CA, ? PE
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with hx met breast ca progressive sob, spiking
fevers, now with l common femoral DVT,
REASON FOR THIS EXAMINATION:
CTA r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 66-year-old woman with history of metastatic breast
cancer with progressive shortness of breath and spiking fevers
with left common femoral DVT. Please perform CT angiogram to
rule out pulmonary embolus.
COMPARISON: CT chest without contrast [**2156-6-25**].
TECHNIQUE: Multidetector CT images were obtained first through
the lungs without contrast, followed by a CT angiogram of the
chest in the pulmonary arterial phase. Coronal, sagittal, and
oblique sagittal reformatted images were obtained.
CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST:
There is no evidence for central or segmental pulmonary embolus.
The aorta contains atherosclerotic calcifications. There are
coronary artery calcifications. Otherwise, the heart is
unremarkable. A filling defect in the right internal jugular
vein is probably in situ thrombus related to the adjacent Port-
A-Cath catheter.
The airways are patent to the segmental level bilaterally;
however, there is mild interval worsening of the bilateral
multifocal interstitial opacities predominantly in the upper
lung lobes suggesting worsening atypical pneumonia.
Centrilobular and paraseptal emphysema, predominantly upper
lobe, and biapical pleuroparenchymal scarring are unchanged.
There is no pleural or pericardial effusion, and no
pathologically enlarged axillary or hilar lymphadenopathy.
Mediastinal lymph nodes in the precarinal region and
aortopulmonary window up to 7 mm wide, are stable, and do not
meet the CT criteria for pathologic enlargement.
Limited images through the upper abdomen show a right upper pole
renal cyst. The liver contains unchanged hypodensities. The
views of the spleen, gallbladder, and pancreas are unremarkable.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions. Again seen is a wedge deformity of a lower thoracic
vertebral body, unchanged.
CT REFORMATS: Coronal, sagittal, and oblique sagittal
reformatted images confirm the axial findings. Value Grade I.
IMPRESSION:
1. No evidence for pulmonary embolus.
2. Slight worsening of interstitial opacities within the upper
lung lobes predominantly, suggesting worsening atypical
pneumonia. most likely viral in etiology.
3. Port-related in situ thrombus, right internal jugular vein.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2156-6-28**] 9:07 AM
*
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2156-6-25**] 8:22 AM
CHEST (PORTABLE AP)
Reason: progressive dyspnea, fevers chills, now with cough
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with metastatic breast cancer who p/w fever
REASON FOR THIS EXAMINATION:
progressive dyspnea, fevers chills, now with cough
HISTORY: Metastatic breast CA. Fever.
AP bedside chest. There is patchy predominantly interstitial
consolidation involving several segments of the right upper
lobe. Lungs otherwise clear without vascular congestion or
effusions. Heart normal size. Slight prominence right superior
mediastinum probably reflecting positioning. Tip of left
subclavian double lumen Port-A-Cath lies in mid SVC. Since exam
one day previous ([**2156-6-24**]) the right upper lobe process is
slightly more prominent (possibly reflecting technical factors).
IMPRESSION: Short interval slight progression right upper lobe
pneumonia which was not present on study [**2156-5-28**].
DR. [**First Name (STitle) **] M. [**Doctor Last Name **]
Approved: FRI [**2156-6-25**] 4:35 PM
*
RADIOLOGY Final Report
BILAT LOWER EXT VEINS [**2156-6-25**] 5:12 PM
BILAT LOWER EXT VEINS
Reason: LEG SWELLING.. MET BR CA EVAL FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with metastatic breast cancer with leg
swelling.
REASON FOR THIS EXAMINATION:
Please evaluate for DVT
INDICATION: Metastatic breast cancer with leg swelling. Evaluate
for DVT.
BILATERAL LOWER EXTREMITY VEIN DOPPLER ULTRASOUND: Grayscale and
Doppler examination of bilateral common femoral, superficial
femoral, deep femoral and popliteal veins were performed. There
is a incomplete intraluminal clot within the left common femoral
vein. All remaining veins demonstrate normal compressibility,
waveforms, augmentation and Doppler flow.
IMPRESSION: Deep venous thrombosis of the left common femoral
vein. Dr. [**Last Name (STitle) **] has been paged to communicate this finding at
6:05 p.m. on [**2156-6-25**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 46933**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2156-6-26**] 12:49 AM
*
RADIOLOGY Final Report
MR L SPINE SCAN [**2156-6-21**] 2:11 PM
MR L SPINE SCAN
Reason: please evaluate for possible tumor progression/bone dz
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with met breast CA, s/p incomplete xrt to
spine, with lower extremity weakness
REASON FOR THIS EXAMINATION:
please evaluate for possible tumor progression/bone dz
CONTRAINDICATIONS for IV CONTRAST: None.
MRI EXAM OF THE LUMBAR SPINE
CLINICAL INDICATION: Metastatic breast cancer, assess for
compression or tumor progression.
MRI exam of the lumbar spine was obtained according to standard
departmental protocol. Sagittal inversion recovery images are
also performed. Comparison is made to the prior exam from [**5-27**], [**2156**].
Extensive metastatic deposits are noted involving the lower
thoracic, the lumbar spine and the sacrum. The lesions have been
mostly stable in size since the previous exam. No pathologic
compression fractures are seen. The conus demonstrates normal
contour and signal and terminates at T12 level. There is
involvement of the pedicles at several levels. Small metastatic
deposits are also noted involving the iliac portion of the
sacroiliac joint. Annular bulge of the disc is seen at L4-L5
level with a left-sided facet effusion. No spinal canal stenosis
was seen.
IMPRESSION: Extensive metastatic disease involving the lumbar
spine, the sacrum and iliac portions of the sacroiliac joints in
addition to the visualized portion of the lower thoracic spine.
There is no pathologic compression fracture seen. No significant
progression of disease is noted since [**2156-5-27**].
DR. [**First Name (STitle) 39063**] [**First Name8 (NamePattern2) **] [**Doctor Last Name 58748**]
Approved: MON [**2156-6-21**] 11:40 PM
*
Brief Hospital Course:
A/P: 66 W with undergoing chemothrapy for widely metastatic CA
of unknown origin admitted with febrile neutropenia and
soft-tissue swelling of the neck x 2 days.
.
#Respiratory distress: Patient was intubated in the ED for
airway protection - no documented stridor or hypoxia. Unclear
etiology of neck swelling as below, although it was thought it
may be angioedema as an allergic reaction from an ACEI vs
peritonsillar or retropharyngeal infection. CT neck in the ED
did not show any fluid collection or abscess that would
represent an infection. She was placed on broad spectrum
coverage with her febrile neutropenia, and steroids were
continued as per her chemo regimen. On HD#3, pt developed the
start of improved cuff leak around the ETT tube, and was
evaluated by ENT who after a repeat CT neck was unchanged, and
laryngoscopy was unremarkable, recommended for extubation. Pt
was extubated on HD#4 and did well post-extubation, weaning down
off o2 quickly. Her respiratory status remained stable on room
air for the rest of her hospital course, and her steroids were
slowly tapered.
.
#Fever Neutropenia: Ddx was broad in this neutropenic patient
including bacterial, viral, and fungal etiologies. Given
concurrent neck swelling, was initially concerning for possible
infection by oral flora including anaerobes and her history of
extensive thrush is worrisome for possible systemic or localized
fungemia. She was started on IV Vanco, Cefepime, Clindamycin,
and IV Caspofungin for broad coverage. U/A was negative, CXR
negative for possible PNA. Blood cx's remained NGTD at time of
discharge. Her counts rose to normal prior to discharge from
teh ICU and GCSF was discontinued, her antibiotics were
discontinued, and she remained stable. She did spike low grade
fevers with a maximum of 101, antiobiotics were held, blood and
urine cultures were unrevealing. A chest xray demonstrated a
possible early developing pneumonia, but this could not be
correlated clinically. As she continued to spike fevers, a CT
scan was ordered revealing ground glass opacities in the Right
lung fields, as she continued to spike fevers, she was placed on
zosyn and vancomycin for the possibilit of hospital acquired
pneumonia, in discussion with ID she was transitioned to flagyl,
ceftazadine and vancomycin. Her oxygen requirement continued to
increase to 2liters and she continued to spike fevers, and
pulmonology was consulted. Azithromycin was added for coverage
of atypical infections, and an induced sputum was attempted but
no sputum could be collected. In addition, legionella, and viral
cultures from a nasal swab were collected but without growth.
Her clinical status improved and she remained afebrile, and
bronchoscopy was deferred. She was weaned to room air, and her
antiobiotics were slowly tapered, first flagyl was removed were
her remaining stable. Her vancomycin was discontinued on the day
of discharge. Her ceftazadime should be d/c'ed on [**First Name8 (NamePattern2) 1017**] [**7-4**] if she remains afebrile. Her azithromycin should be
continued until [**2156-7-6**] to complete a ten day course from
the day that she became afebrile.
*
# MSK: After call out from the ICU, she was noted to have
increasing proximal muscle weakness as her steroids were
tapered. A cortisol stimulation test was performed to determine
if adrenal insufficiency was a component of her weakness, she
responded within normal limits to the cosyntropin stimulus,
steroid myopathy was considered as an alternative hypothesis of
her proximal muscle weakness. An MRI of the spine while
demonstrating spinal involvement was negative for cord
compression.
Her steroid was tapered slowly, she was discharged with 6mg am,
4mg pm of dexamethasone with plans to decrease her am dose to 5
mg on [**First Name8 (NamePattern2) 1017**] [**7-4**]. Futher adjustments will be determined by
her primary oncologist. She also continued physical therapy.
.
# Anxiety: She had continued anxiety during her hospital course
which was thought to be exacerbated by her steroid use. She was
placed on standing ativan with good effect. She complained of
insomnia during her hospital course and was treated with
trazadone and zolpidem with some relief. Other etiologies for
increased anxiety were negative, including UTI, thyroid,
metabolic causes.
.
# DVT: Noted to have a clot in the left common femoral, started
on heparin drip, then transitioned to lovenox, noted to have an
elevated antifactor xa,
.
#Cardiac:
Her antihypertensives were held as patient admitted on a sepsis
protocol. Her ACEi was permanently held as it was felt this was
her allergy that contribted to her neck swelling. Her other
agents were restarted this admission prior to discharge. She
had an episode of sinus tachycardia during her hospital course
likely secondary to anxiety, she was monitored on telemetry and
her cardiac enzymes were cycled without abnormalities noted.
She was symptomatically treated with ativan.
.
#Lacrimal Duct Obstruction: Per daughters, improved since
starting new steroid eye drops. She was continued on eye drops
and artificial tears during her hospital stay. Her right sclera
was noted to have a erythema and lesion, and optho was consulted
and she was to follow up with a clinic appointment in 4 days.
.
# Metastatic CA of unknown origin: presumed to be breast CA,
undergoing chemotherapy, was restarted fentanyl patch 25mcg q 72
hours. Further treatment were to be discussed as outpatient.
.
#Access: L dual lumen Porta Cath. R femoral line. PIV.
.
#PPx: holding heparin [**2-12**] low platelets. PPI. HOB up 30
degrees.
.
#CODE: DNR (Do not resuscitate) - no compressions, no shocks;
pressors are okay
.
#Dispo: ICU
.
#Communication: family (numbers in chart) Daughter [**Name (NI) 6177**] is
HCP.
Medications on Admission:
Zolpidem 10 mg PO HS
Metoclopramide 10 mg PO QIDACHS
Levothyroxine 112 mcg PO QD
Diphenhydramine HCl 25 mg PO HS
Isosorbide Mononitrate 30 mg Tablet SR PO QD
Metoprolol Tartrate 25 mg PO QD
Pantoprazole 40 mg PO QD
Pyridoxine 50 mg Tablet PO QD
Morphine 15 mg Tablet PO Q6H PRN
Fentanyl 25 mcg/hr Patch Q 72HR
Lisinopril 5 mg PO QD
Nystatin 100,000 unit/mL Suspension 5 ML PO QID PRN
Aspirin 81 mg PO QD
Artificial Tear with Lanolin 0.1-0.1 % Ointment PRN
Dexamethasone 4 mg PO BID
Morphine 15 mg PO every 6-8 hours PRN
Artificial Tears 1.4-0.6 % Drops QID PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Angioedema ACEI associated
Pneumonia
Discharge Condition:
Stable, sating well on room air.
Discharge Instructions:
Please take your medications as directed
If you experience increased pain fevers chills or other
concerning symptoms please call your doctor.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2156-7-6**] 10:00 Eye clinic.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-7-9**] 9:30
Name: [**Known lastname 10828**],[**Known firstname 3650**] A Unit No: [**Numeric Identifier 10829**]
Admission Date: [**2156-6-13**] Discharge Date: [**2156-7-2**]
Date of Birth: [**2089-12-21**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Clonazepam
Attending:[**Last Name (NamePattern1) 2808**]
Addendum:
Thrombocytopenia:
Her platelet count slowly recovered as her counts returned but
began to slowly fall on two days prior to discharge. To monitor
this please draw a CBC on [**First Name8 (NamePattern2) 7290**] [**7-4**] and fax the results to
Dr. [**Last Name (STitle) **] at 1 [**Telephone/Fax (1) 10830**]/([**2156**].
.
Discharge Disposition:
Extended Care
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 2809**]
Completed by:[**2156-7-2**]
|
[
"197.6",
"198.5",
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"284.8",
"E942.9",
"486",
"300.00",
"V15.3",
"401.9",
"244.9",
"359.4",
"197.7",
"174.8",
"464.30",
"V45.82",
"453.8",
"197.0",
"375.56",
"995.1",
"518.81",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"31.42",
"96.04",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
21543, 21728
|
13745, 19550
|
304, 310
|
20258, 20293
|
5008, 6841
|
20484, 21520
|
4296, 4407
|
12149, 12246
|
20198, 20237
|
19576, 20139
|
20317, 20461
|
4422, 4989
|
257, 266
|
12275, 13722
|
338, 1993
|
2015, 4136
|
4152, 4280
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,203
| 122,842
|
13598
|
Discharge summary
|
report
|
Admission Date: [**2188-7-14**] Discharge Date: [**2188-8-7**]
Date of Birth: [**2130-2-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine / Keppra / Acetylcysteine
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Thoracic embolization
T8/9 corpectomy with cage and instrumented fusion and bone
marrow aspiration
transfusions
Thoracentesis
Bronchoscopy and BAL
History of Present Illness:
Dr. [**Known lastname 10132**] is a 58 year old female with a history of metastatic
renal caricnoma to the brain, spine and lungs s/p multiple
thoracic procedures for resesection of pulmonary metastases who
was admitted to the neurosurgical service on [**2188-7-14**] for planned
vertebrectomy and reconstruction of T8 and T9. She underwent
this procedure on [**2188-7-16**].
The procedure was uncomplicated and she has been healing well
from a surgical perspective. She was extubated on the 9th. She
notes that she has had a cough since extubation but has not been
bringing up significant secretions. She notes that she feels as
if she has a weak cough. She spiked a fever to 102 degrees on
[**2188-7-18**] and was noted to have wheezing. She had a portable CXR
which was suggestive of pneumonia and was started on
levofloxacin. She spiked again on [**2188-7-19**] and had cultures
drawn. She had a CT T-spine to evaluate post-operatively and
although not protocoled to evaluate the lungs, lung windows
revealed a moderate-to-large left pleural effusions, small right
pleural effusion with bibasilar dependent consolidations, left
greater than right, concerning for pneumonia and pleural
effusions. Her pulse was in the high 90s on [**2188-7-17**] and has risen
gradually to the 120s. A trigger was called on the floor at
16:29 on [**2188-7-19**] when she developed worsening respiratory
status. She was noted to appear anxious with labored breathing
with respiratory rates in the 30s and HR in the 130s. She
reports that her acute respiratory distress started shortly
after receiving acetylcysteine She received 1 mg PO ativan and a
MICU evaluation was called. ABG was 7.46/41/64. She received a
nebulizer treatment which she says improved her symptoms and was
also placed on 50% by facemask. She was started on vancomycin
and cefepime. She was transferred to the MICU for further
management.
On arrival the MICU she reports that her respiratory symptoms
have dramatically improved. She is no longer coughing. She has
mild pain with deep inspiration but is able to take a deep
breath. She has cough productive of minimal sputum and feels as
if her cough is weak. She feels chills but is not currently
febrile. Her appetite is poor. She has no nausea, vomiting,
abdominal pain, diarrhea, dysuria, hematuria, leg pain or
swelling. She has not had a bowel movement for 3 days.
Past Medical History:
Metastatic Renal Cell Carcinoma
- diagnosed in [**3-/2181**]
- s/p left radical nephrectomy [**4-10**] with pathology consistent
with clear cell carcinoma
- s/p right upper lobe wedge resection for pulmonary metastasis
[**8-12**]
- right frontal lobe brain metastasis s/p resection [**3-13**] with
sterotactic radiosurgery to resection site [**4-13**]
- s/p high dose IL-2 [**10-13**]
- s/p right bilobectomy (right upper and right middle lobe)
[**12-14**]
- s/p right chest wall resection [**10-15**]
- s/p right lower lobe wedge resection [**3-16**]
- T8 s/p cyberknife [**10-16**]
- s/p sunitinib [**7-16**] complicated by hand foot syndrome,
mucositis
- RAD001 trial [**12-16**] to present
- s/p T8 and T9 vetebrectomy and recontruction [**2188-7-16**]
Hypertension
Peptic Ulcer Disease (h. pylori positive)
Hyperglycemia
Social History:
Works as a pediatrician in a private practice. She will be
returning to work during her weeks that she is feeling well.
Family History:
non-contributory
Physical Exam:
Vitals: T: 100.3 BP: 135/55 P: 123 R: 16 O2: 94% on 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry with evidence of mucocytis
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds throughout. Scarce expiratory
wheezes througoug with bronchial breath sounds at left base. No
egophony. No clear decrease in tactile fremitus.
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: Well healing surgical incision with staples in place, no
erythema, warmth
Pertinent Results:
[**2188-7-15**] 09:00AM BLOOD WBC-10.6 RBC-3.97* Hgb-7.6* Hct-25.9*
MCV-65* MCH-19.1* MCHC-29.2* RDW-17.8* Plt Ct-226
[**2188-7-15**] 09:00AM BLOOD Plt Ct-226
[**2188-7-15**] 09:00AM BLOOD PT-11.2 PTT-24.4 INR(PT)-0.9
[**2188-7-15**] 09:00AM BLOOD Glucose-142* UreaN-16 Creat-1.0 Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
[**2188-7-15**] 09:00AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
[**2188-7-19**] 06:45AM BLOOD Glucose-108* UreaN-6 Creat-0.7 Na-138
K-4.7 Cl-105 HCO3-27 AnGap-11
[**2188-7-22**] 03:40AM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-136
K-4.2 Cl-99 HCO3-29 AnGap-12
[**2188-8-4**] 07:30AM BLOOD Glucose-137* UreaN-17 Creat-0.8 Na-139
K-4.5 Cl-98 HCO3-31 AnGap-15
[**2188-7-26**] 06:25AM BLOOD calTIBC-152* VitB12-326 Folate-6.9
Ferritn-595* TRF-117*
.
CBC trend:
[**2188-7-17**] 02:27AM BLOOD WBC-7.2 RBC-3.49* Hgb-8.8* Hct-25.5*
MCV-73* MCH-25.1* MCHC-34.3 RDW-19.9* Plt Ct-174
[**2188-7-18**] 05:10AM BLOOD WBC-11.5*# RBC-3.19* Hgb-8.2* Hct-24.5*
MCV-77* MCH-25.6* MCHC-33.3 RDW-20.2* Plt Ct-213
[**2188-7-18**] 06:25PM BLOOD WBC-14.9* RBC-3.20* Hgb-8.2* Hct-24.9*
MCV-78* MCH-25.5* MCHC-32.8 RDW-20.6* Plt Ct-238
[**2188-7-20**] 04:42AM BLOOD WBC-12.7* RBC-3.17* Hgb-7.9* Hct-24.2*
MCV-76* MCH-24.8* MCHC-32.5 RDW-22.2* Plt Ct-340
[**2188-7-21**] 05:00AM BLOOD WBC-10.3 RBC-3.05* Hgb-7.7* Hct-23.7*
MCV-78* MCH-25.2* MCHC-32.4 RDW-22.1* Plt Ct-368
[**2188-7-22**] 03:40AM BLOOD WBC-9.3 RBC-3.36* Hgb-8.6* Hct-26.2*
MCV-78* MCH-25.7* MCHC-32.8 RDW-21.8* Plt Ct-432
[**2188-7-23**] 06:30AM BLOOD WBC-9.8 RBC-3.23* Hgb-8.1* Hct-25.4*
MCV-79* MCH-25.2* MCHC-32.0 RDW-22.2* Plt Ct-450*
[**2188-7-24**] 06:05AM BLOOD WBC-9.7 RBC-3.23* Hgb-8.4* Hct-25.3*
MCV-78* MCH-26.1* MCHC-33.3 RDW-22.5* Plt Ct-491*
[**2188-7-25**] 06:30AM BLOOD WBC-9.2 RBC-3.00* Hgb-7.7* Hct-23.5*
MCV-78* MCH-25.8* MCHC-32.9 RDW-22.2* Plt Ct-493*
[**2188-7-26**] 06:25AM BLOOD WBC-9.2 RBC-3.16* Hgb-7.8* Hct-25.2*
MCV-80* MCH-24.7* MCHC-31.0 RDW-22.5* Plt Ct-568*
[**2188-7-27**] 06:50AM BLOOD WBC-10.7 RBC-3.71* Hgb-9.5* Hct-30.3*
MCV-82 MCH-25.6* MCHC-31.4 RDW-21.8* Plt Ct-560*
[**2188-7-29**] 06:35AM BLOOD WBC-9.8 RBC-3.35* Hgb-8.7* Hct-27.3*
MCV-82 MCH-25.9* MCHC-31.7 RDW-22.1* Plt Ct-579*
[**2188-7-30**] 06:50AM BLOOD WBC-7.2 RBC-3.39* Hgb-8.5* Hct-27.1*
MCV-80* MCH-25.1* MCHC-31.4 RDW-21.8* Plt Ct-576*
[**2188-8-1**] 06:45AM BLOOD WBC-6.4 RBC-3.60* Hgb-9.0* Hct-28.8*
MCV-80* MCH-25.0* MCHC-31.3 RDW-21.7* Plt Ct-639*
[**2188-8-2**] 06:10AM BLOOD WBC-7.0 RBC-3.84* Hgb-9.5* Hct-30.5*
MCV-80* MCH-24.8* MCHC-31.2 RDW-21.9* Plt Ct-619*
[**2188-8-4**] 07:30AM BLOOD WBC-5.0 RBC-3.65* Hgb-9.3* Hct-28.6*
MCV-78* MCH-25.6* MCHC-32.6 RDW-21.3* Plt Ct-504*
.
ABG:
[**2188-7-18**] 02:11PM BLOOD Type-ART Temp-37.6 pO2-90 pCO2-43 pH-7.42
calTCO2-29 Base XS-2 Intubat-NOT INTUBA
[**2188-7-19**] 05:18PM BLOOD Type-ART pO2-64* pCO2-41 pH-7.46*
calTCO2-30 Base XS-4
.
All Blood Cx, Pleural fluid Cx, BAL Cx No growth
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Meso Macro
Other
[**2188-7-24**] 03:54PM 155* 420* 45* 4* 0 16* 21* 14*1
.
1. ATYPICAL CELLS,REFER TO CYTOLOGY
REVIEWED BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2188-7-25**]
.
PLEURAL CHEMISTRY TotProt Glucose LD(LDH)
[**2188-7-24**] 03:54PM 2.7 133 124
.
OTHER BODY FLUID
OTHER BODY FLUID pH
[**2188-7-24**] 05:53PM 7.521
.
Pleural Fluid ASPERGILLUS GALACTOMANNAN ANTIGEN neg
.
[**2188-7-19**] CT SPINE: IMPRESSION:
1. Status post posterior fusion spanning from T5 to T12 with
appropriate
anatomical alignment, no evidence for hardware failure.
Intervertebral cage device between T8/T9.
2. Moderate-to-large left pleural effusions, small right pleural
effusion
with bibasilar dependent consolidations, left greater than
right, concerning for pneumonia and pleural effusions.
3. Status post left nephrectomy.
.
[**2188-7-20**] CT TORSO: IMPRESSION:
1. Bilateral airspace opacities, predominantly at the left lung,
concerning for pneumonia. Airspace opacity at the right apex,
could be due to early lymphangitic spread of tumor with
metastatic burden here increased from prior.
2. Large dependent pleural effusion on the left and small
pleural effusion on the right.
3. Status post posterior fusion spanning from T5 to T12 with
appropriate
anatomic alignment, and no evidence of hardware failure.
Intervertebral cage device between T8 and T9.
The measurements for the target lesions were updated in the
oncology table.
.
[**2188-7-20**] CT NECK: IMPRESSION:
1. No definite evidence of upper airway obstruction.
2. No significant lymphadenopathy in the neck according to CT
size criteria.
3. Bilateral peribronchial opacities at the lung apices,
described in more
details on the CT torso from the same day.
Final Attending Note:
If there is concern for tracheomalacia, tracheal fluoroscopy may
be useful.
.
TTE [**7-23**]:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 60%). 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, but
cannot be fully excluded due to suboptimal image quality. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. The pulmonary artery
systolic pressure could not be determined. No masses or
vegetations are seen on the pulmonic valve, but cannot be fully
excluded due to suboptimal image quality. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2187-12-20**], no major change is evident.
IMPRESSION: Suboptimal image quality. No definite vegetations
seen
.
[**7-31**] CXR PA/Lat: FINDINGS: There is persistence of airspace
disease in the left middle lung and the right lung base.
Extensive retrocardiac changes likely indicate coarse
bronchiectasis. Diffuse bilateral reticulonodular interstitial
markings (right greater than left) likely represent lymphangitic
carcinomatosis given clinical history, and is consistent with
findings on chest CT from [**2188-7-20**].
There is interval removal of thoracic surgical clips. Rods for
fixation of
the thoracic spine appears intact. Upper abdominal surgical
clips are in
place.
IMPRESSION:
1) Persistent bilateral pleural effusions and pulmonary
infiltrates.
2) Reticulonodular interstitial disease likely lymphangitic
carcinomatosis.
.
[**7-24**] Pleural fluid cytology: negative for malignant cells
.
[**7-26**] Pathology of Lung, left lower lobe, transbronchial biopsy:
Carcinoma morphologically consistent with metastatic renal
cell carcinoma (history of renal cell carcinoma)
Brief Hospital Course:
The patient is a 58 year old female with a history of metastatic
renal carcinoma to the brain, spine and lungs who was admitted
for an elective vertebrectomy and reconstruction of T8 and T9
for spinal stabilization.
She tolerated this procedure well on [**2188-7-15**], but developed
postoperative respiratory distress and likely hospital acquired
PNA. She was briefly transferred to the MICU for respiratory
disress, and then to the oncology service.
.
1) Hospital Acquired Pneumonia/Respiratory Distress: Patient
transferred to the MICU on [**2188-7-19**] for acute respiratory
distress with tachycardia, tachypnea and fevers. Pt with poor
pulmonary reserve s/p multiple lung resections with mild
restrictive defect on recent PFTs at baseline. CT torso showed
pneumonia and dependent effusion in L lung. CT neck without
obstruction of upper airways. She completed an antibiotics
course as follows: Meropenem ([**Date range (1) 41055**]), vancomycin and cipro
([**Date range (1) 31559**]), and Cefipime ([**Date range (1) 41056**]). Patient was persistently
febrile on antibiotics, and underwent thoracentesis and
bronchoscopy/BAL, but all blood cultures, pleural fluid cultures
and BAL cultures were negative. In addition, a TTE was
performed showing no evidence of any vegetations. During this
period, the patient was treated with supplemental oxygen,
ipratropium, atrovent and lidocaine nebulizers, as well as
guaifenesin and benzonatate for cough. On [**7-29**], the patient
restarted everolimus and on [**8-1**] all antibiotics were stopped.
.
2)T8 + T9 vertebrectomy and reconstruction: Pt was admitted and
brought to INR suite where she underwent embolization to the
thoracic spine in prepartion for OR. She tolerated this
procedure well. There was concern about possible extension into
T9 vertebral body as well as T8 and she therefore also underwent
bone scan on [**2188-7-15**]. This showed uptake at T8 adjacent to a
larger photopenic area, likely related to osteoblastic activity
in a known mixed lytic and sclerotic metastasis and minimally
increased activity at multiple thoracic levels not as avid and
extensive as would be expected from the appearance on CT
suggesting the tumor is primarily osteoclastic, decreasing the
sensitivity of the bone scan for visualization of metastatic
disease. She was readied for the OR and on [**2188-7-16**] under general
anesthesia she underwent T8 and 9 vertebrectomies with fusion
including cage, hooks, pedicle screws and rods. She tolerated
this procedure well with intraop transfusions and was
transferred to TICU. Due to long time in prone position of
surgery she remained intubated overnight. Post op she had full
strength. CT T-spine with appropriate anatomical alignment, no
evidence for hardware failure. Patient treated initially with
dilauded and morphine for pain control, which was gradually
stopped. The patient underwent a trial of Toradol with good
relief. At discharge, pain well-controlled on standing tylenol
and naproxen, with fentanyl lozenges prn. Plan to followup with
neurosurgery six weeks postoperative.
.
3) Metastatic Renal Cell Carcinoma: Patient taking everolimus as
part of the RAD001 protocol prior to surgery, restarted on [**7-29**]
with significant improvement in breathing. No obstructing mass
see on bronchoscopy, but biopsies positive for renal cell
carcinoma.
.
4) Persistent Tachycardia: Likely multifactorial in setting of
acute illness, fever, anxiety, anemia and medications such as
xopenex. EKG showed sinus tachycardia with no acute ischemic
changes.
.
5) Chronic normocytic anemia, likely related to renal cell
carcinoma and chronic inflammatory state. On aranesp at home.
Patient transfused with 3 units PRBCs over the course of her
hospitalization. Also treated with B12 and folate
supplementation.
.
6) vaginal candidal infection on examination [**8-2**]. Patient
asymptomatic, treated with vaginal nystatin while inpatient.
.
7) Peptic Ulcer Disease, continued Protonix 40 mg [**Hospital1 **].
.
8) Diabetes, on glyburide at home. Treated with humalog sliding
scale while inpatient.
.
#Access: peripherals
.
#Code: DNR/DNI
.
Communication: Patient and partner [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 41057**]
Medications on Admission:
Glyburide 5 mg daily
Naprosyn d/c'd
Omeprazole 20 mg daily
Tylenol (as needed)
Zofran
Aranesp injector, everolimus 20 mg daily
Ativan 0.5 to 1 mg (as needed)
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every other
day as needed for shortness of breath or wheezing.
3. Fentanyl Citrate 400 mcg Lozenge on a Handle Sig: One (1)
Lozenge on a Handle Buccal Q12h () as needed for Pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for constipation.
5. Everolimus 10 mg Tablet Sig: One (1) Tablet PO Daily ().
6. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for nausea.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*30 units* Refills:*1*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Vitamin B-12 1,000 mcg Tablet, Sublingual Sig: One (1)
Sublingual once a day for 1 months.
Disp:*30 tabs* Refills:*0*
14. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
15. Nebulizer Kit Sig: One (1) Miscellaneous every four (4)
hours.
Disp:*1 kit* Refills:*0*
16. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
17. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-11**] Tablet,
Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea.
18. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
19. Home oxygen Sig: One (1) Continuous as needed for
shortness of breath or wheezing: 2L continuous pulse dose for
portability.
Disp:*1 tank* Refills:*0*
20. 3-in-1 commode Sig: One (1) as needed.
Disp:*1 commode* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
Renal cell carcinoma metastatic to thoracic spine
Anemia
pneumonia/bilateral pleural effusions
Discharge Condition:
Good: afebrile, ambulatory off of O2, Neurologically stable,
taking PO
Discharge Instructions:
You have a diagnosis of metastatic renal cell carcinoma and were
admitted to the hospital for an elective spinal surgery.
Postop, you had respiratory distress and pneumonia, treated with
antibiotics. In addition, your respiratory distress was treated
with oxygen, nebulized bronchodilators and cough suppressants.
After a course of antibiotics, you were restarted on your prior
treatment drug, Everolimus, with significant improvement in your
breathing.
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
.
If you experience any of the above symptoms, chest pain,
dizziness, persistent high fevers, or significant worsening of
your shortness of breath, please return to the hospital or call
your primary oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**].
Followup Instructions:
Please Call [**Telephone/Fax (1) 13016**] to make an appointment with Dr. [**Last Name (STitle) 1729**]
for tuesday [**Hospital **] clinic in 2 weeks.
.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN 6 WEEKS from the date of your surgery.
YOU WILL NEED XRAYS PRIOR TO APPOINTMENT
|
[
"511.9",
"285.22",
"197.0",
"518.5",
"198.5",
"112.0",
"112.1",
"285.1",
"V10.52",
"198.3",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"99.25",
"33.24",
"99.79",
"84.51",
"34.91",
"81.63",
"77.79",
"81.99"
] |
icd9pcs
|
[
[
[]
]
] |
18371, 18428
|
11767, 16019
|
317, 466
|
18586, 18659
|
4686, 11744
|
20660, 21006
|
3899, 3917
|
16227, 18348
|
18449, 18565
|
16045, 16204
|
18683, 20637
|
3932, 4667
|
268, 279
|
494, 2895
|
2917, 3745
|
3761, 3883
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,240
| 114,556
|
49061+49062
|
Discharge summary
|
report+report
|
Admission Date: [**2149-1-13**] Discharge Date: [**2149-1-21**]
Date of Birth: [**2098-10-28**] Sex: F
Service: ACOVE MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
female with multiple medical problems status post recent
admission to Medicine for hyponatremia and seizures who
presented with generalized weakness and inability to transfer
herself at home with a swollen knee. In the ED, she was
noted to have focal seizures and left facial twitching. She
denied generalization. Treated with Ativan 2 mg IV. A left
subclavian line was placed for IV access. Swollen left knee
prompted a tap of the knee times three with no fluid
obtained. Left lower extremity negative with no DVT. The
patient was given vancomycin times one dose prophylactically
after knee tap. U/A revealed positive UTI. The patient was
given Levaquin in the ED. Positive urinary incontinence
without dysuria, without back pain, but has knee pain.
PAST MEDICAL HISTORY:
1. Complex partial seizure with a right temporal occipital
lobectomy, VP shunt in [**2137**].
2. OCD.
3. Depression.
4. Chronic left lower extremity edema.
5. History of bilateral hip arthroplasty.
6. History of MRSA infection in the left hip.
7. Left hip osteoporosis.
8. Anorexia.
9. B12 deficiency.
10. Anemia.
11. Incontinence.
12. PVD.
13. SIADH secondary to Tegretol.
ADMISSION MEDICATIONS:
1. Tiagabine 4 mg q.h.s.
2. Amoxapine 50 mg twice a day.
3. Oxybutynin 10 twice a day.
4. Protonix 40 once a day.
5. Risperidone 1 twice a day.
6. Loxapine 60 once a day.
7. Phenobarbital 30 three times a day.
8. Baclofen 10 four times a day.
9. Hydrazine 25 p.m.
10. Sodium chloride 4 grams three times a day.
11. Lactulose 30 three times a day p.r.n.
12. Colace 100 twice a day.
13. Calcium.
14. Vitamin D.
15. Senna one twice a day.
16. Tegretol XL 200 a.m., 200 afternoon, 300 p.m.
17. Hydrocortisone cream p.r.n.
18. Ibuprofen 600 p.r.n.
19. Oxycodone sustained release 10 twice a day.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 110/70, pulse 100, respiratory rate 20, temperature
99.3, saturating 100% on 2 liters. General: The patient was
frail and ill appearing. HEENT: The extraocular movements
were intact. The oropharynx was clear. Neck: Supple.
Chest: Clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm, normal S1, S2, negative murmur,
rubs, or gallops. Abdomen: Soft, nontender, nondistended.
Back: She has a stage I sacral decubitus. Extremities:
Left foot erythematous, 4+ edema to the knee. Pain over the
left knee without appreciable effusions, without warmth.
Upper extremity revealed bilateral hand erythema, [**12-5**]+ edema.
Neurological: The patient was alert and oriented times
three.
LABORATORY DATA UPON ADMISSION: White count 6.0, hematocrit
28.9, platelets 440,000. Sodium 134, potassium 4.4, chloride
84, bicarbonate 27, BUN 11, creatinine 0.2, glucose 86. The
U/A revealed greater than 50 white cells, moderate
leukocytes, positive nitrates. The urine culture is pending.
LENI negative for DVT.
Knee film revealed osteopenia.
HOSPITAL COURSE: The patient is a 50-year-old female well
known to the team who presented with a potential seizure,
SIADH, although not with obvious hyponatremia and UTI.
1. INFECTIOUS DISEASE: The patient's UTI was treated with
Cipro. The patient also had likely cellulitis of the hands.
The patient was started on a 14 day course of vancomycin.
The patient had a PICC line placed for vancomycin prior to
discharge.
2. NEUROLOGIC: The patient was continued on medications
without seizures. The patient has very small seizures. The
patient was also found to be unresponsive one morning.
The patient was transferred to the SICU which is likely
urosepsis. The patient responded with fluids and
antibiotics. The patient was discharged back to the floor
the next day without incident.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient had a
sodium of 134, retested the patient's sodium was 120, 134 was
likely an error in the laboratory. The patient's sodium came
up appropriately with fluid restriction and salt tabs.
4. KNEE PAIN: No workup was really done. This patient is
well known to Dr. [**Last Name (STitle) 7111**] and is to have outpatient workup of
pain.
5. PSYCHIATRY: The patient's medicines were continued.
6. GASTROINTESTINAL: The patient was put on a bowel
regimen. Protonix was continued.
7. ENDOCRINE: The patient was continued on calcium, vitamin
E.
8. PAIN: MS04 and Oxycodone were held as the patient was
found to be unresponsive. The patient was changed to
Percocet.
9. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
given a regular diet with Boost.
10. LINES: The patient's left subclavian was changed to a
PICC.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSIS: Unable to care for self.
DISCHARGE MEDICATIONS:
1. Tiagabine 4 q.h.s.
2. Amoxapine 50 b.i.d.
3. Oxybutynin 10 b.i.d.
4. Pantoprazole 40 once a day.
5. Risperidone one twice a day.
6. Loxapine 60 once a day.
7. Phenobarbital 30 three times a day.
8. Baclofen 10 four times a day.
9. Hydroxyzine 25 p.r.n.
10. Sodium chloride 4 grams t.i.d.
11. Colace 100 twice a day.
12. Calcium 500 three times a day.
13. Vitamin D 400 once a day.
14. Senna one twice a day.
15. Carbamazepine 200 in the a.m., 200 in the p.m., 300 in
the evening.
16. Ibuprofen for pain.
17. Acetaminophen for pain.
18. Ciprofloxacin 500 b.i.d.
19. Vancomycin 750 b.i.d.
20. Lactulose 30 three times a day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 23023**]
MEDQUIST36
D: [**2149-1-17**] 04:35
T: [**2149-1-17**] 23:13
JOB#: [**Job Number **]
Admission Date: [**2149-1-13**] Discharge Date: [**2149-1-21**]
Date of Birth: [**2098-10-28**] Sex: F
Service:
ADDENDUM: The patient's discharge was on [**2149-1-21**].
The patient waited over the weekend to have a peripherally
inserted central catheter line placed and a right double
lumen peripherally inserted central catheter placed on
Monday, [**2149-1-20**].
DISCHARGE DIAGNOSES:
1. Urinary tract infection.
2. Cellulitis.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications were as follows)
1. Tiagabine 4 mg p.o. q.h.s.
2. Amoxapine 50 mg p.o. b.i.d.
3. Oxybutynin 10 mg p.o. b.i.d.
4. Protonix 40 mg p.o. q.d.
5. Risperidone one tablet p.o. b.i.d.
6. Raloxifene 60 mg p.o. q.d.
7. Baclofen 10 mg p.o. q.i.d.
8. Phenobarbital 30 mg p.o. t.i.d.
9. Hydroxyzine 25 mg p.o. as needed.
10. Sodium chloride 4 g p.o. t.i.d.
11. Colace 100 mg p.o. b.i.d.
12. Calcium 500 mg p.o. t.i.d.
13. Vitamin D 400 mg p.o. q.d.
14. Senna one tablet p.o. b.i.d.
15. Carbamazepine 200 mg to 300 mg at breakfast, lunch, and
dinner.
16. Heparin 5000 units subcutaneously b.i.d. (until out of
bed consistently).
17. Ciprofloxacin 500 mg p.o. b.i.d. (times one day).
18. Vancomycin 750 mg p.o. q.12h. (times eight days).
19. Lactulose 30 mg p.o. t.i.d.
20. Percocet one to two tablets p.o. q.4-6h. as needed.
21. Ibuprofen 600 mg p.o. q.i.d. as needed.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 23023**]
MEDQUIST36
D: [**2149-1-21**] 10:19
T: [**2149-1-21**] 10:21
JOB#: [**Job Number 44972**]
|
[
"599.0",
"707.0",
"300.3",
"311",
"266.2",
"780.39",
"253.6",
"733.00",
"788.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
4838, 4845
|
6208, 6264
|
4916, 6187
|
4867, 4893
|
6356, 7533
|
3153, 4816
|
1401, 2023
|
6279, 6329
|
2814, 3135
|
994, 1378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,957
| 112,886
|
3863
|
Discharge summary
|
report
|
Admission Date: [**2122-6-4**] Discharge Date: [**2122-6-18**]
Date of Birth: [**2065-9-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Hypoxia, Increased Work of Breathing
Major Surgical or Invasive Procedure:
nasopharyngeal intubation
PICC line
Arterial line
Oropharyngeal Intubation with Mechanical Ventilation
Tracheostomy
History of Present Illness:
Ms. [**Known lastname 17315**] is a 56 y/o F with a h/o morbid obesity, metabolic
syndrome and restrictive lung disease who initially p/w weakness
and dehydration. On admission she was found to be hypoxic by
EMS to 78% on RA. She was also found to have LE cellulitis, a
UTI, [**Last Name (un) **] and an elevated BNP and troponin. She was admitted to
the medical floor, where she was started on ceftriaxone for her
UTI and vancomycin for her cellulitis. An echo was done for
further evaluation of her hypoxia, which showed a dilated right
ventricle and right ventricular volume overload. Given her echo
findings, elevated BNP/troponin the floor team was concerned
that she may have a PE so she was empirically started on a
heparin gtt as she was unable to get a CTA because of her [**Last Name (un) **]
and radiology felt a V/Q scan would not be useful in the setting
of her poor baseline CXR.
.
She initially was stable but with worsening renal function, when
on the day of transfer she was found to be somnolent, confused
and with an oxygen saturation of 87% on 4LNC. She was placed on
6LNC with improvement in her oxygen satuartion improved to 92%
but she remained tachypneic. ABG done at that time was
7.22/59/70, she was placed on her nighttime bipap for her
respiratory distress. A CXR was done that was unchanged from
prior, she was also noted to be febrile to 102.5 at that time.
Given her need for bipap, a transfer to the ICU was initiated.
VS on arrival to the ICU were: 100.4, 80, 105/43, 20, 99% on
bipap with 6L. Shortly after her arrival to the ICU she
desaturated to the low 80's, at that time we transferred her to
NIPPV with settings of [**10-19**] and an FiO2 of 100%, her oxygen
saturations improved quickly on the new bipap settings.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Obesity
DM
HTN
Hyperlipidemia
Hypothyroidism
Lymphedema
Urinary Incontinence
Osteoarthritis
Sinusitis
Carpal tunnel
Social History:
- Tobacco: None
- Alcohol: None
- Illicits: None
Lives independently at home with the help of a home health aid.
She uses a wheelchair when going out, but a walker when at home.
Family History:
3 sisters with hypertension, father died of ischemic stroke,
Mother died of gallstone perforation, No history of heart
disease, diabetes or cancer.
Physical Exam:
Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 69 (66 - 78) bpm
BP: 146/57(83) {114/40(62) - 178/67(101)} mmHg
RR: 16 (13 - 21) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 145.4 kg (admission): 164 kg
General Appearance: Well nourished, Overweight / Obese, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, bipap mask
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), diminished heart
sounds
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar , Diminished: throughout )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: bilateral lymphedema with accompanying erythema
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed
Pertinent Results:
=
=
=
=
=
=
=
=
=
=
=
================================================================
ADMISSION LABS
=============================
[**2122-6-4**] 07:25PM ALT(SGPT)-30 AST(SGOT)-48* LD(LDH)-297* ALK
PHOS-67 TOT BILI-0.4
[**2122-6-4**] 07:25PM cTropnT-0.18*
[**2122-6-4**] 05:39PM URINE HOURS-RANDOM CREAT-239 SODIUM-25
POTASSIUM-90 CHLORIDE-20 TOT PROT-314 PROT/CREA-1.3*
[**2122-6-4**] 05:39PM URINE OSMOLAL-398
[**2122-6-4**] 12:10PM URINE HOURS-RANDOM
[**2122-6-4**] 12:10PM URINE UCG-NEGATIVE
[**2122-6-4**] 12:10PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
[**2122-6-4**] 12:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG
[**2122-6-4**] 12:10PM URINE RBC-4* WBC-144* BACTERIA-MANY YEAST-NONE
EPI-3
[**2122-6-4**] 12:10PM URINE HYALINE-24*
[**2122-6-4**] 12:10PM URINE MUCOUS-FEW
[**2122-6-4**] 11:54AM TYPE-[**Last Name (un) **] PO2-87 PCO2-40 PH-7.41 TOTAL CO2-26
BASE XS-0 COMMENTS-GREEN TOP
[**2122-6-4**] 11:54AM GLUCOSE-170* LACTATE-1.7 K+-4.7
[**2122-6-4**] 11:45AM GLUCOSE-178* UREA N-47* CREAT-2.6* SODIUM-144
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-18
[**2122-6-4**] 11:45AM estGFR-Using this
[**2122-6-4**] 11:45AM CK(CPK)-321*
[**2122-6-4**] 11:45AM cTropnT-0.30*
[**2122-6-4**] 11:45AM CK-MB-6 proBNP-6419*
[**2122-6-4**] 11:45AM WBC-26.2*# RBC-3.94* HGB-11.5* HCT-35.5*
MCV-90 MCH-29.2 MCHC-32.5 RDW-14.5
[**2122-6-4**] 11:45AM NEUTS-87* BANDS-6* LYMPHS-4* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2122-6-4**] 11:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2122-6-4**] 11:45AM PLT SMR-NORMAL PLT COUNT-389
[**2122-6-4**] 11:45AM PT-14.5* PTT-24.2 INR(PT)-1.3*
=
=
=
=
=
=
=
=
=
=
=
================================================================
DISCHARGE LABS
=============================
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-6-18**] 02:30 7.5 3.04* 9.0* 27.8* 91 29.4 32.2 14.1 440
PT PTT INR(PT)
[**2122-6-18**] 02:30 16.1* 83.2* 1.4*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-6-18**] 02:30 187*1 72* 2.2* 144 3.5 94* 41*2 13
Calcium Phos Mg
[**2122-6-18**] 02:30 9.8 5.1 2.2
=
=
=
=
=
=
=
=
=
=
=
================================================================
MICRO DATA
==============================
URINE CULTURE (Final [**2122-6-7**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
=
=
=
=
=
=
=
=
=
=
=
================================================================
IMAGING/PROCEDURES
=======================
=======================
CT Chest abdomen pelvis w/o contrast [**2122-6-5**]:
=======================
FINDINGS: The major airways are patent to subsegmental levels
bilaterally. No pulmonary consolidation, masses or pulmonary
nodules are detected. Linear subsegmental and dependent
atelectasis is seen in both lung bases. There are no pleural or
pericardial effusions. The heart is mildly enlarged. The
thoracic aorta is unremarkable, except for scattered
atherosclerotic calcification, without aneurysmal dilation. Mild
coronary arterial calcifications are seen. Mild dilation of the
main pulmonary artery measuring 4 cm, consistent with pulmonary
arterial hypertension. Few mediastinal lymphnodes are seen,
which do not meet CT criteria for significant adenopathy.
CT OF THE ABDOMEN WITH ORAL CONTRAST: Limited non-contrast
evaluation of the liver, spleen, adrenal glands and pancreas are
normal. A 3.2 cm gallstone is seen within the gallbladder,
without evidence of acute cholecystitis. Both kidneys are
unremarkable, without hydronephrosis, stones or large renal
masses. There is dilatation of the left ureter up to 1.7cm from
the renal pelvis to approximately 2cm above the UVJ. No
obstructing cause is noted. Few sub- centimeter left renal
lesions are seen, consistent with simple renal cysts. The
stomach, small and large bowel are normal, without evidence of
bowel wall thickening or obstruction. The appendix is normal.
There is no intra-abdominal free fluid or air. The abdominal
aorta has scattered calcification, without aneurysmal dilation.
No significant retroperitoneal or mesenteric lymphadenopathy is
seen.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder
is empty with a Foley catheter in place. The rectum and sigmoid
colon are normal. The uterus and adnexa are unremarkable.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection
or
malignancy are seen. Chronic deformity of both femoral necks, is
unchanged. A femoral nail traversing both femoral necks are
seen. The femoral nail traversing the left femoral neck impinges
on the acetabular articular surface.
IMPRESSION:
1. No acute pulmonary pathology, especially no evidence of
pneumonia or
pulmonary edema. Pulmonary arterial hypertension.
2. Left hydroureter measuring up to 1.7cm from the renal pelvis
to approx 2cm above the left UVJ. No obstructing cause is
visualized and this may represent congenital megaureter, further
evaluation with retrograde ureterogram is recommended for
confirnation.
3. Cholelithiasis without evidence of acute cholecystitis.
=====================
LENI [**2122-6-5**]:
=====================
IMPRESSION: Non-diagnostic evaluation for DVT in either the left
or right leg.
=====================
Chest X-ray ([**2122-6-6**]):
=====================
FRONTAL CHEST RADIOGRAPH: Study is markedly limited by
underpenetration. The degree of vascular congestion has
worsened. There is no definite new focal consolidation. Small
effusion are unchanged.
IMPRESSION: Worsening pulmonary vascular congestion.
=====================
Chest X-ray ([**2122-6-18**]):
=====================
FINDINGS:
Tracheostomy tube terminates 4.1 cm above the carina. NG tube
courses in the
stomach, its tip out of view. Left PIC catheter is seen coiling
in the
brachiocephalic veinor in azygos vein, unchanged in position.
Low lung volumes. Widened mediastinum can be attributed to
mediastinal
lipomatosis, as seen on [**2122-6-5**] CT exam. Moderate right
pleural effusion is
increased in size priom prior exam. Heart size is moderately
enlarged. No
pneumothorax. Pulmonary vascular congestion persists.
IMPRESSION:
1. Moderate right pleural effusion, increased in size from
[**2122-6-16**] exam.
2. Persistent pulmonary vascular congestion.
=====================
Echocardiogram:
=====================
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. The right ventricular
cavity is dilated with probably depressed free wall
contractility. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve is not well seen. The mitral valve
leaflets are not well seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2114-12-19**], the right ventricle is now dilated
with probably depressed free wall motion
.
Labs Pending at time of discharge: 2 blood cultures and 1 Urine
culture
Brief Hospital Course:
Hypoxic and Hypercarbic respiratory failure: The etiology of her
hypoxemia is likely multifactorial, including obesity-related
hypoventiliation syndrome, pulmonary edema, and possible PE. A
heparin infusion was initiated for a presumptive diagnosis of
pulmonary embolism. Definitive imaging was unable to be obtained
based on patient's body habitus and renal function precluding
her from VQ scan or CT scan. A heparin drip was empirically
started. She required nasal intubation in the ICU due to poor
oropharyngeal anatomy, begining on [**2122-6-6**], and was unable to be
successfully extubated as she developed post extubation stridor.
She was oropharyngeal reintubated. Tracheostomy was pursued
with good results on [**2122-6-17**]. Additionally, given possible
pulmonary edema aggressive diuresis was initiated with a lasix
infusion and metolazone, resulting in a net negative diuresis of
about 10 liters for her length of stay. Patient was started on
oral coumadin prior to discharge. At time of discharge, her INR
was still subtherepeutic. She will require at least 6 months of
oral anticoagulation.
Acute Tubular Necrosis: She had muddy brown casts in her urine
on admission. Her creatinine peaked at 3.2. Etiology thought to
be related to hypoxia with presentation. She was treated with a
furosemide infusion and metolazone. A nephrology consultation
was obtained. Her creatinine improved and stabilized at a value
of about 2.7 upon discharge. This will likely be her new
post-ATN creatinine. Her medications should continue to be
renally dosed. Of note, her Valsartan and Lisinopril were held
given renal compromised.
Complicated Urinary Tract Infection: On admission her urine
culture grew two speciations of E.Coli, both sensitive to
ceftriaxone. She was treated with ceftriaxone for 7 days.
Cellulitis: She was treated for cellulitis of the right lower
extremity with vancomycin for a total of 14 days. Goal
vancomycin serum levels were 15-20. Her cellulitis improved.
She continued to have evidence of venous stasis changes in both
lower extremities post antibiotic course.
Diabetes Mellitus II: She was treated with subQ insulin, which
resulted in suboptimal glucose control. An insulin infusion was
initiated, resulting in improved glycemic control. Her insulin
was titrated to glargine 8 U qday with a regular insulin sliding
scale every 6 hours. As the patient was only receiving tube
feeds upon discharge, this will most likely require adjustment,
specifically changes to short acting insulin and meal time
dosing.
Hypertension: Her home medications of HCTZ, lisinopril and
valsartan were initially held. Once she was stabalized, she was
started on amlodipine 5mg daily with adequate blood pressure
control. Given multiple antihypertensives prior to admisison,
will most likely require reinstitution of additional
antihypertensive agents if goal of <130/80 mmHg is not acheived.
.
Obstructive Sleep Apnea: her family brought in her home bipap
machine. After tracheostomy, patient did not require any
positive pressure ventilation, only trach mask for saturations
around 96%. She will most likely require positive airway
pressure when tracheostomy closes up as lots of redundant oral
pharyngeal soft tissue.
Hyperlipidemia: Last measured in [**10/2121**] and LDL was 118.
Continued Fenofibrate nanocrystallized 150 mg daily and Crestor
40 mg daily
Hypothyroidism: TFT??????s were normal in house. Continued
Levothyroxine 137 mcg daily
Urinary Incontinence: chronic issue. Continued Detrol LA 4 mg
qHS.
Sinusitis: chronic issue that is currently stable. Continued
visine drops for allergy symptoms.
Depression: currently stable. Continued Venlafaxine 75 mg [**Hospital1 **].
Carpal tunnel: Gets intermittent numbness and tingling in her
digits bilaterally per report. Given admission gabapentin was
subtherepeutic, held given renal dysfunction.
.
Labs Pending at time of discharge: 2 blood cultures and 1 Urine
culture
Medications on Admission:
Fenofibrate nanocrystallized 145 mg daily
Fexofenadine 180 mg daily
Fluocinonide 0.05% cream
Fluticasone 50 mcg [**Hospital1 **]
Gabapentin 200 mg [**Hospital1 **]
HCTZ 25 mg daily
Humalog
Levothyroxine 137 mcg daily
Lisinopril 30 mg daily
Crestor 40 mg daily
Detrol LA 4 mg qHS
Vaslartan 40 mg daily
Venlafaxine 75 mg [**Hospital1 **]
Aspirin 81 mg daily
MVI daily
Omega-3 Fatty Acids
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
6. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. desonide 0.05 % Cream Sig: One (1) Appl Topical TWICE A DAY
() as needed for dry skin.
9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-11**]
Drops Ophthalmic PRN (as needed) as needed for Dry eyes.
10. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fevers/pain.
12. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for fungal infection.
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for Hypoxia.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral
Solution Sig: SLIDING SCALE Intravenous SLIDING SCALE: Please
continue heparin drip while achieving therepeutic INR on oral
coumadin. Heparin drip may be discontinued once INR is [**2-12**] for
>48 hours.
====================
HEPARIN SLIDING SCALE
.
Initial Infusion Rate: 3000 units/hr
Target PTT: 60 - 100 seconds
.
PTT <40: 6000 units Bolus then Increase infusion rate by 700
units/hr
.
PTT 40 - 59: 3000 units Bolus then Increase infusion rate by 350
units/hr
.
PTT 60 - 100*: GOAL
.
PTT 101 - 120: Reduce infusion rate by 350 units/hr
.
PTT >120: Hold 60 mins then Reduce infusion rate by 700 units/hr
.
20. insulin glargine 100 unit/mL Solution Sig: Eight (8) Units
Subcutaneous once a day.
21. insulin regular human 100 unit/mL Solution Sig: SSI
Injection every six (6) hours: Sliding Scale
--------------------
71-100 mg/dL 0U
101-150 mg/dL 2U
151-200 mg/dL 4U 201-250 mg/dL 6U 251-300 mg/dL 8U
301-350 mg/dL 10U
351-400 mg/dL 12U
> 400 mg/dL Notify M.D.
.
22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
23. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing.
24. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Hypoxic Respiratory Failure
Pulmonary Embolism
.
Secondary:
Diabetes Mellitus
Hypertension
Obesity
Hyperlipidemia
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 17315**],
You were admitted to the hospital because of respiratory
distress. Your breathing became so poor that you required
mechanical intubation to help you breathe. Attempts were made
to take you off the ventilator, however you were unable to
safely have the tube removed due to airway swelling. As a
result, you had a tracheostomy performed.
There was concern that your difficutly breathing was due to a
blood clot in your lungs. You were started on a heparin drip to
keep your blood thin, as well as another medication called
"Warfarin (aka Coumadin)" to keep your blood thin. This will
help your body dissolve any possible clots and prevent clots
from recurring.
Additionally, you had a urinary tract infection in the
hospital as well as lower leg cellulitis, both which were
treated with antibiotics.
Lastly, your kidney function was impaired upon admission.
This is likely due to the low blood oxygen you experienced on
initial presentation. Your kidney function improved, but should
continue to be monitored by your physician.
[**Name10 (NameIs) **] had some medications changed. Please refer to your new
medication list attached in this packet. Of note, the following
medications were discontinued. Please speak with your doctor
before making any changes in your medication regimen.
.
STOP TAKING:
Valsartan 40 mg daily
HCTZ 25 mg daily
Gabapentin 200 mg twice daily
Lisinopril 30 mg daily
.
You will be going to [**Hospital 100**] Rehab facility for further
strengthening and care.
It has been a pleasure taking care of you Ms. [**Known lastname 17315**]!
Followup Instructions:
*PLEASE ASSIST PATIENT WITH ARRANGING PCP FOLLOW UP PRIOR TO
LEAVING REHAB*
You have the following follow up appointments scheduled:
.
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2122-10-23**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
You mentioned your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3441**],
will be graduating from her residency program. If you would
like to continue to receive your care at the [**Hospital 191**] clinic at
[**Hospital1 18**], please call [**Telephone/Fax (1) 250**] to schedule an appointment after
you are discharged from rehab. In the hospital, you were seen
by resident physicians Drs [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17316**], [**Name5 (PTitle) **] Piccarillo, and
Nishan Tchekmedyian. You can arrange follow up with them or any
of the residents at the [**Hospital 191**] clinic.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"244.9",
"327.23",
"415.19",
"V85.41",
"276.4",
"599.0",
"788.30",
"277.7",
"682.6",
"785.50",
"278.01",
"250.40",
"585.9",
"311",
"416.8",
"041.4",
"372.30",
"518.81",
"278.03",
"583.81",
"584.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19989, 20055
|
12621, 16589
|
341, 459
|
20237, 20237
|
4255, 12598
|
22048, 23294
|
3035, 3185
|
17026, 19966
|
20076, 20216
|
16615, 17003
|
20413, 22025
|
3200, 4236
|
2272, 2682
|
264, 303
|
487, 2253
|
20252, 20389
|
2704, 2822
|
2838, 3019
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,590
| 188,518
|
2408+55378
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-6-24**] Discharge Date: [**2154-6-25**]
Date of Birth: [**2083-8-18**] Sex: F
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with history of HIV, end-stage renal disease, three
vessel disease status post stent to left circumflex on [**2154-6-4**], history of congestive heart failure with ejection
fraction of 25 percent who was recently discharged from the
[**Hospital1 69**] status post non-ST
elevation myocardial infarction, status post left circumflex
stent, who experienced left sternal chest pain, back pain and
dyspnea at 6:00 a.m. on the day of presentation while getting
out of bed to go to the bathroom. The patient remained
symptomatic and was taken to the [**Hospital1 190**] by EMS where she was found to have a systolic
blood pressure of 210. She was given aspirin, Lopressor 5 IV
times three, Lasix 40 IV times one and was started on
intravenous nitroglycerin drip with resolution of all
symptoms. The patient also has undergone a CT angiogram that
showed no evidence of dissection. The patient had a chest x-
ray that showed right costophrenic angle opacity. The
patient's CT showed signs of left ventricular strain. By the
time she was seen by the Coronary Care Unit team, her
systolic blood pressure was in the 180's and she was symptom
free.
ALLERGIES: Colchicine, allopurinol, ethambutol.
PAST MEDICAL HISTORY: Coronary artery disease, three vessel
disease status post non-ST elevation myocardial infarction in
[**2154-6-4**], status post taxis down to left circumflex in
[**2154-6-4**].
Congestive heart failure. Ejection fraction 25-30 percent.
History of malignant hypertension.
Status post intubation for flush pulmonary edema on [**2154-6-3**], complicated by laryngeal edema.
History of human immunodeficiency virus, CD4 count 74, viral
load less than 60 on [**2154-3-4**], on HAART therapy.
End-stage renal disease on hemodialysis, HIV nephropathy.
Type 2 diabetes, diet controlled.
Spinal tuberculosis.
Hypercholesterolemia.
Hepatitis C viral infection.
Gout.
Anemia.
SOCIAL HISTORY: No smoking, no alcohol, no drug use.
FAMILY HISTORY: Noncontributory.
OUTPATIENT MEDICATIONS: Lipitor 10, Bactrim 160/800 mg p.o.
q. day, aspirin 325 mg p.o. q. day, Imdur 30 mg p.o. q. day,
calcium acetate three tablets t.i.d. with meals, Colace,
vitamin B complex, Sevelamer, Plavix 75 mg p.o. q. day,
lisinopril 40 mg p.o. q. day, _______ XL 150 mg p.o. q. day,
Protonix 40 mg p.o. q. day, Neviratin 200 mg p.o. b.i.d.,
zidovudine 120 mg p.o. b.i.d., lamivudine 100 mg p.o. q.
day.
PHYSICAL EXAMINATION: Temperature 98.5, heart rate 80, blood
pressure 180/100, respirations 23, 97 percent on four liters.
General: Thin, cachectic African-American female in no
apparent distress. HEENT: Moist mucus membranes. Poor
dentition. Neck: Jugular venous distention 10 cm. Normal
carotid upstrokes. Pulmonary: Crackles one-third up, right
greater than left. Cardiovascular: Regular rate and rhythm,
normal S1, S2. Murmur of mitral regurgitation. No rubs or
gallops. Abdomen: Positive bowel sounds, soft, non-tender,
non-distended. Extremities: No clubbing, cyanosis or edema.
Left arteriovenous fistula.
LABORATORY ON ADMISSION: White count 4.8, hematocrit 37.8,
platelet count 269,000, INR 1.0, PTT 28.7. Sodium 139,
potassium 4.3, chloride 100, bicarb 27, BUN 83, creatinine
6.4, glucose 145, calcium 9.4, phosphorus 6.1, magnesium 1.9,
troponin-I 0.49.
ELECTROCARDIOGRAM: Normal sinus rhythm at 81 beats per
minute. Left axis deviation. Positive left ventricular
hypertrophy with strain pattern. T-wave inversions 1, aVL,
V5, V6. This EKG is similar to [**2154-6-4**].
HOSPITAL COURSE: Hypertensive urgency: When evaluated by
Coronary Care Unit team the patient's systolic blood pressure
was in the 180's. The patient had no symptoms of chest pain
or shortness of breath. Nitroglycerin drip was weaned off
and labetalol drip was started with a goal diastolic blood
pressure of less than 100 and decrease of systolic blood
pressure by 25 percent within the first three to six hours
with goal systolic blood pressure 150's to 160's. This goal
was reached in two hours. The patient has undergone
hemodialysis with removal of three liters of fluid after
which patient's systolic blood pressure was in the 120's.
Labetalol drip was stopped and patient remained asymptomatic
with a blood pressure goal in the 140's to 150's. The
patient's lisinopril was continued at the present dose but
changed to 20 mg p.o. b.i.d. to achieve better blood pressure
control and less blood pressure fluctuation. It was thought
that the event that led to patient's admission was
hypertensive urgency with fluid overload which was likely
exacerbated by receiving a dye load required for CT
angiogram.
Coronary artery disease: The patient has known three vessel
disease. She is status post left circumflex stent on [**2154-6-4**]. The patient had no signs of ongoing ischemia. The
patient's chronically elevated troponin-I was likely due to
chronic subendocardial ischemia in patient with end-stage
renal disease. The patient was continued on aspirin, Plavix,
Lipitor. Enzymes were cycled and were negative. The
patient's Lopressor was changed to labetalol to ensure better
blood pressure control which the patient tolerated well.
Congestive heart failure: The patient was maintained on
outpatient hemodialysis schedule. This went uneventfully.
Human immunodeficiency virus: The patient was continued on
outpatient HAART medications.
Diabetes: Fingersticks were stable and patient was covered
with regular insulin sliding scale.
The rest of the discharge summary is to be dictated in an
addendum by another physician who is taking over care for
this patient.
INCOMPLETE DICTATION
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 12421**]
Dictated By:[**Last Name (NamePattern1) 6602**]
MEDQUIST36
D: [**2154-6-25**] 13:53:38
T: [**2154-6-25**] 14:37:29
Job#: [**Job Number 12422**]
Name: [**Known lastname 1839**],[**Known firstname 1840**] Unit No: [**Numeric Identifier 1841**]
Admission Date: [**2154-6-24**] Discharge Date: [**2154-6-26**]
Date of Birth: [**2083-8-18**] Sex: F
Service: [**Hospital Unit Name 319**]
Allergies:
Allopurinol / Ethambutol / Colchicine / Efavirenz
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
chest pain, shortness of breath, back pain
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
As per discharge summary.
Past Medical History:
As per discharge summary.
Brief Hospital Course:
On [**2154-6-25**], Toprol XL was discontinued and the patient was
switched to labetalol 200 mg [**Hospital1 **] for better blood pressure
control. Patient received hemodialysis on [**2154-6-26**] and tolerated
it well. Renagel was increased on [**2153-6-25**] to 1600 mg TID before
discharge. Blood pressure well controlled and ready for
discharge on [**2154-6-26**].
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
3. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
6. Calcium Acetate (Phos Binder) 667 mg Tablet Sig: One (1)
Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
8. Zidovudine 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Labetalol HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
Discharge Diagnosis:
Hypertensive urgency
HIV nephropathy
Hep C
CAD s/p stent to LCX
Discharge Condition:
Good.
Discharge Instructions:
Return to the ER or call your primary physician if you
experience any chest pain, shortness of breath, lightheadedness,
dizziness, nausea or vomiting. Remember to take new blood
pressure medications: labetalol and lisinopril twice a day. Stop
taking Toprol XL.
Followup Instructions:
1. Call Dr. [**Last Name (STitle) **] for appointment in [**1-4**] weeks.
2. Please follow up Provider: [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) 1846**], [**Name Initial (NameIs) **].D. Where: LM
[**Hospital Unit Name 1847**] (ENT) Phone:[**Telephone/Fax (1) 1848**]
Date/Time:[**2154-6-27**] 8:15
3. Provider: [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 189**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 1849**] Date/Time:[**2154-7-2**] 2:00
4. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 495**] DISEASE Phone:[**Telephone/Fax (1) 496**] Date/Time:[**2154-7-9**] 1:30
5. Hemodialysis on [**2154-6-28**] or as per Dr. [**First Name (STitle) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1850**] MD [**MD Number(2) 1851**]
Completed by:[**2154-6-26**]
|
[
"428.30",
"403.01",
"583.9",
"428.0",
"042",
"V45.82",
"414.01",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8487, 8544
|
6732, 7102
|
6591, 6605
|
8652, 8659
|
8968, 9945
|
2168, 2186
|
7125, 8464
|
8565, 8631
|
3731, 6492
|
8683, 8945
|
2211, 2604
|
2627, 3247
|
6509, 6553
|
6633, 6660
|
3262, 3713
|
6682, 6709
|
2113, 2151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,564
| 161,743
|
25928
|
Discharge summary
|
report
|
Admission Date: [**2186-9-28**] Discharge Date: [**2186-10-3**]
Date of Birth: [**2135-12-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Back Pain radiating down left leg
Major Surgical or Invasive Procedure:
L4-S1 Fusion
History of Present Illness:
60-year-old gentleman who presents with metastatic
melanoma. He has known metastases to the axilla, liver, hip, and
L4 vertebral body. There is suspicion on recent imaging that the
L4 lesion is progressing in spite of CyberKnife and systemic
chemotherapy. He reports severe low back pain. He also has pain
that radiates down the left lower extremity. He has been limping
at work. He does feel that the pain is better, walking and
sitting, and there is not a clear positional component
Past Medical History:
Melanoma diagnosed in [**2181**] with axillary lymph node involvement
with re-occurance in [**2182**]. Has received chemo/radiation and
other clinical trials. He currently has metatases to axilla,
liver, hip and vertebral body.
Social History:
Married, currently working, non smoker, 3 drinks per week.
Family History:
Noncontributory
Physical Exam:
Neurologic exam:
On examination, his motor strength was [**4-11**] in the iliopsoas
bilaterally. The quadriceps were graded [**3-12**] on the left and were
normal on the right. Dorsiflexion and plantar flexion were
normal bilaterally. His sensory examination was intact, although
there may have been some mild decreased appreciation of light
touch over the left knee. His back was flat and nontender. His
reflexes were normal and symmetric
Pertinent Results:
[**2186-10-2**] 06:25AM BLOOD WBC-6.6 RBC-3.43* Hgb-10.7* Hct-29.6*
MCV-86 MCH-31.2 MCHC-36.1* RDW-15.0 Plt Ct-131*
[**2186-10-2**] 06:25AM BLOOD Plt Ct-131*
[**2186-9-28**] 08:29PM BLOOD Neuts-92.9* Lymphs-4.7* Monos-2.2 Eos-0.1
Baso-0.2
[**2186-10-2**] 06:25AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
[**2186-10-2**] 06:25AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.1
Brief Hospital Course:
Mr [**Known lastname 64467**] [**Last Name (Titles) 1834**] a L4-S1 fusion without complication, he had
a wound drain in placed interoperatively. His neurologic exam
improved on a daily basis he progressed to full strength in his
left leg (which was weaker pre-op) his pain and numbness in his
left leg also improved. He did develop some right calf and thigh
pain and numbness, LENIs non invasive ultrasound was negative
for DVT. He required 4 units of PRBC due to high output of wound
drain. His crit on dc was 30.
On DC he was tolerating a regular diet, voiding without
difficulty. His neurological exam was full strenght in his lower
extremities with right leg complaints of numbness which has
improved in the last 24 hours. His standing films showed good
alignment of the hardware.
Medications on Admission:
Tylenol and Aleve
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: [**12-9**] Capsules PO twice a day: Use
while taking percocet.
Disp:*40 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Renal Cell
Discharge Condition:
Neurologically intact no deficits
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry you may shower now/ No tub
baths or pool swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Have your staples removed on Monday [**10-9**] please call
[**Telephone/Fax (1) 2992**] for an appointment. You will also need an
appointment in 6 weeks with Dr [**Last Name (STitle) 548**].
Dr[**Name (NI) 2845**] office is located at [**Last Name (NamePattern1) 439**] in the [**Hospital Unit Name 3269**] directly across from the ER
Completed by:[**2186-10-3**]
|
[
"V87.41",
"198.89",
"E878.1",
"V15.3",
"458.29",
"198.5",
"782.0",
"V10.82",
"338.18",
"197.7",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"80.99",
"77.79",
"81.63",
"84.52",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
3262, 3268
|
2143, 2930
|
354, 369
|
3334, 3370
|
1723, 2120
|
5076, 5442
|
1229, 1246
|
2998, 3239
|
3289, 3313
|
2956, 2975
|
3394, 5053
|
1261, 1261
|
281, 316
|
397, 886
|
1278, 1704
|
908, 1137
|
1153, 1213
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,280
| 146,949
|
49896+59210
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-10-26**] Discharge Date: [**2133-12-29**]
Date of Birth: [**2079-4-27**] Sex: M
Service: [**Hospital1 139**] Medicine and transferred to MICU
HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old man
with a complicated and prolonged medical course. Briefly,
was admitted on [**2133-10-26**] after presenting with shortness of
breath and was subsequently found to have pericardial
effusion. Had 1800 cc of fluid drained by pericardiocentesis
on [**10-28**]. Pericardial fluid grew aspergillus, with negative
cytology, and patient was started on a regimen of
Voriconazole and Augmentin. Had echocardiogram which showed
global hypokinesis. Had episodes of recurrent AFib with
rapid ventricular response.
On [**11-3**], had an episode of asystole with spontaneous
recovery, and was subsequently evaluated by EP with no
interventions suggested. On [**11-15**], had a syncopal event with
hypotension, low urine output, and anasarca that was
unresponsive to low dose dopa. A repeat echocardiogram found
reaccumulation of pericardial effusion and evidence of
constrictive pericarditis.
On [**11-17**], underwent pericardectomy and subsequently underwent
a pericardial stripping on [**11-19**]. On [**11-20**], the patient's
antibiotics were changed to
Voriconazole/Vancomycin/Unasyn/caspofungin. Unasyn was
subsequently changed to Zosyn on [**11-22**] for Enterobacter
cloacae. Patient's postoperative course complicated by
anasarca with difficult diuresis and worsening renal failure.
Renal consult obtained. Patient also with respiratory
failure and intubation with difficult wean for which
Pulmonary was consulted and for which patient was transferred
to the MICU team on [**2133-11-30**].
PAST MEDICAL HISTORY:
1. Lung cancer status post XRT/chemotherapy/right lower
lobectomy.
2. Chronic right lung collapse.
3. Chronic left pleural effusion.
4. Paroxysmal atrial fibrillation.
5. Radiation-induced pericarditis.
6. Internal jugular clot [**6-29**].
7. Bronchiectasis.
8. Recurrent [**Doctor First Name **].
9. Hypertension.
10. Chronic renal insufficiency with history of
membranoproliferative glomerulonephritis diagnosed by renal
biopsy summer of [**2132**].
11. ASD by echocardiogram [**5-29**].
12. Questionable remote history of TB in [**Country 651**].
ALLERGIES: Levofloxacin, Percocet.
MEDICATIONS ON TRANSFER TO THE MICU TEAM:
1. Voriconazole started [**10-28**].
2. Caspofungin started [**11-22**].
3. Zosyn.
4. Amiodarone.
5. Metoprolol 12.5 p.o. b.i.d.
6. Hydralazine 10 mg IV q.4. prn.
7. Heparin drip.
8. Bumetanide drip.
9. Atrovent MDI six puffs q.4-6h. prn.
10. Albuterol six puffs q.6h. prn.
11. Epo 5,000 units subQ 3x/week Tuesdays, Thursdays,
Saturdays.
12. Protonix 40 mg IV q.24.
13. Morphine prn.
14. Ativan prn.
15. Ambien prn.
16. Lacrilube one application O.U. prn.
17. Bisacodyl 10 p.r. q.d.
18. Colace 100 mg ng b.i.d.
19. Multivitamin one cap ng q.d.
20. Thiamine 100 mg ng q.d.
PHYSICAL EXAM ON TRANSFER: T max 99.0, blood pressure
109-160/58-79, heart rate 64-71, respiratory rate 12-26,
satting 100% on 30% FIO2. General: Is alert in no acute
distress. HEENT: Intubated. Cardiovascular: Regular rate
and rhythm, normal S1, S2. Pulmonary: Left lung clear,
decreased breath sounds on right. Abdomen was soft, mildly
distended and nontender. Extremities had 2+ pitting edema.
HOSPITAL COURSE: Patient is a 56-year-old man with a history
of lung cancer status post XRT/chemotherapy/right lower
lobectomy, chronically infected nonfunctional right lung and
left lung with decreased compliance resulting in difficult
wean from the ventilator. Hospital course complicated by
recurrent pericardial effusion and constrictive pericarditis
status post pericardial stripping, aspergillus pericarditis,
and left hemothorax, status post VATS.
1. Respiratory failure: Patient's prolonged weaning from the
ventilator secondary to combination of nonfunctional right
lung and left lung with decreased compliance also in the
setting of likely respiratory muscle weakness. Patient is
currently alternating between assist control (250/20/5/0.40)
and trials of pressure support (25/5/0.40). Goal is for a
pCO2 of approximately 55 to 60, which correlates roughly with
a minute ventilation of approximately 7-8 liters/minute.
Patient has a baseline tachypnea of 30-40
respirations/minute, etiology is unclear, but anxiety appears
to be a component. Given his baseline tachypnea, the tidal
volume must be adjusted to obtain desired minute ventilation.
Plan is for continued wean of ventilator support as
tolerated.
Additionally, patient had his right pulmonary artery ligated
during his pericardial procedure in an anticipated for a
staged right pneumonectomy, if patient is able to regain
adequate functional and nutritional status prior to
undergoing procedure.
2. Hemothorax: Patient had hemothorax on left lung on [**12-3**]
of unclear etiology (suspect lysis of clot associated with
removal of chest tube a few days prior). Patient developed
respiratory distress, followed by cardiac arrest (SBP
approximately 50, heart rate approximately 10). Patient
received atropine, Epinephrine, CPR with return of heart
rate, blood pressure, and pulse. Two chest tubes were placed
by the surgical team. Patient was on Heparin at the time for
history of AFib (PTT 91.7), which was subsequently D/C'd.
His hematocrit dropped from 30 to 15, and he was aggressively
resuscitated with blood products. Resuscitation efforts were
complicated by difficulty ventilating the patient, ABG
(6.92/150/97) requiring high peak pressures (65-70) and a
therapeutic paracentesis to relieve abdominal distention.
Patient was stabilized and underwent a VATS [**12-7**] for
evacuation of the hematoma. After the procedure, patient's
ventilatory mechanics improved, and he has had no further
episodes of bleeding or reaccumulation of hematoma.
3. ID: Patient is currently being treated with caspofungin
and Voriconazole for an aspergillus pericarditis. Length of
treatment is currently indefinite and will likely remain such
time as patient has right lung removed. In setting of
continued antifungal therapy, patient needs to have his LFTs
checked approximately every week. He received a 14 day
course of Zosyn for Enterobacter ventilator associated
pneumonia. He had an episode of hypothermia, hypotension
[**12-9**]. He was treated empirically with a seven day course of
cefepime for a sputum culture with resistant Enterobacter
(although he had no evidence of pneumonia on chest x-ray or
physical exam).
Adrenal insufficiency was also a likely contributing
component of this episode, and patient responded well to a
seven day course of stress dosed steroids. Patient has had a
low-grade fever and leukocytosis likely secondary to
sinusitis in the setting of an indwelling nasogastric tube.
His white count has been steadily trending down since removal
of the nasogastric tube. His last positive culture was a
sputum on [**12-13**] with moderate growth of gram-negative rods
(sputum on [**12-9**] grew Enterobacter and Klebsiella).
4. Cardiovascular: Patient is status post pericardial
stripping secondary to effusion and constrictive
pericarditis. Has history of paroxysmal atrial fibrillation,
is on amiodarone and metoprolol. He has been in normal sinus
rhythm for the majority of his MICU course. At this time, he
is not on anticoagulation secondary to his hemothorax
episode. Patient's last echocardiogram [**11-24**] revealed an EF
of 25-30% with severe global hypokinesis and 3+ TR.
5. Renal: Patient has a history of membranoproliferative
glomerulonephritis diagnosed by biopsy 07/[**2132**]. His baseline
creatinine ranges from 1.1-1.5. He has intermittently had
difficult diuresis and has responded to Bumex 2 mg IV b.i.d.
to t.i.d. He had two separate episodes of ATN during his
hospital course secondary to hypotension, which both
resolved.
6. Ascites/anasarca: Patient with volume overload in the
setting of hypoalbuminemia. Has been slowly resolving as
patient's diuresis.
7. Coagulopathy: Patient with INR as high as 1.8 during his
stay. Currently 1.4. Etiology likely secondary to poor
nutrition and has responded to vitamin K therapy.
8. Anemia: Patient is guaiac negative. His hematocrit has
been slowly trending down likely secondary to phlebotomy. He
remains on Epogen 5000 units 3x/week.
9. Nutrition: Patient's tube feeds are currently at goal of
75 cc/hour. He receives free water boluses prn for
hypernatremia.
10. Access: Patient has a double lumen PICC. He also has a
post-pyloric feeding tube.
11. Prophylaxis: Patient has subQ Heparin, proton-pump
inhibitor, and Colace.
12. Patient is full code.
13. Patient had open tracheostomy on [**2133-12-18**].
CONDITION ON DISCHARGE: Patient is in stable, but guarded
condition. He is still requiring ventilator support and
remains with substantial nutritional and Physical Therapy
deficits.
DISCHARGE STATUS: Patient is to be discharged to a
ventilator rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Hemothorax status post VATS.
3. Aspergillus pericarditis.
4. Ventilator-associated pneumonia.
5. Adrenal insufficiency.
6. Paroxysmal atrial fibrillation.
7. Congestive heart failure (ejection fraction 30%).
8. Chronic renal insufficiency secondary to
glomerulonephritis.
9. Anasarca.
10. Anemia.
DISCHARGE MEDICATIONS:
1. Ipratropium six puffs q.4-6h. prn.
2. Albuterol six puffs q.6h. prn.
3. Voriconazole 200 mg p.o. q.12h.
4. Artificial Tears O.U. prn.
5. Colace 100 mg p.o. b.i.d.
6. Amiodarone 400 mg p.o. q.d.
7. Heparin 5,000 units subQ q.8h.
8. Metoclopramide 10 mg p.o. q.i.d.
9. Diazepam 2 mg p.o. q.8h. prn.
10. Metoprolol 12.5 mg p.o. b.i.d.
11. Lansoprazole 30 mg p.o. q.d.
12. Epoetin 5000 units subQ 3x/week (Tuesday, Thursday, and
Saturday).
13. Nystatin 5 mL p.o. q.i.d. prn.
14. Caspofungin 50 mg IV q.d.
FOLLOWUP: Patient is to be discharged to ventilator rehab
facility. He is to have ongoing followup as indicated with
his PCP and Dr. [**Last Name (STitle) 217**] (his pulmonologist).
MAJOR SURGICAL OR INVASIVE PROCEDURES:
1. Pericardial centesis.
2. Median sternotomy with pericardial stripping and ligation
of right pulmonary artery.
3. Left VATS with evacuation of hematoma.
4. Open tracheotomy.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36
D: [**2133-12-27**] 23:43
T: [**2133-12-28**] 07:17
JOB#: [**Job Number 104245**]
Name: [**Known lastname **], [**Known firstname **] Y Unit No: [**Numeric Identifier 16893**]
Admission Date: [**2133-10-26**] Discharge Date: [**2134-1-21**]
Date of Birth: [**2079-4-27**] Sex: M
Service: THORACIC S
ADDENDUM: This is an addendum to the previous discharge
summaries.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Congestive heart failure.
3. Aspergillus pericarditis.
Since the previous discharge summary, the patient has been
able to be weaned off the AC and put on pressure support and
has tolerated going down on pressure support from 28 in the
past few days to 25 and now to 22, and further going down
further without any difficulty. His VBGs were actually
consistently within normal limits and provided further
support that he is tolerating the pressure support
ventilation.
He also had a voice tracheostomy inserted which needs to be
worked on since the patient's vocal cords actually seem to be
too weak to be able to still talk. Additionally, he has edema
of the supraglottic larynx c/w GERD.
Also, his feeding has gotten much better. He is now off the
tube feeds because he is tolerating his regular diet without
any difficulty and his NG tube has also been discontinued and
removed.
The patient has remained afebrile and white blood cell counts
have resolved and have remained relatively constant and
unchanged.
Within this time period, he was changed for his left partial
thrombus in his left subclavian vein and left cephalic vein.
He was initially put on Coumadin with INR goal of 1.5 to 1.6,
at which point it was changed later on after talking to
Surgery to Lovenox since the Coumadin was interfering with
his cyclic antibiotic treatments. He just finished his two
week course of Bactrim antibiotic for which he is going to
have two weeks off and then later on following up with a two
week course of azithromycin per his Pulmonary doctor, Dr.
[**Last Name (STitle) **]. Still he is going to go on cyclical
prophylactic antibiotic treatments of Bactrim two weeks off,
Azithromycin two weeks, and so on.
Pre-discharge, we obtained a chest CT which revealed multiple
nodules on the right, thought to represent healing aspergillosis
- the ID team suggested continuing both caspofungin and
voriconazole, and Mr. [**Known lastname **] is scheduled for a f/u visit and CT
with the ID team.
The patient is in stable condition and is now working with
Physical Therapy and will require more rehabilitation
treatments to further facilitate care.
DISCHARGE MEDICATIONS: As written.
No surgical intervention.
[**First Name8 (NamePattern2) 77**] [**Name8 (MD) **], M.D. [**MD Number(1) 3616**]
Dictated By:[**Name8 (MD) 1902**]
MEDQUIST36
D: [**2134-1-21**] 12:42
T: [**2134-1-21**] 15:36
JOB#: [**Job Number 16894**]
|
[
"510.9",
"428.0",
"420.99",
"518.84",
"998.11",
"117.3",
"427.5",
"423.2",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"37.31",
"37.12",
"99.15",
"37.21",
"33.24",
"37.0",
"96.6",
"99.04",
"77.61",
"38.85",
"34.09",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10958, 13138
|
13162, 13448
|
3397, 8794
|
216, 1744
|
1766, 3379
|
8819, 9068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,637
| 117,843
|
554
|
Discharge summary
|
report
|
Admission Date: [**2196-5-13**] Discharge Date: [**2196-5-16**]
Service:
CHIEF COMPLAINT: GI bleed, transfer from [**Hospital3 4527**].
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman with a history of Sjogren syndrome with sicca syndrome
and also CREST with predominant Raynaud's, history of GI
bleed in the past thought secondary to gastritis and
arteriovenous malformations, status post left gastric and
left gastroduodenal artery embolizations in [**7-18**] and [**6-18**]
respectively. She presented to [**Hospital3 4527**] in mid-[**2196-4-17**] with bright red blood per rectum and an hematocrit drop
from 34 to 28. Her work-up at that time consisted of an
abdominal CT that revealed a pancolitis, increased
splenomegaly, and new ascites. She was transfused two units
and discharged to rehabilitation on [**2196-5-7**], and then two to
three days prior to admission the patient noted dark stools
and on the morning prior to admission the patient had nausea,
decreased appetite, and an episode of vomiting bright red
blood. She subsequently went to [**Hospital3 4527**] on [**2196-5-12**]
in the morning. In the emergency room there her systolic was
in the 90s, hematocrit was 18, down from 28 on discharge.
Her INR was 1.7. She had a left IJ triple-lumen catheter
placed, a right EJ peripheral line, and she subsequently
underwent EGD which revealed grade 0-1 esophageal varices,
portal gastropathy, gastric varices, but no active bleed,
although there were multiple blood clots in the stomach. She
was treated with IV Protonix and was started an octreotide
drip. She was transfused several units, which improved her
hematocrit from 18 to 28, and then on the morning of the 27th
around 1 AM she had a repeat episode of hematemesis, and
nasogastric lavage did not clear after two liters of saline.
An emergency EGD was performed that revealed a large varix at
the gastroesophageal junction, and there was blood in the
fundus. Sclerotherapy was attempted, which resulted in an
initial blood spurt, however the bleeding subsequently
stabilized and overall during the resuscitative efforts, she
was given six units of red cells and four units of fresh
frozen plasma, and she was transferred to [**Hospital1 346**] for evaluation of emerging TIPS.
Here in the intensive care unit the patient was comfortable
with no nausea or vomiting, no further hematemesis. She
denied any abdominal pain.
PAST MEDICAL HISTORY: 1. Sjogren's with sicca syndrome. 2.
CREST with predominant Raynaud's. 3. History of GI bleed
status post left gastric artery embolization in [**7-18**], and
left gastroduodenal artery embolization in [**6-18**]. 4. History
of pancolitis. 5. Recent episode of bleeding points. 6.
Irritable bowel syndrome. 7. Hypertension. 8. Hashimoto's
hypothyroidism with positive antibody. 9. Diverticulosis.
10. History of left femoral DVT in [**6-18**]. 11. History of
chronic obstructive pulmonary disease/bronchitis.
MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2.
Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent,
albuterol nebulizers. 5. Vitamin K subcutaneous x 3.
ALLERGIES: The patient is allergic to sulfa and penicillin.
SOCIAL HISTORY: The patient lives in [**Location (un) 4528**] skilled
nursing facility. Her son lives locally, daughter is on the
west coast. Minimal alcohol history and remote tobacco. The
patient has a son with [**Name (NI) 4522**] disease.
PHYSICAL EXAMINATION: On arrival her temperature was 98,
blood pressure 160/80, heart rate 80s, respiratory rate 16,
saturating 95% on two liters. General: She was a
well-appearing, elderly, frail woman. HEENT: She had
crusted blood in her oropharynx. Pupils equal, round and
reactive to light. Sclerae anicteric. Neck: Supple, with
no lymphadenopathy. Chest: Examination revealed decreased
breath sounds at the left base and bronchial breath sounds at
the right base. Cardiac: There was a [**12-24**]
crescendo/decrescendo systolic murmur at the right upper
sternal border without radiation. Abdomen: Benign, positive
bowel sounds, nontender. There was no fluid wave. No liver
edge was appreciated. Extremities: There was no peripheral
edema. Skin: There was no jaundice notable. Neurologic:
The patient was alert and oriented x 3, otherwise nonfocal.
LABORATORY DATA: On the morning of admission white count was
10.8, hematocrit 31.9, which had been up from 22 earlier in
the morning, platelet count 68, which was around her
baseline, SMA-7 was unremarkable. BUN and creatinine were
normal. INR was 1.3. PT 14.1, PTT 32.8, fibrinogen was 161,
albumin 3.2. ALT, AST, and alkaline phosphatase were within
normal limits. Total bilirubin was 2.1. Urinalysis on the
morning of arrival had been negative.
EKG showed sinus tachycardia at [**Street Address(2) 4529**] depressions in 2,
3, aVF, V4 to V6, but no acute change compared to old.
HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient
was thought to have cirrhosis of unclear etiology with new
ascites and new splenomegaly on recent abdominal CT, and on
endoscopy at the outside hospital, portal gastropathy and
esophageal varices were found. The patient was initially
transferred to [**Hospital1 69**] for
evaluation for emerging TIPS. The patient had a type and
cross with four units of red cells and fresh frozen plasma on
hold. She had a central line in her left neck as well as a
right EJ. She was continued on octreotide drip at 50 mcg per
hour. She was continued on Protonix 40 IV b.i.d. Her
coagulopathy, her hematocrit and platelet count were
corrected with products as needed. The patient was evaluated
by the liver team, who felt that given her comfortable status
and high risk of precipitating encephalopathy, TIPS would not
be the best strategy; rather the patient was observed on
octreotide drip. Her daughter and son were available as well
as the patient during this conversation and agreed that
conservative management of her varices was the best route.
The patient was continued on octreotide drip for the plan of
five days, and was continued on Protonix IV b.i.d. She was
started on nadolol for further decrease of her portal
hypertension, and a work-up was initiated for her etiology of
cirrhosis including hepatitis panel, [**Doctor First Name **], SPEP, and
antimitochondrial antibody.
A right upper quadrant ultrasound was performed that revealed
no evidence of portal vein thrombus and a cirrhotic liver.
The patient had no further episodes of hematemesis during her
hospitalization. Her hematocrit remained stable throughout
her hospitalization.
2. Mental status change: The patient initially was alert and
oriented upon arrival, however became delirious within 24
hours of her hospitalization. Further work-up revealed a
positive urinalysis consistent with a urinary tract
infection, probably catheter related. The patient also had
4/4 bottles positive for gram-positive cocci in clusters in
her blood, which were drawn off a left IJ, consistent with a
line infection with sepsis. The patient had already been
DNR, however now the patient's code status after discussion
with her daughter and son, was changed to DNR/DNI, and made
comfort measures. No antibiotics were given for her line
infection. The line was not changed due to the morbidity
involved in a central line procedure, and unfortunately, the
passed away likely due to overwhelming sepsis both from line
infection and urinary tract infection.
The patient was pronounced at 10:20 PM on [**2196-5-16**]. Daughter
and son were present at the bedside.
DISCHARGE DIAGNOSES:
1. Line infection/sepsis.
2. Urinary tract infection.
3. Variceal bleed/hemorrhage.
4. New diagnosis of cirrhosis in addition to her diagnoses on
arrival.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2196-6-21**] 11:09
T: [**2196-6-27**] 07:14
JOB#: [**Job Number 4530**]
|
[
"287.4",
"491.20",
"428.0",
"572.2",
"456.20",
"578.0",
"571.5",
"710.1",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7622, 8006
|
4937, 7601
|
3475, 4919
|
100, 147
|
176, 2433
|
2456, 3204
|
3221, 3452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,662
| 109,584
|
413
|
Discharge summary
|
report
|
Admission Date: [**2127-9-20**] Discharge Date: [**2127-9-30**]
Date of Birth: [**2077-7-23**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Left Occipital Epidural Hematoma
Major Surgical or Invasive Procedure:
Evacuation of left occipital epidural hematoma
History of Present Illness:
50yo WF with PMH significant for cervical disc herniation
that presented to outside neurosurgeon 2-2.5 weeks ago for
evaluation. Following that appointment for which no intervention
was pursued, patient started to have episodes of falling to the
ground with any attempt at standing up. Patient denied HA,
seizure activity/symptoms, LOC, or lightheadedness with each
episode, simply stating that "the world started to spin around"
whenever she experienced one of these episodes; pt did c/o
occasional nausea and retching with the episodes. Pt began to
require balance assistance to stand each time, and still had
multiple episodes of going to ground resulting numerous
abrasions, and three broken ribs. On the evening of [**9-19**],
patient
had another episode resulting in a backward fall onto a concrete
slab that did not cause LOC but was worrisome enough for patient
to contact her PCP who told her to have a low threshold for
visiting an ER. On morning of [**9-20**], with no resolution of sxs
patient was seen at OSH where CTH showed large left occipital
EDH.
Past Medical History:
Depression
Social History:
Lives alone, divorced, denies etoh/tobacco/ivda
Family History:
Non-contributory
Physical Exam:
VS: T 98.9 HR 113 BP 167/97 RR 23 Sat 99% RA
PE: Well-appearing, well-nourished, with moderate level anxiety
from hospitalization.
HEENT: Occipital pain on palpation, L Hemotympanum
CV: RRR s m/g/r
Neuro
MS: AA&Ox3, speech fluent, follows 3-point commands, easily
comprehensible No neologisms or paraphrasic errors.
CN: I--not tested; II-could read nametag,III-PERRLA 5-3mm,
III,IV,VI-EOMI w/ left beat nystagmus, V--sensation intact to
LT,
and masseter strength; VII-no facial asymmetry, muscles of
facial
expression strong; VIII- intact to FR bilaterally; IX,X--voice
normal, palate elevates symmetrically, uvula midline;
XII--tongue
protrudes midline, no atrophy or fasciculation.
Motor: normal bulk and tone, no pronator drift. Strength:
Delt [**Hospital1 **] Tri Grip IO Psoas Quad Ham TA [**First Name9 (NamePattern2) 3568**] [**Last Name (un) 938**]
C5-6 C5-6 C6-8 C7-8 C7-8 L2-4 L2-4 L5-S2 L5-S1 S1-2 L4-5
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Coord: no dysmetria. FNF intact bilaterally, right better than
left
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 2 | 2 | dn |
R | 2 | 2 | 2 | 2 | 2 | up |
[**Last Name (un) **]: LT intact to all four extremities/trunk
Pertinent Results:
[**2127-9-20**] 06:20PM PT-12.4 PTT-20.5* INR(PT)-1.0
[**2127-9-20**] 06:20PM PLT COUNT-246
[**2127-9-20**] 06:20PM NEUTS-90.1* BANDS-0 LYMPHS-2.7* MONOS-3.5
EOS-0.1 BASOS-0.1
[**2127-9-20**] 06:20PM WBC-7.9 RBC-3.12* HGB-11.4* HCT-30.7* MCV-99*
MCH-36.6* MCHC-37.2* RDW-15.8*
CTH [**9-20**] Large left epidural hematoma with adjacent mass effect,
cerebral
edema, compression of the ventricle and concern for uncal
herniation
CTH [**9-21**] Interval drainage of epidural hemorrhage. No evidence
of new
bleeding.
CTH [**9-22**] Unchanged pneumocephalus in the left supratentorial
epidural
space. Stable small epidural hematoma in left posterior fossa.
No new
hemorrhage or evidence of major vascular territorial infarction
or
hydrocephalus.
CT C-Spine [**9-20**] Abnormality at the left C1-C2 facet, of
uncertain age. The lytic and sclerotic appearance could be
consistent with a less acute process, although an acute injury
cannot be excluded
Plain Films Bilateral Knees [**9-21**] Unremarkable radiographs of the
bilateral knees
Plain Films Bilateral Ankles [**9-23**] Acute left lateral malleolar
avulsion fracture. Left medial malleolar tiny avulsion fracture
of uncertain chronicity (no soft tissue swelling). Clinical
correlation needed.
No right ankle fracture. Right calcaneal tuberosity is excluded
from the
image.
MRI C-spine [**9-23**] Small right-sided foraminal disc herniation at
C6-C7 level possibly contacting the right exiting [**Name (NI) 3569**] nerve root.
Small left paracentral disc herniation at C5-C6 level. T2
hyperintensity involving the right facet joint at C3-C4 and
C4-C5 levels with slight hyperintensity within the right C3
pedicle. This could be related to possible osseous contusion and
neck injury. No definite fractures are identified; however,
thin-section CT might be useful for further imaging to detect
any suspected subtle fractures
Brief Hospital Course:
Patient taken directly from ER Trauma bay on [**9-20**] to OR for
emergent evacuation of large left occipital epidural hematoma.
Pt tolerated the procedure well and was transferred after
stabilization in the PACU to ICU. Pt was maintained in ICU in
stable condition until HD 3 (POD #1) at which time head drain
was removed, patient was transfused two pRBC's for anemia, and
transferred to step-down [**Hospital Ward Name 121**] 5. Based on C1-C2 facet joint
irregularity seen on CT c-spine, Spine Consult was obtained, and
with f/u MRI of spine, it was determined that the patient needed
to maintain hard c-spine collar on for 6 weeks, until follow up
with orthopaedic spine. On HD4, orthopaedics was consulted for
left ankle fx and their recommendations were to place patient
leg in air splint, with weight bearing on foot as tolerated. Pt
was transferred to regular floor status on [**9-24**] while awaiting
PT and social work recommendations.
Pt continued to have headaches a repeat head CT was done on
[**9-25**]
Neurology saw patient for vertigo they felt shecharacteristics
of this patient's dangerous and disabling vertigo do have a
peripheral vestibular not central quality. The features are not
lateralized enough to suggest vertebrobasilar vascular
insufficiency, nor are there the assoc. features of this DX. The
gradual escalation of symptoms is not compat. with stroke, but
also not with most of the acute labyrinthitidies, and is also
not typical of vertigo due to demyelinating disease. Rather I
suspect an otovestibular condition such as Meniere's disease, or
a more subacute process such SLE . Doubt mass lesion as the
hearing loss (if indeed not directly due to resolving
hemotympanium) is spontaneously remitting.
[**Last Name (un) 3570**].: In view of her severe multiple trauma, hemotympanium,
neck
[**Last Name (LF) **], [**First Name3 (LF) **] not feel it useful, practicable or safe to begin a
diagnostic evaluation of this patient's vertigo. Both hearing
testing (site of lesion) and otovestibular testing must be
delayed until cervical stability is established. Until then her
vertigo must still be considered to place her at risk for
further
unpredictable falls, and life-threatening injury. Until a
definitive W/U can be realized, I would therefore recommend that
she be placed in Rehab ([**Location (un) 38**]-Healthcare South would be
ideal because of the excellent otovestibular lab. there) or at
the very least, a [**Hospital1 1501**] facility until w/u can proceed.
Medications on Admission:
Per patient: zoloft, and "some other depression medication"
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*1*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
6. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Aberjona Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
Left Occipital Epidural Hematoma
Discharge Condition:
Stable
Discharge Instructions:
Please resume all home medications. Please return to hospital ER
if you experience fever in excess of 101 degrees, begin to have
worsening nausea/vomiting or headaches, or note increased
redness or purulent drainage from head wound.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 739**] in 6 weeks with a Head
CT prior to visit. Please call [**Telephone/Fax (1) 3571**] to schedule an
appointment
Please follow up with orthopaedic spine, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3572**]
office, in six weeks. Please call [**Telephone/Fax (1) 3573**] to schedule an
appointment
If you continue to have foot pain you can follow up with Dr
[**Last Name (STitle) 2637**] from Orthopedics otherwise just wear air cast for 2
weeks
Please follow up with your primary care provider [**Last Name (NamePattern4) **] 2 weeks
regarding high blood pressure
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2127-9-30**]
|
[
"780.4",
"722.0",
"805.02",
"851.82",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
8468, 8541
|
4808, 7319
|
352, 401
|
8618, 8627
|
2896, 4785
|
8908, 9673
|
1614, 1632
|
7429, 8445
|
8562, 8597
|
7345, 7406
|
8651, 8885
|
1647, 2877
|
280, 314
|
429, 1499
|
1521, 1533
|
1549, 1598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,044
| 172,095
|
20658
|
Discharge summary
|
report
|
Admission Date: [**2152-11-5**] Discharge Date: [**2152-11-19**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
man with a history of diabetes mellitus type 2, hypertension,
hyperlipidemia, tobacco abuse, coronary artery disease status
post MI, peripheral vascular disease status post right lower
extremity bypass, who was originally admitted for angioplasty
of his right lower extremity.
Ultrasound graft surveillance had demonstrated a stenosis of
his right bypass. During the procedure he was doing well
until the sheath was pulled. At that time he was noted to
have a blood pressure of 50/palp, he became acutely short of
breath and was placed on a 100% non-rebreather. A code blue
was called. IV fluids were given and Dopamine was initiated.
His blood pressure recovered and was 112/60 upon transfer to
the MICU. He was found to have a hematocrit of 27 and was
given 1 unit of packed red blood cells.
The patient underwent angiogram on [**11-7**] and became
hypotensive with shortness of breath and transiently lost his
pulse when the sheath
was pulled. He was initially resuscitated with Dopamine and IVF
and
stabilized briefly in the CCU and went back to the vascular
service.
This episode could have been vasovagal. The hematocrit was
stable. The patient was ruled out by enzymes. The patient had
new EKG changes and had a new T wave inversion in V2 through
V6, and therefore underwent an echo, which showed worsening
EF of 25% to 30%, compared to 45% to 50% in [**2152-7-9**]. An
extensive LV systolic dysfunction consistent with multivessel
coronary artery disease. He then went on the P-MIBI. There
was thought a possible reversal defect, so the patient
therefore underwent cath on [**11-10**].
Cath demonstrated severe 80% proximal RCA and stent
restenosis, moderate diffuse disease of the mid and distal
RCA. The LMCA had a 30% stenosis. The mid LAD stent was
patent with a 50% stenosis proximal to the stent. The D1 had
a 99% ostial stenosis and was a large vessel. The left
circumflex was diffusely diseased and it was a 100% occluded
after the OM1. PCI of the RCA in D1 was planned and heparin
and Integrilin were administered. The patient became
hypotensive shortly thereafter requiring IV pressors (Neo).
Right heart cath demonstrated extremely low filling
pressures. MRA is 3, RV of 25/1, PAP of 17/12 and wedge of 5.
Angiography of the left iliac and femoral artery demonstrated
retroperitoneal bleed from the earlier distal external iliac
puncture from 1 to 2 days ago. The site of the bleed was
tamponaded using a 7 x 40 mm Agile track balloon for 6
minutes with successful sealing of the bleeding site. Heparin
was reversed with protamine and Integrilin was discontinued.
The patient was unable to provide further history on transfer
to cardiology. At the time of the examination he denied chest
pain, shortness of breath, nausea, vomiting, any pain or
other symptoms.
PAST MEDICAL HISTORY: Peripheral vascular disease, coronary
artery disease (3 vessel disease), cath [**2152-7-14**] status
post stent to mid LAD (80%, 70%), distal, mid and proximal
RCA with fiber metal stents, hypertension, history of CVA in
[**2144**] with residual left-handed weakness, diabetes mellitus
type 2 with neuropathy, hypertension, hypercholesterolemia,
history of colon cancer status post colon resection, and BPH.
CHF, status post right leg grafting x2, status post right
jump graft from right femoral artery to popliteal artery, BPG
to DP with right arm vein, status post right vein ligation
[**2130**], status post colon resection for cancer in [**2135**], status
post right femoral artery to popliteal artery bypass graft in
[**2145**], status post right first toe amputation with debridement
of his right fifth metatarsal [**2151**], status post left CFA to
DP arterial bypass with vein, first toe amputation, left
fifth toe.
PHYSICAL EXAMINATION: At the time of transfer, afebrile,
blood pressure 126 to 150/50 to 75, pulse 86, respirations
20, 100 room air, lying in bed in no apparent distress,
smiling. Neck supple. PERRLA. MMM. MNO moist and clear. No
lymphadenopathy. CTAB anterior exam. Normal S1 and S2.
Normoactive bowel sounds, not tender, not distended.
Ecchymosis tracking on right down to buttocks. Extremities 1
times 4, no palpable DP or MM pulses bilaterally. Trace
bipedal edema. Right arm cath swollen, erythematous, but with
good distal pulse. CN II through XII grossly intact.
LABORATORY DATA: Sodium 134, potassium 4.2, chloride 100,
bicarb 25, BUN 22, creatinine 0.9, glucose 212 for a gap of
9. White blood count 7, hematocrit 35.2, platelets 171, CK
21.
MEDICATIONS: Medications at the time of transfer, ascorbic
acid; aspirin; Atorvastatin 10; heparin prophylactic; insulin
sliding scale; glyburide 5 per day; Levofloxacin 500 per day;
Metoprolol 50 b.i.d.; morphine 1 to 2 q.4h as needed;
Atropine at bedside; Captopril 6.25 t.i.d.; Plavix 75 per
day; Docusate; multivitamins; Oxycodone 5 q.4 p.r.n.;
Protonix 40 per day; zinc 220 per morning.
Ultrasound [**11-7**] demonstrated small AV fistula of the
left common femoral vessels. No severe aneurysm identified.
Ultrasound of graft [**11-7**] demonstrated a patent right
femoral to tibial bypass graft. No evidence of stenosis.
Echo [**11-8**] demonstrated extensive left ventricular
systolic dysfunction consistent with multivessel disease,
mild aortic regurgitation, mild mitral regurgitation, EF 25%
to 30%.
1. P-MIBI dated [**2152-11-9**] demonstrated moderate
inferior and inferolateral predominantly fixed perfusion
defect, which appears less reversible on today's
examination when compared to prior study.
2. New mild anteroseptal fixed perfusion defect.
3. Severe global hypokinesis with LV at 44%.
Right femoral ultrasound [**11-15**], no AV fistula, no
pseudoaneurysm.
Cath dated [**2152-11-17**], LAD with patent stent, left
circumflex patent, 99% dye stented RCA with proximal ostial
and in-stent restenosis stented.
SOCIAL HISTORY: Married. Retired shoemaker. Former smoker.
FAMILY HISTORY: Unknown.
BRIEF HOSPITAL COURSE: As above in the history of present
illness at the time of transfer, the patient was clinically
stable. He was observed for several days following his
catheterization, and was stable. He was then discharged to
physical therapy.
MEDICATIONS ON ADMISSION: Nitroglycerin patch 0.2 mg per
hour per day; insulin sliding scale and fixed dose;
Collagenase ointment; Atorvastatin pen; Lansoprazole 30 per
day; Metoprolol 25 b.i.d.; Glyburide 5 b.i.d.; Docusate 100
b.i.d.; zinc sulfate 220 q a.m.; ascorbic acid 500 q a.m.;
multivitamins; magnesium oxide 400 per day; aspirin 81 per
day; Furosemide 60 po q a.m.; Plavix 75 per day.
MEDICATIONS ON DISCHARGE:
1. Docusate 100 b.i.d.
2. Zinc sulfate 20 per day.
3. Atorvastatin 10 at hour of sleep.
4. Multivitamin.
5. Ascorbic acid.
6. Plavix 75 per day.
7. Metoprolol tartrate 50 b.i.d.
8. Aspirin 325 per day.
9. Ecotrin.
10. Prevacid 30 per day.
11. Glyburide 5 per day.
12. Lantus 15 at hour of sleep.
13. Furosemide 60 per day.
14. Magnesium oxide 400 per day.
15. Potassium chloride 10 mEq capsule, 1 per day.
16. Levafloxin 500 per day for 2 days.
17. Lisinopril 5 per day.
DISCHARGE DIAGNOSES:
1. Vasovagal hypotension with sheath pulse x2.
2. Retroperitoneal bleed.
3. Acute blood loss anemia.
4. NSTEMI.
5. Hypotension.
6. Hypoxia.
7. Left foot ulcer.
Follow up was arranged with primary care with Dr. [**Last Name (STitle) **],
the vascular surgeon, and Dr. [**Last Name (STitle) **], the cardiologist.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7258**], M.D. [**MD Number(1) 7252**]
Dictated By:[**Last Name (NamePattern1) 22001**]
MEDQUIST36
D: [**2153-8-15**] 17:39:36
T: [**2153-8-16**] 11:25:07
Job#: [**Job Number 55189**]
|
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icd9cm
|
[
[
[]
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[
"37.23",
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"99.04",
"36.07",
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icd9pcs
|
[
[
[]
]
] |
6099, 6327
|
6065, 6075
|
7253, 7858
|
6751, 7232
|
6354, 6725
|
3903, 5987
|
116, 2931
|
2954, 3880
|
6004, 6048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,206
| 135,168
|
25997
|
Discharge summary
|
report
|
Admission Date: [**2179-9-21**] Discharge Date: [**2179-9-28**]
Date of Birth: [**2106-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Chest tube placement and removal
Endotracheal Intubation ([**9-21**]) and extubation ([**9-23**])
PICC placement
History of Present Illness:
73yo male w/ stage IIIB squamous cell lung cancer, s/p recent
chemo and radiation, coming from a [**Hospital1 1501**] with dyspnea since
yesterday. No reported fevers, but also developed lower
extremity edema. EMS found him with shortness of breath, with
oxygen saturations in low 80s, put on non-rebreather, then CPAP
for transfer. No history of CHF. Appears cachectic.
Of note, the patient was recently admitted from [**9-13**] to
[**2179-9-17**] to [**Hospital 3278**] medical center with dysphagia and diagnosed
with radiation esophagitis. He was started on a PPI and
carafate, as well as Percocet. He tolerated a diet and was
discharged with follow-up with his oncologist. Attending was Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Etten.
In the ED, initial vitals were 99.0 151 113/87 30 93% on CPAP.
Patient was found to have a right-sided pneumothorax, so a
right-sided chest tube was placed, which drained 300cc of
foul-smelling purulent fluid after a large gush of air. Repeat
CXR showed incomplete expansion of the right lung. Chest tube
has put out another 300cc. Initially on BiPAP, then weaned to
non-rebreather. Given vanc/Zosyn. Labs notable for anemia of
33.8, lactate 3.3, WBC 7.3 with 33% bands. 2 PIV placed. To get
CT scan, and on return to the ED had worsening hypoxia and
respiratory distress and was intubated. Received total 3L IV
fluid. Prior to transfer were 99, 73, 142/88, 24, 98%
non-rebreather.
Intubated and sedated, cannot provide further history.
Past Medical History:
- Stage IIIB squamous cell cancer diagnosed [**6-/2179**] with large
right lower lobe [**Location (un) 21851**] extending into the subcarina.
Right supraclavicular and R paratracheal lymphadenopathy.
Lesions in the stomach and liver suspicious for mets being
worked up. Has been on carboplatin and paclitaxel, as well as
completing a full course radiation.
- hypertension
- hyperlipidemia
Social History:
- Tobacco: 12 pack year smoking history, has quit
- Alcohol: none
- Illicits: none
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
General: Intubated, sedated.
HEENT: Sclera anicteric, PERRL
Neck: JVP not elevated, no LAD
Lungs: Bilateral R>L coarse breath sounds.
CV: Tachy, regular, no audible murmurs
Abdomen: soft, non-tender, non-distended
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
VS: RR 20 (16-22), pain 0/10
General: NAD, though restless. Not-intubated. Interactive.
Lungs: Decreased breath sounds in the R lung field, coarse
breath sounds throughout the left lung field
GU: no foley
Ext: cool, 2+ pulses, no clubbing, cyanosis, edema
Otherwise physical exam upon discharge is unchanged from
admission.
Pertinent Results:
ADMISSION LABS:
[**2179-9-21**] 10:54AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.9* Hct-33.8*
MCV-89 MCH-28.7 MCHC-32.2 RDW-15.3 Plt Ct-228
[**2179-9-21**] 10:54AM BLOOD Neuts-58 Bands-32* Lymphs-6* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2179-9-21**] 10:54AM BLOOD PT-12.4 PTT-26.7 INR(PT)-1.0
[**2179-9-21**] 10:54AM BLOOD Glucose-131* UreaN-24* Creat-0.7 Na-141
K-4.2 Cl-100 HCO3-28 AnGap-17
[**2179-9-21**] 04:34PM BLOOD ALT-14 AST-22 LD(LDH)-267* CK(CPK)-68
AlkPhos-70 TotBili-0.6
[**2179-9-21**] 04:34PM BLOOD CK-MB-3 cTropnT-<0.01
[**2179-9-21**] 11:07AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0
[**2179-9-21**] 11:27AM BLOOD Type-ART pO2-270* pCO2-44 pH-7.42
calTCO2-30 Base XS-4 Intubat-INTUBATED
[**2179-9-21**] 10:59AM BLOOD Glucose-124* Lactate-3.3* K-4.4
[**2179-9-21**] 05:31PM BLOOD freeCa-0.98*
DISCHARGE LABS:
[**2179-9-24**] 03:08AM BLOOD WBC-4.6 RBC-2.79* Hgb-7.6* Hct-23.4*
MCV-84 MCH-27.2 MCHC-32.4 RDW-14.9 Plt Ct-145*
[**2179-9-24**] 03:08AM BLOOD Glucose-114* UreaN-13 Creat-0.4* Na-135
K-3.7 Cl-99 HCO3-31 AnGap-9
[**2179-9-24**] 03:08AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.8
URINE:
[**2179-9-21**] 12:41PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2179-9-21**] 12:41PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2179-9-21**] 12:41PM URINE RBC-<1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
PLEURAL FLUID:
[**2179-9-21**] 04:15PM PLEURAL WBC-[**Numeric Identifier 42344**]* RBC-7000* Polys-100*
Lymphs-0 Monos-0 Macro-0
[**2179-9-21**] 04:15PM PLEURAL TotProt-2.1 Glucose-21 LD(LDH)-9470
MICRO:
[**2179-9-21**] BCx: NEGATIVE
[**2179-9-21**] UCx: NEGATIVE
[**2179-9-21**] MRSA screen: NEGATIVE
[**2179-9-21**] Pleural fluid Cx:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GAMMA(I.E. NON-HEMOLYTIC) STREPTOCOCCUS. SPARSE GROWTH.
VIRIDANS STREPTOCOCCI.
SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
[**2179-9-21**] Sputum Cx: GRAM STAIN (Final [**2179-9-21**]): >25 PMNs, 4+
PMNs RESPIRATORY CULTURE (Final [**2179-9-23**]): GNRs SPARSE
GROWTH.
NO LEGIONELLA ISOLATED.
STUDIES:
[**2179-9-21**] EKG: Sinus tachycardia with non-specific ST-T wave
changes in the lateral precordial leads.
[**2179-9-21**] CXR:
1. Large right-sided pneumothorax with deviation of mediastinal
structures to the left concerning for tension.
2. Hazy density in the left mid and lower lung zones which may
represent infectious process.
[**2179-9-21**] CT chest:
1. Per clinical concern for empyema, there is minimal layering
fluid within the right hemithorax without organization or
enhancing walls to suggest underlying empyema. There are dense
consolidations, worse in the right lower lobe with central areas
of hypoattenuation and air which are most compatible with
necrotizing pneumonia. Multifocal pneumonia is suspected with
extensive patchy opacities also noted in the right upper, left
upper and left lower lobes. Only the consolidation of the right
lower lobe demonstrates areas of necrosis. Given the
distribution, aspiration is a consideration.
2. Persistent right pneumothorax with indwelling chest tube.
Chest tube course as described above. There is baseline
pneumonia. No significant mediastinal shift is seen to suggest
recurrence of tension physiology.
3. Marked visceral pleural thickening, particularly of the lower
right hemithorax. This is of indeterminate etiology or
chronicity. This could be related to underlying infection. Given
the lack of parietal pleural thickening or other abnormality,
malignancy is felt less likely but is not excluded.
[**2179-9-24**] CHEST (PORTABLE AP): Diffuse abnormality in the right
lung continues to clear, particularly following removal of the
right pleural tube suggesting that most of this abnormality was
due to combination of edema and hemorrhage rather than
pneumonia. On the other hand consolidation in the left lower
lung has increased progressively since [**9-22**] and may well
be pneumonia. Small-to-moderate right pleural effusion remains.
There is no pneumothorax. Heart size is top normal, improved
since earlier in the day. Left PIC line ends in the upper SVC.
Brief Hospital Course:
Mr. [**Known lastname **] is a 73M with stage IIIB squamous cell lung cancer, s/p
chemo and palliative radiation, coming from a [**Hospital1 1501**] with SOB,
found to have MSSA multifocal pneumonia, empyema, and
pneumothorax, s/p chest tube placement and now removal.
# Goals of Care: Family meeting was held with pt's daughter and
wife. It was decided to make the patient comfort measures only,
with the exception of keeping antibiotics on board. Pt will be
transitioning to hospice, at which point antibiotics will be
discontinued. Pt had no further lab draws.
# Respiratory failure: Patient was admitted with pneumothorax,
pneumonia, and empyema. He was intubated for respiratory
distress on admission, extubated on [**2179-9-23**]. Chest tube was in
place for empyema, removed on [**2179-9-24**]. Culture growing coag +
staph (pan-sensitive), GNR, Strep viridans, and Gamma strep. He
was treated with Zosyn from [**2179-9-21**] to [**2179-9-28**] and Tobramycin
from [**2179-9-21**] to [**2179-9-27**], after which they were discontinued as
pt was transitioned to hospice. He was on morphine and
nebulizers for comfort.
# Lung cancer, stage 3b: MRI was negative for brain mets.
Patient s/p palliative radiation with adjuvant weekly
[**Doctor Last Name **]/taxol x3 cycles in [**Month (only) 359**]. However, pt is no longer a
candidate for palliative chemo and his overall prognosis poor.
Patient's dexamethasone was tapered off.
# Esophagitis: Secondary to recent radiation. He was continued
on a PPI and sucralfate for comfort.
Medications on Admission:
- dexamethasone 8mg daily (supposed to be only day prior and day
of chemo)
- omeprazole 10mg daily
- Zofran 4mg TID PRN
- Oxycodone 5mg TID PRN
- Sucralfate 10mL QID
Discharge Medications:
1. sucralfate 1 gram Tablet [**Month (only) **]: One (1) Tablet PO QID (4 times
a day).
2. guaifenesin 100 mg/5 mL Syrup [**Month (only) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob or wheezing.
5. Lorazepam 0.5-1 mg IV Q3H:PRN anxiety/distress
6. acetaminophen 650 mg Suppository [**Last Name (STitle) **]: One (1) suppository
Rectal three times a day as needed for pain or tactile fever.
7. scopolamine base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) patch
Transdermal every seventy-two (72) hours as needed for nausea or
secretions.
8. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 2.5-7.5 mL PO q2h as needed
for pain.
Disp:*1 bottle* Refills:*1*
9. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) suppository Rectal
once a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
Pneumothorax
Necrotizing multifocal pneumonia
Empyema
Secondary Diagnosis:
Stage IIIB squamous cell lung cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your hospital stay
at [**Hospital1 69**]. You were admitted with
shortness of breath, but then then found to have a small hole in
your lung, pneumonia, and empyema (an infection in the fluid
that surrounds your lungs). The small hole in your lung was
treated with placement of a chest tube and its subsequent
removal, which helped to seal the hole. The pneumonia and
empyema were treated with antibiotics.
After a discussion with your family it was decided to shift the
focus of your care to comfort, as well as complete a course of
antibiotics. Therefore, any intervention that would cause
discomfort was held or discontinued.
With regards to your medications, please make the following
changes.
Please START taking:
1. Albuterol - for difficulty breathing
2. Acetaminophen - for pain and fever
3. Docusate - to help with bowel movements
4. Lansoprazole - to help with heartburn
5. Lorazepam - for anxiety or distress
6. Morphine elixir - for pain
Please STOP taking:
1. Dexamethasone
2. Omeprazole
3. Zofran
4. Oxycodone
Otherwise, please take your home medications as prescribed in
your discharge paperwork.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (tel:
[**Telephone/Fax (1) 8236**]), as needed.
Completed by:[**2179-9-28**]
|
[
"573.8",
"401.9",
"482.41",
"510.9",
"537.89",
"787.91",
"E879.2",
"518.81",
"162.5",
"512.89",
"285.9",
"348.30",
"785.6",
"272.4",
"530.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.71",
"34.04",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10973, 11056
|
8077, 9617
|
293, 408
|
11231, 11231
|
3188, 3188
|
12627, 12869
|
2476, 2494
|
9833, 10950
|
11077, 11151
|
9643, 9810
|
11411, 12604
|
4010, 8054
|
2509, 2827
|
2843, 3169
|
246, 255
|
436, 1947
|
11172, 11210
|
3204, 3994
|
11246, 11387
|
1969, 2359
|
2375, 2460
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,581
| 116,399
|
40499
|
Discharge summary
|
report
|
Admission Date: [**2135-5-1**] Discharge Date: [**2135-5-8**]
Date of Birth: [**2085-9-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
49y/o M transfer from OSH for evaluation of possible toxic
alcohol ingestion. Patient was brought to OSH by EMS after
family found him shaking/foaming at the mouth. Pt reported
drinking 6 beers/day x 2 days. He has a history of heavy EtOH in
the past however he reports being sober x~1yr. Per EMS report,
had had been on a "2-day" binge, stopping yesterday, with prior
history of withdrawal seizures. There is also report from EMS
and OSH that the patient has hisotry of ETOH abuse and prior
seizures. The patient denies this.
.
He initially went to [**Hospital 15405**], where he was reported to have an
anion gap of 28, and an osmolar gap of 24. His lactate was 6.8,
and serum EtOH of 29. No ASA/APAP was detected. An ABG was
performed 7.46/37/140. LFT's with AST/ALT 126/75. PCC was
contact[**Name (NI) **] and recommended fomepazole. Pt was given 15mg/kg of
fomepazole (1050mg), as well as a total of 100mg thiamine, 1mg
folic acid, 1gm magnesium, 30mg of IV Valium, 1gm of ceftriaxone
and 4mg of zofran prior to transfer.
.
His initial vitals in the ED were 99.4 122 142/88 100% 2L NC.
Toxicology was consulted and they will continue to follow. The
patient denies ingestionof any other substances. Pt denies F/C,
HA, CP, SOB, abd pain, N/V/D, tinitus, visual disturbance. He
received additional 5 IV valium. He was tachycardic to 110 and
this increased to 140-150 with any movement. vitals on transfer:
150/100 110 18 98 RA 99.4
.
On arrival, patient is interviewed with interpreter. He again
denies drinking before this current episode since [**Month (only) 404**]. He
denies fever/chills/ cough/chest pain/nausea/vomiting. He had
difficulty recalling his girlfriend's phone number and his home
phone number. His daughter [**Name (NI) 12208**] was contact[**Name (NI) **] and she stated
that he has been drinking chronically for at least a month.
Past Medical History:
headaches
Social History:
Lives with two daughters. [**Name (NI) 12208**], age 19, another daughter age
7. [**Name2 (NI) 1403**] in construction. Has a wife in [**Country **]. denies
tobacco and drugs
Family History:
non-contributory
Physical Exam:
On Admission:
VS: Temp: 99.2 BP: 150/100 HR:115 RR: O2sat 98RA
General Appearance: Anxious, Diaphoretic
Cardiovascular: (S1: Normal), (S2: Normal), tachy
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Normal, tremulous
On Discharge:
VS: Temp: 97.0 m98.0 BP: 124/92 (100-126/72-92) HR: 80 (77-103)
RR: 18 O2sat100%RA
Tele: 70s-80s; occasional jumps to 120s
Gen: NAD
HEENT: EOMI, PERRL, clear oropharynx
Neck: supple, no LAD
CV: nl S1, S2, RRR, no m/r/g
Pulm: CTAB, no rhonchi, rales, wheezes
Abdominal: Soft, Non-tender, bowel sounds present
Extremities: WWP, 2+ DPs, no edema, cyanosis, clubbing
Skin: No rashes, lesions
Neurologic: Attentive, motor strength and sensation grossly
intact; intact FNF, rapid alternating movements, and heel to
shin; wide based ataxic gait
Pertinent Results:
On Admission:
[**2135-5-1**] 06:40PM BLOOD WBC-7.4 RBC-3.95* Hgb-13.2* Hct-37.3*
MCV-94 MCH-33.3* MCHC-35.3* RDW-16.1* Plt Ct-106*
[**2135-5-1**] 06:40PM BLOOD Neuts-78.6* Lymphs-14.1* Monos-6.8
Eos-0.2 Baso-0.3
[**2135-5-1**] 06:40PM BLOOD PT-12.3 PTT-23.4 INR(PT)-1.0
[**2135-5-1**] 06:40PM BLOOD Glucose-98 UreaN-4* Creat-0.6 Na-141
K-2.8* Cl-99 HCO3-27 AnGap-18
[**2135-5-1**] 09:51PM BLOOD ALT-68* AST-100* AlkPhos-69 TotBili-1.6*
[**2135-5-1**] 06:40PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
[**2135-5-1**] 06:40PM BLOOD Osmolal-288
[**2135-5-1**] 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2135-5-1**] 08:40PM BLOOD Type-[**Last Name (un) **] pO2-66* pCO2-32* pH-7.51*
calTCO2-26 Base XS-2 Comment-GREEN-TOP
[**2135-5-1**] 07:31PM BLOOD Lactate-1.8
.
On Discharge from MICU:
[**2135-5-4**] 05:42AM BLOOD WBC-6.2 RBC-3.78* Hgb-12.7* Hct-36.4*
MCV-96 MCH-33.5* MCHC-34.8 RDW-15.8* Plt Ct-132*
[**2135-5-4**] 05:42AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0
[**2135-5-4**] 05:42AM BLOOD Glucose-91 UreaN-6 Creat-0.6 Na-139 K-3.4
Cl-102 HCO3-29 AnGap-11
[**2135-5-4**] 05:42AM BLOOD ALT-54* AST-69* AlkPhos-61 TotBili-1.5
[**2135-5-4**] 05:42AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
.
On Discharge:
[**2135-5-8**] 06:30AM BLOOD WBC-8.1 RBC-3.71* Hgb-12.2* Hct-36.6*
MCV-99* MCH-32.9* MCHC-33.3 RDW-16.1* Plt Ct-321
[**2135-5-8**] 06:30AM BLOOD WBC-8.1 RBC-3.71* Hgb-12.2* Hct-36.6*
MCV-99* MCH-32.9* MCHC-33.3 RDW-16.1* Plt Ct-321
[**2135-5-8**] 06:30AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-143
K-3.8 Cl-107 HCO3-29 AnGap-11
[**2135-5-4**] 05:42AM BLOOD ALT-54* AST-69* AlkPhos-61 TotBili-1.5
[**2135-5-8**] 06:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8
[**2135-5-7**] 06:20AM BLOOD VitB12-809
Imaging:
[**2135-5-2**] CXR: Single view of the chest is obtained without the
prior study. There is possible bilateral hilar fullness. The
lungs are clear. Heart is within normal limits. Comparison with
the prior chest x-ray would be helpful.
[**2135-5-8**] MRI Brain: There is mild cerebellar atrophy. The
ventricles and cerebral sulci are abnormally large for age,
consistent with mild cerebral atrophy. There is no acute
infarction. There are scattered foci of high T2 signal in the
supratentorial white matter, as well as a focus of high T2
signal in the midline pons and a focus of high T2 signal in the
right cerebellar hemisphere, consistent with small chronic
infarctions. The major arterial flow voids are preserved. There
is no evidence of parenchymal blood products. There is a small
focus of polypoid mucosal thickening in the inferior left
maxillary sinus.
IMPRESSION:
1. Mild cerebellar and cerebral atrophy, abnormal for age.
2. Scattered small chronic infarctions in the supratentorial
white matter,
pons, and right cerebellar hemisphere. No acute infarction.
Brief Hospital Course:
49 y/o with confirmed history of chornic alcohol use (though
patient denies) presented to OSH with seizure and transferred
here for eval of possible toxic alcohol ingestion and treatment
of withdrawal.
.
# Alcohol withdrawal. Patient had witnessed seizure secondary to
ETOH withdrawal. Patient denies ETOH ingestion before two days
ago but daughter confirms chronic drinking. Patient was admitted
to the MICU and treated agressively with valium and transferred
to the floor on [**5-4**] once requirement decreased to q4hours. He
received close to 500 mg of valium during his hospital stay.
After he was no longer [**Doctor Last Name **] on CIWA, he remained ataxic and
tachycardic with movement. Was seen by PT who felt that his
ataxia was related to his chronic alcohol abuse and would not
benefit from further PT/rehab. Patient treated with thiamine,
folate and MVI.
.
# ? Toxic alcohol ingestion: Received fomepizole x 1 at osh.
transferred here for tox eval. seen by tox here. on review of
OSH labs, his osmolar gap was accounted for by alcohol and
lactate and it has resolved. There was minimal concern for toxic
alcohol ingestion and no indication for further fomepizole.
.
# H/o lactic acidosis: 6.8 at OSH - resolved. Likley [**2-16**]
seizure.
.
# Ataxia- Patient note to have broad based ataxic gait even
after no longer [**Doctor Last Name **] on CIWA. Cerebellar exam was otherwise
intact and non-focal. B12 level was checked and within normal
limits. He underwent MRI brain to assess for cerebellar lesions-
this was notable for age advanced global atrophy and scattered
chronic small infarcts. Was seen by PT who felt that his
deficits were not likely to be improved by further physical
therapy and rehab and were more likely chronic in nature
secondary to his long standing alcohol abuse. He was felt safe
for discharge.
.
# Social: Patient initialy denied chronic alcohol use though
family confirms. Patient was seen by social work and continued
to deny use of alcohol and necessity of detox/rehab. Eventually
admitted use of alcohol and voiced desire to quit but wanted to
do so on his own without rehab. We emphasized to the patient
through an interpreter that he puts his life at risk by drinking
and that his seizures, ataxia and brain atrophy were directly
related to his use of alcohol. We asked him to establish care
with a PCP through [**Name9 (PRE) 191**] or in his home town if more convenient.
Medications on Admission:
Denies
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Alcohol Withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 10010**],
You were admitted to the hospital because you were having a
seizure. We believe the seizure was due to withdrawal from
alcohol. You were treated with medications and monitored closely
in the medical intensive care unit and then transferred to the
general medicine floor when your condition improved. You were
seen by social work and physical therapy who offered you
resources on alcohol abuse and assessed your physical condition.
You had an MRI of your head which showed shrinkage of your brain
which we believe is related to your use of alcohol.
We strongly recommend you STOP DRINKING ALCOHOL as you put your
life and the lives of others in danger when you drink. We also
recommend you establish care with a doctor who can help manage
your health conditions (see below).
We have started you on the following medications:
- Folic Acid
- Thiamine
- Multivitamin
Please take them as directed. We wish you a speedy recovery.
Followup Instructions:
Please call [**Telephone/Fax (1) 1247**] to establish care with a primary care
doctor.
Completed by:[**2135-5-8**]
|
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27,194
| 142,739
|
33514
|
Discharge summary
|
report
|
Admission Date: [**2124-3-11**] Discharge Date: [**2124-3-28**]
Date of Birth: [**2046-10-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
CVVH
bronchoscopy
left IJ dialysis line placement
History of Present Illness:
77 yo F hx severe AS, CAD, CRI, DM, HTN admitted to OSH on [**3-1**]
w/ acute dyspnea. A chest CT showed airspace consolidation lower
lobes b/l, RM and RUL, as well as small right pleural effusion.
She was started on doxy/azithro, then ctx and avelox for 5days,
then changed to cefdinir for 3 days, and then 2 more days of
avelox. In total, received 10 d of abx. Initial BNP [**Telephone/Fax (1) 77706**].
She subsequently developed ARF (cr peaked 5.9), requiring
initiation of HD. She initially had renal bx on [**3-6**] which was
benign. While awaiting bx results she was empirically treated
with steroids, which have since been discontinued. She
continued to have peristent hypoxemia, was treated with BiPAP,
also required pressors, was intermittently on dopamine,
dobutamine, levophed. Pt was transferred to [**Hospital1 18**] on [**3-11**] for
further care. After admission, she had a trial of diuresis for
hypoxia and concern for fluid overload was resistant to
diuretics, nicardipine qtt, then placed on CVVHD.
Pt has 4L removed yesterday and additional 1L removed today. Pt
notes fair improvement in her dyspnea. She has been receiving
BiPAP nightly and high flow face mask during the day, however
today has required continued BiPAP. She recalls to me very
gradual progression of dyspnea over months, + orthopnea. Denies
any associated fever/chills or cough. She denies nausea, had
one episode of vomiting. No chest or abdominal discomfort, no
palpitations, no diarrhea or dysuria. Her dry weight is 192 lbs,
weight 215 lbs at time of admission to CCU.
Past Medical History:
CAD s/p PCI with stents to LAD and LCx in '[**19**], cath [**1-28**] with
in-stent proximal LAD stenosis 70% planned for CABG with AVR.
CHF with AS, MR
CRI (cr 1.5)
HTN
DM II
hx AFib - had been on flecainide, amiodarone, not on coumadin as
outpt as she did not want to monitor INR
hx uterine CA s/p TAH
OA
Gout
R cataract
Social History:
widowed, lives alone, has children who live nearby. Works as
bookkeeper in a flower shop. Denies tobacco or recreational
drugs, rare etoh.
Family History:
noncontrib
Physical Exam:
Initial Exam on transfer to CCU
VS: T 96.4, BP 148/50, HR 53 in NSR, O2 sat 97% on BiPAP 60%/[**4-24**]
Gen: pleasant, obese female, speaks in short sentences while on
BiPAP, fully awake, alert, states breathing is considerably
improved since initiation of CVVHD
HEENT: anicteric, OP clear:
Neck: L IJV HD catheter emplaced, impressive diffuse ecchymosis
involving most of L neck and upper chest
CV: RRR, nl s1, s2, III/VI systlic murmur RUSB
Resp: good breath movement bilaterally
Abd: soft, obese, NT, ND, + BS
Extr: 1+ edema b/l, 2+ DP pulses b/l, R wrist with A-line
Neuro: pleasant, AAOx3, mild resp distress
on discharge patient had persistant bronchial breath sounds at
left mid to lower lung fields. high pitched systolic murmur
continued. Pedal edema had resolved. Chest still had large
area of ecchymosis which was resolving.
Pertinent Results:
[**2124-3-11**] 03:34PM BLOOD WBC-15.1*# RBC-4.06* Hgb-11.5* Hct-35.2*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.0 Plt Ct-221
[**2124-3-16**] 04:12AM BLOOD WBC-13.9* RBC-3.27* Hgb-9.4* Hct-28.2*
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.9 Plt Ct-166
[**2124-3-17**] 02:28AM BLOOD WBC-14.0* RBC-3.08* Hgb-8.6* Hct-26.8*
MCV-87 MCH-27.8 MCHC-31.9 RDW-15.0 Plt Ct-148*
[**2124-3-18**] 03:13AM BLOOD WBC-8.7 RBC-2.74* Hgb-7.9* Hct-24.0*
MCV-88 MCH-28.8 MCHC-32.9 RDW-15.3 Plt Ct-118*
[**2124-3-20**] 08:13AM BLOOD WBC-9.6 RBC-3.34* Hgb-9.6* Hct-29.3*
MCV-88 MCH-28.7 MCHC-32.7 RDW-15.7* Plt Ct-95*
[**2124-3-21**] 06:22AM BLOOD WBC-9.1 RBC-3.36* Hgb-9.6* Hct-28.9*
MCV-86 MCH-28.7 MCHC-33.3 RDW-16.6* Plt Ct-86*
[**2124-3-21**] 02:52PM BLOOD Hct-28.5* Plt Ct-87*
[**2124-3-24**] 06:10AM BLOOD WBC-5.1 RBC-2.92* Hgb-8.6* Hct-26.0*
MCV-89 MCH-29.6 MCHC-33.2 RDW-16.5* Plt Ct-86*
[**2124-3-26**] 06:18AM BLOOD WBC-4.6 RBC-2.68* Hgb-7.9* Hct-23.5*
MCV-88 MCH-29.4 MCHC-33.4 RDW-16.8* Plt Ct-105*
[**2124-3-11**] 03:34PM BLOOD PT-13.8* PTT-48.5* INR(PT)-1.2*
[**2124-3-24**] 06:10AM BLOOD PT-13.0 PTT-32.6 INR(PT)-1.1
[**2124-3-25**] 06:17AM BLOOD PT-27.0* PTT-33.7 INR(PT)-2.7*
[**2124-3-26**] 06:18AM BLOOD PT-58.5* PTT-36.5* INR(PT)-6.9*
[**2124-3-12**] 03:10PM BLOOD D-Dimer-2767*
[**2124-3-25**] 06:17AM BLOOD Ret Aut-3.8*
[**2124-3-11**] 03:34PM BLOOD Glucose-163* UreaN-102* Creat-3.8*#
Na-131* K-4.3 Cl-88* HCO3-28 AnGap-19
[**2124-3-14**] 02:36AM BLOOD Glucose-166* UreaN-130* Creat-4.3*
Na-129* K-4.1 Cl-89*
[**2124-3-21**] 06:22AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2124-3-22**] 03:42AM BLOOD Glucose-92 UreaN-21* Creat-1.4* Na-136
K-3.7 Cl-99 HCO3-24 AnGap-17
[**2124-3-22**] 03:01PM BLOOD Glucose-122* UreaN-26* Creat-1.7* Na-135
K-3.8 Cl-100 HCO3-23 AnGap-16
[**2124-3-23**] 05:13AM BLOOD Glucose-115* UreaN-31* Creat-1.9* Na-135
K-3.5 Cl-100 HCO3-22 AnGap-17
[**2124-3-24**] 06:10AM BLOOD Glucose-89 UreaN-41* Creat-2.2* Na-131*
K-4.2 Cl-95* HCO3-22 AnGap-18
[**2124-3-25**] 06:17AM BLOOD Glucose-111* UreaN-53* Creat-2.7* Na-132*
K-5.0 Cl-97 HCO3-24 AnGap-16
[**2124-3-26**] 06:18AM BLOOD Glucose-91 UreaN-55* Creat-2.6* Na-135
K-4.9 Cl-100 HCO3-25 AnGap-15
[**2124-3-18**] 03:13AM BLOOD proBNP-[**Numeric Identifier 77707**]*
[**2124-3-25**] 06:17AM BLOOD calTIBC-293 Hapto-88 Ferritn-443* TRF-225
[**2124-3-13**] 06:43PM BLOOD TSH-5.0*
[**2124-3-15**] 05:56AM BLOOD T4-4.3* T3-35*
[**2124-3-12**] 03:10PM BLOOD ANCA-NEGATIVE B
[**2124-3-12**] 03:10PM BLOOD ANCA-NEGATIVE B
[**2124-3-12**] 03:10PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2124-3-22**] 03:42AM BLOOD PEP-HYPOGAMMAG IFE-NO MONOCLO
.
CT chest without contrast [**3-11**]
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is dense air
bronchogram containing solid and ground-glass consolidation
involving the right and left upper lobes (right greater than
left), with additional small regions of ground-glass
opacification noted within the right middle lobe and right lower
lobe with scattered nodular opacities present. Additionally,
there are small bilateral simple pleural effusions, right
slightly greater than left, with adjacent compression
atelectasis and/or pneumonia. Airways are patent to the
subsegmental level and no pathologically enlarged lymph nodes
are present, the largest measuring 8 mm in short axis within the
precarinal chain. There is marked underlying cardiomegaly with
left ventricular and left atrial dilatation, as well as
atherosclerotic disease within the coronary circulation, aortic
annulus and aorta. Artifact is noted from the indwelling
Swan-Ganz catheter whose tip is in the right ventricle.
Visualized images of the upper abdomen display a probable small
cyst of the interpolar portion of the left kidney and bilateral
flank edema. No lucent or sclerotic osseous lesions are noted.
IMPRESSION:
1. Multifocal predominantly upper lobe pneumonia, with small
regions of consolidation and compression atelectasis within the
lower lobes. Small right slightly greater than left simple
pleural effusions.
2. Tip of Swan-Ganz catheter is in the right ventricle
.
Chest CT [**3-18**] without contrast
FINDINGS: Since the examination of [**3-11**], there has been
removal of the right-sided central venous access catheter and
placement of a left internal jugular venous access catheter.
There is a new hematoma in the left supraclavicular region which
is incompletely imaged but which measures 3.3 x 4.0 cm in
transaxial dimension in its imaged portion (2:2). An
endotracheal tube terminates above the level of the carina.
Slight stranding extends into the superior mediastinum from the
left supraclavicular hematoma, although there is no evidence of
mediastinal hematoma about the great vessels. The aorta is
normal in caliber and contour with mural calcifications
consistent with atheromatous disease. Multiple mediastinal lymph
nodes do not meet CT criteria for pathologic enlargement. There
are extensive coronary artery calcifications as well as aortic
valvular and mitral annular calcifications. The catheter which
had been previously coiling in the right atrium has been
removed. There is no evidence of pericardial effusion. A
nasogastric tube is in place within the stomach, new since the
previous examination.
Bilateral areas of consolidation in the upper lobes have
improved since [**3-11**]. There is additional improvement of
bilateral lower lobe consolidation with residual areas of
atelectasis and consolidation at the lung bases. Small bilateral
pleural effusions have decreased slightly in size. Residual
areas of patchy and nodular consolidation are present in the
upper lobes bilaterally. There is no pneumothorax.
Limited images of the upper abdomen show a small amount of
perihepatic free fluid. Hyperdense material within the
gallbladder could relate to vicarious excretion of contrast or
hyperconcentrated bile. The imaged portion of the liver, spleen,
pancreas, adrenal glands, and upper poles of the kidneys appear
otherwise within normal limits allowing for non-contrast
technique.
Asymmetric subcutaneous edema in the left chest wall is probably
related to dependent positioning, although clinical correlation
is recommended.
BONE WINDOWS: No lesions worrisome for osseous metastatic
disease are identified.
MULTIPLANAR REFORMATS: Coronal and sagittal reformations are
helpful in delineating the above-described findings.
IMPRESSION:
1. New left supraclavicular hematoma, 3.3 x 4.0 cm in diameter
and partially imaged.
2. Interval improvement in bilateral pulmonary consolidation
with residual patchy and nodular opacities consistent with
infectious or inflammatory process. Followup imaging after
treatment is recommended to assess complete resolution.
3. Slight improvement in bilateral pleural effusions.
.
Echocardiogram [**3-13**]
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The right
atrium is moderately dilated. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are severely thickened/deformed. There is moderate aortic
valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets and supporting structures are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with low normal systolic function. At
least moderate mitral regurgitation. Mild aortic regurgitation.
.
Chest PA/Lat
Brief Hospital Course:
A&P: 77 yo F hx CAD, AF, DM, HTN, CHF with mod AS (gradient 32
mmHg) who presented with gradually worsening dyspnea,
complicated by renal failure.
.
# Hypoxia - pt initially presented with gradual progression of
DOE, orthopnea, no infectious symptoms. Initial imaging with
question of infection so treated with empiric course for
community acquired pneumonia, which is completed. Sputum
eventually grew stenotrophomonas and enterobacter which were
treated with 7 days of Bactrim and Cipro respectively. Her
imaging and exam were felt to be consistent with fluid overload
and she was treated with CVVHD with an eventual total diuresis
of approximately 10L. There was also felt to be a significant
component of atelectasis. She was initially on Bipap only
nightly, but then progressed to continuous Bipap in an effort
to recruit alveoli. However even on continusous bipap she began
to tire and was intubated. Although she was intubated for
hypoxic respiratory failure initial ABGs after intubation did
not show significant A-a gradient and patient was successfully
extubated within a few days. While intbuated, she had a
bronchoscopy with BAL. Viral, fungal, and legionella tests were
negative. Overall hypoxia was felt to be due to a combination
of fluid overload, pneumonia, and atelectasis. Amiodarone
toxicity was considered but this was not entirely clear. She
may have an underlying lung process and should have pulmonary
followup to evaluate for progression/improvement. At time of
discharge she had persistant atelectasis and effusion causing
bronchial breath sounds at the left base, and crackles at the
bases bilaterally.
.
# Acute diastolic CHF and aortic stenosis- pt appeared to be
fluid overloaded on arrival felt to be related to AS. However
echocardiogram and hemodynamics via Swan-Ganz catheter did not
demonstrate severe systolic impairment (either due to
ventricular dysfunction or AS). Still patient did have chronic
volume overload, likely exacerbated by renal failure. Fluid
removed via CVVH and at time of discharge patient was
maintaining an even to slightly negative fluid balance. Her
hypertension was controlled with metoprolol and nifedipine.
Lisinopril was stopped given renal failure pending stable
creatinine. Also given patient's AS and relatively preserved
systolic function, it was not felt that she needed aggressive
afterload reduction.
.
# Afib - pt with hx of afib in past, and episode of AF during
admission, not clearly correlated to CHF exacerbation. She was
previously on amiodarone, but pattern not fully consistent with
amiodarone toxicity. Amiodarone and fleccainide were held and
while in the CCU she was initially mostly in sinus rhythm but
then AF became more predominant. Metoprolol was titrated for
rate control and patient agreed to anticoagulation with
warfarin. INR to be followed by PCP, [**Name Initial (NameIs) **] [**1-23**]. She was
initially started on coumadin 5mg PO daily, and her INR climbed
as high as 7.0. This occurred in the setting of concurrent
antibiotic administration which may have altered the metabolism
of coumadin. nonetheless, her coumadin was held until her INR
trended back down between [**1-23**]. She should see an
electrophysiologist in the future for discussion of rhythm
control as she will need atrial kick once AS progresses. You
should continue with coumadin 2mg PO daily. You should check
your INR daily and dose coumadin accordingly.
.
# CAD - there was no evidence of recent ischemia and she was
continued on ASA, metoprolol, statin.
.
# Acute on chronic renal failure - pt with some renal
dysfunction at baseleine developed acute renal failure after
presentation. Had full evaluation including renal biopsy which
now has been confirmed as negative ([**Doctor First Name **], ANCA neg, C3, C4 nl).
Now off steroids, renal lytes initially c/w pre-renal, but
likely from poor cardiac flow rather than hypovolemia. Overall
etiology of renal function remains unclear. Renal team did not
feel she would need further hemodialysis, although she did
sustain a significant diminution of her renal function. She
does not need to be on a renal diet. She had a renal ultrasound
performed which has not been read yet.
.
# DM - Pioglitazone was stopped given renal failure. She should
not continue this medication. Blood sugars were controlled
without need for sliding scale insulin. She should continue to
have blood sugar followed and alternate oral hypoglycemics
should be considered.
.
# Gout - allopurinol continued at qOD dosing which was discussed
with nephrology for prevention of gout.
.
# CAD - no evidence of recent ischemia, cont ASA, metoprolol,
statin.
.
# Thrombocytopenia
multiple possible causes including antibiotics, overall illness
causing marrow suppression, TTP, heparin-induced
thrombocytopenia, consumption while on CVVH. PF4 antibodies
were sent given intermediate probability of HIT (4T score of 4)
and are pending at this time. She was already therapeutically
anticoagulated with warfarin so argatroban was not started.
She should have platelet count rechecked once she has recovered
from acute illness and antibiotics stopped. There was no
evidence of hemolysis.
.
# Anemia
unclear if anemia was due to generalized marrow suppression vs.
renal disease vs. acute blood loss anemia. Iron studies
suggested anemia of chronic disease/renal insufficiency. Her
stool was guaiac negative and the subcutaneous ecchymosis she
had developed was stable. hemolysis labs negative. Initially
her anemia was felt to be due to consumption while on CVVH as
she did not require tranfusion once off CVVH. Given her new
renal dysfunction, she should be followed by nephrology and
consideration given to erythropoetin therapy.
Medications on Admission:
Home Meds:
Allopurinol 150mg daily
ASA 81mg daily
Lovastatin 40mg daily
Toprol-XL 25mg daily
Nifedipine XL 30mg daily
Actos 30mg daily
Plavix 75mg daily
Flecainide 50mg [**Hospital1 **]
Lasix 80mg daily
Lisinopril 40mg daily
.
Transfer meds:
Insulin SS
Allopurinol 150 mg PO every other day
Albuterol inh q4h
Metoprolol 25 mg PO BID
Aspirin 81 mg PO daily
Nifedipine 30mg daily
Atorvastatin 40 mg PO daily
Heparin IV drip
home med of amiodarone stopped
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**]
Drops Ophthalmic PRN (as needed).
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-22**] Sprays Nasal
QID (4 times a day) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Outpatient Lab Work
INR check daily
16. coumadin
1-3mg PO daily, according to INR
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Primary:
Chronic systolic Congestive Heart Failure
aortic stenosis
Atrial Fibrillation
Pneumonia
Acute on Chronic renal failure
.
Secondary:
Diabetes
Gout
Discharge Condition:
Good O2 sat 94% 4L
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. You
were found to have a pneumonia and treated with antibiotics.
You were also found to have congestive heart failure. In
addition, you developed acute renal failure and received
hemodialysis.
.
Your lisinopril and pioglitazone were discontinued, as these
medications should not be taken in the setting of acute renal
failure.
.
Your amiodarone and flecainide were also discontinued.
.
Your lovastatin was discontinued, and switched with atorvastatin
.
You were started on coumadin. You will need to have your INR
checked daily in order to properly dose your coumadin. You
should continue with 2mg Po of coumadin and alter the dose
accorrding to the INR.
.
Your nifedipine was increased to 60mg PO daily for improved
blood pressure control.
.
You will need to follow-up with a pulmonologist to evaluate the
etiology of your lung disease.
.
You will need to follow-up with a nephrologist to discuss the
need for iron supplementation.
.
You will need to follow-up with a cardiologist to discuss
treatment for your atrial fibrillation.
.
Please call your doctor or return to the hospital if you
experience shortness of breath, chest pain, fever, or any other
concerning symptoms.
Followup Instructions:
Please call your PCP [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 62229**] tp
schedule an appointment within two weeks.
.
Please call your Cardiologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67025**] [**Telephone/Fax (1) **] to
schedule an appointment within two weeks.
.
Please call your nephrologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77708**] [**Telephone/Fax (1) 60**] to
schedule an appointment within two weeks.
|
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"E879.1",
"585.9",
"276.4",
"396.2",
"V58.67",
"427.31",
"518.0",
"E931.0",
"272.0",
"274.9",
"693.0",
"715.90",
"276.1",
"414.01",
"398.91",
"366.9",
"V45.82",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"93.90",
"38.91",
"39.95",
"96.04",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
19096, 19182
|
11470, 17219
|
323, 374
|
19381, 19403
|
3383, 11447
|
20689, 21240
|
2496, 2508
|
17723, 19073
|
19203, 19360
|
17245, 17700
|
19427, 20666
|
2523, 3364
|
276, 285
|
402, 1978
|
2000, 2323
|
2339, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,313
| 101,462
|
45486
|
Discharge summary
|
report
|
Admission Date: [**2169-3-29**] Discharge Date: [**2169-4-4**]
Date of Birth: [**2092-11-3**] Sex: M
Service: MEDICINE
Allergies:
Neosporin / Latex
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Fever at home and pus draining from sternal wound
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 76 year old man with history of CAD, 4-vessel cabg [**2166**] c/b
sternal osteo, sternotomy, flap, multiple wound infections, DM2,
COPD, small cell lung carcinoma of RUL followed by Rad Onc for
cyper knife treatment currently, who presented 2 days ago with
pus draining from sternal wound, fever and change in mental
status for two days. He was admitted 2 weeks earlier for UTI/?
LLL PNA/? wound infection and was discharged with PO levo (7 day
course finished two days earlier) and VNA [**Hospital1 **] dressing changes.
Then nurse and wife noted increasing confusion, unsteady gait,
fever to 99.4 and pus draining from sternal wound.
Past Medical History:
RUL nodule- biopsied on [**2169-3-6**]: poorly differentiated
carcinoma, likely small cell ca; currently followed by Radiation
Oncology with ongoing preparation for Cyber Knife Therapy.
CAD - IMI in [**2165**], s/p CABGx4 in [**2166**], which was complicated by
mediastinitis and sternal osteomyelitis and MRSA wound
infection. He had a pec flap repair on [**5-16**].
incisional hernia -- s/p repair and recurrence
COPD/emphysema on home night time O2
T2DM - controlled by meds and diet
HTN
hypercholesterolemia
GERD
anemia - monthly procrit
hyperlipidemia
prior right frontal lobe and left caudate infarct
Social History:
Married for 52 years; taken care by wife at home. Former
smoking of cigar x 20yrs, and 10ppy hx of cigarettes; quit 30
years ago. No EtOH.
Family History:
FH: no h/x of cancer or CAD
.
Physical Exam:
PE: T 97; HR 90, BP 150/90; 93%RA; FS 124
Gen: comfortable in bed, NAD;
HEENT: ROMI PERRL Face symmetric; no JVD
Chest: R sternal wound with dressing stained with serosanginous
fluid; some erythema surrounding the wound; breath sounds
distant;
Cor: RRR, no murmurs
Abd: +BS, NT, obese; reducible umbilical hernia
ext: No edema or rash, 2+ DP pulses; extremities are warm.
neuro: AOx3, baseline mental status
.
Pertinent Results:
[**2169-3-29**] 01:05PM WBC-6.7# RBC-3.84* HGB-10.4* HCT-30.6*
MCV-80* MCH-27.0 MCHC-33.9 RDW-16.5*
[**2169-3-29**] 01:05PM NEUTS-80* BANDS-0 LYMPHS-10* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2169-3-29**] 01:05PM PLT COUNT-266
[**2169-3-29**] 01:05PM GLUCOSE-123* UREA N-22* CREAT-1.0 SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
[**2169-3-29**] 01:11PM LACTATE-1.3
[**2169-3-29**] 03:05PM TYPE-ART PO2-105 PCO2-46* PH-7.36 TOTAL
CO2-27 BASE XS-0
[**2169-3-29**] 03:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2169-3-29**] 03:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2169-3-29**] 03:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-RARE
EPI-0-2
[**2169-3-29**] 03:45PM URINE HYALINE-0-2
[**2169-3-29**] 08:30PM PT-12.9 PTT-25.8 INR(PT)-1.1
[**2169-3-29**] 08:30PM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.9
MAGNESIUM-1.8
[**2169-3-29**] 08:30PM CK-MB-NotDone cTropnT-0.07*
[**2169-3-29**] 08:30PM LIPASE-15
[**2169-3-29**] 08:30PM ALT(SGPT)-23 AST(SGOT)-16 LD(LDH)-165
CK(CPK)-37* ALK PHOS-72 TOT BILI-0.4
[**2169-3-29**] 08:30PM GLUCOSE-208* UREA N-25* CREAT-1.0 SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
[**2169-3-30**] 02:33AM BLOOD WBC-6.4 RBC-3.79* Hgb-9.9* Hct-30.5*
MCV-81* MCH-26.0* MCHC-32.3 RDW-16.3* Plt Ct-265
[**2169-4-1**] 05:00AM BLOOD WBC-5.0 RBC-3.72* Hgb-10.1* Hct-29.9*
MCV-80* MCH-27.3 MCHC-33.9 RDW-16.4* Plt Ct-307
[**2169-4-1**] 05:00AM BLOOD Plt Ct-307
[**2169-3-31**] 02:25AM BLOOD PT-12.3 PTT-26.6 INR(PT)-1.1
[**2169-3-31**] 02:25AM BLOOD Glucose-132* UreaN-36* Creat-1.0 Na-139
K-3.9 Cl-108 HCO3-25 AnGap-10
[**2169-4-1**] 05:00AM BLOOD Glucose-109* UreaN-23* Creat-0.8 Na-143
K-3.9 Cl-107 HCO3-26 AnGap-14
[**2169-3-29**] 08:30PM BLOOD ALT-23 AST-16 LD(LDH)-165 CK(CPK)-37*
AlkPhos-72 TotBili-0.4
[**2169-3-30**] 02:33AM BLOOD CK(CPK)-37*
[**2169-3-30**] 09:00AM BLOOD CK(CPK)-33*
[**2169-3-29**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2169-3-30**] 02:33AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2169-3-30**] 09:00AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2169-3-30**] 02:33AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9
[**2169-3-31**] 02:25AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.1
[**2169-4-1**] 05:00AM BLOOD WBC-5.0 RBC-3.72* Hgb-10.1* Hct-29.9*
MCV-80* MCH-27.3 MCHC-33.9 RDW-16.4* Plt Ct-307
[**2169-4-3**] 03:41PM BLOOD Hct-28.4*
Brief Hospital Course:
A/P: 76 year old man with history of CAD (4V CABG [**2166**]),
sternotomy/MRSA infection, flap, T2DM, COPD, recently diagnosed
smal cell lung CA in RUL, presented with 2 day history of pus
draining from bronchoscopy/mediastinoscopy wound, fever to 99.4,
and change in mental status.
.
1. fever: This presentation is similar to his prior presentation
two weeks earlier. Fever's source this time is presumed to be
an infected wound, given the pus drainage. Wound and blood
cultures were taken immediately in the ED, and he was started on
IV vanco, given his MRSA history. Shortly after, a purulent
material was expressed from his sternal wound during
exploration; one minute after this, the patient was noted by his
wife to "turn red all over", becoming tachypneic and tachycardic
to the 130's, and with notable and new, diffuse wheezing. An
ECG was obtained which showed an SVT at 143, with lateral ST
depressions. Patient had received IV vanco previously without
incident. He was admitted to MICU for close monitoring. MICU
staff felt it was unlikely to be Redman syndrome, and more
likely a transient episode of bacteremia caused by wound
exploration or an anxiety attack. IV vancomycin was continued,
without further incident. [**Hospital1 **] wet to dry dressing changes
continued, and thoracic surgery followed the patient; they felt
the wound to be not infected. On HD#[**3-17**], his erythema
surrounding the wound improved. His wound culture returned
sparse MSSA, and he was switched from IV vanco to IV oxacillin.
Patient never developed a fever in the hospital. Blood cultures
were negative at the time of discharge. A PICC line was placed
in RUE. He will continue to receive 9 more days of IV oxacillin
for a total of 2-week IV antibiotics course.
.
2. CAD: Patient's lateral ST depressions on EKG that occurred
during the episode after IV vanco infusion resolved with the
resolution of tachycardia. He was ruled out for MI, with CKs of
37, 37, 33, and TnT of 0.07, 0.05 and 0.03. Patient was
continued on Lipitor, Zetia, Toprol, losartan, and SL NG prn; he
was started on 81mg of aspirin. He remained on telemetry for
his two day stay in the MICU; upon transfer to the medicine
floor, he remained off of telemetry. On HD#3, he had an echo,
which showed LV EF 30% and LV infereolateral akinesis (see echo
[**2169-3-31**]).
.
3. Sternal Wound: No more pus was expressed from the wound while
in the hospital. [**Hospital1 **] wet to dry dressing changes continued.
Thoracic surgery team examined the wound daily and felt the
wound to be not contaminated. Erythema surrounding the wound
resolved. He was maintained on IV vanco for 3 days, and then
switched to IV oxacillin after wound culture grew sparse MSSA.
He will continue on IV oxacillin for 9 more days for a total of
2-week IV antiobiotics course.
.
4. HTN: home medications were continued.
.
5. DM: His home meds of metformin was continued. He was also
covered with regular insulin sliding scale. He was on a heart
healthy diet. His blood sugar was relatively well controlled
during this admission, with finger sticks ranging from 100 to
low 200s.
.
6. small cell cancer in R lung: This is a new diagnosis for the
patient from the FNA cytology done on [**2169-3-23**]. Patient and
family was made known of this diagnosis during this admission.
Further therapy will be coordinated asn an outpatient between
Dr. [**Last Name (STitle) 952**] of thoracics, Dr. [**Last Name (STitle) **] of radiation oncology, and
Dr. [**Last Name (STitle) 3274**] of oncology. Dr. [**Last Name (STitle) 3274**] was emailed about this
patient.
.
Medications on Admission:
prevacid 30mg qd
toprol XL 50mg qd
furosemide 20mg qd
metformin 500mg tid
potassium 20meq prn
vitamin C 500mg [**Hospital1 **]
colace 100mg [**Hospital1 **]
ferrous sulfate 300mg [**Hospital1 **]
zetia 10mg qd
lipitor 10mg qd
MVI qd
atrovent 2 puff QID prn: wheezing
spiriva 18mcg qd
advair 1 pufff 250/50 qd
cozaar 50mg qd
Discharge Medications:
oxacillin 2mg IV Q6hr
aspirin 81mg qd
prevacid 30mg qd
toprol XL 50mg qd
furosemide 20mg qd
metformin 500mg tid
potassium 20meq prn
vitamin C 500mg [**Hospital1 **]
colace 100mg [**Hospital1 **]
ferrous sulfate 300mg [**Hospital1 **]
zetia 10mg qd
lipitor 10mg qd
MVI qd
atrovent 2 puff QID prn: wheezing
spiriva 18mcg qd
advair 1 pufff 250/50 qd
cozaar 50mg qd
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
fever and wound infection
Discharge Condition:
Stable to be discharged to home with VNA services for wound
care.
Discharge Instructions:
Please contact Dr. [**Last Name (STitle) 8430**], your PCP, [**Name10 (NameIs) **] you should develop fever
above 100.4 or have pus draining out of your wound.
Followup Instructions:
Please see Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] (thoracic surgery) in two weeks. An
appointment has been made for you on [**4-13**] at 4pm in [**Hospital1 18**]
[**Hospital Ward Name 23**] [**Location (un) **]. Please call his office at [**Telephone/Fax (1) 170**] if
you have any questions.
You should see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**], [**First Name3 (LF) **] oncologist and lung cancer
specialist. Both Dr. [**Last Name (STitle) 3274**] and his office staff were
notified, and they will contact you to arrange an appointment.
If you do not hear from Dr.[**Name (NI) 3279**] office in the next few
days, you can call [**Telephone/Fax (1) 15512**]. You may have your initial
appointment at [**Hospital1 18**] in [**Location (un) 86**], and then follow up in [**Location (un) 620**].
Please call Dr.[**Name (NI) 97057**] office [**Telephone/Fax (1) 8431**] to schedule a
follow-up appointment in [**2-13**] weeks.
|
[
"285.9",
"V45.81",
"486",
"998.59",
"272.4",
"530.81",
"250.00",
"E878.2",
"162.3",
"496",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9120, 9183
|
4742, 8360
|
326, 332
|
9253, 9321
|
2287, 4719
|
9529, 10524
|
1810, 1841
|
8734, 9097
|
9204, 9232
|
8386, 8711
|
9345, 9506
|
1856, 2268
|
237, 288
|
360, 1003
|
1025, 1635
|
1651, 1794
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,682
| 195,979
|
27251
|
Discharge summary
|
report
|
Admission Date: [**2192-9-12**] Discharge Date: [**2192-9-26**]
Date of Birth: [**2116-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
# Hypercarbic respiratory failure
# Hypertensive urgency
# Syncope
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
History dervied from report from floor team and patient's wife
as patient unable to provide much at time of transfer. Briefly,
this is a 76 yo male with h/o HTN, RAS, thoracic dissection s/p
stent and abdominal AAA repair who intially presented to the ED
on [**9-11**] after experiencing a syncopal episode on [**9-10**]. He was
at the pharmacy and had a witnessed syncopal event. At that time
had no CP, N/V, SOB, diaphoresis. He awoke and felt weak but
otherwise okay and elected to go to the ED on [**9-10**]. He came in
for evaluation on [**9-11**] as he was feeling generally fatigued. Per
wife, he has been very fatigeud and sleepy for the past few
days.
.
In the ED --> was hypertensive with SBP ~ 200. He was given IV
and PO lopressor, followed by hydralazine IV, and was ultimately
transferred on a nitroglycerin gtt. CXR showed postoperative
changes, low lung volumes, no obvious infiltrate. His head CT
was negative for ICH. Given intermittent hypoxia while in the
ED, underwent V/Q scan --> low prob for PE.
.
On arrival to floor, patient still on nitro gtt. When floor team
evaluated the patient they noted him to be very somnolent but
able to answer questions when asked. They also noted him to be
intermittent hypoxic with sats 85-100% on face mask. ABG with pH
7.18/ pCO2 106/pO2 82. Patient was given lasix 40 mg IV x 1. EKG
was unremarkable. CE sent. ECHO with LVEF > 55%, pulmonary HTN.
Given hypercarbia, patient was transferred to the ICU for closer
monitoring.
.
On transfer to ICU patient started on CPAP, which he did not
tolerate. He was then intubated. Following intubation, BP
dropped with SBP 70-90 and patient was briefly on dopamine. This
was weaned off and patient was again hypertensive and nitro gtt
restarted.
Past Medical History:
- hypertension - per patient, SBPs 120-130 with home cuff
- ? CAD
- elevated cholesterol
- PAF (in setting of bleed / surgery)
- s/p endovascular repair of thoracic aortic aneurysm ([**2191-4-25**])
complicated by hemothorax / VATS
- s/p ballooning of thoracic stent in [**6-22**] to manage type I
endoleak
- s/p infrarenal abdominal aortic aneurysm repair.
- chronic renal insufficiency - baseline Cr 1.6, renal scan in
6/0 shows no visible blood flow to right kidney - left kidney
appears to be performing 90 % of the total renal function and
the right kidney performing 10%
- right hydronephrosis - s/p ureteral stent in [**6-23**]
- Obesity
Social History:
Patient is married and lives with his wife. Former [**Name2 (NI) 1818**] but
quit 40 yrs ago.
Family History:
non-contributory
Physical Exam:
t 95.6 ax, bp 199/109, hr 103, rr 17, sat 99%
Vent: TV AC TV 600 FiO2 100% RR 16 PEEP 5
Gen: initially somnolent but answering questions
appropriately,now intubated and sedated
HEENT: pupils reactive, MMM
Lungs: occ insp/exp wheezes bilat, bibasilar crackles
Heart: reg, no murmurs appreciated
Abd: + bs, soft, non-tender
Ext: [**12-20**] + lower ext edema, pitting
Pertinent Results:
[**2192-9-11**] 06:43PM BLOOD WBC-6.1 RBC-4.47* Hgb-13.3* Hct-41.7
MCV-93 MCH-29.8 MCHC-31.9 RDW-16.4* Plt Ct-157
[**2192-9-11**] 06:43PM BLOOD Glucose-89 UreaN-35* Creat-1.8* Na-147*
K-4.1 Cl-107 HCO3-34* AnGap-10
[**2192-9-11**] 06:43PM BLOOD CK(CPK)-41
[**2192-9-11**] 06:43PM BLOOD cTropnT-0.01
[**2192-9-12**] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2192-9-12**] 03:44PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2192-9-12**] 05:14PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.7*
[**2192-9-12**] 09:16PM BLOOD TSH-0.63
[**2192-9-19**] 04:34AM BLOOD Type-ART Temp-36.9 O2 Flow-3 pO2-62*
pCO2-62* pH-7.43 calTCO2-43* Base XS-13 Intubat-NOT INTUBA
[**2192-9-19**] 02:02AM BLOOD Type-ART Temp-37.1 FiO2-70 O2 Flow-12
pO2-91 pCO2-70* pH-7.39 calTCO2-44* Base XS-13 Intubat-NOT
INTUBA
[**2192-9-18**] 10:55AM BLOOD Type-[**Last Name (un) **] Temp-36.2 Rates-/15 PEEP-5
FiO2-50 pO2-40* pCO2-72* pH-7.35* calTCO2-41* Base XS-10
Intubat-INTUBATED
.
Renal ultrasound
[**2192-9-13**]
Bilateral kidney demonstrate echogenic cortex which may be
associated with a variety of diffuse parenchymal renal diseases.
There is no evidence of obstruction, hydronephrosis or calculi.
Technically limited Doppler evaluation however no definitive
evidence of renal artery stenosis was seen
.
CTA [**9-13**]
1. Post endovascular repair of the thoracic aortic aneurysm,
there is persistent significant endoleak with slight increase in
the size of the thoracic aortic aneurysm as described above.
2. Stable aortic dissection with the left main renal artery
supplied by the false lumen, the celiac artery, superior
mesenteric artery, right renal artery and accessory left renal
artery supplied by the true lumen.
3. Stable appearance to the excluded right common iliac artery
aneurysm with retrograde filling. Stable right external iliac
artery aneurysm.
4. Cardiomegaly with bibasilar effusions and passive atelectasis
of the lower lobes likely suggestive of CCF.
5. JJ stent in a decompressed atrophic right kidney and stable
renal hypodensities, likely cysts.
6. Stable left adrenal myelolipoma.
.
V/Q scan [**9-11**]
1. Low likelihood ratio for acute pulmonary embolism. 2.
Findings consistent with a tortuous thoracic aorta, as seen on
CXR, as well as central tracer pooling suggestive of airways
disease.
Brief Hospital Course:
76 yo male who presents after a syncopal episodes two days ago,
now with hypertensive urgency and marked fatigue. On the floor
noted to be increasingly somnolent and found to have an elevated
CO2.
.
#Syncope
Patient initially presented for syncope work-up. Although soon
after admission he required mechanical ventilation for
hypercarbic respiratory failure, many etiologies of syncope were
inadvertently evaluated during admission. Telemetry showed many
PVC's but no malignant arrhythmias. Echocardiogram revealed
moderate concentric LVH, mild AS, grade I diastolic dysfunction,
and moderate pulmonary hypertension. EKG and subsequent cardiac
enzymes ruled him out for a myocardial infarction. CTA of the
chest showed increased size of thoracic aneurysm, however
without rupture. The most likely sources of syncope include
hypercarbia or vaso-vagal syncope. He will require follow up
with his PCP in two weeks (appointment scheduled).
.
# Hypercarbic respiratory failure
During initiation of hospitalization patient experienced sudden
hypercarbic respiratory failure which required mechanical
ventiliation and itubation. Patient has extensive smoking
history as well as history of CPAP use at night. In conjunction
with chronically elevated bicarbonate, provision dx of COPD and
OSA are likely contributors to his respiratory failure. He was
initially ruled out for pneumonia and pulmonary embolus.
Treatment for pneumonia included vancomycin / piperacillin -
tazobactam x 5 days for presumed hospital acquired pneumonia,
however subsequent BAL showed no evidence of this. Patient also
has a history of diastolic dysfunction, which may have
contributed to impaired ventilation; CXR showed evidence of
pulmonary congestion and patient was diuresed as well. Patient
was extubated on hospital day eight and transferred to the
floor. Diuresis and nebulization w/ albuterol / atrovent were
continued and incentive spirometry was started. PT was
consulted and recommended home with PT. At discharge the
patient required 2L of oxygen by nasal cannula to keep his O2
sats > 91%. The new O2 requirement was thought to be secondary
to his not-fully diagnosed COPD and OSA. We recommended that he
follow up with his PCP for likely [**Name9 (PRE) 1570**]'s in the future. Home VNA
and PT was also established. Lastly, he was also continued on
albuterol / atrovent until further workup with his PCP.
.
# Hypertension
Patient presented w/ hypertensive urgency. It was initialy
thought that increased blood pressures were [**1-20**] to renal artery
stenosis, however, no doumented RAS in the chart. Repeat renal
imaging showed impaired flow to right kidney, which is chronic.
Although transiently hypotensive in the ICU, patient's baseline
elevated BP resumed and was treated w/ home doses of
antihypertensives. His lisinopril dose was increased and his
imdur dose was decreased. Upon discharge his SBP was in the
90-100 range without lightheadedness, weakness, shortness of
breath. His BP was titrated to be low given his TAA and AAA.
.
# Urinary retention
Patient initially failed a voiding trial in setting of increased
R sided hydronephrosis. Urology was consulted regarding his
right ureteral stent and recommended stent replacement in the
near future. Urology will contact the patient regarding this
procedure.
.
# Likely CAD
Exact history is unclear, however w/ known AAA and thoracic
aneurysm, unlikely patient does not have CAD. Home meds of
include asa, imdur, bblocker were continued. He ruled out for
MI w/ 4 sets of cardiac enzymes.
.
# Thoracic and Abdominal aortic aneurysms
Known hx of TAA and AAA. CT evaluation showed increased size of
thoracic aneursym w/ endograft leak as well as stable abdominal
dissection at the level of the left renal artery. Thoracic
surgery evaluated patient and discussed management options w/
the patient. The patient elected to forgo surgical management
in lieu of medical management (BP control, statin).
.
Patient was admitted w/ syncope. He subsequently underwent
mechanical ventilation for respiratory failure, likely due to
COPD / OSA / atelectasis. He was diuresed, provided w/
nebulizers and his resp status improved. He has chronically
elevated bicarbonate and CO2 retention. Once transferred to the
floor the patient remained hemodynamically stable and afebrile.
He was started on home O2, albuterol, and atrovent.
.
Medications on Admission:
ASA 81 qd
Simvastatin 20 mg qd
Metoprolol 50mg tid
Lisinopril 10mg qd
Imdur 60mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs * Refills:*0*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*qs * Refills:*0*
5. Home oxygen
Please dispense home oxygen; 2L by NC, continuous flow.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*qs * Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Isosorbide Mononitrate 30 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:*0*
11. Outpatient Lab Work
Please have full chemistry panel checked in 1 week. Please fax
this to your PCP @ [**Telephone/Fax (1) 66827**] for management.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]/[**Hospital 3597**] Home Health and Hospice
Discharge Diagnosis:
Primary: hypercarbic respiratory failure, syncope NOS
Secondary: Thoracic aortic aneursym, abdominal aortic aneursym,
hypertension, obesity
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital after losing consciousness
(syncope or fainting). In the hospital you had difficulty
breathing and required intubation (a breathing tube) for several
days. We think this is due to underlying lung disease from
smoking and being overweight. We were unable to determine an
exact cause of why you fainted.
.
If you feel short of breath, experience fevers, difficulty
breathing, chest or abdominal pain, please call your doctor or
return to the emergency room for evaluation.
.
You also had difficulty urinating after the foley (bladder) was
removed. The urologists evaluated you and determined that you
need a stent change in your right ureter. The urology office
will call you to schedule this appointment. If you need to
contact them, please call [**Telephone/Fax (1) 3752**].
.
WE CHANGED THE DOSE OF 2 MEDICATIONS;
TAKE ONLY 30 MG DAILY OF IMDUR.
TAKE 20 MG DAILY OF LISINOPRIL.
.
WE ALSO STARTED A FEW NEW MEDICATIONS.
TAKE ALBUTEROL AND IPATROPRIUM
Followup Instructions:
Please make sure to see your primary care doctor (EHRIG) on [**10-8**], [**2191**] at 2:30pm. Please call [**Telephone/Fax (1) 66828**] to make any
changes to this appointment. Pleae have your blood checked
(chemistry panel) in 1 week; have these results faxed to your
PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 66827**].
.
Please make sure to follow up with the urologists regarding your
ureteral stent. Please call the above number with questions or
changes.
|
[
"518.81",
"403.00",
"788.20",
"496",
"591",
"785.50",
"584.9",
"276.0",
"585.3",
"428.0",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"38.91",
"96.72",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11458, 11553
|
5687, 10082
|
380, 392
|
11737, 11746
|
3382, 5664
|
12785, 13266
|
2963, 2981
|
10216, 11435
|
11574, 11716
|
10108, 10193
|
11770, 12762
|
2996, 3363
|
274, 342
|
420, 2167
|
2189, 2836
|
2852, 2947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,588
| 149,063
|
51393
|
Discharge summary
|
report
|
Admission Date: [**2200-8-20**] Discharge Date: [**2200-9-19**]
Date of Birth: [**2148-3-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Imipenem
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
Fiberoptic intubation [**2200-8-23**], [**2200-8-28**]; left subclavian central
venous line placement [**2200-8-23**], left radial arterial line
placement [**2200-8-23**]; surgical tracheostomy tube placement and PEG
tube placement [**2200-9-4**]; staple insertion in head laceration
[**2200-8-23**], removal [**2200-9-2**]
History of Present Illness:
Mr. [**Known lastname 106548**] is a 52 year old male with history of chronic
lymphocytic leukemia status post allogeneic bone marrow
transplant in [**2188**],
cutaneous GVHD recent admission for pneumonia who presents with
3 days of shortness of [**Year (4 digits) 1440**].
He was feeling "okay" until 3 days prior to admission when he
noted shortness of [**Year (4 digits) 1440**] upon awakening. It was worse with
exertion/walking but improved throughout the day. This occurred
again over the next two days. The shortness of [**Year (4 digits) 1440**] was not
associated with chest pain, palpitations, lightheadedness,
diaphoresis, nausea, vomiting. He notes orthopnea x several
months. No PND/leg swelling. He does note some
nausea/lightheadedness after taking famvir. He denies fevers,
chills, sweats, worse/productive cough. He denies diarrhea. He
does note some decreased appetite and PO intake.
He called Dr.[**Name (NI) 6168**] office today and was told to increase his
prednisone from 20 mg to 40 mg. Of note, he receives inhaled
pentamadine for PCP [**Name9 (PRE) **] but has missed a few doses. He is unsure
the date of his last dose.
In the ED, the CTA was negative for PE, but notable for
resolving pna and stable tree and [**Male First Name (un) 239**] appearance. He was given 1
dose of ceftriaxone/vanco. His ECG was sinus 94, old q in avF,
LAD, LVH and new TWI in V4-V6. He was given asa and 1 set of CE
was negative.
Past Medical History:
1. Chronic lymphocytic leukemia, status post
allo-bone marrow transplant 10 years ago at [**Hospital1 336**]. Oncologist is
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**].
2. extensive chronic graft vs. host
3. diffuse osteopenia treated with bisphosphonate
4. cyclosporine induced renal toxicity
5. shingles - admitted in [**2197-5-11**] with IV acyclovir
6. left parietal actinic keratosis s/p
nitrogen treatment
7. SCC, R 3rd finger, recurrent, pt referred for Mohs excision
on [**11-15**]
Social History:
Lives in [**Location 4047**], Married for many years, one son 14 years old.
He has been disabled for many years but previously worked as a
systems analyst for several companies throughout his life. No
tob or etoh. He has 6 brothers and 4 sisters.
Family History:
Mother had lung cancer due to tobacco abuse, his father died at
[**Age over 90 **] years of age, his sister died of Asthma at age 51.
Physical Exam:
VS - T 97.2, BP 110/60, HR 100, RR 22, sats 95% RA
Gen: Thin, cachectic male, +alopecia, NAD, nontoxic, no
increased work of breathing
HEENT: PERRL, EOMI. Sclera anicteric. MMM. OP clear. chronic GVH
scleritic type lesions but no ulcers, vesicles, lesions
suggestive of thrush
NECK: supple, no JVD, no LAD
CV: RR, normal S1, S2. No m/r/g.
Lungs: decreased BS throughout, no wheeze/crackle/rhonci, no
egophony
Abd: SNTND. NABS
Ext: cold hands and feet. Erythematous shins. small areas of
breakdown. Could not palpate PT pulses, 2+ radial pulses
bilaterally. No c/c/e.
Derm: Skin thick, firm, pale.Extensive chronic GVHD of the
scleroderma type.
Neuro: CN II-XII grossly intact.
Pertinent Results:
137 | 93 | 47 88
---------------/
5.8 | 34 | 1.7
\ 13.1 /
17.3 ------- 211
/ 40.7 \
N:81 Band:12 L:2 M:3 E:0 Bas:0 Metas: 2
Anisocy: OCCASIONAL Macrocy: OCCASIONAL
Plt-Est: Normal
PT: 15.1 PTT: 25.7 INR: 1.4
.
Imaging:
[**2200-8-20**] Chest CTA:
1. Resolution of left lower lobe consolidation with mild
scarring or atelectasis remaining.
2. Small 2 cm and 1 cm areas of patchy opacity of the anterior
base of the left lower lobe and peripheral right upper lobe are
nonspecific but unchanged.
3. No change in 7 mm soft tissue density in the rightchest
wallt, which may represent a sebaceous cyst.
.
[**8-23**] CT C Spine (prelim):
1. No evidence of fracture or malalignment within the cervical
spine.
2. Right upper lobe pulmonary nodule.
.
[**8-23**] CT Head: No intracranial hemorrhage or mass effect.
.
[**8-23**] EKG: NSR 97, lat TWI, no ST changes
.
[**2200-8-25**] TTE: Conclusions:
The left atrium is normal in size. A patent foramen ovale is
present. A
right-to-left shunt across the interatrial septum is seen at
rest. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. 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. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2199-7-30**], no
change. IMPRESSION: Patent formamen ovale with right to left
shunting at rest (probably mild).
.
[**8-27**]: Right hip XR
IMPRESSION: Limited exam. No obvious right proximal femur
fracture identified. Alignment of the right hip is within normal
limits on the AP view, but not well evaluated on the lateral.
.
[**2200-8-30**] ECG: Sinus tachycardia. Possible right atrial
abnormality. Left ventricular hypertrophy with ST-T wave
abnormalities. The ST-T wave changes are diffuse. Clinical
correlation is suggested. Since the previous tracing of [**2200-8-29**]
sinus tachycardia is now present.
Brief Hospital Course:
A/P: 52yo M w/ CLL s/p alloBMT in [**2188**] with chronic skin GVHD
admitted for hypercarbic respiratory failure of unclear etiology
with GI bleed, leukopenia.
.
1. Respiratory failure-This patient developed apneic hypoxic and
hypercarbic respiratory failure. DDx includes pulmonary GVHD,
pleural fibrosis, sleep apnea, or airway obstruction. DDx for
acute cause of respiratory failure include hypophosphatemia
(0.3), increase in sedation, mucus plug, CVA, or acute head
injury. Pt was intubated and doing well but had poor negative
inspiratory force with moderately reduced combined lung and
chest wall compliance secondary to chronic GVHD changes. Though
he had a favorable RSBI when he was extubated on [**8-28**] he
required reintubation after approx 2 hrs of extubation for
increased work of breathing, likely related to mechanical muscle
weakness. He had a tracheostomy tube and PEG tube surgically
placed on [**9-4**] for for more slow weaning off the vent via
sprint-rest trach mask trials and was awaiting placement in a
respiratory rehabilitation center, however throughout the week
prior to his death, he was requiring higher vent settings and
continued to desaturate. Repeat bronchoscopy did not alleviate
his respiratory failure and it was felt that he was continuing
to mucous plug secondary to VAP and his inability to clear his
own secretions. His health care proxy (wife) along with the
team, made the decision to make Mr. [**Known lastname 106548**] [**Last Name (Titles) **] measures
only, and expired on the morning of [**2200-9-19**].
.
2. VAP-While awaiting tracheostomy tube placement he developed
increased FIO2 requirement, low-grade fever, and leukopenia with
bandemia in the setting of new LLL and RUL opacity, so [**9-3**] was
started on cefipime, vanco, levofloxacin for VAP. He also was
found to have gram + rods and cocci on sputum culture.
.
3. Leukopenia-he developed leukopenia [**9-2**], with WBC count
trending down during his hospital course, possibly
myelosupression from medication vs infection vs myleodysplastic
syndrome, differential showed bandemia suggestive of infection.
He was on cellcept for GVHD whcih was held starting [**9-4**] but he
was continued on steroid taper and plaquenil and followed by
BMT.
.
4. Chest pain- Around the time of extubation he developed chest
pain with ST-T wave changes on ECG and elevated troponin thought
to be stress induced tropinism. DDx includes cardiac ischemia vs
noncardiac causes including pleuritis due to resolving
pneumonia/fibrosis, esophagitis, ulcer, or myopathy. Aspirin and
heparin were held as he also had bright red blood per recutm,
enzymes trending down, ECG changes resolved. He was maintained
on metoprolol.
.
5. Blood per rectum-he developed BRBPR on [**8-30**] and continued to
have melenotic stools, most likely lower GI source due to rapid
onset, DDx includes diverticulosis, AVM, hemmroids, ulcer,
gastritis, DIC labs neg. GI was consulted but preferred not to
scope emergently as hct stabilized and he was high risk given
recent cardiac changes. He was maintained on pantoprazole [**Hospital1 **].
.
6. Thrombocytopenia: He developed relative thrombocytopenia [**8-30**]
that was likely consumptive (GI bleed) vs drug induced
cellcept/pentamidine) that stablized. DIC labs neg, heparin
dependent antibody neg, cellcept decreased per BMT rec due to
potencial cause of thrombocytopenia .
.
7. HTN-He had quite labile blood pressures ranging from 80's to
200's systolic with tachycardia that were controlled ultimately
with metoprolol, captopril and PRN hydralazine.
.
8. GVHD: chronic cutaneous disease, stable, continued on
fluconazole for fungal prophylaxis, pentamidine for PCP
[**Name Initial (PRE) 1102**] (last [**2200-8-24**]), steroids, plaquenil, but cellcept
held [**9-4**] for leukopenia.
.
9. Chronic renal insufficiency - cyclosporine induced renal
toxicity, baseline creat 1, creatinine stable during this
hospital course.
.
Medications on Admission:
Cellcept 500mg PO BID
Prednisone 40 mg PO QD
Warfarin 1mg PO QD
Plaquenil 200 mg PO bid
Protonix 40mg PO QD
Metoprolol 25mg PO BID
Neurontin 300mg PO QHS
Lorazepam 0.5mg PO QHS prn
Fentanyl patch 50 mcg
Oxycodone 5mg PO Q4-6hrs prn
Pentamidine inh Q monthly - unclear when last dose
[**Name (NI) 10687**] 1 tab PO BID
Simethicone 40-80mg PO QID prn
Famvir - ? dose or start date
Fluconazole - ?dose or start date
Advair
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"934.8",
"873.0",
"996.85",
"482.83",
"V58.65",
"584.9",
"518.84",
"275.3",
"E912",
"E888.9",
"276.7",
"585.9",
"578.1",
"204.10",
"786.59",
"276.51",
"733.90",
"V10.83",
"401.9",
"287.5",
"701.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"31.1",
"86.59",
"96.04",
"43.11",
"38.91",
"99.04",
"38.93",
"96.6",
"99.05",
"96.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10545, 10560
|
6100, 10046
|
320, 645
|
10612, 10622
|
3786, 4552
|
10679, 10690
|
2938, 3073
|
10516, 10522
|
10581, 10591
|
10072, 10493
|
10646, 10656
|
3088, 3767
|
240, 282
|
673, 2112
|
4561, 6077
|
2134, 2656
|
2672, 2922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,895
| 135,290
|
35461
|
Discharge summary
|
report
|
Admission Date: [**2165-12-15**] [**Month/Day/Year **] Date: [**2166-1-18**]
Date of Birth: [**2125-12-1**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
IR embolization [**2165-12-15**]
Endotracheal intubation
Blood transfusion
hemodialysis
L knee arthrocentesis
History of Present Illness:
For full H&P please see admission note. Briefly, this is a 40M
with h/o HTN, aortic dissection in [**2156**] s/p [**Hospital3 9642**] valve on
coumadin, who presented to OSH approx 1 week ago with fatigue
and R flank pain, found to have right RP perinephric bleed. Was
transferred to [**Hospital1 18**], stabilized with FFP and IR embolization,
with stable HCTs. Subsequently developed ATN with Cr 6.0 and
progressive volume overload requiring intubation and CVVH. With
improved Cr and UOP, the patient was successfully extubated. He
develop a R pleural effusion, which is not tappable per IR. The
patient was transferred out of the TICU by urology to the
medicine service for further management of anticoagulation
(currently on heparin gtt, therapeutic x 48hours with stable
HCTs). Per urology there is right sided renal mass which does
not require inpatient work-up at this time. For hypertension the
patient had been treated with labetalol, with SPB 120-160s).
Patient currently feel well, no chest pains or shortness of
breath, minimal ([**12-31**]) pain in his right flank. He can 'feel
water on my lungs' but doesnt feel short of breath or have a
cough. He is most concerned about getting home to his family at
this point.
Past Medical History:
Ascending aortic dissection s/p repair with st jude's valve
([**2160**]), transient HD during time of dissection, HTN
.
Social History:
married, has 3 children. occasional EtOH, denies tobacco
Family History:
Mother, father with hypertension, sister with CVA
Physical Exam:
VS 100.7 84 149/66 92-93% on 2L 16
GEN: pleasant gentleman in NAD
HEENT: NCAT MMM anicteric
Neck: R dialysis cath in place, dressing c/d/i
Chest: L subclavian line removed, dressing c/d/i. Decreased
breath sounds b/l R>L, no wheezes, rhonchi or rales
CV: RRR S1S2 prominent click c/w prosthetic valve, 2/6 SEM at
RUSB
ABD: +bs slightly distended but nontender, no HSM
GI/GU: no CVA tenderness
EXT: warm, well perfused 2+dp pulses
SKIN: no visible ecchymoses, rashes
Pertinent Results:
[**2165-12-15**] 10:00PM PT-26.7* PTT-26.5 INR(PT)-2.7*
[**2165-12-15**] 10:00PM PLT COUNT-246
[**2165-12-15**] 10:00PM NEUTS-92.3* LYMPHS-4.8* MONOS-2.2 EOS-0.3
BASOS-0.3
[**2165-12-15**] 10:00PM WBC-10.1 RBC-3.81* HGB-11.2* HCT-31.6* MCV-83
MCH-29.3 MCHC-35.4* RDW-14.4
[**2165-12-15**] 10:00PM estGFR-Using this
[**2165-12-15**] 10:00PM GLUCOSE-140* UREA N-40* CREAT-2.4* SODIUM-135
POTASSIUM-7.4* CHLORIDE-108 TOTAL CO2-19* ANION GAP-15
[**2165-12-17**] MRA kidney
1. Abdominal aortic dissection, extending into the proximal
superior
mesenteric artery and celiac axis.
2. Slow flow in the narrowed right renal artery, supplied by
retrograde flow
in the small aortic false lumen. Right kidney has been
embolized. Widely
patent left renal artery.
3. Large right renal upper pole mass. Though no intravenous
contrast could be
administered, appearances are suspicious for renal cell
carcinoma. Slight
intravoxel fat may suggest clear cell etiology though large size
without
regions of necrosis also suggests chromophobe.
4. Extensive retroperitoneal and subcapsular hemorrhage
extending from the
right kidney.
5. Probable cholelithiasis.
[**2166-1-15**] MRI renal:
1. Large 13-cm mass arising from the right renal upper pole.
Increased
heterogeneity suggests interval central necrosis possibly due to
prior
embolization procedure or hypoperfussion in the setting of prior
hypovolemia
and renal bleed. The differential diagnosis includes a
chromophobe renal cell
carcinoma or an oncocytoma. A papillary renal cell carcinoma is
considered
less likely. Signal characteristics are not typical of a clear
cell carcinoma.
No renal vein invasion or lymphadenopathy.
2. Hemorrhagic 4 cm cortical lesion arising from the right renal
lower pole.
Given the distribution of the retroperitoneal hemorrhage, this
lesion is the
likely source. Since prior embolization could explain the
minimal to no
enhancement, a neoplasm is not excluded. The differential
diagnosis includes
hemorrhagic cyst, renal cell carcinoma, and cortical infarct.
3. Evolution of the right perinephric and retroperitoneal
hemorrhage, without
increase in extent.
4. Two hemorrhagic left renal cysts. Several additional tiny
left renal
cysts containing proteinaceous or hemorrhagic material.
5. Aortic dissection extending into the superior mesenteric
artery and both
common iliac arteries. The right renal artery arises from the
smaller right
lumen.
6. Moderate right pleural effusion.
7. Small splenic lesion, likely a hemangioma.
[**2166-1-16**] 05:10AM BLOOD WBC-5.4 RBC-3.11* Hgb-8.6* Hct-25.6*
MCV-82 MCH-27.8 MCHC-33.7 RDW-14.4 Plt Ct-221
Brief Hospital Course:
# ICU course: Post-IR embolization, the patient was admitted and
monitored in the ICU. He remained on heparin drip for
anticoagulation. His creatinine rose to 6 and potassium remained
elevated. Renal consult was called and suggested IV fluids and
lasix. However given aggressive fluid rescucitation and acute
renal failure he developed fluid overload and respiratory
distress, requiring intubation and CVVH. This occurred over the
course of 2 days, with resolution of hyperkalemia and decrease
of creatinine. This also improved his hypertension, however he
continued to run in SBPs of 180s. The patient was also noted to
have a right pleural effusion, but on ultrasound did not appear
large enough to tap. Once extubated, hemodynamically stable and
no longer requiring CVVH, he was transferred to the medicine
service on heparin drip for further anticoagulation and
management.
.
# Coagulopathy: On arrival to the medicine service, the patient
was on a heparin drip only, yet his INR was elevated to 2.7. The
cause of this remained unclear but it was thought to be
secondary to acute liver injury, given his elevated enzymes on
admission that were slowly resolving. He was given a 2mg dose of
vitamin K to which he responded appropriately. Coumadin was
initially held for thoracentesis and potential for other
procedures but was eventually started with heparin bridge.
The patient was discharged with an INR of 2.5; he has an
appointment on Monday (day post-[**Month/Day/Year **]) for repeat INR check
and coumadin dose adjustment.
.
# Acute renal failure: The patient had some underlying renal
insufficiency (Cr 1.6-1.7 at baseline) before the acute
hemorrhagic insult. His creatinine and BUN were trended,
nephrotoxins were avoided when possible, and the renal service
was consulted for recommendations on treatment and restarting
anti-hypertensives. His creatinine improved significantly, and
prior to dischage returned to his baseline of 1.5. He will be
seen by the renal service as an outpatient.
.
# Anemia: This was felt to be due to both his hemorrhagic insult
as well as anemia of chronic disease given his chronic renal
failure. He maintained a stable hematocrit of 22 for some time.
In the setting of improved blood pressure control, he was given
a one-time dose of Epogen to which he responded with a
hematocrit of 24. This was short-lasting, and several days later
he returned to hct 22. At that point (again, with improved blood
presures) he was transfused with 1U PRBC and hct jumped to 27.
His iron studies were normal (except for ferritin which was
elevated in the setting of acute illness). His hematocrit was
monitored and remained stable for the remaineder of his
admission.
.
# Hypertension: On transfer to the medicine service, the
patient's blood pressure ran 160-200/40-60s. He was continued on
carvedilol, and several other agents were added during the
course of his stay including amlodipine, lasix, hydralazine,
clonidine patch and lisinopril. With improvement in his renal
function, we slowly removed hydralazine and clonidine from his
regimen with good response. Lisinopril was added on last but
caused an acute jump in his creatinine from 1.9 to 3.0. On
removal his creatinine returned to baseline. His blood pressure
was well controlled and prior to [**Month/Day/Year **] lisinopril was
restarted at low dose (5mg daily). His blood pressure should be
maintained in goal range of 120-130s in the setting of
dissection.
.
# Respiratory failure/pleural effusion: The right pleural
effusion was noted on CXR during his ICU stay. Initially
afebrile, the patient had several fever spikes (max 102.3) which
prompted a thoracentesis and addition of vancomycin and zosyn
for hospital acquired and vent-acquired pneumonia. His fevers
resolved for several days, then returned at low grade despite
antibiotics. At that time it was felt that the origin could have
been from his abdomen. Coverage was switched to levofloxacin and
flagyl for a 2 week course. His thoracentesis was consistant
with an exudative effusion, however it was not felt this was an
empyema. He remained afebrile and did not require supplemental
oxygen for the remaineder of his stay. Last day of antibiotics
is [**1-16**]. He should have a repeat chest xray done within several
weeks after [**Month/Year (2) **] to ensure resolution of pleural effusion.
.
# Renal mass: The patient had multiple imaging modalities to
evaluate the mass, however it is still unclear as to the
etiology. There are two separate massess noted, the larger one
being on the superior pole of the kidney and a smaller one on
the inferior pole. On discussion between the renal service,
urology and hematology/oncology the patient will follow-up once
discharged for further imaging. There is concern for multiple
etiologies such as renal cell carinoma, hemorrhagic cysts,
lymphoma, etc. Further work-up needs to be pursued upon
[**Month/Year (2) **]. A renal MRI w&w/o contrast was performed.
.
# Gout: During his admission the patient had recurrent episodes
of polyarticular gout, which was confirmed by arthrocentesis of
the left knee. Given his renal status, it was felt that a
one-time dose of prednisone may be the best way to treat his
symptoms. A 50mg po prednisone dose was administered which
resolved his symptoms. He had another, less painful bout of gout
a week later and received another 40mg po dose of prednisone.
His colchicine was restarted on [**Month/Year (2) **].
.
Medications on Admission:
Coumadin 3mg daily, Coreg 120mg daily, Trimaterene-HCTZ 50-25mg
daily, Lotrel 10-20mg [**Hospital1 **], Colchicine 0.6mg daily, Doxazosin 8mg
daily, Tricor 145mg daily
[**Hospital1 **] Medications:
1. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
Disp:*240 Tablet(s)* Refills:*2*
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*1*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **] Disposition:
Home
[**Hospital1 **] Diagnosis:
perinephric, retroperitoneal bleed
acute renal failure
hyperbilirubinemia
anemia
hypertension
[**Hospital1 **] Condition:
hemodynamically stable and afebrile
[**Hospital1 **] Instructions:
You were admitted to the hospital with flank and abdominal pain
and found to have a bleed in your abdomen. You were treated by
interventional radiology and had embolization of actively
bleeding arteries. You were also treated for acute kidney
failure, fluid overload with hemodialysis and intubation while
you were having trouble breathing. You will require close
follow-up for your blood pressure and to make sure you are
further evaluated by the urology service for your kidney mass.
Please make sure to follow-up with your physicans (appointments
scheduled below) and have your coumadin level followed each week
in coumadin clinic. You need to have your coumadin checked first
thing Monday morning ([**1-20**]) to ensure your INR is therapeutic.
Over the weekend please take your 3mg coumadin pills as you did
prior to your admission.
For blood pressure control, your medications were changed to:
amlodipine, carvedilol, and lisinopril. Your primary care doctor
can adjust these as needed. You can continue taking your
colchicine and tricor as before. You will need to have your
creatinine levels checked regularly as both of these medications
may need to be adjusted based on kidney function.
When you see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **], make sure
you have a repeat chest xray done to ensure resolution of the
pleural effusion.
If you experience abdominal or back pain, nausea/vomiting,
fevers, chills, blood in the stool or urine, dizziness or
lightheadedness, or any other concerning symptoms please call
your doctor or return to the emergency room.
Followup Instructions:
** Please make sure to go to [**Location (un) 5503**] Assoc. to have your
coumadin checked on Monday [**2166-1-20**].
Provider: [**Name10 (NameIs) 1169**], [**Name11 (NameIs) **], MD Phone: [**Telephone/Fax (1) 40420**] [**2-26**],
3:45pm
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2166-2-12**] 1:00
-Urology appt: Dr[**Doctor Last Name **] office will call you with the date and
time of your next appointment within the next several days.
|
[
"285.1",
"585.2",
"V43.3",
"276.6",
"274.9",
"573.8",
"285.21",
"753.19",
"276.7",
"403.10",
"518.4",
"593.81",
"997.31",
"584.5",
"593.9",
"518.81",
"557.0",
"V58.61",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"34.91",
"39.95",
"38.91",
"81.91",
"96.04",
"96.6",
"38.93",
"96.71",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
5113, 10568
|
301, 413
|
2459, 5090
|
13698, 14244
|
1906, 1957
|
10594, 10763
|
1972, 2440
|
249, 263
|
11839, 11845
|
10793, 11809
|
441, 1672
|
11873, 12035
|
1694, 1816
|
1832, 1890
|
12066, 13675
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,475
| 118,745
|
9568+56044
|
Discharge summary
|
report+addendum
|
Admission Date: [**2134-9-24**] Discharge Date: [**2134-10-15**]
Date of Birth: [**2058-11-11**] Sex: F
Service: VSU
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
female, who underwent repair of a suprarenal and abdominal
aortic aneurysm on [**1-24**]. The approach was lateral
retroperitoneal. The operation was complicated by redo of
the distal anastomosis. She required reimplantation of the
left renal artery.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Anemia.
History of a right bundle branch block.
PAST SURGICAL HISTORY: Appendectomy in [**2131**].
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide.
2. Avapro.
3. Zetia.
4. Captopril.
5. Norvasc.
6. Folic acid.
7. Propranolol.
8. Detrol.
9. Aspirin.
10. Multivitamins.
SOCIAL HISTORY: The patient does have a history of smoking,
having quit eight years ago. Occasional alcohol use.
PHYSICAL EXAMINATION: Postoperatively, the patient's
temperature was 31.4. Pulse 56. Blood pressure 151/80.
Respiratory rate of 12. Saturating 99 percent. She was
awake and alert. She had a right IJ catheter in place.
Pupils are equal, round, and reactive. Head was atraumatic,
normocephalic. Lungs were clear to auscultation bilaterally.
The heart rate was regular. Abdomen was soft, nontender,
nondistended. She had bilateral cold lower extremities. She
had Dopplerable pulses in all extremities.
LABORATORIES: White count of 6.8, hematocrit 42.2, platelets
of 80. Her chemistry was significant for a potassium of 2.8
and was otherwise within normal limits. Her BUN and
creatinine were 11 and 0.6. Calcium, magnesium, and
phosphorus were 9.5, 1.2, and 2.9.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit postoperatively. She was given Kefzol
for a total of three doses. She had a lumbar drain in place.
On postoperative day number one, she continued to be on the
ventilator. She was sedated with propofol and Fentanyl. Her
urine output was noted to be good. She continued to get the
perioperative Kefzol.
Due to some hypotension and tachycardia on postoperative day
number three, she was pancultured. A chest x-ray showed an
opacity that was consistent with pneumonia. It was decided
to restart antibiotics. Her chest tube was discontinued on
postoperative day 10.
On postoperative day 12, she was successfully extubated and
transferred to the Vascular Intensive Care Unit on
postoperative day 12. At the time of transfer, she was on
levo and the cultures were being followed regularly. She
worked with PT and at the time of transfer, she was receiving
tube feeds for nutrition.
The patient was somewhat distended on postoperative day
number 16. Nasogastric tube was attempted, but was
unsuccessfully placed. Her Dobbhoff tube was discontinued on
the same day. The patient was made nothing by mouth and her
distention resolved the following day.
She was screened for rehab on postoperative day number 18.
Her central line was discontinued and peripheral lines were
placed. She was started on calorie counts and Boost
supplements; and the patient was discharged to rehab facility
on postoperative day number 20. At the time of discharge,
she was tolerating a regular diet with Boost supplements.
She was working with Physical Therapy. Prior to discharge,
she received some electrolyte replacements due to a low
potassium and some fluid resuscitation for BUN and
creatinine, which were 63 and 1.4. Prior to discharge, the
patient's electrolytes were rechecked and were found to be
within normal limits. It was decided that she will be
discharged to followup as an outpatient for her electrolyte
checks.
MEDICATIONS AT DISCHARGE:
1. Famotidine 20 mg by mouth twice a day.
2. Albuterol inhaler as needed.
3. Dulcolax 5 mg extended release.
4. Colace 150 mg/15 cc one dose by mouth twice a day.
5. Tylenol 325 mg one to two tablets by mouth every 4-6 hours
as needed.
6. Folic acid 1 mg by mouth every day.
7. Multivitamins by mouth every day.
8. Propranolol 80 mg one tablet by mouth three times a day.
9. Acetamide 10 mg by mouth every day.
10. Tolterodine tartrate 4 mg by mouth every day.
11. Aspirin 325 mg by mouth every day.
12. Norvasc 5 mg by mouth every day.
13. Nystatin suspension 5 mL by mouth every day.
14. Metronidazole 500 mg by mouth three times a day.
15. She was to continue the Flagyl for one week.
DISCHARGE INSTRUCTIONS: The patient was instructed to
followup with Dr. [**Last Name (STitle) **] in two weeks in [**Hospital **] Clinic.
She was given the appropriate phone number to make an
appointment.
DISCHARGE CONDITION: The patient was stable at the time of
discharge, tolerating a regular diet, and working with
Physical Therapy.
Please call with questions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D: [**2134-10-15**] 10:26:39
T: [**2134-10-15**] 10:48:50
Job#: [**Job Number 32471**]
Name: [**Known lastname 5640**],[**Known firstname 5641**] Unit No: [**Numeric Identifier 5642**]
Admission Date: [**2134-9-24**] Discharge Date: [**2134-10-19**]
Date of Birth: [**2058-11-11**] Sex: F
Service: SURGERY
Allergies:
Hmg-Coa Reductase Inhibitors / Sulfa (Sulfonamides) / Shellfish
/ Cefaclor / Robitussin / Macrodantin / Dobutamine / Ivp Dye,
Iodine Containing
Attending:[**First Name3 (LF) 1546**]
Chief Complaint:
aaa with renal artery stenosis
Major Surgical or Invasive Procedure:
Triple A repair [**2134-9-24**] with reimplantation of left renal
artery
Brief Hospital Course:
[**2134-10-18**] Patient remined in [**Last Name (un) **] awaiting rehabiltation bed.
Developed WBC of 14.0 [**2134-10-14**] CXR with retrocardiac density.??
atelectasis vs pleural reaction. urine cultures and stool for C.
difficil were negative. Patient WBC at discharge 15.9
started on levofloxcin 500mgm qd x 2 weeks. followup with Dr.
[**Last Name (STitle) **] 2 weeks.
Medications on Admission:
see d/c medications
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 170**] Senior Healthcare - [**Location (un) 171**]
Discharge Diagnosis:
Repair of aortic aneurysm with reimplantation of left renal
artery
Anemia
Hypertension
Elevated cholesterol
Right bundle branch block
Discharge Condition:
stable. working with physical therapy .tolerating regular diet
Discharge Instructions:
Please call ER or surgery clinic if you observe any increased
swelling, bleeding, drainage, pain, or temperature > 101.5
Followup Instructions:
Follow up in two weeks with Dr. [**Last Name (STitle) **]. call for appointment
([**Telephone/Fax (1) 5643**])
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2134-10-19**]
|
[
"458.29",
"440.1",
"285.1",
"486",
"426.4",
"441.4",
"E878.2",
"276.5",
"276.2",
"272.0",
"998.11",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"96.72",
"96.6",
"38.34",
"99.07",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
6167, 6257
|
5722, 6097
|
5624, 5699
|
6435, 6499
|
6669, 6940
|
6278, 6414
|
6123, 6144
|
1702, 3695
|
6523, 6646
|
586, 615
|
931, 1684
|
3709, 4432
|
5554, 5586
|
167, 451
|
474, 562
|
809, 908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,868
| 135,406
|
52926
|
Discharge summary
|
report
|
Admission Date: [**2164-11-19**] Discharge Date: [**2164-11-27**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Hemodialysis catheter placement
History of Present Illness:
74 yo F w/ DMII, ESRD on HD, dCHF, afib who presents with
hypoxia, tachycardia and hypertension after dialysis. She
presented to [**Hospital1 112**] yesterday with increased lethargy, rigors,
tachycardia, and a fingerstick above 600. She had a WBC of 22
and a positive urinalysis. Bcxs grew CONS 3/4 bottles on [**11-18**]
and NGTD on [**11-19**]. She was started on vanc/ceftaz. Her urine
grew klebs sensitive to everything except ampicillin. Her INR
was notable for an elevation to 7.4. She received 5 mg of oral
vitamin K. Repeat INR was 9.6.
.
Overnight she was complaining of some chest pressure. Her
troponin increased from 2.4 to 3.7. Cardiology was consulted at
[**Hospital1 112**]. They felt that the increase in troponin was related to
demand ischemia. Her hematocrit decreased significantly during
the admission without obvious signs of bleeding. She was 34.3 on
arrival and decreased to 25. This was felt to be related to
IVF's.
.
She was transferred to [**Hospital1 18**] for continuity and was doing well
on the floor until this afternoon when she went to dialysis.
When she came back she was noted to be hypoxic then also noted
to be tachycardic and hypertense w/ systolics in the 200s. An
ABG showed acute respiratory acidosis. She was given 80mg IV
lasix as she still makes urine. When she arrived in the ICU she
was somnolent, not answering questions and so was intubated. At
intubation she became hypotense and was started on peripheral
neo. A RIJ was attempted but curled back into the subclavian. A
femoral line was then placed.
Past Medical History:
# ESRD on hemodialysis secondary to diabetes; qMWF schedule at
[**Location (un) **] [**Location (un) **]
# DM2 on insulin
# HTN
# Chronic diastolic CHF (LVEF >75%) with a history of
tachycardia-induced acute LVOT obstruction
# Hyperlipidemia
# PVD s/p bilateral BKAs (left in [**2156**]; right in [**2157**])
# Paroxysmal a-flutter s/p failed ablation with subsequent
atrial fibrillation; on warfarin
# Chronic nighttime hypoxemia on 3 L/min nc
# Secondary hyperparathyroidism
# No occlusive coronary disease on cardiac cath [**12/2162**]
# Left eye blindness since [**2161**] after cataract surgery, per the
pt.
# Mild functional mitral stenosis
# GERD
# Tobacco use-- still smokes up to 6 cigarettes per day as of
[**9-28**]
# h/o VRE UTI's
# H/o Tibial fracture
Social History:
Significant for the presence of current tobacco use, [**5-27**]
cigarettes per day and [**12-23**] PPD x 50 years. There is no history
of alcohol or IV drug abuse. She lives in [**Hospital3 **]
facility with once weekly [**Hospital3 269**] and 5 day a week home health aide.
She uses a mobile wheelchair or a walker with prostheses.
Family History:
Father with DM2, Mother deceased of stroke. Siblings died of
cancer (unknown type), stroke and brain cancer. Seven health
children. Extended family history positive for CAD, cancer and
DM.
Physical Exam:
Vitals - T: 98.4 BP: 93/46 HR: 103 RR: 24 02 sat: 100 on FIO2
70%
GENERAL: Sedated on the vent
HEENT: NO elevation in JVP appreciated
CARDIAC: 2/6 systolic murmur, irregularly irregular
LUNG: Diffuse expiratory rhonchi
ABDOMEN: +BS, NT, ND
EXT: bilateral lower extremity amputations
NEURO: moving upper extremities spontaneously
Pertinent Results:
[**2164-11-19**] 09:15PM BLOOD WBC-20.3*# RBC-3.43* Hgb-9.6* Hct-31.9*
MCV-93 MCH-28.0 MCHC-30.1* RDW-18.2* Plt Ct-229
[**2164-11-21**] 03:02AM BLOOD WBC-22.5* RBC-3.25* Hgb-8.8* Hct-30.3*
MCV-93 MCH-27.0 MCHC-28.9* RDW-18.0* Plt Ct-233
[**2164-11-24**] 02:42AM BLOOD WBC-26.9* RBC-2.74* Hgb-7.7* Hct-24.9*
MCV-91 MCH-27.9 MCHC-30.8* RDW-18.5* Plt Ct-234
[**2164-11-25**] 03:58AM BLOOD WBC-28.2* RBC-2.95* Hgb-8.0* Hct-27.2*
MCV-92 MCH-27.0 MCHC-29.3* RDW-18.3* Plt Ct-220
[**2164-11-26**] 03:14AM BLOOD WBC-37.5* RBC-3.13* Hgb-8.5* Hct-28.9*
MCV-92 MCH-27.3 MCHC-29.5* RDW-18.7* Plt Ct-244
[**2164-11-19**] 09:15PM BLOOD PT-140.6* PTT-59.8* INR(PT)-18.7*
[**2164-11-20**] 06:10AM BLOOD PT-21.4* PTT-36.4* INR(PT)-2.0*
[**2164-11-20**] 07:30AM BLOOD Vanco-19.1
[**2164-11-22**] 05:05AM BLOOD Vanco-16.1
[**2164-11-23**] 04:00PM BLOOD Vanco-17.7
[**2164-11-25**] 03:58AM BLOOD Vanco-18.8
[**2164-11-26**] 05:39AM BLOOD Vanco-16.9
[**2164-11-26**] 11:44AM BLOOD Type-ART pO2-136* pCO2-33* pH-7.48*
calTCO2-25 Base XS-2 Comment-GREEN TOP
[**2164-11-25**] 01:06PM BLOOD Glucose-163* Lactate-2.5*
[**2164-11-25**] 05:01PM BLOOD Glucose-147* Lactate-2.1*
[**2164-11-25**] 10:20PM BLOOD Glucose-191* Lactate-2.2*
[**2164-11-26**] 03:34AM BLOOD Lactate-2.0
[**2164-11-26**] 11:44AM BLOOD Lactate-4.9*
[**2164-11-27**] 12:38AM BLOOD VoidSpe-CLOTTY SPE
Brief Hospital Course:
Mrs. [**Known lastname 1007**] was admitted with fevers and rigors initially to [**Hospital1 112**].
Blood cultures there grew coag negative staphylococcus and urine
cultures grew Klebsiella. She was started on vancomycin and
ceftriaxone. She was transferred to [**Hospital1 18**] and determined to have
a HD line infection. Her HD line was removed and replaced 2 days
later. While on the floor she had two episodes of afib w/ rvr
resulting in flash pulmonary edema and then intubation. She was
extubated in the ICU and her WBC was noted to continue to
climb, after the HD catheter was removed so a stool sample was
sent for c.diff which was positive. She was started on oral
vancomycin and IV metronidazole but her WBC continued to climb
and her mental status deteriorated. The possibility of colectomy
was discussed with her health care proxy [**Name (NI) 1154**] who decided
that her mother would not want a major surgery. Her abdomen
remained benign but her lactate continued to climb in the face
of volume resuscitation. She remained hemodynamically stable
without an O2 requirement and on [**2164-11-27**] she developed
bradycardia during her amiodarone infusion which then developed
into PEA arrest with a narrow complex bradycardia. She was coded
for approximately 45 minutes and expired at 12:45.
Medications on Admission:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB,
wheezing.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Acetaminophen 500 mg Capsule Sig: [**12-23**] Capsules PO Q6H (every
6 hours) as needed for Headache, pain .
19. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous twice a day: Inject 4 units twice per
day: once at breakfast and once at bedtime.
20. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): On hemodialysis days, please do not take your afternoon
dose of this medication.
Vancomycin 1g QHD
Ceftazidime
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
Completed by:[**2164-11-27**]
|
[
"427.31",
"008.45",
"995.92",
"588.81",
"996.62",
"276.2",
"V49.75",
"599.0",
"428.33",
"518.81",
"348.39",
"038.19",
"403.91",
"785.52",
"305.1",
"585.6",
"427.32",
"272.4",
"250.40",
"428.0",
"041.3",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"39.95",
"96.71",
"99.60",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
8351, 8360
|
5015, 6323
|
323, 356
|
8412, 8422
|
3648, 4992
|
8479, 8519
|
3090, 3284
|
8322, 8328
|
8381, 8391
|
6349, 8299
|
8446, 8456
|
3299, 3629
|
277, 285
|
384, 1935
|
1957, 2723
|
2739, 3074
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
634
| 168,186
|
15629
|
Discharge summary
|
report
|
Admission Date: [**2116-7-17**] Discharge Date: [**2116-7-26**]
Date of Birth: [**2053-12-21**] Sex: M
Service: HEPATOBILIARY SURGERY/GENERAL SURGERY/BLUE
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
gentleman who initially presented with common bile duct
stricture with question of cholangiocarcinoma, who underwent
exploratory laparotomy and cholecystectomy with negative
biopsies now thought to have represented a Mirizzi syndrome
and resolution of his symptoms. However, he developed a
recurrent strictureafter that required PTC and percutaneous
balloon dilatation. He had an initial response but recurred
after the PTC catheter was removed. A repeat PTC demonstrated
a stricture of the CHD at the bifurcation and distal RHD.Prior
to the operation, the patient denied any fever, chills,
nausea, vomiting.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post stent.
2. Diabetes mellitus type 2.
3. Hypertension.
4. Mirizzi syndrome.
5. Common bile duct stricture.
6. Chronic renal failure.
PAST SURGICAL HISTORY:
1. Status post coronary artery bypass graft.
2. Status post exploratory laparotomy and cholecystectomy.
MEDICATIONS ON ADMISSION:
1. Lopressor 25 mg twice a day.
2. Glyburide 2 mg once daily.
3. Lisinopril 20 mg p.o. once daily.
4. Pioglitazone 4 mg once daily.
5. Atorvastatin 20 mg p.o. once daily.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2116-7-17**], where common bile duct resection, roux-en-y,
hepatojejunostomy was performed (please see operative note
for details). The patient was transfused four units of red
blood cells intraoperatively. The patient tolerated the
procedure well and was transferred to Post Anesthesia Care
Unit in stable condition.
Postoperative day one, the patient had a low grade fever,
hypotensive in 90/40. His epidural dose was decreased and
then eventually turned off. He received fluid boluses which
would intermittently improve his blood pressure. His
Propofol was turned off. He also had two blood cultures to
rule out infection. He was also started on Albumin infusion.
On postoperative day number two, the patient is afebrile,
still hypotensive. He was started on Neo for pressors and
transfused two units of fresh frozen plasma to keep platelet
count above 100,000. Antibiotics of Levofloxacin and Flagyl
were changed to Zosyn.
On postoperative day number three, the patient is afebrile.
His blood pressure improved and he was continued on Albumin.
He was weaned off pressors. He was successfully extubated.
His epidural was restarted without hypotensive episodes. His
[**Location (un) 1661**]-[**Location (un) 1662**] is putting out large volumes (up to two free
liters of serous fluid). His [**Location (un) 1661**]-[**Location (un) 1662**] and bowel
cultures grew pansensitive enterococcus.
On postoperative day number four, the patient is afebrile and
vital signs are stable. Good urine output, still high
[**Location (un) 1661**]-[**Location (un) 1662**] output. His nasogastric tube was removed. The
patient is doing well, starting to ambulate.
On postoperative day number five, the patient is afebrile,
vital signs are stabile. He is ambulating with help. His
epidural was capped, unable to remove it because of
coagulopathy (INR 1.7). The patient was started on
subcutaneous Vitamin K for total of two doses. He is started
on clears which he is tolerating well. The patient's
creatinine which raised after his surgery to a level of 3.0
continues to be elevated.
On postoperative day number six, the patient is afebrile and
vital signs are stable. He is ambulating and tolerating
clears. Renal consultation was obtained who felt that the
patient's acute on chronic renal insufficiency (baseline
creatinine 1.8) is probably due to a combination of
medications and dye. The patient also underwent a T tube
study which showed that the right sided transhepatic tube
was open with free flow and the left side seemed to be either
kinked or plugged distally. After the study, the left tube
was capped. The patient's epidural was removed.
On postoperative day number seven, the patient is afebrile,
and vital signs are stable. He is tolerating advance to
regular diet, tolerating well, left tube capped, tolerating
well. Bilirubin decreased from 3.2 to 2.8. He is having
bowel movements and ambulating with help. [**Location (un) 1661**]-[**Location (un) 1662**] is
still putting large amount of clear serous exudate. He was
started on ******************* which resulted in a
significant improvement in the patient's peripheral edema.
The patient was also switched from Zosyn to Ciprofloxacin
p.o.
On postoperative day number eight, the patient is afebrile
and vital signs are stable. He is tolerating regular diet,
somewhat decreased amount of [**Location (un) 1661**]-[**Location (un) 1662**] output, however,
it is still high. The right sided T tube is open to gravity
and draining well. Lisinopril was discontinued. The wound
is clean, dry and intact. He is ambulating with help, and
normal bowel movements. An ultrasound for further kidney
workup will be done later today.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is discharged home with VNA. The
patient should ambulate as much as possible, may take shower,
no baths, no swimming. [**Location (un) 1661**]-[**Location (un) 1662**] to bulb suction. T
tube to gravity. Change dressings once daily. Check wound
once daily. Diet is diabetic diet.
MEDICATIONS ON DISCHARGE:
1. Tylenol one to two tablets p.o. q4-6hours p.r.n. pain.
2. Albuterol inhaler one to two puffs q6hours p.r.n.
3. Ipratropium one to two puffs q6hours p.r.n.
4. Lopressor 25 mg p.o. twice a day.
5. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
6. Colace 100 mg p.o. twice a day.
7. Ciprofloxacin 500 mg p.o. twice a day.
8. Spironolactone 100 mg p.o. once daily.
9. Lasix 40 mg p.o. once daily.
10. Protonix 40 mg p.o. twice a day.
DISCHARGE DIAGNOSES:
1. Common bile duct stricture, status post roux-en-y
hepatojejunostomy.
2. Hypertension.
3. Diabetes mellitus type 2.
4. Chronic renal failure.
5. Acute renal failure.
6. Postoperative coagulopathy.
7. Postoperative anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2116-7-25**] 12:50
T: [**2116-7-25**] 13:14
JOB#: [**Job Number 45149**]
|
[
"576.2",
"518.81",
"V45.81",
"285.1",
"414.00",
"584.9",
"403.91",
"286.7",
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] |
icd9cm
|
[
[
[]
]
] |
[
"51.69",
"38.93",
"54.59",
"87.54",
"51.37"
] |
icd9pcs
|
[
[
[]
]
] |
6011, 6503
|
5538, 5990
|
1203, 1380
|
1398, 5167
|
1070, 1177
|
205, 847
|
869, 1047
|
5192, 5512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,124
| 106,175
|
49719+59196
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-12-7**] Discharge Date: [**2189-12-11**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
? Sepsis
Major Surgical or Invasive Procedure:
Removal of HD catheter
History of Present Illness:
56M ESRD:PD here w/ lethargy and low blood pressure. Pt has had
fairly difficult course with multiple failed HD access as well
as cath infections, recently started on peritoneal dialysis with
occasional HD for fluid removal. Combined HD/PD therapy has been
instituted for the last two months, which is when patient's wife
noted that he was becoming relatively hypotensive. USOH of this
health until ~ 2 weeks ago, developed increasing lethargy, worse
over last two days. In addition, noted to have lower BP 60s-
100s, and notably more lethargic following hemodialysis and
during hypotensive sessions. Otherwise, was told to increase
sodium intake outside of dialysis with some good effect on blood
pressure, but recurrent lower extremity edema - which is primary
measurement of fluid status.
In addition, over last two days, has developed diarrhea, as well
as nausea and vomiting today. Furthermore, low grade fever, but
no chills over last day. Otherwise, no CP, abdominal pain,
occasional shortness of breath, especially today, recent
development of non-productive cough over last day, states having
decreased appetite. Of note, did not have HD last week.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**], then PD since
[**9-9**]
2. DM2
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy; ?osteo in past
10. h/o depression
11. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
12. s/p L AV graft: [**7-7**]
13. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
14. MRSA cath tip infection
Social History:
Lives w/ wife, son, daughter-in-law, and three grandchildren in
[**Location (un) 86**] area, has been unemployed [**2-5**] disability, smokes tobacco
1 ppd x45 years, past alcohol, no recreational drug use.
Family History:
NC
Physical Exam:
VS T 99.5 BP 116/53 HR 93 RR 24 O2Sat 100% on 2L
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, mmm, pale conjunctiva
NECK: no LAD, JVD at 6cm
COR: S1S2, regular rhythm, no r/g, [**1-9**] high pitched murmur over
precordium non radiating
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, mild tenderness over lower
abdomen, no rebound or guarding
Skin: warm extremities, no rash, multiple small ecchymosis over
the chest and arms
EXT: 2+ DP, no edema/c/c
Neuro: moving all extremities, following commands, PERRLA
Pertinent Results:
[**2189-12-7**] 03:00PM GLUCOSE-86 UREA N-35* CREAT-11.1*# SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-21
[**2189-12-7**] 03:00PM estGFR-Using this
[**2189-12-7**] 03:00PM ALT(SGPT)-9 AST(SGOT)-18 LD(LDH)-220
CK(CPK)-181* ALK PHOS-115 TOT BILI-0.2
[**2189-12-7**] 03:00PM CK-MB-7 cTropnT-0.67* proBNP-[**Numeric Identifier **]*
[**2189-12-7**] 03:00PM ALBUMIN-3.3*
[**2189-12-7**] 03:00PM HAPTOGLOB-306*
[**2189-12-7**] 03:00PM PT-32.4* PTT-43.4* INR(PT)-3.5*
[**2189-12-7**] 03:00PM D-DIMER-1027*
[**2189-12-7**] 01:41PM LACTATE-2.4* NA+-142 K+-5.0 CL--104
[**2189-12-7**] 01:30PM WBC-6.7 RBC-3.85* HGB-12.2* HCT-38.3*
MCV-100*# MCH-31.6# MCHC-31.7 RDW-19.9*
[**2189-12-7**] 01:30PM NEUTS-80.6* BANDS-0 LYMPHS-10.4* MONOS-5.8
EOS-2.4 BASOS-0.8
[**2189-12-7**] 01:30PM PLT SMR-NORMAL PLT COUNT-288
TTE [**5-9**]: EF 70%-80%, Moderate to severe [3+] TR. Moderate PA
systolic hypertension.
.
[**9-9**] MIBI: EF 59% Resting and stress perfusion images reveal a
moderate reversible inferior and inferolateral defect.
.
[**12-7**] CXR:
The heart size is borderline normal. Once again, a right
subclavian central venous line is visualized with its tip within
the distal SVC. Once again seen are multiple linear and discoid
atelectases of the left mid zone and right lung base. There
could be small bilateral pleural effusions. The lungs are
otherwise clear. The patient is noted to be status post cervical
fusion with hardware unchanged compared to previous exam.
Brief Hospital Course:
56M ESRD HD/PD, admitted with hypotension, found to have coag
negative staph line infection.
.
#ID: 1. Coag negative staph from line x 2 bottles. Sensitivities
pending. Hypotension appears to be due to dialysis rather than
sepsis. On Vanco (by level) for line infection; will continue on
Vanco IP 2 grams with PD by level as an outpatient for a 2 week
course (goal trough 15-20).
2. PNA- The patient was thought to possibly have pneumonia by
CXR, as well as a new O2 requirement and cough; therefore he was
initially treated empircally with levofloxacin then ceftriaxone
([**Date range (1) 101716**]). However, repeat CXR was not suggestive of PNA;
pt's pulmonary symptoms most likely due to volume overload;
therefore ceftriaxone was discontinued. At discharge the patient
was satting 91% on room air. [**Female First Name (un) **] team is deferring possible
pulmonary function tests to his PCP, [**Name10 (NameIs) **] his long history of
smoking.
.
# Hypotension/lethergy- likely due to intravascular volume
depletion (despite total body fluid overload); correlates with
timing of peritoneal dialysis. SBP at home reportedly as low as
60's (per pt's wife); during hospitalization SBP ranged from
75-130's. Pt feeling better overall at the time of discharge,
with systolic blood pressure of 100-110.
.
* ESRD: Continue peritoneal dialysis, renal meds per renal. Pt
on transplant list.
.
* Mental status: Etiology of recent MS changes unclear, ddx
includes Uremia, infection, hypotension; some improvement with
improvement in SBP to >80 per patient's wife. Currently at
baseline upone discharge.
.
* h/o DVT- anticoagulated on Coumadin 5mg, follow INR.
.
* Chronic pain: Continue methadone and oxycodone.
.
* FEN: Renal diet, PD
.
* Prophylaxis: PPI, anticoagulated
Medications on Admission:
Neurontin 300mg/600mg
Methadone 10mg
Seroquel 25
Metoprolol 12.5 TID
Norvasc 5
Warfarin 5
Mirtazapine 15
Protonix 40mg
Renagel 1200 TID
Sensipar 30mg
Oxycodone 10 QID
Paxil 20
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed.
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Methadone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed: Take as needed to maintain 2 bowel movements
daily.
Disp:*1 bottle* Refills:*0*
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Vancomycin
Vancomycin: dose by level. Give 2 grams IP if level is equal to
or less than 15. Last day: [**2189-12-21**].
13. Outpatient Lab Work
Vancomycin Level. Please check every other day until [**2189-12-21**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Primary: Line infection, Hypotension, ESRD
Discharge Condition:
Good. BP stable, satting well (91% on RA), afebrile, blood
cultures negative, appropriate followup arranged.
Discharge Instructions:
During this admission you have been treated for an infection of
your dialysis catheter and low blood pressure.
*Please continue to take all medications as prescribed. You are
being treated with Vancomycin (an antibiotic); this medication
will be given via peritoneal dialysis for a total of 2 weeks.
*Please call your doctor or come to the emergency room if you
experience lightheadedness or dizzyness, confusion, fevers,
chills, worsening cough, or any other concerning symptoms.
Followup Instructions:
Follow up with [**Doctor First Name 3040**] in Peritoneal Dialysis. She will arrange
for your Vancomycin to be given (dosed by level).
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-12-17**]
8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2189-12-17**] 10:00
Name: [**Known lastname 16842**] JR,[**Known firstname 2360**] J Unit No: [**Numeric Identifier 16843**]
Admission Date: [**2189-12-7**] Discharge Date: [**2189-12-11**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11279**]
Addendum:
Clarification:
Pt to have Vancomycin 2 grams IP at PD unit, next dose will be
Tuesday, [**2189-12-15**].
The remainder of his Vanco course will be determined by his
outpatient Renal team; VNA will not be checking Vanco levels at
home.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
[**First Name11 (Name Pattern1) 3344**] [**Last Name (NamePattern4) 11280**] MD [**MD Number(2) 11281**]
Completed by:[**2189-12-11**]
|
[
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"428.0",
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"996.68",
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"585.6",
"357.2",
"799.02",
"285.21",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9366, 9585
|
4364, 5759
|
324, 348
|
7665, 7776
|
2841, 4341
|
8306, 9343
|
2278, 2282
|
6365, 7500
|
7599, 7644
|
6164, 6342
|
7800, 8283
|
2297, 2822
|
276, 286
|
376, 1538
|
5774, 6138
|
1560, 2035
|
2051, 2262
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,277
| 103,668
|
52608+52619+52609
|
Discharge summary
|
report+report+report
|
Admission Date: [**2131-1-6**] Discharge Date: [**2131-1-21**]
Date of Birth: [**2093-10-20**] Sex: F
Service:
CHIEF COMPLAINT: Hypercarbic respiratory failure secondary
to bronchiectasis and likely pneumonia.
HISTORY OF PRESENT ILLNESS: This is a 37 year-old year-old
woman with a complicated past medical history including
respiratory distress syndrome, aspergillus and tuberculosis
leading to left pneumonectomy, bronchiectasis, congestive
heart failure and dilated cardiomyopathy. The patient was in
her usual state of health until approximately two days prior
to admission when she noticed an increase in her baseline
shortness of breath, increased sinus drainage and secretions,
increased coughing, which was productive of green sputum.
over the last week and upon contacting Dr.[**Name (NI) 21360**]
nurse [**First Name (Titles) **] [**Last Name (Titles) 2875**] Amoxicillin yesterday for symptoms she
attributed to sinusitis. There was no improvement in her
symptoms for the past day. Her temperature was 99.4 at home.
There were no chills or rigors. No chest pain. No pleuritic
pain. No increase in orthopnea of three pillows baseline.
No change in lower extremity edema. No headache, nausea,
vomiting, visual changes, abdominal pain, urinary or bowel
changes. She noted decreased po intake and decreased
appetite recently. She had also used her BiPAP overnight the
day prior to admission, which she does not always use unless
she is not feeling well. Her mother also gave her chest
physical therapy yesterday.
In the Emergency Department O2 sat 92% on 2 liters increased
to 100% on 2 liters after nebulization. PCO2 was 51,
received .5 mg of Ativan and started on BiPAP, received 1
gram of Ceftriaxone 10 units of insulin, 1 amp of D50, 1 amp
of calcium gluconate for K of 6.4.
PHYSICAL EXAMINATION: Temperature 97.2. Blood pressure
98/43. Heart rate 118. Oxygen saturation 99% on 25% FIO2
BiPAP. General, thin young female in moderate distress with
accessory muscle usage. HEENT extraocular movements intact.
Pupils are equal, round and reactive to light. Slightly dry
mucous membranes. Neck, no JVD, supple. No lymphadenopathy.
Chest, rhonchi on right. No rales or wheezes. No breath
sounds on the left. Status post pneumonectomy. Heart
tachycardic, normal S1 and S2, present S3. Abdomen positive
bowel sounds, nontender, nondistended. G tube in place with
some erythema and induration. Extremities 2+ pitting edema
bilaterally, purplish color bilaterally. Neurological
sedated after Ativan and on BiPAP, later responded
appropriately to questions and moved all extremities.
LABORATORY: Chem 7 138, 6.4, 88, 50, 37, 0.6, 145. Calcium,
magnesium, phos 9.4, 2.0, 4.3. CBC 9.4, 40.8, 267.
Differential 68 neutrophils, 16% bands, 3% lymphocytes, 10%
monocytes, 0 eosinophils, 1 baso, 1 atypical, 1 meta. PT
11.6, PTT 38.7, INR 0.9, arterial blood gases 1:30 p.m.,
7.15/151/294, at 2:25 p.m., 7.19/142/87 on 40% O2 with
lactate of 1.0. Chest x-ray, possible early pneumonia at
right lung base, patchy increased density, some right pleural
thickening versus small effusion, status post left
pneumonectomy. Electrocardiogram sinus tachycardia rate at
113, right axis deviation. No peaked T waves. Normal
intervals, down sloping ST in lead 3. No change compared to
old electrocardiogram. Spirometry FEV1 equals 0.41, 13% of
predicted, FVC equals 0.6, 15% of predicted, FEV1/FVC equals
68 87% of predicted.
HOSPITAL COURSE: 1. Respiratory: The patient has a
baseline elevated CO2 likely due to bronchiectasis with VQ
mismatch as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12794**] effect and decreased
respiratory drive. The CO2 is now elevated above baseline
likely secondary to infection. The patient was treated with
Ceftazidime and Levofloxacin. She received BiPAP as
tolerated during the day as well and Albuterol and Atrovent
nebulizers and chest physical therapy and frequent
suctioning. Sputum cultures grew Xanthemonas. The patient
was not treated with steroids. The patient was initially
treated with intubation and mechanical ventilation, but was
successfully extubated on [**2131-1-16**]. On the [**7-17**] the
patient's blood gas was 7.40/62/181 and it was felt the
patient had improved significantly enough to transfer to
pulmonary rehabilitation or the floor service. The patient
was transferred to the floor, but returned to the Intensive
Care Unit on [**1-18**], with hypercarbic respiratory failure
likely secondary to decreased ability to suction the patient,
provide chest physical therapy and respiratory treatment on
the floor. She continued on BiPAP at night and received 2
liter transtracheal oxygen with saturations in the 100%
range. After intensive suctioning and chest physical therapy
the patient could tolerate even 1 liter transtracheal O2 with
an oxygen saturation on 100% Subacute decline necessitated
reintubation [**2131-1-21**], and eventually patient underwent bedside
percutaneous tracheostomy placement to facilitate ventilation
and allow adequate suctioning. Plan was to work towards
eventual liberation from mechanical ventilation if tolerated..
She is to be screened for and admitted to a pulmonary rehab
facility.
2. Cardiovascular: The patient had no signs of pulmonary
edema on chest film. There was no increase in lower
extremity edema or rales or JVD on admission. However, over
time it was felt that she was gaining weight above her
baseline of approximately 112 to 114 pounds and should be
diuresed especially given the development of crackles in the
right lower lung base. When she returned from the unit to
the floor she received a Lasix drip, which resulted in
greater then 1 liter fluid extraction. She was started on a
po regimen of Lasix, which she could continue as an
outpatient.
3. Infectious disease: The patient was given Ceftazidime
and Levo empirically for coverage of gram negative,
Pseudomonas and pulmonary gram positive and atypical
pathogens. She completed a fourteen day course, but appeared
to have some increasing patchiness in her right lower lobe on
chest film of [**2131-1-18**] and was restarted on Levo and Ceptaz
after a fourteen day course had just completed. In addition
her sputum grew out Stenotrophomonas from the culture and was
sensitive to Bactrim. However, she has a sulfa allergy and a
repeat culture was sent to determine the sensitivity as the
initial plate had been discarded by the laboratory. On
[**1-21**] she remained afebrile with temperature of 98.6.
4. Gastrointestinal: The patient tolerated tube feeds well
and was given Zantac for prophylaxis. She intermittently
took food by mouth having more difficulty with solids then
liquids. However, there were no witnesses of this episode of
severe aspiration.
5. FEN: The patient was initially thought not to be fluid
overloaded, but over time it was noticed that her weight was
increased and a goal was established to diurese her back to
approximately her normal outpatient weight of 114 pounds.
For this reason she was starred on a Lasix drip and titrated
after which she was started on a po Lasix regimen and the
Foley was removed.
6. Psychiatric: The patient expressed significant grief of
the difficulty she is faced due to her medical issues and the
desire for her to go home and refuse care. She was seen by
psychiatry consult who found her to be in acute delirium and
having both passive and active suicidal ideation with plan to
drown herself in the bathtub at times. Psychiatry
recommended her to be started on 15 mg of Remeron q.h.s. to
be initially used for sedation at night, while weaning her
off 1 mg of Ativan she has usually been taking in house, but
then the Remeron could be increased to give as an
anti-depressant dose as an outpatient. An outpatient
psychiatry appointment will be set up before the patient's
discharge so that this issue can be addressed thoroughly.
7. Code: Full.
8. Communication: [**Name (NI) 1356**], mother, sister, Dr. [**Last Name (STitle) 217**].
DISPOSITION: To pulmonary rehabilitation facility, pending.
A discharge summary addendum will be added to this discharge
summary upon the patient's discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (STitle) 18486**]
MEDQUIST36
D: [**2131-1-21**] 14:02
T: [**2131-1-24**] 12:10
JOB#: [**Job Number **]
Admission Date: [**2131-1-6**] Discharge Date: [**2131-1-21**]
Date of Birth: [**2093-10-20**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 37 year-old female
with a complicated past medical history involving Hodgkin's
disease in [**2114**], histoplasmosis in [**2116**], adult respiratory
distress syndrome, aspergillus and tuberculosis leading to a
left pneumonectomy as well as bronchiectasis, congestive
splenectomy. She was in her usual state of health until
approximately two days prior to admission when she noted an
increase in her baseline shortness of breath, increased sinus
drainage and secretions that she thought was secondary to
sinusitis as well as coughing productive of green sputum.
She was also noted by her mother to be more lethargic over
the last week and she called Dr. [**Last Name (STitle) 217**] and spoke to
prior to admission with no improvement in her symptoms.
Temperature at home was 99.4. No chills or rigors. No chest
pain. No pleuritic pain. No increase in baseline orthopnea
(three pillows). No increase in lower extremity edema. Some
decrease in po intake and appetite recently. She has used
her BiPAP overnight the day before admission, which she does
not always use unless she is not feeling well. Mother also
gave her chest physical therapy yesterday. No headaches,
nausea, vomiting, visual changes, abdominal pain, no urinary
incontinence or urinary symptoms. No change in bowel habits.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (STitle) 18486**]
MEDQUIST36
D: [**2131-1-21**] 13:35
T: [**2131-1-24**] 11:17
JOB#: [**Job Number **]
Admission Date: [**2131-1-21**] Discharge Date: [**2131-1-31**]
Date of Birth: [**2093-10-20**] Sex: F
Service:
ADDENDUM:
HOSPITAL COURSE: 1.) Pulmonary. The patient has a sub acute
decline on [**2131-1-22**] when she became less responsive,
hypotensive and had mottling of her extremities, but no
performed which showed 7.21/153/125 and the patient was
intubated for respiratory acidosis. A tracheostomy was
placed for long term ventilation. It was thought that the
failure to wean was either due to volume overload or myopathy
or both, given that she had been minimally mobile times two
weeks.
Pressure support ventilation was continued during the day
with pressure controlled ventilation at night for rest and
the patient was stable in terms of blood gases.
Because of this, and to allow for movement around the unit,
the arterial line was continued. She has been stable since.
A Passey-Muir valve was placed towards the end of her stay,
in the Intensive Care Unit, to allow for speech and this is
to be removed at night. The tracheostomy tube may be used
through the tracheostomy site.
2.) Cardiac. After the initiation of positive pressure
ventilation, the patient became increasingly hypotensive on
[**2131-1-22**]. This was thought to be due to positive pressure
causing decreased pre-load and the patient was given normal
saline boluses. Due to the hypotension, the patient was
started temporarily on Levofed to maintain blood pressure.
This was weaned to off once the pressure stabilized.
3.) Psych/agitation. Remeron was discontinued, as this was
thought to possibly contribute to her confound delirium.
Ativan 0.5 mg q. h.s. plus prn Haldol were used for the
control of anxiety. She was started on Ambien 2.5 mg q. h.s.
for sleep.
4.) Gastrointestinal. The patient had an episode of bright
red blood per rectum in house, with a stable hematocrit,
which resolved on its own. She has a history of hemorrhoids.
Her constipation regimen was increased. Tube feeds and
Zantac were continued. The patient's gastric tube was
replaced on [**2131-1-30**], due to the presence of irritation around
the entrance site.
5.) FEN. The patient continued to be diuresed, since this
was thought to be one of the major impediments to her vent
weaning. Lasix drip was instituted and active diuresis was
instituted until the patient's weight was 51.0 kg which was
her outpatient weight. Lasix was changed to 20 mg p.o. twice
a day to keep the patient even.
6.) Infectious disease. Remained afebrile. No clear
organism was identified from cultures of blood or urine.
MEDICATIONS ON DISCHARGE:
Heparin 5,000 units subcutaneous twice a day.
Zantac 150 mg twice a day.
Digoxin 0.125 mg q. day.
[**Doctor First Name **] 100 mg q. day.
Colace 100 mg twice a day.
Humibid one to two tablets every 12 hours.
Lasix 20 mg twice a day.
Ambien 2.5 mg q. h.s.
Ativan 0.5 mg q. h.s. prn.
Haldol 0.5 to 1 mg q. four hours prn.
Albuterol MDI, two puffs every two hours prn.
Percocet, one to two tablets p.o. every four to six hours
prn.
Miconazole powder, topical, twice a day, prn.
Combivent inhaler, two puffs four times a day.
Tube feeds, promote with fiber at 60 cc per hour.
TREATMENTS:
Chest physical therapy.
Physical therapy.
Occupational therapy.
Aggressive suctioning.
DIET:
Tube feeds plus p.o. as tolerated.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Pulmonary rehabilitation facility with a
ventilatory capacity.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (STitle) 108597**]
D: [**2131-2-28**] 13:27
T: [**2131-2-2**] 15:59
JOB#: [**Job Number 56865**]
|
[
"482.1",
"578.1",
"494.1",
"518.5",
"425.4",
"458.9",
"293.0",
"276.6",
"569.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.91",
"38.93",
"31.1",
"96.6",
"97.02",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
13609, 13955
|
12872, 13587
|
10403, 12846
|
1842, 3470
|
144, 227
|
8662, 10385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,948
| 162,568
|
41030
|
Discharge summary
|
report
|
Admission Date: [**2110-2-1**] Discharge Date: [**2110-2-13**]
Date of Birth: [**2043-2-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain with paraplegia
Major Surgical or Invasive Procedure:
L2 vertebrectomy with L1-3 fusion
History of Present Illness:
Patient is a 66 yo male with h/o Parkinson's dx, with failed
back surgery syndrome s/p revision laminectomy with fusion L1-L5
in [**2109**] and [**Date range (1) 89492**] [**2110**] including anterior and posterior
fusion of L2/3, transpedicular decompression. Patient was
discharged in stable condition. On [**2110-2-1**] patient fell off of
the toilet at his rehab resulting in hardware failure and a
large epidural hematoma causing cauda equina syndrome.
Past Medical History:
PMHx:
-HTN
-Parkinson's
-DDD
PSHx:
-3 back surgeries
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
LLE- 1/5 strength at hip flexion; 0/5 remaining lower extremity;
RLE- 0/5 strength
Pertinent Results:
[**2110-2-11**] 05:35AM BLOOD WBC-10.1 RBC-3.36* Hgb-9.7* Hct-28.2*
MCV-84 MCH-28.7 MCHC-34.2 RDW-14.5 Plt Ct-240
[**2110-2-10**] 02:19AM BLOOD WBC-10.5 RBC-3.44* Hgb-9.9* Hct-28.6*
MCV-83 MCH-28.7 MCHC-34.4 RDW-14.3 Plt Ct-230
[**2110-2-9**] 01:20PM BLOOD WBC-13.4* RBC-3.18* Hgb-9.0* Hct-26.4*
MCV-83 MCH-28.3 MCHC-34.1 RDW-14.7 Plt Ct-338
[**2110-2-8**] 06:13PM BLOOD WBC-18.3*# RBC-3.67* Hgb-10.5* Hct-30.7*
MCV-84 MCH-28.6 MCHC-34.2 RDW-14.3 Plt Ct-483*
[**2110-2-2**] 02:53AM BLOOD WBC-13.2* RBC-3.49* Hgb-10.0* Hct-30.6*
MCV-88 MCH-28.8 MCHC-32.8 RDW-14.1 Plt Ct-625*
[**2110-2-1**] 05:30PM BLOOD WBC-14.4* RBC-3.80* Hgb-10.6* Hct-33.0*
MCV-87 MCH-28.0 MCHC-32.2 RDW-14.3 Plt Ct-669*#
[**2110-2-11**] 05:35AM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-135
K-3.5 Cl-98 HCO3-31 AnGap-10
[**2110-2-9**] 02:09AM BLOOD Glucose-141* UreaN-20 Creat-0.9 Na-135
K-4.3 Cl-102 HCO3-28 AnGap-9
[**2110-2-3**] 05:06AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
[**2110-2-1**] 05:30PM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-145
K-4.1 Cl-107 HCO3-27 AnGap-15
[**2110-2-11**] 05:35AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.0
[**2110-2-11**] 05:35AM BLOOD WBC-10.1 RBC-3.36* Hgb-9.7* Hct-28.2*
MCV-84 MCH-28.7 MCHC-34.2 RDW-14.5 Plt Ct-240
[**2110-2-13**] 05:03AM BLOOD ESR-75*
[**2110-2-7**] 04:00PM BLOOD FactVII-58
[**2110-2-13**] 08:42AM BLOOD Vanco-16.3
[**2110-2-10**] 06:39AM BLOOD Vanco-16.4
Brief Hospital Course:
Mr. [**Known lastname 73762**] was taken emergently to the OR for a washout of an
epidural hematoma and fracture repair. Please see operative
note for procedure in detail.
Post-operatively he was given pain medication and antibiotics.
He did not regain lower extremity function. He was followed by
the infectious disease service and recommendations followed. He
will follow up with the ID service for length of antibiotics.
He was discharged to rehab.
Medications on Admission:
amlodipine 10 mg daily
atenolol-chlorthalidone 50 mg-25 mg daily
carbidopa-levodopa 25 mg-250 mg TID
gabapentin 300 mg TID
naproxen 500 mg [**Hospital1 **]
potassium chloride 20 mEq daily
pramipexole 0.5 mg TID
quinapril 40 mg daily
aspirin 81 mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for narcotics.
5. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO q8h ().
6. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
QAM (once a day (in the morning)).
11. carbidopa-levodopa 25-100 mg Tablet Sig: Three (3) Tablet PO
QHS (once a day (at bedtime)).
12. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO Q
24H (Every 24 Hours).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. 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.
16. Vancomycin 1500 mg IV Q 12H
17. Outpatient Lab Work
Please check weekly CBC, C. diff, BUN/Cr and LFTs. Fax to
[**Telephone/Fax (1) **].
18. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO once
a day: Please begin one week after discharge from hsopital and
discontinue heparin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
L2 fracture
Cauda equina
Epidural hematoma
Paraplegia
Discitis
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion L1-3 and L2 vertebrectomy
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to inspect the incisions for signs of infection.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days. Call [**Telephone/Fax (1) **] for an
appointment
Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2110-2-20**] 3:00
Provider: [**Name10 (NameIs) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2110-3-10**] 10:00
Completed by:[**2110-2-13**]
|
[
"401.9",
"722.93",
"344.60",
"790.92",
"324.1",
"293.0",
"567.38",
"E884.6",
"996.49",
"567.31",
"996.67",
"332.0",
"805.4",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"80.99",
"81.37",
"03.53",
"81.62",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
5237, 5334
|
2810, 3266
|
333, 369
|
5441, 5448
|
1372, 2787
|
7620, 8026
|
974, 979
|
3572, 5214
|
5355, 5420
|
3292, 3547
|
5472, 5578
|
994, 1353
|
7428, 7509
|
7531, 7597
|
5614, 5807
|
268, 295
|
5843, 6298
|
6310, 7410
|
397, 856
|
878, 933
|
949, 958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,464
| 155,982
|
1737+55309
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-1-24**] Discharge Date: [**2121-2-15**]
Date of Birth: [**2051-3-9**] Sex: F
Service: MEDICINE
Allergies:
Protonix / Aggrenox
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 69f with metastatic renal cell ca, cva, and a recent
admission for GIB who presents with one week of fatigue and
pallor and was found to anemic at 26.6 (last hct from discharge
[**1-16**] was 30). She was recently admitted for [**Date range (1) 9892**] when her
pcp found her to have a hct of 24. She had a negative ng lavage,
guaiac negative, egd negative, colonoscopy negative, capsule
endoscopy negative; her fe studies showed a ferritin > [**2115**], and
the thought was that this was related to anemia of chronic
disease. She felt better after her admission, with a "rosy"
complexion; however, over the next few days she became
increasingly pale and fatigued. On the day of presentation, she
was confused, going into the wrong room at home, unable to
distinguish between dreams/reality; in the ed, she was a&o and
said she didn't feel confused, just that her thinking was
"slow." She denies recent f/c, ha, focal weakness,
lightheadeness, loc, vis changes, chest pain, sob, cough, abd
pain, n/v/d/c, back pain, dysuria/hematuria.
In the ED, she got 2units prbc and was seen by neurology.
Past Medical History:
Metastatic renal cell cancer (mets to parotids, lung, pancreas)-
dx'ed in [**2111**], s/p R nephrectomy- [**2111**]
h/o +PPD
HTN
TIA
osteoporosis
VRE--colonizer (rectal swab)
Social History:
works as receptionist at [**Hospital **] Medical Society
no tobacco, quit 40 years ago
no alcohol
Family History:
lung cancer- father
Physical Exam:
Vitals: T 98.6
BP 124/50
HR 95
R 24
Sat 99% RA
*
PE: G: Elderly female, cachectic, NAD, nondyspneic
[**Hospital 4459**]: Clear OP, MMM, no thrush
Neck: Supple, No LAD, No JVD sitting upright in chair
Lungs: Distant BS BL. No W/R/C
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS.
Ext: 0-1+ edema. 2+ DP pulses BL.
Neuro: Flattened affect.
Pertinent Results:
Admission Labs:
[**2121-1-23**] 07:40PM BLOOD WBC-11.2* RBC-3.13* Hgb-8.3* Hct-26.6*
MCV-85 MCH-26.4* MCHC-31.0 RDW-17.3* Plt Ct-573*
[**2121-1-23**] 07:40PM BLOOD Neuts-77* Bands-0 Lymphs-11* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2121-1-23**] 07:40PM BLOOD Plt Ct-573*
[**2121-1-23**] 07:40PM BLOOD PT-13.7* PTT-24.5 INR(PT)-1.3
[**2121-1-23**] 07:40PM BLOOD Glucose-157* UreaN-16 Creat-0.9 Na-132*
K-5.0 Cl-96 HCO3-26 AnGap-15
[**2121-1-23**] 07:40PM BLOOD ALT-44* AST-50* AlkPhos-636* Amylase-76
TotBili-0.9
[**2121-1-23**] 07:40PM BLOOD Lipase-77*
[**2121-1-23**] 07:40PM BLOOD Albumin-2.4*
[**2121-1-24**] 08:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
[**2121-2-3**] 06:05AM BLOOD WBC-12.2* RBC-3.70* Hgb-9.9* Hct-30.9*
MCV-84 MCH-26.8* MCHC-32.0 RDW-16.9* Plt Ct-280
[**2121-1-30**] 03:42PM BLOOD Neuts-92.2* Bands-0 Lymphs-6.6*
Monos-0.9* Eos-0.2 Baso-0.1
[**2121-1-28**] 05:15AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Target-1+
Schisto-1+
[**2121-2-3**] 06:05AM BLOOD Glucose-171* UreaN-15 Creat-0.5 Na-138
K-3.3 Cl-103 HCO3-24 AnGap-14
[**2121-1-31**] 02:45AM BLOOD CK(CPK)-11*
CXR ([**2-1**]): CHEST, SINGLE AP PORTABLE VIEW.
The upper chest and thoracic inlet is excluded from the film.
Allowing for this, the ET tube is no longer visualized. There
are patchy interstitial and alveolar opacities centered about
both pulmonary hila. No upper zone redistribution or effusion is
identified. The opacities most likely represent resolving
changes due to pulmonary edema and are slightly decreased
compared with [**2121-1-31**]. Multiple clips noted in the abdomen.
Density over left upper quadrant is consistent with
calcification within the splenic artery.
IMPRESSION: Apparent removal of ET tube. Slight interval
improvement in perihilar infiltrates thought to represent
resolving pulmonary edema. Clinical correlation requested.
MRI Head ([**1-24**]): TECHNIQUE: Multiplanar T1- and T2-weighted
brain imaging. Diffusion-weighted images were obtained.
FINDINGS: Again seen are areas of T2 hyperintensity in the right
posterior parietal and both occipital lobes. Decreased signal
centrally in the occipital lobe foci are consistent with
necrosis. Increased T1 signal in the rims of these areas is
consistent with laminar necrosis. Associated susceptibility
within these foci are consistent with prior hemorrhage.
Diffusion sequences demonstrate thin rims of increased signal
which may be related to susceptibility or T2 shine-through. No
other diffusion abnormalities are identified to suggest acute
ischemia. T2 hyperintensity in the periventricular cerebral
white matter is consistent with chronic microvascular ischemia.
There is no hydrocephalus, mass effect, or shift of normally
midline structures. Surrounding osseous and soft tissue
structures are unremarkable.
TECHNIQUE: 3-D time-of-flight imaging with multiplanar
reconstructions.
FINDINGS: The major tributaries of the circle of [**Location (un) 431**] are
patent without evidence of significant stenosis or aneurysmal
dilatation. Within the limits of this exam, no sign of an
arteriovenous malformation is apparent.
IMPRESSION:
1. Overall stable MRI appearance of the brain with
redemonstration of posterior parietal and occipital lobe
infarcts.
2. Normal circle of [**Location (un) 431**] MRA.
EEG ([**1-24**]): FINDINGS:
ABNORMALITY #1: Throughout this recording, the background rhythm
remained in the 5 to 6 Hz frequency range. They did not reach
normal
levels.
ABNORMALITY #2: Superimposed bursts of mixed frequency
generalized delta
and theta slowing were observed periodically. No sharp features
were
associated with this slowing.
BACKGROUND: As described above.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient remained drowsy throughout the entire
recording with
no stage II sleep observed.
CARDIAC MONITOR: Showed a generally regular rhythm with average
rate of
72 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of
diffuse
background slowing throughout the recording. In addition,
overlying
bursts of generalized mixed frequency delta and theta slowing
were seen.
No epileptiform features were observed with this slowing. No
electrographic seizures were recorded. This EEG is most
consistent with
encephalopathy. Common causes of encephalopathy include
medications and
metabolic disturbances.
Brief Hospital Course:
FATIGUE/CONFUSION/WEAKNESS: Neurology was consulted in the ED
for evaluation. Among the findings was an MRI that showed no
focal findings, and an EEG that showed a toxic-metabolic
picture. She had a history of [**Doctor Last Name 4116**] syndrome ([**3-13**] bilateral
occipital/parietal CVA felt to be likely in the setting of
vertebro-basilar insufficiency), with an element of [**Doctor First Name 9893**]
syndrome (anosgnosia of visual deficit) elicited by the
neurologist, but otherwise had no new focal findings, and the
encephalopathy was attributed to toxic/metabolic etiology,
likely in the setting of hypercalcemia. She was also treated for
a UTI with Levofloxacin for 7 days. She was also found to be
hyponatremic on admission; all of these factors, along with her
malnutrition in the setting of malignancy, likely contributed to
her presentation. She was given IVFs aggressively, with
resolution of the hypercalcemia and hyponatremia. She was also
given pamidronate and calcitonin, and lasix for treatment of the
hypercalcemia. PTH was normal, and the hypercalcemia was
attributed to the patient's malignancy. The calcium normalized
with the above treatment. The patient's mental status improved,
although she had a persistent poor PO intake. She passed a
speech and swallow study, but was noted to have had a poor
appetite. After intubation and ICU stay, her mental status
remained stable and she had a persistently poor appetite. She
was started on Megace, and prior to admission noted an
improvement in her appetite.
RESPIRATORY DISTRESS: On [**1-30**], the patient was noted to have
coughed a bit after eating, cleared the food, but then developed
acute respiratory distress that required intubation and transfer
to the ICU. The CXR showed findings c/w pulmonary edema, and
the patient was felt by the ICU team to have developed flash
pulmonary edema. Her last Echo [**10-14**], showed a normal EF with
some focal wall motion abnormalities. EKG and cardiac enzymes
were normal. She was treated with lasix, as well as empirically
for aspiration PNA with levofloxacin and flagyl. She improved
over the next 3 days, and was extubated without event. Given
her wall motion abnormalities, diastolic failure in the setting
of ischemia was a distinct possibility, and the depending on the
prognosis of the renal cell cancer, may warrant a stress test as
an outpatient. Her breathing remained stable on room air, and
she was discharged on metoprolol and levo/flagyl with plan of a
10 day course.
DEPRESSION: The patient was noted to have flattened affect, was
seen by the social worker, and started on prozac for depression.
ANEMIA: The patient was noted on prior hospitalization to have
had a negative workup for anemia including EGD/colonoscopy. The
anemia was attributed to chronic disease. She required a few
transfusions, and on d/c her Hct was stable.
ELEVATED LFTs: Noted to have elevation, attributed to metastatic
disease.
CODE: Patient was full code throughout.
Medications on Admission:
1.)Ranitidine 150mg [**Hospital1 **]
2.)Metoprolol 50mg [**Hospital1 **]
3.)MVI
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
11. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Renal cell carcinoma
Urinary tract infection
Aspiration pneumonia
Anemia of chronic disease
Depression
Oral candidiasis
Discharge Condition:
Stable
Discharge Instructions:
Continue all medications as written.
Encourage PO intake.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2121-3-3**]
11:00
Name: [**Known lastname **],[**Known firstname 1355**] Unit No: [**Numeric Identifier 1356**]
Admission Date: [**2121-1-24**] Discharge Date: [**2121-2-15**]
Date of Birth: [**2051-3-9**] Sex: F
Service: MEDICINE
Allergies:
Protonix / Aggrenox
Attending:[**First Name3 (LF) 161**]
Addendum:
Mrs. [**Known lastname 734**] was not able to be discharged on [**2121-2-4**] because
of some complications with her insurance. She remained in the
hospital, but became progressively weaker. Her PO intake trailed
off and she developed thrush in her mouth, which made it more
difficult for her to swallow. Her mental status also began to
wax and wane, with the patient spending most of the day
sleeping. When awake, she had difficulty managing her
secretions. Deep suctioning was done with some improvement in
her symptoms, but the patient was very uncomfortable with the
suctioning. Mrs. [**Known lastname 734**] had been on telemetry earlier in her
stay for persistent sinus tachycardia. Her HR was as high as the
120s and she began to receive IVF (NS at 80cc/hr to prevent
flash pulmonary edema) in case dehydration/hypovolemia was the
cause of her tachycardia. Her BP always remained stable. On the
morning of [**2121-2-11**], Mrs. [**Known lastname 734**] did not look well. Her thrush
was abundant and caused her to have a hoarse voice and to be
unable to swallow her pills. She was also lethargic, and,
although oriented, had difficulty answering questions and
staying awake. Her exam was notable for a sinus tachycardia w/
rate in the 120s. Lungs were clear, with no evidence of volume
overload, and she had no JVD or peripheral edema. By the time
the attending went to round on her, Mrs. [**Known lastname 734**] had a HR in the
170s. EKG revealed atrial fibrillation/flutter. She was put on
telemetry and was given 5mg lopressor x2 which broke the
arrhythmia and put her back into NSR. However, she went back
into the same arrhythmia later that afternoon and was more
difficult to break. She required 5mg lopressor x3 and 10mg
dilitiazem x1 in order to break her rhythm. After that
intervention, the patient and her husband had a discussion about
their goals of care and Mrs.[**Known lastname 1357**] wishes. Mrs. [**Known lastname 734**]
decided to change her code status from FULL to DNR/DNI. The
following day, she again went into an atrial
fibrillation/flutter and again required a total of 15mg of
lopressor and 10mg of diltiazem to bring her back into NSR. A
discussion was held between the patient, her husband, the [**Name (NI) **]
attending on call Dr. [**Last Name (STitle) **], and Mrs.[**Doctor Last Name 1357**] oncologist
Dr. [**Last Name (STitle) **] and the decision was made to move more towards
CMO. Pain and Palliative Care saw the patient, as did social
work, and helped support the family in making the transition to
hospice care.
.
It was unclear what the precipitating event was for Mrs. [**Doctor Last Name 1358**] arrhythmia. Based on some nonspecific ST changes on
her EKGs, she had cardiac enzymes cycled x3 which were negative.
The second leading concern was for an infection, particulary
when she began to develop a leukocytosis. She had a CXR which
was more consistent with volume overload. Blood cx, stool cx,
UA, urine cx and stool cx were negative or no growth to date.
She was continued on levo/flagyl (which she had been on
previously for an aspiration pneumonia), and was changed from PO
nystatin to IV fluconazole for thrush.
.
Mrs. [**Known lastname 734**] continued to deteriorate and her mental status
began to wax and wane. The decision was made not to attempt
transfer to a hospice facility as she was likely too fragile for
transfer. She went into rapid atrial fibrillation again and she
and her family decided on no further interventions, including
medications for rate control. In keeping with her goals of care,
attempts were made to make her comfortable. She was given oxygen
and morphine for respiratory distress and ativan for seizure
activity. Her family then decided that the oxygen mask made her
more uncomfortable and asked to remove the mask. She died
shortly thereafter, peacefully, with her family present. Her
husband, who was her HCP, declined an autopsy.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]
Completed by:[**2121-4-3**]
|
[
"V10.52",
"518.81",
"599.0",
"401.9",
"198.89",
"788.30",
"197.7",
"349.82",
"275.42",
"112.0",
"368.16",
"780.79",
"276.52",
"197.8",
"507.0",
"428.31",
"285.29",
"250.00",
"783.7",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15653, 15888
|
6758, 9759
|
286, 299
|
11103, 11112
|
2234, 2234
|
11218, 15630
|
1760, 1781
|
9890, 10837
|
10960, 11082
|
9785, 9867
|
11136, 11195
|
2959, 6735
|
1796, 2215
|
239, 248
|
327, 1430
|
2251, 2942
|
1452, 1628
|
1644, 1744
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,992
| 168,055
|
37652
|
Discharge summary
|
report
|
Admission Date: [**2134-8-26**] Discharge Date: [**2134-9-7**]
Service: CARDIOTHORACIC
Allergies:
Fentanyl / Demerol
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
[**2134-8-30**] Aortic valve replacement (19 mm CE Magma pericardial)
History of Present Illness:
This 87 year old white with known aortic stenosis is pre-op for
knee surgery. Preop workup included an echocardiogram which
demonstrated critical aortic stenosis and a cardiac
catheterization was scheduled. This confirmed severe Aortic
stenosis with moderate mitral regurgitation also. She was
transferred from [**Hospital1 **] for surgery.
Past Medical History:
Aortic stenosis
hypertension
mitral regurgitation
degenerative joint disease
chronic atrial fibrillation
chronic obstructive pulmonary disease
h/o right leg deep vein thrombophlebitis
chronic venous stasis cahnge right foot
s/p right total hip arthroplasty
Social History:
Lives with: alone
Occupation: retired
Tobacco: quit 20 yrs ago
ETOH: 2 drinks/day
Family History:
non-contributory
Physical Exam:
Admission:
T 98.7 Pulse: 81 Resp: O2 sat: 95%-RA
B/P Right: 110/76 Left:
Height: 4'[**35**]" Weight: 49.5 K/109 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur: 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: 1+ bilat
Varicosities: None [] venous stasis color changes
Neuro: Grossly intact [x] A&Ox3 MAE follows commands
Pulses:
Femoral Right: 2+ cath Left: 2+
DP Right: dop Left: dop
PT [**Name (NI) 167**]: dop Left: dop
Radial Right: 1+ Left: 1+
Carotid Bruit Right:radiated murmur Left: radiated murmur
Pertinent Results:
IMPRESSION:
1. Dense aortic valve calcification, in keeping with known
aortic stenosis
with moderate-to-severe atherosclerotic calcification in the
thoracic aorta.
2. Dense mitral annular calcification.
3. Enlarged pulmonary arteries, most likely in keeping with
pulmonary
hypertension.
4. Tiny pulmonary nodules in the right lung as described above.
Suggest
followup in six months' time for further evaluation.
5. Nonspecific, hypodense lesions in the caudate lobe and
segment II of the
liver. If clinically indicated, these may be further
investigated with
ultrasound.
The study and the report were reviewed by the staff
radiologist.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 20 %).
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. with moderate global free wall
hypokinesis.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
There is severe mitral annular calcification. Moderate (2+)
mitral regurgitation is seen. There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on [**Known firstname 17236**]
[**Known lastname **] before bypass.
POST-BYPASS: Patient on milrinone
Moderate global RV hypokinesis.
LVEF 20%
Aortic bioprosthesis is stable and functioning well with mean
gradient of 10mm of Hg.
Thoracic aorta is intact.
Mild to Moderate mitral regurgitation.
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) **] [**2134-8-31**] 12:14
[**2134-9-7**] 05:30AM BLOOD WBC-8.7 RBC-3.39* Hgb-9.8* Hct-31.7*
MCV-94 MCH-28.8 MCHC-30.8* RDW-14.8 Plt Ct-311
[**2134-9-7**] 05:30AM BLOOD PT-17.9* INR(PT)-1.6*
[**2134-9-6**] 05:35AM BLOOD PT-15.4* INR(PT)-1.4*
[**2134-9-5**] 06:25AM BLOOD PT-14.6* INR(PT)-1.3*
[**2134-9-4**] 07:15AM BLOOD PT-13.2 INR(PT)-1.1
[**2134-9-3**] 04:55AM BLOOD PT-12.2 PTT-28.1 INR(PT)-1.0
[**2134-9-2**] 02:28AM BLOOD PT-13.0 PTT-30.1 INR(PT)-1.1
[**2134-9-7**] 05:30AM BLOOD Glucose-96 UreaN-29* Creat-0.8 Na-135
K-4.4 Cl-97 HCO3-31 AnGap-11
Brief Hospital Course:
She was transferred from [**Hospital1 **] on [**8-26**]. Preoperative workup
wascompleted including an echo that revealed severe MR. [**First Name (Titles) 9786**] [**Last Name (Titles) 84447**]n done and she was cleared for surgery. IV heparin
was begun while coumadin was held post-cath.
She underwent tissue aortic valve replacement by Dr. [**First Name (STitle) **] on
[**8-31**]. the mitral regurgitation was felt to be not sever enough
in the Operating [**Last Name (un) **] after aortic replacement to warrant
surgical repair. She weaned from bybass on multiple pressors
including Levophed, Milrinone, Vasopressin and Propofol drips.
The Milrinone was changed to dobutamine, her cardiovascular
status improved asnd all agents were weaned to off in 24 hours
with good hemodynamics. She was exubated on POD 1 and remained
stable. The Coumadin was resumed for atrial fibrillation and she
was transferred to the floor.
Physical therapy worked with the patient or mobility and
strengthening. Due to her overall physical condition she was
sent to a rehabilitation facility for further recovery prior to
return home.
Wounds were clean and dry and healing well at discharge.
Arrangements were made for out patient followup. She will be on
Coumadin for her chronic atrial fibrillation.
Medications on Admission:
Diltiazem CD 180', HCTZ 12.5',
Advair250/50", Atrovent 2P", MVI, Calcium, Warfarin 2.5', Ultram
50-prn, Methimazole 2.5', Tylenol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
7. Methimazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Tablet(s)
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 5 mg Tablet Sig: 0.5 Tablet PO [**9-7**] for 1 doses.
14. Warfarin 1 mg Tablet Sig: as ordered Tablet PO DAILY
(Daily): INR goal 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3548**] [**Hospital 3549**] Nursing and Rehab Center
Discharge Diagnosis:
Aortic stenosis
s/p aortic valve replacement
mitral regurgitation
Chronic atrial fibrillation on coumadin
Hypertension
chronic obstructive pulmonary disease/asthma
osteoarthritis/ degenerative joint disease
h/o right leg deep vein thrombophlebitis
chronic lower extremity venous stasis disease
Discharge Condition:
good
Discharge Instructions:
no lotions, creams, powders or ointments on any incision
no lifting greater than 10 pounds for 10 weeks
shower daily and pat incision dry
no driving for at least one month AND off all narcotics
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
please call and schedule the following appointments
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 6051**] ([**Telephone/Fax (1) 25493**]) in [**11-27**] weeks
Dr. [**First Name (STitle) 1075**] in 4 weeks ([**Telephone/Fax (1) 6256**])
Dr. [**Last Name (STitle) **] (for Dr. [**First Name (STitle) **] in 4 weeks at [**Hospital1 **]
[**Telephone/Fax (1) 6256**]
Please see Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 1075**] on same day
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2134-9-7**]
|
[
"428.0",
"401.9",
"459.81",
"287.5",
"396.2",
"493.20",
"440.0",
"427.31",
"V12.51",
"715.96",
"E878.2",
"V43.64",
"416.8",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7455, 7546
|
4607, 5898
|
246, 318
|
7884, 7891
|
1893, 4584
|
8246, 8874
|
1085, 1103
|
6079, 7432
|
7567, 7863
|
5924, 6056
|
7915, 8223
|
1118, 1874
|
191, 208
|
346, 688
|
710, 969
|
985, 1069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,024
| 199,903
|
25360
|
Discharge summary
|
report
|
Admission Date: [**2159-8-10**] Discharge Date: [**2159-8-27**]
Date of Birth: [**2097-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2159-8-13**] Two vessel coronary artery bypass grafting utlizing the
left internal mammary to left anterior descending with vein
graft from left internal mammary to obtuse marginal.
[**2159-8-10**] Cardiac catheterization with placement of IABP
History of Present Illness:
This is a 61 year old Portuguese speaking man with history of
hypertension and hyperlipidemia was admitted for an elective
catheterization after an increase in DOE and increasing CP with
walking. At present he is able to walk only 2 blocks before he
becomes short of breath.
He was previously quite active and athletic until two years ago
when he began to have significant dyspnea on exertion and
fatigue. He has a long standing history of tobacco and alcohol
abuse. In [**2158-6-27**] while having a doctor's appointment, he
was found to be extremely hypertensive and was admitted to
[**Hospital3 2737**]. Testing at that time included a Cardiolite ETT
where he exercised 5 minutes 31 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, 87%
max PHR, stopping due to leg pain. EKG was non diagnostic due to
baseline ST abnormalities. He had no chest pain. Imaging did not
reveal any definite evidence of inducible ischemia. EF was noted
at 22%. Echo on [**2158-7-25**] revealed a dilated LV with an EF of 25%
with severe global hypokinesis.
Last month the patient was admitted to [**Hospital6 **] in
[**Location (un) 5503**] for a syncopal event. This was witnessed by a family
member. He apparently had lost consciousness for several
minutes. He was ruled out for an MI and told that this was most
likely due to dehydration as it was a very hot day. Per Dr. [**Name (NI) 63433**] notes, an echo suggested a regional wall motion
abnormality and persantine ETT suggested some anterior apical
infarct with some
inferoposterior ischemia. Cardiac catheterization was
recommended but the patient refused. His family has since been
able to convince him to have angiography. His daughter reports
that her father can look short of breath at
rest and with any type of walking. Previously he was quite
athletic and now he cannot even walk a of a mile. She states
that he easily becomes lightheaded when involved in light
exertion or on a hot day. She also reports that over the past
few months he has been getting chest discomfort with walking. He
does
not use SL nitroglycerin. She is unclear if he has a history of
orthopnea or PND. She reports that he does not have LE edema. He
does complain of leg
fatigue with minimal amounts of walking. She reports that he has
smoked 2 packs a day for over forty years and he has recently
cut back to a pack a day. She also states that he has been
drinking for at least forty years, currently
imbibing in several beers and several glasses of wine throughout
the day. He is also very non compliant with medications.
Past Medical History:
Cardiomyopathy, History of Syncope, ? Prior MI, Hypertension,
Hyperlipidemia
Social History:
Patient is widowed and currently lives with his mother. [**Name (NI) **] is
Portuguese speaking. He previously worked in a warehouse until
last year, stopping d/t his health. Daughter reports that he has
smoked 2 packs a day for over forty years and he has recently
cut back to a pack a day. She also states that he has been
drinking for at least forty years, currently imbibing in several
beers and several glasses of wine throughout the day. His
daughter [**Name (NI) **] helps out with his care.
Family History:
Mother with several [**Name (NI) 5290**] and a CVA in her 70's.
Physical Exam:
Vit: 140-150's/80-90, 81 regular, 18
Gen: WDWN male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
CV: regular rate and rhythm, normal s1s2, no murmur or rub
Pulm: clear bilaterally
Abd: benign, no organomegaly
Ext: warm, no edema
Skin: no lesions
Neuro: alert and oriented, mood appropriate, cranial nerves
grossly intact, FROM, 5/5 strength, no focal deficits
Pertinent Results:
[**2159-8-25**] 06:40AM BLOOD WBC-11.0 RBC-3.51* Hgb-10.8* Hct-31.0*
MCV-88 MCH-30.6 MCHC-34.7 RDW-13.9 Plt Ct-696*
[**2159-8-26**] 06:20AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-133
K-4.4 Cl-99 HCO3-24 AnGap-14
[**2159-8-24**] 07:05AM BLOOD Mg-1.9
[**2159-8-11**] 08:44AM BLOOD Triglyc-144 HDL-43 CHOL/HD-4.2
LDLcalc-108
[**2159-8-11**] 08:44AM BLOOD TSH-3.5
Brief Hospital Course:
Mr. [**Known lastname 19688**] was admitted and underwent elective cardiac
catheterization which was signficant for severe three vessel
disease(including left main) and severely depressed left
ventricular function. Angiography demonstrated a co-dominant
system with an 80% distal left main lesion, a heavily calcified
LAD with 80% mid stenosis, an 80% lesion in the first obtuse
marginal and a proximal 60% lesion in the right coronary artery.
Ventriculogram revealed 1+ mitral regurgitatin and an LVEF of
25%. Based on his critical coronary anatomy, an IABP was placed
to augment diastolic filling. Of note, catheterization was
complicated by vasovagal episode which responded well to IV
fluids and Atropine. Cardiac surgery was subsequently consulted
and further evaluation was performed. An echocardiogram on [**8-11**] was notable for normal left ventricular cavity size. The
overall left ventricular systolic function was
moderately-to-severely depressed (ejection fraction 30%)
secondary to
severe hypokinesis of the anterior septum, anterior free wall,
and apex. There was only mild(1+) mitral regurgitation. Workup
was otherwise unremarkable and he was cleared for surgery. He
remained pain free on medical therapy.
On [**8-13**], Dr. [**Last Name (STitle) **] performed two vessel coronary artery
bypass grafting. Operative findings were notable for a heavily
calcified aorta. A cross-clamp was not utilized. The heart was
therefore on bypass beating and the Guidant CTS off-pump system
was used to obtain exposure on a beating empty heart. His
operative course was otherwise uneventful and he transferred to
the CSRU for further invasive monitoring. Within 48 hours, he
awoke neurologically intact and was extubated. He maintained
stable hemodynamics as he weaned from inotropic support. The
IABP was removed without complication. He experienced
intermittent fevers with negative workup - blood and urine
cultures remained negative. On postoperative day four, he
transferred to the SDU.
He went on to experience some confusion/agitation which
initially required Haldol. Narcotics were also withheld. His
symptoms progressed to visual hallucinations, diplopia, left
visual field cuts associated with mild left sided weakness and
facial droop. Neurology was urgently consulted and a head
MRI/MRA was obtained on [**8-20**]. Findings were suggestive of a
large subacute right occipital lobe infarct, within posterior
cerebral artery territory. No was no evidence of intracranial
bleed. Aspirin therapy was continued. Over the remainder of his
hospital stay, his neurologic/mental status gradually improved
and nearly returned to baseline. He worked daily and continued
to improve with physical and occupational therapies. At
discharge, his confusion had resolved and he had normal motor
function. Unfortunately, he continued to experience left visual
field cuts. He had no more diplopia.
Given his depressed LV function, he was maintained on an ACEI
and Coreg. He remained in a normal sinus rhythm without atrial
or ventricular dysrhythmias. He was concomitantly diuresed
toward his preoperative weight. He responded well to Lasix and
by discharge, was near his preoperative weight with oxygen
saturations of 98% on room air. His renal function remained
normal. Just prior to discharge, he was treated with a short
course of intravenous antibiotics for a superficial phlebitis.
He was eventually discharged to home on postoperative day 14. He
will be tranisitioned to PO antibiotics and follow up with Dr.
[**Last Name (STitle) **] in approximately 4 weeks.
Medications on Admission:
Metoprolol 50mg twice a day
Lipitor 20mg daily
Lisinopril 10mg daily
HCTZ 12.5mg daily
Digoxin 0.25mg daily
Asa 325mg daily
NTP (unknown dose) daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Southeastern MA
Discharge Diagnosis:
CAD - s/p CABG
Rt occipital CVA(postop)
Cardiomyopathy
s/p MI
HTN
Hyperlipidemia
Phlebitis
Discharge Condition:
Good.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 2 pounds in
one day or five in one week. Call with temperature more than
101.5, redness or drainage from incision.
No driving, no lifting more than 10 pounds until follow up with
surgeon.
Adhere to 2 gm sodium diet
2 quarts Fluid Restriction
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Local PCP 2 weeks
Cardiologist Dr. [**Last Name (STitle) 8098**] in 2 weeks
Completed by:[**2159-9-13**]
|
[
"401.9",
"E849.8",
"599.7",
"997.02",
"424.0",
"428.0",
"E878.2",
"303.91",
"458.29",
"411.1",
"E849.7",
"E879.0",
"425.4",
"453.8",
"414.01",
"305.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.53",
"37.61",
"88.56",
"37.23",
"36.11",
"39.61",
"97.44",
"99.04",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9935, 9985
|
4703, 8273
|
342, 591
|
10119, 10126
|
4318, 4680
|
10482, 10627
|
3835, 3900
|
8472, 9912
|
10006, 10098
|
8299, 8449
|
10150, 10459
|
3915, 4299
|
283, 304
|
619, 3202
|
3224, 3303
|
3319, 3819
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,024
| 118,379
|
42157
|
Discharge summary
|
report
|
Admission Date: [**2103-10-6**] Discharge Date: [**2103-10-8**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Bile duct injury.
Major Surgical or Invasive Procedure:
[**2103-10-7**]: Exploratory laparotomy.
History of Present Illness:
86-y.o. male underwent laparoscopic cholecystectomy for acute
cholecystitis at [**Hospital6 204**] on [**2103-10-1**].
Post-operatively, he had an increase in WBC (peak 18.5 on
[**2103-10-6**] at 06:00) and t-bili (max 2.4 on [**2103-10-6**] at 06:00)
and developed ileus. CT abd/pelvis was performed on [**2103-10-5**],
which demonstrated "ascites." HIDA scan on [**2103-10-6**]
demonstrated a bile leak. Pt was transferred to [**Hospital1 18**] for ERCP.
Past Medical History:
COPD, DMII, GERD, hyperlipidemia, h/o Meniere's disease.
Past Surgical History:
Laparoscopic cholecystectomy [**2103-10-1**].
Social History:
Has been married 65 years. Lives with wife. Completely
independent ADLs. Smokes 1 pack/day. No EtOH. WWII veteran.
Family History:
Father died of tooth infection at age 42. Mother died of unknown
causes at age 68. Sister, age [**Age over 90 **], alive and well.
Physical Exam:
On [**2103-10-6**] at time of surgical consult:
PE: (on fentanyl gtt at 50, midazolam gtt [**Company 91426**] 98.2 P 103 BP 83/40 RR 17 O2sat 93% CMV 0.7/450x24/12
bladder pressure 27
Gen: intubated, sedated, jaundiced
CVS: slightly tachy, reg rhythm
Pulm: CTA b/l, intubated
Abd: very distended, tympanitic, diffusely tender, no BS; OGT in
place - ~150cc feculent fluid in canister, suction not
functioning
Ext: no c/c/e
Pertinent Results:
[**2103-10-6**] 07:24PM WBC-2.3* RBC-4.44* HGB-14.1 HCT-41.7 MCV-94
MCH-31.7 MCHC-33.7 RDW-13.5
[**2103-10-6**] 07:24PM PLT COUNT-438
[**2103-10-6**] 07:24PM GLUCOSE-162* UREA N-61* CREAT-1.1 SODIUM-133
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-20* ANION GAP-18
[**2103-10-6**] 07:24PM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-2.9*
[**2103-10-6**] 07:24PM ALT(SGPT)-39 AST(SGOT)-44* LD(LDH)-297*
CK(CPK)-97 ALK PHOS-148* TOT BILI-2.8*
CT abd/pelvis ([**10-5**], reviewed with radiology resident): [**2-22**]
intraparenchymal R hepatic abscesses (not noted on OSH read),
non-organized fluid collections in LUQ, R abd, pelvis.
ERCP ([**10-6**]): extravasation at cystic duct c/w large bile leak;
filling defect in bile duct c/w sludge; sphincterotomy, sludge
extraction, and biliary stenting performed.
Reviewed cholangiogram images with Dr. [**First Name (STitle) **]: given location
of clips (and abscesses), R hepatic artery was likely taken in
lap chole instead of cystic artery.
Brief Hospital Course:
On [**2103-10-6**], the patient was transferred to [**Hospital1 18**] for ERCP.
Extravasation at cystic duct was noted. Sphincterotomy, sludge
extraction, and biliary stenting were performed.
[**Name (NI) 1917**], pt was unable to be extubated and was
transferred to the [**Hospital Unit Name 153**]. He became hypotensive and is currently
being resuscitated with NS (also hyponatremic). OGT was placed,
150cc feculent material drained. After surgical consultation,
the patient was transferred to the TISCU on the hepatobiliary
surgery service. He rapidly deteriorated - despite 4-5L IVF in
and 4 pressors at max dose, SBP in mid-80s. Increasing vent
requirements. Bladder pressure 14 on arrival, increased to 21.
Increasing lactate (~5), acidosis (pH<7.2, bicarb 15), Cr (1.5).
Duplex US of liver failed to demonstrate R hepatic arterial
flow. TEE performed by TSICU team demonstrated minimal cardiac
function, EF~20%. Case discussed with Dr. [**Last Name (STitle) **] and IR. Pt was
too unstable for operative intervention. IR did not believe his
liver lesions are organized enough to drain at this time.
Supportive management w/ bicarb gtt (BP is responsive to this -
SBP 90s-115), pressors, antibiotics (vancomycin, zosyn,
meropenem). Both TSICU and Hepatobiliary Surgery teams have
discussed critical nature of situation with family.
On [**2103-10-7**], family consented to bedside exploratory
laparotomy, where 3 liters of bilious fluid wer drained from the
peritoneal space. The attempt at abdominal decompression did
not significantly improve ventilation or cardiovascular
function. By [**2103-10-8**], the patient remained in critical
condition with no interval improvement. After discussion with
the family, the patient was rendered CMO and he expired.
Medications on Admission:
Reglan 10', NPH 4U qAM/12U qhs, simvastatin 80', Combivent
2puffs prn, Prilosec 20'
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Bile peritonitis
Cholangitis
Sepsis
Multi-organ system failure
Discharge Condition:
Expired.
Discharge Instructions:
He who has gone, so we but cherish his memory.
Followup Instructions:
None.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2103-10-8**]
|
[
"584.5",
"567.81",
"576.1",
"785.52",
"518.81",
"576.8",
"288.50",
"427.31",
"995.92",
"276.2",
"729.73",
"V70.7",
"238.71",
"998.89",
"272.4",
"E878.8",
"250.00",
"496",
"276.1",
"572.0",
"305.1",
"997.4",
"530.81",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"96.71",
"39.95",
"99.62",
"38.97",
"38.95",
"54.19",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
4646, 4655
|
2702, 4483
|
267, 310
|
4762, 4773
|
1692, 2679
|
4868, 5032
|
1098, 1231
|
4617, 4623
|
4676, 4741
|
4509, 4594
|
4797, 4845
|
902, 949
|
1246, 1673
|
210, 229
|
338, 799
|
821, 879
|
965, 1082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,482
| 148,512
|
3104+55442
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-8-14**] Discharge Date: [**2113-8-22**]
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 yo woman with COPD (on 3L NC at home), CHF, HTN, DM-II who
was brought in from [**Hospital3 537**] for acute SOB and hypoxia. She
was found in respiratory distress and reportedly had an O2 sat
of 52% on 2 liters on the way to the hospital. All of her care
is at [**Hospital1 2177**] so we have no records.
She had been living with her brother up until two weeks ago when
placed her in a nursing home while he had knee surgery. He
states that at the nursing home her room has been hot and that
she has complained that it has made it more difficult for her to
breath.
In the ED she was found to have an axillary temp of 102.5,
tachycardia, a mild leukocytosis, and an acute on chronic
respiratory acidosis. She was treated with BiPAP, morphine,
lasix, levaquin, solu-medrol, albuterol, and atrovent.
Past Medical History:
Primary:
1. AECOPD Exacerbation.
2. LLL Pneumonia.
3. Urinary Tract Infection.
Secondary:
1. 02 Dependent COPD (3L)
2. CHF - EF unknown.
3. Diabetes Mellitis.
Social History:
Lives as [**Hospital3 537**] x 2 weeks.
Family History:
Non-contributory.
Physical Exam:
VS: 102.5, 99.2, 115/43 (80-180/50-80), 96 (79-140), 16-20,
85-88RA on admission up to 96% after Nebs and BiPAP. Now
100%/3L.
Gen: Pt supine with head of bed at 45 degrees, conversant,
somewhat confused, NAD, no apparent dyspnea
HEENT: PERRL, EOMI, NC/AT, dry MM
Neck: Supple
Chest: poor air movement, no crackles
Cor: distant heart sounds, RR, nl s1 s2, no murmur appreciated
Abd: incisional scar, reducible large periumbilical hernia,
decreased BS, soft, NT/ND
Ext: no edema, mae
Pertinent Results:
[**2113-8-13**] 05:28PM LACTATE-1.5
[**2113-8-13**] 05:34PM PT-12.9 PTT-24.5 INR(PT)-1.1
[**2113-8-13**] 05:34PM PLT COUNT-167
[**2113-8-13**] 05:34PM NEUTS-76* BANDS-6* LYMPHS-6* MONOS-9 EOS-2
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2113-8-13**] 05:34PM WBC-11.5*# RBC-4.06* HGB-11.8* HCT-37.0
MCV-91 MCH-29.1 MCHC-31.9 RDW-13.1
[**2113-8-13**] 05:34PM ALBUMIN-4.4 CALCIUM-9.2 PHOSPHATE-3.9
MAGNESIUM-2.0
[**2113-8-13**] 05:34PM CK-MB-NotDone cTropnT-<0.01
[**2113-8-13**] 05:34PM LIPASE-35
[**2113-8-13**] 05:34PM ALT(SGPT)-19 AST(SGOT)-36 LD(LDH)-357*
CK(CPK)-54 ALK PHOS-91 AMYLASE-45 TOT BILI-0.3
[**2113-8-13**] 05:34PM GLUCOSE-245* UREA N-20 CREAT-0.8 SODIUM-144
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-34* ANION GAP-15
[**2113-8-13**] 06:00PM URINE RBC-0-2 WBC-[**3-3**] BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2113-8-13**] 06:00PM URINE BLOOD-SM NITRITE-POS PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-8-13**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2113-8-13**] 06:02PM TYPE-ART TEMP-37.2 RATES-/22 TIDAL VOL-450
PO2-87 PCO2-88* PH-7.27* TOTAL CO2-42* BASE XS-9 -ASSIST/CON
INTUBATED-NOT INTUBA
CXRAY: No CHF. Atelectasis vs. early pneumonia in the left lower
lobe.
EKG: Sinus tachycardia.
BCx NGTD x 3 days.
UCx neg
Brief Hospital Course:
86 yo woman with COPD and 3L O2 requirement, transferred from
nursing home with desaturation to 52%/2L associated with
confusion.
1. Respiratory distress - LLL pneumonia and COPD exacerbation.
Pt's saturation responded to BIPAP, solumedrol, nebs to 100% on
3LNC in ED, her baseline. Respiratory acidosis improved. Pt
started on Levo 250mg qd (renally dosed) for LLL pneumonia for
10 days total. Prednisone 60mg qd x 2 weeks total, careful to
tightly control blood sugars. Albuterol/atrovent nebs scheduled
with albuterol inh for rescue breathing. Pt is a mouth
breather, so nasal canula was switched to face mask with good O2
sats (>95%).
2. UTI - by U/A, though UCx after Abx neg. Covered with Levo.
3. h/o CHF - No old records. No signs of active CHF now. No
EKG evidence of old ischemia; CK and trop negative x 1. Dig
level 0.6, which is okay.
4. Delerium - likely due to UTI and hypercarbia. Improved after
BIPAP.
5. Code - DNR/DNI, Son [**Doctor First Name **] [**Telephone/Fax (1) 14733**], (w) [**Telephone/Fax (1) 14734**]
6. PPX - H2-blocker, Vit D, Calcium, while on steroids. Heparin
SQ.
7. Dispo - Per PCP, [**First Name8 (NamePattern2) 14735**] [**Last Name (NamePattern1) **] ([**Hospital1 14736**],
[**Telephone/Fax (1) 7799**] #6104) who said that Ms. [**Known lastname 14737**] is a home care
patient and does not have any baseline ABGs, PFTs, or ECHOs. Pt
d/c'd back to [**Hospital3 537**] nursing home.
DNR/DNI
Medications on Admission:
1. Insulin SC (per Insulin Flowsheet)Sliding Scale
2. Acetaminophen 650 mg PO Q4-6H:PRN fever, pain
3. Ipratropium Bromide Neb 1 NEB IH Q6H
4. Albuterol Neb Soln 1 NEB IH Q4H
5. Lactulose 30 ml PO QD:PRN constipation
6. Albuterol [**12-30**] PUFF IH Q4-6H:PRN SOB/wheezing
Please keep at bedside for rescue breathing
7. Levofloxacin 250 mg IV Q24H
8. Aspirin 81 mg PO QD
9. Bisacodyl 10 mg PO/PR QD
10. Prednisone 60 mg PO QD
11. Ranitidine 150 mg PO QD
12. Calcium Carbonate 500 mg PO TID W/MEALS
13. Senna 1 TAB PO BID
14. Docusate Sodium 100 mg PO BID
15. Vitamin D 400 UNIT PO QD
16. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*30 * Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*30 * Refills:*0*
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QD (once a
day) as needed for constipation.
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for SOB/wheezing.
Disp:*1 * Refills:*0*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*0*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*0*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
16. Glyburide 1.25 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
17. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks: Don't give with Tums.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. AECOPD Exacerbation.
2. LLL Pneumonia.
3. Urinary Tract Infection.
Secondary:
1. 02 Dependent COPD (3L)
2. CHF - EF unknown.
3. Diabetes Mellitis.
Discharge Condition:
Pt was in good to fair condition but stable.
Discharge Instructions:
Please return to hospital or call your doctor if you experience
shortness of breath, chest pain, pain or burning with urination,
arm or jaw pain, sweating, palpitations.
Continue taking prednisone as prescribed for a total of 2 weeks.
Concurrently, take calcium, vitamin D, and ranitidine as
prescribed.
Followup Instructions:
Follow up with your primary care doctor in 1 month (Dr. [**First Name8 (NamePattern2) 14735**]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10238**]).
Name: [**Known lastname 2336**],[**Known firstname 2337**] Unit No: [**Numeric Identifier 2338**]
Admission Date: [**2113-8-14**] Discharge Date: [**2113-8-22**]
Date of Birth: [**2026-11-29**] Sex: F
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2339**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
Brief Hospital Course:
1. Respiratory distress - LLL pneumonia and COPD exacerbation.
Pt's saturation responded to BIPAP, solumedrol, nebs to 100% on
3LNC in ED, her baseline. Respiratory acidosis improved. Pt
started on Levo 250mg qd (renally dosed) for LLL pneumonia for
14 days total with Prednisone 60mg qd x 2 weeks total, careful
to
tightly control blood sugars. Then she became increasingly
agitated which was likely secondary to CO2 narcosis. She was
started on BiPAP for increasing respiratory distress and
agitation and she improved on BiPAP however as she became
increasingly agitated she would not keep the BiPAP on. The next
day her resp status remained stable with intermitent distress
requiring BiPAP and then she was noted to go into rapid afib
which was controlled with diltiazem and then she was transferred
to the MICU for further monitoring. Her respiratory distress
was stable in the unit, but as she could not tolerate BiPAP this
was held and her resp status improved with IV steroids and
adding ceftriaxone as she now had a new RML pneumonia. Her
respiratory status remained stable and she was transferred back
to the floor where she has remained stable on 2-3LNC which is
her home requirement. She will continue to complete a 2week
course of levofloxacin and prednisone. She will continue on
nebulizers with scheduled long acting beta agonist and steroids.
2. Atrial fibrillation- she had an acute episode of rapid afib
during her respiratory distress that improved with diltiazem and
rate control and she had an echo which was otherwwise normal.
She was continued to po diltiazem with good relief and converted
to sinus rhythm spontaneously and was not started on
anticoagulation. She will continue on the diltiazem daily.
3. Urinary tract infection- patient came in with a UTI by her
urinalysis but she remained covered for UTI with her antibitoics
for her pneumonia.
3. Delerium- on admission came in very confused and was most
likely secondary to acute infection and CO2 retention from her
COPD- as her infection was treated and her COPD was managed with
BiPAP, steroids, nebulizers and supplemental O2.
4. Diabetes - her diabetes remained stable while here even with
steroids. She was continued on her home oral regimen with
supplemental sliding scale becuse of her steroids.
5. Hypernatremia- she had slight;y elevated sodiums which
remained stable with encouraged hydration.
DNR/DNI: confirmed by pt's PCP during this admission.
Medications on Admission:
as previous summary
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*30 * Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*30 * Refills:*0*
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QD (once a
day) as needed for constipation.
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for SOB/wheezing.
Disp:*1 * Refills:*0*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*0*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*0*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
16. Glyburide 1.25 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
17. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Don't give with Tums.
Disp:*5 Tablet(s)* Refills:*0*
18. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for SBP < 100, or HR < 55.
Disp:*120 Tablet(s)* Refills:*0*
19. Advair Diskus 100-50 mcg/DOSE Disk with Device Sig: One (1)
Inhalation every six (6) hours.
Disp:*1 diskus* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 42**]
Discharge Diagnosis:
Primary:
1. COPD Exacerbation.
2. LLL Pneumonia.
3. Urinary Tract Infection.
Secondary:
1. 02 Dependent COPD (3L)
2. CHF - EF unknown.
3. Diabetes Mellitis.
Discharge Condition:
Pt was in good to fair condition but stable.
Discharge Instructions:
Please return to hospital or call your doctor if you experience
shortness of breath, chest pain, pain or burning with urination,
arm or jaw pain, sweating, palpitations.
Continue taking prednisone as prescribed for a total of 2 weeks.
Concurrently, take calcium, vitamin D, and ranitidine as
prescribed.
Continue taking Levofloxacin for a total of 2 weeks.
Followup Instructions:
Follow up with your primary care doctor in 1 month (Dr. [**First Name8 (NamePattern2) 2340**]
[**Last Name (NamePattern1) 2341**] [**Telephone/Fax (1) 2342**]).
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**] MD [**MD Number(1) 628**]
Completed by:[**2113-8-22**]
|
[
"276.2",
"427.31",
"276.0",
"401.9",
"780.09",
"486",
"250.00",
"491.21",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13180, 13252
|
8486, 10943
|
8456, 8463
|
13453, 13499
|
1853, 3178
|
13907, 14228
|
1315, 1334
|
11013, 13157
|
13273, 13432
|
10969, 10990
|
13523, 13884
|
1349, 1834
|
8409, 8418
|
254, 1059
|
1081, 1242
|
1258, 1299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,349
| 102,891
|
6972
|
Discharge summary
|
report
|
Admission Date: [**2101-4-30**] Discharge Date: [**2101-5-2**]
Date of Birth: [**2026-1-3**] Sex: M
Service: MEDICINE
Allergies:
Amantadine Hcl / Zocor
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
OSH transfer for sepsis
Major Surgical or Invasive Procedure:
brochoscopy
History of Present Illness:
75 y/o M with hx type 2 DM c/b ESRD and failed renal tx started
on HD 3 months ago, CAD s/p CABG, PVD, afib on coumadin who is
transferred from OSH for sepsis.
.
He had been in USOH until [**4-27**] when after HD he began to
experience fatigue, malaise, weakness and shaking chills. At OSH
ED, he received CTX 1 gm IV X1, azithromycin 500 mg IV X1, Vanc
1 gm X1, lantus 12 U X 1. No other medications were given
including home meds. Blood Cx drawn X 2 (one from HD line). CXR
c/w mild volume overload or possible pneumonia. He underwent HD
and was noted to be more lethargic. He was subsequently
transferred to ICU at OSH for declining mental status and T 104.
His HD line was removed at OSH. Per family request, he was
transferred to [**Hospital1 18**].
Currently, he reports feeling much better. He denies any
pain,N/V/diarrhea/URI/hematuria/dysuria. He does endorse mild
non productive cough. He denies any CP, palpitations, SOB, DOE.
At baseline at home he walks 1 mile/day.
Past Medical History:
# Diabetes: insulin dependent c/b ESRD, neuropathy
-- rarely has low glucose readings at home, but recently had low
readings in hospital
# Hypothyroidism
# ESRD s/p failed cadaveric renal transplant in [**2089**] now on HD
(M/W/F)
# left AV graft placement in the past
# toe ulcers s/p toe amputation
# CHF: EF 35%, presumed ischemic
# biventricular ICD pacemaker
# s/p myocardial infarction with CABG [**2090**]
# chronic atrial fibrillation on Coumadin
# hypertension
# dyslipidemia
# PVD with revascularization procedures including stents in his
SMA for intestinal ischemia last year.
# s/p appy for acute appendicitis [**2099**]
Social History:
Lives with his wife and spends [**11-20**] time in [**State 108**]
Smoking: remote 20 pack year hx, but quit 40 years ago
EtOH: social
Illicits: none
Family History:
The patient notes a brother with coronary artery disease as well
as a coronary artery bypass graft. The patient also notes a
mother with coronary artery disease. Father died at age 70 of
colon cancer.
Physical Exam:
Vitals: T: 101 BP: 130/51 P:61 R: 18 O2:99% 2LNC
General: Alert, oriented X3, lethargic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse crackles at bases R>L
CV: paced, 1/6 SEM, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
[**2101-4-30**] 5:06 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL FLUID.
GRAM STAIN (Final [**2101-4-30**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2101-5-2**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2101-5-2**]):
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
[**2101-5-1**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2101-5-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
Blood culture [**4-30**], [**5-1**] NGTD at discharge
Urine [**5-1**] negative
RSV culture [**4-30**] pending, CMV VL pending
[**2101-4-30**] 03:31AM BLOOD WBC-8.8# RBC-4.07* Hgb-12.6* Hct-37.6*
MCV-92 MCH-31.0 MCHC-33.6 RDW-16.7* Plt Ct-108*
[**2101-5-2**] 05:20AM BLOOD WBC-5.0 RBC-3.97* Hgb-11.8* Hct-36.7*
MCV-92 MCH-29.6 MCHC-32.1 RDW-16.4* Plt Ct-124*
[**2101-4-30**] 03:31AM BLOOD Neuts-79.8* Lymphs-13.7* Monos-5.5
Eos-0.6 Baso-0.3
[**2101-4-30**] 03:31AM BLOOD PT-18.7* PTT-31.6 INR(PT)-1.7*
[**2101-5-2**] 05:20AM BLOOD PT-16.3* PTT-30.2 INR(PT)-1.4*
[**2101-4-30**] 03:31AM BLOOD Glucose-71 UreaN-46* Creat-2.8* Na-137
K-3.6 Cl-100 HCO3-28 AnGap-13
[**2101-5-2**] 05:20AM BLOOD Glucose-130* UreaN-96* Creat-4.1* Na-134
K-3.9 Cl-96 HCO3-22 AnGap-20
[**2101-4-30**] 03:31AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.7
[**2101-5-2**] 05:20AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.1
[**2101-5-2**] 11:15AM BLOOD Vanco-10.1
[**2101-4-30**] 07:50PM BLOOD B-GLUCAN-PND
[**2101-4-30**] 07:50PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2101-5-1**] 06:45AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2101-5-1**] 06:45AM URINE Blood-TR Nitrite-NEG Protein-500
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2101-5-1**] 06:45AM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-0
[**2101-4-30**] 05:06PM OTHER BODY FLUID Polys-60* Lymphs-6* Monos-4*
Macro-30*
CXR [**5-1**]
The lungs are hyperinflated and diaphragms are flattened,
consistent with
COPD. There is borderline cardiomegaly with left ventricular
configuration.
The patient is status post sternotomy, with mediastinal clips.
The two lower sternotomy wires may be fractured, but are
unchanged compared with [**2096-10-18**]. The aorta is calcified and
slightly unfolded. ICD device with 3 leads is unchanged.
Lucencies are seen crossing several of the wires associated with
the leads, but this is also unchanged compared with [**2096-10-18**].
There is patchy opacity in the right suprahilar and perihilar
region and to a lesser extent in the right cardiophrenic region
and possible minimal
atelectasis at the left base. There is minimal blunting of right
and ? left
costophrenic angles, consistent with a small amount of pleural
fluid and/or
thickening.
IMPRESSION:
Compared with one day earlier and allowing for technical
differences, patchy perihilar opacity is probably unchanged.
OSH cultures ([**Hospital **] hospital)
HD line tip [**4-29**] coag neg staph (grew [**5-2**]), [**Last Name (un) 36**] to gent, vanc,
tetra, rifampin only
blood cultures 6/11 NGTD
Brief Hospital Course:
75 y/o M with CAD s/p CABG, CHF (EF 20%) with ICD, severe PVD,
DM c/b ESRD s/p failed transplant now on HD presents with
pneumonia.
.
# Fever: Etiology is most likely line infection vs pneumonia.
CXR consistent with pneumonia. Urine legonella and strep pneumo
negative at the OSH. Covered empirically with Vancomycin,
Ceftriaxone, and azithromycin but was broadened to vanco,
cefepime, and cipro for HCAP coverage given that he is at
dialysis centers. Beta glucan and galactomannan were sent.
Brochoscopy was performed for BAL on HD#2, and samples were
negative at time of discharge. Patient remained afebrile in the
ICU and was transferred to the floor on HD #2. His HD line tip
from the OSH grew Coag neg staph (see sensitivities on previous
page). His fevers were therefore thought most likely to be due
to a line infection (without bacteremia as blood cultures were
still negative) and pneumonia. He was switched to Vancomycin
and Levofloxacin only at time of discharge to complete a 10-day
course. Patient remained afebrile on the floor.
.
# ESRD s/p failed tx: Renal was following along. Patient was
continued on cellcept and steroids, as well as bactrim
prophylaxis. After blood cultures were negative for 48 hours, a
tunneled line was placed by IR on the right side on [**5-2**] given
plans for eventually AV fistula on the left.
.
# HTN: BP medications held while in the ICU. These were
restarted on the floor.
.
# DM: lantus 12 units QAM and humulog SS AC only
.
# afib on coumadin: Coumadin held while awaiting new HD line. It
was restarted at discharge.
.
# PVD: On fenofibrate, hx statin intolerance
.
# CAD/?ischemic cardiomyopathy: EF 35%; currently appears
euvolemic. Torsemide restarted prior to discharge.
.
# Hypothyroid - Continued LT4 75 mcg daily
.
# Bone health: on chronic immunosuppression and known
osteopenia. He has fallen a few times his past year, but no
fractures. Continued Calcium.
.
# Code: full, discussed with family and patient in ICU
Medications on Admission:
Medications on Transfer:
CTX 1 gm X 1
Azithro 500 X 1
Vanc 250 X 1
Per report: Zosyn and bactrim (not in papers from OSH)
Lantus 12 QAM
.
Home Medications:
Synthroid 75 mcg daily
Torsemide 40 mg daily
Lantus 12 units QAM + humalog SS
Calcium carbonate 600 mg [**Hospital1 **]
Coumadin 2.5 mg daily
Carvedilol 25 mg [**Hospital1 **]
Amlodipine 10 mg daily
ASA 325
fenofibrate 48 mg daily
Bactrim DS M/W/F
Cellcept [**Pager number **] mg [**Hospital1 **]
Prednisone 5 mg daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Insulin
Lantus 20units in the morning
Resume home humalog sliding scale
4. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO twice a day.
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: take as directed by your coumadin clinic.
6. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
10. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO Q M/W/F ().
11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous HD PROTOCOL (HD Protochol): continue through [**5-10**].
14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO ONCE for 1
doses: take on [**5-3**].
Disp:*1 Tablet(s)* Refills:*0*
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H for 3
doses: start on [**5-5**].
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-pneumonia
-line infection
Secondary
-ESRD on HD
-T2DM
-CAD
-atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of fever and concern of infection while you were at
dialysis. You were found to have a pneumonia and an infection
of your dialysis catheter.
Your dialysis catheter was removed at [**Hospital6 33**] and
you were started on antibiotics. You had a new dialysis
catheter placed at [**Hospital1 69**] on [**5-2**].
While you were here, some of your medications were changed.
You should continue antibiotics through [**5-10**]:
Vancomycin (to be given at dialysis)
Levaquin orally
Continue all other medications as prescribed by your doctors.
Be sure to follow-up with your doctors at the [**Name5 (PTitle) 648**] below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2101-5-6**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAT-PREADMISSION TESTING
When: TUESDAY [**2101-5-10**] at 8:30 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2101-8-16**] at 9:20 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
|
[
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"996.81",
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"V58.67",
"E878.0",
"V45.11",
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"V45.02",
"038.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
10443, 10449
|
6635, 8612
|
306, 319
|
10584, 10584
|
2831, 3694
|
11550, 12512
|
2170, 2373
|
9138, 10420
|
10470, 10563
|
8638, 8638
|
10767, 11527
|
2389, 2812
|
8794, 9115
|
3997, 6612
|
3727, 3960
|
243, 268
|
347, 1329
|
10599, 10743
|
8663, 8776
|
1351, 1986
|
2002, 2154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,394
| 107,229
|
11219
|
Discharge summary
|
report
|
Admission Date: [**2105-3-24**] Discharge Date: [**2105-3-27**]
Date of Birth: [**2057-2-17**] Sex: F
Service: [**Last Name (un) **]
TIME OF DEATH: [**2105-3-27**] at 1856.
HISTORY OF PRESENT ILLNESS: Patient is a 48 year-old female
who flu-like symptoms for 1 weeks, 4 to 5 days of right upper
quadrant pain, nausea, vomiting, dark diarrhea, decreased
p.o. intake and was reported by family to be jaundiced. She
had been taking approximately Tylenol #3 Extra Strength and
noted that her urine had been dark. She denies any alcohol or
exposure to rural mushrooms in the last year.
PAST MEDICAL HISTORY: Asthma, heartburn. She denies stroke
or myocardial infarction.
PAST SURGICAL HISTORY: Only tubal ligation.
ALLERGIES: She has no known allergies.
FAMILY HISTORY: Diabetes, hypertension.
PHYSICAL EXAMINATION: At presentation she was afebrile.
Heart was 74, 90/58, 16, 98%. She was jaundiced, alert and
oriented. Scleral icterus. Her lungs were clear. She had
hepatomegaly. The right upper quadrant was tender. Rectal:
Guaiac negative.
A 48 year-old female who had acute hepatitis. Etiology of the
hepatitis was unclear. Supposedly related to Tylenol. She had
an acetaminophen level of 17 at time of presentation. AST was
8,124, ALT was 6,780, alkaline phosphatase was 209 and total
bilirubin was 17.8.
Patient was admitted to the medical service and followed
approximately for 1-1/2 days, given Mucomyst and as her care
progressed and her INR decided to drift up and her liver
function continued to deteriorate patient was taken over by
the transplant surgery service. At this point in time factor
7 was given on multiple occasions. Fresh frozen plasma drip
was started and patient was intubated for airway protection
as she was developing encephalopathy. Additional to that a
neurosurgical consultation was obtained and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36066**] drain
was placed for ICP monitoring. The ICP initially at
presentation was in the 30s. It was elevated shortly after a
CT scan was found to be normal immediately after placement of
ICP monitoring device. Approximately 6 hours later
neurosurgical attending was again at the bedside evaluating
the drain for elevated ICP in the 48 to 51 range. Pupils were
reactive at that point in time and an attempt was made to
decrease the ICP with blowing off the CO2. The ventilator was
increased for a period of time. She is blowing off the CO2 to
change the ICP. The ICP did not change in response to these
maneuvers. Additional to that her sodium was already 154 and
the decision was undertaken not to give Mannitol at the time.
The patient had equally reactive pupils. She was then taken
to the CT scanner and evaluated again with serial CT scan
imaging of the head and was found to have some measure of
cerebral edema. The patient progressed throughout the course
of the day, worsening, hepatic dysfunction and additional
vasculopathy or cerebral edema progressed. Eventually
discussion was undertaken with family about CMO status. CMO
status was agreed upon by family and patient actually had an
asystolic event shortly thereafter. A family meeting was
undertaken and family agreed to autopsy.
FINAL DIAGNOSES: Hepatic encephalopathy.
Acute hepatic failure.
Coagulopathy.
Brain death.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2105-3-27**] 20:32:25
T: [**2105-3-27**] 21:49:45
Job#: [**Job Number 36067**]
|
[
"E935.4",
"493.90",
"572.2",
"276.7",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"96.04",
"01.18",
"99.04",
"99.06",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
797, 822
|
717, 780
|
3233, 3575
|
845, 3215
|
225, 606
|
629, 693
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,223
| 136,222
|
47551
|
Discharge summary
|
report
|
Admission Date: [**2126-12-16**] Discharge Date: [**2126-12-19**]
Date of Birth: [**2045-11-3**] Sex: M
Service: MEDICINE
Allergies:
Accupril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Hypotension, Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an 81 year-old male with a history of severe dCHF,
CAD
s/p cath [**2121**] (prox LAD), restictive cardiomyopathy, myocardial
biopsy + for amyloid, a-fib on coumadin, HTN, HL,
hypothyroidism, recently discharged s/p large-volume
pericardiocentesis presenting from home with hypotnesion. VNA
checked patient's INR earlier in the week, came back at 5.0,
measured a blood pressure at 60/p, called EMS. After 250 cc
bolus given by EMS, BP increased to 80/palp. On arrival to the
ED, vitals were T 98.1 HR 130s in AFib BP 73/44. After 2 x 500
cc NS bolus, BP increased to SBP 80. Patient was asymptomatic,
reporting no chest pain, dizziness, SOB, palpitations. CXR
showed cardiomegaly, but decreased size compared to last week.
Echo was done at the bedside, and showed a pericardial effusion,
unlcear about the size compared to last week, no tamponade
physiology. Triple Lumen catheter was placed, and patient was
started on levofed. At time of transfer, HR 132 BP 55/27 RR 25
97% 2L. Foley was put in, patient had put out 275 cc by time of
transfer.
.
On review of systems, he does endorse increasing weakness and
poor PO intake the last several days. He also reports early
satiety. 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. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- [**2121**]: 95% lesion in the proximal LAD, which was stented with a
Cypher stent
.
3. OTHER PAST MEDICAL HISTORY:
- Chronic permanent atrial fibrillation
- Amyloid/restrictive CM
- Severe diastolic dysfunction of the left ventricle (EF 50-55%)
- Restrictive cardiomyopathy of the left ventricle
- Moderate to large pericardial effusion
- Right ventricular contractile dysfunction
- Severe tricuspid regurgitation
- Severe pulmonary hypertension.
- HTN
- Hypercholesterolemia
- Hyperthyroidism
- BPH
- OA s/p total knee replacement
- OSA on BiPAP at home
Social History:
Lives alone at home, completely independent in ADLs. Has a
live-in house keeper. Smoked 1ppd x 20yrs, quit 20 yrs ago. [**12-1**]
glasses of wine per night previosuly, but now drinks milk
instead.
Family History:
Mother died of heart disease at young age. Brother has [**Name2 (NI) 499**] ca
and CAD. Son recently died of [**Name2 (NI) 499**] ca in his 50's.
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: CTAB in anterior fields.
ABDOMEN: Mildly distended. Soft, NT. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema to mid-shin b/l. 1+ pedal pulses
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
.
[**2126-12-16**] 05:15PM BLOOD WBC-11.4* RBC-3.73* Hgb-10.9* Hct-33.4*
MCV-90 MCH-29.2 MCHC-32.6 RDW-16.0* Plt Ct-276
[**2126-12-16**] 05:15PM BLOOD PT-45.2* PTT-37.0* INR(PT)-4.8*
[**2126-12-16**] 05:15PM BLOOD Glucose-105* UreaN-90* Creat-3.5*#
Na-131* K-5.4* Cl-99 HCO3-19* AnGap-18
[**2126-12-16**] 05:15PM BLOOD CK-MB-9 cTropnT-0.29*
[**2126-12-16**] 05:15PM BLOOD CK(CPK)-338*
[**2126-12-17**] 03:33AM BLOOD Calcium-9.2 Phos-7.4*# Mg-2.5
[**2126-12-16**] 05:28PM BLOOD Glucose-99 Lactate-1.5 K-5.4*
.
DISCHARGE LABS:
[**2126-12-18**] 02:12AM BLOOD WBC-8.9 RBC-3.36* Hgb-10.0* Hct-30.3*
MCV-90 MCH-29.6 MCHC-32.9 RDW-15.7* Plt Ct-236
[**2126-12-18**] 02:12AM BLOOD PT-21.8* PTT-31.1 INR(PT)-2.0*
[**2126-12-18**] 02:12AM BLOOD Glucose-136* UreaN-77* Creat-2.6* Na-138
K-4.7 Cl-108 HCO3-19* AnGap-16
[**2126-12-17**] 03:33AM BLOOD CK(CPK)-296
[**2126-12-17**] 03:33AM BLOOD CK-MB-8 cTropnT-0.27*
[**2126-12-18**] 02:12AM BLOOD Calcium-7.9* Phos-5.5*# Mg-2.2
[**2126-12-17**] 03:39AM BLOOD Lactate-1.3
.
ECHO [**12-17**]:
The left atrium is moderately dilated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. with depressed free
wall contractility. The aortic root is mildly dilated at the
sinus level. The ascending aorta is 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. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. The pulmonic valve leaflets are thickened.
There is a loculated pericardial effusion, measuring 2.0 cm,
behind the lateral wall of the LV with the patient in left
lateral decubitus position. There is no free-flowing pericardial
fluid elsewhere.
IMPRESSION: Loculated pericardial effusion as described above.
Biventricular wall thickening, c/w known diagnosis of cardiac
amyloidosis. Mild right ventricular systolic dysfunction. Mild
aortic and mitral regurgitation.
Compared with the prior study (images reviewed) of [**2126-12-9**],
the findings are similar.
Brief Hospital Course:
81 year-old male with a history of severe dCHF, CAD s/p cath
[**2121**] (prox LAD), restictive cardiomyopathy, myocardial biopsy +
for amyloid, a-fib on coumadin, HTN, HL, hypothyroidism,
recently discharged s/p large-volume pericardiocentesis
presenting from home with hypotension, dehydration.
.
#. Palliative Care: After conversation with patient and
patient's family, patient decided that he would like to go home
with hospice care and would like comfort measures only. His
medication regimen was revised as outlined below. Palliative
care was consulted and home hospice was set up for the patient
upon discharge.
.
#. Hypotension: Patient hypotensive at baseline, with SBPs
usually in the 80s. Etiology of worsening hypotension was
thought to be secondary to dehydration and overdiuresis in the
setting of no PO intake for several days. Echo showed no
increase in size of pericardial effusion and patient had no
signs of tamponade. Torsemide was held and patient was given
IVFs. Levophed was weaned off and patient's MAPs remained in
the 50s, at his baseline, for the remainder of the admission.
.
# CHF: Restrictive CM with myocardial biopsy positive for
amyloid, taken last week. Echo showed an extremely small LV
cavity. Torsemide was held throughout admission as patient was
hypovolemic. He was discharged with the plan to weigh himself
every day and to take torsemide iof his weight goes up by 3 lbs
in one day. He has scheduled follow-up with Dr. [**First Name (STitle) 437**].
.
# C. Diff Colitis: Patient began to have profuse diarrhea and C.
diff toxin came back positive. He was discharged on PO
Vancomycin and bismuth/probiotic for symptom control.
.
#. Gout flare: Patient given a prednisone taper for gout flare
on right foot with improvement in symptoms.
.
# CAD: Aspirin and statin was discontinued as patient made CMO
as above.
.
#. RHYTHM: Patient has chronic atrial fibrillation. Patient
discharged on metoprolol 100 XL. Coumadin was discontinued as
patient made CMO as above.
.
# HLD: Statin discontinued as patient made CMO as above.
.
#. OSA: Remained on CPAP. Patient will go home with CPAP.
Medications on Admission:
1. aspirin 325 mg PO DAILY (Daily)
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. budesonide-formoterol 160-4.5 mcg/Actuation HFA Aerosol
Inhaler Sig: One (1) puff Inhalation twice a day.
4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
6. nitroglycerin Sublingual
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO at bedtime as needed for pain.
8. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. warfarin 5 mg Tablet Sig: One (1) Tablet PO weekdays.
11. warfarin 1 mg Tablet Sig: 4.5 Tablets PO once a day: Sat and
Sun only.
12. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
14. Multi-Day Tablet Sig: One (1) Tablet PO once a day.
15. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
16. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Discharge Medications:
1. budesonide-formoterol 160-4.5 mcg/Actuation HFA Aerosol
Inhaler Sig: One (1) puff Inhalation twice a day.
2. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO once a day.
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for weight gain: Please only take prn for weight inc more
than 3 pounds in 1 day or 5 pounds in 3 days.
6. lactobacillus acidophilus Capsule Sig: One (1) Capsule PO
twice a day.
Disp:*60 Capsule(s)* Refills:*2*
7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO four times
a day for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
8. Bismuth Maximum Strength 525 mg/15 mL Suspension Sig: Fifteen
(15) ml PO four times a day as needed for diarrhea: Please take
2 hours before or after vancomycin.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Amyloid Cardiomyopathy
Acute Kidney Injury
Chronic Diastolic congestive Heart Failure
Atrial fibrillation
Pericardial Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with very low blood pressure. This is from
your amyloid heart disease and likely will not get better. You
will have hospice services at home that will help you be
comfortable and stay at home. You requested that the foley
catheter be kept in for now, you can have the visiting nurse
remove that at any time if you want. You were diagnosed with a
bowel infection called c difficile. You will be on antibiotics
for a total of 2 weeks to treat this infection. The diarrhea
should slowly resolve. It is recommended that you eat a diet
with white rice, white toast, bananas and applesauce. Please
avoid any milk products.
We made the following changes to your medicines:
1. Please stop taking aspirin, atorvastatin, vitamin d,
nitroglycerin, oxycodone, tamsulosin, warfarin, iron,
multivitamin and potassium.
2. Start taking prednisone for 3 days to treat your gout
3. Start taking vancomycin pills to treat the infection in your
bowel.
4. Start taking acidophillus as needed to help with the diarrhea
5. Start taking pepto bismol as needed to help with the diarrhea
Weigh yourself every morning, call Dr [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP
if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2126-12-30**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2127-1-1**] at 8:20 AM
With: DR. [**First Name (STitle) **]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2126-12-24**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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10376, 10434
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301, 308
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,600
| 149,682
|
963
|
Discharge summary
|
report
|
Admission Date: [**2197-5-25**] Discharge Date: [**2197-5-30**]
Date of Birth: [**2135-5-14**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
61 year old female with h/o SCLC dx'ed '[**88**] s/p XRT, chemo, stem
cell rescue, and prophylactic TBI recently admitted for
respiratory failure with recurrent nonmalignant R pleural eff.
and pseudomonas pna. s/p intubation, trach/PEG, now returns from
rehab with respiratory distress per the physician caring for
her. The patient had been weaned to trach collar before d/c to
rehab. At rehab, she was placed on IMV and then switched to AC
on account of respiratory distress. She had no increase in
secretion, cough, or fever. She was noted to have PIPs in the
50s, RR 20-30, and diaphoresis. At rehab, she had been diuresed
heavily, started on diltiazem, digoxin, andlopressor for rate
control of sinus tachycardia, prednisone for possible COPD
exacerbation. She presented with a bicarbonate of 50 upon
return to the [**Hospital1 18**] MICU.
Past Medical History:
1. SCLC dx'ed '[**88**] s/p XRT, chemo, stem cell rescue, and
prophylactic TBI
2. COPD
3. hypothyroidism
4. atypical pna's
5. recurrent R pleural eff s/p multiple taps (cytology negative)
6. cognictive impairment since TBI
7. recurrent R pneumonia secondary to pseudomonas
8. sinus tachycardia
9. met alkalosis
Social History:
Daughter [**Name (NI) **] is HCP. Former [**Name2 (NI) 1818**] 70 pack-yrs. Quit '[**88**].
No EtOH or drugs.
Family History:
mother- DM, father- HTN.
Physical Exam:
Afebrile 108/60 91 13 99%
Vent: AC 500 x 8 5 .4/ 400-500 13
GEN: well-appearing NAD, trach'ed
HEENT: MMM PERRL EOMI
NECK: No LAD, trach C/D/I
CARD: RRR NL S1S2 no MRG
PULM: decreased BS at R base, coarse BS, no wheezes
ABD: soft NT ND (+) BS
XTRMT: R > L LE edema
NEURO: alert, cooperative, responsive
Pertinent Results:
[**2197-5-25**] 10:39PM TYPE-ART PO2-127* PCO2-72* PH-7.46* TOTAL
CO2-53* BASE XS-23
[**2197-5-25**] 10:39PM O2 SAT-98
[**2197-5-25**] 10:34PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-84*
LYMPHS-1* MONOS-12* MACROPHAG-3*
[**2197-5-25**] 05:55PM GLUCOSE-138* UREA N-16 CREAT-0.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-86* TOTAL CO2-50* ANION GAP-7*
[**2197-5-25**] 05:55PM CK(CPK)-14*
[**2197-5-25**] 05:55PM CK-MB-3 cTropnT-<0.01
[**2197-5-25**] 05:55PM ALBUMIN-3.1* CALCIUM-8.8 PHOSPHATE-2.0*
MAGNESIUM-2.0
[**2197-5-25**] 05:55PM DIGOXIN-0.4*
[**2197-5-25**] 05:55PM WBC-6.0 RBC-3.55*# HGB-10.4*# HCT-33.5*#
MCV-94 MCH-29.3 MCHC-31.0 RDW-15.6*
[**2197-5-25**] 05:55PM NEUTS-90.5* LYMPHS-4.7* MONOS-4.7 EOS-0
BASOS-0
[**2197-5-25**] 05:55PM HYPOCHROM-3+ MACROCYT-1+
[**2197-5-25**] 05:55PM PLT COUNT-160
[**2197-5-25**] 05:55PM PT-12.5 PTT-27.5 INR(PT)-1.0
Brief Hospital Course:
1. RESP INSUFF: The patient was admitted to the MICU for
report of respiratory distress at rehab. The ddx included
pnuemonia, mucous plug, increasing effusion, bronchospasm from
BBlocker, and severe contraction alkalosis leading to increased
CO2 in a patient with limited pulmonary reserve. Chest X ray
on admissions showed persistent R pleural effusion and no change
from her discharge film. The patient underwent bronchospopy
upon admission and was found to have a large obstructing mucous
plug in the right mainstem along with copious secretions. BAL
was sent. Her antibiotics from her previous admission were
continued. He respiratory status improved and she required less
ventilatory support.
2. TACHYCARDIA: likely driven by her medical illness and
possibly contributed by residual thyroid abnormalities. LVEF
was depressed to 30- 40% on most recent echo likely secondary to
tachycardia or hypothyroidism (now being treated). The
patient's heart rate improved. She warranted a CAD evaluation
with likely dobutamine MIBI or echo however this was deferred to
when she was more stable from a pulmonary standpoint.
Cardiology consulted and felt that ischemic evaluation was
indeed warranted (dobutamine MIBI) when she was more stable from
a pulmonary standpoint. An echo when patient weaned off vent
was also recommended. An ACEi was added for afterload
reduction. The patient was discharged to a weaning/pulmonary
rehab facility.
3. MET ALK: patient was vigorously diuresed with furosemide at
rehab and thus presented with a contraction alkalosis that
likely worsened her respiratory status. Her diuretics were held
and her alkosis improved as did her resp. status.
4. HYPOTHYROID: she was continued on her thyroid replacement.
Patient was to be referred to endocrine at time of d/c.
5. DM: she was continued on humalog sliding scale and
fingerstick glucose monitoring.
6. PROPH: heparin SQ, venadynes, PPI
7. F/E/N: she was given tube feeds and the transitioned to a
PO diet after S+S evaluation.
8. CODE: FULL
9. COMM: with HCP, daughter.
10. R LE EDEMA: doppler was negative for DVT.
Medications on Admission:
ceftazidime 2g TID
flovent MDI
atrovent MDI
albuterol MDI
heparin SQ
levoxyl 125 mcg QD
tylenol
colace
senna
captopril 12.5 mg TID
humalog sliding scale
lorazepam 1-2 mg q4 prn
prevacid
prednisone 60 mg QD
lopressor 12.5 mg [**Hospital1 **]
diltiazem 30 mg TID
morphine sulfate prn
dulcolax
digoxin .125 mg QD
lasix 20 mg [**Hospital1 **]
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 MDI* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
Disp:*1 MDI* Refills:*2*
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection Q12H (every 12 hours).
Disp:*[**Numeric Identifier 6415**] units* Refills:*2*
5. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q4H
(every 4 hours) as needed.
Disp:*1 bottle* Refills:*0*
14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
15. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Disp:*1 bottle* Refills:*2*
17. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
pnuemonia, respiratory failure, metabolic alkalosis
Discharge Condition:
stable
Discharge Instructions:
Physical therapy as tolerated
Continued vent weaning.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2197-6-27**] 8:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2197-8-17**]
|
[
"491.21",
"934.1",
"482.1",
"518.84",
"E912",
"276.4",
"511.9",
"428.0",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.56",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7661, 7732
|
2982, 5116
|
331, 346
|
7828, 7836
|
2085, 2959
|
7939, 8291
|
1704, 1730
|
5505, 7638
|
7753, 7807
|
5142, 5482
|
7860, 7916
|
1745, 2066
|
271, 293
|
374, 1225
|
1247, 1559
|
1575, 1688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,566
| 129,502
|
39061
|
Discharge summary
|
report
|
Admission Date: [**2126-2-22**] Discharge Date: [**2126-3-8**]
Date of Birth: [**2059-11-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Amoxicillin / Lisinopril / Nadolol /
Amiodarone
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation
History of Present Illness:
Ms. [**Known lastname **] is a 66 F with PMH IDDM, A flutter on Coumadin who was
admitted for elective lumbar fusions [**2126-2-25**] and [**2126-2-26**] is
called out of the TSICU after a two day admission for hypoxia in
the setting of right upper lobe pneumonia and BL pleural
effusions. While in the ICU, she had a CTA chest which was
negative for PE in the central pulmonary arteries though
segmental and subsegmental pulmonary arteries could not be
evaluated secondary to poor bolus timing. She was treated with
Vancomycin and Zosyn for HCAP and weaned down from
Non-rebreather to 3L nasal canula.
.
While in the TSICU, she was intermittantly agitated with
waxing/[**Doctor Last Name 688**] mental status (not her baseline according to
primary team). Narcotics were thought to be playing a role and
were discontinued the morning of transfer.
.
Vitals on transfer t99.0 BP113/43 p61 100% RA. She was somnolent
and oriented to person and place, she was occasionally tearful
and very concerned about her confusion while in the ICU. She
reported moderate pain at the anterior/posterior surgical sites.
She denied dyspnea, chest pain.
Past Medical History:
Hyperlipidemia,
Atrial fibrillation,
Complete heart block
s/p pacemaker placement, c/b myocardial perforation
Carotid stenosis
DM1 (c/b retinopathy and peripheral neuropathy),
depression
Essential tremor
Congestive Heart Failure with Diastolic Dysfunction (EF >55%)
Amiodarone cardiopulmonarytoxicity
Social History:
Lives at home. 20 pack year smoking history.
Family History:
No history of Coronary artery disease
Physical Exam:
Admission
Vitals - Tm:99.9 Tc:99.0 BP:113/43 () HR:61 () RR:18 02 sat:100%
RA
GENERAL: Elderly female appearing somnolent and occasionally
tearful,
HEENT: Mucous membs dry, no lymphadenopathy, JVP non elevated
CHEST: R>L ronchi with inspiratory rales.
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: Well healed surgical wound with steri strips and staples in
place soft non tender. no rebound/guarding, neg HSM. neg
[**Doctor Last Name 515**] sign.
EXT: wwp, no edema. DPs, PTs 2+.
SKIN: no rash
PSYCH: tearful
.
Discharge
Vitals - Tc:98 BP:136/66 (109-142/57-72) HR:61 RR:18 02 sat:97%
RA
GENERAL: Elderly female appearing though comfortable
HEENT: Mucous membs dry,
CHEST: Bibasilar inspiratory rales.
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: Well healed surgical wound with steri strips in place
distended though soft non tender. no rebound/guarding.
BACK: steri strips over well healed surgical wound
Pertinent Results:
Admission Labs:
[**2126-2-22**] 06:45PM GLUCOSE-281* UREA N-23* CREAT-1.2* SODIUM-135
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
[**2126-2-22**] 06:45PM estGFR-Using this
[**2126-2-22**] 06:45PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2126-2-22**] 06:45PM WBC-8.9 RBC-4.10* HGB-12.8 HCT-37.2 MCV-91
MCH-31.1 MCHC-34.4 RDW-13.6
[**2126-2-22**] 06:45PM PT-33.7* PTT-33.6 INR(PT)-3.4*
Discharge Labs:
[**2126-3-8**] 05:03AM BLOOD WBC-10.4 RBC-3.10* Hgb-9.2* Hct-28.4*
MCV-92 MCH-29.6 MCHC-32.3 RDW-14.1 Plt Ct-448*
[**2126-3-8**] 12:03PM BLOOD PT-39.2* PTT-38.1* INR(PT)-4.1*
[**2126-3-8**] 05:03AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.0
[**2126-3-4**] 08:51AM BLOOD VitB12-1365* Folate-18.8
[**2126-3-6**] 06:40AM BLOOD %HbA1c-8.5* eAG-197*
[**2126-3-4**] 08:51AM BLOOD TSH-6.0*
[**2126-3-4**] 08:51AM BLOOD T4-4.9
.
TECHNIQUE: Contiguous helical acquisition through the chest was
performed
with without intravenous contrast. Coronal, sagittal, and
oblique images of the pulmonary arteries were created.
FINDINGS: The heart is mildly enlarged. There are dense
calcifications of
the coronary arteries and mitral valve annulus. Minimal
calcification is
noted within the aortic arch and descending aorta. There is no
pericardial
effusion. Numerous small mediastinal lymph nodes are noted,
which are not
pathologically enlarged by size criterion. A pacemaker lies
within the left chest wall with leads in appropriate position.
Secretions are noted
dependently within the trachea.
.
Following contrast administration, the aorta opacifies normally
without
evidence of dissection. The central pulmonary arteries opacify
normally
without evidence of intraluminal thrombus. The segmental and
subsegmental
pulmonary arteries are not well opacified secondary to poor
bolus timing and therefore cannot be evaluated.
.
There are bilateral pleural effusions, large on the right and
moderate on the left. Also noted are bibasilar consolidations,
which may in part represent atelectasis, in addition to
multifocal areas of airspace consolidation are noted throughout
the right lung and also within the lingula and left lower lobe.
.
No suspicious lytic or sclerotic lesions are identified.
Mild-to-moderate
multilevel degenerative changes are noted throughout the spine.
.
Although the study that was not designed for subdiaphragmatic
evaluation,
images of the upper abdomen demonstrate no abnormalities.
.
The IVC is enlarged and the right ventricle and right atrium are
prominent in appearance. There is mild deviation of the
interventricular septum to the left, all of which may reflect
right ventricular dysfunction.
.
IMPRESSION:
1. No evidence of pulmonary embolism within the central
pulmonary arteries. Evaluation of the segmental and
subsegmental branches is limited secondary to poor bolus timing.
2. Multifocal areas of airspace consolidation throughout both
lungs, with
large right and moderate left pleural effusion. These findings
are most
consistent with multifocal pneumonia versus aspiration.
3. Prominent right ventricle and right atrium, mild leftward
deviation of the interventricular septum and enlarged IVC, all
of which raise the concern for right ventricular dysfunction.
Correlation with clinical history and cardiac echo is
recommended.
.
ECHO
.
IMAGING
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. 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. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild right ventricular cavity enlargement with low
normal systolic function. Pulmonary artery hypertension.
Moderate tricuspid regurgitation. Normal left ventricular cavity
size and regiona/global systolic function. Increased PCWP.
This constellation of findings is suggestive of a primary acute
pulmonary process (e.g., pulmonary embolism, pneumonia,
bronchospasm, etc.)
CLINICAL IMPLICATIONS:
Based on [**2122**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
A 66 yoF with PMH IDDM, A-flutter on coumadin admitted for
elective lumbar spine fusion who developed pneumonia and
delirium was admitted to the ICU for two days related to
hypoxemia.
.
# Lumbar fusions: Patient underwent fusion of L4-S1 in a two
staged proceedure involving an anterior followed by a posterior
approach. On post op day 2 she developed hypoxemia and pneumonia
and was transfered to the ICU. She will need to continue to take
oxycodone and tylenol for pain control and should be weaned off
pain medication in [**2-17**] weeks. She will need to follow up with
Dr. [**Last Name (STitle) 363**] in 1 week, and should not lift more than 10 lbs. She
will benefit from rehabilitation for <30 days.
.
# ICU course: On admission to the ICU, she underwent she had a
CTA chest which was negative for pulmonary embolism. ECHO
cardiogram showed right ventricular strain consistent with
pneumonia. She was found to have a clinically significant
pleural effusion and was treated with thoracentisis which
produced 600cc of exudative fluid. She was started on Vancomycin
and Zosyn for healthcare associated pneumonia. She was weanted
from a facemask down to nasal canula and eventually to room air.
She completed an 8 day course of antibiotic therapy on [**2126-3-8**].
.
# Delirium: While in the ICU, patient was intermittantly
agitated with waxing/[**Doctor Last Name 688**] mental status and hallucinations
(not her baseline according to her family). She was
intermittantly agitated and tearful. She had been treated with
high dose fentanyl and benzodiazepines which were the most
likely cause of delirium. UA was negative for infection, TSH was
checked which was low thought T4 was normal. She was also found
to be severely consitpated. Pain medications were limited and
she was continueally re-oriented. Gradually, her orientation
improved, and hallucinations resolved. She was contined on low
dose oxycodone and acetaminophen for pain control and mental
status improved. Delirium is related to pain medication and
prolonged hospitalization.
.
# Constipation: patient developed severe consitpation related to
pain medication. She was manually disimpacted and started on an
agressive bowel regimen. Abdominal plain films showed large
amount of gas but no obstruction. Constipation resolved after
lactulose po and enema in addition to
senna/colace/miralax/bisacodyl. She will need to continue to
take stool softeners until she is done taking pain medication.
.
# A-Flutter: on coumadin as outpatient, coumadin was initially
supra therapeutic relataed to poor po intake, warfarin was held
and INR trended down to 2.4, Warfarin 5mg was resumed however
INR was supratheraputic at 4.1 and warfarin was held. She will
need to have her INR checked daily and warfarin dosed with a
goal of INR [**3-21**]. She was rate controled with diltiazem and
discharged on her home regimen.
.
# Subclinical hypothyroidism: patient noted to have low TSH and
normal T4 suggesting subclinical hypothyroidism, she will need
to have her THS and T4 re-checked in one month.
.
# Depression/anxiety: throughout hospital course, she was
intermittantly tearful related to delirium. with improvment in
delirium, tearfulness improved. She was continued home regimen
of sertraline 200mg daily.
Medications on Admission:
Coumadin 3-6mg
Diltiazem ER 240 [**Hospital1 **]
insulin Humalog
Lantus 25U QHS
Torsemide 20mg [**Hospital1 **]
Simvastatin 80mg
Zoloft 200mg daily
Discharge Medications:
1. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks: Hold for loose stool.
2. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime.
3. Insulin Humalog
SLIDING SCALE, check sugars qachs
BG 71-150: 0 units
BG 151-200: 2 units Insulin
BG 200-249: 4 units Insulin
BG 250-299: 5 units Insulin
BG 300-349: 6 units Insulin
BG 350-400: 7 units bolus Insulin
4. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day.
6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 7 days.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 7 days: Final day [**3-15**].
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO once a day for 2 weeks: hold for loose stool.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks: Hold for loose stool.
11. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
12. Outpatient Lab Work
Daily INR, resume Warfarin 5mg when INR [**3-21**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Lumbar disc degeneration and spondylosis
Discharge Condition:
Good
Discharge Instructions:
As you know, you were admitted to the [**Hospital1 827**] for spine surgery. You underwent Anterior and
posterior lumbar decompression with fusion. After the procedure,
you developed pneumonia and were admitted to the intensive care
unit. While in the intensive care unit, you developed confusion
related to pain medication and constipation. When you came out
of the ICU, your pain medication was reduced and you moved your
bowels, your confusion resolved.
You are being discharged to rehabilitation to improve your
strength.
Activity limitations:
-Activity: You should not lift anything greater than 10 lbs for
1 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
-You should resume taking your normal home medications. Do not
take any anti-inflammatory medications such as ibuprofen or
aspirin.
Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Last Name (LF) **], [**First Name3 (LF) **] BLDG. RM 239, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appointment: [**Last Name (LF) 2974**], [**3-15**] at 11AM
|
[
"362.01",
"738.4",
"427.32",
"285.1",
"V45.01",
"250.53",
"428.32",
"486",
"511.9",
"721.3",
"250.63",
"244.8",
"564.09",
"722.52",
"E935.2",
"357.2",
"416.8",
"V58.61",
"300.4",
"291.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"34.91",
"84.51",
"81.62",
"81.07",
"77.89",
"81.06"
] |
icd9pcs
|
[
[
[]
]
] |
12463, 12535
|
7762, 11028
|
342, 398
|
12620, 12627
|
3014, 3014
|
13712, 14085
|
1966, 2005
|
11227, 12440
|
12556, 12599
|
11054, 11204
|
12651, 13392
|
3434, 7480
|
2020, 2995
|
7503, 7739
|
293, 304
|
13427, 13689
|
426, 1563
|
3030, 3418
|
1585, 1888
|
1904, 1950
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,534
| 194,151
|
5473
|
Discharge summary
|
report
|
Admission Date: [**2186-4-9**] Discharge Date: [**2186-4-13**]
Date of Birth: [**2104-4-27**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Ciprofloxacin / Spironolactone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
weakness and lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 year old man with DM2, Parkinson's Disease, CAD with recent
medically managed NSTEMI [**3-9**] but also s/p multiple PCAs most
recent w/ POBA to mid-RCA [**1-4**], and RCC s/p nephrectomy
presented to ED with altered mental status on [**2186-4-9**]. Per his
wife who is his main care-giver and [**Name Initial (MD) **] retired RN, he has not
been himself for the last 4 days. Four days ago he started to
drop things, including his coffee mug. He was lethargic, and
slightly bradycardic at home to the 40s. He denies fever,
diarrhea, nausea, abdominal pain, dysuria, or frequency. The
only other positive on review of systems is that he had one
episode on the night before admission of waking up breathing
very fast. He did not complain of chest pain at the time and it
quickly resolved.
.
Of note, he has had a similar episodes of delirium every time he
is sick and was hospitalized from [**Date range (3) 22139**] at [**Hospital1 18**]
during which he was treated for a MRSA UTI with a 10 day course
of vancomycin. After this he also had a VRE UTI. He also had an
NSTEMI that was felt to be demand ischemia from hypotesion
related to sepsis from his urinary tract infection. Moreover, he
has had hypercarbic respiratory failure from CHF with PCO2 in
the 60s and very non-responsive. He was put on bipap in the unit
and did get better at that time.
.
In the ED, initial vitals were 95.5 54 137/64 16 100% 2L . He
was AAOx3, somnolent, his heart rate was 22. Labs and imaging
significant for Trop 0.29, Na 149, K 4.2, Creatinine 1.3
(baseline 1.0-1.2), positive U/A. EKG showed SB, LAD, QRS
prolonged at 136 (previous EKG with QRS 144), no ischemic
changes. CT head was negative for acute process. Patient given
Calcium Gluconate 1g IV, Atropine Sulfate 1mg IV x1, Insulin
Regular 10 units IV x1 with Dextrose 50% 50mL due to concern for
hyperkalemia on EKG for prolonged QRS although K returned wnl.
He was also given Aspirin 600mg PR, Ceftriaxone 1g IV x1, and
Carbidopa-Levodopa CR 50-200 mg PO x1. Vitals on transfer were
98.5 46 108/56 18 96% on 2L.
.
On the floor, patient was sleepy was but arousable. He was not
able to answer any questions. Cardiac biomarkers were trended
with a peak to 0.36, which was felt to be secondary to demand in
the setting of possible urosepsis, with urine growing Ecoli. He
was initally treated with vancomyin and zosyn, which were later
switched to ciprofloxacin. Patient was ordered for aspirin,
plavix and statin, but due to his mental status he was not able
to take these medications. Given goals of care and DNR status,
no further intervention was pursued. Delirium was felt to be due
to infection, and workup included negative head imaging and a
normal TSH. Patient had an oxygen requirement of [**1-29**] L, which
was felt to be due to sepsis and aspiration. SBP was never below
98 on the floor and HR remained in the 40s to 70s. Yesterday an
ABG showed a pO2 of 52, but peripheral sats in the 90s. Patient
was started on a NRB, and became more lethargic, with a rise in
CO2 on ABG to 52, and an improvement in O2 to 211. Mental status
gradually cleared with no intervention, and patient was
downtitrated to 2L oxygen.
.
This morning, the patient became suddenly bradycardic to 35,
hypotensive with SBP of 66, and hypoxic to 76 on a NRB with 10L.
Urgent MICU consult was requested. Peripheral dopamine was
started and SBP improved to 70s. After agressive suctioning,
oxygen saturation improved to 90. He was transferred to the ICU
for further care. After transfer, dopamine was stopped and
patient was downtitrated to 6 L oxygen via NC. An ABG during the
event showed 7.13/81/71 on NRB, and improved marginally to
7.18/71/71 on 6L after deep suctioning.
Past Medical History:
- Diabetes
- Dyslipidemia
- Hypertension
- CAD
- PCI with DES to RCA and LAD in [**2179**], NSTEMI [**2185-3-9**] that was
medicallly managed. Most recent Cath in [**12/2183**]: showed 3VD.
PTCA (POBA) of the mid-RCA was performed. Stent placement was
unsuccessful.
- Ischemic cardiomyopathy (systolic and diastolic) with LVEF 25%
- Parkinson's Disease
- h/o Renal Cell Carcinoma [**2170**], s/p partial left nephrectomy
now with chronic kidney disease
- h/o prostate cancer s/p radiation therapy
- spinal stenosis
- Cerebrovascular disease with TIA [**12/2183**]
- Osteoporosis
- h/o left hip fracture, s/p left hemiarthroplasty
- h/o left foot TMA, by Dr. [**Last Name (STitle) 1391**]
- Polyneuropathy and amyotrophy
Social History:
The patient was a concert pianist with 12 CDs. He is married to
a retired ER nurse ([**Doctor First Name **]) who provides support to him and care
with most of his ADLs. He has two adult children one of whom
lives with them currently. He has not smoked cigarettes since
[**2160**]; he has a 40 pack-year history of smoking. He has alcohol
occasionally. He ambulates with the assistance of a WC.
Family History:
Father died of likely an MI at 55yo. No one they know of with
Parkinson's disease but many of his relatives died in the
holocaust.
Physical Exam:
Admission Exam:
VS: 91 axillary (doubt accuracy and RNs rechecking), 98/5164 16
88 on RA, 95 on 2L NC
GENERAL: NAD, sleeping but wakes up when stimulated.
HEENT: Fixed left surgical pupil. No scleral icterus.
PERRLA/EOMI. dry MM.
NECK: Supple, No LAD. JVP flat
CARDIAC: bradycardic but regular. distant heart sounds. Normal
S1, S2. No m/r/g.
LUNGS: decreased breath sounds at bases but only able to listen
anteriorly and as far around as can get to his back as patient
unable to sit up. no w/w/r.
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: 3+ pedal edema to just above knees, 2+ dorsalis
pedis. S/p amputation of left toes. Erythematous rash over his
right toes with fungal infection of the nails.
NEURO: Somnolent but arousable. Over course of evening did wake
up a couple times and ask where he was.
Discharge Exam: not applicable, patient expired.
Pertinent Results:
ADMISSION LABS:
[**2186-4-9**] 04:45PM BLOOD WBC-4.1 RBC-3.92* Hgb-11.0* Hct-34.8*
MCV-89 MCH-28.0 MCHC-31.5 RDW-16.0* Plt Ct-119*
[**2186-4-9**] 04:45PM BLOOD Neuts-78.8* Lymphs-15.3* Monos-3.0
Eos-2.1 Baso-0.8
[**2186-4-9**] 04:45PM BLOOD PT-14.2* PTT-40.6* INR(PT)-1.2*
[**2186-4-9**] 04:45PM BLOOD Glucose-129* UreaN-64* Creat-1.3* Na-149*
K-4.2 Cl-110* HCO3-30 AnGap-13
[**2186-4-9**] 04:45PM BLOOD ALT-8 AST-29 LD(LDH)-180 CK(CPK)-105
AlkPhos-78 TotBili-0.4
[**2186-4-9**] 04:45PM BLOOD Calcium-8.8 Phos-4.9*# Mg-2.3
[**2186-4-9**] 04:45PM BLOOD TSH-2.2
.
PERTINENT LABS:
[**2186-4-9**] 04:45PM BLOOD CK-MB-18* MB Indx-17.1*
[**2186-4-9**] 04:45PM BLOOD cTropnT-0.29*
[**2186-4-10**] 06:50AM BLOOD CK-MB-16* MB Indx-20.3* cTropnT-0.31*
[**2186-4-10**] 03:48PM BLOOD CK-MB-11* MB Indx-14.7* cTropnT-0.36*
[**2186-4-11**] 06:25AM BLOOD CK-MB-8 cTropnT-0.35*
[**2186-4-11**] 03:51PM BLOOD CK-MB-8 cTropnT-0.34*
[**2186-4-12**] 03:02AM BLOOD CK-MB-10 MB Indx-11.4* cTropnT-0.31*
[**2186-4-9**] 04:59PM BLOOD Lactate-1.1
[**2186-4-9**] 11:08PM BLOOD Lactate-0.8
[**2186-4-10**] 08:28AM BLOOD Lactate-0.8
[**2186-4-10**] 09:33AM BLOOD Lactate-0.6
[**2186-4-11**] 03:34PM BLOOD Lactate-1.4
[**2186-4-11**] 06:00PM BLOOD Lactate-0.7
[**2186-4-12**] 02:54AM BLOOD Lactate-1.3
.
BLOOD GASES:
[**2186-4-9**] 11:08PM BLOOD Type-ART pO2-49* pCO2-67* pH-7.25*
calTCO2-31* [**2186-4-10**] 08:28AM BLOOD Type-ART pO2-52* pCO2-40
pH-7.42 calTCO2-27 [**2186-4-10**] 09:33AM BLOOD Type-ART pO2-211*
pCO2-50* pH-7.33* calTCO2-28 [**2186-4-10**] 04:06PM BLOOD Type-[**Last Name (un) **]
pO2-136* pCO2-47* pH-7.38 calTCO2-29 [**2186-4-11**] 06:30AM BLOOD
Type-[**Last Name (un) **] pO2-226* pCO2-53* pH-7.31* calTCO2-28
[**2186-4-11**] 02:39PM BLOOD Type-ART pO2-71* pCO2-81* pH-7.13*
calTCO2-29
[**2186-4-11**] 03:34PM BLOOD Type-ART pO2-71* pCO2-71* pH-7.18*
calTCO2-28 [**2186-4-11**] 06:00PM BLOOD Type-ART pO2-76* pCO2-61*
pH-7.25* calTCO2-28 [**2186-4-12**] 02:54AM BLOOD Type-ART pO2-79*
pCO2-70* pH-7.21* calTCO2-30
.
MICROBIOLOGY:
[**2186-4-12**] Sputum Cx: upper respiratory contamination
[**2186-4-9**] Blood Cx: no growth to date
[**2186-4-9**] Urine Cx: E. Coli >100,000 organisms/ml
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING:
[**2186-4-9**] CXR: Redemonstrated are large bilateral pleural
effusions which obscure evaluation of the cardiac silhouette.
These are similar in size when compared to the prior study.
Bibasilar airspace opacities likely reflect compressive
atelectasis, although infection cannot be excluded. There is
mild pulmonary vascular congestion, but no evidence of overt
pulmonary edema. No large pneumothorax is present. There are
degenerative changes of the thoracic spine.
IMPRESSION: Large bilateral pleural effusions with bibasilar
airspace opacities, likely compressive atelectasis. Infection
cannot be excluded.
.
[**2186-4-9**] CT Head: Evaluation is somewhat limited due to
positioning; however, no acute hemorrhage, edema or mass effect
is seen. The [**Doctor Last Name 352**] white matter differentiation appears
preserved. Prominence of the ventricles and sulci reflects
generalized atrophy, age related. Areas of periventricular and
subcortical white matter hypodensity likely reflect sequelae of
chronic small vessel ischemic disease. There are dense
calcifications of the bilateral carotid siphons. No concerning
osseous lesion is seen. The visualized paranasal sinuses are
grossly clear.
IMPRESSION: No evidence of acute intracranial process.
.
[**2186-4-10**] CXR: Today there is more vascular engorgement in the
upper lungs which could be due to mild cardiac decompensation.
Heart is obscured by pleural and parenchymal abnormality and
difficult to assess. No pneumothorax.
.
[**2186-4-11**] ECHO: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. There is mild
regional left ventricular systolic dysfunction with mid to
distal anteroseptal hypkinessi/akinesis and apical
akinesis/hypokinesis. 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. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. Compared
with the prior study (images reviewed) of [**2185-10-27**], left
ventricular systolic function is now improved with less
extensive wall motion abnormalities.
.
[**2186-4-13**] CXR: Bilateral large pleural effusion in combination
with pulmonary edema appears to be slightly progressed. The
patient's head is projecting over the apices. There is no
apparent evidence of pneumothorax.
Brief Hospital Course:
81 year old man with a history of Parkinson's, CAD, and systolic
CHF, who presented with lethargy, altered mental status,
bradycardia, and hypotension, and was found to have a UTI and
elevated cardiac enzymes. He was later transferred to the MICU
for acute on chronic hypercarbic respiratory acidosis and
concern for sepsis.
.
# DELIRIUM/HYPOTENSION/HYPOTHERMIA: Upon admission the patient
was noted to have a U/A suggestive of a UTI and was given a dose
of ceftriaxone and then empirically started on vancomycin and
zosyn given his history of multi-drug resistant infections. His
urine culture revealed E. coli sensitive to Ciprofloxacin,
Meropenem, and Bactrim. Given the patients inability to tolerate
PO intake, antibiotics were changed to IV Cipro. He was noted to
have an elevation in his troponins, with a peak to 0.36, which
was believed to be secondary to demand ischemia in the setting
of his underlying illness. His delirium was felt to be due to
the UTI and hypernatremia. CT head was negative and TSH was
normal. His hypernatremia improved with infusion of D5W. The
patient became more lethargic, hypoxic, bradycardic, and
hypotensive and was started on a dopamine drip and transferred
to the MICU out of concern for sepsis. Ciprofloxacin was changed
to Meropenem. His vital signs temporarily improved, but he then
developed worsening hypotension, again requiring pressors. We
did not initiate CPR given his DNR/DNI status. He died at 2:40pm
on [**2186-4-13**]. His family declined an autopsy and the medical
examiner waived the case.
.
# BRADYCARDIA: EKG revealed a 1st degree AV delay and the
patient was noted to have occasional runs of a likely
ventricular escape rhythm on telemetry. Unclear etiology,
however the patient was previously on metoprolol which may have
exacerbated a sick sinus syndrome. Also with severe CO2
retention and possible central apnea likely from CHF, which may
be resulting in apnea causing bradycardia. There is a question
of autonomic instability in the setting of Parkinson's disease.
.
# CAD: The patient's aspirin and simvastatin were held since the
patient was not tolerating oral intake. The metoprolol was held
in the setting of bradycardia.
.
# ACUTE ON CHRONIC KIDNEY DISEASE: Creatinine was 1.3 on
admission, up from baseline 1.0-1.2, likely prerenal in the
setting of poor PO intake or poor forward flow.
.
# CHF: The patient has known systolic and diastolic dysfunction
with an LVEF 25% in 9/[**2185**]. He recieved 20mg IV Lasix for
hypoxia and volume overload on CXR, but it was then decided to
hold off on further diuresis given concern for sepsis. he was
felt to be overall volume overloaded but intravascularly dry
given his ARF and hypernatremia, and so was started on a slow
infusion of D5W to replete free water.
.
# PARKINSONS: Patient may have had some autonomic dysfunction
contributing to his hypothermia and bradycardia as a result of
his Parkinsons disease. Sinemet was changed over to a
dissolvable form as he could not reliably take PO intake.
.
# DIABETES: Lantus was held given poor PO intake and he was
monitored via a humalog sliding scale.
.
# CORONARIES: 3 VD s/p multiple PCAs most recent w/ POBA to
mid-RCA [**1-4**]. If RCA is supplying his sinus node and he has
developed more extensive RCA plaque then ischemia here could be
contributing to his bradycardia. His elevated cardiac enzymes
were felt to be due to demand ischemia in the setting of
infection. Initially, his troponin was continuing to trend
upwards, but his MB as decreasing. Trop started to trend
downwards on HD3. His ASA was continued asstatin was changed to
atorvastatin 80. He was loaded with 300mg Plavix and started on
75mg daily. The risks of heparin were felt to outweigh the
benefits in this setting.
Medications on Admission:
1. Lantus 12units QHS
2. Humalog 100 unit/mL Sub-Q as directed three times a day
before meals
3. Vitamin D 1,000 unit Tab by mouth once a day
4. Simvastatin 20 mg Tab by mouth once a day
5. Sinemet CR 50 mg-200 mg Tab by mouth [**Hospital1 **]
6. Sinemet 25 mg-100 mg by mouth once a day
7. [**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral Once Daily
8. metoprolol tartrate 25 mg Tab PO Twice Daily
9. furosemide 20 mg Tab 0.5 Tablet PO Once Daily
10.Flomax 0.4mg QHS
11. Tylenol PRN
12. Motrin PRN
13. Colace 100mg QHS
14. Calcium 600mg [**Hospital1 **]
15. B12 500mcg daily
Discharge Medications:
Not applicable, patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Chief cause of death: cardiovascular collapse
Immediate cause of death: multisystem organ failure
Other antecedent causes: coronary artery disease
Discharge Condition:
Expired.
Discharge Instructions:
Not applicable, patient expired.
Followup Instructions:
Not applicable, patient expired.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"V10.52",
"250.00",
"V45.73",
"518.81",
"293.0",
"276.0",
"427.89",
"038.9",
"584.9",
"585.9",
"V10.46",
"332.0",
"995.92",
"403.90",
"410.72",
"599.0",
"V49.86",
"785.52",
"E928.9",
"414.01",
"E849.9",
"428.0",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16041, 16050
|
11598, 15355
|
330, 336
|
16256, 16266
|
6254, 6254
|
16347, 16518
|
5236, 5368
|
15984, 16018
|
16071, 16235
|
15381, 15961
|
16290, 16324
|
5383, 6185
|
6201, 6235
|
269, 292
|
364, 4065
|
9486, 11575
|
6270, 6816
|
6832, 9477
|
4087, 4808
|
4824, 5220
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,886
| 114,839
|
22745
|
Discharge summary
|
report
|
Admission Date: [**2167-2-26**] Discharge Date: [**2167-3-11**]
Date of Birth: [**2093-4-25**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
woman with known aortic stenosis and mitral stenosis,
admitted in [**2164-3-23**], with acute congestive heart failure
and a myocardial infarction. Catheterization at that time
showed no significant coronary artery disease. The patient
was again admitted in [**2166-11-24**], with congestive heart
failure and referred for stress testing. Stress test done in
[**Month (only) 404**] showed an ejection fraction of 70 percent with no
inducible ischemia. Catheterization done on [**2167-2-20**],
showed three vessel disease as well as aortic and mitral
stenosis. The patient was then referred to Cardiothoracic
Surgery for aortic valve replacement, mitral valve
replacement, coronary artery bypass graft. Transesophageal
echocardiogram done [**2167-2-10**], showed an aortic valve area
of 0.5 to 0.6 centimeter squared with one plus aortic
insufficiency and moderate to severe mitral stenosis with a
mitral valve area of 1.4 and two plus mitral regurgitation.
It also showed severe mitral annular calcification and left
ventricular hypertrophy with an ejection fraction of 65
percent.
PAST MEDICAL HISTORY: Hypertension.
Hyperlipidemia.
Diabetes mellitus.
Congestive heart failure.
Aortic stenosis.
Mitral stenosis.
Peripheral vascular disease.
Gastroesophageal reflux disease.
Osteoporosis.
PAST SURGICAL HISTORY: Right carotid endarterectomy done in
[**2163**].
ALLERGIES: The patient states no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg daily.
2. Lipitor 40 mg daily.
3. Toprol 12.5 mg daily.
4. Lotrel 5 to 20 mg daily.
5. Aspirin 81 mg daily.
6. Protonix 40 mg daily.
7. K-Lor 20 daily.
8. Fosamax 70 mg weekly, typically taken on Sunday.
SOCIAL HISTORY: Widowed, livers with son in [**Name (NI) 3494**].
Remote tobacco history, quit over twenty years ago, and rare
alcohol use.
FAMILY HISTORY: Significant for mother who died of
myocardial infarction at age 57 and father who died of
myocardial infarction at age 80.
PHYSICAL EXAMINATION: Height five feet, weight 151 pounds.
Vital signs revealed temperature 98, heart rate 66, sinus
rhythm, blood pressure 105/38, respiratory rate 18, oxygen
saturation 97 percent in room air. In general, she is lying
in bed in no acute distress. Neurologically, she is alert
and oriented times three, moves all extremities, follows
commands, nonfocal examination. Respiratory is clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm, S1 and S2, with a IV/VI systolic ejection murmur
radiating bilaterally to the carotids. Abdomen is soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities are warm and well perfused with no edema or
varicosities. Pulses - Radial two plus bilaterally, dorsalis
pedis and posterior tibial one plus bilaterally.
LABORATORY DATA: White blood cell count 5.4, hematocrit
30.0, platelet count 165,000. Prothrombin time 14.0, partial
thromboplastin time 28.0, INR 1.2. Sodium 135, potassium
4.5, chloride 104, CO2 23, blood urea nitrogen 30, creatinine
1.2, glucose 88. Liver function tests within normal limits.
Urinalysis is negative. Carotids with mild plaque
bilaterally with no hemodynamic significance.
HOSPITAL COURSE: The patient was a direct admission to the
operating room where she underwent an aortic valve
replacement, mitral valve replacement, coronary artery bypass
graft times three. Please see the operative report for full
details. In summary, the patient had an aortic valve
replacement with a number 19 St. [**Male First Name (un) 923**] mechanical valve,
mitral valve replacement with a number 25 St. [**Male First Name (un) 923**] mechanical
valve and a coronary artery bypass graft times three with
left internal mammary artery to the left anterior descending
coronary artery, saphenous vein graft to obtuse marginal and
saphenous vein graft to right coronary artery. Her bypass
time was 223 minutes with a cross clamp time of 198 minutes.
The patient tolerated the operation and was transferred from
the operating room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had Milrinone at 0.25
mcg/kg/minute and Neo-Synephrine at 1.5 mcg/kg/minute. The
patient did well in the immediate postoperative period. Her
anesthesia was reversed. She was weaned from all sedation,
moved all extremities to commands and then was resedated
during the course of the operative night. On postoperative
day number one, her sedation was again lightened. She was
weaned from the ventilator and successfully extubated. She
remained hemodynamically stable throughout this period. On
postoperative day number two, the patient continued to
progress. She was begun on beta blockade. Her Swan-Ganz
catheter was removed and her activity level was advanced with
the assistance of the nursing staff. Later in the day of
postoperative day number two, the patient went into a rapid
atrial fibrillation which she did not tolerate well
hemodynamically and therefore she remained in the
Cardiothoracic Intensive Care Unit. Additionally, an
Amiodarone infusion was begun. On postoperative day number
three, the patient was hemodynamically stable on beta
blockade as well as Amiodarone drip. Diuretics were also
begun at that time. She was transfused with two units of
packed red blood cells and her chest tubes were removed.
Because of intermittent atrial fibrillation, the patient
remained in the Cardiothoracic Intensive Care Unit.
Postoperative day number four, the patient continued to have
episodes of rapid atrial fibrillation which she did not
tolerate hemodynamically. Amiodarone infusion continued.
The patient was also begun on Heparin at that time.
Additionally, she was loaded with Digoxin which seemed to
slow her ventricular response rate. Ultimately, the patient
returned to a sinus rhythm, however, during this period, the
patient had poor urine output and during that time she was
begun on a Natrecor infusion as well. Postoperative day
number five, the patient had improved hemodynamically. She
remained in sinus rhythm with adequate cardiac output and
index. She was aggressively diuresed. he Swan-Ganz catheter
was removed on postoperative day number six. The patient
continued to make progress hemodynamically. Her Amiodarone
infusion was stopped and she was begun on oral Amiodarone.
Her Natrecor infusion was weaned. She was placed on oral
diuretics postoperative day number seven. The patient
continued to do well. Her beta blockade was increased. Her
temporary pacing wires were removed. Her right IJ was
removed. On postoperative day number eight, she was
transferred to the floor for continued postoperative care and
cardiac rehabilitation. Additionally, the patient was begun
on oral Coumadin. Once on the floor, the patient had an
uneventful postoperative course. Her activity level was
increased with the assistance of the nursing staff as well as
the physical therapy staff. On postoperative day thirteen,
it was decided that the patient was stable and ready to be
discharged to home with visiting nurses. At the time of this
dictation, the patient's physical examination is as follows:
Temperature 100, heart rate 80 and sinus rhythm, blood
pressure 123/62, respiratory rate 18, oxygen saturation 95
percent in room air. Weight preoperatively 69 kilograms and
at discharge 67.3 kilograms. Laboratories showed sodium 140,
potassium 4.1, chloride 101, CO2 32, blood urea nitrogen 25,
creatinine 1.3, glucose 107. Prothrombin time 14.0, partial
thromboplastin time 75, INR 2.3. White blood cell count is
4.5, hematocrit 38.0, platelet count 467,000. Physical
examination, neurologically, the patient is alert and
oriented times three, moves all extremities, follows
commands, nonfocal examination. Pulmonary is clear to
auscultation bilaterally. Cardiac regular rate and rhythm,
sternum stable and incision with Steri-Strips without
drainage or erythema. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with trace edema. Right endoscopic
saphenous vein graft harvest site with Steri-Strips, open to
air, clean and dry. Left open saphenous vein graft harvest
site with staples, open to air, clean and dry.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass grafting times three, left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to obtuse marginal and saphenous
vein graft to right coronary artery.
Aortic stenosis, status post aortic valve replacement with
number 19 St. [**Male First Name (un) 923**] mechanical valve.
Mitral stenosis, status post mitral valve replacement with
number 25 St. [**Male First Name (un) 923**] mechanical valve.
Diabetes mellitus.
Hypertension.
Hypercholesterolemia.
Congestive heart failure.
Peripheral vascular disease.
Gastroesophageal reflux disease.
Osteoporosis.
Status post right carotid endarterectomy.
DISCHARGE STATUS: The patient is to be discharged home with
visiting nurses.
FOLLOW UP: She is to have follow-up with Dr. [**Last Name (STitle) **] in one
to two weeks, with Dr. [**Last Name (STitle) **] in two to four weeks, and
with Dr. [**Last Name (STitle) **] in four weeks.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Aspirin 81 mg daily.
3. Percocet 5/325 one to two tablets q4-6hours as needed.
4. Captopril 12.5 mg three times a day.
5. Prilosec 40 mg daily.
6. Lipitor 40 mg daily.
7. Amiodarone 400 mg daily times seven days, then 200 mg
daily.
8. Metoprolol 75 mg three times a day.
9. Lasix 40 mg daily.
10. Potassium Chloride 20 mEq daily.
11. Warfarin as directed with a target INR of 3.0 to
3.5. Initial INR check is on Friday, [**2167-3-13**], with
results to be called to Dr.[**Name (NI) 58873**] office.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2167-3-11**] 16:56:31
T: [**2167-3-11**] 19:06:18
Job#: [**Job Number 58874**]
|
[
"997.1",
"272.0",
"396.0",
"530.81",
"278.00",
"443.9",
"427.31",
"250.00",
"E878.1",
"401.9",
"412",
"733.00",
"398.91",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"89.68",
"35.24",
"35.22",
"00.13",
"99.04",
"89.64",
"36.15",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2037, 2161
|
8476, 9260
|
9491, 10290
|
1657, 1878
|
3385, 8422
|
1524, 1631
|
9272, 9465
|
2184, 3367
|
165, 1283
|
1306, 1500
|
1895, 2020
|
8447, 8454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,837
| 150,864
|
5462
|
Discharge summary
|
report
|
Admission Date: [**2166-6-3**] Discharge Date: [**2166-6-19**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
white male with a history of coronary artery disease with
three-vessel disease, diabetes mellitus, chronic renal
failure with recent acute renal failure admitted to outside
hospital on [**2166-5-29**] with hypoxia. He was transferred to
[**Hospital1 69**] for further management
of respiratory failure. In the early even of [**2166-5-29**] at
rehabilitation the patient complained of shortness of breath.
Oxygen saturations decreased to the 60s. He was sent to an
outside hospital where he reportedly became unresponsive with
oxygen saturations of 80% on 100% face mask. He was
intubated and sent to the intensive care unit. He was
treated for presumed aspiration pneumonia with Levaquin and
started on vancomycin for one out of two blood cultures
positive for "staph". No further isolation was noted. White
blood cell count was 15.9. There was no documented fever.
The patient was diuresed with Lasix 80 mg IV b.i.d. with a
pulmonary capillary wedge pressure of approximately 15. He
was placed on a dopamine drip for hypotension with systolic
pressures in the 70s. On the morning of transfer the patient
was noted to be in atrial fibrillation with a rate of 160s to
170s. He was started on a diltiazem drip in addition to the
dopamine pressor for rate control as well as a heparin drip.
The wife requested transfer to [**Hospital1 188**] where he was recently hospitalized [**2166-4-7**] through
[**2166-4-19**] for left hip fracture, non-ST elevation myocardial
infarction, stent to the right coronary artery, acute renal
failure secondary to contrast dye requiring dialysis x 2, and
repair of hip fracture with a left open reduction and
internal fixation. Upon transfer he was on SIMV
16-[**Medical Record Number 22113**], heparin drip, dopamine drip, diltiazem drip and
insulin drip. Of note, in addition to his respiratory
failure he was in diabetic ketoacidosis with a metabolic
acidosis. He had blood loss anemia with an hematocrit of 19
and he was in shock with a picture most consistent with
sepsis.
PAST MEDICAL HISTORY: 1. Coronary artery disease status post
non-ST elevation myocardial infarction on [**2166-4-7**],
catheterization on [**2166-4-9**] with three-vessel disease, stent
right coronary artery. 2. Hypertension. 3.
Hypercholesterolemia. 4. Congestive heart failure with an
ejection fraction of approximately 25%. 5. Chronic renal
failure with acute renal failure [**4-10**] secondary to
catheterization dye load requiring hemodialysis x 2 sessions.
6. Anemia with decreased hematocrit to 20 with prior
hospitalization, source unknown. 7. Status post left open
reduction and internal fixation [**2166-4-15**]. 8. Status post a
right THA. 9. Status post transurethral resection of the
prostate. 10. Gastroesophageal reflux disease. 11. History
of a seizure disorder, questionably four years ago. 12.
Status post appendectomy. 13. Urinary tract infection. 14.
Diabetes mellitus type 2 followed by the [**Hospital **] Clinic.
SOCIAL HISTORY: He is a music composer. He has been
recovering at [**Hospital **] Rehabilitation. He has a very
involved wife.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON HOSPITAL TRANSFER: 1. Dopamine drip at 6. 2.
Diltiazem drip at 15. 3. Insulin drip at 2. 4. Heparin drip
at 400. 5. Coumadin 1 mg p.o. q.d. 6. Famotidine 20 mg q.
12. 7. Dilantin 200 mg b.i.d. 8. Levaquin 250 mg q.d. day
number five. 9. Vancomycin 1 gram q. 24, day unknown. 10.
Morphine 6 mg received in the AM.
MEDICATIONS AS AN OUTPATIENT: 1. Phenytoin 200 mg b.i.d. 2.
Colace 100 mg b.i.d. 3. Lente Insulin 20 units q.a.m. with a
Humalog sliding scale. 4. Metoprolol 50 mg b.i.d. 5. Plavix
75 mg q.d. 6. Trazodone 25 mg q.h.s. 7. Coumadin 1 mg q.d.
8. Aspirin 325 mg q.d. 9. Calcium carbonate 1 gram b.i.d.
10. Multivitamin q.d. 11. Lactulose p.r.n. constipation.
12. Lasix 100 mg p.o. q.a.m., 60 mg p.o. q.p.m. 13.
Lorazepam p.r.n. 14. Lansoprazole 30 mg q.d. 15. Combivent
2 puffs b.i.d. 16. Albuterol-Atrovent p.r.n. 17.
Amoxicillin ? 18. Cipro ?
PHYSICAL EXAMINATION: Temperature 103 axillary, blood
pressure 90s/50s to 70s/30s, heart rate 100, vent AC at
600-6, FIO2 35%. In general he was responsive to touch,
moved eyes to voice command. HEENT showed pinpoint pupils.
Kyphoscoliosis. Mucous membranes were dry. heart was
regular rate and rhythm with a 1/6 systolic murmur at the
left sternal border. Lungs had breath sounds somewhat
coarse, clear with suctioning. Mild basilar crackles.
Abdomen soft, nontender, no stool in the vault. Foley
catheter had yellow clear urine. Extremities were warm and
well perfused. Upper extremity edema was noted on hands. No
lower extremity edema. The patient had a right brachial line
with Swan in place, left radial arterial line, no stranding
erythema. On neurological examination he moved all
extremities. He had pinpoint pupils noted.
LABORATORY DATA: White count was 1.1, hematocrit 23.4,
decreased from 27.4 on [**2166-6-1**]. Platelet count was 100.
Neutrophils 83.8, eosinophils 2, basos none. Sodium was 127,
potassium 5.2 hemolyzed, chloride 95, bicarbonate 18, BUN 60,
creatinine 2.5, baseline 1.8, glucose 298, calcium 7.7,
magnesium 1.9, phosphorous 5.5. PT 20, PTT 72.5, INR 2.7.
Vancomycin level was 25.1. Cardiac enzymes were CK 80,
troponin less than 0.3. Arterial blood gases were 7.45, 29,
114, 21.
Chest x-ray showed a Swan-Ganz catheter tip seen in the right
main pulmonary artery. ETT 2 cm above the carina. He had
improved pulmonary edema, no acute cardiopulmonary process
noted.
Echocardiogram from [**4-10**] showed left ventricular ejection
fraction of 25%, AK anterior septum, anterior free wall,
apex, moderate HK inferior septum and lateral free wall.
There was 1+ mitral regurgitation, trace aortic
regurgitation, moderate tricuspid regurgitation, moderate
pulmonary hypertension.
Catheterization on [**2166-4-9**] showed three-vessel disease with
left anterior descending coronary artery 70% proximal lesion,
100% mid with collaterals from PDA. LCX 60% lesion, RCA 80%
x 2 with stent x 2 with good flow.
EKG showed normal sinus rhythm, rate 105, prolonged PR, left
axis, poor R wave progression, less than [**Street Address(2) 4793**] depression
noted in the inferior leads. AVL with Q waves, T wave
inversion, new when compared to the EKG from [**2166-4-17**].
HOSPITAL COURSE: 1. Respiratory failure: The patient was
admitted to an outside hospital with acute hypoxia, etiology
unknown, although aspiration pneumonia presumed, question
also of PE given recent surgery, question also of pulmonary
edema given history of severe congestive heart failure. The
patient required ventilatory support for several days.
Initial wean was complicated by flash pulmonary edema and
agitation requiring reintubation. At this time code status
was discussed at length with the wife. She decided on DNI
after next extubation. The patient was successfully
extubated on [**2166-6-10**] on a nitroglycerin drip and Lasix drip
with a bolus. His respiratory status continued to improve
throughout the rest of his hospital stay. At the time of
discharge he was consistently saturating 98-100% on a
two-liter nasal cannula and required minimal suctioning.
2. Shock: On admission the patient had a blood
pressure of 70s/30s with a temperature of 103 consistent with
septic shock. His brachial and Swan line were removed and
replaced with a subclavian line. He was weaned off of his
diltiazem and dopamine drip with the initiation of Levophed.
After initiation of antibiotics as well as volume repletion
with blood products, he was weaned successfully off of his
Levophed. Mild hypotension persisted until the patient was
extubated. Since this time he has remained normotensive.
3. Congestive heart failure: The patient had an ejection
fraction of 25% consistent per repeat echocardiogram done.
He received p.r.n. Lasix boluses and required a Lasix drip at
the time of extubation and given flash pulmonary edema. He
was started on a nitroglycerin drip with hydralazine for
preload and afterload reduction. His oxygen saturation
continued to improve. At the time of discharge he received
20 of IV Lasix q.d. with goal I's and O's even.
4. Pneumonia: The patient was under treatment for pneumonia
with Levaquin and questionably vancomycin at the time of
hospital transfer. Both vancomycin and Levaquin were
continued for a 14-day course with interval improvement on
his chest x-ray and decreased leukocytosis. Blood cultures
remained negative while in house. Sputum culture did grow
MRSA for which he was placed on precautions.
While in house a swallow study was done and he was determined
to be at a high risk for aspiration pneumonia. He was kept
n.p.o. for this reason.
5. Blood loss anemia: On admission the patient's hematocrit
was 24.6 and rapidly decreased to 19.6 without clear source
of bleed. Concurrently the patient experienced a demand
ischemia myocardial infarction. He was transfused to an
hematocrit greater than 30. After this event his hematocrit
remained stable with intermittent transfusions for iatrogenic
blood loss. Of note the patient had a similar episode of
blood loss with his prior hospitalization. He was guaiac
negative. Hematocrit remained stable at the time of
discharge.
6. Coronary artery disease: The patient has severe
three-vessel disease status post recent stent x 2 to right
coronary artery. While in house he was followed by Dr.
[**Last Name (STitle) **], his outpatient cardiologist, who did not recommend
repeat catheterization at this time. He was medically
managed with aspirin and beta blocker as tolerated. At the
time of discharge he tolerated metoprolol 25 b.i.d. He
should be started on a long-acting nitrate as tolerated as an
outpatient.
7. Atrial fibrillation: Per hospital transfer notes the
patient had an initial episode of atrial fibrillation the
morning of [**2166-6-3**]. At the time of extubation he was noted
to be in rapid atrial fibrillation controlled with IV
Lopressor. On standing Lopressor the patient remained in
sinus rhythm with a heart rate between 80 and 100. He was
continued on aspirin. No further anticoagulation was
initiated at this time.
8. Acute on chronic renal failure: At the time of admission
the patient had elevated creatinine thought to be due to
decreased perfusion from sepsis. Renal function improved
with increased systolic blood pressure and transfusion,
however after aggressive diuresis with pulmonary edema, the
patient's creatinine worsened. Again, goal ins and outs are
to remain approximately even at this time. His creatinine
should be followed closely. He was started on Epogen.
9. Diabetes type 2: The patient has a history of
poorly-controlled diabetes. On admission he was noted to be
in diabetic ketoacidosis with a metabolic acidosis. This was
controlled with IV hydration and insulin drip. Throughout
the course of his stay he was continued on an insulin drip
for close glucose control. At the time of discharge he was
switched to subcutaneous insulin with q. 4 hour fingersticks.
His sugars should be followed closely and after his new
insulin requirement is determined, he should be switched to a
long-acting insulin. Of note, the patient previously was on
Lantus with Humalog sliding scale.
10. Fluids, electrolytes and nutrition: As noted the patient
failed video swallow study and is noted to be at a high
aspiration risk. The possibility of a PEG tube was discussed
with the patient's wife, however she is not ready to pursue
this at this time. A Dobbhoff tube was placed per
fluoroscopy. At the time of discharge he was on Nepro tube
feeds and receiving p.o. medicine through his Dobbhoff tube.
11. Constipation: Of note, the patient's first bowel
movement throughout the course of the hospital stay was on
the day of discharge. He should remain on stool softeners
and p.r.n. stimulants.
12. Code status: After multiple family meetings it was
decided that his code status will be DNR/DNI.
13. Acute cholecystitis: While intubated the patient was
noted to have increasing alkaline phosphatase with a positive
GGT, as well as a sensitive right upper quadrant. Right
upper quadrant ultrasound was done which showed thickening of
the gallbladder wall as well as a stone in the cystic duct.
He was consulted by both general surgery and interventional
radiology who felt that his operative risk was too high given
his comorbidities. He was started on Flagyl in addition to
Levaquin for acute cholecystitis and was kept n.p.o. on TPN.
He symptomatically improved with a decrease in his alkaline
phosphatase. At the time of discharge he tolerated tube
feeds.
DISCHARGE STATUS: To [**Hospital **] Rehabilitation.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: He will see his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 22114**], in one to two weeks.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Coronary artery disease.
3. Demand ischemia.
4. Blood loss anemia.
5. Aspiration pneumonia.
6. Diabetes mellitus type 2.
7. Diabetic ketoacidosis with metabolic acidosis.
8. Acute cholecystitis.
9. Septic shock.
10. Respiratory failure.
11. Atrial fibrillation.
12. Acute on chronic renal failure.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg p.o. q.d.
2. Hydralazine 10 mg p.o. q. 6 hours.
3. Metoprolol 25 mg p.o. b.i.d.
4. Aspirin 325 mg p.o. q.d.
5. Epogen 4,000 units subcutaneous biweekly.
6. Heparin 5,000 units subcutaneous b.i.d.
7. Insulin sliding scale with q. 4 hour fingersticks to be
converted to long-acting insulin per required dose.
8. Colace 100 mg p.o. b.i.d., liquid form.
9. Tylenol 325-650 mg p.o. q. 4-6 hours p.r.n. pain.
10. Dulcolax p.r. q.d. p.r.n. constipation.
11. Lasix 40 mg p.o. q.a.m. hold for creatinine increase,
goal I's and O's even.
12. Tube feeds - Nepro solution at 35 cc goal.
13. Two-liter nasal cannula titrated to oxygen saturation
greater than 92%.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 3219**]
MEDQUIST36
D: [**2166-6-19**] 10:37
T: [**2166-6-19**] 11:00
JOB#: [**Job Number 22115**]
|
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icd9cm
|
[
[
[]
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] |
[
"38.91",
"96.72",
"96.04",
"99.15",
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icd9pcs
|
[
[
[]
]
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13126, 13457
|
13480, 14400
|
6546, 12932
|
12978, 13105
|
4235, 6528
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112, 2181
|
2204, 3131
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3148, 4212
|
12957, 12966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,323
| 133,194
|
34964
|
Discharge summary
|
report
|
Admission Date: [**2138-10-9**] Discharge Date: [**2138-10-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Gastroesophagoduodenoscopy
History of Present Illness:
86 F with HTN, CHF, [**Hospital 79982**] transfer from OSH with duodenal bleed
for push enteroscopy. She was admitted to [**Hospital3 **] on
[**2138-10-4**] with dyspnea. She reports about 1-2 weeks of dyspnea on
exertion (after walking to BR, for example). Recently ([**9-21**])
also admitted to OSH pneumonia. Presented to OSH and found to
have hct 29. Initially also treated with antibiotics
(ceftriaxone and azith) and diuresis. Then developed melanotic
stools, and BRBPR while hospitalized. She required 11 units
PRBCs over the last four days. Has also gotten platelets and
FFP. EGD on [**2138-10-7**] showed antral ulcers and unremarkable first
part of duodenum. Tagged RBC scan was positive for distal
duodenal/proximal jejunal bleed. Capsule endoscopy showed
bleeding in the duodenum. She was then transferred to [**Hospital1 18**] for
further workup. She reportedly had no hypotension or
hemodynamic instability at OSH.
At [**Hospital1 18**], she remained hemodynamically stable. She had an EGD
which showed ulcers in the distal bulb and second part of the
duodenum. The duodenal ulcers were cauterized. She had H.
pylori serum antibody and serum gastrin levels sent which are
still pending at the time of discharge. She was hypertensive at
the hospital, and was restarted on Amlodipine 5mg [**Hospital1 **] and
metoprolol tartate 25mg [**Hospital1 **]. She was switched from atenolol to
metoprolol because of her elevated creatinine.
Past Medical History:
1. Hypertension, currently on amlodipine and metoprolol
2. Hypothyroidism, on levothyroxine
3. Anxiety - takes diazepam prn
4. CHF. Per OSH cardiology consult, CHF R<L, hyperdynamic LV,
mod-severe TR, mod PA HTN
5. H/O PNA one month ago
6. CKD, baseline creatinine unknown
7. PUD, now s/p duodenal ulcer cauterization
8. Osteoporosis
Social History:
Lives at home with her husband. [**Name (NI) **] son lives next door. Able
to perform ADLs with some difficulty. Former smoker quit 20
years ago, 50 pack years. EtOH of [**1-6**] drinks per day. Denies
past history of withdrawal, has gone ??????2-3 days?????? without a drink.
Family History:
Non-contributory
Physical Exam:
O: Vitals 97.8 96.5 148-172/60s 60 20 99% 2L
Gen: Well appearing, interactive, sitting in bed eating
breakfast, NAD
Neuro: AAOx3. Attention intact via WORLD backwards. CN II-VI
intact via PERRL, EOMI, visual fields. CNV intact via facial
sensation bilaterally. CN VII intact via symmetric smile,
eyebrow raise. CNVIII intact via response to tuning fork
bilaterally. CN IX,X intact via uvula midline. CNXI via shoulder
shrug, head turn strength bilaterally. CNXII intact via tongue
midline. Biceps and patellar reflexes 2+ bilaterally. Cerebellar
function intact via finger-to-nose. Strength 5/5 in biceps,
hiops, knees and ankles bilaterally.
HEENT: Moist mucous membranes. Oropharynx without lesions. Some
white plaques on tongue, patient reports these come off with
brushing.
No cervical, submandibular, occipital, supraclavicular or
axillary lymphadenopathy
CV: RRR, grade II/VI systolic murmur heard best over left
sternal border.
Pulm: CTAB. Good aeration bilaterally. No crackles or wheezes
appreciated
Abd: +BS 4Q. Soft, non-tender, non-distended. No masses.
Extrem: warm, well-perfused. Strong dorsalis pedis and medial
malleolar pulses bilaterally. No edema. Pneumoboots on.
Skin: No rashes. Ecchymoses around PIV sites.
Pertinent Results:
Laboratory data on admission:
GLUCOSE-95 UREA N-36* CREAT-1.6* SODIUM-144 POTASSIUM-4.0
CHLORIDE-111* TOTAL CO2-25 ANION GAP-12
ALT(SGPT)-24 AST(SGOT)-37 LD(LDH)-210 ALK PHOS-84 TOT BILI-1.4
ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.7 IRON-48
VIT B12-1085* FOLATE-GREATER TH FERRITIN-209*
TSH-5.1*
FREE T4-1.2
WBC-6.7 RBC-3.84* HGB-12.0 HCT-33.8* MCV-88 MCH-31.1 MCHC-35.4*
RDW-17.2*
NEUTS-73.4* LYMPHS-17.3* MONOS-5.6 EOS-3.5 BASOS-0.3
PLT SMR-VERY LOW PLT COUNT-68*
PT-12.7 PTT-28.7 INR(PT)-1.1
CT ABD/PELVIS [**10-11**]:
1. Evidence of severe portal hypertension, with widely
recanalized umbilical
vein, ascites and splenomegaly, likely related to chronic liver
disease.
2. Anasarca. Small bilateral pleural effusions, with related
bibasilar
atelectasis.
3. Mild thickening and stranding surrounding second and third
portions of
duodenum.
4. If there is concern for pancreatic mass, as can be seen in
Zollinger-
[**Doctor Last Name 9480**] syndrome, dedicated CTA pancreas would be required. No
suggestion of pancreatic mass seen on the current study which
was not designed to evaluate the pancreas.
5. Status post hysterectomy.
CXR [**10-9**]:
AP chest reviewed in the absence of prior chest radiographs:
Heart is mildly enlarged. There may be extremely heavy mitral
annulus calcification. Left pleural effusion is small. A
probable small hiatus
hernia obscures some of the left lung base. Lungs are otherwise
clear aside from mild vascular congestion. No pneumothorax.
EGD [**10-10**]:
Erosion in the pre-pyloric region
Ulcers in the distal bulb and second part of the duodenum
(thermal therapy)
Otherwise normal EGD to jejunum
Brief Hospital Course:
Ms. [**Known lastname **] is an 86 year old female with PMH significant for
peptic ulcer disease, hypertension, hypothyroidism, CHF who was
trasnferred from OSH for management of GI bleed.
#GI Bleed: At OSH, the patient had melena and BRBPR and required
multiple transfusions. She has evidence of a lower duodenal
bleed by trbc scan, capsule endoscopy and EGD. At [**Hospital1 18**], an EGD
showed lower duodenal ulcers which were then cauterized. H.
pylori serology was negative. She remained hemodynamically
stable and did not have further episodes of bleeding, and she
was discharged with pantoprazole and sucralfate. Please note
that strong consideration should be given to obtaining a serum
gastrin level to rule out Zollinger [**Doctor Last Name 9480**] syndrome given her
multiple duodenal ulcers.
# Acute blood loss anemia: She was transferred a total of 12
units of PRBCs at the OSH, along with FFP and platelets. Her
hematocrit remained stable at [**Hospital1 18**], without need for additional
platelet transfusions. B12 and folate levels were within normal
limits.
# Thrombocytopenia: The patient had an initial platelet count of
144 at OSH, which then dropped to 55. She received FFP and
platelets at OSH. Her thrombocytopenia was likely due to an
active bleed and platelet consumption. Her platelet count
improved during her hospital stay and was 113 at discharge.
# CHF: Per OSH, the patient has hyperdynamic LV function,
moderate TR and PA hypertension. The etiology of her CHF is
unclear, though OSH reports suggest primary pulmonary pathology,
and diastolic dysfunction.
# HTN: The patient's blood pressures were elevated and she was
restarted slowly on her antihypertensives. Her atenolol was
switched to Metoprolol due to chronic kidney disease, as
atenolol is renally cleared. Recommend maintaining the patient
on Amlodipine and Metoprolol XL 50 mg qd.
# CKD: Baseline Cr unknown; 1.7-1.9 at OSH, around 1.5 at [**Hospital1 18**].
If another antihypertensive is added to her regimen, consider
ace-inhibitor given renal function.
# Hypothyroidism: TSH elevated, free T4 wnl. Levothyroxine was
continued.
# Severe portal HTN: CT scan showed signs of severe portal
hypertension, ascites and splenomegaly. No transaminitis.
Further work-up was not pursued, but should be
considered in the out-patient setting, including referral to the
[**Hospital1 18**] Liver Center if judged appropriate.
# EtOH: The patient admits to drinking [**1-5**] drinks daily, but
says she can stop when she wants. She says she began drinking
more when her husband left his job. She has not exhibited any
signs of withdrawal. Her EtOH use is particularly concerning
given her use of diazapam for anxiety. She is at risk for
thiamine defiency and was repleted. She should continue her
MVI.
Medications on Admission:
Medications at home:
amlodipine 5 mg [**Hospital1 **]
atenolol 50 mg QAM
levoxyl 50 mcg daily
diazepam prn
imdur 30 mg daily
Medications on transfer:
Protonix IV 8 mg/hr
albuterol/ipratropium nebs QID
amlodipine 5 mg [**Hospital1 **]
atenolol 50 mg daily
lasix 20 mg daily
isosorbide mononitrate 30 mg daily
levothyroxine 50 mcg daily
reglan [**4-12**] IV prn
tylenol prn
colace
senna
diazepam 2.5 mg prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Isosorbide Mononitrate 30 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*
6. Diazepam Oral
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. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Acute upper GI bleed secondary to duodenal ulceration
2. Acute blood loss anemia
3. Chronic diastolic heart failure
4. Thrombocytopenia
5. Stage 1 chronic kidney disease
6. Portal hypertension
Discharge Condition:
Stable
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital.
You were admitted to [**Hospital1 18**] because you had bleeding coming from
your digestive system. We did studies that looked at your
digestive system and found ulcers that may have been causing the
bleeding. We burned some of these ulcers so that they would no
longer bleed. It is very important that you decrease your
alcohol intake and also your use of ibuprofen or Aleve, as these
things can irritate your digestive system and cause more
bleeding. You should have outpatient follow up with a
gastroenterologist and your primary care doctor.
Please call your doctor or go to the emergency department if you
experience dark or bloody stools, bright red blood coming from
your rectum, blood in your vomit, lightheadedness, fevers,
chills, shortness of breath, or other concerning symptoms.
Please take all of the medications listed below. Please attend
all of your outpatient appointments.
Followup Instructions:
1. Please make an appointment to be seen by a doctor at the
[**Hospital1 18**] Gastroenterology Department in the next two weeks. The
phone number is ([**Telephone/Fax (1) 451**]
2. Please see your primary care doctor within the next week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2138-10-21**]
|
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icd9pcs
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75,759
| 198,316
|
17269
|
Discharge summary
|
report
|
Admission Date: [**2122-6-28**] Discharge Date: [**2122-7-9**]
Date of Birth: [**2053-9-21**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Nausea, vomiting, epigastric pain
Major Surgical or Invasive Procedure:
percutaneous transhepatic cholangiography
History of Present Illness:
This patient is a 68M with history of IgG4 associated autoimmune
cholangitis/primary sclerosing cholangitis, autoimmune
pancreatitis, and compensated cirrhosis (biopsy [**2114**], removed
from transplant list in [**2-/2122**] due to low MELD score), as well
as insulin dependent diabetes who presents to the Emergency
Department on [**2122-6-28**] with 24-hour history of nausea/vomiting
and tremors/rigors.
.
The patient reports he had uncooked seafood on Friday, then
epigastric pain and nausea/vomiting started yesterday afternoon.
Minimal PO intake since then, [**2-19**] ongoing nausea. Blood sugars
running up to high 200s. Denies F/C/S, CP, SOB, palpitations.
Notes that his belly has appeared larger over past week.
.
Of note, patient was admitted in [**2119**] with same presentation.
MRCP showed cholangiohepatitis. Had IR-guided internal and
external biliary drains placed. BCx grew pan-sensitive E coli.
Treated with IV Zosyn while inpatient, discharged on PO
Cipro/Flagyl.
.
In the ED, triage vitals were 98.4 103 102/71 18 98%. Labs
notable for WBC of 27.8 with 11% bands, lactate of 3.5,
creatinine 1.6 (baseline 0.8), t-bili 1.8, and AST 236, ALT 127.
Blood cultures obtained. ECG per report sinus tachycardia 102,
no ischemic changes. Noncontrast CT abdomen/pelvis wetread
showed no acute process. CXR wet read showed possible bibasilar
process, cannot rule out infection.
Liver was consulted in the ED, no recs so far. ERCP was
consulted as well, and stated he is not candidate for ERCP
(anatomy not amenable); would need IR-guided drainage of biliary
fluid. IR was then consulted and is aware of patient. Patient
was started on Vanc/Cipro/Flagyl. He was given total 4L IV NS in
ED. He spiked fever to 102, and was given Tylenol 1 gram and
Ibuprofin 600mg. Foley was placed, drained 600cc urine. Vitals
prior to transfer: 121/84, satting mid 90s on 2-3L NC (switched
to NRB prior to transfer because NC falling off).
.
On arrival to the MICU, vitals are: 103.1 84/48 138 30 94% NRB.
Patient AAOx3, mildly flushed and diaphoretic, NAD, talking
comfortably. Endorses mild LUQ pain and mild dyspnea. Denies
nausea, chest pain, dysuria, diarrhea, palpitations, rash,
arthralgia.
Past Medical History:
-IgG4 assoc. autoimmune cholangitis/primary sclerosing
cholangitis
-Cirrhosis
-Autoimmune pancreatitis
-Hx ascending cholangitis
-S/p bilateral percutaneous biliary drain placements
-S/p distal pancreatectomy and splenectomy, side-to-side
-Roux-en-Y hepaticojejunostomy, TruCut biopsy of the liver,
intraoperative choledochoscopy, and intraoperative
cholangiogram, performed on [**2113-6-14**] for primary sclerosing
cholangitis and lymphoplasmacytic sclerosing pancreatitis.
-DMII, insulin dependent
-Bilateral inguinal hernia repair [**2095**]
-S/p BCC excision
-S/p laparascopic cholecystectomy [**2112**]
-Psoriasis
Social History:
Lives with wife at home. Works in Human Resources, getting ready
to retire. Drinks heavily, about [**1-19**] gallon of liquor per week.
Denies tobacco or illicits.
Family History:
Father with CVA 80s.
Physical Exam:
ADMISSION
Vitals: 103.1 84/48 138 30 94% NRB.
General: [**Male First Name (un) 4746**], AAOx3 diaphoretic and flushed, mildly short of
breath while talking
HEENT: sclera anicteric, dry MMs, PERRL, EOMI
Neck: flat neck veins. No JVD, no LAD.
Cardiac: RRR S1 S2 no rubs/murmurs/gallops
Lungs: fine crackles at bases, no wheezes/rhonchi
[**Last Name (un) **]: softly distended, obese, +BS, no fluid wave, no peritoneal
signs, no HSM/masses
Extrem: WWP 2+ pulses no C/C/E
Neuro: CN II-XII grossly intact
.
DISCHARGE
Vitals: afebrile, BPs 120s-130, HR 80s, 18, mid-90s on RA
Gen: AOx3, appropriate and pleasant, NAD, breathing comfortably
HEENT: sclera anicteric, moist MMs, PERRL, EOMI
Cardiac: RRR S1 S2 no rubs/murmurs/gallops
Lungs: fine crackles at bases, no wheezes/rhonchi
[**Last Name (un) **]: soft, slightly distended, +BS, no fluid wave, no
tenderness, biliary drain in place and c/d/i
Extrem: WWP 2+ pulses no C/C/E
Neuro: CN II-XII grossly intact, normal gait
Pertinent Results:
ADMISSION LABS:
[**2122-6-28**] 03:45PM BLOOD WBC-27.8*# RBC-4.30* Hgb-14.3 Hct-43.9
MCV-102* MCH-33.1* MCHC-32.5 RDW-13.4 Plt Ct-236
[**2122-6-28**] 03:45PM BLOOD Neuts-82* Bands-11* Lymphs-2* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2122-6-28**] 03:45PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Target-OCCASIONAL How-Jol-1+ Pappenh-OCCASIONAL
[**2122-6-29**] 12:07AM BLOOD PT-15.4* PTT-35.6 INR(PT)-1.4*
[**2122-6-29**] 12:07AM BLOOD Fibrino-435*
[**2122-6-28**] 03:45PM BLOOD Glucose-248* UreaN-37* Creat-1.6* Na-132*
K-5.0 Cl-94* HCO3-24 AnGap-19
[**2122-6-28**] 03:45PM BLOOD ALT-127* AST-236* AlkPhos-124
TotBili-1.8*
[**2122-6-28**] 03:45PM BLOOD Lipase-11
[**2122-6-28**] 03:45PM BLOOD Albumin-3.7
[**2122-6-28**] 03:55PM BLOOD Lactate-3.5*
.
DISCHARGE LABS
[**2122-7-9**] 06:05AM BLOOD WBC-9.8 RBC-3.65* Hgb-12.1* Hct-37.4*
MCV-102* MCH-33.0* MCHC-32.3 RDW-13.9 Plt Ct-629*
[**2122-7-9**] 06:05AM BLOOD PT-12.8* PTT-30.6 INR(PT)-1.2*
[**2122-7-9**] 06:05AM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-135
K-4.2 Cl-101 HCO3-27 AnGap-11
[**2122-7-9**] 06:05AM BLOOD ALT-29 AST-30 AlkPhos-153* TotBili-1.7*
[**2122-7-9**] 06:05AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.0 Mg-2.0
[**2122-6-30**] 03:52AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2122-6-30**] 03:52AM BLOOD HCV Ab-NEGATIVE
.
MICROBIOLOGY:
-Blood cultures ([**2122-6-28**]): pan-sensitive E.coli
-Blood cultures [**Date range (1) 48372**]: no growth
-Urine cultures ([**2122-6-28**]): no growth
.
CT ABD/PELVIS WITHOUT CONTRAST ([**2122-6-28**]):
1. No definite acute intra-abdominal process to explain the
patient's
symptomatology. There is no indication or biliary dilatation,
but evaluation is difficult on non-contrast CT; ultrasound or MR
may be helpful to evaluate the liver further, noting high
clinical suspicion for a biliary cause of severe infection.
2. Fatty infiltration of the liver.
.
CHEST X-RAY ([**2122-6-28**]): Bibasilar opacification, increased but
non-specific. Pneumonia is a consideration but the appearance
could be compatible with atelectasis. Correlation with a CT
performed earlier on the same day is also more concordant with a
noninfectious explanation, however.
.
TTE [**6-29**]: The left atrium is mildly dilated. 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%). Right ventricular chamber size is normal.
with mild global free wall hypokinesis. The diameters of aorta
at the sinus, ascending and arch levels are normal. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity size with low normal global LV systolic function and mild
right ventricular free wall contractility. Pulmonary artery
hypertension. Mild mitral regurgitation.
.
Biliary Drain placement [**6-29**]
1. Successful percutaneous access to the right anterior biliary
ducts.
2. Moderate-to-severe focal stricture involving the right
intrahepatic
central duct at the junction of the right anterior and posterior
ducts.
3. Balloon dilatation of the right-sided ductal stricture up to
6 mm with persistence of the stenosis after balloon dilatation.
4. Uncomplicated placement of 8 French internal-external
biliary drainage catheter via the right anterior ductal system
and across the
hepaticojejunostomy.
.
CXR [**6-29**]
Interval increase in now moderate pulmonary edema, with
bibasilar opacities which may reflect atelectasis, though
infection is not excluded.
.
MRCP [**7-2**]
1. Multifocal intrahepatic biliary strictures are unchanged in
location
compared to the prior study. There is more marked signal
abnormality within the liver parenchyma surrounding the dilated
segments II and III of bile duct suggestive of acute on chronic
cholangitis. This is very similar in location compared to the
prior study; however, the degree of biliary duct dilatation,
particularly in the left lobe, has increased
There is a similar but less marked appearance in segment V. No
new strictures seen.
.
CXR [**7-5**]
There are lower lung volumes. Cardiac size is top normal.
Small bilateral pleural effusions are unchanged. Bibasilar
opacities have minimally improved, could be due to atelectasis
but superimposed infection cannot be excluded. Pulmonary edema
has markedly improved. There is no evident pneumothorax.
Brief Hospital Course:
68M with history of IgG4 associated autoimmune
cholangitis/primary sclerosing cholangitis, autoimmune
pancreatitis, and compensated cirrhosis (biopsy [**2114**], removed
from transplant list in [**2-/2122**] due to low MELD score), h/o
ascending cholangitis s/p [**Name (NI) 48373**] PTC ([**2119**]), s/p lap chole
([**2112**]), and insulin dependent diabetes who presents with nausea,
vomiting and rigors, found to be sepsis with concern for
ascending cholangitis as source.
.
# SEPSIS/CHOLANGITIS:
The patient presented in a septic shock state, received a
central line and was started on levophed and neo. The patient
went for a percutaneous biliary drain and following the
procedures aggressive fluid resuscitation continued so he was
off pressors by HD2. There was a question of possible shellfish
consumption prior to the onset of symptoms so antibiotic
coverage was initially broad and included coverage for vibrio.
The patient had [**4-22**] GNRs in blood cultures, but he was contined
on broad coverage in the setting of septic shock until
speciation/sensitivities on [**7-1**] showed pan-sensitive E.coli at
which time he was narrowed to IV ciprofloxacin. His bilirubin
rose to 3 on [**7-2**] so he underwent repeat MRCP which showed some
increased dilation in the left lobe of the liver but no new
strictures. As he remained afebrile and clinically well with
stable bilirubin and alkaline phosphatase, his drained was
capped on [**7-3**]. Patient did spike a low-grade fever to 100.2
after drain capping. He was broadened to IV cipro and flagyl but
the drain remained capped and he had no further fevers. On [**7-8**],
patient was transitioned to oral ciprofloxacin and he remained
afebrile with downtrending WBC count. He was discharged on oral
ciprofloxacin which he will continue until about five days after
the drain is removed. Decision to remove the drain will be made
between IR and hepatology.
.
# HYPOXIA
**ICU Course**
As above, likely due to aggressive volume resuscitation, no
indication of acute infectious pulmonary process on CXR, O2
requirements was weaned and he is currently saturating from
97-98% on 3L nasal cannula. No increase in cough and no sputum
production was noted.
***MEDICINE COURESE***
Patient arrived to floor on 2L nasal cannula, as urine output
was significant no additional diuretics were administered.
Earlier CXR read was concerning for multifocal pneumonia though
patient without pulmonary symptoms. By time of transfer to the
liver service, he was requiring 4L nasal cannula. CXR was
suggestive of volume overload versus infectious process but
patient had no symptoms of infection and was afebrile so he was
aggressively diuresed and his hypoxia resolved. He was satting
well on room air and without any dyspnea at the time of
discharge.
.
# [**Last Name (un) **]: Presented with creatinine of 1.6 that was likely ATN in
setting of sepsis causing poor end-organ perfusion. This
resolved with volume resuscitation. He auto-diuresed well and
was at his baseline creatinine at discharge.
.
# H/O COMPENSATED CIRRHOSIS: AST 236, ALT 127. Pt reports
significant EtOH intake, [**1-19**] gallon liquor per week. LFT
elevation most likely [**2-19**] ascending cholangitis per above, but
initial 2:1 ratio also raised concern for alcoholic hepatitis.
Hepatology felt unlikely ETOH related and more likely due to
biliary process. LFTs continued improve throughout his
admission.
.
#Cardiac:
Septic cardiomyopathy is routinely seen in septic patients -
there was no EKG indication of an acute coronary event and the
patient has had excellent hemodynamics since being weaned off
pressors on HD2. No additional studies or measures were taken.
.
# H/O AUTOIMMUNE PANCREATITIS and PSC: Patient is s/p Whipple
due to PSC. He was continued on his home Creon and ursodiol
.
# IDDM: He was maintained on a diabetic diet and his home
insulin regimen.
.
Transitional Care Issues:
-EtOH: continue social work help with this
-Cholangitis: Patient will remain on oral cipro until biliary
drain is removed. Decision to remove drain will occur between IR
and hepatology once infection is felt to be cleared.
-IgG4 disease: Patient will follow-up with his hepatologist
regarding potential steroid therapy for his disease once his
infection has resolved
Medications on Admission:
-insulin glargine 26u
-regular insulin sliding scale
-creon [**Numeric Identifier 890**] six capsules TID
-omeprazole 20mg daily
-ursodiol 1500mg daily
-vardenafil 20mg daily
-aspirin 81mg daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Creon 12 6 CAP PO TID W/MEALS
3. Ursodiol 1500 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *Cipro 500 mg twice a day Disp #*60 Each Refills:*0
6. Multivitamins 1 TAB PO DAILY
7. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
E.coli bacteremia
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 48374**]. You
were admitted with nausea and vomiting. You were found to have a
bacterial infection from your biliary tract (cholangitis). You
were started on antibiotics and your condition improved. An
internal-external biliary drain was placed. You completed a
course of IV antibiotics. You will leave the hospital on an
antibiotic you can take by mouth. You will need to continue to
take this antibiotic until the drain is removed.
Please continue your home medications with the following
changes:
1. Ciprofloxacin
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2122-7-20**] at 8:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"584.5",
"V45.89",
"E944.4",
"785.52",
"571.2",
"514",
"V58.67",
"276.1",
"038.42",
"696.1",
"303.90",
"576.1",
"995.92",
"577.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.51",
"38.97",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
14145, 14151
|
9277, 13165
|
302, 346
|
14225, 14225
|
4434, 4434
|
14986, 15250
|
3408, 3430
|
13805, 14122
|
14172, 14204
|
13585, 13782
|
14376, 14963
|
3445, 4415
|
229, 264
|
13191, 13559
|
374, 2568
|
4450, 9254
|
14240, 14352
|
2590, 3211
|
3227, 3392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,294
| 149,551
|
25918
|
Discharge summary
|
report
|
Admission Date: [**2148-12-30**] Discharge Date: [**2149-1-7**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2148-12-30**]: ORIF Right femur fx
[**2148-12-30**]: Removal of large LLL PE
[**2148-12-30**]: IVC filter placement
History of Present Illness:
Ms. [**Known lastname 59353**] is an 82 year old female who sustained a mechanical
fall resulting in a right femur fracture. She presentes for
evaluation.
Past Medical History:
PMH: CAD h/o IMI, CABGx4 '[**35**], CHF (BNP 1600 at baseline), LBBB,
AF, HTN, CRI, CVA [**3-25**] & TIA [**7-25**] w/o residual effect,
depression, diverticulitis, hemorrhoids, kyphoscoliosis, h/o
LGIB, fatty liver and h/o ascites, h/o fecal impaction, h/o
urinary retention requiring foley at home, gout, osteoporosis,
renal carcinoma [**2122**], hyperlipidemia (no h/o pulm dz or
diabetes), h/o benign abdominal tumor removed, sacral decubiti
PSH: Distal R supracondylar fx repair ([**2148-12-30**]); CABGx4 [**2135**].
CCY, TAH BSO, APPY, R nephrectomy [**2122**], benign abdominal tumor
removal
Social History:
Lives with daughter [**Name (NI) **]
works part time at [**Name (NI) 39532**]
Uses walker at baseline
Family History:
n/c
Physical Exam:
Upon admission
Alert
Cardiac: Regular rate rhythm
Chest: Lungs clear
Abdomen: Soft non-tender non-distended
Extremities: RLE +sensation/movment/pulses, +deformity no open
area
Pertinent Results:
[**2149-1-6**] 03:12PM BLOOD WBC-15.3*# RBC-2.75* Hgb-8.6* Hct-24.6*
MCV-90 MCH-31.4 MCHC-35.1* RDW-18.1* Plt Ct-111*#
[**2149-1-5**] 06:26PM BLOOD WBC-10.5 RBC-2.94* Hgb-9.2* Hct-25.7*
MCV-87 MCH-31.3 MCHC-35.8* RDW-17.2* Plt Ct-68*
[**2149-1-4**] 08:59PM BLOOD Hct-28.1*
[**2149-1-4**] 05:36AM BLOOD WBC-9.6 RBC-2.86* Hgb-9.2* Hct-25.0*
MCV-88 MCH-32.1* MCHC-36.7* RDW-17.5* Plt Ct-53*
[**2149-1-3**] 02:54AM BLOOD WBC-8.9 RBC-3.06* Hgb-9.3* Hct-26.5*
MCV-87 MCH-30.2 MCHC-34.9 RDW-17.4* Plt Ct-44*
[**2149-1-2**] 05:06PM BLOOD WBC-9.9 RBC-3.25* Hgb-9.8* Hct-27.7*
MCV-85 MCH-30.2 MCHC-35.4* RDW-17.3* Plt Ct-56*
[**2149-1-2**] 12:00PM BLOOD WBC-12.9* RBC-3.32* Hgb-10.2* Hct-28.7*
MCV-86 MCH-30.7 MCHC-35.5* RDW-17.2* Plt Ct-60*
[**2149-1-2**] 04:30AM BLOOD WBC-13.5* RBC-3.63* Hgb-10.8* Hct-30.7*#
MCV-85 MCH-29.9 MCHC-35.3* RDW-16.6* Plt Ct-60*#
[**2149-1-1**] 09:12PM BLOOD Hct-21.4*
[**2149-1-1**] 04:25PM BLOOD Hct-23.8*
[**2149-1-1**] 10:50AM BLOOD Hct-25.7*
[**2149-1-1**] 03:32AM BLOOD WBC-18.6* RBC-3.06* Hgb-9.2* Hct-26.1*
MCV-85 MCH-30.1 MCHC-35.3* RDW-17.2* Plt Ct-124*
[**2148-12-31**] 05:56PM BLOOD Hct-28.0*
[**2148-12-31**] 11:22AM BLOOD Hct-30.3*
[**2148-12-31**] 08:31AM BLOOD Hct-31.7*#
[**2148-12-31**] 04:55AM BLOOD Hct-24.0*
[**2148-12-31**] 02:45AM BLOOD WBC-15.1* RBC-3.19* Hgb-9.8* Hct-28.3*
MCV-89 MCH-30.7 MCHC-34.7 RDW-16.9* Plt Ct-123*
[**2148-12-31**] 12:16AM BLOOD Hct-29.6*
[**2148-12-30**] 03:09PM BLOOD WBC-19.3*# RBC-3.52* Hgb-11.1* Hct-31.9*
MCV-91 MCH-31.5 MCHC-34.8 RDW-16.5* Plt Ct-103*
[**2148-12-30**] 12:20AM BLOOD WBC-11.3* RBC-3.19* Hgb-10.2* Hct-29.8*
MCV-93 MCH-32.1* MCHC-34.4 RDW-16.4* Plt Ct-146*
[**2148-12-30**] 12:20AM BLOOD PT-13.6* PTT-23.7 INR(PT)-1.2
[**2149-1-6**] 03:02AM BLOOD Glucose-156* UreaN-78* Creat-5.8* Na-137
K-4.3 Cl-106 HCO3-19* AnGap-16
[**2149-1-5**] 05:45AM BLOOD Glucose-118* UreaN-72* Creat-5.3* Na-139
K-4.6 Cl-107 HCO3-17* AnGap-20
[**2149-1-4**] 01:52AM BLOOD Glucose-98 UreaN-66* Creat-4.8* Na-138
K-5.1 Cl-107 HCO3-18* AnGap-18
[**2148-12-30**] 12:20AM BLOOD Glucose-129* UreaN-43* Creat-1.7* Na-142
K-4.1 Cl-105 HCO3-24 AnGap-17
[**2148-12-30**] 03:09PM BLOOD Glucose-206* UreaN-37* Creat-1.7* Na-139
K-4.9 Cl-108 HCO3-16* AnGap-20
[**2148-12-31**] 02:45AM BLOOD Glucose-152* UreaN-38* Creat-2.0* Na-138
K-4.3 Cl-110* HCO3-18* AnGap-14
Brief Hospital Course:
Ms. [**Known lastname 59353**] presented to the [**Hospital1 18**] on [**2148-12-30**] after a fall. She
was evaluated by the orthopaedic surgery department and found to
have a right femur fracture. She was then prepped and consented
and taken to the operating room. In the operating room the
surgery was uneventful until the end when she became hypotensive
and was suspected of having a pulmonary embolism. She was taken
from the operating room directly to the Angio suite where a
catheter noted a large left lower lobe embolism which was broken
up. Also in Angio an IVC filter was placed. She was then taken
to the intensive care unit remaining intubated and sedated with
a swan ganz catheter in place. She went into acute renal
failure and was started on a Lasix drip. Also she was placed on
argatroban due to developing heparin induced thrombocytopenia.
On [**2149-1-4**] a hemodialysis catheter was placed and she was
started on CVVHDF with little response. [**2149-1-6**] she was made a
DNR/DNI by her family and was extubated. She passed away on
[**2149-1-7**].
Medications on Admission:
Lasix 120/80
coreg 6.25"
lovastatin 40'
Kdur 20"'
colace prn
vitamin E
MVI
vicodin prn
bactroban for buttocks
nitroquick PRN
ASA 325'
plavix 75 (on hold since [**2148-12-12**])
Naproxen 375"
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
right femur fracture
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2150-3-29**]
|
[
"401.9",
"821.23",
"585.9",
"V45.73",
"428.0",
"997.1",
"V45.81",
"V10.52",
"427.31",
"427.5",
"E885.9",
"584.5",
"415.11",
"518.5",
"285.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.72",
"38.93",
"96.6",
"79.35",
"88.43",
"99.04",
"88.72",
"99.05",
"00.17",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
5259, 5268
|
3910, 4990
|
276, 399
|
5332, 5341
|
1566, 3887
|
5393, 5557
|
1344, 1349
|
5231, 5236
|
5289, 5311
|
5016, 5208
|
5365, 5370
|
1364, 1547
|
228, 238
|
427, 584
|
606, 1209
|
1225, 1328
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,340
| 144,841
|
9184
|
Discharge summary
|
report
|
Admission Date: [**2136-5-28**] Discharge Date: [**2136-6-7**]
Date of Birth: [**2071-10-10**] Sex: M
Service: MEDICINE
Allergies:
Tegaderm / Prinivil / Reglan
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
debridement of right foot ulcer
PICC line placement
History of Present Illness:
[**Known firstname **] [**Known lastname **] 64 yo male hx of PVD, DM s/p renal transplant
[**2130**]. and ulcers. Patient states that he has been nauseated
with vomiting and diarrhea for the past 2 weeks. He reports
having decreased food intake and that he has not been able to
take or keep his medications down consistently. He states that
in the past when he has been hyperglycemic, he has not had
nausea and vomiting like this. He also reports SOB and DOE for
the past 4-5 days. He denies orthopnea and PND. He reports some
edema in his legs bilat which is a chronic problem. [**Name (NI) **] came to
the ER today because his wife finally made him after his
temperature spiked to 102. Patient also has chronic ulcers. His
wife helps care for them and has not noticed any increasing
erythema 2 days ago when last she changed the dressing.
However, in ED, found to have swollen RLE with right ulcers some
and surrounding erythema concerning for celluliti. In ED found
to be hyperglycemic with BS of 420 and AG 24. They treated him
with SQ insulin rather than an insulin drip because they were
concerned about hypoglycemia. ED with q 1-2 hr fingersticks
brought AG down to 16 currently.
ED concerned about possible cellulitis started on Vanco and
unsyn for cellulitis. xray of leg did not show osteomyelitis.
CXR clear. [**Name (NI) **] was consulted and they took a foot cx.
Podiatry also saw patient. Patient was going go to floor when
INR came back at 20.0. Patient then given FFP x1 unit and Vit K.
Past Medical History:
1. Coronary artery disease s/p CABG X 4 in [**2128**]. Echo [**9-2**] nml
LV function
2. Type 1 Diabetes with complications including retinopathy,
neuropathy, end-stage renal disease, and Charcot foot
3. End-stage renal disease status post cadaveric renal
transplant [**10-1**]
4. Right lower extremity DVT since [**7-4**] requiring life-long
anticoagulation on coumadin and IVC filter placement
5. Hypertension
6. GERD
7. Osteopenia of hip [**10-31**]
8. Neuropathy Rfoot > Lfoot
9. Bilateral cataract surgery
[**37**]. Right foot surgery and Charcot foot [**12/2125**]
11. Diverticulosis
12. Status post flexible bronchoscopy with biopsy of RUL,
lingula [**4-3**]
13. Cryptococcus pneumonia, treated with Fluconazole
14. ORIF left ulna [**4-3**]
15. IVC filter placement [**4-3**]
16. [**2135-6-9**]: Abdominal aortogram with RLE extremity
runoff, angioplasty of popliteal stenosis.
Social History:
He retired from his job as an electrician in the Marine Corps,
which required travel to HI, CA, NC, [**Country 5976**]. He lives at home with
his supportive wife. They have 3 children (M36, F34, M26).
Alcohol: History of up to [**7-8**] drinks daily, 5x/wk for many
years, only 1-2 beers/ week recently.
Tobacco: 30 pack years, quit [**2121**] after MI.
Family History:
DM type II in father and paternal grandfater. Mother had "heart
disease."
Physical Exam:
Tmax: 38.4 ??????C (101.2 ??????F)
Tcurrent: 38.4 ??????C (101.2 ??????F)
HR: 82 (82 - 93) bpm
BP: 127/52(69) {123/51(68) - 127/52(69)} mmHg
RR: 20 (20 - 22) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 65 Inch
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral [**Year (4 digits) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed), capillary refill WNL
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, Obese
Extremities: Right: 1+, Left: Trace, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed, Rash: area of erythema on right lower leg
surrounding wound. purpura present on back of hands.
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
person, place & time, Movement: Purposeful, Tone: Not assessed
Pertinent Results:
Admit labs:
134 90 34
---------------< 420
3.8 20 2.1 D
LDH: 296
.
WBC: 12.3
HCT: 37.8
PLT: 243
N:88.9 L:7.5 M:3.5 E:0.1 Bas:0.1
.
HCT: 37 -> 32 -> 29
AG: closed prior to d/c out of ICU
.
CXR: neg
Ankle: Cortical irregularity and soft tissue swelling at the
base of the
fifth metatarsal are unchanged. Stable neuropathic changes in
the mid foot. No new areas identified to indicate osteomyelitis.
.
EKG: NSR, Q III, no acute ST-T changes
.
Brief Hospital Course:
Mr. [**Known lastname **] is a 64 yo male with a history of T1DM s/p cadoveric
renal transplant, chronic RLE ulcers, and IVC filter on
coumadin, who was admitted with DKA in the setting of one week
of N/V, diarrhea and fevers.
#. DKA: Thought [**12-31**] infection (MRSA bacteremia and C diff
colitis found in workup) He received aggressive IVF and IV
insulin bolus but no gtt. His gap closed overnight in the ICU.
EKG without signs of active ischemia. He was restarted on his
home insulin regimen once gap closed, with no further incidents.
#. R FOOT ULCER/CELLULITIS: was previously treated with
linezolid and followed by podiatry as out-patient; seen by
[**Month/Day (2) 1106**] and podiatry on admission. He was started on vanco and
unasyn on admission, and this was narrowed to just vanco after
his culture data returned. Initial wound swab grew MRSA and was
the likely source of MRSA bacteremia. He underwent debridement
in OR by podiatry on [**2136-5-31**], cultures sent from OR and also grew
MRSA. ID consulted and suggested 6 weeks vancomycin: his wound
probes to bone so there was certainly concern for osteomyelitis.
Pathology eventually confirmed acute osteomyelitis. He will
follow up with Dr. [**Last Name (STitle) 31564**] of podiatry.
# MRSA BACTEREMIA: [**12-31**] sets on admission. Source likely foot
ulcer. TTE negative. Surveillance blood cultures neg to date.
Treating with 6 weeks vancomycin as above.
#. NAUSEA/VOMITING, DIARRHEA, C DIFF COLITIS: sx improved with
appropriate tx with flagyl. Will be treated with 2 weeks Flagyl
and if diarrhea recurs while on vancomycin, will consider
retreating with Flagyl.
#. SOB: sx resolved without further intervention. No signs ACS
or pneumonia. Low suspicion PE. No hypoxia
#. Right knee pain: There was initially significant concern for
possible septic knee in the setting of MRSA bacteremia; however
on further evaluation by rheum, they reported that he had no
effusion, no fluid for arthrocentesis. Their differential
included CPPD/crystalline disease, other musculoskeletal such as
meniscal tear, avascular necrosis (chronic steroids), occult
fracture. MRI showed no evidence of meniscal or ligamentous
injury, non-specific circumferential subcutaneous edema, and
only trace joint fluid. His pain improved with conservative
management.
#. Coagulopathy: INR 20 on presentation likely [**12-31**] diarrhea and
poor PO intake over last week; received 1 unit FFP in the ED as
well as vitamin K. INR improved to 6. We held coumadin but
also gave no further vitamin K in the ICU. His INR was allowed
to drift down and was 3.7 on discharge. He will follow up with
[**Hospital3 **] who will determine when he will restart
coumadin.
#. ARF: Cr 2.1 on admission; with IVF in ED. Likely prerenal as
it improved with appropriate hydration. Continued
prednisone/prograf for renal allograft. On resumption of his
outpatient diuretics, his creatinine started rising again.
Diuretics were held as urine lytes suggested this was again
prerenal. Given his worsening lower extremity edema and after
his creatinine had stabilized around 1.7-1.8, Lasix was
restarted at 40mg qd and florinef was stopped.
#. Hx heavy EtOH use: ciwa scale and mvi/folate/thiamine; no
signs withdrawal so CIWA discontinued.
# T1 DM, uncontrolled with complications: as above, DKA
resolved with appropriate insulin IV in ICU and tx of multiple
infections.
# CAD s/p CABG: continued ASA, Plavix
# Anemia: he was guaiac negative and iron studies were
consistent with ACD. Procrit was started in-house, to be
continued as an outpatient.
Medications on Admission:
Medications confirmed with pt's wife who has a handwritten list
OXYCODONE - (Prescribed by Other Provider) - 5 mg Capsule -
as
needed for pain ---> wife says most recently he has been using
percocet
ACETIC ACID (BULK) - (Prescribed by Other Provider) - 3 %
Liquid
- to wash foot wound daily apply dressing after wash
AMLODIPINE [NORVASC] - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ASCENSIA ELITE TEST STRIPS - - USE AS DIRECTED
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth hs
BECAPLERMIN [REGRANEX] - (Prescribed by Other Provider) - 0.01
%
Gel - as needed
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a
day
COUMADIN - 1MG Tablet - one to three Tablet(s) by mouth once a
day
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth once a day
FLUDROCORTISONE [FLORINEF] - 0.1 mg Tablet - 1 Tablet(s) by
mouth
once a day - No Substitution
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth every other day
GLUCAGON EMERGENCY KIT - 1MG Kit - USE AS DIRECTED
IMDUR - 60MG Tablet Sustained Release 24 hr - ONE TABLET EVERY
DAY
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 36 units every noon
METOPROLOL TARTRATE - 50MG Tablet - ONE TABLET TWICE A DAY
NITROQUICK - 0.4MG Tablet, Sublingual - USE 0.4 MG UNDER THE
TONGUE AS NEEDED FOR CHEST PAIN
NOVOLOG - 100 U/ML Solution - SLIDING SCALE - [**First Name8 (NamePattern2) **] [**Last Name (un) **]
OS-CAL 500+D - 500-200 Tablet - ONE TABLET THREE TIMES A DAY
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day
PAPAIN-UREA [ETHEZYME] - (Prescribed by Other Provider) - 1.1
million unit/gram Ointment - as needed
PAPAIN-UREA-CHLOROPHYLLIN [PANAFIL] - (Prescribed by Other
Provider) - 521,700 unit/gram-10 %-0.5 % Ointment - as needed
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq
Tab
Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth once a day
PREDNISONE - 5MG Tablet - ONE Tablet(s) by mouth q day
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 Tablet(s) by mouth once
a week take on empty stomach with lots of water, stay upright
for
30 min afterwards
SILVER SULFADIAZINE - (Prescribed by Other Provider) - 1 %
Cream
- as needed
TACROLIMUS [PROGRAF] - 1 mg Capsule - 1 Capsule(s) by mouth
twice
a day
TRAVOPROST (BENZALKONIUM) [TRAVATAN] - (Prescribed by Other
Provider) - 0.004 % Drops - 1 drop in the left eye once a day
TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] - (Prescribed by Other
Provider) - 400 mg-80 mg Tablet - one Tablet(s) by mouth mon,
wed,fri
Medications - OTC
ALCOHOL SWABS - Pads, Medicated - USE AS DIRECTED
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
500
mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN [ASPIRIN EC] - (OTC) - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) - 500
mg Tablet, Chewable - Tablet(s) by mouth as needed
COLACE - 100MG Capsule - ONE TABLET TWICE A DAY
HYDROCOLLOID DRESSING [AQUACEL HYDROFIBER DRESSING] -
(Prescribed by Other Provider) - Dosage uncertain
HYDROCOLLOID DRESSING [AQUACEL HYDROFIBER DRESSING] -
(Prescribed by Other Provider) - 4" X 4" Bandage - as needed
LANCETS - Misc - AS DIRECTED 5 TIMES PER DAY
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a
day
NON-ADHERENT BANDAGE [ADAPTIC] - (Prescribed by Other Provider)
- Dosage uncertain
POVIDONE-IODINE [BETADINE] - (Prescribed by Other Provider) -
10
% Solution - as needed
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q48H (every 48 hours) for 5 weeks.
Disp:*18 g* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*100 ML(s)* Refills:*1*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection once a week.
Disp:*4 mL* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a
day: in left eye.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
24. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
25. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Insulin Glargine 100 unit/mL Solution Sig: Thirty Six (36)
Units Subcutaneous once a day.
27. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Methicillin Resistant Staph Aureus bacteremia
Right foot ulcer infection
Diabetic ketoacidosis, resolved
Acute renal failure
Clostridium difficile colitis
Secondary:
Type 1 diabetes mellitus with complications
hx of renal transplant
Coronary artery disease, s/p coronary artery bypass graft
peripheral [**Hospital1 1106**] disease
bilateral deep vein thrombosis
Discharge Condition:
stable, afebrile, ambulating with cane
Discharge Instructions:
You were admitted with cellulitis and found to have MRSA
bacteremia, likely from a foot ulcer. The ulcer was debrided by
podiatry and also grew MRSA. You will need IV antibiotics
(vancomycin) for 6 weeks from the date of [**2136-5-31**]. Visting nurses
will draw blood once a week and fax results to the [**Hospital **] clinic.
You should take Flagyl for one more week.
You should continue to hold coumadin. VNA will draw blood for
INR and fax the results to the [**Hospital3 **]. They will
tell you when to resume coumadin.
Resume your Lasix at 40mg daily. Depending on your creatinine
level, this may be adjusted by Dr. [**First Name (STitle) 805**] or Dr. [**Last Name (STitle) **].
If you have recurrent fevers, chills, worsening pain, or any
other concerning symptoms, call your doctor immediately.
If you have recurrent diarrhea, call the [**Hospital **] clinic, as you may
need to restart Flagyl.
Followup Instructions:
Podiatry: follow up with Dr. [**Last Name (STitle) **] in his [**Location (un) 701**] office
on [**6-15**] at 3:10.
PCP: [**Name10 (NameIs) **] up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**]
[**Last Name (NamePattern1) **], on [**6-13**] at 11:10am. You may call his office at
[**Telephone/Fax (1) 250**] with any questions.
[**Telephone/Fax (1) **]: Follow up with Dr. [**Last Name (STitle) **] on [**7-24**] at 1pm.
Renal: Follow up with Dr. [**First Name (STitle) 805**] on [**7-9**] at 11am.
ID: Follow up with Dr. [**Last Name (STitle) 12838**] on [**2136-6-21**] at 1:30pm.
Phone:[**Telephone/Fax (1) 457**]
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53,650
| 184,951
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5394
|
Discharge summary
|
report
|
Admission Date: [**2127-5-6**] Discharge Date: [**2127-5-20**]
Date of Birth: [**2072-9-3**] Sex: F
Service: MEDICINE
Allergies:
Red Dye / Gabapentin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
cough and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 year old female with PMH of hypocomplimentemia (C3 and C4)
and necrobiosis lipoidica with chronic leg ulcers on long term
immunosuppressant therapy who presents today with cough,
dyspnea, diarrhea for the last 4 days. She started having cough
on Saturday w/ overall body malaise and nausea. She then
developed diarrhea ([**1-23**] watery stools on Sunday and Monday)
which then resolved. She was also febrile, but denies having
chills. She denies vomiting, no melana or blood in the stool. No
urinary symptoms, no dysuria, change in urine color or smell.
She has decrease in appetite and minimal PO intake for the last
4 days. The wound in her left leg has been unchanged as per pt.
Today she went to her PCP office and was found to have O2 sats
at 82% with crackles. She denies feeling short of breath and has
a productive cough. She states that her husband was [**Name2 (NI) **] with a
cough last week prior the beginning of her symptoms. She was
placed on non-rebreather with O2 sats improving to 100%. She was
then brought to the ED.
.
Of note, she was hospitalized in [**2124**] for pseudomonal sepsis and
pneumonia. Pt had recurrent UTIs with most recent culture with
pan-sensitive E.coli in [**2126-10-22**]. Pt had multiple UTIs in [**2125**]
included Enterococcus (resistant to tetracycline), Enterobacter,
and pseudomonas resistant to cipro and meropenem. Her leg wound
has been chronic and has required skin grafts it was also
infected back in [**2124**] when pt was septic.
.
In the ED, initial vs 100.1F, 100, 110/60, 20s, 95%4L -> 100%6L
NC. Chest x-ray showed bilateral basilar infiltrates consistent
with multifocal pneumonia. Patient was given vanco 1 g IV,
levoflox 750 mg IV. She was given 1.5 L of IV fluids then had
decrease in SBP to 70s felt "woozy" got 1.5L more still
hypotensive 70-80s (baseline 95-120 SBP). She was then started
on low-dose levophed. Her BP increased to 90/50. She had a right
SC line placed and position verified in the ED.
.
On arrival to the [**Name (NI) 153**], pt is alert and conversing. She is
breathing comfortably on 4L NC and is sating at 95%, temp 98.3,
HR 82, BP 107/57 on levophe.
Review of systems:
(+) Per HPI,
(-) Denies 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:
-Notable for cyclic neutropenia
-Raynaud's phenomenon
-hypothyroidism
-sicca keratitis
-MGUS
-chronic anemia/pancytopenia
-chronic right tibial wound, necrobiosis lipoidica
-connective tissue disease, not otherwise specified
-hypothyroidism.
-hypocomplimentemia (C3 and C4)
-Depression
Social History:
Non-smoker, non-drinker, lives at home with husband and son, but
recently at [**Hospital1 **] for IV abx and wound care. Pharmacy
technician.
Family History:
NC
Physical Exam:
98.3, HR 82, BP 107/57 on 0.04 of levophed, RR 22 on 4L N/C
General: Cachetic, Alert, Ox3 , conversing , no acute distress
HEENT: Sclera anicteric,MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bil bases up to mid-lung fields. No wheezes,
rales, rhonchi
CV: Regular rate and rhythm, II/VI SEM heard at bil upper
sternal boarder no rubs, gallops
Abdomen: soft, concave, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cool, bluish finger and toe tips, 1+ pulses bil LE, no
clubbing. Bil LE with trace of edema L>R, erythema and wound on
left shin area- 6 cmx 1cm wide half moon shape with
Pertinent Results:
ADMISSION LABS:
[**2127-5-6**] 12:40PM BLOOD WBC-4.8 RBC-5.17 Hgb-13.0 Hct-43.0 MCV-83
MCH-25.2* MCHC-30.3* RDW-17.1* Plt Ct-267
[**2127-5-6**] 12:40PM BLOOD Neuts-75.9* Lymphs-10.0* Monos-9.8
Eos-3.7 Baso-0.6
[**2127-5-6**] 09:00PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+
Burr-1+ Acantho-OCCASIONAL
[**2127-5-6**] 09:00PM BLOOD PT-14.8* PTT-38.7* INR(PT)-1.3*
[**2127-5-6**] 12:40PM BLOOD Glucose-64* UreaN-18 Creat-0.9 Na-135
K-3.9 Cl-96 HCO3-29 AnGap-14
[**2127-5-6**] 09:00PM BLOOD ALT-19 AST-24 LD(LDH)-127 AlkPhos-86
TotBili-0.7
[**2127-5-6**] 12:40PM BLOOD cTropnT-<0.01
[**2127-5-6**] 09:00PM BLOOD Albumin-2.3* Calcium-6.5* Phos-2.8
Mg-1.5*
[**2127-5-6**] 09:00PM BLOOD TSH-6.2*
[**2127-5-6**] 01:10PM BLOOD Lactate-2.3* K-3.6
[**2127-5-6**] 09:02PM BLOOD Lactate-1.0
[**2127-5-6**] 09:02PM BLOOD O2 Sat-66
[**2127-5-7**] 05:32PM BLOOD Type-ART O2 Flow-4 pO2-103 pCO2-50*
pH-7.28* calTCO2-24 Base XS--3 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
MICRO:
[**2127-5-6**] 10:55 pm URINE Source: Catheter.
**FINAL REPORT [**2127-5-8**]**
URINE CULTURE (Final [**2127-5-8**]): NO GROWTH.
[**2127-5-6**] 10:55 pm URINE Source: Catheter.
**FINAL REPORT [**2127-5-7**]**
Legionella Urinary Antigen (Final [**2127-5-7**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
SPUTUM (INDUCED): PND
BLOOD CULTURES: PND
IMAGES/STUDIES:
EKG [**2127-5-6**] 12:32:22 PM
Baseline artifact. Sinus rhythm. RSR' pattern in lead V1.
Precordial
and inferior T wave abnormalities. No previous tracing available
for
comparison. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 150 94 [**Telephone/Fax (2) 21910**] -2
CXRAY ON [**2127-5-6**]:
FINDINGS: Single view of the chest was compared to multiple
prior radiographs, the most recent dated [**2125-11-9**] and
CT chest dated [**2125-4-24**]. There are bibasilar opacities
consistent with bilateral lower lung pneumonia. There is also
subtle opacity in the right upper lung. No pleural effusions or
pneumothoraces are identified. The surrounding soft tissue and
osseous structures appear unremarkable.
IMPRESSION: Multilobar pneumonia.
Discharge Labs:
Brief Hospital Course:
54 year old woman with undiagnosed connective tissue disorder
(cyclic neutropenia, hypocomplementemia, necrobiosis lipoidica,
Raynaud phenomenon, MGUS, SICCA, etc) who presented with
multifocal pneumonia and sepsis/septic shock. She presented with
cough, hypoxia, episode of diarrhea, and hypotension. She slowly
improved with broad spectrum antibiotics for health care
associated pneumonia including empiric coverage for
pneumocystis. Induced sputa could not be obtained, so serum
galactomannan and Beta D Glucan assays were ordered.
Beta-d-glucan was negative and galactomannan was borderline
(0.5). Antibiotics were stopped after 7 days of therapy for
bacterial infections, and Bactrim was decreased to prophylactic
dosing. She had good oxygen saturations on room air for several
days prior to discharge. She developed a DVT at the site of her
PICC and superficial thrombosis. Enoxaparin was started and a
CTA was negative for PE. She was discharged on Lovenox for an
anticipated one month course of treatment. She was not bridged
to Coumadin because of inconsistent PO intake and concern that
her INR's would fluctuate widely. Her chronic LLE wound appeared
stable and without infection, and wound care was continued. Her
narcotics were initially decreased significantly given
somnolence and severe constipation. Her MS Contin was then
increased from 15 mg to 30 mg prior to discharge, and she was
instructed to follow-up with her PCP for further upward
titration as needed. She should follow-up with her outpatient
wound specialist as needed. She had one loose bowel movement
each morning for the three mornings prior to discharge. A C.Diff
was sent and was negative. He diarrhea eventually resolved (3
days without diarrhea prior to discharge). She was also noted to
have a standing weight of 74.5 pounds and a BMI of 13. This was
significantly below her ideal body weight of 115 pounds. An
eating disorder protocol was initiated on [**2127-5-16**], with a goal
of obtaining 80% of her ideal body weight. Patient and husband
were in agreement with this plan. She actually ate 100 % of her
meals and gained weight. Her discharge weight was 79 pounds. She
had no evidence of severe electrolyte abnormalities from her low
weight and continued to be asymptomatic. She remained in the
hospital just for monitoring her eating habits and caloric
intake. She was finally discharged home with PCP follow up for
weekly weight measurement and VNA with visiting nutritionist at
home. She was restarted on Lasix 40 MG daily, her usual per
admission dose. I increased her Levothyroxine dose, however, her
elevated TSH was mostly related to [**Date Range **] euthyroid syndrome. A
repeat TSH is needed in about 6 weeks. She was discharged home
as her weight increased steadily and was medically stable. I
spoke to her and her husband at length on the discharge day and
they agreed with the plan. Total discharge time greater than 30
minutes.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2 puffs(s) inhaled q 3-6 hrs prn
DIAZEPAM - 5 mg Tablet - 0.5 to 1 Tablet(s) by mouth [**Hospital1 **] prn
FUROSEMIDE - 20 mg Tablet - 1 to 2 Tablet(s) by mouth qd or as
directed
HYDROMORPHONE - 4 mg Tablet - 1 Tablet(s) by mouth tid prn as
needed for pain
LEVOTHYROXINE - 50 mcg Tablet - one Tablet(s) by mouth once a
day, TWO on Sundays
MORPHINE - 30 mg Tablet Sustained Release - [**11-23**] Tablet(s) by
mouth tid prn - 28 day supply
MORPHINE - 60 mg Tablet Sustained Release - 1 Tablet(s) by mouth
[**Hospital1 **] prn
ONDANSETRON HCL [ZOFRAN] - (Prescribed by Other Provider) -
Dosage uncertain
PAROXETINE HCL - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime
PREDNISONE - 20 mg Tablet - [**11-26**] Tablet(s) by mouth use to adjust
dose
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (OTC) - Capsule - one Capsule(s) by mouth once a
day
SENNA - (d/c meds) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
a day as needed for constipation
.
Discharge Medications:
1. Calcium Carbonate 500 mg PO/NG DAILY
2. Enoxaparin Sodium 40 mg SC BID
Stop on [**2127-6-10**].
Disp #*21 Day(s) Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO/NG Q8H:PRN pain
Hold for sedation, RR less than 12
Disp #*10 Dose(s) Refills:*0
4. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash
5. Morphine SR (MS Contin) 30 mg PO Q12H pain
Please hold for sedation or RR<12.
6. PredniSONE 20 mg PO/NG DAILY
7. Paroxetine 40 mg PO/NG DAILY Start: In am
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
Disp #*30 Day(s) Refills:*1
10. Vitamin D 400 UNIT PO/NG DAILY
Disp #*1 Month(s) Refills:*2
11. Furosemide 40 mg PO DAILY
12. Levothyroxine Sodium 100 mcg PO/NG Q SUN AND Q MON
13. Levothyroxine Sodium 50 mcg PO/NG Q TUE, WED, [**Last Name (un) **], FRI, SAT
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Pneumonia
Deep venous thrombosis (clot)
Atypical eating disorder
Connective tissue disease
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 a pneumonia and were
treated with IV antibiotics. Your respiratory status slowly
improved, and you had good oxygen saturations on room air prior
to discharge.
During your stay you were also diagnosed with a clot in your arm
in the area of your PICC line, for which you are being treated
with Lovenox for one month. Please stop Lovenox on [**2127-6-10**].
Given your low weight, you were placed on an eating disorders
protocol and were seen by Psychiatry, Nutrition, and Social
Work. Your weight at the time of discharge was 79 pounds. You
will have VNA with nutritionist visitng at home.
Followup Instructions:
Department: [**Location (un) 2788**] INTERNAL MED.
When: TUESDAY [**2127-5-27**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,009
| 139,851
|
45883+58861+58862
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2133-4-20**] Discharge Date: [**2133-5-15**]
Date of Birth: [**2074-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Ciprofloxacin / Levofloxacin / Percocet
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2133-4-24**] CABG x4 (LIMA to LAD, SVG to OM, SVG to DIAG, SVG to
PDA)/
MV repair (26 mm [**Company 1543**] ring)/ left carotid endarterectomy
[**2133-5-7**] sternal wound debridement
[**2133-5-13**] Debridement of bilateral pectoralis musculocutaneous
advancement flap.
History of Present Illness:
The patient is a 59 year old female with known CAD (50% LMCA, TO
mRCA, and 90% mLCx), CHF (EF 40%,) DM, HTN, HL, and tobacco who
presents with complaints of chest pain. The patient had two
prior admissions for heart failure in the end of [**2132**]. A TTE
during those hospitalizations showed new inferior WMA and a
reduced EF. A PMIBI confirmed a new severe fixed inferolateral
defect with the left
ventricle also demonstrating inferolateral akinesis and a
reported ejection fraction of 28%. The patient was reffered by
her PCP to cardiology for evaluation of cardiac catherization.
In [**1-30**], the patient underwent an elective diagnosic cardiac
catheterization, which demonstrated a totally occluded mRCA,
diffusly diseased LAD, 90% mLCx, and a 50% discrete LMCA lesion.
The patient was reffered to CT surgery for possible CABG. In the
interim, the plan was to optimize the patients modifiable risk
factors.
The patient represented in early [**3-30**] with complaints of chest
pain. She was having frequent chest pain with activity. Her
cardiac markers were cycled negative, EKG showed non-specific TW
changes. CT surgery was consulted. The option of bypass surgery
was discussed with patient. The discharge summary from that
admission indicated that the patinet opted to continue medical
management at this time, however the patient says that the team
had decided that surgery wasn't an option. Review of scanned
records show that decision prefered to [**Hospital 81920**] medical Rx, and if
failed, then surgery. The patient was discharged with a new
prescription for imdur.
Since discharge, the patient has responded well to the imdur,
and has not had any angina. On the night of presentation, the
patient was watching TV, when she began to develop a banding
chest pressure. The quality of the pain was similar to prior
angina, but more intense, without radiation. She was becoming
increasingly more uncomfortable. She took 2 SLNG, without any
relief. EMS was activated, who provided an additional 2 SLNG
with complete resolution of pain. She has been chest pain free
since. She denies any associated N/V, diaphoresis,
lightheadedness, or palpitation. She hasn't had any recent
orthopnea, PND, or LE edema. The patient was taken to [**Hospital1 18**] for
further manegement.
.
On presentation to the [**Hospital1 18**] ED, initial vitals were 98 95
151/84 100 on RA. Her first set of cardiac markers showed a
slighly elevated trop at 0.04, flat CK. EKG reportedly unchanged
from prior. She was given 25mg of PO metoprolol, started on a
heparin gtt. She remained CP free. She is now admitted to [**Hospital1 1516**]
service for further manegement.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
- CAD: 50% LCCA and 90% mid LCx
- DM Type 2 x 20 yrs, most recent HgA1c 9.5. Reports diabetic
neuropathy
- Hypertension (HTN)
- systolic (EF 40-45%) and diastolic CHF
- Dyslipidemia
- Anxiety
- Depression
- Hypothyroidism
- PVD, per imaging studies in [**2129**]- reports at baseline she
walks 50 yds or up 1 step until she gets pain
- Chronic low back pain
- Osteoarthritis of left knee
- Diverticulitis/diverticulosis s/p partial colectomy 20 yrs ago
and several hospitalizations for abd abscess since then although
last was several yrs ago
- Obesity
- Smoking, now [**1-23**] PPD, h/o smoking x40 years, as much as 2PPD
CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension, + Family history, +Tobacco abuse
.
CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: Cardiac cath [**1-30**] showed
2VD with 50% LCMA. No interventions taken, patient declined
CABG, and has been managed medically.
Social History:
She has a 40pkyr tobacco history and quit in [**11-29**]. However,
just two to three weeks ago she restarted 1/2ppd. Denies any
alcohol use in the last 40 years. Denies any illicit drug use.
Lives alone, no family close by. Adult daughter lives in
[**Name (NI) **], [**Name (NI) **]. Not employed x1 yr, former secretary. Patient's
closest contact is her boyfriend [**Name (NI) **] [**Name (NI) 1356**] who lives two
houses away from her.
Family History:
Admits majority of family members have various forms of heart
disease including heart attacks, HTN, and arrythmias requiring
pacemakers.
Physical Exam:
VS 880, 12, 130/80
General: comfortable
Skin: unremarkable
HEENT: unremarkable
Neck: supple, full ROM
Chest: lungs CTAB
Heart: RRR, +murmur [**1-27**] apex
Abd: soft, NT, ND, +BS
Ext: warm, well perfused, -edema
varicosities: minimal spider veins
Neuro: grossly intact
Pertinent Results:
Admission labs:
[**2133-4-20**] 12:35AM BLOOD WBC-11.1* RBC-3.98* Hgb-12.2 Hct-35.1*
MCV-88 MCH-30.7 MCHC-34.8 RDW-13.9 Plt Ct-281
[**2133-4-20**] 12:35AM BLOOD Neuts-77.8* Lymphs-17.4* Monos-3.0
Eos-1.3 Baso-0.5
[**2133-4-20**] 12:35AM BLOOD PT-13.0 PTT-29.4 INR(PT)-1.1
[**2133-4-20**] 12:35AM BLOOD Plt Ct-281
[**2133-4-20**] 12:35AM BLOOD Glucose-323* UreaN-24* Creat-1.1 Na-135
K-3.8 Cl-99 HCO3-25 AnGap-15
[**2133-4-20**] 06:20AM BLOOD ALT-14 AST-25 LD(LDH)-182 CK(CPK)-132
AlkPhos-111 TotBili-0.3
[**2133-4-20**] 12:35AM BLOOD cTropnT-0.04*
[**2133-4-20**] 12:35AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.0
.
Conclusions
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesia of the apex, apical and mid portions of the inferior
wall, inferior septum and inferolateral walls. Overall left
ventricular systolic function is mildly depressed (LVEF= 40% %).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. 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. No aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
7. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2133-4-24**] at 1000am.
Post bypass
1. Patient is in sinus rhythm and receiving an infusion of
phenylephrine.
2. Biventricular function is unchanged.
3. Annuloplasty ring seen in the mitral position. Appears well
seated and there is no mitral stenosis or regurgitation. There
is no [**Male First Name (un) **].
4. Aorta is intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2133-4-26**] 14:42
?????? [**2127**] CareGroup IS. All rights reserved.
[**2133-5-14**] 11:49AM BLOOD WBC-16.6*# RBC-2.88* Hgb-8.6* Hct-27.0*
MCV-94 MCH-29.7 MCHC-31.7 RDW-14.4 Plt Ct-584*
[**2133-5-14**] 11:49AM BLOOD Glucose-173* UreaN-20 Creat-1.2* Na-132*
K-4.5 Cl-98 HCO3-25 AnGap-14
[**2133-5-14**] 11:49AM BLOOD Mg-2.2
Brief Hospital Course:
The patient is a 59 year old female with known severe coronary
artery disease, systolic congestive heart failure (ejection
fraction of 40%,) hypertension, dyslipidemia, and diabetes
mellitus who presented [**2133-4-20**] with recurrent chest pain. The
patient's chest pain had resolved by time of arrival to the
emergency department. The patient was admitted to cardiology
service and ruled in for non-ST elevation myocardial infarction
on hospital day 1 with peak Troponins of 0.55. She was placed on
a heparin gtt to which Integrilin gtt was added when she ruled
in. She remained on Integrilin gtt for approximately 12 hrs
until troponins trended down and heparin gtt for 48 hrs. She
was continued on her home beta blockade, aspirin, statin, lasix.
CT surgery was consulted and pre op workup was performed which
included negative urine analysis, liver function tests, chest
radiograph. Also transthoracic echocardiogram was done with
results as above. Ultrasound lower extremity veins, pulmonary
function tests and arterial blood gases were done. [**Month/Day/Year **]
surgery was consulted for possible carotid endarterectomy.
Combined coronary artery bypass grafting and carotid
endarterectomy was planned by [**Month/Day/Year 1106**] and cardiac surgery for
[**2133-4-24**].
During work-up for coronary artery bypass grafting, carotid
ultrasound revealed severe left carotid disease, and left
carotid endarterectomy planned with Dr. [**Last Name (STitle) **] at time of
coronary artery bypass grafting. Plavix was held. She underwent
surgery with Drs. [**Name5 (PTitle) **]/ [**Doctor Last Name **] on [**4-24**]. She was transferred
to the cardiovascular intensive care unit in stable condition on
milrinone, phenylephrine, propofol, and nitroglycerin drips. She
was extubated on post operative day two and her pressors were
weaned. Her chest tubes removed per protocol. She was
transferred to the surgical step down floor. She underwent a
right-sided thoracentesis for 300 mL of serosanguinous fluid.
She continued to diurese. A 2cm portion of her inferior
mediastinal wound was opened and packed secondary to drainage.
She as placed on Keflex for the same. She was seen in
consultation by the [**Hospital **] clinic for persistently elevated
blood sugars and lantus was incrementally increased. Infectious
disease was also reconsulted for elevated white blood cell
counts. The mediastinal wound was opened along the length of
the incision and packed. The patient returned to the OR on 4/
16 for superficial sternal debridement with placement of vac.
Antibiotics were changed to vancomycin. Plastic surgery was
consulted for further wound management. They took the patient
to the OR on [**5-13**] and performed debridement of bilateral
pectoralis musculocutaneous advancement flap. Overall the
patient tolerated the procedure well and post-operatively was
transferred back to the floor with 2 JP drains. She continued
to make progress and was discharged to rehab on [**2133-5-15**].
Medications on Admission:
1. Aspirin 325 mg DAILY
2. Amitriptyline 10 mg PO HS
3. Citalopram 20 mg Tablet daily
4. Ezetimibe 10 mg PO DAILY
5. Furosemide 40 mg PO BID
6. Metoprolol Succinate 100 mg DAILY
7. Trazodone 150 mg PO HS
8. Valsartan 320 mg Tablet DAILY
9. Isosorbide Mononitrate 30 mg DAILY
10. Levothyroxine 50 mcg PO DAILY
11. Pravastatin 10 mg Tablet PO DAILY
12. Insulin
Please continue prior home insulin regimen with Lantus 14 units
at night and Novolog divided into three dose throughout the day.
13. Plavix 75 mg PO once a day.
14. Nitroglycerin
Discharge Medications:
1. Outpatient Lab Work
CBC with differential, BUN/Cre, Vanco trough on Tuesday [**2133-5-19**]
with results sent to Dr. [**Last Name (STitle) 97727**] of ID at ([**Telephone/Fax (1) 16411**]
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
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. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. Vancomycin 1250 mg IV Q 24H Start: In am
for sternal wound
**Hold for trough level >20
20. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
21. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
23. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q6H (every 6 hours).
24. Furosemide 10 mg/mL Solution Sig: Two (2) Injection once a
day.
25. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous dinner.
26. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
coronary artery disease
peripheral [**Location (un) 1106**] disease
carotid disease
mitral regurgitation
insulin-dependent diabetes mellitus
diastolic heart failure
hypertension
hyperlipidemia
inferolateral myocardial infarction
anxiety/depression
hypothyroidism
chronic low back pain
osteoarthritis of left knee
obesity
diverticulitis/ diverticulosis s/p prior partial colectomy
Discharge Condition:
good
Discharge Instructions:
no driving for one month
no lifting greater than 10 pounds for 10 weeks
no lotions, creams, or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**1-23**] weeks
see Dr. [**Last Name (STitle) **] in [**2-24**] weeks
see Dr. [**Last Name (STitle) **] in [**2-24**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
please call for appts.
Outpatient Lab Work
CBC with differential, BUN/Cre, Vanco trough on Tuesday [**2133-5-19**]
with results sent to Dr. [**Last Name (STitle) 97727**] of ID at ([**Telephone/Fax (1) 16411**]
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2133-6-4**] 1:00
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2133-5-21**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2133-5-15**] Name: [**Known lastname 15588**],[**Known firstname **] Unit No: [**Numeric Identifier 15589**]
Admission Date: [**2133-4-20**] Discharge Date: [**2133-5-15**]
Date of Birth: [**2074-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Ciprofloxacin / Levofloxacin / Percocet
Attending:[**First Name3 (LF) 265**]
Addendum:
The patient is also instructed to follow up with Dr. [**First Name (STitle) 735**] in 1
week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2133-5-15**] Name: [**Known lastname 15588**],[**Known firstname **] Unit No: [**Numeric Identifier 15589**]
Admission Date: [**2133-4-20**] Discharge Date: [**2133-5-15**]
Date of Birth: [**2074-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Ciprofloxacin / Levofloxacin / Percocet
Attending:[**First Name3 (LF) 265**]
Addendum:
Please note changes in medications and discharge instructions.
Discharge Medications:
1. Outpatient Lab Work
CBC with differential, BUN/Cre, Vanco trough on Tuesday [**2133-5-19**]
with results sent to Dr. [**Last Name (STitle) **] of ID at ([**Telephone/Fax (1) 3830**]
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
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. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Vancomycin 1250 mg IV Q 24H Start: In am
for sternal wound
**Hold for trough level >20
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
20. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
22. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q6H (every 6 hours).
23. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous dinner.
24. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per sliding scale.
25. Motrin 400 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
26. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
Discharge Instructions:
no driving for one month
no lifting greater than 10 pounds for 10 weeks
no lotions, creams, or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Mediastinal incision should be washed daily with soap and water
and patted dry. Cover with vaseline gauze. Please record [**First Name8 (NamePattern2) 2021**]
[**Last Name (NamePattern1) **] output daily.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2133-5-15**]
|
[
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"244.9",
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"414.01",
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"410.71",
"443.9",
"349.82",
"300.4",
"424.0",
"401.9",
"357.2",
"998.59",
"V58.67",
"278.00",
"250.60",
"428.0",
"998.32",
"272.4",
"433.10",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"36.13",
"83.82",
"39.61",
"77.61",
"36.15",
"86.22",
"38.93",
"00.40",
"34.91",
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] |
icd9pcs
|
[
[
[]
]
] |
19758, 19844
|
8140, 11147
|
331, 608
|
14792, 14799
|
5661, 5661
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15116, 16517
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5218, 5357
|
17223, 19735
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14389, 14771
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11173, 11715
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19868, 20463
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5372, 5642
|
281, 293
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636, 3813
|
5678, 8117
|
3835, 4746
|
4762, 5202
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,681
| 178,556
|
37868+58158
|
Discharge summary
|
report+addendum
|
Admission Date: [**2198-5-21**] Discharge Date: [**2198-6-12**]
Date of Birth: [**2168-1-12**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Subfrontal craniotomy for resection of tumor
History of Present Illness:
30 yo M with a history of a growth hormone secreting pituitary
macroadenoma s/p resection in [**2195**], hypothyroidism, diabetes,
and adrenal insufficiency, who presents with intermittent blurry
vision and headache since yesterday. Pt notes headache localized
to the top of the head and behind the eyes more pronounced on
the left. Pain incrased with eye movement particularly with left
lateral gaze. Denies loss of vision or visiual deficits however
notes general blurriness to vision. He denies any stiff neck,
recent trauma,increased weakness of extremitites, new neurologic
symptoms including new weakness/numbness, nausea, fevers/chills,
cough. Denies any changes to speech, memory, gait.
.
He presented to OSH, where head CT was consistent with stable
1.7 X1.5 cm hyperdense sellar and suprasellar mass present . He
was transferred to [**Hospital1 18**] for neurosurgery evaluation.
.
In the ED initial vital signs were 97.7 74 128/86 12 98% 3L.
Neurosurgery was consulted who recommended MRI with and without
contrast. The patient was given 1mg IV dilaudid. MRI performed
and patient transferred to the floor.
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No cough, shortness of breath, or
wheezing. GI: No diarrhea, constipation or abdominal pain. No
recent change in bowel habits, no hematochezia or melena. GUI:
No dysuria or change in bladder habits. MSK: No arthritis,
arthralgias, or myalgias. DERM: No rashes or skin breakdown.
NEURO: No numbness/tingling in extremities. PSYCH: No feelings
of depression or anxiety. All other review of systems negative.
Past Medical History:
1. panhypopituitarism secondary to growth hormone secreting
macroadenoma.
2. Diabetes mellitus with hemoglobin A1c of 17.
3. History of sleep apnea, diagnosed recently.
4. History bacteremia with coag-negative staphylococcus,
resistant to oxacillin.
5. Adrenal insufficiency.
6. Hypothyroidism.
7. Diabetes insipidus.
8. Growth hormone-secreting pituitary macroadenoma status post
resection.
9. Acromegaly.
10. Superficial septic thrombophlebitis with bacteremia.
11. He has had some history of vaccination as in childhood with
right arm deformity.
12. CRANIOTOMY with resection of pituitary macroadenoma,
[**2196-10-28**]
13. chronic left MCA territory infarct
Social History:
He is an illegal immigrant from [**Country 6257**] who has lived in [**Location (un) 29158**] for the past eight years. He does not currently work. He
does not drink alcohol. He used to smoke one pack per day of
cigarettes, but has not smoked since his hospitalization. He
drinks mostly decaf coffee, and reports no illicit drug use.
Family History:
Patient is unaware of any history of diabetes or other
endocrinopathies.
Physical Exam:
On admission:
VS: 130/100, 76, 18, 99%3L
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Macroglossia. no LAD. no JVD. neck supple.
No cervical, supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in L extremities. DTRs 2+
BL in patella/biceps. sensation intact to LT, cerebellar fxn
intact to rapid alternating movements. gait WNL. Right arm is
held flexed at elbow and wrist.Right UE [**4-3**] compared to LUE [**5-3**].
[**Month/Day (1) 12588**] fields grossly intact. Pain with eye movement to the left
lateral side.
Pertinent Results:
On admission:
[**2198-5-21**] 01:40PM BLOOD WBC-5.2# RBC-4.03* Hgb-10.4* Hct-31.2*
MCV-77*# MCH-25.9* MCHC-33.4 RDW-16.2* Plt Ct-326
[**2198-5-21**] 01:40PM BLOOD Neuts-52.1 Lymphs-36.8 Monos-4.8 Eos-5.6*
Baso-0.7
[**2198-5-21**] 01:40PM BLOOD Glucose-265* UreaN-16 Creat-0.5 Na-136
K-4.1 Cl-100 HCO3-24 AnGap-16
[**2198-5-23**] 07:35AM BLOOD ALT-23 AST-14 AlkPhos-104 TotBili-0.3
[**2198-5-22**] 06:40AM BLOOD Calcium-9.6 Phos-4.7* Mg-1.6
[**2198-5-21**] 01:40PM BLOOD calTIBC-662* Ferritn-6.3* TRF-509*
[**2198-5-22**] 06:40AM BLOOD %HbA1c-10.5* eAG-255*
[**2198-5-23**] 07:35AM BLOOD Triglyc-373* HDL-55 CHOL/HD-4.4
LDLcalc-112 LDLmeas-148*
[**2198-5-23**] 07:35AM BLOOD Triglyc-373* HDL-55 CHOL/HD-4.4
LDLcalc-112 LDLmeas-148*
[**2198-5-22**] 06:40AM BLOOD Prolact-5.7
[**2198-5-22**] 06:40AM BLOOD T4-7.6 T3-120
[**2198-5-23**] 07:35AM BLOOD Cortsol-18.6
[**2198-5-23**] 07:35AM BLOOD PSA-0.1
.
Imaging:
[**5-21**] MRI: Evaluation of the sella reveals marked interval
enlargement of the residual pituitary adenoma centered in the
left sella, with suprasellar and left cavernous sinus extension.
The sella remains expanded. The pituitary mass measures 2.6 CC x
1.8 AP x 1.7 TRV cm, with extension into the medial aspect of
the left cavernous sinus, abutting the medial aspect of the
cavernous left carotid, and surrounding approximately 270
degrees of the supraclinoid left carotid after it exits the
cavernous sinus. The left optic nerve is difficult to follow,
but appears encased by the suprasellar and sellar portions of
the mass in the prechiasmatic region. The visualized portions of
the optic nerve does have normal signal. The tumor insinuates
between the prechiasmatic portions of the optic nerves with mild
mass effect upon the right prechiasmatic optic nerve as well.
The left A1 segment is at least partially encased by the mass,
and the mass displaces the A2 segment anteriorly and abuts these
vessels.
Chronic post-operative changes are seen in the left subfrontal
and pterional region from craniotomy with duraplasty. The floor
of the sella remains displaced inferiorly. However, there is no
definite evidence of extension into the sphenoidal sinus, nor is
there evidence of extension into the left infratemporal fossa.
The remainder of the brain is significant for chronic left MCA
territory infarct. No other mass is seen. Major intracranial
flow voids are preserved, including the left internal carotid
where it is partially surrounded by the mass.
IMPRESSION: Significant interval enlargement of the residual
pituitary macroadenoma centered in the left pituitary with
suprasellar and left cavernous sinus extension.
CT Head [**6-1**]
Status post left frontal craniotomy with expected post-surgical
pneumocephalus. Small amount of residual hyperdense material in
the resection bed could represent mass versus hemorrhage.
MRI [**6-2**]
At the margin of surgical cavity blood products are seen. There
is a residual area of enhancement measuring 10 x 7 mm visualized
in the left suprasellar region adjacent to the brain. Blood
products and small subdural collection are identified from
recent surgery. There remain blood products adjacent to the left
optic nerve and optic side of the optic chiasm.Soft tissue
changes are seen in the visualized sphenoid sinuses secondary to
surgery.
Brief Hospital Course:
Mr [**Known lastname **] is a 30 yo M with a history of a growth hormone
secreting pituitary macroadenoma s/p resection in [**2195**],
hypothyroidism, diabetes, and adrenal insufficiency, who
presented with intermittent blurry vision and headache of 1 day
duration found to have regrowth of pituitary macroadenoma with
new [**Year (4 digits) **] deficits.
.
#Pituitary Macroadenoma: MRI head demonstrated significant
interval enlargement of the residual pituitary macroadenoma, and
[**Year (4 digits) **] field testing showed new R eye deficit. Endocrine was
consulted and started pt on Somatostatin LAR 10mg IM qmo (first
dose 5/24). Neurosurgery was consulted and felt that pt is a
surgical candidate given mass effect and new deficits. Pain was
controlled with oxycodone prn. No evidence of cosecretion with
prolactin. ACTH, IGF-1, HGH pending. On [**6-2**] he underwent a
subfrontal craniotomy for resection of suprasellar mass. Post
operatively he was transferred to the ICU for further care
including strict blood pressure control and neuro monitoring. He
was left intubated in preparation for repair of CSF leak as he
had consistent rhinorrhea. On [**6-4**] a lumbar drain was placed
since the amount of rhinorrhea had significantly decreased.
After remaining on bedrest for 24hrs with the drain in place, he
had no drainage from his nose. On [**6-6**] he again had no drainage
from his nose so he was cleared to advance his diet. On [**6-8**] his
lumbar drain was removed without complication. He was
transferred to the floor in stable condition. While on the floor
the patient was noted to be draining clear fluid from the nose.
On [**2198-6-10**] he was made NPO in preparation for the O.R on [**6-11**]
for repair of CSF leak. He was found to no longer be leaking
CSF so his OR was placed on hold
.
#Diabetes Mellitus: Unlcear what home meds pt was taking
(clearly poorly controlled given HgA1d 10.7%) but these were
held and he was started on Insuline therapy with the guidance of
the endocrine team. He was on lantus and insulin sliding scale.
His lantus dosing was changed to 40 [**Hospital1 **]. On the evening of [**6-10**]
his lantus dosing was changed to 26 units [**Hospital1 **] as he was NPO. The
dosing returned to 40 [**Hospital1 **] after he was canceled for the OR.
.
#Adrenal Insufficiency: Continued hydrocortisone 20 mg in AM, 10
mg in afternoon. On [**6-10**] he was changed to hydrocortisone 100mg
IV q8 hours per endocrinology rec's in preparation for his
repeat craniotomy which ltimately did not occur.
.
#Diabetes Insipidus: Pt was continued on home desmopressin 0.1mg
TID however Na decreased from 136 to 131 o/n so desmopressin was
held, then restarted at 0.1mg qHS and sodium stabilized. On [**6-4**]
he required additional DDAVP for increased urine output and it
responded appropriately. On [**6-6**] his DDAVP was increased to [**Hospital1 **]
dosing and on [**6-8**] back to QHS dosing.
.
#Hypothyroidism: Continued home synthroid.
.
#. Microcytic Anemia: Long standing anemia however MCV down to
77. Iron studies showed iron low nl, ferritin low, TIBC high.
Should be started on iron as an outpatient.
.
#Sleep Apnea: Pt has central sleep apnea so needs 4L
supplemental oxygen overnight. Previous sleep study showed
increased apnea with cpap. Has been using a friend's nasal cpap
at home. Needs outpt sleep study after discharge. He remained
intubated post op until [**6-5**] due to extreme difficulty with
intubation, and concern for possible need to return to the OR.
.
#. Blurry vision; likely [**1-31**] macroadenoma encroaching on the
optic chiasm, possibly exacerbated by hyperglycemia.
.
# FEN: Diabetic diet, replete electrolytes PRN
.
# PPx:
- Pain control: Tylenol, oxycodone Morphine for breakthrough
- Bowel regimen: senna and colace
- DVT PPx: heparin sc
.
# Comm: [**Name (NI) **] (brother) [**Telephone/Fax (1) 84695**]
[**Doctor Last Name **] (Father) [**Telephone/Fax (1) 84696**]
.
# Code: FULL
On [**6-12**] he was deemed fit for discharge to home and was given
instructions for follow-up
Medications on Admission:
Metoprolol 100mg [**Hospital1 **]
Metformin 1000mg qAM, 1500mg qPM
Lisinopril 10mg daily
Hydrocortisone 20mg qAM, 10mg q4pm
Levothyroxine 75mcg 1 tab daily
Amlodipine 10mg 1 tab daily
Famotidine 20mg [**Hospital1 **]
Glipizide 10mg [**Hospital1 **]
Pioglitazone 13mg daily
Desmopressin 0.1mg TID
Insulin Humulin Sliding scale
Omeprazole 20mg daily
Insulin NPH (30u qAM, 25u qPM)
Discharge Medications:
1. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
6. hydrocortisone 20 mg Tablet Sig: see below Tablet PO QPM
(once a day (in the evening)): Take 1 tab QAM and 0.5 tabs QPM.
Disp:*90 Tablet(s)* Refills:*2*
7. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous Breakfast and bedtime.
Disp:*1 pen* Refills:*2*
8. Humalog KwikPen 100 unit/mL Insulin Pen Sig: See Sliding
Scale Subcutaneous per sliding scale: per sliding scale given
to patient.
Disp:*1 pen* Refills:*2*
9. lancets Misc Sig: One (1) lancet Miscellaneous when
checking blood glucose.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary macroadenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-8**] 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**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please contact your primary care physician to be seen in 1 week
?????? You will be contact[**Name (NI) **] by the endocrinology office to
schedule a follow-up appointment
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**6-18**] @
3pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need a CT scan of the brain without contrast.
??????You will not need an MRI of the brain with/ or without
gadolinium contrast.
Completed by:[**2198-6-12**] Name: [**Known lastname **],[**Known firstname 3547**] Unit No: [**Numeric Identifier 13404**]
Admission Date: [**2198-5-21**] Discharge Date: [**2198-6-12**]
Date of Birth: [**2168-1-12**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 599**]
Addendum:
added prescriptions for testosterone, pepcid, and lopressor
Discharge Medications:
1. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*1 box* Refills:*2*
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
4. desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
6. hydrocortisone 20 mg Tablet Sig: see below Tablet PO QPM
(once a day (in the evening)): Take 1 tab QAM and 0.5 tabs QPM.
Disp:*90 Tablet(s)* Refills:*2*
7. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous Breakfast and bedtime.
Disp:*1 pen* Refills:*2*
8. Humalog KwikPen 100 unit/mL Insulin Pen Sig: See Sliding
Scale Subcutaneous per sliding scale: per sliding scale given
to patient.
Disp:*1 pen* Refills:*2*
9. lancets Misc Sig: One (1) lancet Miscellaneous when
checking blood glucose.
Disp:*1 box* Refills:*2*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2198-6-12**]
|
[
"E878.8",
"253.0",
"255.41",
"227.3",
"349.81",
"280.9",
"368.8",
"250.00",
"348.30",
"253.5",
"244.9",
"377.49",
"253.2",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"07.64",
"03.09",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
17400, 17543
|
7441, 11493
|
317, 364
|
13017, 13017
|
4106, 4106
|
14587, 16193
|
3206, 3280
|
16216, 17377
|
12971, 12996
|
11519, 11899
|
13168, 14564
|
3295, 3295
|
1566, 2154
|
269, 279
|
392, 1512
|
4121, 7418
|
13032, 13144
|
2176, 2839
|
2855, 3190
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,672
| 177,737
|
40518
|
Discharge summary
|
report
|
Admission Date: [**2174-8-15**] Discharge Date: [**2174-9-2**]
Date of Birth: [**2103-11-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath, chest pain
Major Surgical or Invasive Procedure:
CoreValve on [**2174-8-16**]
History of Present Illness:
Ms. [**Known lastname 16905**] is a 70-year-old woman who was
referred with critical aortic stenosis.
In [**2173-10-18**], she suffered a syncopal episode and presented
to [**Hospital2 **] [**Hospital3 6783**] Hospital where evaluation documented critical
aortic stenosis by both catheterization as well as
echocardiography. Coronary angiography at that time
demonstrated
an occluded proximal LAD, moderate diffuse disease in the LCx,
and an occluded RCA. There was a patent SVG to the right
coronary and a patent SVG tot he LAD. Quantitation of her aortic
stenosis yielded a mean transvalvular gradient of 46 mmHg and a
valve area of 0.6 by Fick estimate. At that time, the patient
reportedly had a significantly elevated pulmonary arterial
pressure of systolic of 115mmHg, though no wedge pressure was
available in the report. She was evaluated by Dr. [**Last Name (STitle) 50180**] of
Cardiothoracic Surgery at [**Hospital2 **] [**Hospital3 6783**] and deemed to be
prohibitively high-risk candidate for traditional aortic valve
surgery.
Over the ensuing six months, the patient has had recurrent
episodes of syncope as well as falls due to gait instability.
She
has continued to have exertional chest pressure, but no
palpitations and she has been hospitalized several times
following falls at home. She has profound dyspnea on exertion
(NYHA Class III) and has had several episodes of syncope per
month. She now reports onset of chest discomfort after 15 feet
of
walking.
She has met inclusion criteria for Corevalve study and does
not meet exclusion criteria. Her findings have been reviewed,
submitted, and accepted for the Extreme arm Corevalve study.
Since last seen in office, she is only able to ambulate
short distances (room to room) due to shortness of breath. She
comes in this am somewhat lethargic and diaphoretic, blood
glucose was 43, she was treated with 1/2 amp of D50w, and oral
juice, blood glucose 188. Patient somnolent, family reports she
took 2 doses of clorazepam at 2am. Patient reports she has been
anxious about procedure and has been unable to sleep. Answers
questions appropriately, somnolent unless verbally stimulated.
ABG done on baseline O2 3L nc. Acceptable findings.
NYHA Class: III-IV
Past Medical History:
1. aortic stenosis
2. aortic valvuloplasty [**2174-3-24**]
3. CAD - s/p CABG x 2 ([**2159**]), PCI, chronic RBBB
4. COPD - home oxygen x 5 years
5. severe pulmonary hypertension
6. diabetes
7. hypertension
8. hyperlipidemia
9. obstructive sleep apnea -has own CPAP machine
10. obesity
11. renal insufficiency
12. osteoarthritis
13. situational depression
14. presbyopia
15. gout
16. nasal fracture secondary to [**2159**]7. cholecystectomy
[**80**]. knee pain s/p [**2080**]9. ventral hernia
Social History:
SOCIAL HISTORY: She lives with her sister, [**Name (NI) 4248**]. She has another
sister, [**Name (NI) 37620**] who assists with her [**Name (NI) 5669**]. Ambulates at home
with
walker, uses wheelchair when out of house. Has 4 steps to enter
home, and chair lift once inside. Currently, physical therapy
sees her once weekly for her knee injury.
[**Name (NI) 37620**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 88728**]
[**Doctor First Name **] (neice) [**Telephone/Fax (1) 88729**]
Average Daily Living:
Live independently Yes [x] No [ ]
Bathing [ ] Independent [x] Dependent
Dressing [ ] Independent [x] Dependent
Toileting [x] Independent [ ] Dependent
Transferring [ ] Independent [x] Dependent
Continence [x] Independent [ ] Dependent
Feeding [x] Independent [ ] Dependent
Family History:
FAMILY HISTORY: Positive for diabetes and coronary artery
disease. Her father died in his 50s of an MI and her mother died
at 98 of a CVA.
Physical Exam:
ADDMISSION EXAM:
Pulse: 46, B/P: Right 143/57, Resp: 18, O2 Sat: 95 (O2 2.5L),
Temp: 93.5 ax
Height: 160cm Weight: 98.6kg
General: Elderly heavy set female in wheelchair with O2 notably
SOB with conversation.
Skin: Pale, skin warm and dry.
HEENT: Normocephalic. Anicteric.
Neck: Supple, trachea midline. Bilat. carotid bruit vs. murmer.
Chest: Able to speak in short phrases only.
Heart:murmer throughout
Abdomen: Rotund, soft, (+)bowel sounds.
Extremities: 2+ lower extremity edema bilaterally. Bilateral
knee
pain.
Neuro: A+O x 3, c/o pain to bilateral knees. Somnolent,
upperextremities. UE's muscle wasting.
Pulses: palpable peripheral pulses
DISCHARGE EXAM:
Temp: 98 HR: 60 RR: 18 BP: 130/47 O2 sat 96% RA. Weight 83.3 kg.
.
GENERAL: 70 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated.
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2, 1/6 systolic murmur at RUSB, Normal in quality and
intensity RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: feet warm, no edema, pulses palp. Left groin with large
open wound from surgical cutdown s/p bovine patch and staple
closure (staples now removed). Wound has dehiscence in the upper
proximal portion. Wound has circumferential redness and mild
yellow drainage and copious tan serous drainage from an
underlying seroma. See page 1 for dressing instructions.
NEURO: CNs II-XII intact. 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears calm today, A/O.
Pertinent Results:
Cardiac Catheterization: ([**2174-3-24**] [**Hospital1 112**] - valvuloplasty)
Diagnostic results-
Two Vessel CAD involving the LAD and RCA
s/p CABG: all grafts patent
s/p CABG: 2 patent of 2 total grafts
Elevated Right Heart Filling Pressures RA= 24 mmHg
Elevated Right Heart Filling Pressures RV= 102/20 mmHg
Elevated Right Heart Filling Pressures PA= 96/34 (57) mmHg
Elevated Left Heart Filling Pressures [**Last Name (un) 5767**] PCWP = 26 mmHg
Aortic stenosis: severe
Aortic calculated [**Location (un) 109**]: 0.59 cm2
Aortic mean gradient: 63.2
.
Echocardiogram: TTE (Complete) Done [**2174-7-8**] at 1:00:00 PM
FINAL
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55%
Left Ventricle - Stroke Volume: 63 ml/beat
Left Ventricle - Cardiac Output: 4.02 L/min
Left Ventricle - Cardiac Index: 2.19 >= 2.0 L/min/M2
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Mean Gradient: 37 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
IMPRESSION: Critical calcific aortic stenosis. Symmetric LVH
with
normal global and regional systolic function. Mild to moderate
mitral regurgitation. Severe pulmonary hypertension.
EKG: [**2174-6-17**] 10:43:36 AM
ECG interpreted by ordering physician.
[**Name10 (NameIs) 357**] see corresponding office note for interpretation.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 130 150 488/493 59 86 21
CT: ([**2174-7-8**])
IMPRESSION:
1. Evidence of known aortic stenosis. Measurements regarding the
aortic valve as well as iliac arteries will be provided
separately.
2. Extensive aortic calcifications with no evidence of
dilatation.
3. Anterior abdominal hernia containing part of the transverse
colon, with no evidence of obstruction at this point.
4. Pulmonary nodules that, based on the size, should be
reevaluated in one year.
5. Status post CABG with what appears to be patent bypass to
distal LAD and PDA.
6. Borderline mediastinal lymph nodes that might be reevaluated
on subsequent study.
7. Evidence of pulmonary hypertension.
8. Right hypodense kidney lesion as well as hypodense liver
lesion that should be correlated with ultrasound.
9. Diffuse enlargement of the thyroid with multiple nodules that
might be evaluated by thyroid ultrasound.
PFT's:
[**Hospital3 14325**];s Hospital at WMC
FVC 1.06 (39%)
FEV1 0.75 (36%)
FEV1/FVC 71 (92%)
TLC 2.45 (50%)
FRC 1.48 (53%)
IC 0.97 (46%)
RV 1.38 (64%)
RV/TLC 56 (130%)
DLCO 5.50 (24%)
DLCO/VA 3.82 (72%)
.
CTA AORTA/BIFEM/ILIAC RUNOFF [**8-31**]:
Impression: Lung volumes demonstrate marked reduction in the
TLC, FRC, RV, and VC. Spirometry demonstrates a much reduced
FVC
and FEV1 with a normal FEV1/FVC. The DLCO is mildly reduced.
.
IMPRESSION:
1. Large postop seroma in the left inguinal region measuring 8.7
x 9.8 x 6.7 cm.
2. Diffuse soft tissue stranding and mild swelling of the left
leg compared to the right.
3. Right upper lobe tree-in-[**Male First Name (un) 239**] opacities concerning for
aspiration with
small bilateral simple pleural effusions.
4. Patent arterial system with no flow-limiting stenoses noted.
5. Grade 1 anterolisthesis of L4 on L5.
.
[**8-23**] ECHO:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). The right ventricular free wall
is hypertrophied. Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. An aortic CoreValve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
A mild paravalvular aortic valve leak is present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
a minimally increased gradient consistent with trivial mitral
stenosis. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] 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.
.
ECG [**8-26**]:
Sinus rhythm with probable biventricular pacemaker. Intra-atrial
conduction defect with atrial tracking. Since the previous
tracing of [**2174-8-21**] atrial pacing is no longer present.
.
VS on discharge:
temp 98, HR 60, RR 18, BP 130/70, O2 sat 97% RA. Weight: 83.3
kg.
.
Exam on Discharge:
GENERAL: 70 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated.
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2, 1/6 systolic murmur at RUSB, Normal in quality and
intensity RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: feet warm, no edema, pulses palp. Left groin with mod tan
serous drainage r/t underlying wound seroma, decreasing today.
Also has mild circumferential redness that is improving with
small yellow purulent drainage.
NEURO: CNs II-XII intact. 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears calm today, A/O.
Brief Hospital Course:
IMPRESSION: 70yo female with severe symptomatic aortic stenosis
including chest pain and near syncope with significant COPD,
continuous home O2, and moderate to severe pulmonary
hypertension. h/o CABG x 2 with patent grafts.
1.Symptomatic Aortic Stenosis: Patient had a critical AS (area
0.6cm2) and received a percutaneous bioprosthetic aortic valve
replaement on [**8-16**]. She was started on plavix and was
maintained on her 81 mg aspirin dose. Procedure was complicated
by AV dissociation with junctional escape rhythm and ventricular
tachycardia requiring cardioversion x2. A permanent pacemaker
was placed from the left subclavian and the patient was AV
sequentially paced at 80 bpm. Procedure was otherwise
successful. Post-operatively she required intubation and
pressure support for three days. Pt was also NO for pulm htn
after procedure and ultimately weaned to 100% O2. Vent was
weaned and blood pressures improved and pt was extubated on [**8-19**].
On [**2174-8-23**], a post-procedure echo showed a normal trans aortic
gradient. A mild paravalvular aortic valve leak was present. She
has had a slow recovery but reports decreased DOE with
ambulation, no chest pain and no episodes of syncope. She is
scheduled for cardiac f/u in 2 weeks.
.
2. COPD/pulmonary HTN/sleep apnea: An admimssion ABG and CXR
were preformed which showed: 121/51/7.38/31. As mentioned above,
she required extended intubation post procedurally. Pulmonary
was consulted and she was weaned off NO with 100%O2 and vent
settings were weaned. Pt was extubated on [**8-19**] and tolerated
home O2 of 3L NC and CPAP for OSA. She needs to be encouraged to
bring in her CPAP machine from home to use.
.
3. Left femoral artery injury: Iatrogenic left femoral injury
during fem-fem bypass was repaired with bovine pericardium,
closed [**8-17**] at bedside. Staples were kept in place until [**8-30**].
Incision site was complicated by cellulitis and CTA with runoff
of lower extremity did not show evidence of infected graft. Gram
stain showed GNR, GPC, GPR, speciated pseudomonas. She was
started on IV antibiotics and discharged on vancomycin and Zosyn
IV until [**9-12**] (total of 2 week course)and then needs to be
changed to ciprofloxacin PO for another 2 week course. Please
see page one for specific dressing changes and contact number
for concerns or questions. She was scheduled for a f/u appt with
Dr. [**Last Name (STitle) 22423**] in 2 weeks. Fluconazole was started to treat a
presumed vaginal yeast infection.
.
5. Complete heart block: Procedure was complicated by AV
dissociation with Vtach s/p two cardioversions and DDD PPM was
placed. On [**8-23**] device was interrogated revealing intrisic rhythm
of complete heart block without escape and PPM was A-V
sequential paced at rate of 60.
.
6. Diabetes: Pt was managed on insulin ss and home standing
insulin. HgbA1C was 6.2.
.
7. CKD: baseline Cr is 1.5. After corevalve, cr elevated to 2.3
secondary to prerenal etiology, then decreased to under her
baseline at 1.3.
.
8. Depression/anxiety: Pt has a long history of depression and
had symptoms of impaired coping with her prolonged
hospitalization. She has an outpatient psychiatrist who sees her
frequently. Psych was consulted and did not recommend any
changes to her anti depressants but advised haldol at HS. This
was started but stopped at discharge because of mild tremor. Her
sleep has improved and anxiety decreased during her hospital
stay. She would benefit from a psychiatric consultation at
rehab.
Medications on Admission:
ASA 81mg daily
metoprolol tartrate 12.5mg daily
simvastatin 20mg qhs
furosemide 20mg [**Hospital1 **]
metolazone 2.5mg 2x/week (qmon&fri)
insulin glargine (Lantus) 22units daily (pt regulates- varies)
insulin Lispro (humalog)3u bkfst,2u lunch,8u dinner, 3u hs
potassium chloride 20meq tid
ferrous sulfate 325mg daily
lansoprazole 30mg daily
MVI 1 tab daily
Allopurinol 150 daily
Buproprion HCL SR 200mg [**Hospital1 **]
clonazepam 2mg qhs
excitalopram Oxalate (Lexapro) 30mg daily
nitroglycerin SL 0.4mg SL prn chest pain
trazodone 100mg qhs prn insomnia
hydrocodone-acetaminophen 5/500mg 1-2 tabs q6h prn pain
oxygen 3L nasal cannula continuously
tolterodine (detrol) 2mg po bid
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID (2 times a day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks: Start only after IV antibiotics is done on [**9-12**], then
continue for 2 week course.
8. Vancomycin 1000 mg IV Q 24H
Monitor levels closely and dose based on goal peak and trough.
Please consult pharmacy for assistance in dosing.
9. Piperacillin-Tazobactam 4.5 g IV Q8H
Cont for total of two weeks, last day is [**2174-9-12**].
10. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
11. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
12. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
13. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety.
15. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
16. hydrocodone-acetaminophen 5-500 mg Capsule Sig: [**12-19**] Capsules
PO three times a day as needed for pain.
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous at bedtime.
20. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: see attached sliding scale.
21. fluconazole 100 mg Tablet Sig: 1.5 Tablets PO once a day for
2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Aortic stenosis s/p corevalve placement
Complete heart block
Acute on Chronic Diastolic congestive heart failure
Coronary artery disease
Chronic Obstructive pulmonary disease on home oxygen
Diabetes mellitus
Obstructive sleep apnea
Acute on Chronic kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 16905**],
You were admitted to the hospital for placement of a corevalve
prosthesis because of your aortic stenosis. You had some
hypotension after the procedure and needed medicine to keep your
blood pressure up. You developed some fluid overload and
required lasix to get rid of the extra fluid. You were on a
breathing tube that was removed on [**8-19**]. Your rhythm was slow and
a pacemaker was implanted. This will need to be followed every 6
months to make sure it is working properly. The left groin site
where the catheters were is slow to heal, has had a lot of
drainage and is mildly infected. You will need to continue
intravenous antibiotics for 2 weeks and get frequent dressing
changes.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start Zosyn and vancomycin for the infection in the groin
2. Metoprolol was changed to a long acting verson
3. Furosemide was increased to 40 mg twice daily
4. Start Plavix to decrease the chance of a blood clot on the
new valve
5. Metolazone was held for now
6. Decrease potassium to once daily
7. Decrease lexapro to 20 mg daily
8. discontinue Detrol
9. Start lisinopril 5 mg daily to lower your blood pressure and
help your heart pump better.
10. Start fluconazole to treat the vaginal yeast infection from
the antibiotics.
Followup Instructions:
Vascular:
Department: VASCULAR SURGERY
When: THURSDAY [**2174-9-15**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
***Please have your pcp send an insurance referral to Dr
[**Last Name (STitle) 88730**] office before the visit. Fax to [**Telephone/Fax (1) 17352**]
.
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 9:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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20,867
| 165,191
|
54006
|
Discharge summary
|
report
|
Admission Date: [**2172-4-9**] Discharge Date: [**2172-4-17**]
Date of Birth: [**2128-11-26**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Morphine Sulfate
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
dysphagia, r/o airway compromise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43M w/ HTN, asthma, ?polymyositis, OSA on CPAP now being
transferred from OSH for ENT evaluation of left peritonsillar
phelegmon/soft tissue swelling and concerns of airway
compromise.
Admitted to OSH on [**4-6**] with complaints of tongue swelling and
left mouth pain in the setting of recent dental procedure about
1 week prior to evaluation. Per records, had been evaluated in
ED and given clindamycin prior to admission. No fevers, chills,
n/v/sob but had noted dysphagia w/ both solids and liquids.
At OSH, was afebrile, hemodymically stable w/o respiratory
compromise although labs did demonstrate leukocytosis to 16K.
Initial neck CT on [**4-6**] reported left parapharyngeal phlegmotous
changes vs early abscess without invasion into retropharyngeal
space or airway compromise. Started on IV clinda and solumedrol
w/ histamine blockade. Symptoms appeared stable but w/
persistent dysphagia. However, repeat neck CT on [**4-8**] at OSH
reportedly demonstrated increased enlargement of left
peritonsillar soft tissue w/ compromise of adjacent oropharanyx
and complete occlusion of nasopharynx. Apparently, anesthesia
had evaluated airway and graded ASA II. Plans made for transfer
to [**Hospital1 18**] for ENT evaluation.
In ED, afebrile, labs notable for leukocytosis to 15.8. ENT
evaluation at bedside included review of OSH scans and
fiberoptic eval demonstrating unremarkable nasopharynx w/
swelling of left base of tongue without obvious mucosal
abnormality and normal epiglottis. Larynx rotated slightly to
right but TVC easily visualized, left vocal cord paralysis.
Meanwhile, minimal FVC edema w/ secretions in vallecula and
pyriform sinus. OSA w/ collapse of lateral pharyngeal wall.
Differntial dx per ENT included atypical angioedema, ?tongue
malignancy or infection. Recommended MICU admission for airway
observation w/ continued IV abx and airway steroid doses.
History from patient reveals that he had been treated with
zithromax for uri type sx prior to routine filling of left upper
molar on [**3-30**]. Procedure was uncomplicated but on day following
began to note left mouth/facial ache w/ radiation to left head.
No fever, chills, st. Apaprently spoke w/ dentist for these sx
and apparently prescribed pcn. Several days later, was eating
salad with friends when suddenly noted left tongue swelling and
difficulty w/ swallowing food - getting stuck at the back of
throat. This has persisted since that time - difficulty w/ solid
consistency. Also noted consistent hoarsenss of voice. No ST. No
n/v. No acid reflux although was prescribed omeprazole for ?of
reflux related sx. He apparently sought ED eval on [**4-4**] and
given po clinda for unclear reasons. Symptoms progressed until
hopsitaliaztion. Dysphagia has been stable but persistent during
hospitalization.
ROS notable for mild cough but no SOB or wheezing or CP. HA has
persisted, mostly left sided, no neck stiffness, ?mild
photophobia but o/w no vision changes/hearing changes. Has had
abdominal discomfort for which recent w/u included reported neg
EGD and csope. No urinary sx or change in bowel habits. Does
admit to 20 lb weight loss over last month secondary to
decreased appetite while off steroids. No rash/pruritus.
Past Medical History:
HTN
OSA on CPAP 25/17
asthma, never intubated or hospitalized, unsure of peak flows
lyme dz in '[**69**] - ?related to polyarticular sx
inermittent tongue swelling
s/p bx ventral tongue
?polymyositis for which on prednisone d/c'd [**3-2**]
Social History:
lives on [**Hospital3 **] and works for indian health services.
Not married. 15 pack year tobacco, but quit 20 y/a, no etoh,
ivda
Family History:
diabetes, vasculitis in mother
cad in father
Physical Exam:
97.5 172/85 82 15 99%3L
PE: obese middle age male, comfortable in bed, walking w/ ease,
no resp distress, pleasant
heent: ncat, anicteric sclera, perla, eomi, mmm,
?edema/hypertrophied left side of tongue w/ ?deviation of tongue
to left, unable to visualize large portion of OP but limited
clear, no lad, jvp flat, no inspiratory stridor
cv: s1, s2 regular w/ no mrg appreciated
pulm: mild right apical exp wheezing, o/w clear
abd: soft, ntnd, no scars, no cvat
ext: no edema
neuro: left CN X and XII deficit including tongue weakness,
hoarse voice No other gross deficits including normal strength
extremities, no pronator drift. .
Pertinent Results:
[**2172-4-17**] 06:20AM BLOOD WBC-14.9* RBC-4.50* Hgb-15.3 Hct-43.8
MCV-97 MCH-33.9* MCHC-34.8 RDW-13.5 Plt Ct-227
[**2172-4-17**] 06:20AM BLOOD Plt Ct-227
[**2172-4-16**] 06:00AM BLOOD Glucose-119* UreaN-16 Creat-0.9 Na-135
K-4.0 Cl-100 HCO3-24 AnGap-15
[**2172-4-15**] 06:10AM BLOOD Mg-2.4
[**2172-4-11**] 05:42AM BLOOD C3-118 C4-24
[**2172-4-15**] 09:20AM BLOOD HIV Ab-NEGATIVE
.
Microbiology:
[**4-8**], [**4-9**]: Blood cultures no growth
CSF culture: No growth
RPR: non-reactive
Lyme serology: no antibodies
C.diff: negative x1
.
Imaging:
CT Neck: Soft tissue thickening at the level of base of the
tongue to the left of the midline, as noted on prior MRI, but
without evident edema. Perhaps the finding reflects cranial
nerve dysfunction. Please correlate clinically
.
Video swallow: Mild-to-moderate pharyngeal dysphasia
.
[**4-15**] CT neck with contrast: The present study does not suggest
an inflammatory process. Tortuous distal left internal carotid
artery, whose pathological significance relative to the
above-noted findings is unclear
.
Csf cytology: No malignant cells
.
MRI/MRA neck: FINDINGS: There is no evidence for obstruction of
either arterial or venous structures. However, there is
confirmation of a very tortuous, corkscrew- shaped distal left
internal carotid artery just proximal to its entrance into the
carotid foramen. Surrounding this vessel is high T1 signal seen
prior to contrast infusion, and without perceptible contrast
enhancement. The findings raise the question of an arterial
dissection at this locale, with the tortuous vessel impressing
itself on the region of the jugular bulb. Posterior displacement
of the left side of the tongue base is again well shown and
there are no other extravascular lesions appreciated at this
time.
CONCLUSION: The findings are of concern for a left-sided
cervical internal carotid artery dissection, possibly with
aneurysmal dilatation.
COMMENT: This study, as well as all preceding imaging
examinations related to this patient performed at this hospital
were forwarded in order to obtain consultation with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 20400**], chief of Radiology, [**State 51252**],
[**Location (un) 86**], [**State 350**]. During a telephone conversation on [**4-17**], [**2172**], Dr. [**Last Name (STitle) 20400**] agreed that the most likely explanation for
left sided cranial neuropathy (involving nerves IX, X and [**Doctor First Name 81**]),
was secondary to a mass effect arising from the suspected left
internal carotid artery dissection.
Brief Hospital Course:
43M w/ HTN, obesity, OSA now being eval for persistent dysphagia
and enlarged left peritonsillar soft tissue, found to have
multiple cranial nerve deficits and left carotid dissection.
1. ? Left peritonsillar swelling: On admission the etiology was
not clear. Initial concerns were for infectious process such as
peritonsillar abscess although pt was afebrile and furthermore
did not appear toxic. However, this was in the face of steroids
and near continuous ABX since early [**Month (only) 958**]. He was maintained on
Clindamycin IV and Decadron per ENT recs. Blood cultures were
obtained which were negative. Based upon initial CT at OSH
suggestive of airway compromise, pt maintained in MICU for
observation. He has undergone several fiberoptic exam via ENT
and there was no evidence of airway compromise, epiglottis,
although there are concerns about left vocal cord paralysis. CT
scan of the neck was obtained which appeared to show soft tissue
swelling. Additionally, a neurology consult was obtained who
elicited CN cranial nerve palsies including left 12, probably L
recurrent laryngeal (see their consult note) An MRI/MRA of the
neck was obtained. The MRI images were reviewed extensively by
neurology, radiology and were also discussed with a radiologist
at [**Hospital 13128**]. Concluded that his cranial nerve deficits
as well as his other physical exam finding were secondary to
left carotid artery dissection. He was started on Coumadin and
neurology continued to follow him. At discharge he was able to
take PO and had no new neurologic deficits or other symptoms. He
will follow up with neurology as an outpatient.
2. ?allergic reaction: Given morphine on hospital day 2 and then
experienced facial plethora and rhinorrhea and nasal congestion
w/ ?difficult clearing of secretions. No stridor. Quickly
resolved w/ Benadryl and pt was already on histamine blockade w/
Pepcid and steroids. Allergy was consulted and not clear that
this represents true allergic response to morphine and his
complement levels were unremarkable.
3. HTN: continued on HCTZ.
4. Diarrhea: Patient had watery diarrhea which was concerning
for C. Diff given that he had been on clindamycin. C.dif was
negative x 1, but he was continued on a course of PO Flagyl
empirically. His WBC remained stably slightly elevated likely
secondary to steroids, but he was afebrile and appeared other
wise well.
5. OSA: Patient normally requires CPAP but this was deferred
until imaging returned ruling out structural abnormalities.
6. Asthma: continued w/ inhalers
7. FEN: A video swallow was obtained which revealed mild to
moderate pharyngeal dysphagia. The patient was started on ground
solids and thin liquids which he tolerated well.
8. code: full
Medications on Admission:
Quinine 260 qhs
HCTZ 25 qd
Tylenol w/ codeine PRN
clinda 150 tid (?duration)
fexofenadine 180 qd
Ambien CR 12.5 qhs PRN
omeprazole 20 qhs
Albuterol IH tid
folate 400 mcg qd
vit c 500 qd
vit B12 250 mcg qd
stool softeners
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO QHS.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please check PT, INR starting Monday [**2172-4-20**] and PRN as per PCP.
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 55375**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Multiple cranial nerve palsies secondary to carotid artery
dissection
Secondary
1. Obstructive sleep apnea
2. Hypertension
Discharge Condition:
Hemodynamically stable, afebrile, stable O2 sats on RA.
Discharge Instructions:
You were admitted to the hospital for an abnormality in your
neck that was found to be a dissection in your carotid artery
which has affected some of the nerves in you head resulting in
your tongue functioning abnormally. If you have any shortness of
breathing, worsening of your difficulty swallowing, chest pain,
fever, chills, cough, numbness, weakness, tingling or any other
concerning symptoms call your doctor or come to the emergency
room.
.
Please take all of you medications as directed:
You are now taking coumadin 5 mg once before bedtime. You will
need to have your bloodwork checked (INR) on Monday. Your
primary doctor will be following up these results and adjusting
your coumadin as directed. Your goal INR is [**2-28**].
.
You are also on an antibiotic to treat a presumed C. diff
infection which is causing your diarrhea. You are taking
metronidazole 500 mg three times per day for 10 days.
.
Please keep all of you follow-up appointments.
.
Please continue to eat a diet that consistents of ground solid
foods and thin liquids.
Followup Instructions:
You have the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2172-7-2**] 11:00
.
You have a follow up appointmemt with Dr. [**First Name (STitle) **] [**Name (STitle) **] from ENT
on [**4-27**] at 8:15 pm. Please call [**Telephone/Fax (1) 29891**] with questions
or if you have to reschedule.
Please call to make a follow up appointment in the neurology
clinic ASAP. You should call [**Telephone/Fax (1) 6856**] to make and
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-28**] weeks. If they tell you
this is not possible tell them that he saw you while you were in
the hospital and said that they should squeeze you in and
overbook.
.
You should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 36558**] [**1-27**]
weeks after discharge. In the meantime, you will need to have
your bloodwork checked on Monday and the results will be
followed up by Dr. [**Last Name (STitle) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"352.6",
"475",
"780.57",
"478.31",
"493.90",
"443.21",
"710.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11259, 11265
|
7318, 10060
|
320, 327
|
11443, 11501
|
4727, 7295
|
12596, 13789
|
4003, 4057
|
10332, 11236
|
11286, 11422
|
10086, 10309
|
11525, 12573
|
4072, 4708
|
248, 282
|
355, 3575
|
3597, 3839
|
3855, 3987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,153
| 144,868
|
30850
|
Discharge summary
|
report
|
Admission Date: [**2105-10-6**] Discharge Date: [**2105-10-12**]
Date of Birth: [**2038-10-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Aortoiliac atherosclerosis with disabling claudication
Major Surgical or Invasive Procedure:
Aorta biprofunda bypass with [**First Name5 (NamePattern1) 899**] [**Last Name (NamePattern1) 72997**] [**10-6**]
Post-op NSTEMI
History of Present Illness:
This 66-year-old gentleman with severe peripheral vascular
disease has severe disabling claudication in both of his
extremities. He has had a previous femoral- femoral graft which
has failed. He underwent an arteriogram
which showed his aorta to be diseased. His right common iliac
artery was ectatic and ended at the internal iliac artery with
no external iliac artery on that side. On the left side, his
entire iliac system is totally occluded with a very large
profunda femoris artery reconstituting collaterals in the
groin. Both common femoral arteries also totally occluded.
Because of the extent of his disease and his severe symptoms, he
was advised of an aortobifemoral bypass.
Past Medical History:
CAD
COPD
PVD s/p peripheral revascularization in [**2095**] ?fem-fem ([**Hospital1 2025**])
NIDDM
HTN
"Hepatitis" >20 yrs ago
+ tob abuse
+ ETOH abuse
EF 20-25%
Social History:
Social history is significant for the presence of current
tobacco use. There is history of alcohol abuse. Lives alone. Has
one daughter ([**Name (NI) **] [**First Name8 (NamePattern2) **] [**Name (NI) 46**]). retired
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: 98.5 P: 85 BP 143/66 RR: 23 Spo2: 93% RA
General: NAD
Neuro: Alert and oriented x 3
Cards: RRR, SR on tele
Lung: CTA bilaterally
Abdominal: soft, nt, nd
Wounds: Midline Abdominal incision CDI. Bilateral groin incision
CDI with staples, without signs/symptoms of infection.
Pulses: Femoral palp bilaterally
DP, PT [**Name (NI) **] bilaterally
Pertinent Results:
[**2105-10-11**] 05:15AM BLOOD WBC-7.1 RBC-3.38* Hgb-10.7* Hct-30.2*
MCV-89 MCH-31.6 MCHC-35.4* RDW-15.0 Plt Ct-128*#
[**2105-10-11**] 05:15AM BLOOD Plt Ct-128*#
[**2105-10-12**] 05:45AM BLOOD Glucose-137* UreaN-17 Creat-1.3* Na-136
K-3.6 Cl-100 HCO3-26 AnGap-14
[**2105-10-9**] 03:35AM BLOOD CK(CPK)-184*
[**2105-10-9**] 03:35AM BLOOD cTropnT-0.52*
[**2105-10-12**] 05:45AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
[**2105-10-9**] 03:35AM BLOOD Ammonia-13
[**2105-10-8**] 08:27AM BLOOD TSH-5.2*
[**2105-10-10**] Blood culutures pending
[**2105-10-8**] 2:59 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2105-10-10**]**
GRAM STAIN (Final [**2105-10-8**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2105-10-10**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2105-10-8**] 4:13 pm BLOOD CULTURE Source: Line-artearial.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Final [**2105-10-11**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) 72998**] ON [**2105-10-9**] @2051 .
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST.
OPERATIVE REPORT
[**Last Name (LF) 1111**],[**First Name3 (LF) 1112**] B.
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 72999**]
Service: Date: [**2105-10-6**]
Date of Birth: [**2038-10-20**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2287
PREOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease with
severe claudication and failed femoral-femoral bypass.
POSTOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease with
severe claudication and failed femoral-femoral bypass.
PROCEDURE: Aortobifemoral bypass with 16 x 8 Dacron graft,
proximal aortic and left renal endarterectomy and
reimplantation of inferior mesenteric artery into the graft.
ASSISTANT: [**Doctor Last Name 29316**].
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 800 cc.
COMPLICATIONS: None.
INDICATIONS: This 66-year-old gentleman with severe
peripheral vascular disease has severe disabling claudication
in both of his extremities. He has had a previous femoral-
femoral graft which has failed. He underwent an arteriogram
which showed his aorta to be diseased. His right common iliac
artery was ectatic and ended at the internal iliac artery
with no external iliac artery on that side. On the left side,
his entire iliac system is totally occluded with a very large
profunda femoris artery reconstituting collaterals in the
groin. Both common femoral arteries also totally occluded.
Because of the extent of his disease and his severe symptoms,
he was advised of an aortobifemoral bypass.
PROCEDURE: Under adequate general tracheal anesthesia the
abdomen and groins were prepped and draped in the usual
sterile fashion. The old groin incisions were opened. There
was extensive scar formation in the groins. Ultimately the 2
femoral anastomoses of the [**Doctor Last Name 4726**]-Tex femoral-femoral graft
were encountered. The graft was divided close to the femoral
arteries. The common deep and superficial femoral arteries
were dissected out on both sides and encircled with vessel
loops. The common and superficial femoral arteries were
chronically occluded. The profunda femoris artery was the
only artery available for outflow.
On the right side the profunda femoris artery took off high
and took an unusual medial course to the superficial femoral
artery, and in fact it appeared as though the femoral-femoral
bypass had been implanted on the right into the superficial
femoral artery. On the left side the common femoral and
superficial femoral arteries were occluded, the graft was
into the common femoral artery. The profunda femoris artery
was calcified proximally, was soft distally, but somewhat
small in caliber.
Tunnels were created under the inguinal ligaments into the
retroperitoneal space and the femoral grafts were completely
removed from the femoral arteries where they had been
attached and the artery over sewn with 5-0 Prolene sutures.
We then made a xiphoid to pubis midline abdominal incision
and entered the abdomen without difficulty. The sigmoid colon
was pulled superiorly and the viscera retracted to the right.
The ligament of Treitz was incised and the abdominal aorta
was exposed from the crossing left renal vein to the iliac
bifurcation. The aorta was heavily calcified and there
appeared to be one area proximally near the renal arteries
which was relatively soft and appeared as safe to clamp.
There was a low-lying left renal artery which was actually
known to be 1 of 2 left renal arteries on that side. We
decided to incorporate this renal artery into a beveled
anastomosis proximally.
I had initially given some thought to an end-to-side
anastomosis because there was a very large inferior
mesenteric artery distally, but in seeing the aorta, felt
that it was too diseased for anything other than end-to-end
anastomosis. We dissected out the very large inferior
mesenteric artery encircled with vessel loop, as well as the
left renal artery. We then created retroperitoneal tunnels
between the groins and this dissection.
The patient was then heparinized and proximal distal control
was obtained. The aorta was transected in an oblique fashion
with the high end of the oblique cut tracking towards the
right side, and the left lower end cut below the left renal
artery. A large amount of atheromatous debris and plaque was
found in the aorta and this was carefully endarterectomized
including plaque in the origin of the left renal artery. The
wall of the aorta was then extraordinarily thin after doing
this, particularly on the right side. A 16 x 8 Dacron graft
was taken, it was beveled proximally to match the oblique cut
in the aorta.
We then did an end-to-end anastomosis using a running
continuous suture of 4-0 Prolene with the entire anastomosis
buttressed with a felt strip around the entire anastomosis.
Once this was done, it was tested and found to be hemostatic.
Flow through the 2 iliac limbs was quite good. We then pulled
the graft limbs through the respective retroperitoneal
tunnels into proximity with the femoral arteries. Warm
ischemic time was less than 30 minutes on the left renal
artery which now had an excellent Doppler signal present
within it.
We then ligated the inferior mesenteric artery flush with the
aorta and separated it from the aorta. We over sewed the
distal end of the aorta with a running continuous suture of 3-
0 Prolene in 2 layers. Using a coronary aortic punch, a hole
was made in the aortic component of the graft. The inferior
mesenteric artery was beveled and an end-to-side anastomosis
was fashioned between the [**Female First Name (un) 899**] and the aortic graft with
running continuous 5-0 Prolene suture. Flow was reestablished
into the [**Female First Name (un) 899**] which had an excellent Doppler signal present
within it.
We then turned our attention into the groins. These were
quite bloody because of the heavy scar tissue that had been
divided to expose the artery. Proximal and distal control was
obtained on the left profunda femoris artery which actually
was a reasonably large artery. There was a fair amount of
disease in it when the arteriotomy was made and extensive
long arteriotomy was made until the soft normal distal
portion of the artery was encountered. We then trimmed and
beveled the right limb of the aortobifemoral graft and
performed a long end-to-side anastomosis with 5-0 Prolene
sutures from either end. Flow was reestablished into the
right limb after flushing the graft and this was done without
difficulty.
Attention was turned to the left side and proximal and distal
control obtained on the profunda femoris artery again and a
2nd arteriotomy was made. Backbleeding from this profunda
femoris artery was quite good, but there was absolutely no
antegrade bleeding whatsoever. The left limb of the graft was
then trimmed and spatulated and a 2nd end-to-side anastomosis
fashioned again with 5-0 Prolene sutures from either end.
Flow was reestablished in identical fashion. The patient's
blood pressure dropped a little with the 2nd anastomosis and
responded to volume replacement.
We then returned our attention to the abdomen was some oozing
from the retroperitoneal bed which had been fairly
extensively dissected to allow the anastomosis that was
created in the aorta. Some bleeding lumbar venous branches
were clipped. Other areas electrocoagulated with cautery. The
heparin was fully reversed with protamine. The
retroperitoneal tissue was then closed over the aortic graft
with running continuous 3-0 Prolene suture from either end.
The peritoneum was reperonitonealized because of the oozing
with a 2-0 Vicryl suture. All blood was washed out of the
pelvic gutter. The viscera returned to their normal position.
Prior to doing this Doppler interrogation demonstrated good
flow in the [**Female First Name (un) 899**], the left renal and also the right renal
artery.
All packs and retractors were removed. Sponge and lap count
was done and the midline fascia closed with a running
continuous suture of double-stranded #1 PDS from either end.
Groins were closed then in multiple layers after securing
hemostasis with interrupted and running sutures of 2-0 Vicryl
and the skin was closed with skin staples. The patient
tolerated this lengthy and difficult procedure well, a dry
sterile dressing was applied and the patient was taken to the
recovery room still intubated, but in stable condition, all
counts having been reported correct.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern4) 73000**]
Brief Hospital Course:
[**2105-10-6**]
Taken to the OR for End-to-End Aortabiprofunda bypass w/ graft
[**Female First Name (un) 899**] reimplantation. See attached operative note. Received 4
units PBC for Hct 29.9. Transferred to ICU. Blood pressure
stable and pain controlled.
[**2105-10-7**]
POD #1 Vitals stable.Pain management and BP control. NPO until
Hct stable. Transferred to VICU. Cardiology consulted for
elevated post-op Troponin. Ruled in for NSTEMI and was treated
with IV beta blockers, ASA and high dose Statin. Cards
recommended medical management with no evidence of acute HF.
Aggressive Ativan given for EtOH withdrawal. A code purple was
called when the patient became suddenly agitated and aggressive.
Psych was consulted. Haldol TID initiated.
[**2105-10-8**]
Psych following for EtOH withdrawal. ABGs within normal limits.
CIWA protocol. Cardiology following. Transferred back to CVICU
for increased agitation, HTN and tachycardia. Restrained for
patient safety.
[**2105-10-9**]
Monitored in CVICU. Continued on Haldol,. Transfused 1 unit
PRBCs. Sputum culture 2+ Gram -/+, started on Zosyn. Psych eval
better, now fully oriented.
[**2105-10-10**]
[**Last Name (un) **] consulted for DM control. Lantus dose increased. Vanco
started for + blood cx. Cleared by Physical Therapy for home.
[**2105-10-11**]
VS Stable. Transferred back to floor. Post-op delirium improved.
[**2105-9-12**]
No acute events. Discharge planning. Follow-up with Dr.
[**Last Name (STitle) **] in 1 week, will have staples removed at that time.
PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 12551**] for post-MI follow-up in 2
weeks. Will fax DC summary to PCP and [**Name9 (PRE) 73001**] office visit.
Medications on Admission:
Asa 81', furosemide 40', lisinopril 5', lopressor 50'', plavix
75', lantus 26U hs.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Continue to take medication per Cardiac Surgery
recommendations.
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Insulin Glargine 100 unit/mL Cartridge Sig: 18 units
Subcutaneous at bedtime.
9. Insulin
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50 mg/dL 1 amp D50 1 amp D50 1 amp D50 1 amp D50
51-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 3 Units 3 Units 3 Units 0 Units
161-200 mg/dL 6 Units 6 Units 6 Units 0 Units
201-240 mg/dL 8 Units 8 Units 8 Units 3 Units
241-280 mg/dL 10 Units 10 Units 10 Units 6 Units
281-320 mg/dL 12 Units 12 Units 12 Units 8 Units
321-360 mg/dL 12 Units 12 Units 12 Units 8 Units
361-400 mg/dL 14 Units 14 Units 14 Units 10 Units
> 400 mg/dL Notify M.D.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Peripheral Vascular Disease
COPD
NIDDM
Hypertension
Post-op NSTEMI
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? NO DRIVING Dr. [**Last Name (STitle) **] will discuss the plan for driving in
the future in your follow-up appointment
?????? Call and schedule an appointment to be seen in 1 week for post
procedure check and staple removal
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
DO NOT RETURN TO WORK. Follow-up with Dr. [**Last Name (STitle) **] at office
visit for plans to return to work.
Followup Instructions:
Please call [**Telephone/Fax (1) 3121**] to follow-up with Dr. [**Last Name (STitle) **] on
Thursday [**2105-10-21**] for an office visit. You will have your
staples removed at that time.
Follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks [**Last Name (NamePattern4) **],VARTAN
[**Telephone/Fax (1) 12551**]
Completed by:[**2105-10-12**]
|
[
"440.0",
"997.1",
"428.0",
"496",
"E878.2",
"250.00",
"401.9",
"428.22",
"996.74",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.59",
"38.14",
"38.16",
"99.04",
"39.25",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
15596, 15602
|
12284, 13984
|
371, 502
|
15737, 15746
|
2130, 3252
|
18483, 18837
|
1655, 1737
|
14118, 15573
|
15623, 15716
|
14010, 14095
|
15770, 17789
|
17815, 18460
|
1752, 2111
|
277, 333
|
3282, 12261
|
530, 1219
|
1241, 1404
|
1420, 1639
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,293
| 135,022
|
42758
|
Discharge summary
|
report
|
Admission Date: [**2167-7-3**] Discharge Date: [**2167-7-7**]
Date of Birth: [**2088-10-27**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Pacemaker Placement
Foley Catheter
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 92234**] is a 78 y/o man with PMH significant for ESRD on
dialysis secondary to type 2 DM and hypertension, CAD s/p
NSTEMI, and left internal cartotid artery stenosis who presented
to the ED this morning c/o worsening shortness of breath. Mr.
[**Known lastname 92234**] reports that he just "didn't feel right" after
dialysis yesterday. He had worsening shortness of breath as the
day went on, until it became so bad this morning that the family
called an ambulance. The shortness of breath is not affected by
position. The patient denies chest pain at any time.
In the ED, vital signs were: SBP 230s, HR 48-58, SpO2 90% on
room air. On exam, he had moderate respiratory distress, JVD,
pulm edema, and bipedal edema. EKG showed AV dissociation. The
patient was seen by renal in the ED, started on CPAP, and
started on nitro drip which was titrated up to control BP and
aspirin.
.
On review of symptoms, he denies fevers, nausea or vomiting .
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope
Past Medical History:
* Known RBBB and LAFB with prolonged PR interval: (saw Dr.
[**Last Name (STitle) **] in [**3-/2166**])
* Known CAD: Patient diagnosed with a non-Q wave MI in [**2150**]. EKG
had biphasic T-waves in V2 through V4 which evolved into T-wave
inversion in V1-V6. His CPK total was serially 221, 155 and 121
with O% MBs. But he was still thought to have an MI due to his
EKG. He was treated with nitroglycerin, heparin, Inderal,
aspirin, lasix (had pulm. edema.) During this hospitalization,
he underwent exercise treadmill test in which he went four
minutes, obtaining 80% of maximum heart rate and stopped due to
fatigue. His thallium scan was normal. A persantine MIBI in [**12-15**]
showed normal myocardial perfusion. ECHO in [**7-19**] showed mild LVH
with normal LV size and regional LV systolic function. LVEF>55%.
LA was mildly enlarged. RV chamber size and function was normal.
NO AS, AR, 1+ MR.
* Left internal carotid artery stenosis: (Carotid US in [**3-19**]
showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no
right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on
Plavix
* ESRD: Paitent started on hemodialysis in [**5-20**] for ESRD due to
hypertension and DMII. Patient receives hemodialysis on Tuesday,
Thrusday and Saturday via a left AV fistula.
* Type 2 DM: (last A1c 6.6% in [**11-19**])
* Hypertension
* Chronic anema: (baseline hct ~ 35)
* Hyperlipidemia: (total 180, TG 95, HDL 57, LDL 104 in [**11-19**])
* Secondary hyperparathyroidism
* Bilateral cataracts s/p surgical intervention
* s/p ERCP for bile duct stenosis
* Mild dementia
Social History:
Lives with wife and son. [**Name (NI) **] another son who lives in downstairs
apartment. He worked as a bricklayer for many years. Reports a
45 pk/yr h/o tobacco but quit over 20 yrs ago. Has glass of wine
with lunch and dinner. Occasional beer on a hot day.
Family History:
Mother- DM, CAD
Physical Exam:
VS: T 98.6, BP 195/45, HR 55, RR 22, O2 96% on 5L NC
Gen: Pleasant WDWN elderly 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.
Neck: Supple with JVP of 9 cm. No [**Doctor Last Name **] a waves appreciated
CV: Distant heart sounds.Audible L neck ?radiated bruit from L
AV fistula, Decreased heart sounds (increased AP diameter) RR,
normal S1, S2. No S4, no S3.
Chest: Mild respiratory distress, no accessory muscle use.
Decreased BS R >L, especially at bases, with crackles on L.
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; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG [**7-3**] demonstrated bradycardia with AV dissociation, complete
heart block.
.
TELEMETRY demonstrated: bradycardia 50s.
CXR ([**2167-7-3**]): Mildly enlarged heart. Right-sided pleural
effusion and right lower lobe opacification. Pulmonary vascular
congestion suggest heart failure.
.
CXR ([**7-3**]): New moderate right-sided pleural effusion and right
lower lobe opacification and pulmonary vascular congestion
suggests heart failure.
.
LABORATORY DATA:
WBC 8.8 (68% neutrophils, 21% lymphs), Hct 34, Plt 276
K 3.9, bicarb 37, creatinine 3.6
INR 1
CK 56 --> 40, MB not done, trop 0.10 --> 0.08
[**2167-7-3**] HGB-11.8*
Brief Hospital Course:
78 yr old gentleman with remote hx MI '[**50**], ESRD on HD, HTN
admitted with acutely worsening shortness of breath, found in
the ED to be bradycardia and in complete heart block.
# Third degree AV block - Over fifteen year hx of long PR
interval, known history of RBBB and L ant. fascicular block,
seen by cardiology in [**3-20**]. He has been asymptomatic to date.
Escape rhythm in 50s, with rates as low as 38. The patient was
closely monitored for further decrease in heart rate, and then
went for permanent pacemaker placement on [**7-6**], which he
tolerated well. CXR prior to discharge confirmed lead
placement. Patient was treated with a 3 day course of IV
vancomycin dosed renally after hemodialysis. Patient recieved
last dose on the day of discharge. Patient is to follow up in
device clinic in one week to have his pacemaker checked. An
initial appointment with cardiology was scheduled with Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]-[**Location (un) 620**].
# Dyspnea - Likely volume overload, and may be secondary to
decreased CO in setting of complete heart block. Also, patient
hypertensive on arrival with SBPs in 200s which may have caused
pulmonary edema. History of renal failure. Pleural effusion on
CXR. Infection unlikely - patient afebrile with normal WBC
count. Volume overload was addressed with hemodialysis.
# Hypertension - Hx of HTN with SBPs in 170s at home. Due to
complete heart block, all nodal agents were held. Initially he
was restarted on his outpatient [**Last Name (un) **], but his SBPs continued to
be in the 190s. Po hydralazine and nifedipine were added to his
regimen with good response. Patient experienced episode of
hypotension the am of dialysis and his regimen was adjusted to
nifedipine 30 every 8hours and valsartan 160mg twice daily.
# Hyperlipidemia - Home Lipitor was continued.
# ESRD - Received ultrafiltration and hemodialysis during this
admission with the removal of volume. Last dialysis performed
on [**7-7**]. Ultra filtration was performed on [**7-6**] and [**7-7**] with
3.5 kg removed over those two days. Renal followed during stay.
Patient received erythropoetin during stay. Patient to return
to his T/TH/S dialysis schedule on discharge.
# DMII - Uncontrolled with HbA1c of 11.8 on admission. Blood
glucose level was monitored and ISS given as needed. On
discharge, home medications were resumed. Patient advised to
follow up with primary physician for further blood glucose
control.
# h/o Left internal Carotid artery stenosi - Patient continued
on home plavix 75mg daily.
# PPx: Hep SC for DVT prophylaxis and bowel regimen of senna and
colace were administered during this admission.
# FEN: Cardiac/Renal diet, replete lytes as needed.
# Code: Full
Medications on Admission:
Lipitor 20
Plavix 75
Trandolapril 2
Nifedipine 90
Glipizide
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
Disp:*270 Capsule(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation. Capsule(s)
6. Glipizide 5 mg Tablet Sig: [**12-16**] Tablet PO once a day.
7. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
8. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Third Degree Heart Block status post pacemaker placement
Hypertension
End-stage renal dialysis on hemodialysis
Diabetes Mellitus type II
Secondary:
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were evaluated for an arrhythmia and have been treated for
complete heart block with a permanent pacemaker.
Please continue all medications as directed on discharge. You
have been scheduled for follow up with the electrophysiology
team and a cardiologist.
Please call you physician or return to the emergency department
if you experieince any chest pain, shortness of breath,
lightheadedness, palpitations, or fever.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Thursday
[**7-16**] at 10:10 am. [**Telephone/Fax (1) 1579**]
Please follow-up with a cardiologist. We have scheduled you an
appointment with Dr. [**Last Name (STitle) **] at [**Hospital1 **] [**Location (un) 620**] on [**8-11**] at 2
pm. His office is located on the [**Location (un) 448**] of [**Hospital1 **] [**Location (un) 620**].
[**Telephone/Fax (1) 4105**]
Please follow-up at device clinic since [**Telephone/Fax (1) 59**] you just
had your pacemaker placed and this will need to be checked out
next week. You have an appointment on Tuesday [**2167-7-14**] at 4 pm.
The office is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building.
|
[
"403.91",
"250.00",
"428.30",
"585.6",
"E942.9",
"433.10",
"518.81",
"458.29",
"428.0",
"426.0",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"37.83",
"39.95",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
8615, 8672
|
4984, 7747
|
287, 337
|
8880, 8889
|
4331, 4961
|
9361, 10127
|
3386, 3404
|
7858, 8592
|
8693, 8859
|
7773, 7835
|
8913, 9338
|
3419, 4312
|
228, 249
|
365, 1417
|
1439, 3093
|
3109, 3370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,449
| 104,862
|
8664
|
Discharge summary
|
report
|
Admission Date: [**2135-6-22**] Discharge Date: [**2135-7-2**]
Date of Birth: [**2076-4-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male with a history of metastatic melanoma to bowel and known
pulmonary and CNS metastases status post craniotomy with
resection of the brain metastases. The patient presented
with a three day history of intermittent worsening and crampy
abdominal pain in the lower quadrants, worse on the right
than on the left. The pain was described as severe. The
patient had a bowel movement until the day prior to
admission. KUB on arrival in the Emergency Department showed
dilated loops of small bowel with air fluid levels. A CT
scan obtained shortly thereafter showed two large mesenteric
masses with erosion into small bowel and free perforation of
the more proximal segment of small bowel, as well as
mechanical mid small bowel obstruction.
PAST MEDICAL HISTORY:
1. Metastatic melanoma with metastases to the lung, brain,
bowel, left flank
MEDICATIONS:
1. Nexium 40 mg po qd
2. Flomax
3. Flonase
4. Compazine
5. Ambien 10 mg
6. Quinine 260 mg
7. Prednisone 10 mg po
8. 50 mcg fentanyl patch
The patient had recently been on his first week to Taxol
dexamethasone therapy and had also been through four cycles
of IL-2/temozolomide for his metastatic melanoma.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient had smoked one pack per day for
about 20 years, but quit 20 years ago.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.8??????, blood pressure 120/70, pulse
117, respiratory rate 20, O2 saturation 96% on room air.
GENERAL: The patient was awake and comfortable and appeared
well nourished.
HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous
distention, no palpable nodes. Oropharynx was clear.
NECK: Supple.
HEART: S1, S2, tachycardic with no murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Distended, nontender, no hepatosplenomegaly. There
were decreased bowel sounds. Abdomen was tense and was a 7
cm subcutaneous mass on the left flank.
EXTREMITIES: There was no lower extremity edema, cyanosis or
clubbing.
LABS: White cell count 9.8, hematocrit 13.8, platelets 947.
PT 12.8, PTT 21.5, INR 1.1. Chem-7 - sodium 136, potassium
4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6,
glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2.
HOSPITAL COURSE: The patient arrived in the hospital on the
evening of [**6-22**] and evaluation was initiated. The patient
was taken to the Operating Room late in the night of [**6-22**]
where, per the Operating Room note, tumors were discovered in
the ileum and jejunum with free perforation of both lesions.
The patient was then transferred to the Intensive Care Unit.
The patient was started on ampicillin, levofloxacin and
Flagyl.
On postoperative day #2, which was [**2135-6-25**], the patient was
started on TPN. His antibiotics were continued. On
postoperative day #3, the patient was noted to have a
slightly increased temperature to 100.2??????. He was pan
cultured given the fact he had recently been on steroids.
His central line was also changed. During the course of the
day, the patient was agitated at one point and pulled his
A-line. Haldol was prescribed.
On postoperative day #4, the patient appeared to be less
confused. He was transferred to the floor with a sitter. By
postoperative day #5, while the patient was on the floor, he
was appearing much more lucid, communicating appropriately
and the sitter was discontinued. The patient was continued
on total parenteral nutrition. Because of continued increase
in white cell count from 14.3 on postoperative day #4 to 16.0
on postoperative day #5, the patient was sent for an
abdominal CT. Although no abscess was identified that could
explain the patient's increase in white cell count, the
patient was noted to have developed mural thrombus in his
abdominal aorta and in the left iliac artery. The patient
was also noted to develop some new bilateral pleural
effusions with some barium in the left lung base. On being
notified of these findings, the surgical team immediately
consulted the patient's neuro-oncologist and oncologist team
for advice on the propriety of placing the patient on
anticoagulation.
The patient was seen by his neuro-oncologist on postoperative
day #6, which was the [**4-29**]. The patient's
neuro-oncologist requested head CT be obtained to rule out
any new brain metastases with bleeding because this would
determine the patient's suitably for anticoagulation. The
head CTs were negative and per neuro-oncology, there was no
contraindication to anticoagulating the patient. The patient
was seen by his oncologist team also on postoperative day #6.
Oncology was of the opinion of the patient, was unsuitable
for anticoagulation with Coumadin or heparin but that aspirin
could be initiated. The patient was therefore started on
aspirin.
The patient's steroids were also tapered beginning on
postoperative day #7. His fluconazole was discontinued. At
the suggestion of the patient's oncology team, the surgery
team also transfused the patient with 1 unit packed red blood
cells on postoperative day #8 for borderline low hematocrit
of 26.1. On postoperative day #7, the patient's diet was
changed from NPO to sips. The patient tolerated this well
and so on postoperative day #8, the patient was advanced to a
clear liquid diet and his TPN was discontinued. By the
evening of postoperative day #8, the patient was able to
tolerate a regular diet and on the day of discharge, which
was [**2135-7-2**], the patient had a regular breakfast without any
problems. [**Name (NI) **] is to be discharged home with visiting nurse
assistant for wound care. Mr. [**Known lastname **] continues to have an
open vertical incision in the midline of his abdomen that
would require wet to dry dressings twice a day.
DISCHARGE MEDICATIONS:
1. Flomax
2. Flonase
3. Compazine
4. Ambien
5. Quinine
6. Prednisone 10 mg po qd
7. Protonix 40 mg po bid
8. Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours
9. Levofloxacin 500 mg po qd x5 more days
FOLLOW UP: The patient is to follow up with oncology on [**7-18**]. The patient is to call Dr.[**Name (NI) 1863**] office for
follow up appointment this coming week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**First Name (STitle) 30359**]
MEDQUIST36
D: [**2135-7-2**] 10:51
T: [**2135-7-2**] 11:14
JOB#: [**Job Number 18599**]
|
[
"560.9",
"511.9",
"198.3",
"569.83",
"197.0",
"197.4",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5979, 6194
|
2448, 5956
|
1529, 2430
|
6206, 6634
|
158, 930
|
952, 1413
|
1430, 1514
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,279
| 114,580
|
55162
|
Discharge summary
|
report
|
Admission Date: [**2157-8-4**] Discharge Date: [**2157-8-17**]
Date of Birth: [**2082-6-28**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Abdominal pain, bilateral ovarian masses on CT
Major Surgical or Invasive Procedure:
Total abdominal hysterecomty, bilateral salpingoophorectomy,
pelvic side wall tumor resection, omentectomy, cystoscopy,
proctoscopy
History of Present Illness:
Ms. [**Known lastname 1005**] presented to GYN Oncology secondary to a possible
diagnosis of advanced ovarian cancer. Ms. [**Known lastname 1005**] is a
75-year-old gravida 2, para 2 who has had, over the course of
the four to six months prior to presentation, nonspecific lower
abdominal discomfort.She felt that her problems were related to
irritable bowel syndrome. She reported bloating and a nagging
abdominal discomfort that worsened and extended up to her
xiphoid. While traveling in the [**Country 31115**], she had a
worsening discomfort and was seen by a physician, [**Name10 (NameIs) 1023**] ordered
imaging studies. An ultrasound revealed ascites and a CT scan
of the torso revealed ascites, bilateral cystic ovarian masses
and an omental cake. Also, noted was a left lower lobe nodule,
which had features consistent with inflammatory change. Imaging
studies were all consistent with advanced ovarian cancer. Ms.
[**Known lastname 1005**] has changed her diet so that she is able to tolerate
liquids and smaller portions of food. She denied constipation.
Decision was made to manage surgically.
Past Medical History:
PMHx:
Hypertension and diabetes, both of which are very well
controlled. Barrett's esophagitis. She denies any history of
cardiac disease and has recently had a stress test and EKG, both
of which normal. She denies any history of asthma or
thromboembolic disorder.
PSHx:
She underwent an appendectomy and cholecystectomy in [**2112**]. She
has had bilateral knee replacements and a left shoulder rotator
cuff surgery.
OB/GYN HISTORY:
She is gravida 2, para 2 woman. She denies any history of
pelvic infections or abnormal Pap smears and her last was
obtained two years ago.
Social History:
She is widowed. She is accompanied by her daughter. She lives
in [**State 760**] most of the year. She denies tobacco, drug or
alcohol use.
Family History:
Aunt with a history of ovarian cancer and mother with kidney
cancer. Three sisters with atrial fibrillation.
Physical Exam:
Physical Exam on Discharge:
VSS
Gen: NAD, Comfortable
CV: Regular rate rhythm
Pulm: Lungs clear to auscultation bilaterally
Abd: Soft, nondistended, nontender, +BS, incision clean dry
intact
Ext: Warm well perfused, nontender to palpation.
Pertinent Results:
[**2157-8-4**] 11:15AM BLOOD WBC-7.0 RBC-4.88 Hgb-10.2* Hct-33.8*
MCV-69* MCH-20.8* MCHC-30.0* RDW-16.5* Plt Ct-297
[**2157-8-5**] 09:57PM BLOOD WBC-15.0*# RBC-6.03* Hgb-12.5 Hct-42.5
MCV-71* MCH-20.8* MCHC-29.4* RDW-17.0* Plt Ct-336
[**2157-8-7**] 02:45PM BLOOD WBC-11.7* RBC-4.89 Hgb-10.2* Hct-33.4*
MCV-68* MCH-20.8* MCHC-30.5* RDW-17.6* Plt Ct-355
[**2157-8-7**] 10:05AM BLOOD Glucose-130* UreaN-18 Creat-0.8 Na-139
K-4.0 Cl-100 HCO3-28 AnGap-15
Brief Hospital Course:
Ms [**Known lastname 1005**] was admitted on [**2157-8-4**] with pelvic mass and likely
advanced ovarian cancer and on HD2 underwent diagnostic
laparoscopy, exploratory laparotomy, lysis of adhesions, total
abdominal hysterectomy, bilateral salpingo-oophorectomy, radical
resection of abdominopelvic tumor, omentectomy, and cystoscopy.
[**Hospital **] hospital course was complicated by atrial fibrillation
with rapid ventricular response, episode of hypoxia,ICU
transfer, post-operative ileus and UTI.
*) Atrial fibrillation with rapid ventricular response: This was
first noted on day of admission, [**2157-8-4**], when patient was in the
OR prior to surgery, case was cancelled and patient was
transferred to the floor, evaluated by cardiology and started on
PO metoprolol dosing, at which point she spontaneously converted
to normal sinus rhythm. Patient underwent a TTE the following
day which showed normal global and regional biventricular
systolic function with mild mitral regurgitation with good rate
control, and cardiology reported no contraindications to
surgery. Post operatively, atrial fibrillation with RVR
recurred on [**2157-8-7**], requiring diltiazem 45 mg IV and metoprolol
15 mg IV dosing, as well as diltiazem PO 30 mg PO QID, on top of
metoprolol dosing already being given. Patient was transferred
to the [**Hospital Unit Name 153**] due to need for diltiazem gtt. Cardiology continued
to follow and recommended no cardioversion as patient was
asymptomatic. The diltiazem drip was stopped and Ms [**Known lastname 1005**]
continued to be tachycardic and was unable to be controlled with
verapimil drip. Patient was started on metoprolol and digoxin IV
with good control. She was transferred back to the floor. After
over 24 hours in sinus rhythm patient converted back to afib
with RVR however again was asymptomatic and patient started back
on PO Metoprolol 100mg TID and spontaneously converted back to
sinus rhythm after 8 hours. Patient had two more episodes of
afib with RVR during hospital stay, patient was asymptomatic
through all episodes of afib with RVR. Digoxin was stopped by
cardiology as was felt to have little effect. Patient started on
therapeutic dose of lovenox with plans to initiate bridge to
coumadin once on consistent diet. Cardiology continued to
follow patient during hospitalization and prior to discharge
recommended patient go home on Metoprolol XL and [**Last Name (un) 28031**] with
follow up appointment with Dr [**Last Name (STitle) 171**] on [**2157-8-29**].
*) Ileus: Patient developed nausea and vomiting and KUB
consistent with ileus on post operative day 3 while in ICU. An
NGT was placed and put on suction and pt decompressed. Patient's
symptoms improved with NGT. This was continued on transfer to
the floor. Patient had return of bowel function after another
24 hours with NGT and at that time NGT was pulled and patient
tolerated sips. Patient tolerated slow advance of diet and was
tolerating a regular diet on discharge.
*) Urinary Tract Infection: On post operative day 9 patient
reported urinary frequency and urgency as well as multiple
episodes of incontinence. UA was positive and patient was
started on 7 day course of Cipro with some improvement in
symptoms. On day of discharge urine cultures came back with e.
coli resistant to cipro and patient switched to Macrobid 7 day
course.
*) Hypoxia: Patient developed hypoxia with oxygen saturations at
88% RA on post-op day 2. A CTA was done to rule out PE and CXR
showed no evidence of pneumonia. This was likely atelectasis.
Continued incentive spirometry. Resolved spontaneously.
*) Low urine output: Pt developed low urine output while in ICU.
Patient slowly responded to multiple IV boluses. Urine lytes
were sent and corresponded to a pre-renal source. Resolved on
transfer back to floor with consistent IV hydration.
*) Hypertension: Continued home amlodipine initially. This was
stopped as BP was controlled with metoprolol after development
of Afib with RVR. Amlodipine restarted once transferred back to
the floor in sinus rhythm. Switched back to home dose of [**Last Name (un) 28031**]
on discharge.
*) Ovarian cancer: Stage IIIC optimally cytoreduced serous
adenocarcinoma. Port placed for chemo prior to discharge. Plan
to follow up at [**Hospital1 107**] [**Doctor Last Name **]-Kettering for chemotherapy.
*) Diabetes mellitus: Patient on Januvia and metformin at home.
These were held while admitted and patient was placed on an
insulin sliding scale. Started back on home dose of metformin
once ileus resolved and tolerating PO. Instructed to resume
home medications on discharge.
Patient discharged in stable condition on [**2157-8-17**] with follow up
appointments with Dr [**Last Name (STitle) 171**] in cardiology and Dr [**Last Name (STitle) 2028**] with
plans to receive chemotherapy at [**Hospital1 107**] [**Doctor Last Name **]-Kettering.
Medications on Admission:
AMLODIPINE-OLMESARTAN Dosage uncertain
ATORVASTATIN Dosage uncertain
METOPROLOL SUCCINATE Dosage uncertain
PIOGLITAZONE Dosage uncertain
SITAGLIPTIN-METFORMIN Dosage uncertain
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*0*
2. docusate sodium 100 mg capsule Sig: One (1) capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 capsule(s)* Refills:*1*
3. alprazolam 0.25 mg tablet Sig: Two (2) tablet PO QHS (once a
day (at bedtime)).
4. acetaminophen 500 mg tablet Sig: One (1) tablet PO Q6H (every
6 hours) as needed for pain: Do not exceed 4000mg acetaminophen
in 24 hrs.
Disp:*50 tablet(s)* Refills:*0*
5. oxycodone 5 mg tablet Sig: One (1) tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 tablet(s)* Refills:*0*
6. Macrobid 100 mg capsule Sig: One (1) capsule PO twice a day.
Disp:*14 capsule(s)* Refills:*0*
7. metoprolol succinate 50 mg tablet extended release 24 hr Sig:
Three (3) tablet extended release 24 hr PO every twelve (12)
hours.
Disp:*180 tablet extended release 24 hr(s)* Refills:*2*
8. [**Last Name (un) 28031**] 10-20 mg tablet Sig: One (1) tablet PO once a day.
Disp:*30 tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Ovarian Mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 1005**],
You were admitted to the gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
Medication:
* Please resume taking your home medications for diabetes.
* Please stop taking prior blood pressure medications.
* Please take new medications for blood pressure/atrial
fibrillation until follow up with cardiology in 1 week at which
point they may be changed or adjusted.
* New medications: [**Last Name (un) 28031**] [**11-19**] Qday, Metoprolol XL 150mg taken
twice daily.
* Please take Macrobid (Nitrofurantoin) for 7 days twice a day
for urinary tract infection.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**].
Followup Instructions:
You have an appointment with DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**9-8**] at 10:15am
Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2157-9-8**] 10:15
You have an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-29**] at
2:20pm. Please call [**Telephone/Fax (1) 1989**] if you need to change time or
reschedule. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2157-8-29**] 2:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
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icd9cm
|
[
[
[]
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[
"65.61",
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|
[
[
[]
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9470, 9528
|
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|
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525, 1640
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1662, 2244
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2260, 2405
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,361
| 140,920
|
7763
|
Discharge summary
|
report
|
Admission Date: [**2195-8-14**] Discharge Date: [**2195-9-8**]
Date of Birth: [**2142-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe superior sulcus
tumor. Right exploratory thoracoscopy; right thoracotomy
and right upper lobectomy with en bloc chest wall resection
ribs 2, 3, 4 and 5; reconstruction with [**Doctor Last Name 4726**]-Tex mesh;
thoracic lymphadenectomy.
Major Surgical or Invasive Procedure:
R thoracotomy, RUL Lobectomy for CA, and chest wall resection ,
T2-4 right rib resection and chest wall reconstruction
Trach ([**8-21**]) s/p PEG ([**9-3**])
History of Present Illness:
Mr. [**Known lastname 28145**] is a 52 year-old man with history of HIV and
Hepatitis
C infection who presented in winter [**2193**] with history of right
sided shoulder discomfort. A PET/CT was done in [**2195-3-3**]
that
showed a spiculated mass in right lung apex. A biopsy was taken
and Pathology described it as Non-small cell carcinoma,
consistent with squamous cell carcinoma. A medisatinoscopy was
done in [**2195-4-2**] which didn't show evidence of lymph node
involvement. The patient started neo-adjuvant chemoradiation in
[**2195-4-23**] and completed radiation on [**2195-6-4**] complicated by
severe hematologic toxicity from his chemotherapy.
Admitted on [**2195-8-14**] for Right exploratory thoracoscopy; right
thoracotomy
and right upper lobectomy with en bloc chest wall resection
ribs 2, 3, 4 and 5; reconstruction with [**Doctor Last Name 4726**]-Tex mesh;
thoracic lymphadenectomy.
Past Medical History:
Oncology History:
DIAGNOSIS: Superior sulcus, T3, N0 non-small cell lung cancer.
Histology: squamous cell carcinoma.
TREATMENT:
Radiation [**2195-4-23**] to [**2195-6-4**]
Chemotherapy: 1 cycke cisplatin/etoposide, 2nd cycle cysplatin
Planned for surgical resection/thoracics evaluation
.
OTHER PAST MEDICAL HISTORY
# HIV: diagnosed [**2183**], current CD4 count in [**2195-6-2**] 41, was
previously maintained 300-500.
# Hepatitis C - s/p interferon treatment [**2187**] w/o viral
supression, liver bx [**2193**] w/grade 2 inflamm, stage II fibrosis
# Thrombocytopenia - felt [**1-3**] HAART
# mild hypogonadism is listed in previous notes
# depression also listed in previous notes
.
Social History:
SH: over 70-pack-year history of smoking. No current etoh. Last
IVDU 13 years ago.
.
Family History:
FH: [**Name (NI) 28142**] aunts w/lung cancer in 40s and 50s. father alive
w/o CA, mother w/ asthma and s/p removal of breast lesion.
Physical Exam:
VS: 98.7, 56, 19, 145/60, 96% on 50% Trach mask
general: frail, thin male in NAD. trach in place.
HEENT: trach #7 portex placed [**2195-8-21**]. Fitted for passey muir
valve.
Chest: right thoracotomy site healing, no redness, no drainage.
Breath sounds intermittantly coarse on right, clear on left.
Abd: Peg tube placed [**2195-9-3**].
Extrem: no C/C/E
Neuro: alert and communicative. answers questions approp.
Pertinent Results:
[**8-4**] CTC: The pre-existing subtotal consolidation of the left
lowerlobe has markedly improved. The right upper lobe spiculated
mass appears minimally smaller than at the last examination. The
extent of pleural thickening is unchanged. No new lesions have
occurred in the right upper lobe. Overall slight regression in
size of mediastinal lymph nodes.
[**8-23**] post ws CXR: slight interval increase in R apical ptx; with
air extending towards chest wall, improved lung aeration with
partial resolution of mulitfocal cosilidations although still
present. Stomach [**Month/Year (2) 65**] inflated, advance doboff.
[**8-25**]:right pneumothorax decreased, now small to moderate. Right
apical air pocket is unchanged. Dobhoff tube ends in the
stomach.Diffuse parenchymal opacities, more marked on the left
are grossly unchanged, could be infectious. No other change.
[**8-22**]: RUQ us no evidence cholelithiasis
[**8-29**]; pre-existing bilateral parenchymal opacities are
unchanged. right apical postoperative lesions and the
pre-existing right-sided rib lesions also unchanged.
Micro:
BAL 9/17:3+ PMN; NO MICROORGANISMS SEEN.
BAL [**8-17**] GPC >100,000 ORGANISMS/ML. oropharyngeal flora
BAL [**8-16**] GPC >100,000 ORGANISMS/ML. oropharyngeal flora
[**8-17**] BlCx x 2: P
[**8-17**] Ucx: P
[**8-26**]: BAL: 4+ PMN
[**8-26**] BLOOD CULTURE:P
[**8-26**] CMV Viral Load-neg
[**8-26**] BAL: NG
[**8-27**] Sputum: NG
[**8-28**] Cath: NG
Brief Hospital Course:
pt admitted and taken to the OR on [**2195-8-14**] for Right exploratory
thoracoscopy; right thoracotomy and right upper lobectomy with
en bloc chest wall resection
ribs 2, 3, 4 and 5; reconstruction with [**Doctor Last Name 4726**]-Tex mesh; thoracic
lymphadenectomy.
An epidural was placed for pain control and was split
(epidural/PCA) on POD#1 for improved pain control. 2 chest tubes
were placed at the time of surgery and was placed on sxn
w/positive air leak.
ID was consulted for ongoing follow up for previous LLL which
grew out aspergilus fungatus/mycelia on BAL [**2195-7-10**] and was being
treated w/ voriconazole and bactrim suppression therapy.
On POD#2 Pt was seen by RT for sxning for low O2 sats w/ copious
secretions. required 100% NRB and was subsequently transferred
to the ICU for resp distress. Was intubated and bronched for
copious secretions for presumed aspiration PNA. Food particles
were sxn from airways during bronch. CXR w/ RLL collapse.
Started on broad spectrum abx- vanco/zosyn. Micro from serial
BAL's revealed no growth.
POD#3 bronch done for pul tiolet to remove secretions from LUL
as seen by LUL collapse on CXR. Extubated but failed d/t
inability to manage secretions and required re-intubation in
8hrs.
POD#4 epidural migrated out and was d/c'd.
POD#5 hypotensive and was treated w/ IVF and intermittant
pressors, propofol was decreased. Bronch'd for pul tiolet nd
extubation failed again requiring reintubation.
POD#6 one of the chest tubes was removed and the other tube
remained on sxn. Oral feeding tube was placed for tube feeds.
POD#7 Trach performed. Required intermittant neo/IVF boluses for
BP support. Chest tube to water seal.
POD#[**7-12**] chest tube d/c'd. Weaning vent slowly. Heme was
consulted for low PLT count which was felt to be multifactorial.
Pt did rec transfusion of PLTS and PRBC.
POD# 11- 17 Cont'd to have difficulty weaning from the vent w/
periods of agitation. neuro was consulted and felt MS changes
were d/t delirium.
POD# 18 failed swallow. Eval for PEG.
POD# 20 peg placed.
POD#21 progressed well MS cleared, weaned from vent, started
feeds. transferred from the ICU to the floor.
POD# 22 pt transferred to the icu after he developed somulence
w/ passey muir valve in place. hypercarbic. Passey muir valve
removed, symptoms improved.
POD#23 Pt transferred from the icu to the floor. Remains NPO on
tube feeds at goal. Passed swallow for nectar thick liqs and
pureed but will NOT start po's until re-assessed at follow up
visit. [**Last Name (un) **] passey muir valve.
Intermittantly required pressors for hypotension
Medications on Admission:
Combivir, Letvita, zoloft, klonopin, MVI, trazodone prn,
methadone, dilaudid, voriconazole
Discharge Medications:
1. Emtricitabine-Tenofovir 200-300 mg Tablet [**Last Name (un) **]: One (1) Tablet
PO DAILY (Daily): via G-tube.
2. Bisacodyl 10 mg Suppository [**Last Name (un) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (un) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: 3-5 MLs
Miscellaneous Q8H (every 8 hours) as needed.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for O2 sat <93%.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime): via peg.
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily): via peg.
8. Olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day): via peg.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): via-peg.
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed: via peg.
11. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO BID (2
times a day) as needed: via peg.
12. Fosamprenavir 700 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H
(every 12 hours): via peg.
13. Multivitamins Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily): via peg.
14. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Six Hundred (600) mg PO
TID (3 times a day) as needed for pain: via peg.
15. Sertraline 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): via peg.
16. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day): via peg.
17. Methadone 10 mg/mL Concentrate [**Last Name (STitle) **]: Seventy Five (75) mg PO
QAM (once a day (in the morning)) as needed for maintenance.
18. Voriconazole 200 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]:
Two [**Age over 90 1230**]y (250) mg PO Q12H (every 12 hours).
19. Albuterol 90 mcg/Actuation Aerosol [**Age over 90 **]: Four (4) Puff
Inhalation Q2H (every 2 hours) as needed.
20. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Age over 90 **]: Two (2)
Puff Inhalation QID (4 times a day).
21. Erythromycin 5 mg/g Ointment [**Age over 90 **]: .5 qid Ophthalmic QID (4
times a day).
22. regular insulin
per sliding scale fingerstick
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HIV+ HEP C+ sp R thoracotomy, RUL Lobectomy for CA, and chest
wall resection , T2-4 right rib resection and chest wall
reconstruction, transfer w/acute MS change, pO2=42, ?aspiration,
now s/p Trach ([**8-21**]) s/p PEG ([**9-3**])
.
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you develop fever,
chills, redness or drainage from your incision site or have any
symptoms that concern you.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on Date/Time:[**2195-9-22**] 11:30 on
the [**Hospital Ward Name **] clinical center [**Hospital Ward Name **] building [**Hospital1 **] one.
please arrive 45 minutes prior to your appointment and report to
the [**Location (un) 470**] radiology for a chest XRAY.
Completed by:[**2195-9-15**]
|
[
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icd9cm
|
[
[
[]
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[
"38.93",
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icd9pcs
|
[
[
[]
]
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9889, 9968
|
4551, 7149
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575, 735
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10245, 10261
|
3084, 4528
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10487, 10825
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281, 537
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763, 1673
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,152
| 119,150
|
52292
|
Discharge summary
|
report
|
Admission Date: [**2183-3-14**] Discharge Date: [**2183-3-21**]
Date of Birth: [**2130-7-17**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Iodine Containing Agents Classifier / adhesive tape / Reglan
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Recurrence of leiomyosarcoma
Major Surgical or Invasive Procedure:
Exploratory laparotomy, extensive lysis of adhesions, resection
of abdominal wall mass, resection of pelvic mass, rectosigmoid
resection, cystoscopy
History of Present Illness:
Ms. [**Known lastname 62297**] is a 52-year-old woman with a history of a recurrent
low-grade sarcoma to the pelvis. She underwent her last
resection in [**6-/2178**] some 10 years after her primary resection.
Patient has been monitored for evidence of recurrence with CT
scans and physical exams. She is overall doing well and has no
focal complaints or concerns.
Patient has a pelvic mass noted on CT scan, measuring 5 x 5 cm.
It extends from the vaginal apex along the rectosigmoid and
towards the right pelvic sidewall. This has an appearance of
recurrent disease. All options for treatment were discussed and
the decision was made to proceed with surgery.
Past Medical History:
PMH: hypercholesterolemia, Type 2 DM diagnosed [**5-30**]
PSH: ex-lap and RSO; L tuboplasty then salpingectomy; cesearean
section; TAH with temporary L ureteral stent placement in [**2167**]
for uterine leiomyoma of uncertain malignant potential (8 hr
surgery, complicated by vascular injury requiring repair)
GynHx: fibroids, infertility. No Hx abnl paps, STIs.
ObHx: G2P3, c/s for 2nd twin distress
Social History:
Married. Denies tobacco, alcohol, or drug use.
Family History:
The patient was adopted and knows very little of her family
history of cancer.
Physical Exam:
Exam at pre-operative visit:
GENERAL: She appears her stated age, in no apparent distress.
HEENT: Normocephalic, atraumatic. Oral mucosa without evidence
of thrush or mucositis. Eyes, sclerae are anicteric.
NECK: Supple, no masses.
LYMPHATICS: Lymph node survey, negative cervical,
supraclavicular, axillary, or inguinal adenopathy.
EXTREMITIES: No clubbing, cyanosis, or edema. There is no calf
tenderness to palpation.
PELVIC: Normal external genitalia. Inner labial folds normal.
Urethral meatus normal. Walls of the vagina are smooth. The
apex is visibly normal. Bimanual exam reveals the mass at the
vaginal apex that appears tethered to the bowel. It extends
over
to the right side. This corresponds to the lesion that we see
on
CT scan. Rectal exam reveals the lesion noted above is smooth
walled.
Pertinent Results:
Labs prior to discharge home:
[**2183-3-20**] 06:56AM BLOOD WBC-11.7* RBC-3.30* Hgb-9.8* Hct-29.9*
MCV-91 MCH-29.6 MCHC-32.7 RDW-14.3 Plt Ct-321
[**2183-3-20**] 06:56AM BLOOD Glucose-109* UreaN-5* Creat-0.6 Na-139
K-3.5 Cl-106 HCO3-26 AnGap-11
[**2183-3-20**] 06:56AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0
Brief Hospital Course:
MICU course:
Patient was transferred to the ICU after a prolonged surgery.
She received a total of 3 units of PRBCs in the OR. She remained
intubated overnight in the ICU. She was extubated on POD#1
without difficulty. She remained hemodynamically stable
throughout her hospitalization.
GYN FLOOR COURSE:
On POD#1, the patient was transferred out of the ICU to the GYN
post-operative floor. Her post-operative course remained
uncomplicated.
The patient was in lithotomy position for approximately 12 hours
during her surgery, however after extubation, her strength and
sensation remained normal. She was able to ambulate on POD#2
without difficulty.
Patient's pain was initially controlled with a Dilaudid PCA.
Once she was able to tolerate PO, she was transitioned to PO
Dilaudid, which made her dizzy. Her pain remained controlled
with Motrin and Tylenol #3.
Given her rectosigmoid resection, patient remained NPO until
POD#4, at which time she was advanced to clears when passing
flatus. On POD#5, her diet was advanced to regular, which she
was able to tolerate well.
Given her left ureteroureterostomy and left double J ureteral
stent placement, the urology team continued to follow the
patient closely. Her foley catheter remained in place until
POD#5. She was able to void without difficulty. Her JP drain
remained in place until POD#7 with minimal output. She will
follow up with urology in 8 weeks for stent removal.
She remained on SQ heparin throughout her admission.
She was discharged home on POD#7 in stable condition. She was
able to ambulate, void, and tolerate PO without difficulty.
Medications on Admission:
Ambien 10mg [**1-26**] tab PO QHS; PRN insomnia
Ibuprofen PRN
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*40 Tablet(s)* Refills:*0*
2. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain: Do not exceed 4000mg Tylenol
in 24 hours.
Disp:*60 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Low grade leiomyosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- No heavy lifting for 6-8 weeks.
- You may shower. No bath tubs for 2 weeks.
- Take Motrin and Tylenol with codeine for pain. Do not drive
while taking narcotics.
Followup Instructions:
- Please call Dr.[**Name (NI) 27357**] office to arrange to come to his
office on Tuesday or Wednesday to have your staples removed.
Phone: [**Telephone/Fax (1) 5777**].
- Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2183-4-24**] 4:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
[
"998.2",
"E878.2",
"250.00",
"198.1",
"197.6",
"722.0",
"171.6",
"197.5",
"V88.01",
"272.0",
"285.1",
"628.9",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"59.8",
"45.94",
"56.75",
"57.32",
"48.69",
"48.23",
"56.41",
"54.3"
] |
icd9pcs
|
[
[
[]
]
] |
5319, 5325
|
2978, 4593
|
363, 514
|
5394, 5394
|
2652, 2955
|
5733, 6176
|
1715, 1795
|
4706, 5296
|
5346, 5373
|
4619, 4683
|
5545, 5710
|
1810, 2633
|
295, 325
|
542, 1207
|
5409, 5521
|
1229, 1634
|
1650, 1699
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,770
| 162,565
|
27722
|
Discharge summary
|
report
|
Admission Date: [**2121-7-30**] Discharge Date: [**2121-8-11**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
85F with increasing SOB and s/p NSTEMI for CABG.
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->Ramus, RCA)[**8-4**]
History of Present Illness:
This 85F had an NSTEMI [**2121-7-7**] and had increasing SOB. She was
worked up for this and was also found to have anemia and a colon
mass with ovarian mets. Cardiac cath at that time revealed: a
non obstructive plaque in the distal LM and severe disease of
the proximal LAD and 100% occlusion of the RCA. LVEF was 50%.
She underwent a work up for anemia and was found to have a cecal
mass and ovarian mets. She is now admitted for elective CABG.
Past Medical History:
Thalessemia trait
HTN
chronic anemia
CAD
Colon ca w/ ovarian mets.
^chol.
Social History:
Lives with son.
Cigs: none
ETOH: none
Family History:
Unremarkable
Physical Exam:
Elderly WF in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Lungs: sl. bibasilar rales
CV: RRR without R/G/M, no. S1, S2
Abd: +BS, soft, nontender, without masses or hepatospenomegaly
Ext: without C/C/E, pulses 2+=bilat. throughout.
Neuro: nonfocal
Pertinent Results:
[**2121-8-11**] 06:30AM BLOOD WBC-14.2* RBC-4.15* Hgb-9.8* Hct-29.0*
MCV-70* MCH-23.7* MCHC-33.9 RDW-21.9* Plt Ct-254
[**2121-8-11**] 06:30AM BLOOD PT-18.0* PTT-PND INR(PT)-1.7*
[**2121-8-10**] 08:33AM BLOOD Glucose-170* UreaN-55* Creat-2.2* Na-127*
K-4.1 Cl-93* HCO3-23 AnGap-15
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2121-8-6**] 9:49 AM
CHEST (PORTABLE AP)
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman s/p chest tube pull
REASON FOR THIS EXAMINATION:
PTX
HISTORY: Status post chest tube removal.
COMPARISON: [**2121-8-5**].
CHEST: AP portable upright view. The left chest tube and
mediastinal drains have been removed. There is no pneumothorax.
Small bilateral pleural effusions appear unchanged. There is no
pulmonary edema. Evidence of CABG is again noted. Left lower
lobe atelectasis is slightly improved. New linear atelectasis is
noted in the left mid lung zone, adjacent to previous location
of the chest tube. The Swan-Ganz catheter has been removed. The
remaining right internal jugular venous sheath terminates in the
upper SVC.
IMPRESSION:
1. No pneumothorax.
2. Small bilateral pleural effusions, unchanged.
3. Slight improvement in left lower lobe atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2121-8-7**] 10:09 AM
Brief Hospital Course:
The patient was admitted on [**2121-7-30**] with weakness and SOB. She
r/o for an MI and cardiac surgery was consulted. Her creatinine
was elevated to 2.2 and she was evaluated by renal. Cardiac
surgery was consulted and after she was cleared by renal, she
underwent CABGx3(LIMA->LAD, SVG->Ramus and RCA) on [**2121-8-4**]. She
tolerated the procedure well and was transferred to the CSRU in
stable condition on Neo and Propofol. She was extubated on
POD#1 and had her CTs d/c'd on POD#2. During her postop course
she was followed by the renal service and her creatinine
remained in the 2 range.
On POD#2 she had intermittent confusion and required Haldol.
She was transferred to the floor and her mental status returned
to baseline on POD#4. Her wires were d/c'd on POD#3 and she
went into AF that PM. She was loaded with Amio and remained in
AF. She was anticoagulated with heparin and coumadin and
discharged to rehab in stable condition on POD#7.
Medications on Admission:
Lisinopril 5 mg PO daily
Lopressor 75 mg PO TID
Allopurinol 100 mg PO daily
Protonix 40 mg PO daily
ASA 81 mg PO daily
NTG patch
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x 1 week then 200mg QD.
9. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
4mg [**8-11**] then as directed to maintain INR 2-2.5.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD, SVG-Ramus, SVG-RCA)[**8-4**]
PMH:CAD s/p MI, HTN, Colon CA w/ovarian mets(untreated),
Thallesemia trait, ^chol, Gout, s/p T&A, s/p lipoma excision,
s/p cataract [**Doctor First Name **], anemia
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 3 months.
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17234**] 2-3 weeks after d/c from rehab
Completed by:[**2121-8-11**]
|
[
"428.0",
"403.91",
"272.0",
"427.31",
"414.01",
"198.6",
"584.9",
"282.5",
"285.22",
"153.9",
"293.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5056, 5146
|
2898, 3859
|
317, 363
|
5405, 5412
|
1319, 1703
|
5684, 5863
|
1012, 1026
|
4039, 5033
|
1740, 1778
|
5167, 5384
|
3885, 4016
|
5436, 5661
|
1041, 1300
|
228, 279
|
1807, 2875
|
391, 842
|
864, 940
|
956, 996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,536
| 199,790
|
36814
|
Discharge summary
|
report
|
Admission Date: [**2174-5-23**] Discharge Date: [**2174-6-1**]
Date of Birth: [**2099-11-13**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Patient with progressive shortness of breath with new
O2 requirement, LUL mass and left pleural effusion.
Major Surgical or Invasive Procedure:
Medical thoracoscopy on the left side, Pleural biopsy, Tube
thoracostomy, 24-French, left side.
History of Present Illness:
74 year old female with history of endometrial cancer status
post
TAHBSO and brachytherapy who began having shortness of breath in
[**Month (only) 116**]. At the same time the patient began having back pain as
well
as a pleuritic-type pain in her "left lung". Patient had an
abnormal chest xray which led to a CT scan that revealed 2.2 x
1.7 cm left upper lobe mass, several areas of right pleural
density adjacent to RUL and RLL with the largest being at the
lower lobe posterolaterally measuring 3 x 1.4 cm and a moderate
left pleural effusion with underlying atelectasis. She had a
bronchoscopy at an OSH where there were no endobronchial lesions
and the lesion in the LUL was biopsied (no malignant cells).
PET
scan revealed FDG uptake within multiple pleural deposits as
well
as the slips of the diaphragm and retroperitoneal lymph nodes.
Also noted was some increased avidity in the lower pelvis.
Patient also has a new O2 requirement. She reports limited
activity tolerance, cannot lie flat and still has the left
pleuritic pain.
Past Medical History:
NIDDM
HTN
Hyperlipidemia
Asthma
Status post cholecystectomy
Endometrial cancer, status post TAHBSO, brachytherapy
Social History:
Married. Lives with husband. Does not drink ETOH, has never
smoked. She was a housewife for many years. Husband owned a
woodworking/wood pattern shop.
Family History:
Mother had asthma, Father died from TBI, sister
had lymphoma.
Physical Exam:
Vital Signs: T:98.2 HR: 88 RR:24 O2 sat 94% room air
General: A+O in NAD
Cardiac: RRR
Lungs: decrease Breath Sounds Bil.
Abd: Soft Nt ND + bs
Ext: bil. edma to lower extremities
Pertinent Results:
[**2174-5-26**] 06:30AM BLOOD WBC-9.9 RBC-3.61* Hgb-11.0* Hct-32.2*
MCV-89 MCH-30.6 MCHC-34.3 RDW-14.7 Plt Ct-297
[**2174-5-26**] 06:30AM BLOOD WBC-9.9 RBC-3.61* Hgb-11.0* Hct-32.2*
MCV-89 MCH-30.6 MCHC-34.3 RDW-14.7 Plt Ct-297
[**2174-5-24**] 08:42PM BLOOD WBC-15.9*# RBC-4.02* Hgb-12.2 Hct-36.1
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.2 Plt Ct-350
[**2174-5-23**] 03:20PM BLOOD WBC-7.7 RBC-4.07* Hgb-12.3 Hct-36.7
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.6 Plt Ct-271
[**2174-5-23**] 03:20PM BLOOD Neuts-73.1* Lymphs-13.7* Monos-8.5
Eos-3.8 Baso-0.9
[**2174-5-26**] 06:30AM BLOOD PT-13.8* INR(PT)-1.2*
[**2174-5-27**] 06:25AM BLOOD Glucose-190* UreaN-39* Creat-1.5* Na-135
K-4.8 Cl-98 HCO3-26 AnGap-16
[**2174-5-27**] 02:00AM BLOOD Glucose-159* UreaN-40* Creat-1.5* Na-133
K-4.6 Cl-98 HCO3-23 AnGap-17
[**2174-5-26**] 06:30AM BLOOD Glucose-107* UreaN-46* Creat-1.7* Na-136
K-4.3 Cl-99 HCO3-27 AnGap-14
[**2174-5-25**] 12:29PM BLOOD Glucose-266* UreaN-49* Creat-1.9* Na-135
K-4.2 Cl-97 HCO3-27 AnGap-15
[**2174-5-25**] 06:40AM BLOOD Glucose-140* UreaN-43* Creat-1.8* Na-136
K-4.3 Cl-99 HCO3-27 AnGap-14
[**2174-5-24**] 08:42PM BLOOD Glucose-210* UreaN-39* Creat-1.9* Na-134
K-4.2 Cl-95* HCO3-25 AnGap-18
[**2174-5-23**] 03:20PM BLOOD Glucose-197* UreaN-33* Creat-1.1 Na-137
K-4.6 Cl-96 HCO3-29 AnGap-17
[**2174-5-27**] 02:00AM BLOOD proBNP-632*
[**2174-5-27**] 06:25AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.2
[**2174-5-27**] 02:00AM BLOOD Albumin-3.1* Calcium-9.3 Phos-3.2 Mg-2.1
[**2174-5-23**] 03:20PM BLOOD Calcium-9.8 Phos-3.1 Mg-2.3
[**2174-5-26**] 06:30AM BLOOD CA125-207*
[**2174-5-27**] 02:15AM BLOOD Type-ART FiO2-88 pO2-69* pCO2-38 pH-7.44
calTCO2-27 Base XS-1 AADO2-536 REQ O2-87 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2174-5-27**] 02:15AM BLOOD Type-ART FiO2-88 pO2-69* pCO2-38 pH-7.44
calTCO2-27 Base XS-1 AADO2-536 REQ O2-87 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2174-6-1**] 03:00AM BLOOD WBC-13.0* RBC-3.48* Hgb-10.8* Hct-30.5*
MCV-88 MCH-30.9 MCHC-35.3* RDW-14.7 Plt Ct-400
[**2174-6-1**] 03:00AM BLOOD Glucose-185* UreaN-40* Creat-1.5* Na-129*
K-4.7 Cl-90* HCO3-26 AnGap-18
[**2174-5-27**] 02:00AM BLOOD proBNP-632*
[**2174-5-31**] 01:46AM BLOOD Osmolal-272*
[**2174-6-1**] 03:00AM BLOOD CA125-276*
URINE CULTURE (Final [**2174-5-31**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Left parietal pleura, biopsy:
Metastatic carcinoma, see note.
Pleural Fluid:
POSITIVE FOR MALIGNANT CELLS,
consistent with adenocarcinoma
CT chest
[**Known lastname 83172**],[**Known firstname **] [**Medical Record Number 83173**] F 74 [**2099-11-13**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2174-5-24**]
5:46 AM
[**Last Name (LF) **],[**First Name3 (LF) **] TSURG FA9A [**2174-5-24**] 5:46 AM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 83174**]
Reason: evaluate for malignancy/LAD. Please do CT at 0600.
Patient
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman with pleural effusion, LUL lung nodules and
multiple pleural
based nodules
REASON FOR THIS EXAMINATION:
evaluate for malignancy/LAD. Please do CT at 0600. Patient is
being
premedicated with prednisone and benadryl.
CONTRAINDICATIONS FOR IV CONTRAST:
allergy to iodine
Final Report
EXAM: CT chest [**2174-5-24**].
INDICATION: Pleural effusion, left upper lobe lung nodules and
multiple
pleural-based nodules. Please evaluate for malignancy and
lymphadenopathy.
COMPARISON: None available at time of study interpretation.
TECHNIQUE: Volumetric ct of the chest without IV contrast.
FINDINGS: There are bilateral pleural effusions, moderate to
large on the
left, and small on the right. Within the left pleural fluid,
there are
heterogeneous areas of increased density, suspicious for pleural
nodules.
Several discrete pleural or pleural-based nodules marginate the
left
mediastinal pleura including 1.9 cm nodule (2, 25), 2.9 cm
nodule (2, 28), and
2.1-cm nodule (2, 30).
The right pleural effusion is homogeneous, and relatively low in
density (4
[**Doctor Last Name **]). No definite nodularity is seen in the right pleural
effusion, though
there is a serous density, 1.8 cm pleural-based nodule higher in
the right
hemithorax, located along the lateral right pleural surface (2,
20), and a 3.5
x 1.7-cm anterior, softtissue nodule (2, 44) difficult to
differentiate
between a very inferior pleural nodule and a subdiaphragmatic
nodule.
Several scattered parenchymal nodules in the right upper lobe
measure up to 5
mm (2, 25). Fissural nodularity between the right upper and
lower lobes at the
same level is 1.3 cm long. Atelectasis at the lung bases
bilaterally, left
greater than right, is likely related to passive compression
from adjacent
pleural effusion. Aerated portions of the left lung are grossly
clear.
Heart is not enlarged. There is no pericardial effusion, or
pericardial
nodule. There is mild atherosclerotic calcification of the
coronary arteries.
Central airways are patent to the subsegmental level.
This study is not specifically tailored for subdiaphragmatic
evaluation. Note
is made however of moderate right hydronephrosis, which is
incompletely
imaged. There is a 1.3-cm nodule adjacent to the lateral
peritoneal wall in
the upper abdomen (2, 53). Several small subphrenic lymph nodes
are noted on
the right (2, 41), and there are scattered retrocrural and
retroperitoneal
lymph nodes, none of which meet CT size criteria for pathologic
enlargement.
There is no osseous lesion suspicious for malignancy.
IMPRESSION:
1. Moderate-to-large left pleural effusion with irregular areas
of high
attenuation nodularity is concerning for pleural metastatic
disease.
Additional areas of nodularity adjacent to the left mediastinal
pleura, and in the right upper lobe are also worrisome for
malignancy. Comparison to previous imaging (per clinical notes a
PET-CT has been performed) would be extremely helpful for
correlating these findings.
2. Small right pleural effusion without discrete nodularity,
homogeneously
low in attenuation.
3. Right hydronephrosis of uncertain etiology.
4. At least one nodular peritoneal implant seen in the right
upper abdomen, also worrisome for metastatic disease.
CXR [**5-31**]
The bilateral pleural effusion is present, left more than right,
moderate to large on the left and small to moderate on the
right. There is no evidence of pneumothorax. The degree of
cardiomegaly is difficult to assess as it is obscured by pleural
effusions. No overt pulmonary edema is demonstrated.
Brief Hospital Course:
74 yo f with stage IV endometrial cancer, who was admitted for
procedure.
Initially pt was admitted to Admit to [**Hospital Ward Name 121**] 9 Dr [**Last Name (STitle) **]/Thoracic
Surgery with the DX: Hypoxemia, pleural effusion. She had a
Chest CT that revealed a left pleural effusion with areas
concerning for malignancy in the lungs and the abdomen. She had
a pleuroscopy with biopsy [**2174-5-24**]. The bx of the pleural showed
malignancy as well as the plural fluid. She had 900ml drained
from the lung. 5 gram talc used for pleurodesis chest tube
clamped for 2 hours then sx for 48 hours. That night patient
developed hypotension with BP down to 60 systolic tx with IVF 2
liters with improvement Creatine climbing on admission 1.1 up to
1.9. BP meds were held. Pain controlled with 1 gram of Tylenol q
6 hours. Foley reinserted for accurate I+O's. [**2174-5-25**] Creatine
improving continue to hold Lasix and lisinopril. IVF continued.
[**2174-5-26**] IVF d/c'd and pt encouraged to have PO intake. Chest tube
clamped and then she had SOB 4 hours later. o2sats dropped to
89% chest tube placed back to suction o2 increased O2 sats back
to 92-945 ON 4 LITERS OF O2. Chest x/ray with out changes. CT
back to water seal. Over night patients sats down and resp.
28-30 o2 requirement increased. Chest Tube then d/c'd. Right
lower extremity appeared more edematous Duplex lower ext showed
no DVT. [**Date range (1) 83175**]-Continued to improve and transferred to
onc-med for on [**5-30**].
On Oncology floor, pt became more tachypneic and required
transfer to [**Hospital Unit Name 153**]. She refused intubation. Initially palliative
chemo was going to be attempted, however, with respiratory
distress, pt was not a candidate. Attempt was made to diuresis
pt with Lasix IV and then gtt, but respiratory distress and
tachypnea continued. She was evaluated by IP and not a able to
have a pleuradex cath due to body habitus.
Attending had long discussion with patient and family and she
chose to become CMO on [**5-31**] in PM. She was placed on morphine
gtt and continued on a shovel face mask. She expired in the
afternoon 8:08PM on [**2174-6-1**].
Medications on Admission:
FUROSEMIDE [LASIX] -60 mg by mouth daily
GLYBURIDE - 10 mg Tablet by mouth twice a day
LISINOPRIL - 10 mg Tablet by mouth daily
NEBIVOLOL [BYSTOLIC] - 5 mg by mouth daily
PIOGLITAZONE [ACTOS] - 30 mg by mouth daily
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Bystolic 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Expired
Discharge Diagnosis:
Extensive pleural-based masses on the posterior,
as well as the diaphragmatic surface.
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 10084**] if experience:
Fever > 101 or chills. Increased shortness of breath, cough or
sputum production. Chest pain.
Followup Instructions:
Call Dr.[**Name (NI) 14680**] office for a follow-up appointment.
[**Telephone/Fax (1) 10084**]
Completed by:[**2174-6-2**]
|
[
"599.0",
"V88.01",
"518.0",
"E879.8",
"782.3",
"V58.67",
"493.90",
"799.02",
"458.29",
"276.1",
"511.81",
"V10.42",
"250.00",
"584.5",
"401.9",
"272.4",
"197.2",
"591",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.92",
"34.09",
"34.20"
] |
icd9pcs
|
[
[
[]
]
] |
11735, 11744
|
8723, 10888
|
407, 505
|
11875, 11884
|
2180, 5080
|
12114, 12240
|
1903, 1967
|
11212, 11712
|
5120, 5216
|
11765, 11854
|
10914, 11189
|
11908, 12091
|
1982, 2161
|
262, 369
|
5248, 8700
|
533, 1576
|
1598, 1714
|
1730, 1887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,293
| 154,675
|
29635
|
Discharge summary
|
report
|
Admission Date: [**2171-11-29**] Discharge Date: [**2171-12-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
fever, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86yo woman with recent ICU admission/hospital stay for sepsis
thought secondary to c. difficile colitis now returns two days
after discharge with fever to 102, worsened dyspnea, and
hypoxemia with desaturations to 80's%. Pt has been at
[**Hospital 71048**] rehab since [**10-6**] following L femur ORIF. On [**11-7**] pt
developed fever at rehab and was taken to [**Hospital3 **] ED.
She was started on a 14 day course of levaquin for ? PNA and
returned to rehab. Pt was again taken to NW with fever on [**11-18**].
She was encouraged to continue levaquin, returned to rehab. On
[**11-21**], pt was again taken to NW with fever. Clinical picture c/w
sepsis--febrile, tachycardic with SBPs in 70s. Pt was started on
zosyn and vanc, CVL placed, started on levophed and tx'd to
[**Hospital1 18**] for ICU care. Pt was initially treated with broad spectrum
abx but was transitioned to flagyl with good response. The pt
was discharged on a 14 day course of flagyl on [**11-26**]. Pt was
doing well at rehab. Diarrhea had resolved for approx 1-2 days
and she was afebrile. However, this am was found to have bp
100/52, hr 120s, sats 80s on RA, c/o SOB, was o/w afebrile.
Transferred to [**Hospital1 **].
.
In ED, vitals were: T 102, hr 112, bp 108/58, rr 24, 98% nrb.
She was pan-cultured, and chest film demonstrated bibasilar
infiltrates. CT chest demonstrated small b/l pleural effusions.
She was treated empirically with vancomycin 1g and ceftazidime
2g for ? PNA. CT abd demonstrated pan-colitis. EKG had no
diagnostic ischemic changes, and one set of cardiac enzymes were
negative. Lactate was 1.3. WBC was 29.4 from 12.6 most recently.
BNP 2400. U/A tr leuks/small blood/neg sediment. Transferred to
[**Hospital Unit Name 153**] for further management.
.
On ROS, pt denies dyspnea at present, though + orthopnea for [**3-5**]
years. B/L leg swelling for a few weeks. Denies PND. Denies CP,
HPs. Denies cough. She denies n/v/d/abd pain. + poor appetite
for weeks.
Past Medical History:
1. recent ([**11-21**] - [**11-26**]) admit for sepsis, c. diff colitis.
Currently on 2wk course of flagyl to end [**2171-12-6**]
2. neuropathy
3. L. ORIF [**2174-10-10**]
4. Hypothyroidism
5. s/p L total knee replacement [**2154**]
Social History:
Has never smoked, lives at [**Hospital 71049**] rehab
Family History:
NC
Physical Exam:
Temp 100.7
BP 100/60
Pulse 116
Resp 20
O2 sat 95% 4L NC
Gen - Alert, no acute distress
HEENT - extraocular motions intact, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - crackles at bases bilaterally
CV - Normal S1/S2, tachy no murmurs
Abd - Soft, nontender, mild distension, hyperactive bowel sounds
Extr - +1 edema to knees b/l. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3
Skin - No rash
Pertinent Results:
[**2171-11-29**] 10:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2171-11-29**] 10:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-OCC
EPI-<1
[**2171-11-29**] 09:26AM LACTATE-1.3
[**2171-11-29**] 09:20AM cTropnT-<0.01
[**2171-11-29**] 09:20AM CK-MB-NotDone proBNP-2404*
[**2171-11-29**] 09:20AM WBC-29.4*# RBC-4.06* HGB-11.2* HCT-34.8*
MCV-86 MCH-27.7 MCHC-32.3 RDW-20.2*
.
CTPA:
1. No evidence of pulmonary embolism.
2. Enlarged main pulmonary artery with right ventriculomegaly
suggestive of elevated right ventricular pressures and pulmonary
hypertension.
3. Interval increase in the small bilateral pleural effusions
and pericardial effusion.
4. Moderate ascites.
5. Stable 4-mm right middle lobe nodule
Brief Hospital Course:
1) Fever: Patient was without evidence of consolidation on CT
and no history of cough. Her U/A was negative. Additionally,
there are no signs/symptoms concerning for osteo at surgery
site. On recent admission was found to be positive for C.
difficile in setting of diarrhea and was started on course of PO
flagyl. She was nearly halfway through treatment with flagyl
(to which her diarrhea originally responded) when diarrhea
returned associated with fever. Thus, given history of diarrhea,
recently positive C. diff, grossly elevated WBC and pancolitis
on CT, fever seems most likely secondary to C. diff infection.
It is unclear why C. diff responded originally to flagyl and
then clinical picture worsened, but upon admission to [**Hospital Unit Name 153**],
flagyl was stopped and PO vancomycin was initiated. With PO
vanco her fever resolved, WBC improved and diarrhea resolved.
She will continue on a 2 week course of vanco (10days left at
d/c). Repeat stool studies were unremarkable.
.
2) Dyspnea: Appeared more consistent with heart failure than
pneumonia given long h/o orthopnea/LE edema, elevated BNP on
admission and, as above, without cough nor clear infiltrates on
imaging. There was no echo available in our records, but h/o LE
edema/orthopnea dates back 5+ years. A TTE done here showed
moderate pericardial effusion without evidence of tamponade,
hyperdynamic EF. She may have diastolic dysfunction. The
pericardial effusion is likely from total body fluid overload.
There was no evidence of ACS. AFter her ICU stay, she diuresed
on her own without lasix. Her oxygenation improved and she was
on RA. She had no SOB. Her peripheral edema also improved.
She may need lasix in the future to keep her euvolemic but at
this point is diuresing well without it.
.
3) Tachycardia: Patient was admitted with ST in the setting of
fever. Also, as above, she appeared clinically intravascularly
dry in setting of diarrhea/poor po. Her tachycardia did respond
well to IV hydration (was a total of 6L positive over 1st 24
hours of hospitalization including ED course)and heart rate
improved from 120s on admission to 90s. Given that her EF was
not known on admission, following the IV hydration throughout
the 1st 24 hours of admission, additional maintenance IV fluids
were held while PO fluids were encouraged. Her heart rate was
well controlled henceforth.
.
4) Hyponatremia: Sodium was found to be 136 on admission to
[**Hospital Unit Name 153**] and following NS resuscitation decreased to 132. IVFs were
held and sodium was trended. It improved as the pt diuresed
into the low normal range.
.
5) Anemia: Her baseline is unclear, but hematocrit in our
system has long been low. Hct did drop mildly on admission
following IVFs, but this is in the setting of nearly 6L positive
so is most likely hemodilutional. Hematocrit was followed and
stool guaiac was evaluated. Her hct was stable and iron studies
showed iron deficiency and anemia of chronic disease so she was
started on iron.
.
6) Neuropathy: She was continued on her home dose neurontin
with adequate control of her neuropathic pain.
.
7) S/P Left ORIF: She was continued on her outpatient pain
control regimen with methadone and prn vicodin. Her home
celebrex was stopped in setting of heart failure.
.
8) Hypothyroid: She was continued on her home dose of
synthroid. Her TSH was elevated at 11 but free t4 was wnl so
she likely had sick euthyroid. Thyroid function tests can be
rechecked in [**1-4**] weeks.
Medications on Admission:
Celecoxib 200 mg daily
Gabapentin 100 mg PO BID
Fluoxetine 40mg
lidocaine patch
Levothyroxine 75 mcg
Metronidazole 500 mg Tablet tid (last dose [**12-6**])
Pantoprazole 40 mg PO Q12H
Lidocaine 5 %(700 mg/patch)
Methadone 5 mg po BID
Calcium Carbonate 500 mg PO TID
Vitamin D2 50,000 unit daily X 7 days
vicodin prn
mvi
Discharge Medications:
1. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days. Capsule(s)
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to lower leg.
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO DAILY (Daily).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): if patient remains
bedbound.
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for 1 weeks.
13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain.
14. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Meadowgreen
Discharge Diagnosis:
C diff colitis
CHF, diastolic
Hypothyroidism
Discharge Condition:
Good.
Discharge Instructions:
Please take medications as prescribed.
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**], chills, abdominal pain,
diarrhea, shortness of breath, chest pain, increasing leg edema
or any other symptoms that concern you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 33645**] in [**12-3**] weeks.
|
[
"428.0",
"428.30",
"285.29",
"008.45",
"244.9",
"280.9",
"355.9",
"785.0",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9105, 9143
|
3897, 7400
|
278, 285
|
9232, 9240
|
3091, 3874
|
9538, 9619
|
2623, 2627
|
7770, 9082
|
9164, 9211
|
7426, 7747
|
9264, 9515
|
2642, 3072
|
224, 240
|
313, 2278
|
2300, 2535
|
2551, 2607
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,201
| 123,613
|
13923
|
Discharge summary
|
report
|
Admission Date: [**2189-2-18**] Discharge Date: [**2189-3-17**]
Service: CSU
ADMISSION DIAGNOSES:
1. Aortic stenosis.
2. Coronary artery disease--status post left anterior
descending and obtuse marginal stent.
3. Congestive heart failure.
4. Atrial fibrillation.
5. Hypertension.
6. Peripheral vascular disease.
7. History of skin cancer.
8. History of colon polyps.
9. Gastroesophageal reflux disease.
10. Hiatal hernia.
11. Right carotid stenosis--status right carotid
endarterectomy.
12. Status post total abdominal hysterectomy.
13. Status post cholecystectomy.
14. Status post appendectomy.
DISCHARGE DIAGNOSES:
1. Aortic stenosis--status post aortic valve replacement with
a 19 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve.
2. Coronary artery disease--status post coronary artery
bypass grafting x1 (saphenous vein graft to posterolateral
branch of right coronary artery); history of stents.
3. Bilateral pleural effusions--status post tube drainage.
4. Acute renal insufficiency.
5. Blood loss anemia--status post multiple transfusions.
6. Nonsustained ventricular tachycardia (resolved).
7. Atrial fibrillation.
8. Hypertension.
9. Peripheral vascular disease.
10. History of skin cancer.
11. History of colon polyps.
12. Gastroesophageal reflux disease.
13. Hiatal hernia.
14. Right carotid stenosis--status post carotid
endarterectomy.
15. Status post total abdominal hysterectomy.
16. Status post cholecystectomy.
17. Status post appendectomy.
ADMISSION HISTORY AND PHYSICAL: Ms. [**Known lastname 41672**] is an 83-year-
old woman, with a history of congestive heart failure, who
was found to have aortic stenosis during her cardiac work-up,
for which she was scheduled to have elective repair. She had
had multiple admissions to the hospital for exacerbations of
her congestive heart failure. She also notably had increasing
episodes of angina, and on her cardiac catheterization was
found to have 60% disease of her right coronary, 30% disease
of the diagonal, and 80% to the PDA, with an ejection
fraction of 60%. Her aortic valve area was about 0.3 cm to
0.4 cm on her preoperative catheterization. Given her
constellation of symptoms and her multiple exacerbations, she
was admitted to the hospital for elective repair.
On her initial examination, her weight was 128 pounds, pulse
64 in sinus rhythm, with a blood pressure of 110/65. She was
otherwise satting 95% on room air. She was in no acute
distress. There was no significant JVD. Her lungs were clear.
Her heart was regular. She had a III/VI systolic ejection
murmur throughout the precordium. Her abdomen was otherwise
soft. She had no edema in the lower extremities. Her
hematocrit was 39, and her BUN and creatinine were 15 and
1.7.
HOSPITAL COURSE BY SYSTEMS: The patient was admitted to the
hospital on [**2189-2-18**], and on that same day underwent an
aortic valve replacement with a 19 mm CE tissue valve, and
also coronary artery bypass grafting x1 with saphenous vein
graft to the posterolateral branch of the right coronary
artery. Her cardiopulmonary bypass time was 102 minutes, and
her crossclamp time was 82 minutes. The patient was taken to
the cardiac surgery unit postoperatively.
1. NEUROLOGICALLY: The patient did quite well. She had no
episodes of confusion or agitation, and had adequate pain
control with a combination of narcotic medications in the
initial postoperative period, followed by Tylenol and
ibuprofen as needed.
1. RESPIRATORY: The patient's respiratory status was quite
tenuous during the course of her hospitalization. She did
well initially post extubation on postoperative day 1, but
by postoperative day 4, she began to have worsening oxygen
saturation with increased work of breathing, and was found
to be in mild respiratory acidosis with hypercarbia. Her
chest film. showed bilateral pleural effusions with some
evidence of CHF. She was subsequently transferred to the
intensive care unit for more aggressive monitoring and, in
fact, required BIPAP ventilation. Her pleural effusions
were drained via insertion of pigtail catheters. She put
out a significant amount of fluid when the pigtails were
inserted, with approximately 1,200 cc coming out from the
right chest, and another 350 cc coming out from the left
chest when the catheters were inserted. Her respiratory
status stabilized after insertion of these catheters, and
she began to improve subsequently after more aggressive
diuresis was started.
The remainder of her hospitalization was notable for
significant output from the right and left chest tubes of 500
cc to 1,000 cc per day. Analysis of this fluid revealed it to
be a transudate without any evidence of an infective process.
The drainage catheters were left in place for 2 weeks, but at
that time there was only about 100 cc to 200 cc of fluid
draining from these catheters and; therefore, it was
determined that they should be removed. She subsequently did
reaccumulate some fluid, but the effusions were stable and
well-controlled with diuretics. She did not require
reintubation postoperatively, and her respiratory acidosis
did improve. The pulmonology critical care service was
consulted for assessment of these effusions, and they felt
that these were likely secondary to her congestive heart
failure. They felt that there was no evidence of amiodarone
toxicity contributing to her pulmonary status. By the time of
her discharge, Ms. [**Known lastname 41672**] was satting 94% on room air. She
was otherwise not dyspneic. She did have some decreased
breath sounds at the bases with the presence of mild
bilateral pleural effusions which had been stable on serial
chest imaging. To note, there was some question as to whether
these effusions may have been secondary to nonspecified
postcardiotomy syndrome.
1. CARDIOVASCULAR: On postoperative day 0, the patient
experienced brief runs of nonsustained ventricular
tachycardia, at which time amiodarone was started, but
after the immediate postoperative period, these episodes
resolved. She had been in atrial fibrillation in the past
but, in fact, remained in sinus rhythm throughout the
course of her hospitalization. Her congestive heart
failure was managed with aggressive diuresis and afterload
reduction with ACE inhibitors. There was a question as to
whether her pleural effusions were secondary to congestive
heart failure from a problem with her aortic valve, for
which she underwent repeat echocardiography. Her repeat
echocardiogram showed that her ejection fraction was
normal at greater than 65%. Her aortic valve had a
prosthetic which was seated in good position, but had
somewhat of an increased gradient present. There was 1+
mitral regurgitation. Her aortic valve mean gradient was
36 mm. It was not felt that the valve was responsible for
her recurrent pleural effusions. Her CHF, as noted, was
managed with a combination of beta blockers and ACE
inhibitors. We added calcium channel blockers for some
time after consultation with congestive heart failure
service, but prior to her discharge it was felt that the
combination of beta blockade and ACE inhibitor alone would
be adequate for her control, along with diuretics. She
never had any evidence of postoperative cardiac ischemia,
and her bypass graft seemed to be functioning well.
Prior to her discharge, as noted, she was in sinus rhythm on
a stable dose of beta blocker and ACE inhibitor with
amiodarone. Her Coumadin was not restarted, as she had
remained in sinus rhythm, and otherwise not reverted to
atrial fibrillation, and also due to the fact that there was
concern that there might be some risk of instability while
walking, or falls while on anticoagulation.
1. GASTROINTESTINAL: No major issues.
1. FLUID, ELECTROLYTES AND NUTRITION: The patient was, as
noted, significantly volume overloaded in the initial
postoperative period. First, she was diuresed
aggressively. She remained mildly volume overloaded
throughout the course of her hospitalization, for which
she was diuresed on and off, depending upon her renal
function. By the time of her discharge, we had her weight
down to 59.6 kg. Her preoperative weight was 58.2 kg.
Regarding her nutrition, the patient's albumin was 2.5, which
may have contributed to some of her edema. She was given
nutritional supplementation with each meal to assist her in
returning to appropriate nutritional status.
1. RENAL: The patient's baseline creatinine was between 1.3
to 1.6, which it remained throughout most of her
hospitalization. During periods of aggressive diuresis,
her creatinine did bump to a maximum of 2.3, at which time
her diuretics were held, or decreased. Prior to her
discharge, her BUN and creatinine were 35 and 1.4. She
never became anuric and, as noted, her creatinine had
normalized prior to discharge, and she was making adequate
volumes of urine. Various combinations of diuretics which
were used included acetazolamide, furosemide and Bumex.
The patient responded best to Bumex which she had been
taking at home.
1. HEMATOLOGIC: The patient did require multiple blood
transfusions for her blood loss anemia in the immediate
postoperative period. She responded appropriately to each
transfusion and had no further issues of bleeding. As
noted, her Coumadin was not restarted, given the fact that
she had been in sinus rhythm, and also while ambulating at
one point she had a fall where she did hit her head. She
had no neurologic deficit, and otherwise no lacerations,
or subsequent consequence of the fall, but given the fact
that she may be at risk for this again, it was felt that
the risks of anticoagulation outweighed the benefits.
1. INFECTIOUS DISEASE: During her hospitalization, the
patient had a urinary tract infection for which she was
treated with Bactrim and levofloxacin. She otherwise had
no other infectious complications.
As noted, the patient's overall hospitalization was focused
around management of her congestive heart failure and pleural
effusions. By the time of her discharge, she was doing well.
She was afebrile with a pulse in the 70s, systolic blood
pressure of 115, with an oxygen saturation of 94% on room
air. She was near her preoperative weight at 59.6 kg
(preoperative weight 58.2 kg). Her exam was remarkable for a
sharp II/VI systolic ejection murmur, and otherwise decreased
breath sounds at the bases bilaterally. She otherwise had 1+
edema in her lower extremities. Her BUN and creatinine prior
to discharge were 35 and 1.4 with a bicarbonate of 40. Her
white blood cell count was 7.3 with a hematocrit of 36. Her
chest x-ray was remarkable for bilateral pleural effusions
with some atelectasis, and her EKG was in sinus rhythm. It
was felt that if she was hemodynamically stable with a stable
respiratory status on her regimen of medications that she
could be discharged to rehab in fair condition.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Aspirin 81 mg p.o. once daily.
3. Tylenol as needed.
4. Milk of Magnesia p.r.n.
5. Lipitor 10 mg once a day.
6. Protonix 40 once a day.
7. Amiodarone 200 mg once a day.
8. Bumex 1 mg p.o. b.i.d.
9. Lisinopril 2.5 mg once daily.
10. Ativan 0.25 mg p.o. q. 8 h. p.r.n.
11. Lopressor 25 mg p.o. b.i.d.
12. Albuterol ipratropium inhaler p.r.n.
FOLLOW UP: She was to follow-up with Dr. [**Last Name (STitle) **] in 4 weeks,
her primary care physician [**Last Name (NamePattern4) **] [**11-23**] weeks, and her cardiologist
in 2 weeks.
CONDITION ON DISCHARGE: She was discharged to a
rehabilitational facility in fair condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2189-3-17**] 09:17:26
T: [**2189-3-17**] 10:02:07
Job#: [**Job Number 41673**]
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11582, 11762
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110, 641
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72,309
| 199,909
|
38711
|
Discharge summary
|
report
|
Admission Date: [**2174-2-20**] Discharge Date: [**2174-3-1**]
Date of Birth: [**2129-2-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
PE, head bleed
Major Surgical or Invasive Procedure:
[**2174-2-20**]
IVC filter placement
[**2174-2-21**]
Catheter directed embolectomy of right and left pulmonary
arteries
History of Present Illness:
This is a 45yo male admitted to the trauma service after falling
down 10 stairs and fracturing his neck, in the setting of heavy
alcohol consumption.
He was initially taken to [**Hospital 8641**] Hospital and was found to have
a SAH and type 3 dens fracture on CT. He was transported to
[**Hospital1 18**] via helicopter for eurosurgical evaluation. Upon arrival
in the ER at [**Hospital1 18**] he was awake and alert x 3, with a GCS of 15
per the ER staff. CT of the body was obtained which revealed a
saddle embolus of unkown chronicity. He complained of headache
and left ear pain as well as neck pain. He denied nausea,
vomiting, blurry or double vision.
He was initially placed on a heparin gtt but this was stopped
when his 2nd head CT showed progression of the SAH and also
intraparenchymal hemorrhage of the left cerebellar hemisphere.
An IVC filter was placed due to the finding of fresh left
popliteal thrombus. Thrombectomy of the saddle embolus was
attempted today via IR and was partially successful. He was
intubated for airway protection.
Past Medical History:
PAST MEDICAL HISTORY: DVT in [**2172**] treated with coumadin, per
family "they never figured out why it happened."
Social History:
+ETOH, 1ppd Smoker, denies recreational drug use.
Family History:
No clotting disorders.
Physical Exam:
At discharge:
VS:98.8 80 106/85 90 100%RA
Constitutional: Well appearing, no acute distress
HEENT: bandage over L ear, wound c/d/i no
erythema/hematoma/drainage.
Neck: No masses
CV: RRR, no murmurs
Resp: CTAB, no wheezes or crackles
Abd: Soft, nonTTP, nondistended, +BS
Ext: Warm, distal pulses palpable bilaterally. No LE edema.
Skin: Mild splotchy rash over chest. No warmth/TTP.
Spine, Pelvis and Extremities: Stable
Psychiatric: Normal to judgment, insight, memory, mood and
affect
Neurologic: CN 2-12 intact, strength 5/5 except for mild L LE
foot drop. 2+ DTRs bilat. Sensation intact. Neg rhomberg. Able
to ambulate independently.
Pertinent Results:
[**2174-2-20**]
.
143 106 13 AGap=30
-------------127
4.7 12 1.0
.
ALT: AP: Tbili: Alb:
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 51
Serum EtOH 156
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
.
Urine Opiates Pos
Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative
.
15.0
20.3----- 173
44.1
.
PT: 13.0 PTT: 28.4 INR: 1.1
Fibrinogen: 198
.
UA negative
.
[**2174-3-1**] CT head: stable.
[**2174-2-27**] CT head: Expected interval evolution of
intraparenchymal, subarachnoid, and intraventricular hemorrhage.
No significant change in lateral and third ventricles compared
to [**2174-2-24**].
[**2174-2-24**] CT head: Minimally increased size of lateral ventricles
and third ventricle, most compatible with mild degree of
hydrocephalus, slightly increased since prior exam. Grossly
stable subdural, subarachnoid, intraparenchymal and
intraventricular
hemorrhage as described above. Grossly stable appearance of the
partially imaged paranasal sinuses. Stable appearance of the
left frontal extra-axial space, which is slightly prominent, may
represent an early subdural hygroma or otherwise may be due to
positioning. Attention on followup imaging is recommended.
[**2174-2-21**] CT head min inc size of lat & 3rd ventricles; stable
SAH/SDH/IVH/IPH
[**2174-2-20**] ECHO nl LV fxn, severe RV dilat'n w/ mild global free
wall hypokinesis
[**2174-2-20**] CXR pending
[**2174-2-20**] CTA massive bilateral PE
[**2174-2-20**] CT torso fx at posterior 11th rib
[**2174-2-20**] CT head OSH - mult foci of SAH, IVH, ?L temporal bone
fx
[**2174-2-20**] CT head small L SDH along fx at L petrous apex
[**2174-2-20**] BLE duplex Non-occlusive thrombus within the left
popliteal vein
[**2174-2-20**] CT head sig worsening of multicompartmental ICH & SAH
Brief Hospital Course:
This is a 45 year old male s/p [**2174**]0 stairs in the setting of
significant EtOH intake, transfered from OSH where imaging
showed SAH & IVH; found to have massive saddle PE & L popliteal
DVT. Although initially started on heparin GTT for PE, this was
stopped in the setting of worsening head bleed. He underwent IVC
filter on [**2-21**] and catheter PE thrombectomy [**2-21**]. He was
initially intubated due to concern for loss of airway protection
[**2-8**] head bleed and hypoxia [**2-8**] PE, but was successfully
extubated on [**2174-2-23**].
.
EVENTS:
[**2-21**] on heparin for saddle PE
[**2-21**]: IVF Filter placed
[**2-21**]: Repeat HD CT: worsening bleed, heparin stopped
[**2-21**]: IR for embolectomy, ? chronic PE, could not be removed
[**2-21**]: Spine recs: hard collar x 8 weeks. Neurosurgery recs: no
anticoagulation, repeat HD CT in am of [**2-22**].
[**2-22**]: Repeat CT head slightly worse, NS aware. Loaded with
dilantin. Unable to extubate given problems with secretions and
low [**Name (NI) 85993**] on minimal settings.
[**2-23**]: extubated successfully.
.
Neuro: After intial worsening of ICH, it was seen to be stable
on subsequent CT scans, albeit with mild hydrocepholas. The
patient received 7 days of dilantin as seizure prophylaxis. In
regards to his Dens fracture, ortho spine recommended MiamiJ
collar x8wks as well as follow up with Dr. [**First Name (STitle) **] in 2 weeks w/
repeat head CT. Although initially on IV pain medications, he
was transitioned to PO percocet with good effect.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. His echo showed normal LV
function, severe RV dilation w/ mild global free wall
hypokinesis in the setting of the saddle PE.
.
Pulm: The patient was initiated on Coumadin prior to discharge
as treatment for his PE and DVT. Head CT was stable at that
time. He was on room air without hypoxia at discharge.
.
GI: Post-operatively, the patient was given IV fluids until
tolerating oral intake. The patient's diet was advanced to
regular, which he tolerated well. He was also started on a bowel
regimen to encourage bowel movement.
.
Renal: The patient's urine output was adequate with stable renal
function during this hospitalization.
.
Heme: As noted above, the patient was started on Coumadin as
treatment of his PE and L popliteal DVT. Hematology was
consulted and said that no hypercoaguable work-up was indicated
during this hospitalization as it would not alter management.
The patient will need to be anti-coagulated for life, given the
recurrence of DVT/PE as well as the severity of his PE. He will
need to follow up with a hematologist as an out-patient for
additional evaluation.
.
ID: For his left ear laceration, the patient was treated
prophylactically with levofloxacin. He also had sulfamylon +
xeroform dressing changes [**Hospital1 **] per plastics. He will follow-up in
plastics clinic after discharge.
Medications on Admission:
None
Discharge Medications:
1. Mafenide Acetate 85 mg/g Cream Sig: One (1) application
Topical [**Hospital1 **] (2 times a day).
Disp:*37 grams* 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
S/P Fall
1. Left subdural hematoma
2. Intraventricular hemorrhage at posterior [**Doctor Last Name 534**] of lat & 4th
ventricle
3. Subarachnoid hemorrhage
4. Left ear laceration
5. Type III dens fracture
6. Left neck laceration
7. Left 11th rib fracture
8. Pulmonary embolism
9. Left popliteal deep venous thrombosis
Secondary diagnoses:
1. DVT [**2172**]
2. ETOH abuse
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**] trauma service after a fall
sustaining multiple injuries: you had multiple intracranial
hemorrhages including a subdural hemorrhange and subarachnoid
hemorrhage, laceration of your left ear, a fracture of your
cervical spine (type III dens fx), and a posterior 11th rib fx.
* You were evaluated by neurosurgery and had multiple head CT
scans and your intracranial bleeds were stable at time of
discharge. No operative treatment was needed. You were started
on a prophylactic (preventative) anti-seizure medication called
Dilantin while hospitalized but completed a 7 day course of
this. You will need to follow up with neurosurgery in 2 weeks
with a repeat head CT scan to assess for any change in your head
bleed.
*In evaluation after your fall, you were also found to have a
left leg deep venous thrombosis as well as a large pulmonary
embolism (clot in your lungs). Initially, a heparin drip,
medication to prevent your [**Hospital1 **] from clotting, was started to
treat these conditions, but it had to be stopped when repeat
head CT scan at that time showed worsening bleeding. You were
kept off of any anti-coagulation (medication to prevent your
[**Hospital1 **] from clotting) for several days after this to give your
head bleed time to stabilize. After later repeat head CT scans
showed that your bleed was stable, you were started on the
anti-coagulation medication Coumadin (aka Warfarin).
* You will need to follow up with a regular doctor to have
monitoring of your [**Hospital1 **] levels related to the anti-coagulation
medication coumadin (the INR and PT). These levels will need to
be monitored several times per week during your first few weeks
of treatment until your medication regimen is stabilized. You
will most likely need to take anticoagulant medication for the
rest of your life, due to the size and severity of your [**Hospital1 **]
clots as well as the fact that you have now had recurrent clots.
* No surgical treatment of your neck fracture is needed at this
time. It is very important that you wear your cervical collar at
all times to support your neck. You will need to wear your
cervical collar until released by your surgeon.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
* Any other new and concerning symptom
Tobacco Cessation information:
Quitting tobacco is a wise decision. By no longer using tobacco
you reduce your risk for lung diseases including cancer and
emphysema as well as many other medical problems associated with
tobacco use. Tobacco products are associated with lip,
esophagus, pancreas, kidney, bladder and many other types of
cancers. Tobacco products, especially smoking tobacco, are
associated with allergies as well. Additionally, smoking during
pregnancy can cause low birth weight during pregnancy. There is
no such thing as a safe cigarette. Light cigarettes, cigars, and
cigarillos are all associated with the same risks as cigarettes.
<B> How to stop using tobacco </B>
There are many options when attempting to stop using tobacco.
* Nicotine replacement therapies vary from gum, patches,
lozenges and inhalers. Nicotine replacements help curb the urge
to use tobacco. Typically, users slowly wean off the nicotine
replacements until they no longer need the product.
* Support groups are available for smokers. Nicotine Anonymous
([**URL 85994**]-anonymous.org/) and other organizations
meet regularly to help each other in their efforts to stop using
tobacco.
* Medications such as bupropion (Wellbutrin and Zyban) are
available by prescription and also help to curb the urge to use
tobacco. Talk to your primary care provider about possible
medical options.
* There are many other techniques and recommendations that are
available through counseling and support groups on the internet.
Talk with your primary care provider when you are ready to quit
tobacco as they will be more than willing to help you with your
goal.
Smokefree.gov
Phone: 1-[**Telephone/Fax (1) 85995**]
[**URL 85996**]
American Cancer Society
Phone: 1-[**Telephone/Fax (1) 85997**]
[**URL 85998**]
American Heart Association
Phone: 1-[**Telephone/Fax (1) 85999**]
[**URL 86000**]
American Lung Association
Phone: 1-[**Telephone/Fax (1) 86001**]
[**URL 86002**]
Followup Instructions:
Call Dr. [**First Name (STitle) **] from Neurosurgery for a follow up appointment in
2 weeks with a non contrast head CT. Please call [**Telephone/Fax (1) 86003**]
for an appointment.
Call Dr. [**Last Name (STitle) 1007**] with orthopedic surgery at [**Telephone/Fax (1) 1228**] for a
follow up appointment in 6 weeks.
Call Dr. [**First Name (STitle) **] from Plastic Surgery at [**Telephone/Fax (1) 5343**] for a follow
up appointment [**2174-3-4**].
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 600**] for a follow up appointment in 2
weeks.
You need to see a hematologist after discharge to obtain [**Telephone/Fax (1) **]
tests to find out why you continue to have problems with [**Name2 (NI) **]
clots. You can see someone locally or if you prefer you can
return here to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20642**] RN and she will refer you to the
appropriate person. Her number is [**0-0-**].
Please also call your regular doctor to arrange follow up within
2-3 days after discharge. You need to have [**Year (4 digits) **] work to
monitor your PT and INR now that you are taking Coumadin (an
anticoagulant).
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
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1,203
| 196,080
|
51476
|
Discharge summary
|
report
|
Admission Date: [**2180-9-29**] Discharge Date: [**2180-10-6**]
Date of Birth: [**2126-2-25**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 54 year old female
with past medical history significant for a prior
cholecystectomy who was admitted with complaints of right
upper quadrant pain for about a week. The pain had been
initially intermittent and aching in quality with no
radiation or associated nausea, vomiting, fevers, chills or
changes in bowel movement. She is unable to identify clear
precipitant. The patient noted that on the day prior to
admission the pain became more intense and that she was
nauseated but denies any vomiting.
She was seen by her primary care physician that day who sent
her to [**Hospital1 69**] for an abdominal
CT scan which was read as negative. She then went home to
return to the Emergency Department on [**9-29**] with severe
unrelenting pain that had prevented her from sleeping the
night before. She also noted that the pain now radiated
somewhat to her right scapula and right arm, similar to the
pain that she had felt prior to her cholecystectomy.
At the time of admission, the patient noted that she was
constipated and still had some nausea, but no vomiting and
denied any fever or chills. She was given morphine for pain
control which helped a little. The patient was admitted for
work-up of right upper quadrant pain and pain control.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Basal cell carcinoma status post resection.
4. Raynaud's Syndrome.
5. Acute pancreatitis times one.
6. Cerebrovascular accident secondary to carbon dioxide
embolus.
7. Status post tubal ligation.
8. Lumbosacral osteopenia.
9. Fibroids status post total abdominal hysterectomy and
bilateral salpingo-oophorectomy.
10. Esophageal spasm.
11. Status post cholecystectomy.
12. History of multiple miscarriages.
13. Status post laminectomy and the L3-L4 and L5-S1 discs.
SOCIAL HISTORY: The patient is divorced with two sons. She
denies any tobacco use or intravenous drug use. Notes
occasional alcohol use.
ALLERGIES: Arecoline causes syncope.
MEDICATIONS ON ADMISSION:
1. Gabapentin 600 mg p.o. four times a day.
2. Synthroid 50 micrograms p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Transdermal Estradiol 0.05 mg q. day.
5. Multivitamin.
6. Senna.
7. Colace 100 mg twice a day.
8. Diltiazem 240 mg p.o. q. day.
FAMILY HISTORY: The patient's mother died at age 82 of
ovarian cancer. The patient's father died at 31 secondary to
a myocardial infarction. The patient has one brother with
hypertension and hypercholesterolemia, and a son with
hypercholesterolemia.
LABORATORY: On admission, the patient had a white blood cell
count of 6.5, hematocrit of 41.6 with an MCV of 89 and
platelets of 207. Sodium was 138, potassium 4.5, chloride
104, bicarbonate 23, BUN 15, creatinine 1.2, glucose of 84.
She had an AST of 32, ALT of 35, amylase of 93, lipase 49.
Total bilirubin of 0.6, and alkaline phosphatase of 89.
On admission, a chest x-ray revealed surgical clips in the
right upper quadrant with no acute cardiopulmonary disease.
She also had a right upper quadrant ultrasound which showed a
dilated common bile duct at 7 to 8 millimeters; no
intrahepatic ductal dilatation; no obvious stone.
CT scan findings from [**9-28**] showed no acute appendicitis or
pancreatitis. It was felt that the common bile duct was
consistent in size for a patient status post cholecystectomy.
There was no obvious free fluid or lymphadenopathy.
PHYSICAL EXAMINATION: On admission, the patient had a
temperature of 98.6 F.; blood pressure of 120/80; heart rate
of 74; respiratory rate of 18 and an oxygen saturation of 98%
on room air. In general, this was a thin, pleasant well
groomed female in no apparent distress. Head and Neck:
Pupils are equal, round and reactive to light. Extraocular
movements intact. Sclerae were anicteric. Mucous membranes
were moist. Neck showed no jugular venous distention, no
lymphadenopathy. Lungs are clear to auscultation
bilaterally. Heart examination was regular rate and rhythm
with no murmurs, rubs or gallops and a normal S1 and S2.
Abdomen was soft, nondistended, good bowel sounds; no
hepatosplenomegaly. Tenderness to palpation in the right
upper quadrant; negative [**Doctor Last Name 515**] sign. Extremities with no
cyanosis, clubbing or edema. Right upper extremity notable
for to biopsy sites performed by her dermatologist.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service for further evaluation of her right upper quadrant
abdominal pain. Given the normal findings on right upper
quadrant ultrasound and abdominal CT scan, an MRCP was
performed which showed two small cysts in the tail of the
pancreas, a prominent common bile duct, most likely status
post cholecystectomy with no evidence of common bile duct
sludge and no evidence of choledocholithiasis.
Given the negative findings, a Gastrointestinal consultation
was called. The Gastrointestinal consultation recommended a
formal endoscopic retrograde cholangiopancreatography to
definitively rule out the possibility of a retained stone in
the common bile duct and to further evaluate the pancreatic
cyst seen on the MRCP. The patient underwent an endoscopic
retrograde cholangiopancreatography on Tuesday, [**10-3**];
mild biliary dilatation consistent with previous
cholecystectomy. No evidence of stone or sludge in the
biliary duct. The patient had a normal pancreatic duct and
an otherwise normal endoscopic retrograde
cholangiopancreatography.
After the ERCP, the patient was slow to wake up from the
sedation in the Recovery Room. She began to have shaking
tremors and was not responsive to verbal stimuli. At that
time, a Neurology consultation was called. On examination
she was found to be unresponsive to voice with her pupils
equal, round and reactive to light with no vestibular ocular
reflex. Her tone was decreased in all four extremities.
Reflexes were one plus and symmetrical with downgoing toes
bilaterally. She had mild withdrawal to pain in all four
extremities.
During the examination, she was able to wiggle her fingers
and toes in all four extremities and near the end of the
examination, she was able to attempt opening her eyes.
In summary, the Neurology consultation felt that the patient
was slow to recover following sedation for the endoscopic
retrograde cholangiopancreatography and thought that there
was a possibility of seizure activity, but that she was
recovering from the sedation. They recommended an EEG the
next day, which was normal and showed no evidence of seizure
activity.
The patient was monitored in the Intensive Care Unit
overnight following this question of seizure activity. She
was stable and transferred to the floor the following day.
The patient was stable on arrival to the floor.
Given the negative work-up to this point, the patient was
offered an upper GI series with a small bowel follow through
to further evaluate for any obstruction or lesion in the
gastrointestinal tract. She was n.p.o. after midnight on
[**2180-10-4**].
When the patient was taken down the next morning to have this
study done, scout films revealed that her transverse and
descending colon were full of contrast from the prior CT
scan, therefore, we were unable to complete the upper
gastrointestinal small bowel follow through. The patient was
brought back to the floor and was given laxatives and fluids
to try to clean out the colon.
Throughout her hospitalization, the patient noted that her
right upper quadrant pain was well controlled with Oxycodone
5 mg every three to four hours as needed and Tylenol 500 mg
every six hours standing. She said that with this pain
regimen, her pain which had been an 8 out of 10 was now a 2
out of 10 and very manageable.
The patient did have a bump in her liver function tests
status post the ERCP. Those were followed and were
decreasing at the time of discharge.
At the time of discharge, the patient was also tolerating
liquids but had not yet attempted to eat solid food. Given
the negative work-up to this point, the patient was seen by
Surgery who felt at this time that there was no indication
for surgical intervention in this case given the negative
studies and prior work-up.
Other issues while in the hospital: The patient was seen by
Infectious Disease for question of macrobacterial infection
of her right upper arm lesion. The patient was seen by
Infectious Disease who reviewed the biopsy results done by
her dermatologist. It was felt by the Infectious Disease
consultation that her current abdominal pain was not related
to a chronic mycobacterial skin infection and the likelihood
of a disseminated mycobacterial infection was very rare.
They felt that there was no need to start an anti
mycobacterial therapy until the exact species of the
mycobacterium was known given that the treatment for each of
the different species is very different.
She was scheduled for a follow-up appointment in the
Infectious Disease Clinic on [**2180-10-19**], at 09:30 to
follow-up with test results and to consider treatment
options.
DISPOSITION: The patient was discharged to home.
DISCHARGE STATUS: Good. Her pain was well controlled with
Oxycodone 5 mg every three to four hours and acetaminophen.
All of her imaging studies were within normal limits with no
obvious etiology for abdominal pain. Her AST and ALT were
elevated after her endoscopic retrograde
cholangiopancreatography but were trending down, and she was
able to tolerate liquids without any problem.
DISCHARGE INSTRUCTIONS:
1. The patient was encouraged to follow-up with her primary
care physician in the next week.
2. She was also encouraged to follow-up with a
Gastroenterologist here at the [**Hospital1 188**].
3. She was also encouraged to keep her follow-up appointment
with the Infectious Disease Clinic on [**10-19**].
4. Dr. [**Last Name (STitle) **] is also going to follow-up with her primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**].
DISCHARGE MEDICATIONS:
1. Gabapentin 300 mg, two capsules four times a day.
2. Levothyroxine 50 micrograms, one tablet q. day.
3. Aspirin 325 mg, one tablet q. day.
4. Multivitamin, one tablet q. day.
5. Colace 100 mg, one capsule p.o. twice a day.
6. Diltiazem 240 mg, one caplet p.o. q. day.
7. Amlodipine 5 mg tablet, two tablets p.o. q. day.
8. Protonix 40 mg, one tablet p.o. q. day.
9. Oxycodone 5 mg, one tablet every three to four hours as
needed for pain.
10. Acetaminophen 650 mg every six hours.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 41207**]
MEDQUIST36
D: [**2180-10-6**] 19:11
T: [**2180-10-6**] 20:51
JOB#: [**Job Number 106735**]
|
[
"401.9",
"789.01",
"443.0",
"244.9",
"733.90",
"577.2",
"V10.83",
"285.9",
"300.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"89.14"
] |
icd9pcs
|
[
[
[]
]
] |
2447, 3557
|
10150, 10891
|
2174, 2429
|
4518, 9637
|
9661, 10127
|
3581, 4499
|
168, 1430
|
1452, 1966
|
1984, 2148
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,039
| 153,362
|
5696
|
Discharge summary
|
report
|
Admission Date: [**2206-5-28**] Discharge Date: [**2206-6-13**]
Date of Birth: [**2143-8-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Vancomycin / Nsaids / Iodine / Versed / Ativan / Haldol
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
"I fell"
Major Surgical or Invasive Procedure:
emergent right craniotomy for SDH evacuation [**5-29**]
History of Present Illness:
Mr. [**Known lastname 10653**] is a 62 year old man with type 1 diabetes
complicated by CKD V requiring hemodialysis who was brought to
the [**Hospital3 417**] Hospital ED yesterday after experiencing an
unwitnessed fall in his bathroom with head trauma and a hip
injury. At [**Hospital3 **], he was found to have a small right frontal
subdural hematoma as well as a fracture of his left femur, so he
was transferred to [**Hospital1 18**] for further management. He was admitted
to trauma surgery with neurosurg and ortho consults. A second
head CT showed stability of the subdural hematoma, so
neurosurgery signed off and recommended repeat CT in 4 weeks.
Ortho has been debating operative vs nonoperative management of
his femur fracture. He is transferred to medicine for management
of his BP and other medical issues.
Past Medical History:
1. DM I for 45 yrs, complicated by triopathy
2. ESRD on HD T/Th/Sa
3. h/o Tunneled cath infections
4. UGIB [**2-17**] PUD
5. VSE septic shoulder
6. Osteomyelitis
7. Left BKA
8. HTN w/ visual changes and AMS when SBP <150, must run
150-170/80s
9. Gastroparesis
10. Depression
11. Right femoral dorsalis pedis graft - [**2198-3-15**]
12. H/o gangrenous cholecystitis
13. H/O R pleural effusion
14. h/o frequent episodes of delerium while hospitalized and
infected, always negative work-up
15. Non-specific right and left exudative pleural effusion
(?chylothorax) status post right pleuroscopy, pleural biopsy,
pleurodesis and Pleurex catheter placement (removed on [**2205-10-18**]).
16. Hx of recurrent C.diff
Social History:
Lives in [**Location 701**] with wife [**Name (NI) **] [**Name (NI) 10653**]
(Home: [**Telephone/Fax (1) 22469**], cell: [**Telephone/Fax (1) 22470**]). No EtOH x several
months). Former remote smoker <1 pack per day x 20 yrs. Used to
work in retail 14 yrs ago. Patient reports walking with walker
and wheelchair. No exercise
Family History:
per patient no hx of early MI or arrythmia or HF
Physical Exam:
VS: 126/80, 97.4, 86, 16, 96% 2L
Gen: Chronically ill appearing male in NAD but in pain
HEENT: MMM, no scleral icterus.
Neck: Supple, JVP not elevated, line right
CV: RRR, normal S1, S2. No m/r/g.
Chest: Resp were unlabored, no accessory muscle use. faint
crackles, more prominent over base
Abd: Soft, NTND. No HSM or tenderness.
Ext: Left BKA, upper extremity in cast. Tender to palpation.
Toes amputated on right. 2+ DP pulses on that side but cool LE.
No edema
Neuro:
Mental status: Awake and alert , cooperative with exam, normal
affect. Orientation: Oriented to person, place, and date (with
prompting "[**6-5**]".
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils as above, rt 3.0mm trace reaction, left 3.0mm
surgical
Visual fields are full.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Left BKA. Decreased bulk and tone bilaterally. No
abnormal
movements,tremors. Strength full power -[**5-20**] throughout. No
pronator drift.
Sensation: Decreased to light touch and propioception. Pt with
preexisting bilat. neuropathies. Lt Great and 1st toe amps.
Toes mute on right
Coordination: normal on finger-nose-finger movements, unable to
perform heel to shin
Pertinent Results:
[**2206-5-28**] 06:20PM BLOOD WBC-6.5 RBC-4.23* Hgb-12.2* Hct-38.1*
MCV-90 MCH-28.7 MCHC-31.9 RDW-15.5 Plt Ct-157
[**2206-5-28**] 06:20PM BLOOD Neuts-81.6* Lymphs-8.7* Monos-5.1 Eos-3.5
Baso-1.2
[**2206-5-28**] 06:20PM BLOOD PT-14.6* PTT-34.4 INR(PT)-1.3*
[**2206-5-28**] 06:20PM BLOOD Glucose-90 UreaN-22* Creat-3.5* Na-143
K-4.2 Cl-103 HCO3-32 AnGap-12
[**2206-5-29**] 06:40AM BLOOD CK-MB-6 cTropnT-0.29*
[**2206-5-29**] 06:40AM BLOOD CK(CPK)-60
[**2206-5-31**] 02:14AM BLOOD ALT-20 AST-36 AlkPhos-88 TotBili-0.5
[**2206-5-28**] 06:20PM BLOOD Calcium-9.3 Phos-3.0 Mg-2.4
[**2206-5-30**] 03:32PM BLOOD Albumin-3.1*
[**2206-5-31**] 02:14AM BLOOD VitB12-1109* Folate-15.3
[**2206-6-3**] 03:22AM BLOOD TSH-6.9*
[**2206-5-30**] 03:10AM BLOOD Phenyto-1.2*
[**2206-5-30**] 03:32PM BLOOD Phenyto-14.5
[**2206-5-29**] 03:08PM BLOOD Type-ART pO2-62* pCO2-53* pH-7.38
calTCO2-33* Base XS-4 Intubat-NOT INTUBA
[**2206-5-29**] 04:38PM BLOOD Type-ART pO2-183* pCO2-56* pH-7.37
calTCO2-34* Base XS-5
[**2206-5-29**] 04:38PM BLOOD Hgb-11.3* calcHCT-34
[**2206-5-29**] 04:38PM BLOOD freeCa-1.19
[**2206-6-3**] 02:15PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-480*
Polys-87 Bands-3 Lymphs-1 Monos-8 Metas-1
[**2206-6-3**] 02:15PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-595*
Polys-85 Bands-3 Lymphs-1 Monos-5 Metas-4 Myelos-1 Promyel-1
[**2206-6-3**] 02:15PM CSF TotProt-84* Glucose-96 LD(LDH)-30
CT Scan [**5-28**]:
NON-CONTRAST HEAD CT: There is a small right frontotemporal
subdural
hematoma, predominantly hyperdense. This measures maximally 8 mm
from the
inner table. There is no significant mass effect on the
underlying parenchyma, and no shift of normally midline
structures. There are no other foci of hemorrhage identified.
There is no edema. There is no evidence for acute large vascular
territory infarction.
Marked global parenchymal atrophy, indicated by prominence of
the sulci and ventricles, and periventricular white matter
hypodensity consistent with small vessel ischemic disease, is
unchanged from prior study in [**2205**]. Also redemonstrated are
dense calcifications of the intracranial carotid and vertebral
arteries. The osseous structures demonstrate no suspicious lytic
or sclerotic lesions. There is an air-fluid level seen in the
left maxillary sinus. The remainder of the paranasal sinuses and
mastoid air cells are normally pneumatized and clear.
IMPRESSION:
1. Small acute right frontotemporal subdural hematoma, unchanged
compared to appearance on CT performed at an outside hospital
earlier the same day. There is no significant mass effect, and
no shift of normally midline structures.
2. Unchanged global parenchymal atrophy, small vessel ischemic
disease, and dense intracranial vascular calcifications.
CT Scan [**5-29**] s/p dialysis
FINDINGS: There is a dramatic increase in the size of the right
frontal
subdural hematoma from 9 mm to 20 mm. There is associated new
significant
leftward subfalcine shift of 13 mm. There is effacement of the
right lateral ventricle and apparent obliteration of the
occipital [**Doctor Last Name 534**]. There is right uncal herniation. No
intraparenchymal bleed is seen. There is no fracture. Mastoid
air cells are clear. Visualized paranasal sinuses show an
air-fluid level in the left maxillary sinus.
IMPRESSION: Dramatic increase in size of right frontal subdural
hematoma with a new large 1.3 cm subfalcine herniation and uncal
herniation on the right.
CT [**5-30**]:
FINDINGS: There is subdural blood layering over the right
temporal lobe, as was seen on the pre-evacuation scan of 15:37.
This likely represents
redistribution and less likely new blood. There has been
improvement of the subfalcine herniation with structures now
being essentially midline. There is no intraparenchymal
hemorrhage. Streak artifact and intracranial air limits the scan
but [**Doctor Last Name 352**]-white matter junction appears distinct. There is no
hydrocephalus. Ballooning of left occipital [**Doctor Last Name 534**] has decreased
and is stable secondary to decreased uncal herniation. Basal
cisterns are preserved. Again seen is fluid level within the
left maxillary sinus. Otherwise, paranasal sinuses and mastoid
air cells are clear. The carotid siphons are densely calcified.
IMPRESSION:
1. Status post right subdural hematoma evacuation with
persistent extensive pneumocephalus but decreased mass effect
and uncal herniation. No new intraparenchymal hemorrhage.
Subdural hemorrhage overlying the right temporal lobe is likely
a residua rather than a new bleed. Correlate clinically.
2. Limited exam secondary to artifacts. Consider short-interval
followup to assure [**Doctor Last Name 352**]-white matter differentiation in the
frontal lobe or consider an MR.
CT [**6-1**]
FINDINGS: The patient is status post right parietal craniotomy
and evacuation of right subdural hematoma. There is decreased
pneumocephalus compared to [**2206-5-30**]. However, there is a slight
increase in bilateral extra- axial CSF-attenuation fluid
collections measuring 11 mm in greatest width compared to 8.5 mm
previously. This may reflect interval development of subdural
hygromas. There is a persistent small subdural hematoma adjacent
to the right temporal pole.
The basilar cisterns are preserved and there is no uncal
herniation or
hydrocephalus. No new intracranial hemorrhage or major vascular
territorial infarction is present. Bilateral frontal subgaleal
hematomas are again noted and may be slightly increased on the
right. Calcification of the carotid siphons and distal vertebral
arteries is unchanged.
IMPRESSION:
1. Status post evacuation of right frontal subdural hematoma
with interval
decrease in pneumocephalus from [**2206-5-30**]. Developing subdural
hygromas.
Persistent small right temporal subdural hematoma.
2. No new intracranial hemorrhage or major vascular territory
infarction.
CT [**6-2**]
FINDINGS: The patient is status post right
frontal/parietal/temporal
craniotomy and evacuation of right subdural hematoma. The
previously noted
right subdural, epidural, and subgaleal hypodense collections
are stable in size. Pneumocephalus remains present. The
previously noted hypodense left subdural collection is also
stable in size, consistent with a subdural effusion in the
absence of a previous left subdural hematoma. There is no
evidence of acute intracranial hemorrhage. There is no evidence
of edema in the brain. A small area of encephalomalacia in the
left occipital lobe is again noted. Prominence of the ventricles
and sulci is also again seen, consistent with moderate cerebral
atrophy. Extensive vascular calcifications are again noted.
IMPRESSION: No evidence of new intracranial abnormalities.
Stable right-
sided postsurgical changes. Stable left subdural effusion.
AP CHEST 10:27 A.M. [**5-30**]
IMPRESSION: AP chest compared to [**5-29**], 9:40 p.m.:
Endotracheal tube has been removed. New feeding tube with the
wire stylet in place ends in the upper stomach. Borderline
interstitial pulmonary edema most evident in the right lower
lobe. Small to moderate right, small left pleural effusions
unchanged. Dual channel supraclavicular central venous catheter
previously obscured distally due to cardiac motion is now seen
to reside in the low right atrium.
AP CHEST, 6:17 P.M. ON [**6-1**]:
IMPRESSION: AP chest compared to [**2207-5-30**]:27 a.m.:
Progressive opacification in the right lower chest is due to
combination of increasing moderate right pleural effusion, new
vascular congestion and
probable atelectasis. Left lung shows relatively mild
atelectasis at the
base, otherwise clear. Heart size top normal, increased since
[**5-30**],
accompanied by widening of the azygos vein suggesting increased
intravascular volume. Feeding tube ends in the upper stomach.
Dual-channel right supraclavicular line in the right atrium.
CHEST PORTABLE AP [**2206-6-3**]:
Since [**2206-6-1**], the ETT tip is still 7.6 cm above the
carina, above the level of the clavicular heads. Dobbhoff tube
ends in the proximal stomach. Right central venous line ends in
the right atrium. Bilateral pleural effusions, more marked on
the right, are unchanged. Right basilar opacities continue to
improve. Hyperinflation persists. There is no new focus of
consolidation. Right shoulder degenerative changes are stable.
EEG [**2206-6-4**]:
FINDINGS:
ROUTINE SAMPLING: Showed a markedly slow and disorganized
background
typically in the 5 Hz range in wakefulness. There were also
occasional
sharp slow wave discharges seen over the right posterior
quadrant.
SLEEP: No normal waking or sleep morphologies are seen.
CARDIAC MONITOR: Showed predominantly 60 cycle artifact.
SPIKE DETECTION PROGRAMS: There were 67 entries in these files.
These
showed the above-mentioned right posterior sharp slow wave
discharges.
SEIZURE DETECTION PROGRAMS: There were none.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This 24-hour video EEG showed a slow and
disorganized
background indicative of a moderate to severe encephalopathy.
There was
also occasional right posterior quadrant sharp slow wave
discharges
indicative of an area of underlying cortical irritability. There
were
no pushbutton activations. There was no evidence of
electrographic
seizure.
EEG [**2206-6-5**]:
FINDINGS:
ROUTINE SAMPLING: Showed a generally slow and poorly modulated
background typically reaching a 5 Hz maximum. There was focal
slowing
seen in the parasagittal regions bilaterally. In the earlier
part of
the recording, there are focal spike and slow wave discharges
seen in
the right parietal region. There are also periodic epileptiform
discharges seen more broadly over the right hemisphere at times
reaching
a frequency of 1 Hz. However, as the tracing progressed, the
focal and
broad activity over the right hemisphere was much less
prominent. There
was occasional spread of the discharges to the left hemisphere.
At
8:17:02 on [**6-4**], rhythmic 4 Hz theta activity begins to evolve
in the
right occipital region for approximately 10 seconds but then
does not
progress.
SLEEP: No normal waking or sleep morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
SPIKE DETECTION PROGRAMS: There were 240 entries in these files.
These
showed largely movement artifact and electrode popping without
evidence
of epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were three entries in these
files.
These showed the above-mentioned brief rhythmic theta activity
above.
There is also movement artifact.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This is an abnormal 24-hour video EEG due to a slow
and
disorganized background indicative of a mild to moderate
encephalopathy.
There is also bilateral parasagittal slowing indicative of
subcortical
dysfunction in these regions. There is a focal spike and slow
wave
activity with a right posterior parietal region indicative of an
area of
cortical irritability. In the early part of the recording, there
are
also periodic broad epileptiform discharges seen over the right
hemisphere. These findings are suggestive of a region of ongoing
epileptogenesis over the right hemisphere. There is no evidence
of
electrographic seizure.
Brief Hospital Course:
On admission, Mr. [**Name13 (STitle) 22741**] was with normal mental status and his
upper extremity strength was at his baseline. A repeat
progressive NCHCT >4h after his initial CT was stable with 8mm
SDH and no midline shift / mass effect. He was subsequently
brought to dialysis stable with NBP and a normal mental status.
While receiving HD, he became delerious (complained of a
headache, SOB, then started thrashing around). He was given
ZYPREXA 2.5 mg x 2 & taken to an urgent CT. The CT noted an
increase in the SDH to 20 mm with mass effect (left subfalcine
herniation and rt uncal herniation). No intraparenchymal bleed
or fracture was noted. He was taken to the OR by neurosurg for
an urgent craniotomy to evacuate the SDH immediately that
evening.
Per the anesthesia op note, Mr [**Known lastname 22742**] SBP was in the
110's-130's for at least 30 min total (with the diastolic
ranging from 40's to 100). He was given 600 mcg of phenylephrine
total. Overnight [**Date range (1) 22743**], he had a labile BP (range of
129-170/41-55) and was treated alternatively with ntg and
phenylephrine. He was extubated [**5-30**], was able to follow
commands (squeeze hands), but noted to be "very sleepy." His
phenytoin level was 1.2. He was given phenytion 1 gram at 10 am.
On [**5-31**] his level corrected for low albumin was 35.8. On [**6-2**],
his phenytoin trough was 6.4, corrected to 16.8.
Overnight [**Date range (1) 3643**], his BP remained labile & "low" for him: 24
range was 126-155/38-59.
On [**5-31**] & [**6-1**], he was given Fentanyl for pain (25 x 2 on [**6-1**])
and his RN noted that he became "non verbal, lethargic." It was
DC'd. Per his wife, Mr [**Name (NI) 10653**] was answering questions,
complained of being thirsty and generally was communicative
during her visit that lasted until [**6-1**] about 2 p.m. Per Ms
[**Known lastname 10653**], he was given another medication (dilantin & fentanyl)
and he seemed to become more somnolent.
He had increased oral secretions and was reintubated [**6-1**]
because of respiratory distress, and put on a propofol drip for
sedation. The propofol drip was discontinued the morning of [**6-2**]
at 7:30 a.m. because of concern for his continued somnolence.
The most responsive he had been is gesturing toward his tube
with his right hand.
On [**6-2**], repeat head CT was again stable with no evidence for
rebleed in the context of his mental status changes. Neurology
was consulted and recommended an EEG. His mental status was
noted to was and wane with episodes of minimal responsiveness
and at best the patient would localize to pain with his right
arm.
On [**6-3**] he spiked to 102 and given concern for PNA, he was
started on vancomycin and zosyn. He also underwent an LP and was
noted to have a significantly low blood sugar after his
tubefeeds were held. The LP was significant for minimal WBC and
negative gram stain, though a few bands were noted.
On [**6-4**] a flexiseal was placed for increased stool output, CDiff
toxin test was negative and given cultures from his pneumonia
(MSSA), Zosyn was d/c'ed. He was started on cefepime and a
central line was placed. An EEG was performed on [**6-3**] - [**6-4**]
with the results showed These findings are suggestive of a
region of ongoing
epileptogenesis over the right hemisphere. There is no evidence
of electrographic seizure. On [**6-5**] an additional EEG showed mild
to moderate encephalopathy. "In the early part of the recording,
there are also periodic broad epileptiform discharges seen over
the right hemisphere. These findings are suggestive of a region
of ongoing epileptogenesis over the right hemisphere. There is
no evidence of electrographic seizure."
Mr [**Known lastname 22742**] exam improved subsequently to the point that he
was interacting with the family. However, his repiratory status
remained poor. A family meeting was held where the family
indicated that the patient would not wish to under go
tracheostomy or gastrosteomy. In this context, the patient was
made DNR and DNI. The patient was extubated on [**2206-6-10**]. He did
fair on face tent overnight but suffered respiratory distress
soon thereafter. The patient was made CMO on [**2206-6-12**]. He
expiredon [**2206-6-13**].
Medications on Admission:
Bactroban 2% topical to face TID,
Insulin NPH Human 100unit/m; 8units Qam,4units Qhs, Labetalol
200mg po BID (hold on dialysis days), Lisinopril 80mg po QPM,
Minoxidil 2.5mg Qpm, Nifedipine 60mg po QPM, Phoslo 667mg
tabs;3tabs TID with meals, Zoloft 100mg po QDay
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right Subdural hematoma
MSSA PNA
Renal failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2206-6-13**]
|
[
"852.21",
"997.39",
"707.22",
"707.03",
"348.30",
"E888.9",
"585.6",
"507.0",
"348.8",
"250.43",
"403.91",
"518.5",
"821.01",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.31",
"01.31",
"39.95",
"96.6",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19753, 19762
|
15157, 19409
|
329, 386
|
19853, 19863
|
3977, 5383
|
19916, 19951
|
2331, 2381
|
19724, 19730
|
19783, 19832
|
19435, 19701
|
19887, 19893
|
2396, 2868
|
281, 291
|
414, 1237
|
3149, 3958
|
5392, 15134
|
2883, 3133
|
1259, 1971
|
1987, 2315
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,568
| 188,122
|
1427
|
Discharge summary
|
report
|
Admission Date: [**2177-3-22**] Discharge Date: [**2177-4-3**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Keflex
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
central line placement.
Intubation.
Right shoulder tap x2 and washout.
C-spine I and D.
History of Present Illness:
This is a 84 y/o female with h/o CRI, neuropathy of LE,
depression, hypothyroidism, multiple Klebsiella UTI's, frequent
falls (last one one month ago), p/w "pain all over."
Specifically, she reports pain in her back diffusely x 1 month
since her fall (was recently at [**Hospital3 8528**]) but increased
over the last 4-5 days over the lower back. Also has baseline
neck pain since her last fall. No subjective f/c/s, although
febrile at NH. No h/a, photophobia, CP/SOB/n/v/abd
pain/diarrhea. Last BM 3 days ago. Reports has had ulcers on her
LE since the fall, no pain over the sites. Of note, had dental
work 4 days ago w/o complications. No h/o known valvular
disease.
.
At the NH, she was started on Vantin 200 mg [**Hospital1 **] on [**3-21**] for
possible UTI. Temp was 100.2 today and [**Age over 90 **] yesterday. VS at
rehab prior to transfer: BP 100/58, HR 75, RR 16, SaO2 91%/RA.
Labs checked at rehab were significant for elevated WBC of 23.4.
.
In the [**Name (NI) **], pt was febrile to 100.1, BP 157/65, HR 89, RR 30,
SaO2 93%/RA. Blood cx, urine cx, and CXR done. U/A significant
+. Pt given Vanc, CTX, and flagyl in the ED.
Past Medical History:
1. Congestive heart failure, last EF 75% by P.Mibi
2. Renal insufficiency, baseline Cr 1.4-1.9.
3. Frequent falls.
4. History of dehydration.
5. Neuropathy of legs bilaterally.
6. Urinary incontinence.
7. Hypothyroidism.
8. Mood disorder/depression.
9. History of UTIs with multidrug resistant klebsiella (per our
OMR, R to Nitrofurantoin, fluroquinolones)
10. ?Hardware in back
Social History:
Lives in [**Location **] [**Hospital1 **] NH since [**2-12**]. No tobacco/EtOH/illicits.
Family History:
NC
Physical Exam:
VS: Tc 99.2, Tm 100.2, BP 130/64, HR 73, RR 22, SaO2 98%/2L NC
General: Elderly female in some distress [**1-10**] back pain, AO x 3
HEENT: NC/AT, PERRL, EOMI. MM sl dry, OP clear
Neck: supple, pain with some movement, esp left side of neck,
+muscle spasms; no JVD
Chest: CTA-B, occasional exp wheeze
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS; guiac negative in ED
Ext: b/l LE ulcers (chronic) with chronic venous stasis changes;
no erythema noted; wwp
Back: tenderness over back diffusely, mainly over paraspinal
areas, no focal tenderness over spine; exam limited
Pertinent Results:
[**2177-3-22**] 07:15PM PT-14.2* PTT-29.9 INR(PT)-1.3*
[**2177-3-22**] 07:15PM PLT SMR-NORMAL PLT COUNT-185
[**2177-3-22**] 07:15PM WBC-24.9*# RBC-3.71* HGB-11.4* HCT-34.9*
MCV-94 MCH-30.8 MCHC-32.8 RDW-15.6*
[**2177-3-22**] 07:15PM NEUTS-64 BANDS-20* LYMPHS-3* MONOS-12* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2177-3-22**] 07:15PM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.0
[**2177-3-22**] 07:15PM GLUCOSE-195* UREA N-38* CREAT-1.4* SODIUM-137
POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
[**2177-3-22**] 07:27PM LACTATE-3.5*
[**2177-3-22**] 07:50PM URINE RBC-[**2-10**]* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-[**2-10**]
[**2177-3-22**] 07:50PM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2177-3-22**] 07:50PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2177-3-22**] 10:56PM K+-3.9
.
CXR [**3-22**]: no active pulmonary disease
Micro:
BCX
[**2177-3-26**] NGTD X 4
[**2177-3-25**] NGTD X 6
[**2176-3-24**] NGTD X 2, MRSA X 2
[**2177-3-23**] MRSA X [**2-9**]
[**2177-3-22**] MRSA X 4
UCX
[**2177-3-26**] NGTD
[**2177-3-23**] EColi
[**2177-3-22**] EColi MDR (sensi to Gent, Imipenem, Meropenem,
Nitrofurantoin, Pip/tazo, Tobra, Bactrim)
Brief Hospital Course:
Unfortunately after two transfers to the MICU during this
admission, the first for tachycardia and hypotension and the
second for respiratory failure, the patient passed away. The
patient had a MDR Ecoli UTI, but more importantly, she had an
overwhelming MRSA infection. This organism was cultured
intially from the blood, then the right shoulder and finally the
C-spine. There was MRI evidence that patient might have a
meningitis, lumbosacral discitis and sinusitis. Rather than
continueing to pursue interminable incision and drainage
procedures a decision was made to discontinue life prolonging
measures. The patient expired shortly after extubation and the
family declined an autopsy.
Medications on Admission:
Depakote 250 mg [**Hospital1 **]
Prozac 40 mg qd
ASA 81 mg qd
Percocet 5/325 tid
Lidoderm 5% patch
Neurontin 600 mg [**Hospital1 **]
Tessalon 100 mg tid
Detrol LA 2 mg qd
MVI qd
Premarin 0.65 mg qd
Levothyrozine 88 mcg qd
Dulcolax 10 mg [**Hospital1 **]
Metamucil 2 tabs [**Hospital1 **]
Lopressor 50 mg [**Hospital1 **]
Vantin 200 mg [**Hospital1 **] x 7 days
Vit C 500 mg [**Hospital1 **]
Zinc 220 mg qd
Lactobacillus 1 tab [**Hospital1 **] x 10 days
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2177-4-6**]
|
[
"244.9",
"V09.0",
"427.32",
"722.91",
"324.1",
"711.01",
"322.9",
"785.4",
"799.02",
"355.9",
"428.0",
"707.15",
"518.81",
"041.11",
"041.4",
"730.28",
"428.30",
"707.14",
"590.10",
"790.7",
"416.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"03.09",
"80.51",
"88.72",
"96.72",
"81.83",
"96.04",
"38.93",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
5147, 5156
|
3918, 4615
|
241, 330
|
5208, 5218
|
2642, 3895
|
5271, 5305
|
2025, 2029
|
5118, 5124
|
5177, 5187
|
4641, 5095
|
5242, 5248
|
2044, 2623
|
196, 203
|
358, 1501
|
1523, 1903
|
1919, 2009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,348
| 103,713
|
46446
|
Discharge summary
|
report
|
Admission Date: [**2201-12-3**] Discharge Date: [**2201-12-18**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic rest pain of the left foot
Major Surgical or Invasive Procedure:
Left femoral-femoral bypass graft to below-knee popliteal artery
bypass with nonreversed saphenous vein and angioscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 86-year-old man with ischemic rest pain and severe
flow deficit to his left leg. He has previously had an
aortobifemoral bypass and a left-to-right femoral-femoral bypass
for occlusion of the right limb of the graft. He has extensive
profunda femoral artery disease and a total occlusion of his
superficial femoral and above-knee popliteal arteries. He
reconstitutes a below-knee popliteal artery with runoff via the
anterior tibial artery which was poorly visualized on his
preoperative arteriogram. He is not a candidate for a
catheter-based intervention and was advised to have a bypass
graft. Vein mapping showed suitable vein.
Past Medical History:
PMH: Dyslipidemia, HTN, CAD (h/o STEMI complicated by VT arrest,
PVD, Increasing RLE claudication, Renal Cell Carcinoma
PSH: s/p distal RCA stent ([**2193**]), [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] of RCA
bifurcation ([**2197**]), [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] in left main ([**2198**]).
Aortobifemoral bypass and
left-to-right fem fem bypass.s/p R nephrectomy in [**2176**], [**2195**]
bowel resection and ileostomy for gangrene of the bowel, s/p
hernia repair ([**2176**]), s/p prostatectomy ([**2172**])
Social History:
Married, lives with wife. + Tobacco use in the past, no current
use. 4-5 drinks EtOH per day. No hx of withdrawal. No street
drugs.
Family History:
non-contributory
Physical Exam:
PE
Blood pressure is 114/60. Pulse is 73. Respirations are 18.
NAD AAOx3
RRR
CTAB
Abd soft NT/ND
He has palpable femoral pulses bilaterally, but no distal
pulses. His feet show some rubor and some cyanosis while the
capillary refill, while
diminished, is unchanged. There are no ischemic lesions.
Pertinent Results:
11/12/9:
Hct: 28
PLT: 245
129 98 48
------------- 133 AGap=14
4.9 22 1.8
MB: 7 Trop-T: 0.03
Vein mapping [**2201-11-25**]:
The greater and lesser saphenous veins are patent bilaterally.
Brief Hospital Course:
The patient was admitted to the [**Month/Day/Year 1106**] surgery service for
evaluation and treatment of his severe left lower extremity
ischemia. On [**2201-12-3**] he was taken to the OR for a left fem-BK
[**Doctor Last Name **] bypass with NRGSV. He tolerated the procedure well and was
taken to the PACU postop. He was managed then in the VICU. On
POD1 patient was feeling well and diet was advanced to regular
with adequate po intake and discontinuing his IV fluids. On POD2
(11/14/9) patient coded in the VICU while seated in chair
attempting to ambulate to bed new RBBB. CPR was performed after
V. Tach and PEA arrest and patient cardiopulmonary status came
back. Immediately after that he was transferred to the CVICU.
Heparin gtt initiated empirically. No AA gradient. Could not
obtain CTA [**2-23**] ARF (Cr 1.5 improved from 2.0 on day of surgery).
Cardiology consulted. Echo with mod/severe LV dysfunction w
inferior/infero-lateral akinesis. Hemodynamically stable. CEs
cycled. Trop peaked .34. Cardiology did not think represented
a primary cardiac event. Extubated following day. Course in
CVICU uncomplicated. C/O rib tenderness anterior/inferior left
chest. IS encouraged. CXR with chronic fibrotic scarring. On
POD 5 ([**2201-12-8**]) he was transferred back to VICU from CVICU. As
the etiology of the arrest was not clear and there was a
question of weather a thromboembolic event was the source, LE
u/s was performed and no evidence of DVT was shown. Heparin drip
was discontinued. On SQH. LLE edema, slowly improving. Diuresis
as tolerated. He also developed some Hyponatremia down to 129
that did resolve over the course of his stay with appropriate
free water fluid restrictions. On POD6 he developed Afib with
RVR, converted with amio. We consulted cardiology again and we
started on standing doses of amio and b/blockers. After that he
had some new episodes of Afib all converted with amio. On POD7
with desat responsive to O2. CXR with question of LLL new
infiltrate. Lot of sputum production. Abx started for PNA.
SCx with respiratory flora. Pulmonary status improved but still
with large amount of sputum production. Undergoing chest
Physiotherapy by nursing staff. His foley was removed. He
developed some mild erythema of inferior portion of wound, that
improved during his hospital stay. Having significant edema of
his LLE, we ordered another LE u/s, which showed no evidence of
deep vein thrombosis in the left leg, but persistent complex
fluid collection extending from the left popliteal fossa medial
and posterior along the left calf that was stable from before.
He was diuresed with lasix until balance was daily negative. Hi
LLE looked better and patient was able to ambulate with nursing
staff and physical therapy. Decision was made to send him to a
rehab based on his level of activity. At the time of discharge,
the patient was doing well, afebrile with stable vital signs.
The patient was tolerating a regular diet, ambulating, voiding
with some assistance, and pain was well controlled.
Medications on Admission:
[**Last Name (un) 1724**]: Albuterol prn, Cilostazol 50'', Plavix 75', Folic Acid 1',
Lisinopril 20'', Lopressor 50'', Rosuvastatin 20', Vit C 500',
[**Last Name (un) **] 81', Vit E 400', MVI, bumex 2mg qm/w/f, spironalactone 25'
(meds confirmed with family)
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for pain.
Disp:*20 Lozenge(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) for 10 days.
16. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ischemic rest pain of the left foot with left superficial
femoral artery occlusion.
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Hospital6 **] and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too much
right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use [**2-24**] pillows
or a recliner) every 2-3 hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your legs
elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber, lean
meats, vegetables/fruits, low fat, low cholesterol) to maintain
your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
No driving until post-op visit and you are no longer taking pain
medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too much
right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
Take all the medications you were taking before surgery, unless
otherwise directed
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-12-31**] 3:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2201-12-31**] 4:20
Completed by:[**2201-12-18**]
|
[
"584.9",
"427.5",
"426.4",
"427.1",
"244.9",
"427.31",
"440.4",
"486",
"440.22",
"V45.73",
"V10.52",
"414.01",
"403.90",
"996.74",
"412",
"585.3",
"E878.2",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.29",
"99.60",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7407, 7473
|
2445, 5496
|
298, 420
|
7601, 7610
|
2223, 2422
|
10424, 10807
|
1868, 1886
|
5806, 7384
|
7494, 7580
|
5522, 5783
|
7634, 9889
|
9916, 10401
|
1901, 2204
|
223, 260
|
448, 1113
|
1135, 1701
|
1717, 1852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,903
| 170,026
|
17031
|
Discharge summary
|
report
|
Admission Date: [**2115-5-20**] Discharge Date: [**2115-5-27**]
Date of Birth: [**2062-10-8**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This is a 53-year-old male who
presented to the [**Hospital6 256**]
Emergency Department on [**2115-5-20**] with a chief complaint
of angina. The patient has multiple risk factors for
coronary artery disease including a family history,
hyperlipidemia and past smoking history. Patient reported
experiencing approximately one year of dyspnea on exertion
accompanied by mild tightening in the center of his chest
several weeks prior to admission. Patient reports he
presented to his primary care physician the week prior to
admission with these complaints for which the primary care
physician recommended [**Name Initial (PRE) **] stress test which reportedly
demonstrated inferior reversible ischemia. The patient
subsequently presented to [**Hospital6 2018**] on [**2115-5-20**] for cardiac catheterization, which
demonstrated three vessel disease requiring placement of a
intraaortic balloon pump. The patient was subsequently
recommended for admission for further evaluation and
management.
PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. Albuminuria.
3. History of transient ischemic attacks, status post right
knee arthroscopy.
HOME MEDICATIONS:
1. Aspirin.
2. Lipitor.
3. Multivitamin.
4. Toprol.
5. Plavix.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives in [**Hospital1 1474**] with his wife and
step-son. [**Name (NI) **] is a semi-retired truck driver who works
at Lowe's Hardware Store. Patient has a 100 pack year
history of smoking, quit approximately 13 years ago.
Consumes a 12 pack of beer on weekends, no prior drug
history.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit on [**2115-5-20**] under the direction of Dr. [**First Name4 (NamePattern1) 47897**]
[**Last Name (NamePattern1) 911**]. As referenced previously, the patient's cardiac
catheterization demonstrated three vessel coronary artery
disease, notable for 70% mid vessel stenosis of the left
anterior descending, a long total occlusion of the proximal
and mid vessel left circumflex, and a 50% stenosis of the
right coronary artery. The patient had an estimated ejection
fraction of 50%. An intraaortic balloon pump was
successfully placed through the course of this procedure.
The patient was subsequently evaluated by the Cardiac Surgery
Team, and following a discussion of pros and cons of surgical
intervention, the patient was scheduled for elective coronary
artery bypass graft on [**2115-5-22**].
On [**2115-5-24**], the patient therefore underwent a quadruple
coronary artery bypass grafting procedure. Anastomosis
included connection from the left internal mammary artery to
the left anterior descending coronary artery, saphenous vein
graft from the aorta to the left anterior descending diagonal
coronary artery, saphenous vein graft from the aorta to the
obtuse marginal coronary artery, the saphenous vein graft
from the aorta to the right posterior descending coronary
artery. The patient tolerated the procedure well and was
subsequently transferred to the Cardiac Surgery Recovery Room
for further evaluation and management.
Following arrival in the CSRU, the patient was successfully
weaned and extubated without complication. The patient was
subsequently noted to be tolerant of oral intake and was
gradually transitioned to full regular diet without
complication. The patient was subsequently cleared for
transfer to the floor on postoperative day number two and was
subsequently admitted to the Cardiac Thoracic Surgery Service
under the direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**].
On the floor, the patient progressed well clinically through
to the time of discharge. On postoperative day number two,
the patient's pacing wires were removed without complication.
The patient was evaluated by Physical Therapy, who deemed an
appropriate candidate for discharge to home following
resolution of his acute medical issues.
On postoperative day number three, the patient's chest tubes
were removed without complication and he was noted to have
adequate pain control provided via oral pain medications.
The patient's Foley catheter was removed and he was
subsequently noted to be independently productive with
adequate amounts of urine for the duration of his stay. The
patient progressed well clinically through postoperative day
number five, at which point he was cleared for full
independent ambulation by Physical Therapy and was
subsequently cleared for discharge to home with instructions
for follow-up.
The patient was subsequently discharged on postoperative day
number five, [**2115-5-27**], with instructions for follow-up.
CONDITION OF DISCHARGE: The patient is to be discharged to
home with instructions for follow-up.
STATUS OF DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg po b.i.d.
2. Lasix 20 mg po b.i.d. times ten days.
3. Potassium chloride 20 mEq po q.d. times ten days.
4. Colace 100 mg po b.i.d.
5. Enteric coated aspirin 325 mg po q.d.
6. Dilaudid 2 mg 1-2 tablets po q. 4 hours prn for pain.
7. Atorvastatin 20 mg po q.d.
8. Ibuprofen 400 mg po q. 6 hours prn.
DISCHARGE INSTRUCTIONS: The patient is to maintain his
incisions clean and dry at all times. The patient may
shower, but should pat his incisions afterwards; no bathing
or swimming until further notice. Patient has been
instructed to limit physical activity; no heavy exertion.
Patient has been instructed to resume a cardiac diet. No
driving while taking prescription pain medications. Patient
is to follow-up with his primary care physician within one to
two weeks. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in six weeks. Patient is to call to schedule all
appointments.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**First Name3 (LF) 47277**]
MEDQUIST36
D: [**2115-5-28**] 06:23
T: [**2115-5-28**] 18:26
JOB#: [**Job Number 47898**]
|
[
"794.39",
"V15.82",
"V17.3",
"401.9",
"272.4",
"411.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"37.22",
"88.53",
"37.61",
"88.72",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
4960, 5286
|
1759, 4937
|
5311, 6230
|
1328, 1435
|
172, 1171
|
1193, 1310
|
1452, 1741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,102
| 149,030
|
21585
|
Discharge summary
|
report
|
Admission Date: [**2132-9-24**] Discharge Date: [**2132-10-9**]
Date of Birth: [**2090-11-9**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 41 year old female was
transferred into our Medical Center at 4:30 in the morning,
with a two day history of chest pain radiating to her back.
She had no neurologic symptoms. She had mild dyspnea. The
pain, subjectively by the patient, was 8 over 10 and was
unrelieved by position and medications thus far at the time
of examination. She had no family history of coronary artery
disease at a young age or aortic dissection. No use of
tobacco. She presented to an outside hospital and was
transferred in.
PAST MEDICAL HISTORY: Patent ductus arteriosus closure at
age 7. She was on no medications at the time of examination
and had no known allergies.
PAST SURGICAL HISTORY: After the patient was extubated,
additional medical history was determined with the patient
and her family. Bilateral breast reductions.
Cholecystectomy. Right foot surgery. PPA versus VSD repair
in the past.
FAMILY HISTORY: She had no family history of coronary artery
disease, pulmonary disease, Marfan's, bleeding disorders or
anesthesia complications. She had no use of tobacco and rare
alcohol use.
REVIEW OF SYSTEMS: Unable to be completed secondary to the
patient's agitation and urgency of the patient's situation.
PHYSICAL EXAMINATION: On examination, her pressure was
87/47. She was in acute distress. Heart rate was 80 and
sinus rhythm with a respiratory rate of 24, saturating 94
percent on room air. Her sclera were anicteric and the
conjunctiva appeared pink and moist. Neck was supple without
carotid bruits. Her lungs were clear bilaterally. Heart was
regular rate and rhythm with a grade 4/6 systolic ejection
murmur at the upper right sternal border. Her abdomen was
soft, nontender, nondistended. Her extremities had no
cyanosis, clubbing or edema. She had decreased bilateral
femoral pulses. She was alert and oriented with a nonfocal
neurologic examination. Cranial nerves 2 through 12 were
intact. She had good strength at 5/5 and sensation was intact
in all four extremities. CT scan showed an 8 cm aortic
dissection, beginning above her aortic valve, which measured
approximately 4 cm.
All laboratory studies were pending at the time that the
patient was taken to the operating room.
HOSPITAL COURSE: The patient was taken emergently to the
operating room on [**9-24**], the day of admission and had an
ascending aortic replacement done with a 28 mm Gel-weave
graft and an aortic valve replacement with a 21 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]
mechanical valve and redo sternotomy by Dr. [**Last Name (STitle) **]. The
patient was taken to the cardiothoracic Intensive Care Unit
in stable condition with a Propofol drip with 15 mcg per kg
per minute, an epinephrine drip of 0.03 mcg/kg per minute,
Milrinone drip at 0.5 mcg/kg per minute and a nitroglycerin
drip at 0.5 mcg/kg per minute. On postoperative day number
one, the patient was awake and following commands but
remained intubated. She was in first degree arteriovenous
block. Blood pressure was 111/47. Cardiac index was 2.2.
Postoperative laboratory studies were as follows: White
count 16.6; hematocrit of 29.9; platelet count 148,000.
Potassium 4.0; BUN 12; creatinine 0.9. The plan was to try
and discontinue the patient's epinephrine drip and wean it to
off during the day, as well as attempting to wean off her
Milrinone later that day also. In addition, the patient was
monitored for the possibility of weaning her to extubate her.
On postoperative day number two, the patient continued to
follow commands. She remained intubated on an epinephrine
drip at 0.01, Milrinone at 0.5, nitroglycerin at 0.5 and
insulin drip of two units per hour. Her creatinine remained
stable at 0.7.
Significant efforts were made to aggressively diurese the
patient in the first 48 hour period. This would help to
improve her oxygenation. The patient was also started on
Diamox and initial review was done by case management and
physical therapy. On postoperative day number two, the
patient was extubated and her chest tubes were removed. She
was started on her first dose of Coumadin 3 mg, given prior
for her mechanical [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] valve. On postoperative day
number three, the patient was hemodynamically stable with a
heart rate in the 90's and a pressure of 124/44. She was
saturating well on four liters nasal cannula. She remained
on a Milrinone drip, epinephrine drip had been weaned off.
The patient was started on heparin drip to help keep her
therapeutic while her INR was rising from her first Coumadin
dose. The patient continued to be AV paced as she had
complete heart block with some accelerated junctional
tachycardia periodically. Her cardiac index dropped to 1.6
and dropped her mixed venous to 57 percent, when her heart
rate dropped below 65. Her blood pressure remained stable
but the patient did get diaphoretic and required V-pacing at
that time. Milrinone was increased slightly.
Dr. [**Last Name (STitle) 73**] from electrophysiology/cardiology consulted.
The plan was to watch the patient at this time, in
preparation possibly for a pacer in the near future. On
postoperative day number four, it was determined that the
patient would require Milrinone. She was unable to tolerate
the wean of the Milrinone and remained on her heparin drip,
as she was being dosed with Coumadin. Please refer to Dr.[**Name (NI) 29964**] note from electrophysiology. The patient was
hemodynamically stable and it was determined that we would
wait and watch her periodic heart block. On postoperative
day number five, she could not tolerate her wean of Milrinone
again and remained on Milrinone at 0.2. She remained
hemodynamically stable. She continued with aggressive Lasix
diuresis. Heparin drip was held briefly to discontinue her
pacing wires. The patient was also seen again by physical
therapy and was encouraged to work with them. On
postoperative day number six, her pacing wires were
discontinued. Her heparin drip was discontinued at an INR of
1.7. She received an additional 3 mg of Coumadin and
Captopril was started. Repeat echo showed an ejection
fraction to be 40 percent. Her index was 1.71. She was
alert and oriented. Her lungs were clear. Her heart was
regular rate and rhythm. Her creatinine was stable at 0.9
with a potassium of 4.4. Blood pressure was 129/38. Heart
rate was 65 with first degree AV block.
The patient was seen again by Dr. [**First Name (STitle) 28239**] [**Last Name (NamePattern4) 56846**], M.D.
from electrophysiology and it was recommended that a
temporary pacer be placed or pacing with Swan-Ganz at this
time, with preparation possibly for adding a pacer placed the
following day. On the 19th at 5:00 o'clock in the afternoon,
the patient suffered a respiratory arrest and went into
complete heart block and then into asystole. Complete full
ACLS code was done. The patient was reintubated.
Electrophysiology was called stat to help place a transvenous
pacing wire, which they did. Please refer to the note from
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**].
On postoperative day number seven, the patient was put on PCV
for high end expiratory pressor and hypoxia. Heparin drip
was restarted for an INR of 1.6 as it dropped slightly. The
patient remained otherwise hemodynamically stable with a
pacing wire in place, being V-paced at 90. Hematocrit ws
stable at 29.6 with a BUN of 17 and creatinine of 0.7. The
patient remained intubated and sedated with coarse breath
sounds. Heart was regular in rate and rhythm in her pace
mode. Repeat chest x-ray was done. Ceftriaxone was started
for additional instrumentation for placement of the pacing
wire. The next day, the patient did receive pacemaker
placement by Dr. [**Last Name (STitle) 284**]. Later that day, wean from the
ventilator was begun again. Postoperative day number 8, the
Cordis was changed over to a triple lumen catheter. The
patient remained on Vancomycin and Ceftriaxone for pacer
replacement. Dobutamine was started at 3 mcg/kg per minute.
The patient remained on Propofol for sedation and aggressive
diuresis continued. The patient was moving all four
extremities, had coarse breath sounds and remained in the
paced rhythm. The patient was also seen by critical
nutrition team and was followed by the UP staff. On
postoperative day number eight, the patient also had coughing
with p.o. after the patient was extubated, even though it was
just ice chips. The chest x-ray did show slightly worsening
picture so the patient had a bedside swallow evaluation done.
It was determined that even though the patient did not have
any signs and symptoms of aspiration at this time that she
was a risk for aspiration and recommendations were made and
followed by the nutrition team.
Heparin was increased on postoperative day number eight and
beta blockade with Lopressor was started. The patient was
successfully extubated as previously noted and evaluated by
speech and swallow team. Heparin was continued and Coumadin
was restarted. Aggressive pulmonary toilette was continued
over the next couple of days. The patient also went into
atrial flutter on postoperative day number 10. This was
terminated by the pacemaker. The patient was evaluated again
by case management on postoperative day number 10. The
patient continued to be very edematous and the venous access
team was called to help place a peripheral intravenous but
was unsuccessful. On postoperative day number 11, the
patient started Flagyl for empiric Clostridium difficile.
She was continued on Coumadin. She had a blood pressure of
143/73, saturating 96 percent on four liters nasal cannula.
Hematocrit remained stable at 27.4. White count dropped from
23 to 20.5; creatinine was stable at 0.7. Ceftriaxone was
discontinued. Flagyl was discontinued later in the day.
Triple lumen catheter was changed. Foley was discontinued
and the patient was moved out of bed with physical therapy.
The patient continued to be moving all four extremities,
remained paced, with decreasing amounts of edema over the
next couple of days. Heparin drip was discontinued and the
patient continued to receive Coumadin. PICC line was placed
and the patient was transferred to the floor on postoperative
day number 11. The patient continued to work aggressively
with physical therapy and continue ambulating, in preparation
for going home. On postoperative day number 13, white count
continued to drop to 19.2 and then 14.6 later in the day. A
PICC line had been placed successfully the prior afternoon.
The examination was nonfocal and unremarkable. Incisions
were clean, dry and intact. Vancomycin was discontinued.
Central venous line in the subclavian position was
discontinued. Discussion was had about whether the patient
was ready for going home, versus going to rehabilitation and
the Coumadin dose was increased to 5 mg, as we waited for the
patient's INR to rise appropriately for coverage of her
mechanical aortic valve. On the 26th, EP reinterrogated and
programmed the patient's pacemaker, in preparation for her
going home. On postoperative day number 14, the patient
remained stable. INR was to 2.2. The patient slowly
continued to improve. Her lungs were clear. She was alert
and oriented. We encouraged the patient to continue
ambulating. She received some Milk of Magnesia to help her
with her bowel regimen and the plan was to have the patient
be discharged in the morning, with home physical therapy. At
this point, the patient was receiving p.o. Percocet for
occasional incisional pain. On postoperative day number 15,
the day of discharge, the patient remained stable with a
hematocrit of 28.3. Blood pressure was 111/52, paced at 80
in sinus rhythm with an INR of 2.5. Examination was
unremarkable with the exception of 1 plus peripheral edema in
her extremities. The patient was doing well but needed to
increase her ambulation. The plan was to discharge the
patient home today with VNA services and home physical
therapy. The patient was instructed also to take 2 mg of
Coumadin that night and to follow-up with VNA blood draws for
INR and to receive her Coumadin dosing and laboratory results
from Dr. [**Last Name (STitle) 4783**], telephone number [**Telephone/Fax (1) 5424**]. The
patient was also instructed to follow-up with Dr. [**Last Name (STitle) 4783**] in
the office in one to two weeks for examination and to make an
appointment to see Dr. [**Last Name (STitle) **], her surgeon, for
postoperative surgical visit at four weeks.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement and ascending aortic
graft; status post aortic dissection.
2. Status post patent ductus arteriosus closure at age 7.
3. Hypercholesterolemia.
4. Status post cholecystectomy.
5. Status post right foot surgery.
6. Status post pacemaker placement.
7. Status post PICC line placement.
DISCHARGE ACTIVITIES:
1. Captopril 12.5 mg p.o. three times a day.
2. Albuterol/Ipratropium 103/18 mcg aerosol, two puffs every
four hours.
3. Percocet 5/325 mg one to two tablets p.o. prn every four
to six hours for pain.
4. Aspirin, enteric coated, 81 mg p.o. daily.
5. Colace 100 mg p.o. twice a day.
6. Metoprolol 50 mg p.o. twice a day.
7. Lasix 80 mg p.o. twice a day for ten days.
8. Potassium chloride 20 meq p.o. once a day for ten days.
9. Coumadin 2 mg dose, only for the night of discharge on
[**10-9**] and to take 2 mg dosing as directed by Dr. [**Last Name (STitle) 4783**]
and laboratory draws.
The patient was discharged to home on [**2132-10-9**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2132-11-11**] 15:49:19
T: [**2132-11-11**] 17:09:48
Job#: [**Job Number 56847**]
|
[
"427.41",
"427.5",
"424.1",
"997.1",
"428.0",
"746.4",
"276.3",
"441.01",
"427.32",
"518.0",
"997.3",
"427.1",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"38.93",
"96.71",
"89.64",
"35.22",
"99.62",
"37.78",
"99.07",
"89.68",
"37.83",
"99.04",
"96.04",
"39.64",
"38.91",
"99.05",
"39.61",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
1082, 1263
|
12806, 14050
|
2402, 12785
|
852, 1065
|
1407, 2384
|
1283, 1384
|
165, 679
|
702, 828
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,109
| 108,396
|
45250
|
Discharge summary
|
report
|
Admission Date: [**2116-2-14**] Discharge Date: [**2116-2-23**]
Date of Birth: [**2040-10-10**] Sex: M
Service:
ADMISSION DIAGNOSIS: Positive stress test.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times four.
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old
man who was referred to the [**Hospital6 2018**] for cardiac catheterization secondary to a routine ETT
which revealed 2.5 to 3 mm downsloping ST segment changes in
V4 through V6. There were also 1.5 to [**Street Address(2) 1766**] depressions in
the inferior leads. Stress thallium imaging revealed a
reversible defect in the basilar portion of the inferolateral
wall. Ejection fraction approximately 55%. The patient
denied any anginal symptoms, chest pain, lightheadedness,
claudication symptoms.
PAST MEDICAL HISTORY:
1. Asthma.
2. Hypercholesterolemia.
3. BPH, status post TURP approximately 20 years ago.
ADMISSION MEDICATIONS:
1. Lipitor 10 mg q.d.
2. Lopressor 50 mg b.i.d.
3. Isosorbide 10 mg t.i.d.
4. Beconase nasal spray q.d.
5. Flovent inhaler two puffs q.d.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient is
an elderly man in no acute distress. Vital signs:
Temperature 96.8 degrees Fahrenheit, heart rate 49, blood
pressure 129/61, respirations 18, 99% on room air. HEENT:
Normocephalic, atraumatic. EOMI. PERRL, anicteric. The
throat was clear. Neck: Supple, midline, without masses or
lymphadenopathy. No bruit or JVD. Cardiovascular: Regular
rate and rhythm without murmurs, rubs, or gallops. Chest:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended, without masses or organomegaly.
Extremities: Warm, noncyanotic, nonedematous times four.
Good distal pulses.
LABORATORY DATA ON ADMISSION: CBC 6.6/13.7/40.2/205.
Chemistries 142/4.5/107/27/24/1.2. INR 1.2.
HOSPITAL COURSE: The patient came in for outpatient cardiac
catheterization which revealed an ejection fraction of
approximately 50% and a right dominant coronary artery system
with a severe three vessel disease. The patient was admitted
post catheterization because of left main lesion as well as
oozing from the groin site.
The patient was placed on a nitroglycerin drip to keep
systolic blood pressures in the 120-140 range. The patient
was also maintained on a heparin drip for anticoagulation.
He was preopped for a coronary artery bypass graft in the
standard fashion.
On [**2116-2-17**], the patient was taken to the Operating Room for
a coronary artery bypass graft times four. The patient had
LIMA to mid LAD, saphenous vein graft to descending LAD,
descending RCA and OM. The patient tolerated the procedure
well.
The patient was taken to the CSRU postoperatively for closer
monitoring. The patient was extubated on postoperative day
number zero. On postoperative day number two, the patient's
chest tubes were removed. He was subsequently transferred to
the floor without event.
On postoperative day number three, the patient's pacer wires
were removed. In the middle of the day of postoperative day
number three, the patient had an episode of atrial
fibrillation and was rate controlled using 20 mg of IV
Lopressor and 300 mg of IV Amiodarone. The patient
maintained a heart rate between 100-110 with systolic blood
pressures 85 or greater. The patient spontaneously converted
back to normal sinus rhythm after approximately three to four
hours of atrial fibrillation.
The patient otherwise continued to work with Physical
Therapy. A hematocrit was found to be 22 and 25 on repeat.
The patient received 2 units of packed red blood cells for
this. This helped with his previous orthostatic symptoms of
dizziness as well as orthostatic hypotension. The patient
was then cleared by Physical Therapy for discharge to home
and subsequently discharged to home on postoperative day
number six.
At that time, the patient was tolerating a regular diet, and
had adequate pain control on p.o. pain medications and not
having any anginal symptoms or orthostatic symptoms.
DISCHARGE CONDITION: Good.
DISPOSITION: To home.
DISCHARGE DIET: Cardiac.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Lipitor 10 mg q.d.
3. Percocet 5/325 one to two q. four hours p.r.n.
4. Colace 100 mg b.i.d.
5. Flovent 110 micrograms inhaler two puffs b.i.d.
6. Beconase nasal spray q.d.
7. Lasix 20 mg b.i.d. times seven days.
8. Potassium chloride 20 mEq q.d. times seven days.
9. Lopressor 12.5 mg b.i.d.
10. Amiodarone 400 mg q.d.
11. Ambien 5-10 mg q.h.s. p.r.n.
DISCHARGE INSTRUCTIONS: The patient should follow-up with
Cardiology within one to two weeks. Address the need for
continued diuresis as well as adjustment of cardiac
medications at that time. The patient should follow-up with
Dr. [**Last Name (STitle) 1537**] in four weeks time. Encourage continuing incentive
spirometry and ambulation.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2116-2-23**] 09:51
T: [**2116-2-23**] 10:25
JOB#: [**Job Number 22447**]
|
[
"V17.3",
"414.01",
"413.9",
"998.12",
"427.31",
"493.90",
"272.4",
"300.00",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.64",
"39.61",
"36.15",
"37.22",
"89.68",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4103, 4161
|
4184, 4573
|
198, 852
|
1906, 4081
|
4598, 5199
|
990, 1155
|
154, 177
|
1819, 1888
|
874, 967
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,367
| 176,192
|
24484
|
Discharge summary
|
report
|
Admission Date: [**2144-3-10**] Discharge Date: [**2144-3-17**]
Date of Birth: [**2078-3-18**] Sex: M
Service: MEDICINE
Allergies:
Amitriptyline / Norvasc
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Cough and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 y/o M with PMHx of CAD s/p stenting, Afib/flutter, DM with
neuropathy and tobacco dependance who presents with productive
cough and SOB for 3 days. Pt reports upper respiratory
congestion and cough with yellow sputum but denies fever &
chills. Pt describes PND, orthopnea and new nocturia but has
minimal exertion capacity and denies DOE. He also reports
approx 1 wk of difficulty swallowing, coughing with thin liquids
though no prior history of aspiration. Pt has poor dentition
and difficulty chewing solid foods. He initially presented to
his PCP on [**Name9 (PRE) 766**] morning and was discharged with prescription
of Azithro and plan for outpt CXR. However, his shortness of
breath worsened overnight and he presented to the ED early
tuesday morning.
.
VS on arrival to the ED were: T 97.6 BP 148/104 HR 122 RR 28
Sats 100% on RA. CXR revealed LLL infiltrate and pt received
Ceftriaxone 1gram, Azithromycin 500mg, Prednisone 60mg, Duonebs
and 3L of NS IVF. Pt was given diltiazem 20mg IV for HR of 130
and was noted to have increasing O2 requirement. Pt was unable
to wean from NRB and was started on diltiazem gtt for rate
control. Repeat CXR showed worsening pulm edema and LLL
consolidation.
.
On arrival to CCU, pt was feeling better, still c/o cough and
mild SOB. Denies any fevers/chills, CP/palpitations, abd pain,
nausea/vomiting or diarrhea.
Past Medical History:
# CAD s/p PCI x 2 with a history of MI and angioplasty 12 years
ago. His most recent cardiac catheterization was in [**Month (only) 216**] of
[**2140**] at [**Hospital6 1708**] which revealed non-flow
limiting three-vessel disease and no intervention was performed
at that time.
# Atrial flutter/atrial tachycardia status post ablation in
[**2140-9-5**] with breakthrough atrial tachycardia and atrial
flutter
# Atrial fibrillation- baseline HR 100-120 outpatient
# DM type II - on NPH, recent A1C 6.6
# Neuropathy-[**3-9**] DMII wheelchair bound w/ caregiver
# PVD followed by Dr. [**First Name (STitle) **]
# [**First Name (STitle) **] Ca -- s/p partial colectomy [**2125**], no radiation or chemo
# Neuropathy -- progressing to R arm now; legs unchanged, uses
# Spinal Stenosis -- MRI done [**5-/2141**], no emergent issues, but
some retrolisthesis of L4-5.
# Anemia--Longstanding normocytic, unclear etiology
# Alcoholism- Likely Active
# Retinopathy-
# Intracranial bleed-[**2143-1-5**]- fainted after dose of Amytripile
and had intracranial bleed by rt inner ear.
Social History:
Lives at [**Hospital1 1426**]/[**Location (un) **] with friend/partner [**Name (NI) 61893**] [**Name (NI) **]
([**Telephone/Fax (1) 61891**]); this is also his HCP. Retired, disabled,
wheelchair bound.
Alcohol: Reports [**3-10**] drinks/day everyday for years. Denies
problems with alcohol, but concern for abuse per previous notes.
No h/o WD, DT's, seizure.
Tobacco: 1.5 PPD x 40 yrs
Drugs: Remote marijuana only.
Family History:
no family hx of heart disease. Both parents died at 92 of "old
age."
Physical Exam:
Vitals: T: 97.5 BP: 127/82 P: 127 R: 24 O2: 93% on NRB
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated approx 3cm below angle of the jaw
Lungs: No appreciable wheezes, occaisional rhonchi and
inspiratory crackles at L>R base, clear with coughing.
CV: Irreg/Irreg & tachycardic, diff to apprec murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, 2+ pulses, no edema
Pertinent Results:
[**2144-3-10**] 07:56AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2144-3-10**] 07:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2144-3-10**] 07:56AM URINE RBC-5* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2144-3-10**] 07:56AM URINE MUCOUS-RARE
[**2144-3-10**] 04:56AM LACTATE-1.7
[**2144-3-10**] 04:15AM GLUCOSE-81 UREA N-13 CREAT-0.4* SODIUM-138
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12
[**2144-3-10**] 04:15AM estGFR-Using this
[**2144-3-10**] 04:15AM WBC-7.3 RBC-3.64* HGB-10.4* HCT-30.8* MCV-85
MCH-28.7 MCHC-33.8 RDW-16.1*
[**2144-3-10**] 04:15AM NEUTS-57.0 LYMPHS-35.2 MONOS-4.8 EOS-2.2
BASOS-0.8
[**2144-3-10**] 04:15AM PLT COUNT-393
[**3-10**] ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is low normal (LVEF 50-55%). The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-7**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2142-12-13**],
tricuspid regurgittaion is now more prominent and estimated
pulmonary artery systolic pressure is now higher. Left
ventricular and right ventricular systolic function is less
vigorous.
[**3-10**] CXR
COMPARISON: Chest radiograph from [**2144-3-10**] obtained of
04:16 a.m. and chest radiograph from [**2143-11-8**].
The left lower lobe consolidation accompanied by pleural
effusion is
unchanged but there is overall progression of perihilar vascular
engorgement continuing towards the right lower lung with small
right pleural effusion present. The radiological picture is
consistent with mild-to-moderate pulmonary edema with the
abnormality at the left lung being either a separate entity such
as a pneumonia and parapneumonic effusion or potentially can be
due to asymmetric pulmonary edema. There is no pneumothorax. The
cardiomediastinal silhouette is unchanged.
ADDENDUM: Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] over the
phone by Dr. [**Last Name (STitle) **] approximately at 8:55 a.m. on [**3-10**], [**2144**].
[**3-11**] CXR
1. Increase in consolidation at the left lung base with slight
increase in pleural effusion is concerning for pneumonia.
2. CHF with new mild-to-moderate pulmonary edema is unchanged.
Brief Hospital Course:
65 year-old male with coronary artery disease, atrial
fibrillation, diabetes mellitus type with neuropathy and tobacco
dependance admitted [**2144-3-10**] with productive cough and SOB for 3
days. Patient was initially admitted to MICU, then medicine
service, and finally to cardiology service prior to discharge.
Hospital course was as follows.
1. Hypoxia: Etiology likely multifactorial. On initial
presentation, patient was with adequate O2 saturation on RA and
became progressively hypoxic with IVF resuscitation and Afib
with [**Month/Day/Year 5509**]. Lobar pneumonia treated with good response with
ceftriaxone (ten day course with 3 days of cefpodoxime
prescribed at discharge) and azithromycin (5 day course). Pt
became fluid overloaded intermittently with shortness of breath,
which responded well to 20mg IV furosemide. Pt also experienced
great symptomatic relief with brochodilators suggesting a
brochospasm component to his dyspnea. After several days of
gentle diuresis, antibiotics and nebulizer treatments, patient
was saturating 95% on room and breathing comfortably.
Discharged on continued antibiotics, furosemide, and albuterol.
2. Chronic diastolic heart failure: TTE on [**2144-3-10**] revealed EF
50-55% with minimal decrease in systolic function from prior
TTE. Evidence of pulmonary hypertension. On cardiology service,
patient experienced tachypnea at night which appeared consistent
with PND. He was given Lasix with good response.
3. Atrial fibrillation with [**Date Range 5509**]: Patient has known atrial
fibrillation and is status-post failed ablation. Suspect current
worsening precipitated by CAP, hypoxia & long standing smoking
history. Patient not anti-coagulated per Dr. [**Last Name (STitle) **] given
history of IVH from multiple falls. He was treated with
increased doses of metoprolol and continued to enter A-Fib with
[**Last Name (STitle) 5509**] to the 140's. For a short time his Toprol XL dose was
doubled. On discharge, his heart rate was well-controlled with
diltiazem SR 240mg PO daily and metoprolol succinate 100mg PO
daily.
4. Coronary artery disease: Patient was without chest pain
during episodes of atrial fibrillation with [**Last Name (STitle) 5509**]. EKGs
essentially unchanged though low voltage in limb leads. He was
continued on aspirin, Plavix, beta-blocker, and statin per his
home regimen.
5. Diabetes mellitus, type II: Blood sugars poorly controlled,
in the 300-400 despite excellent outpatient control with A1C of
6.6. This was likely due to prednisone treatment in the ED and
the stress of his illness. [**Last Name (un) **] was involved in management and
guided daily insulin regimen changes. Patient's diabetes
mellitus is complicated by neuropathy; he was continued on
gabapentin 300mg PO TID per home regimen.
6. Alcohol use: Patient has been known to have significant
alcohol intake. His alcohol level was elevated on admission. He
was counseled on alcohol cessation. He was monitored on CIWA
protocol and showed no signs of withdrawal. He was also started
on a MVI, folic acid, and thiamine.
7. Hypertension: Well-controlled throughout hospitalization
with metoprolol and diltiazem as above.
8. Anemia: Hematocrit remained at baseline (~30). Normocytic
with labs consistent with iron deficiency. Patient with known
history of [**Last Name (un) 499**] cancer s/p partial colectomy. Continued iron
325mg PO daily, and recommend to patient that he have a repeat
colonoscopy as an outpatient.
9. ?COPD: No PFTs in our system. Unclear where how this
diagnosis came about. Continued ipratropium prn, and
discontinued albuterol given episodes of tachycardia.
10. Pulmonary hypertension: Moderate based on recent TTE.
Source unclear, but may be related to left heart failure +/-
acute illness. Patient recommended to have pulmonary follow-up
as an outpatient.
11. Nutrition: He was evaluated by speech and swallow given
presumed aspiration pneumonia, as described as above.He was
recommended for a nectar prethickened liquid diet.
**Communication: [**First Name8 (NamePattern2) 61893**] [**Last Name (NamePattern1) **], PCA ([**Telephone/Fax (1) 61894**]
Medications on Admission:
Lipitor 40mg daily
Plavix 75mg daily
Novolog 70/30 14units qam and 4units qpm
Cymbalta 30mg daily
Aspirin 325mg daily
MIV daily
Diltiazem SR 120mg daily
Albuterol inhaler q4hr prn
Azithromycin 500mg x 1, 250mg x 4 (started [**2144-3-9**])
Gabapentin 300mg TID
Folic Acid 1mg daily
Toprol XL 100mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
inhalations Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Disp:*1 month supply* Refills:*0*
14. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 3 days.
Disp:*5 Tablet(s)* Refills:*0*
15. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous In the morning.
Disp:*30 day supply* Refills:*2*
16. Novolog 100 unit/mL Solution Sig: As per attached sliding
scale algorithm Subcutaneous four times a day.
17. Insulin Syringes (Disposable) 1 mL Syringe Sig: As per
Lantus prescription Miscellaneous once a day.
Disp:*10 syringes* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Lobar Pneumonia, community acquired pneumonia vs. aspiration
pneumonia
- Atrial fibrillation with rapid ventricular rate
- Acute on chronic systolic heart failure
Secondary:
- Diabetes mellitus type II complicated by retinopathy and
neuropathy
- History of [**Month/Day/Year 499**] cancer
- Iron-deficient anemia
Discharge Condition:
Hemodynamically stable. Uses wheelchair for mobility (baseline).
Discharge Instructions:
You were admitted to the hospital because of difficulties
breathing and a fast heart rate. You were found to have
pneumonia and extra fluid in your lungs which was making it hard
to breath. During your hospital stay, you were given
antibiotics for your pneumonia and your heart rate was
controlled by increasing some of your medications. We also gave
you a medication to keep fluid off of your lungs. We also
discovered you had a low blood count due to an iron deficiency.
This may mean you have another problem in your [**Month/Day/Year 499**], and it may
be necessary to have another colonoscopy in the future. Please
discuss this with your doctor.
Your medication regimen has changed. Please review your
medication list closely.
Please attend all the follow up appointments indicated below.
If you have any of the following problems or any symptoms that
are concerning to you, please return to the emergency department
or call your physician:
[**Name Initial (NameIs) **] Difficulty breathing,
- Fever,
- Fast heart rate,
- Confusion,
- Inability to eat, or
- Pain or pressure in your chest.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**], MD (Primary care) Phone:[**Telephone/Fax (1) 133**]
Date/Time: [**2144-3-23**] 2:30PM
Provider: [**Last Name (NamePattern5) 7224**], NP (Cardiology) Phone:[**Telephone/Fax (1) 62**]
Date/Time: [**2144-3-31**] 8:00AM, [**Hospital Ward Name 23**] 7
Please follow-up with Dr. [**Last Name (STitle) 4379**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9485**] at [**Last Name (un) **]
within one week.
Completed by:[**2144-4-6**]
|
[
"305.1",
"250.60",
"401.9",
"250.50",
"V58.67",
"362.01",
"443.9",
"486",
"428.0",
"427.31",
"V45.82",
"518.82",
"427.32",
"303.91",
"280.9",
"412",
"357.2",
"414.01",
"272.0",
"428.43",
"491.21",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13126, 13132
|
6800, 10954
|
322, 328
|
13501, 13568
|
3881, 6777
|
14717, 15247
|
3271, 3341
|
11309, 13103
|
13153, 13480
|
10980, 11286
|
13592, 14694
|
3356, 3862
|
253, 284
|
356, 1726
|
1748, 2821
|
2837, 3255
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,017
| 135,820
|
40330
|
Discharge summary
|
report
|
Admission Date: [**2106-11-17**] Discharge Date: [**2106-11-21**]
Date of Birth: [**2082-11-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
24 yo male who rolled tractor into tree, was pinned between
tractor and tree. Self-extricated. Transferred from OHS with
abdominal pain and chest wall pain, hypotension.
Major Surgical or Invasive Procedure:
IR placed 4 coils to 2 branches of replaced R hepatic artery, L
hepatic gel foam, 1 upper splenic branch coil + gel foam
History of Present Illness:
24 yo male was riding tractor, apparently rolled tractor into
tree became trapped between tractor and tree. He self-extricated
and walked back to his house, he was taken to an outside
hospital and transferred here for abdominal pain, chest wall
pain and hypotension. CT head showed no acute intracranial
abnormality. CT C-spine: no fx or traumatic malalignment however
CT torso: large right hepatic laceration with evidence of
extravasation; splenic laceration, also with concern for
extravastaion; jejunal thickening with surround mesenteric
fluid, concerning for trauamtic mesenteric/small bowel injury;
small b/l pneumothoraces; non-displaced right rib fxs.
Past Medical History:
Non contributory
Social History:
Lives with wife. + etoh use, denies illicts
Family History:
Non contributory
Physical Exam:
In the ED trauma bay:
General: Uncomfortable, alert
HEENT: Normocephalic, atraumatic, PERRLA, EOMI, Oropharynx
within normal limits, mucosa moist, c-collar in place
Chest: Clear to auscultation bilaterally, chest wall tenderness
bilaterally, worse on the right
Cardiovascular: Regular Rate and Rhythm, S1 S2, no murmurs or
gallops
Abdominal: Diffuse TTP in all quadrants, mild distension + FAST
Back: No vertebral ttp, no step offs or obvious deformities
Ext: warm and well-perfused, no obvious deformities or edema
Skin: R abdominal abrasion
Neuro: Speech fluent, A&Ox3, CN II-XII intact, strength +[**4-28**]
bilateral upper and lower extremities. Sensation intact in all
distributions.
Pertinent Results:
[**2106-11-17**] 09:38PM UREA N-15 CREAT-1.1
[**2106-11-17**] 09:38PM estGFR-Using this
[**2106-11-17**] 09:38PM LIPASE-46
[**2106-11-17**] 09:38PM ASA-NEG ETHANOL-141* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-11-17**] 09:38PM URINE HOURS-RANDOM
[**2106-11-17**] 09:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2106-11-17**] 09:38PM GLUCOSE-171* LACTATE-3.6* NA+-141 K+-4.6
CL--106 TCO2-21
[**2106-11-17**] 09:38PM WBC-27.2* RBC-4.46* HGB-13.7* HCT-39.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-12.7
[**2106-11-17**] 09:38PM PLT COUNT-189
[**2106-11-17**] 09:38PM FIBRINOGE-129*
[**2106-11-17**] 09:38PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.035
[**2106-11-17**] 09:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2106-11-17**] 09:38PM URINE RBC-[**2-26**]* WBC-[**2-26**] BACTERIA-NONE
YEAST-NONE EPI-0-2
Brief Hospital Course:
The patient was admitted to the ACS surgery service on
[**2106-11-17**] and went directly from the emergency department to
Interventional Radiology where he had 4 coils to 2 branches of
replaced R hepatic artery, L hepatic gel foam, 1 upper splenic
branch coil + gel foam placed. The patient tolerated the
procedure well and was then transferred to the TICU, where he
spent one night.
Neuro: Post-procedurely, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications
including oxycodone.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. His hematocrit was closely
monitored.
Pulmonary: 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. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. His foley was removed on
post-procedure day#3. Intake and output were closely monitored.
ID: The patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient was encouraged to get up and ambulate
as early as possible. He received famotidine for GI prophylaxis.
At the time of discharge on hospital day #5, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled.
Medications on Admission:
None.
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation for 10 days.
Disp:*20 Tablet(s)* Refills:*1*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 10 days.
Disp:*20 Capsule(s)* Refills:*1*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain .
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
liver laceration, splenic laceration, non-displaced right rib
fractures, small bilateral pneumothoraces
Discharge Condition:
Discharge condition: good.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgical service on [**2106-11-17**]
following a tractor accident. You had bleeding from your liver
and your spleen, the bleeding was stopped by an interventional
radiology procedure. You also have several rib fractures, which
will heal on their own. You are being discharged home with pain
medications which will help with the rib fractures. You must
continue to take regular, deep breaths several times an hour to
help prevent getting pneumonia.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* No strenuous activity until instructed by your surgeon.
Followup Instructions:
Please follow-up with your primary care doctor concerning this
hospitalization. Also please follow-up with the acute care
surgical clinic in 2 weeks. Please call [**Telephone/Fax (1) 600**] to make an
appointment.
|
[
"401.9",
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"E821.0",
"860.0",
"807.04",
"305.00",
"458.9",
"864.03",
"780.60",
"865.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
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] |
icd9pcs
|
[
[
[]
]
] |
5169, 5175
|
3154, 4712
|
486, 608
|
5344, 5350
|
2158, 3131
|
6851, 7068
|
1416, 1434
|
4768, 5146
|
5196, 5302
|
4738, 4745
|
5501, 6828
|
1449, 2139
|
277, 448
|
636, 1299
|
5365, 5477
|
1321, 1339
|
1355, 1400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,858
| 184,427
|
38068
|
Discharge summary
|
report
|
Admission Date: [**2185-6-20**] Discharge Date: [**2185-7-6**]
Date of Birth: [**2128-8-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Left neck pain
Major Surgical or Invasive Procedure:
Colonoscopy
PICC placement
History of Present Illness:
Mr. [**Known lastname 84994**] is a 56-year-old man with a history of obesity,
hypertension, diabetes, dyslipidemia, sickle cell trait,
prostate cancer, multiple myeloma (s/p chemotherapy), unilateral
orchidectomy, pulmonary embolism (on coumadin), sleep apnea,
adjustment disorder, presenting with acute onset left neck pain,
including hemibody symptoms.
Mr. [**Known lastname 84994**] [**Last Name (Titles) **] up at 10 a.m. on [**Last Name (Titles) 1017**] with pain at the base of
his neck on the left (he points to the area of the
manubrioclavicular joint on the left). It was associated with
neck stiffness and was aching in character. The pain worsened
and came to include the posterolateral neck, slight distal from
the origin of the left trapezius. His son got some [**Name (NI) 13166**] for him
which helped somewhat and he slept some more. He then awoke with
burning pain in both feet and in his left hand. The ache had
spread to his left arm and leg. He developed a headache that
radiated from the pain in his neck. These symptoms brought him
to the [**Hospital1 18**] ED.
Review of systoms reveals a number of positive features: The
pain varied slightly with breathing, he thinks. He feels that
his arm was weak, but only secondary to pain, he agreed. His
family noted that he was not talking much and that his speech
was slurred, but he was not sure whether this was because of a
speech difficulty, or because of [**9-30**] pain. His ankles have been
swollen lately so he had started Lasix. He was also precribed
nortrytiline to take at night - both of which started on Friday.
He has taken both. The swelling in his anlkes has gone now. He
did notice that he was more short of breath than usual on
[**Last Name (LF) 1017**], [**First Name3 (LF) **] waited for EMS to arrive before tackling the stairs
to the ground floor in his house. He travels to [**Country 16573**]
frequently and has been there within the last few months: Once
in [**Month (only) 1096**], when he actually developed diabetic coma, returning
to the US in [**Month (only) 404**], then again in [**Month (only) 958**], returning on [**5-3**]. He is not sure whether he has been dehydrated, but it has
been very warm this weekend.
Multiple myeloma, according to the patient, was diagnosed after
he visited an [**Location (un) 2274**] hematologist to work up his anemia. Final
diagnosis was made by bone marrow biopsy and he does not know of
any bony lesions/plasmacytomas. Chemotherapy was started the
following week.
In the ED, pain was controlled, Neurology saw him and CT
angiograms of the chest, neck and head were performed, along
with a plain film of the neck. His pain improved with Dilaudid,
but did not resolve completely. His initial vitals were: T 98 HR
89 BP 161/103 RR 18 Sats 99% on RA. CTA of torso ruled out
dissection, CTA head/neck was negative for vascular injury.
Morphine 16mg IV, Dilaudid 1mg x 1 and Aspirin 325mg.
Other review of systems was negative: He had no recent cough,
runny nose, fever, chest pressure, palpitations. No pain on
chewing, visual changes. No sick contacts, no extramarital
sexual relations, no smoking, drugs or alcohol. No particularly
notable stressors. He check glucose frequently and injects
insulin into his shoulders and thighs (not belly). He does not
monitor his blood pressure at home. No GI symptoms, diarrhea,
vomiting, nausea.
Past Medical History:
- Sickle cell trait - no manifestations, per patient
- Obesity, recent BMI 31.8
- Hypertension, on lisinopril, amlodipine, atenolol
- Diabetes, on insulin, poorly controlled per [**Location (un) 2274**] notes
- Cancer of the prostate, radical prostatectomy [**2175**], now
nocturia and frequency
- Leydig cell testicular tumor, s/p unilateral orchidectomy
- Sleep apnea
- Colon polyp, small adenoma on colonscopy [**2182**], repeat advised
[**2184**]
- Impotence, erectile dysfunction
- Anemia, leading to diagnosis of multiple myeloma
- Multiple Myeloma, diagnosed by bone marrow biopsy (50% plasma
cells), s/p velcade/decadron, controlled per patient, IgA type,
IgA level 1900 in [**2184-8-21**]. Oncologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84995**]
([**Telephone/Fax (1) 3468**]). No bony lesions on skeletal survery in [**2184**].
Significant steroid toxicity per Oncology note, so subsequent
treatment could be revlimid or velcade alone.
- Dyslipidemia
- Alcohol abuse, dependence and some struggle to stop when
starting coumadin for PE in [**Month (only) 404**]. Has been prescribed
naltrexone. Not active.
- Steatohepatitis
- Pulmonary embolism, on coumadin (for four months now) -
difficult to keep INR stable, presently supratherapeutic. Likely
provoked during hospitalization for diabetic coma. Admitted to
[**Hospital1 112**] from [**2185-1-29**] to [**2185-1-31**] and started coumadin. Bridged with
Fragmin 18,000 units.
- Diabetic coma, glucose in 600s, occurred while in [**Country 16573**] in
[**Month (only) **] - hospitalized there and given large amount of IV
fluid, noted to also have cough and fever. Also presented to
Urgent Care [**Location (un) 2274**] with symptomatic hyperglycemia.
- Diabetic retinopathy
- Latent TB, negative AFB
- Hypothyroidism in [**Location (un) 2287**] notes - previously on levothyroxine
- Lower extremity edema, given Lasix, amlodipine discussed as
cause also.
Social History:
Lives in [**Location 686**] with his wife. Originally from [**Country 16573**].
Currently works for the [**University/College **] School of Public Health on a
project studying HIV/AIDS in [**Country 480**]. Travels monthly to [**Country 84996**]
or [**Country 84997**]. Reports a history of EtOH (~4 beers/day
w/Scotch, however has recently cut back to 1/day), no smoking,
no illicits.
Family History:
Mother died at 98 of old age. Father died at 85 of old age.
Physical Exam:
T 97.8 F
HR 88
BP 167/70 ( - 179/113)
Respiratory: 20 RR 99 % O2Sat
Fingerstick: 114
Biometrics at admission:
Height: 72 in. [**2185-6-20**]
Weight: 90.72 kgs. (200.00 lbs) [**2185-6-20**]
BMI: 27.1
Present weight: 90.72 kg (but appears heavier, so will check,
last BMI 31.8)
Fluid balance (net in 24 hr): NR
Physical Exam
GEN: Overweight man, unconfortable, little spontaneous movement
of left arm. Ice packs on upper left trapezius and region of
sternoclavicular joint.
Neck: Guarding [**2-22**] pain, not palpable masses posteriorly.
Sternoclavicular joint region very tender and slightly
erythematous under area that ice pack placed.
Cardiovascular: Regular. Systolic murmur that radiates to the
subclavian arteries, but not the carotids, loudest at both RUSB
and LLSB, No R/G. Normal S2. Normal S1, S2 at LUSB.
Respiratory: CTA throughout, good air entry, no wheeze.
Gastrointestinal: Benign. NT, ND, BS+.
Extremities: Unremarkable. No edema.
Neurological: Alert, oriented to person, place, time, context.
No dysathria/aphasia. Cognition normal, superficially. CN II -
XII normal. Guarded movements of neck, left arm, clumsy left
hand but possible pain limitation (also per patient). Decreased
sensation at dorsum of left foot. Fundoscopy, reflexes, gait and
vibration sense deferred (but should be checked).
Psychiatric: Euthymic to concerned, normal thought form,
appropriate and cooperative.
Skin: Darkened, hypotrophic, shiny skin on anterior left lower
leg.
Pertinent Results:
[**2185-6-20**] 10:58AM %HbA1c-6.2* eAG-131*
[**2185-6-20**] 09:40AM GLUCOSE-153* UREA N-8 CREAT-0.9 SODIUM-138
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-27 ANION GAP-19
[**2185-6-20**] 09:40AM CK(CPK)-247
[**2185-6-20**] 09:40AM CK-MB-1 cTropnT-<0.01
[**2185-6-20**] 09:40AM TOT PROT-8.3 CALCIUM-10.4* PHOSPHATE-4.3
MAGNESIUM-1.2*
[**2185-6-20**] 09:40AM PEP-ABNORMAL B IgG-470* IgA-633* IgM-12*
IFE-MONOCLONAL
[**2185-6-20**] 09:40AM WBC-9.0 RBC-4.03* HGB-12.0* HCT-37.2* MCV-92
MCH-29.9 MCHC-32.4 RDW-15.1
[**2185-6-20**] 09:40AM SED RATE-52*
[**2185-6-20**] 04:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2185-6-20**] 04:10AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
[**2185-6-19**] 11:40PM ALT(SGPT)-90* AST(SGOT)-94* LD(LDH)-497*
CK(CPK)-314 ALK PHOS-48 TOT BILI-0.5
[**2185-6-19**] 11:40PM cTropnT-<0.01
[**2185-6-19**] 11:40PM CK-MB-2
[**2185-6-19**] 11:40PM TOT PROT-8.8* ALBUMIN-5.1 GLOBULIN-3.7
CALCIUM-10.2 PHOSPHATE-5.8* MAGNESIUM-1.3*
[**2185-6-19**] 11:40PM CRP-20.8*
Imaging:
TEE: The left atrium and right atrium are normal in cavity size.
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Normal left ventricular cavity size and
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. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation may be present. 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. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow identified
MRI Clavicle:
IMPRESSION:
Bone marrow edema and enhancement of the left medial clavicle
and manubrium concerning for left claviculomanubrial joint
infection and osteomyelitis with surrounding reactive edema. No
drainable fluid collections.
The left medial clavicle and manubrium are better imaged on this
dedicated
study and given differences in imaging technique, abnormalities
likely have not significantly changed or have possibly minimally
progressed since the MR [**First Name (Titles) **] [**2185-6-20**].
Brief Hospital Course:
Mr. [**Known lastname 84994**] presents with numerous medical problems, including
multiple myeloma, latent TB, h/o testicular and prostate cancer
p/w acute onset left neck pain with left arm weakness in setting
of cracking/stretching his neck, developing with strep bovis
bacteremia of unclear source.
Strep Bovis Bacteremia: Found on culture after patient was
spiking fevers while in-house. Subsequently grew Strep bovis.
Empirically started Vancomycin. Bacteremia cleared [**2185-6-23**].
Multiple imaging performed of patient's left neck/shoulder as he
complained of significant pain in the area. MRI of
claviculomanubrial region was consistent with osteomyelitis and
possible septic joint, however no fluid was available for
aspiration. Unfortunately the yield of bone biopsy in setting of
antibiotics is quite low and since the pre-test probability is
high for osteomyelitis in this patient, it was decided to treat
presumptively for osteomyelitis. ID was consulted and felt
ceftriaxone would be the most effective antibiotic for Strep
bovis. Unfortunately, the patient reported a significant
pencillin allergy of facial swelling and difficulty breathing.
He was transferred to the MICU for ceftriaxone desensitization.
This was performed without incident.
Colonoscopy was performed given link between Strep bovis and
colon cancer. Patient had five polyps found, and all biopsied.
Pathology was consistent with adenomas. Polypecetomy was
deferred as patient was on a heparin gtt. In discussion with
patient's PCP, [**Name10 (NameIs) **] was felt the patient no longer needed
anti-coagulation for a provoked PE occuring in [**1-30**]. Since
heparin could be safely stopped, the patient had another
colonoscopy which was terminated due to a poor prep. The
following day, another colonoscopy was attempted and bleeding
occured after the first polypectomy, so the colonoscopy was
terminated early. His hematocrit was trended and was stable,
requiring no blood transfusions. He was taken back for a 4th and
last colonoscopy the following day and all remaining polyps were
removed. The patient had no further complications. He will need
a repeat colonoscopy in one year. Polyp pathology was pending at
time of discharge. This was felt to be the likely source of
patient's bacteremia, as no other potential source was found.
Notably, endocarditis ruled out. TEE was performed and was
negative for vegetations. Patient will continue Ceftriaxone for
a total of six weeks with close ID follow up.
Upper Chest/Neck pain: In setting of patient cracking his neck
then developing acute onset left neck/back pain. Imaging on
presentation was consistent with significant muscle strain. It
was felt the sudden movement may have also caused minor trauma
to clavicularmanubrial region allowing strep bovis to seed the
joint and ultimately infect the clavicle, which exacerbated the
patient's pain in this area. He was initially pain controlled
with IV diluadid, ultram, diazepam, gabapentin, nortryptilline,
tylenol, and lidocaine patches. Prior to discharge he was
needing minimal po dilaudid. He was discharged on gabapentin,
nortryptilline, tylenol, lidocaine patches and po diluadid. He
experienced no pain prior to discharge.
Hypertension: Hypertensive peaks appeared to occur with pain and
resloved with pain control. He was continued on home amlodipine,
atenolol, and lisinopril. During ceftriazone desensitization, BB
and ACE-I were held, but re-started prior to discharge.
Recent PE: Reportedly developed [**1-29**] after a long flight. Was on
coumadin prior to admission. CTA during this admission was
without evidence of PE. Given patient's colonoscopy, coumadin
was held and heparin gtt was started during hospitalization.
Patient's hematocrit was notably decreasing from 37 to 27 during
hospitalization. This was felt to be due to patient's infectious
state, repeated blood draws, and slight ooze from patient's
polyps as he was notably guaiac positive with brown stools.
Heparin gtt was held and patient's hct stabilized in the upper
20s. Spoke with patient's primary care physician who stated
patient did not need systemic anti-coagulation given this was a
provoked PE and patient has been anticoagulated for nearly six
months. Warfarin was discontinued during this admission.
Diabetes: reasonable blood sugar control. Continued home lantus
and HISS for coverage
Multiple Myeloma: Actively being treated in the outpatient with
velcade and decadron. SPEP drawn consistent with IgA subtype.
Stable disease throughout hospitalization.
Latent TB: Uncertain significance at present. No active
Alcohol Abuse: per wife's report, patient drinks excessively on
a daily basis and she is quite concerned for his safety and
health. Social work consulted. Patient will schedule appointment
with [**Hospital1 **] Behavioral Health for further assistance.
Access: Right PICC
Code: Full Code
Medications on Admission:
Not all of these medications are current. Bactrim and antivirals
likely given in context of velcade/decadron and naltrexone given
past alcohol use. Monthly Zometa was also given as part of
chemotherapy. Fluticasone, potassium chloride slow, metformin
500 [**Hospital1 **] and magnesium oxide were also on his DC summary list
from [**Hospital1 112**].
- Lasix 40 mg PO QD
- Nortriptyline 10 mg, started last week, PO QHS to be
uptitrated to 30 mg QHS over three weeks.
- Insulin, SC, Lantus 8 units QPM, Humalog 4 units before
breakfast and supper
- Bactrim 160-800 mg PO BID on M, W, F
- Omeprazole 20 mg (ER) PO QAM
- Naltrexone, 50 mg PO QD:PRN
- Oxybutinin Cl (SR) 10 mg PO QAM
- Warfarin 5 mg PO QPM
- Famcyclovir 250 mg PO BID
- Amlodipine 10 mg PO QD
- Lisinopril 40 mg PO QD
- Atenolol 25 mg or 50 mg (unclear from [**Name (NI) 2287**] notes) PO QD
- Acyclovir 400 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
4. Insulin Lispro 100 unit/mL Solution Sig: Four (4) units
Subcutaneous [**Hospital1 **] (before breakfast and supper).
5. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): You should take this concurrently when taking pain
medication.
7. Nortriptyline 10 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime): take with food to reduce GI upset.
Disp:*90 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
11. Ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous
every twenty-four(24) hours for 5 weeks.
Disp:*58 grams* Refills:*0*
12. Outpatient Lab Work
Every Monday while on antibiotics ([**7-11**], [**7-18**], [**7-25**], [**8-1**]):
CBC/diff, BUN/Cr, ALT, AST, Alkaline Phosphatase, Total
Bilirubin
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
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. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not drive or do anything that
requires significant attention while taking this medication.
Hold for sedation.
Disp:*30 Tablet(s)* Refills:*0*
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Apply 12 hours on and 12 hours off.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary:
Strep bovis bacteremia
SC joint septic arthritis
Presumptive sternal and manubrial osteomyelitis
Neck Strain
Colonic Adenomas
Secondary:
Multiple Myeloma
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of neck pain and subsequently
developed fevers. You were found to have a bacterial infection
in your blood called Streptococcus bovis. This caused you to
have an infection in your breast bone (The sternum) as well as
the joint that connects your sternum to the left clavicle, which
exacerbated your neck/shoulder pain. We gave you antibiotics.
The antibiotic you were initially using was not the best drug
for this bacteria. Since the best drug is in the same family as
pencillin, of which you are allergic, you went to the ICU to
desensitize you to this drug. You tolerated this well. You will
need a full six week course of antibiotics.
***Be sure you do not miss a dose of ceftriaxone, your
antibiotic. If you do miss a day, when you take another dose,
you may have an allergic reaction. You should contact the
infectious disease doctors if [**Name5 (PTitle) **] have any concerns about this.
The number is below.****
We also were looking for a source of infection. You had a
colonoscopy because this bacteria can commonly be in your large
intestine. Five polyps were found and biopsies were taken. These
biopsies did not show cancer. With time, these polyps can
develop into cancer and so need to be removed. You had another
colonoscopy and your polyps were removed. You should follow up
with your primary doctor for the full results of this.
****You must look at your stools every time you have a bowel
movement for the next 3 weeks. If they appear black or red, you
should come to the emergency room. This may mean you are
bleeding from the polyps that were removed in your
colonoscopy*****
You will need a repeat colonoscopy in one year.
We monitored your blood levels closely as these were drifting
down. You may have been bleeding slightly from your polyps when
you were on the blood thinner. We stopped your blood thinner
because you do not need this anymore and your blood levels
remained stable. You will follow up closely with your primary
care doctor for further management.
You should continue all of your medications as prescribed with
the following important changes:
1. STOP Warfarin
2. STOP Lasix (You have not needed this medication)
3. INCREASE Nortriptyline to 30 mg every night. (You were taking
10 mg every night)
4. CONTINUE: Ceftriaxone 2 grams IV every 24 hours for a total
of 6 weeks. Last dose: Thursday, [**8-4**]
5. START: Gabapentin 400 mg three times per day (this is a pain
medication)
6. START Dilaudid 2-4 mg to be taken every four hours as needed
for pain
7. STOP Oxybutinin as you do not need this medication anymore
either
It is important that you keep all of your doctor's appointments.
Followup Instructions:
You have the following appointments scheduled:
1. Department: INFECTIOUS DISEASE
When: THURSDAY [**2185-7-14**] at 3:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
2. Department: INFECTIOUS DISEASE
When: TUESDAY [**2185-8-2**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
*****All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**]
MD in when clinic is closed
3. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 2261**].
Date/Time: [**2186-7-20**]:30 AM
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59,585
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38162
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Discharge summary
|
report
|
Admission Date: [**2157-7-29**] Discharge Date: [**2157-8-4**]
Date of Birth: [**2072-11-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Confusion per family
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 84m who was in his usual state until teh morning of
admission
7 a.m when the wife found him to be confused and disoriented in
his home. EMS was called and pt intially refused transfer but
became agreeable over time. Upon arrival to OSH a CT head was
obtained and showed R parietal hypodensity with associated
hemorrhage. There is no midline shift or hydrocephalus. The pt
currently has no complaints of headache, visual problems, speech
difficulty or weakness/sensory changes in extremities. Pt was
previously on coumadin for afib but has been off of this for
some
time, he only takes ASA 81 currently.
The pt was transfered to [**Hospital1 18**] for further evaluation and ICU
monitoring.
Past Medical History:
CAD, AICD placement, HTN, High cholesterol,
Thrombocytopenia, CRI, AFIB previously on coumadin
Social History:
Nonsmoker. Lives with his wife at home
Family History:
Noncontributory
Physical Exam:
BP: 124/63 HR:70 R 10 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs Full
Extrem: Warm and well-perfused. Sensation intact in all four ext
Neuro:
Mental status: Awake. Alert somewhat drowsy, cooperative with
exam.
Orientation: Oriented to person and year.
Language: Speech fluent with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light bilaterally.
Visual fields are full on the right. Dense left
visual field cut. III, IV, VI: Extraocular movements intact V,
VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-25**] on the right side. Left side is
slightly weaker throughout 4+/5. Left pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Pertinent Results:
[**Known lastname **],[**Known firstname **] H [**Medical Record Number 85122**] M 84 [**2072-11-6**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2157-7-31**]
4:51 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] SICU-A [**2157-7-31**] 4:51 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 85123**]
Reason: [**2157-7-31**] 6 AM CT scan
[**Hospital 93**] MEDICAL CONDITION:
84year old M who in his usual state of health until this
afternoon when he was
found to be confused in the basement of his home by his wife.
Was taken to OSH
and a CT scan revealed a R parietal IPH with evidence of
edema but no midline
shift or hydrocephalus. Pt had a L hemineglect and mild left
sidded weakness.
Of note he has a history of paroxysmal atrial fibrillation
and has been off
coumadin since last [**Month (only) **]. He takes ASA for CAD and has a
history of
thrombocytopenia with a plt count of 30 at the OSH. He was
transferred to [**Hospital1 18**]
for further management.
REASON FOR THIS EXAMINATION:
[**2157-7-31**] 6 AM CT scan
CONTRAINDICATIONS FOR IV CONTRAST:
elevated cr clearance
Provisional Findings Impression: AJy SUN [**2157-7-31**] 5:48 AM
PFI: Little interval change from [**2157-7-30**]. A large right
temporoparietal intraparenchymal hemorrhage with associated
peri-hemorrhagic
edema and local mass effect, including diffuse sulcal effacement
of the right
convexity and 3 mm leftward shift of midline structures, is
stable. Tiny
right subdural, scattered right and left parietal subarachnoid
blood, and
intraventricular blood in the occipital [**Doctor Last Name 534**] of left lateral
ventricle, are
also stable. There is no new hemorrhage, increased mass effect,
or acute
transcortical infarction identified.
Final Report
INDICATION: 84-year-old male with intraparenchymal hematoma.
COMPARISON: [**2157-7-30**].
NON-CONTRAST HEAD CT:
There is little short-interval change in the size or appearance
of large right
temporoparietal parenchymal hematoma, with associated
peri-hemorrhagic edema.
This results in significant local mass effect, with sulcal
effacement
throughout the right hemisphere, and 3 to 4 mm leftward shift of
midline
structures. There is no evidence for transtentorial herniation.
Scattered
foci of right subarachnoid hemorrhage, a tiny right subdural
hematoma, minimal
left parietal subarachnoid blood, and blood layering in the
occipital [**Doctor Last Name 534**] of
the left lateral ventricle are stable.
There is no new hemorrhage. The ventricles and sulci are
unchanged in size
and configuration. The basal cisterns remain patent. There is no
CT evidence
of acute vascular territorial infarction.
The bones demonstrate no fracture or suspicious lytic or
sclerotic lesion. The
visualized paranasal sinuses and mastoid air cells remain clear.
IMPRESSION:
Unchanged multifocal intracranial hemorrhage, including dominant
right
temporoparietal intraparenchymal hemorrhage and associated right
hemispheric
sulcal effacement and 3 mm leftward shift of midline structures.
There is no
new hemorrhage, increased mass effect, or acute territorial
infarction
identified.
As stated previously, the overall development and appearance of
imaging
findings is strongly suggestive of underlying amyloid angiopathy
in a patient
of this age.
The study and the report were reviewed by the staff radiologist.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 85124**]Portable
TTE (Complete) Done [**2157-8-1**] at 3:09:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] W.
[**Last Name (NamePattern1) 439**] #3B
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2072-11-6**]
Age (years): 84 M Hgt (in): 67
BP (mm Hg): 133/62 Wgt (lb): 170
HR (bpm): 69 BSA (m2): 1.89 m2
Indication: Atrial Fibrilation. Stroke.
ICD-9 Codes: 427.31, 435.9, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2157-8-1**] at 15:09 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2010W000-0:00 Machine: Vivid q-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.4 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: 3.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *17 < 15
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - E Wave deceleration time: 180 ms 140-250 ms
Findings
LEFT ATRIUM: Moderate LA enlargement. No LA mass/thrombus (best
excluded by TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Mild (1+) MR.
TRICUSPID VALVE: Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be quantifed. There is no pericardial
effusion.
IMPRESSION: Mild aortic regurgitation. Mild mitral
regurgitation. Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Increased
PCWP.
CLINICAL IMPLICATIONS:
Based on [**2154**] 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 [**Last Name (NamePattern4) **] [**2157-8-1**] 16:54
Brief Hospital Course:
Mr [**Known lastname 3321**] was admitted to the ICU for close neurological
observation. On admission he was awake, alert and orientated X2
prefered eyes closed but followed simple commands and was weaker
on the left side with left visual field deficits. On his first
hospital day he had a CTA with contrast no enhancing lesions it
was felt to be an infarct with hemorrhagic conversion. He was
pre-treated with NA bicarb and mucomyst due to baseline renal
insufficiency. Over the course of [**8-1**] his exam worsened and his
hemorrhage became much larger, after discussion the family the
patient was made DNR/DNI/CMO. He will be discharged to home with
hospice care with a life expectancy of less than 6 months
Medications on Admission:
ASA 81 daily, Coreg 25mg [**Hospital1 **],
Cozaar 25mg daily, Lipitor 20mg daily, Lasix 20mg every other
day, isosorbide 15mg daily
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
Q4hours prn severe pain or breathlessness.
Disp:*1 30ml* Refills:*0*
2. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) mg PO
q6hours as needed for anxiety or agitation.
Disp:*1 30ml* Refills:*0*
3. Atropine-Care 1 % Drops Sig: Two (2) drops Ophthalmic q4hours
PRN secretions.
Disp:*1 5ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
INTRACEREBRAL HEMORRHAGE
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
NONE
Followup Instructions:
NONE
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2157-8-4**]
|
[
"427.31",
"V66.7",
"348.5",
"585.9",
"788.30",
"403.90",
"431",
"272.0",
"787.6",
"414.01",
"287.5",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11218, 11267
|
9929, 10642
|
339, 345
|
11336, 11336
|
2393, 2836
|
11505, 11635
|
1266, 1283
|
10825, 11195
|
2877, 3488
|
11288, 11315
|
10668, 10802
|
11476, 11482
|
1298, 1467
|
9488, 9906
|
279, 301
|
3520, 4371
|
373, 1076
|
1694, 2374
|
4381, 9465
|
11351, 11452
|
1098, 1194
|
1210, 1250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,673
| 158,733
|
26385
|
Discharge summary
|
report
|
Admission Date: [**2131-10-27**] Discharge Date: [**2131-10-30**]
Date of Birth: [**2058-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Dizziness s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 yo Persian W with PMH of CAD s/p CABG, CHF (EF 40%), DM Type
II, HTN, COPD on home O2, schizophrenia who presents with
dizziness s/p fall. Also with HA and neck pain x 2 weeks.
Daughter is primary care taker. Notes that mom with increased
fatigue over last week. Still with good PO intake. No diarrhea.
Did not check temp at home but did not appear to be febrile.
While at home today, mom fell to her knees. No head trauma.
Otherwise mental status unchanged per daughter. At baseline,
able to carry out own ADLs without difficulty. Recently started
physical therapy for neck pain. Per PCP, [**Name10 (NameIs) **] to be DJD. Had
xr neck at OSH on Friday. Unaware of results
.
In the ED, VS: T 101.2 HR 85 BP 117/52 RR 20-30 98% venti mask.
BPs dipped into systolic 85 range briefly and improved without
intervention. LP was attempted 3 times without success. She
received 2g ceftriaxone for empiric meningitis coverage as well
as levaquin 750mg x 1, flagyl 500mg IV x 1. CT Head demonstrated
only air fluid levels in sinuses.
.
ROS: No fevers, chills, SOB, n/v/abdominal pain. + Cough with
green sputum.
Past Medical History:
1. CAD: s/p 4-vessel CABG [**2119**]
2. CHF: ECHO [**1-4**] w/ 1+ MR, minimal AS, EF 40% w/ regional wall
motion abnormalities; Last ECHO [**5-/2130**] EF 60-65% mild AS,
trivial MR [**First Name (Titles) 151**] [**Last Name (Titles) **] apical portion abnormality
3. DM Type 2
4. HTN
5. COPD: on home O2 3.5L/m, BIPAP (settings 14/10) 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 [**1-3**]
9. Hypothyroidism
Social History:
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. Her daughter is mostly with
her in the hospital and serves as translator. She is very
involved in her care.
Family History:
CAD: mother died of MI at unknown age
Physical Exam:
VS: T 99 HR 60 RR 24 91/40 92% venti mask
GEN: Elderly woman, obese in NAD
HEENT: EOMI, PERRL, anicteric
NECK: Supple, tender to palpation; no nuchal rigidity
CHEST: CTA anteriorly, no w/r/r
CV: RRR, S1S2, III/VI systolic murmur at LLSB
ABD: Soft/NT/ND, OBESE, +BS
EXT: NO c/c/e, warm, 2+ DP/PT
SKIN: no rashes
NEURO: CN ii-xii intact, moving all four extremities, toes
downgoing bilaterally, sensation intact; negative kernig and
brudzinski
Pertinent Results:
On Admission:
[**2131-10-27**] 09:15PM WBC-13.3*# RBC-3.80* HGB-11.2* HCT-34.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.8
[**2131-10-27**] 09:15PM NEUTS-85.1* LYMPHS-8.3* MONOS-4.1 EOS-2.2
BASOS-0.2
[**2131-10-27**] 09:15PM PLT COUNT-200
[**2131-10-27**] 09:15PM GLUCOSE-123* UREA N-31* CREAT-1.1 SODIUM-142
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-41* ANION GAP-10
[**2131-10-27**] 09:15PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2131-10-27**] 09:15PM DIGOXIN-<0.2*
[**2131-10-27**] 09:15PM CARBAMZPN-<1.0*
[**2131-10-27**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2131-10-27**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CXR:
1. Mild interstitial edema and small left pleural effusion.
2. Stable moderate-to-severe cardiomegaly
CT Head: Mild prominence of the lateral ventricles relative to
the sulci.
Brief Hospital Course:
This is a 72 yo woman with PMH of CAD s/p CABG, chronic
diastolic CHF, OSA on home BIPAP, DM Type II, HTN, COPD on home
O2 who presented with a fall, dizziness, neck stiffness, and
fever.
# Community Acquired Pneumonia/Sinusitus: On admission the pt
was febrile to 101.2 with WBC count of 13.3. Urine culture
negative, blood cultures negative at time of discharge. The
patient had a severe productive cough without any visible
infiltrates on CXR, but stable pleural effussion and
cardiomegaly. The pt received meningitis doses of ceftriaxone in
the ER as well as levoquin and flagyl for aspiration PNA. LP was
attempted in the ED, but was unsuccessful. Further LP attempts
were not taken as the patients neck pain is chronic in nature.
In the ICU, the patient had [**Month/Day/Year **] cough, but no hemodynamic
unstability, meningismus or altered mental status. Since
suspected meningitis was low, patient was only continued on
Ceftriaxone/Azithromicin (started [**10-28**]) for bronchitis. She
also was noted to have acute maxillary sinusitus on head CT.
Patient did not require steroids for COPD flair. Blood cultures
and urine cultures were negative. She will be transitioned to
Levofloxacin upon discharge to complete a 7 day course (she will
need 4 more days of antibiotics).
.
# Dizziness/fall: The patient's fall was described more as lower
extremity weakness with the patient slumping to the ground. Her
lasix was held on admission, and her dizziness improved with the
administration of 500cc NS bolus on admition to [**Hospital Unit Name 153**]. On
hospital day 3, the patient was not orthostatic when evaluated
by PT and her lasix was resumed.
.
#Neck pain: Likely musculoskeletal vs. DJD changes. Patient
being followed by PCP for this reason. Suspect pt may have nerve
impingement in the C2 region based on her pain. Normal strenth
and slighlty diminished reflexes in upper and lower extremities.
CT C spine done on [**10-26**] as outpatient (ordered by PCP) which
showed degenerative changes and limited study due to cervical
positioning in lateral film. Pt cannot have MRI of her C spine
due to her ICD. Ultram was stopped due to pt sleepiness, and pt
was started on oxycodone 2.5 mg every 6 hours as needed as well
as neurontin 100 mg three times a day. She was also started on a
lidoderm patch and standing motrin (which will need to be
discontinued if renal function is unstable). If she has
increased somnolence or hypercarbia, these may need to be
discontinued. If she continues to have pain, consideration in
the future can be given to a steroid injection at a pain clinic
(for the cervical spine).
.
# Urinary Retention: The patient was noted to have post void
residual of 500 cc after 12 hrs of her foley being removed. Her
foley was replaced. Her ultram was discontinued as this was felt
to be contributing. She will need to have voiding trials at
rehab. Again, the oxycodone she is being started on may also
cause difficulty with urinary retention.
.
# COPD/OSA: Pt was at her baseline CO2 on ABG. She was noted to
often remove her BIPAP intermittently at night, and was very
sleepy during the day. Settings: 14/10 with 2.5-3L NC at home.
Her home regimen was continued with tiotropium and albuterol.
The patient should follow up with a sleep clinic for further
evaluation of her BIPAP settings (given her somnolence)to make
sure they are optimized. Consideration in the future can be
given to a stimulant (ie ritalin) if her CHF tolerates and her
psychiatrist is agreeable.
.
#CAD: She was continued on her asa and statin. Her metoprolol
was restarted HD#2. Per her PCP, [**Name10 (NameIs) **] did not tolerate ACE in past
with hyperkalemia and cough.
.
# Chronic diastolic CHF: EF 50-60%. BNP 482. Mild edema on CXR.
Lasix was restarted on HD#3. She appears euvolemic at this time.
.
# DMII, controlled, no complications: The patients oral
hypoglycemics were held in house initially, but were restarted
when her fingersticks were up to the 300s. She was treated with
insulin sliding scale in house.
.
#HTN: Treated with her metoprolol.
.
# Hypothyroidism: Continued levothyroxine
.
# Schizophrenia: continued aripiprazole, depakote, and risperdal
.
CODE: Per daughter DNR/[**Name2 (NI) 835**], but has ICD in place and on.
.
CONTACT: Daughter [**Name2 (NI) 65262**] [**Name2 (NI) 65263**] [**Telephone/Fax (1) 65258**]
Medications on Admission:
lasix 80 mg qd
digoxin 0.125mg PO daily
levothyroxine 125 ucg daily
Toprol 25mg PO daily
singulair 10 qd
klor-con 10 mg qhs
glyburide 5 mg [**Hospital1 **]
asa 81 mg qd
medroxyprogesterone 10 mg qd
lipitor 10 mg qhs
zoloft 75 mg qd
abilify 40 mg qam
risperdal 2 mg qhs
depakote er 500 mg qam
prenatal iron tablet 90 mg qd
phoslo 1334 TID
duoneb [**Hospital1 **]
advair 1 puff qd
spiriva 18 mcg qd
flonase nasal spray 50 mcg [**Hospital1 **]
ntg prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet 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 HS (at
bedtime).
7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
19. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
22. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
23. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
24. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
25. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Community Acquired Pneumonia
Discharge Condition:
Stable, wearing O2 at 4LPM withO2 sat 92%, able to ambulate
short distances, uses bedside commode, feeds self, non-english
speaking. Wears BIPAP at night. Mask Ventilation: Nasal CPAP
w/PSV (BIPAP) Inspiratory pressure: 14 cm/h2o Expiratory
pressure: 10 cm/h2o Supp O2: 2 L/min to maintain SpO2 to >88 and
<93
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please wear the soft collar
Followup Instructions:
Please see Dr. [**Last Name (STitle) 4922**] on Tuesday, [**2131-11-6**] at 1 pm
[**Apartment Address(1) 65264**]
[**Location (un) **], [**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 2205**]
If unable to keep this appt. please call and reschedule.
Provider: [**Name10 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2131-11-5**] 2:00
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2131-11-19**] 2:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2131-11-19**] 3:00
|
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"276.51",
"305.1",
"458.0",
"V45.02",
"285.9",
"723.1",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11023, 11094
|
3968, 8320
|
337, 343
|
11167, 11480
|
3021, 3021
|
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|
2505, 2544
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|
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|
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|
279, 299
|
371, 1480
|
3878, 3945
|
3035, 3869
|
1502, 2079
|
2095, 2489
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,587
| 127,814
|
10075
|
Discharge summary
|
report
|
Admission Date: [**2161-8-30**] Discharge Date: [**2161-9-14**]
Date of Birth: [**2091-12-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
69M with severe bil. LE pain.
Major Surgical or Invasive Procedure:
Arthrocentesis
Injection of joints
History of Present Illness:
Mr. [**Known lastname 33665**] is a 69 year old male with CAD, DM2 who is S/p CABG
on [**2161-8-19**]. He Returned to the emergency room with RLE pain, LLE
pain at SVG hearvest site. He was discharged to rehab 2 days
prior and was progressing well until developed diffuse, constant
RLE pain from knee to toes. He also developed erythema and pain
around the vein harvest site on the LLE, just superior to
posterior knee that he described as burning, starting at 3 the
previous morning. He is also having fevers and chills with a
tmax of 101.8 here. He was taking colchicine and allopurinol
prior to surgery and has not taken any since surgery. Had RLE in
ED yesterady which was negative for DVT.
Past Medical History:
S/p CABG x 3 [**2161-8-19**]
CAD: 3 stents, 5 balloon angioplasties
[**Hospital1 **]-V pacer placed [**2158**] secondary to pauses
DM type 2
HTN since 17y/o
Polycystic kidney disease
Gout
Social History:
Pt is Egyptian, works as a consultant, and lives in [**Location 33663**], CT
with his wife. [**Name (NI) **] has 4 children, 2 live in NY, 1 in Baharain,
and 1 in [**Hospital1 6930**]. No tobacco, no recreational drug use.
Occassional EtOH.
Family History:
Mother died at age 61 from CAD, father died at age 63 from CAD
Physical Exam:
Vitals: 102F 104ST 161/60 16 93% on RA
General: NAD, uncomfortable
HEENT: NCAT, PERRL, EOMI
CV: RRR
Abd: Obese, NT/ND, NABS
Lungs: CTAB, no W/R/R
Integ: Sternal incision c/d/i with staples
Extrem: RLE warm, swelling diffusely around knee and tender
thoughout. Pulses and sensation intact. LLE with erythema at
harvest site demaracted with mild warmth, no drainage, tender
however less than RLE. Pulses and sensation intact, 1+edema
Pertinent Results:
[**2161-9-11**] 07:16AM BLOOD WBC-8.0 RBC-3.74* Hgb-10.7* Hct-33.3*
MCV-89 MCH-28.5 MCHC-32.1 RDW-15.5 Plt Ct-648*
[**2161-9-14**] 01:16AM BLOOD PT-19.0* INR(PT)-2.4
[**2161-9-11**] 07:16AM BLOOD Glucose-100 UreaN-27* Creat-1.3* Na-140
K-4.1 Cl-98 HCO3-29 AnGap-17
Brief Hospital Course:
Admitted on [**2161-8-31**]. He was seen in consultation by rheumatology
who tapped right knee and recommended a prednisone taper after
infection was ruled out, colchicine. Arthrocentesis revealed
gout crystals and he was diagnosed with polyarticular gout.
He was also seem in consultation by general surgery, and
orthopedics to rule out other sources. He received a TEE which
was negative for vegetation. He went into atrial
fibrillation/flutter for which he was anticoagulated with
coumadin.He continued to progress slowly.
He continued to have pain in the bil. ankles and knees and then
the L shoulder. He was started on high dose steroids and
responded well. He was still unable to ambulate and had his R
knee injected with steroids with good results. He progressed
with PT and was d/c'd to rehab. During his stay he also received
a course of Vanco. Rheeumatology followed him closely and are
sending him on a 10 day course of Prednisone, to be decreased to
5 mg./day for 5 days. He will be seen in rheumatology clinic at
the end of this course and they will give further
reccomendations. He should be started back on Allopurinol 100
mg./ day when he is symptom free for 3 days.
Medications on Admission:
Cochicine, K, [**Last Name (LF) **], [**First Name3 (LF) **], prilosec, lipitor, folate,
finasteride, flomax, glimepiride, flagyl, lasix, levofloxacin,
Toprol XL 100.
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Glimepiride 1 mg Tablet Sig: Four (4) Tablet PO daily ().
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
13. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for
10 days: Give this dose from [**Date range (1) 33666**].
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: Start this dose on [**9-25**].
15. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
goal 2-2.5.
16. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed.
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Polyarticular gout
Discharge Condition:
Good.
Discharge Instructions:
Call with redness, drainage from incision, temperature greater
than 101, or weight gain more than 2 pounds in one day or five
in one week.
No heavy lifting or driving until follow up with surgeon.
Shower, wash sternal incision with mild soap and water and pat
dry.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks from original surgery.
Dr. [**Last Name (STitle) **] after discharge.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14865**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2161-9-30**] 9:00
Completed by:[**2161-9-14**]
|
[
"427.31",
"998.59",
"274.9",
"726.33",
"E878.2",
"250.00",
"401.9",
"V45.02",
"V45.81",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5458, 5531
|
2421, 3611
|
352, 389
|
5594, 5602
|
2132, 2398
|
5915, 6245
|
1600, 1664
|
3828, 5435
|
5552, 5573
|
3637, 3805
|
5626, 5892
|
1679, 2113
|
283, 314
|
417, 1113
|
1135, 1325
|
1341, 1584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,113
| 194,654
|
4726
|
Discharge summary
|
report
|
Admission Date: [**2144-12-20**] Discharge Date: [**2145-1-1**]
Service: MEDICINE
Allergies:
Augmentin / Penicillins / Moxifloxacin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
lethargy, hypotension, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 yo M PMH DM, CAD presenting with 2d of lethargy general
weakness, cough with yellow sputum, SOB and subjective fevers.
EMS was called twice in the last two days for the same
complaints, yesterday BP found to be in 70s, however the first
time he refused transport. Today he has persistent symptoms
particularly of lethargy and he was finally convinced to come to
the ED. His family also noted two episodes of urinary
incontinence.
.
In the ED, initial vs were: T96.9 [**Last Name (un) **] 60 BP: 98/50 RR18 O2Sat:
94% 2L NC. On admission he was initially hypoglycemic and
received D50. CXR with possible LLL infiltrate and mild to
moderate central congestion. BNP 937. Nl WBC ct. He received CTX
and Azithromycin for empiric CAP tx. He also received kayaxalate
30mg PO ONCE for hyperkalemia, ASA 325mg PO ONCE, 1.5L of NS.
After the IVF, his sats worsened quickly from normal to high 80s
on 4L. He was subsequently intubated for his worsening hypoxia
and also to improve his ability to get a CT head. Cardiology was
notified who recommended consideration of a heparin gtt.
Neurosurgery recommended repeating the CT head to fully evaluate
for SAH, which upon repeat was negative. His pressures were
reportedly in the 180s/100s upon transfer and therefore was
given 1gm of nitro paste prior to arrival.
Past Medical History:
# CHF -- echo on [**2144-6-5**] with LVEF 50%
# CAD -- Cardiac Cath on [**2137-3-26**]
-- Three vessel coronary artery disease
-- Successful stenting (Express2 DES) of the proximal and
mid-LAD
# Peripheral [**Date Range 1106**] disease
-- s/p multiple LLE revascularization procedures
# Paroxysmal atrial fibrillation
# Diabetes Mellitus Type 2
# Hypertension
# Hyperlipidemia
# Pulmonary fibrosis
# Endocarditis
# SVT
# BPH
# Osteoarthritis
# Chronic Back Pain
# Allergic rhinitis
# Anemia
# Septic arthritis
# Urosepsis
# Colon polyps
# Rectal carcinoma -- T3, distal within 2 cm of the dentate line
-- Diagnosed by colonoscopy on [**11/2141**]
-- Abdominal perineal resection on [**2142-2-9**]
-- Multiple subsequent surgeries
# Bilateral Inguinal Hernias
-- Laparoscopic repair with mesh on [**2141-12-21**]
# Left Spigelian Hernia
# Left CIA aneurysm
.
Social History:
Widower. He lives in a 3 family home with his daughter below and
son above. His grandson lives with him in the same apartment.
His family helps him manage his medications.
Tobacco: Smoked in his teens, but quit at least 43 years ago.
Alcohol: None
Drugs: None
Family History:
Mother and brother with diabetes.
Multiple other family members with cancer history.
Father died from cancer when patient was young, unsure of type.
Sister died from cancer, unsure of type, either melanoma or
gynecological cancer.
Physical Exam:
Physical Exam on Admission:
General: Intubated sedated, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Rhonchorus to auscultation bilaterally, no wheezes,
rales,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
VS: 98.8, HR-56, BP-112/50, RR-22, SPO2-97% on 2.5LNC
General: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar rales L>R
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
Pertinent Results:
ADMISSION LABS:
[**2144-12-20**] 02:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2144-12-20**] 02:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2144-12-20**] 02:05PM WBC-6.4 RBC-3.66* HGB-10.1* HCT-32.2* MCV-88
MCH-27.5 MCHC-31.2 RDW-16.1*
[**2144-12-20**] 02:05PM cTropnT-0.33*
[**2144-12-20**] 02:05PM LIPASE-28
[**2144-12-20**] 02:05PM GLUCOSE-38* UREA N-71* CREAT-2.4* SODIUM-138
POTASSIUM-5.5* CHLORIDE-100 TOTAL CO2-25 ANION GAP-19
MICRO:
[**12-20**] Blood cultures- No growth
[**2144-12-20**] 8:00 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2144-12-20**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2144-12-22**]):
SPARSE GROWTH Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
[**12-23**] Blood cultures- No growth
[**2144-12-23**] 1:58 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2144-12-23**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2144-12-26**]):
RARE GROWTH Commensal Respiratory Flora.
[**2143-12-30**] Urine culture- No growth.
STUDIES:
[**12-20**] CXR: A left-sided Port-A-Cath terminates within the right
atrium. The left cardiac border and the hemidiaphragms are
obscured by moderate-sized pleural effusions with adjacent
compressive atelectasis. Air bronchograms at the left
retrocardiac region may represent an underlying consolidation.
Hazy central opacities, with Kerley B lines demonstrated in the
periphery, are compatible with central [**Month/Year (2) 1106**] congestion with
mild-to-moderate interstitial edema, worse on the right.
IMPRESSION:
1. Moderate-sized bilateral pleural effusions with adjacent
compressive
atelectasis. A dense left lower lobe opacity is concerning for
pneumonia.
Repeat radiography after diuresis may be of benefit to discern a
discrete
infiltrate.
2. Mild-to-moderate central [**Month/Year (2) 1106**] congestion with
interstitial edema,
worse on the right.
[**12-21**]: Echo IMPRESSION: Suboptimal image quality. Pulmlonary
artery systolic hypertension. Normal left ventricular cavity
sizes with preserved global systolic function.Mild right
ventricular cavity enlargement with low normal free wall motion.
Minimal aortic valve stenosis.
Compared with the prior study (images reviewed) of [**2144-6-5**],
moderate pulmonary artery systolic hypertension is now seen with
mild right ventricular cavity dilation and free wall
hypokinesis. Regional left ventricular systolic dysfunction is
no longer appreciated (may be due to technical factors)
[**12-20**] CT Head: Limited study due to motion despite multiple
acquisitions. No definite gross intracranial hemorrhage or mass
effect. The ventricles are midline and normal in size. Small
hemorrhage, particularly subarachnoid, cannot be entirely
excluded due to motion.
[**12-20**] CXR: Moderate-sized bilateral pleural effusions with
adjacent compressive atelectasis. Area of consolidation within
the left lower lobe is concerning for pneumonia.
Mild-to-moderate central [**Month/Year (2) 1106**] congestion with interstitial
edema.
[**12-29**] AP PELVIS AND TWO VIEWS OF THE RIGHT FEMUR.
The patient is status post right THR, with non-cemented femoral
stem. No
periprosthetic lucency to suggest loosening and no focal
osteolysis is
detected. The femoral component is symmetrically seated within
the acetabular component. There is considerable surrounding
heterotopic ossification. Some notching at the junction between
the acetabulum and inferior pubic ramus is noted similar to the
appearance on the [**2142-3-7**] CT and may be postoperative. Probable
diffuse osteopenia. Scattered [**Month/Day/Year 1106**] calcification present. A
left common iliac stent and multiple clips about the pelvis
noted.
DISCHARGE LABS:
[**2145-1-1**] 05:48AM BLOOD WBC-10.3 RBC-3.77* Hgb-10.2* Hct-32.2*
MCV-85 MCH-27.0 MCHC-31.6 RDW-15.9* Plt Ct-394
[**2145-1-1**] 05:48AM BLOOD Glucose-170* UreaN-32* Creat-1.1 Na-135
K-4.3 Cl-94* HCO3-35* AnGap-10
[**2145-1-1**] 05:48AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
Brief Hospital Course:
86 yo M with multiple medical problems including 3VD s/p
multiple PCIs, PVD, ischemic cardiomyopathy, AF, pulmonary
fibrosis and DMI presenting from home with 2 days of lethargy,
hypotension and subjective fevers initially thought to be most
consistent with severe pneumonia complicated by septic shock.
#) Septicemia:
The pt was hypotensive to SBP=90's while in the ER. He was
transferred to the MICU where he was felt to be septic from
acute bacterial PNA given cough, sputum, fevers and CXR. The
sputum gram stain revealed GNR diplocci, and GPC in pairs and
the pt was given Vancomycin, cefepime, and levofloxacin
initially to cover for hospital acquired pathogens including
MRSA and pseudomonas and was switched to
Vancomycin/Ceftriaxone/Levofloxacin and then to
Vancomycin/Ceftriaxone/Azithromycin on [**12-21**] to cover CAP. His
sputum cx grew out Moraxella and his antibiotics were narrowed
to ceftriaxone and azithromycin on [**12-23**]. The patients cortisol
was normal ruling out adrenal insufficiency and he had an echo
that showed LVEF>55%. He continued to be on Levophed on [**12-23**]
with pressures in the 90's/40's. The antibiotics were
discontinued [**12-24**] as pt was essentially afebrile and had no
leukocytosis and was likely colonized with Moraxella.
Presumably the patient has a low baseline BP and an inciting
event (MI, PE) occured prior to presentation that resulted in
hypotension and AMS. His hypotension resolved and he was
successfully weaned off of pressors on [**12-25**].
# Supraventricular Tachycardia:
Pt had baseline rates in the high 90's. Early the morning of
[**12-24**] the patient had sudden onset tachycardia with rates from
130-140's and a drop in blood pressure to systolics in the 50's.
EKG and rhythm analysis was consistent with AVNRT. The patient
had repeat multiple episodes of SVT during his ICU stay,
converting spontaneously until [**12-26**] when he required adenosine
6mg IV x 2. He was then started on diltiazem qid. He did not
have any further episodes while in the ICU. On transfer to the
medical floor he intermittently had short bursts of tachycardia,
most consistent with an SVT. On the floor he was transitioned
from diltiazem to metoprolol 25mg three times per day, which
helped his heart rate control.
#) Hypoxemia:
The patient was hypoxic in the ER to high 80s on 4L and was
intubated. Pts hypoxia was most likely secondary to V/Q mismatch
from PNA on top of baseline significant restrictive lung disease
from IPF. He had a CXR on [**12-23**] that looked like he may have
some pulmonary edema and a lasix gtt was started with attempt to
diurese and improve respiratory status. He was extubated on
[**2144-12-28**] and was satting well on nasal cannula. After further
discussion with his family we found that he had recently been
started on home oxygen and had been 2LNC at home. At the time
of his discharge he had been weaned to 2.5L nasal cannula.
#) Elevated troponin and CKMB:
The patient intitially had a troponin= 0.33 which was most
likely secondary to demand ischemia and not an NSTEMI given lack
of chest pain, stable enzymes and overall septic picture. His
medications of ASA, statin and plavix were continued.
#) Acute Renal Failure due to Acute Tubular Necrosis:
The patient presented with a creatinine= 2.4 which was likely
secondary to hypotension/shock leading to ischemic ATN as the
creatinine trended down to baseline of 1.0 with IVF hydration.
#) Metabolic Encephalopathy:
Patient with delirium earlier in hospitalization on floor, at
the time of discharge he was alert, attentive, and oriented but
his mental status would wax and wane. He was seen by geriatrics
in consult who recommended preserving his sleep/wake cycle, to
continue the trazodone as needed for sleep and if his delirium
causes him to become a danger to himself then can try 0.5mg of
po haldol, however this was not needed during his hospital stay.
Code Status: In the MICU after his intubation there was
discussion about his code status, it was determined during a
family meeting that he would like to be DNR, at that time it was
also decided that he would be okay with reintubation if needed.
Medications on Admission:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take if your systolic blood pressure is less than 105.
6. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: Two (2)
sprays Nasal twice a day: in each nostril.
7. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation twice a day as needed for
SOB.
9. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED).
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 constipation.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
SOB,wheeze.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
SOB,wheeze.
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for to the hip (right).
12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime)
as needed for insomnia.
16. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
17. sodium chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
18. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
19. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
20. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
Primary:
1. Hypoxemic Respiratory Failure
2. Pneumonia
Secondary:
Pulmonary Fibrosis
Coronary Artery Disease
History of an SVT
Hypertension
Hyperlipidemia
Paroxysmal Atrial Fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 19800**], it was a pleasure caring for you during your
hospital stay. You were initially admitted to the ICU with what
was thought to be a pneumonia and respiratory failure. You
required support with a breathing tube and ventilator for
awhile, also your blood pressure was low and you needed
medications to help keep your blood pressure up. After a few
days you improved and were able to have the breathing tube
removed. As you continued to improve you were able to be
transferred to the medical floor. After you worked with
physical therapy they felt that you were not safe to go home and
would benefit from a stay at rehab to help regain your strength.
.
Changes made to your medication regimen:
1. DECREASED metoprolol to 25mg three times per day
2. DECREASED simvastatin to 20mg daily
3. STOPPED glyburide 5mg daily
4. STARTED insulin sliding scale
5. STARTED trazodone 37.5mg as needed at bedtime for insomnia
6. INCREASED aspirin dose to 325mg daily
7. STARTED lidocaine patch to be worn on your right hip 12 hours
on and 12 hours off
-At the time of discharge please restart Flomax 0.4mg daily and
Finasteride 5mg daily
**Please continue all other medications as previously
prescribed**
Followup Instructions:
Department: ADULT SPECIALTIES
When: WEDNESDAY [**2145-2-24**] at 11:50 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: TUESDAY [**2145-3-23**] at 1:30 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name **] SURGERY
When: [**Hospital Ward Name **] [**2145-3-29**] at 1 PM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2145-1-2**]
|
[
"787.23",
"E944.4",
"V15.82",
"515",
"411.89",
"V15.88",
"276.7",
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"493.90",
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"414.01",
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"428.0",
"293.0",
"V49.72",
"427.89",
"V45.82",
"787.21",
"600.00",
"584.5",
"518.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15728, 15814
|
8384, 12550
|
275, 281
|
16044, 16044
|
3945, 3945
|
17468, 18405
|
2790, 3023
|
13795, 15705
|
15835, 16023
|
12576, 13772
|
16221, 17445
|
8088, 8361
|
3038, 3052
|
207, 237
|
309, 1614
|
6883, 8072
|
3961, 6874
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3066, 3533
|
16059, 16197
|
1636, 2496
|
2512, 2774
|
3558, 3926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,634
| 192,850
|
54666
|
Discharge summary
|
report
|
Admission Date: [**2143-7-16**] Discharge Date: [**2143-7-21**]
Date of Birth: [**2063-2-21**] Sex: F
Service: MEDICINE
Allergies:
Gatifloxacin / Quinolones
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
GI bleed.
Major Surgical or Invasive Procedure:
Noninvasive ventilation.
History of Present Illness:
80yo F with PMHx of COPD, Atrial fibrillation on coumadin,
ulcerative colitis, s/p colon resection who presented from OSH
after acute presentation of BRBPR.
The patient reports that she had been feeling well all day being
able to participate in her PT course during the day. Around [**2051**]
in the evening yesterday, the patient had to use the bathroom to
have a BM. The patient reports that at this time, she passed
BRBPR. The patient denies abdominal pain associated with the
episode or prior to or after the episode. She denies acute onset
of nausea or vomiting associated wtih the episode, reporting
that she does have nausea at times for other reasons. She denies
recent medication changes to her UC medications. She denies a
history of melena or hematochezia prior to this episode of
BRBPR.
She reports a recent hospitalization but she is unable to
remember the details of this recent hospitalization. Discharge
summary included in the patient's paperwork showed that she was
hospitalized for COPD exacerbation on [**2143-7-2**].
She was transferred to the OSH for evaluation of BRBPR. The
patient was noted to have HCT of 23.7 at the OSH ED. The patient
underwent NG lavage and was negative. She was found to have INR
of 3.8 and was given Vitamin K and FFP. R femoral line placed in
the OSH ED.
In the ED at [**Hospital1 18**], the patient initially has SBP 68 which
increased to 92. She was initially on vassopressin, which was
then weaned in the ED. The patient receieved 2 units of pRBCs in
the ED, thus receiving a total of 7 units of pRBCs between [**Hospital1 18**]
ED and OSH ED.
On arrival to the MICU, the patient reports that her breathing
is improved since starting positive pressure ventilation.
Information obtained from OSH records:
--[**2136-6-29**] PFT's: FEV1 51%, FVC/FEV1 42%, total lung capacity
129, diffusion 81, minimum improvement with bronchodilators
--[**2139-5-29**] colonoscopy record: granularity of the mucosa,
appeared to have flat ?adenomatous polyps, anastomasosis at
35cm, could not pass anastamosis given poor prep
--[**2143-5-13**] echo: LVEF 60-65%, RV mild-moderate dilatation,
moderate to severe TR, RV systolic pressure 51mmHg
--[**2139**] bowel resection: resection of left transverese and
descending colon done for left transverse colon stricture, noted
to have a firm area of palpable thickening about 2cm in length,
Crohn's is diagnosis
--baseline creatinine 1.1-1.3
--coumadin is new since rehab (not home med), also on ASA 325 at
home for cardioprotective benefit per patient
Past Medical History:
-Atrial fibrillation, recently started on coumadin
-COPD on home O2
-Crohn's disease, presumed [**2-14**] stricture formation requiring
resection
-s/p hysterectomy
-s/p appendecomy
-s/p left transverse and descending colonic resection
-h/o SVTs
-history skin cancer
-HTN
Social History:
Prior history of smoking. Denies EtOH and illicit drug use.
Currently living at a rehab center in [**Location (un) 5503**].
Family History:
NC
Physical Exam:
Upon admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
At discharge:
Vitals: 97.3 BP 138/69 P 81 R20 O293 BIPap
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: expiratory wheezes bilaterally, no rhonchi present.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: no clubbing, cyanosis, edema
Neuro: alert and oriented x 3
Pertinent Results:
Labs:
[**2143-7-16**] 01:50AM BLOOD WBC-10.3 RBC-3.56* Hgb-11.2* Hct-33.1*
MCV-93 MCH-31.4 MCHC-33.8 RDW-16.0* Plt Ct-123*
[**2143-7-16**] 08:13AM BLOOD Hct-37.5
[**2143-7-16**] 02:13PM BLOOD Hct-36.7
[**2143-7-16**] 08:00PM BLOOD WBC-9.2 RBC-4.24 Hgb-13.0 Hct-38.1 MCV-90
MCH-30.7 MCHC-34.2 RDW-16.3* Plt Ct-116*
[**2143-7-17**] 09:54AM BLOOD WBC-10.0 RBC-4.14* Hgb-12.6 Hct-37.4
MCV-90 MCH-30.4 MCHC-33.6 RDW-15.9* Plt Ct-125*
[**2143-7-16**] 01:50AM BLOOD Neuts-91* Bands-1 Lymphs-5* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2143-7-16**] 01:50AM BLOOD PT-22.0* PTT-28.0 INR(PT)-2.1*
[**2143-7-16**] 08:00PM BLOOD PT-11.6 PTT-27.5 INR(PT)-1.1
[**2143-7-17**] 09:54AM BLOOD PT-10.5 PTT-26.5 INR(PT)-1.0
[**2143-7-16**] 01:50AM BLOOD Glucose-159* UreaN-38* Creat-1.5* Na-133
K-4.2 Cl-100 HCO3-26 AnGap-11
[**2143-7-16**] 08:00PM BLOOD Glucose-178* UreaN-32* Creat-1.3* Na-140
K-4.1 Cl-99 HCO3-31 AnGap-14
[**2143-7-17**] 09:54AM BLOOD Glucose-121* UreaN-25* Creat-1.1 Na-141
K-3.7 Cl-101 HCO3-32 AnGap-12
[**2143-7-16**] 01:50AM BLOOD Calcium-6.1* Phos-4.4 Mg-1.4*
[**2143-7-16**] 08:00PM BLOOD Calcium-8.3* Phos-3.7 Mg-1.4*
[**2143-7-17**] 09:54AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.4
[**2143-7-16**] 01:50AM BLOOD Digoxin-1.3
[**2143-7-16**] 02:18AM BLOOD Lactate-1.4
Micro:
[**2143-7-16**] blood cultures pending x2
Imaging:
[**2143-7-16**] CXR: 1. Hyperinflation and bronchiectasis related to COPD
2. Left basilar opacity is of uncertain etiology. Atelectasis,
pneumonia or scarring are possible.
DISCHARGE LABS:
[**2143-7-21**] 06:55AM BLOOD Glucose-122* UreaN-19 Creat-1.0 Na-135
K-4.5 Cl-93* HCO3-36* AnGap-11
[**2143-7-21**] 06:55AM BLOOD Calcium-10.2 Phos-4.1 Mg-1.9
[**2143-7-20**] 06:45AM BLOOD Digoxin-1.0
Brief Hospital Course:
80 yo female with history of steroid and oxygen dependent COPD,
Atrial fibrillation recently started on coumadin, and Crohn's
disease s/p colon resection who presented from OSH after acute
presentation of BRBPR.
# BRBPR: Patient with acute onset of BRBPR thought to be oozing
from angiodysplasia or diverticular bleed in the setting of full
strength aspirin and warfarin with supratherapeutic INR. She
initially required pressors, 7 units of pRBC, and 2 units of
FFP. She did not have any further BRBPR here at [**Hospital1 18**]. Her
hematocrit was trended and normalized at 37. Her warfarin and
aspirin were held and her INR normalized. Given her end stage
COPD, and the risk of procedure with further bleeding, her
warfarin was stopped and she was only resumed on an aspirin 81mg
daily.
# End Stage COPD: Patient presented with dyspnea worse than
baseline. She has a history of steroid and oxygen dependent COPD
and was recently discharged for a COPD exacerbation. Her
prednisone was increased to 60mg daily and she was continued on
nebs. She was continued on Bipap at night and intermittently
during the day per her home baseline. Prior to transfer to the
floor, she was on a 4L NC. The degree of her end stage COPD was
discussed with her and her family.
# Atrial fibrillation: CHADS2 of 3. Her warfarin was
discontinued given the risk of further bleeding and the need for
procedure likely requiring intubation that may not be
reversible. The risk of embolic event off of warfarin was
discussed with the patient and family. She was continued on
digoxin for rate control during her stay. Her digoxin was
decreased to decrease risk of toxicity. Her verapamil was
increased to 180mg SR daily given history of SVT/ a-fib with
RVR. Cont. on verapamil, digoxin, as noted in discharge
medications. NO coumadin. Please re-evaluate need for
increased verapamil as an outpatient.
#Palliative care: following is note from [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**], palliative
care consultant on [**7-19**]:
"She remembers conversation from [**7-17**] and agrees she is happy
with
her current life but understands she is going to die soon and is
not unhappy about this fact.
She would like an opportunity to hear about hospice care in
rehab
and option for do not re-hospitalize. She understands that
returning to hospital for resp distress will not be helpful as
she has made decision for DNI. Medications such as ativan and
morphine can be administered in rehab and she can be
comfortable.
T/C to both [**Doctor First Name **] and [**Male First Name (un) **] ( grand daughter and daughter)
both agree that pt's wishes about end of life care are
consistent
with their understanding of her wishes. They agree that options
for staying in rehab should be explored as they know pt prefers
to be close to them and they wish to be close to her.
They wish to be supportive and I have counseled them to speak to
staff at rehab re options for end of life care to be managed at
rehab WHEN she fails rehab.
Pt has had Ativan with good success.
Will try morphine 5 mg po X1 to see how she tolerates this and
she will go with orders for morphine and ativan if she needs
aggressive symptom management.
Discussed with attending, resident, RN, case mgr, pt and family.
Total time 45 minutes >50% care coordination and counseling"
--> follow up conversation with Medical Housestaff. Patient
stated her desire to not be re-hospitalized should she
deteriorate at rehab. She would like to continue her current
treatments for now, but should something occur (i.e chest pain,
tachycardia, dyspnea, GI bleed) that would normally prompt
hospitalization she would not want that to occur and would
rather have the focus be on comfort, even knowing that the
deterioration could cause her to pass away. This was
communicated with her daughter and granddaughter who confirmed
that was consistent with conversations they had with [**Known firstname **].
Inactive Issues:
# Crohn's disease: Patient on Asacol as an outpatient. Plan to
continue.
# HTN: HOLD torsemide, have PCP [**Name9 (PRE) 10748**] necessity of
diuretic use.
# GERD: continue with omeprazole
TRANSITIONAL ISSUES:
# Code Status: DNR/DNI confirmed; does not wish to be
re-hospitalized
#Please follow up blood cx x2
#please re-evaluate fluid status and use of torsemide.
#please re-evaluate use of theophylline, will discharge without
torsemide.
Medications on Admission:
--ASA 325ng daily
--Digoxin 0.125mg daily
--Docusate 100mg daily
--FLovent 220mcg 2 puffs daily
--Lisinopril 10mg daily
--Verapamil ER 120mg daily
--Gabapentin 300mg [**Hospital1 **]
--Theophylline 100mg q12hours
--Torsemide 20mg [**Hospital1 **]
--Asacol 800mg TID
--Ipratropium-alculterol 1 puff QID
--Prilosec 20mg daily
--Milk of magnesia 10mL PRN constipation
--Dlucolax 1 suppository PRN constipation
--senna 8.6mg PRN constipation
--AlaMag 200-225 20mL every 6 horus PRN GI distress
--Ondansetron 4mg q6hours PRN nausea
--APAP 650mg q4hours PRN pain/fever
--Zolpidem 10mg qHS PRN insomnia
--Ativan 0.25mg q4hours PRN anxiety
--Prednisone 20mg q48hours
--Prednisone 15mg q48hours
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 Tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
2. Digoxin 0.0625 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg 0.5 (One half) Tablet(s) by mouth every
other day Disp #*7 Tablet Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
4. Lisinopril 10 mg PO DAILY
5. Mesalamine DR 800 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. PredniSONE 20 mg PO EVERY OTHER DAY
8. PredniSONE 15 mg PO EVERY OTHER DAY
9. Verapamil SR 180 mg PO Q24H
hold if sbp<100 hr<60
Please start [**2143-7-20**]
RX *verapamil 180 mg 1 Tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
10. Zolpidem Tartrate 10 mg PO HS
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *Bactrim 400 mg-80 mg 1 Tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
12. Acetaminophen 650 mg PO Q4H:PRN pain/fever
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Docusate Sodium 100 mg PO BID
15. Gabapentin 300 mg PO BID
16. Ipratropium Bromide MDI 1 PUFF IH QID
17. Lorazepam 0.25 mg PO Q4H:PRN anxiety
18. Milk of Magnesia 15 mL PO Q6H:PRN constipation
19. Ondansetron 4 mg PO Q6H:PRN nausea
20. Senna 1 TAB PO BID:PRN constipation
21. Morphine Sulfate IR 5 mg PO Q3H:PRN air hunger
RX *morphine 10 mg/5 mL 2.5 ml by mouth q3h Disp #*150
Milliliter Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 511**] Health Care Center
Discharge Diagnosis:
Primary Diagnosis: GI bleeding
Secondary Diagnosis: COPD, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 6330**],
It was a pleasure to treat you at [**Hospital1 1170**] for your bleeding and your COPD. You had a bleed that
resulted from your blood thinning medication. We stopped all
the blood thinners and gave you medicine to allow the blood to
clot. We also increased your blood pressure medication and
decreased one of you heart medications.
Please follow up with your primary care doctor in 24-48 hours.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Address: [**Street Address(2) 111793**], [**Location (un) **],[**Numeric Identifier 90807**]
Phone: [**Telephone/Fax (1) 111794**]
when you reconnect with him. He has offered 2 pulmonologists in
the [**Location (un) 5503**] area if you need to be refferred prior to seeing
him: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and/or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] both at
[**Telephone/Fax (1) 62464**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2143-7-21**]
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,876
| 113,398
|
53737
|
Discharge summary
|
report
|
Admission Date: [**2172-1-31**] Discharge Date: [**2172-2-2**]
Date of Birth: [**2099-2-10**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obatined from NH notes, [**Name8 (MD) **] MD, and Patient. Patient is
poor historian.
The pt. is a 72 year-old male with PMH of SCC of the tongue s/p
XRT, and NSCLC of s/p RML and LUL resection, COPD on chronic O2
(2L NS), and current smoker, p/w 3 days of increased SOB with
productive cough from his NH (Bengamin Center [**Telephone/Fax (1) 110311**]). Has
been treated with nebs and levo for presumptive PNA over the
past 13 days. + Fevers at home, no shaking chills, no CP, N/V.
Is NPO [**2-20**] neck SCC but is able to swallow sercretion. No
odynophagia or dysphagia. Per NH records, patient was noted to
be 88% on usual 2l NC. On EMS arrival, 100% on NRB, tachypnic
26-28.
Per NH sheets, has refused pneumovax in the past.
He was admitted to the medical intensive care unit. In the MICU,
the patient was started on vanco/zosyn for presumed PNA. Was
maintained on oxygen mask with sating in the low 90's.
Past Medical History:
COPD on home O2 (2L)
Dementia
Squamous cell of the tongue s/p XRT
CHF with EF 20% 2/2 EtOH CM
PUD
NSCLC s/p RML,LUL resection; status post video
assisted left upper lobectomy in [**2159**] and laser ablation,
plus radiotherapy in '[**63**].
Peptic ulcer disease
Status post appendectomy.
History of alcohol (now sober per patient)
+++ tobacco use; 1-2ppd, currently [**Date range (1) 61126**] PPD
Social History:
Homeless, was transferred here from the [**Hospital **] Health Care
facility. He has a 40 pack/year history of smoking and continues
to smoke. He no longer uses alcohol. The patient was seen [**8-18**] status post a successful PEG placement with no
complications.
Family History:
Non-Contributory
Physical Exam:
Vitals: T:96 P:107 R:21 BP:116/76 SaO2:95
General: awake, nodding to questions
HEENT: PERRLA, EOMI without nystagmus, no scleral icterus noted,
mucous membranes very dry
Neck: no JVP or carotid bruits appreciated. XRT skin
hyperpigmentation. No tracheal deviation noted. no palpable
masses appreciated.
Pulmonary: Poor air movment throughout; prolonged exp phase with
end exp wheeze. + upper airway sounds
Cardiac: Tachy, regular, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. PEG site is c/d/i
Extremities: + clubbing; Atrophic limbs. DP and PT pulses b/l.
Pertinent Results:
EKG: ST 136, nl axis and intervals, PRWP, LAE, LVH by >35mm in
precordial leads. STD in V5/V6. c/w [**5-/2166**], PRWP is new and LVH is
more pronounced.
Radiologic Data: left shirt of mediastinum with tracheal
deviation. (unchanged from prior CXR), RUL and lLL new airspace
disease. Small left pleura effusions. on PTX.
Cultures:
[**2172-1-31**] Blood - pending
[**2172-1-31**] Urine - pending
Brief Hospital Course:
The patient was a 72 yo male with severe COPD, RML, LUL wedge
resection,and neck XRT presented with a 2 history of increased
SOB and cough. He had been on ceftriaxone from [**Date range (1) 90581**] and then
levofloxicin for 10 more days. The patient was at risk for
resistent organisms and also the risk of aspiration was great
and given neck XRT, impaired ciliary clearnance increases risk
of pseudomonas. On admission the patients ABG is remarkable for
PaCO2 of 90, but with a pH of 7.39; for chronic resp, acidosis,
expect his bicarb to be 39; thus he had a met alk as well.
Patient does not give any history of nausea/emesis(as one might
expect in Theoph toxicity). The patient had clearly documented
DNR/DNI status at the nursing home and his signed forms were
faxed over. The patient was initally admitted to the medical
intensive care unit. He was started on vanco and zosyn for
broad coverage and started on methylprednisolone q8 for
management of his COPD flare. It was unclear if there was a
superimposed PNA. The ICU team felt that BiPAP was not
indicated as it could serve only be a bridge to intubation and
intubation was against the patient's wishes. The patient was
maintained on NC and fasemask O2. He was transferred to the
medical floor there was no further intensive interventions. He
continued to be tachypnic and require increasing amounts of
oxygent to maintain O2>88%. He was given morphine for worsening
SOB. Multiple attempts were made to contact family members, but
none could be reached. The nursing home reported that the
patient had not had contact with any family member in over 1
year. The patient expired on [**2172-2-2**] at 4:55PM. Further
attempts were made to contact family members without success.
No autopsy was performed.
Medications on Admission:
TF Jevity Plus
Fluoxetine 20mg po qd
Protonix 40mg po qd
Prednisone 40mg po taper on [**1-19**] and completed this on the 11th;
now on baseline 10mg po qd
Trazodone 75mg po [**First Name9 (NamePattern2) 5910**]
[**Last Name (un) **]-24 300mg po BID
Lasix 40mg po BID
Clonazepam 1mg po bid
Percocet prn
combivent INH 3puffs qid prn
albuterol prn
colace/senna/fleets prn
Levo 500 from [**Date range (1) 35535**]
CTX on [**11-18**]
Allergies: LISINOPRIL WHICH CAUSES ANGIOEDEMA.
Discharge Medications:
Patient Expired on [**2172-2-2**] at 4:55 PM
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Lung cancer
Discharge Condition:
Expired [**2172-2-2**] at 4:55 PM
|
[
"V10.11",
"276.51",
"428.0",
"427.1",
"V46.2",
"491.21",
"518.84",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5419, 5428
|
3043, 4821
|
280, 286
|
5504, 5540
|
2621, 3020
|
1957, 1976
|
5350, 5396
|
5449, 5483
|
4847, 5327
|
1991, 2602
|
237, 242
|
314, 1238
|
1260, 1659
|
1675, 1941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,846
| 129,669
|
23205
|
Discharge summary
|
report
|
Admission Date: [**2175-10-23**] Discharge Date: [**2175-11-2**]
Date of Birth: [**2097-7-30**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 78 year old woman with
known multiple medical problems who was admitted to an
outside hospital after falling twice at home. At the outside
hospital she ruled in for a myocardial infarction. She
transferred to [**Hospital1 69**] for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction.
2. Hypertension.
3. History of abdominal aortic aneurysm 4 cm.
4. Peripheral vascular disease.
5. Status post right femoral popliteal bypass.
6. Chronic obstructive pulmonary disease. Patient is [**Age over 90 **]
pack year smoker.
7. Obesity.
8. Anxiety.
9. Left atrophic kidney.
10. Osteoarthritis.
11. Degenerative joint disease.
ALLERGIES: Patient states she is allergic to codeine which
causes nausea and vomiting.
PREOPERATIVE MEDICATIONS: Include Verapamil, Lipitor,
Lisinopril, aspirin, nitroglycerin, Protonix, Bactrim,
Ambien, Celebrex, cimetidine, Tylenol number 3 and Coumadin
which was for her peripheral vascular disease and her femoral
popliteal bypass.
SOCIAL HISTORY: She lives in an apartment by herself in
[**Hospital3 4634**].
HOSPITAL COURSE: On admission to the [**Hospital1 190**] the patient was seen and evaluated by
neurology. At the outside hospital the patient had a CT scan
which showed chronic lacunar ischemic changes in the basilar
region with no acute hemorrhage. It was felt that her
presentation was consistent with a peripheral vestibular
process and it was recommended that patient underwent MRI to
rule out any intracranial event that was not able to be seen
on CT scan and also obtaining a carotid ultrasound. Also
patient had been noted to have elevated creatinine on arrival
to the outside hospital. By the time she arrived at [**Hospital1 1444**] it was down to the 1.5 range.
It had risen to a high of 2.9 at the outside hospital. The
patient underwent an MRI/MRA and a carotid ultrasound. The
carotid ultrasound showed a right internal carotid artery
stenosis of 80 to 99 percent and left internal carotid artery
stenosis of 40 to 59 percent. The MRI/MRA revealed
microvascular disease. No evidence of discrete infarct. Old
cerebellar lesion. Patient was cleared for bypass surgery
and it was felt that it was no indication for carotid
vascularization. Patient was taken to the cardiac
catheterization laboratory on [**10-24**]. Cardiac
catheterization showed a 90 percent distal left main
stenosis, 80 percent proximal left anterior descending
coronary artery lesion, 80 percent origin of the left
circumflex lesion and 50 to 60 percent first obtuse marginal
lesion with a proximally occluded right coronary artery
lesion. The patient underwent echocardiogram which showed an
ejection fraction of 60 percent, mildly dilated left atrium,
left ventricular hypertrophy, normal right ventricular
chamber size and wall motion, mildly dilated aortic arch,
mildly thickened aortic valve leaflet and some mild diastolic
dysfunction.
As patient had been cleared for surgery the patient was taken
to the operating room by Dr. [**Last Name (STitle) **] on [**10-27**] and
underwent a coronary artery bypass graft times two, left
internal mammary artery to the left anterior descending
coronary artery and saphenous vein graft to first obtuse
marginal. The patient tolerated the procedure well. Total
cardiopulmonary bypass time 56 minutes. Crossclamp time 36
minutes. She was transferred to the Intensive Care Unit in
stable condition. Patient remained intubated until
postoperative day number one due to mild hypoxia. She was
weaned and extubated from mechanical ventilation on
postoperative day number one.
Patient continued to have mild hypoxia, was given diuresis
and aggressive pulmonary toilet with gradual improvement in
her oxygen status. On postoperative day number three patient
developed atrial fibrillation. She was started on
amiodarone. She was seen and evaluated by Physical Therapy
where it was determined she would benefit from a stay at
short term rehabilitation. On postoperative day number four
patient was transferred to the Intensive Care Unit to the
regular part of the hospital. When she arrived in the
regular part of the hospital she developed atrial
fibrillation. Patient was given Lopressor to slow her heart
rate. Patient was started on Coumadin for anticoagulation.
On postoperative day number six patient was found to have a
moderate amount of diarrhea. This was sent for C difficile
but concerning the patient had mildly elevated white blood
cell count postoperatively and continued to do so patient was
empirically started on Flagyl for presumed C difficile.
Patient was cleared for discharge to rehabilitation on
postoperative day number six.
CONDITION ON DISCHARGE: Temperature 98.6, pulse 84 in sinus
rhythm, blood pressure 146/70, respiratory rate 20, oxygen
saturation 94 percent on 4 liters nasal cannula. Laboratory
data: White blood cell count 15.9, hematocrit 32.1, platelet
count 252. Sodium 140, potassium 3.3, chloride 102, bicarb
28, BUN 33, creatinine 1.2, glucose 142. PT 14.8, INR 1.4,
PTT 31.7. Neurologically the patient is awake, alert,
oriented times three, nonfocal. The patient is legally
blind. Lungs are clear bilaterally with no rales or wheezes.
Cardiac regular rate and rhythm without rub or murmur.
Incision is clean, dry and intact. There is no drainage or
erythema. Abdomen is soft, nontender, nondistended. Patient
is tolerating regular diet. Patient vein harvest site is
clean and dry. She has a moderate amount of ecchymosis in
her left thigh. She has some serosanguineous drainage at her
left knee at a previous drain site. There is no erythema.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg P.O. B.I.D
2. Lasix 20 mg P.O. B.I.D
3. Potassium chloride 20 mEq P.O. B.I.D
4. Colace 100 mg P.O. B.I.D
5. Aspirin 81 mg P.O. q day.
6. Coumadin 1 mg P.O. on [**11-2**]. Patient is to have a PT/INR
checked daily and titrate Coumadin for a goal INR of 1.5
to 1.8.
7. Regular insulin sliding scale as directed.
8. Percocet 5/325 one to two tablets P.O. q 4 hours PRN
9. Protonix 40 mg P.O. q day.
10. Lipitor 10 mg P.O. q day.
11. Amiodarone 400 mg P.O. B.I.D times one week and then
400 mg P.O. q day times one month.
12. Norvasc 5 mg P.O. q day.
13. Flagyl 500 mg P.O. t.i.d. times seven days.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times two.
3. Status post non-ST elevation myocardial infarction.
4. Hypertension.
5. Abdominal aortic aneurysm.
6. Peripheral vascular disease.
7. Status post right femoral popliteal bypass.
8. Chronic obstructive pulmonary disease.
9. Obesity.
10. Anxiety.
11. Atrophic left kidney.
12. Osteoarthritis.
13. Degenerative joint disease.
14. Urinary incontinence.
15. Carotid artery stenosis.
Patient is to be discharged to rehabilitation in stable
condition. She should follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31187**] in one to two weeks. She should follow
up with Dr. [**Last Name (STitle) **] in three to four weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2175-11-1**] 17:20:41
T: [**2175-11-1**] 18:14:25
Job#: [**Job Number 59661**]
|
[
"E878.2",
"305.1",
"593.9",
"922.8",
"410.71",
"433.10",
"278.00",
"427.31",
"401.9",
"412",
"414.01",
"369.4",
"496",
"386.11",
"997.1",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"88.56",
"88.41",
"99.04",
"37.22",
"36.15",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5863, 6509
|
6530, 7554
|
1311, 4888
|
989, 1213
|
166, 436
|
458, 962
|
1230, 1293
|
4913, 5840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,655
| 179,738
|
12966
|
Discharge summary
|
report
|
Admission Date: [**2160-2-16**] Discharge Date: [**2160-2-26**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female with a history of hypertension, chronic obstructive
pulmonary disease, seizure disorder, who presented at the
[**Hospital3 537**] with hypoxia and respiratory distress.
The patient had recently been admitted to the [**Hospital6 14430**] from [**2-5**] to [**2-14**] with respiratory distress
requiring intubation. She was treated for chronic
obstructive pulmonary disease exacerbation with steroids,
antibiotics including Vancomycin and Cefepime for pneumonia,
and was extubated after two or three days. The patient was
also treated for hypertensive urgency requiring transient
Labetalol drip.
The patient was discharged back to the [**Hospital3 537**] on [**2-14**] on p.o. dose of Levaquin. At that time, her white blood
cell count was 19. She was having low-grade fevers on her
steroid taper, and she had a loculated right pleural effusion
for which the patient had refused thoracentesis.
On [**2160-2-16**], the patient was found by the family at the
[**Hospital3 537**] to have increased respiratory rate and looked
purplish in her extremities. Her oxygen saturation was found
to be 72% on 2 L which decreased to 63% on 4 L. The patient
was then transferred to the [**Hospital6 2018**].
The patient had a blood pressure of 176/44, pulse 110, and
oxygen saturation of 70% on nonrebreather and was intubated
for respiratory distress with subsequent hypotension after
induction.
The patient had a chest x-ray after intubation which showed
prominent right hilar area concerning for vascular
abnormality. A transesophageal echocardiogram was performed
in the Emergency Room which revealed no evidence of
dissection, normal right ventricular size and function, no
acute changes consistent with PE, and normal ejection
fraction greater than 55%.
The patient also had left ventricular hypertrophy with a
small left ventricle. Due to her hypotension, the patient
received approximately 6 L of intravenous fluid in the
Emergency Room. She was also given Ceftriaxone and Flagyl,
as well as Lasix.
In the Intensive Care Unit, the patient was initially
hypotensive to the 90s/50s and was given another liter of
normal saline with mild response. She had a right IJ and
right arterial line in place. Initial CVP was [**5-18**] after 1 L
normal saline.
The patient required subsequent fluid boluses and Levophed
for a ................ less than 60. She was pancultured and
continued on antibiotics.
The patient underwent bronchoscopy while intubated which
showed that the trachea and left side of the bronchi were
within normal limits. The right lower lobe bronchus mucosa
was slightly pale. Biopsies were taken from the superior
segment of the right lower lobe mucosa, as well as BAL
brushings were obtained. There was extrinsic narrowing of
the right lower lobe superior segment bronchus.
The patient also had a deep venous thrombosis detected by
lower extremity ultrasound and was started on a Heparin drip.
She continued to have difficult elevated blood pressures
requiring Hydralazine IV.
The patient was extubated on [**2160-2-19**], after one day of
observation postbronchoscopy.
The patient was then transferred to the ACOVE Medicine
Service on [**2160-2-20**].
PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease reported mild. 2. Hypertension with a recent
urgency at [**Hospital6 **]. 3. Gastroesophageal
reflux disease. 4. Depression. 5. Seizure disorder. 6.
Osteoporosis. 7. Vitamin D deficiency. 8. Chronic back
pain on MS Contin 120 mg p.o. b.i.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is widowed. She ambulated at
baseline. She came here from the [**Hospital3 537**].
MEDICATIONS ON ADMISSION: Levofloxacin, Lisinopril, Colace,
Combivent, Norvasc, Dilantin, Hydralazine, Metoprolol,
Clonidine, Prednisone, Percocet, Multivitamin, Tears,
Aspirin, Calcium Carbonate, Celexa, Neurontin, Clonazepam,
Alendronate, Protonix, MS Contin 120 mg p.o. b.i.d.
MEDICATIONS ON TRANSFER: At the time of transfer from the
Intensive Care Unit to the Medicine Service, the patient was
on Labetalol 30 mg IV q.6., Dilantin 125 mg IV q.12.,
Clonidine 2 patches once a week, Hydralazine 30 mg IV q.6
hours, Vancomycin 1000 mg, Ceftazidime 2 g, Morphine p.r.n.,
Albuterol/Atrovent inhalers, Ranitidine IV, Aspirin, sliding
scale Insulin.
PHYSICAL EXAMINATION: Vital signs: At the time of admission
to Intensive Care Unit temperature was 98.4??????, blood pressure
117/42, pulse 79, respirations 10, SIMV 500, 12, 5, 100%.
General: The patient was intubated, sedated and paralyzed.
HEENT: Pinpoint pupils. ET tube in place. Lungs: Coarse
breath sounds. No wheezes. Heart: Regular, rate and
rhythm. Abdomen: Soft, nontender, nondistended. Positive
bowel sounds. Extremities: No edema. Cyanotic upper
extremities. Chronic venostasis changes at shins anteriorly.
LABORATORY DATA: At the time of admission, white blood cell
count 35.3, hematocrit 41.5, MCV 86, RDW 14, differential
with neutrophils of 96%, bands 3%, atypicals 1%, platelet
count 395; PT 13.5, PTT 25.4, INR 1.2; urinalysis yellow,
cloudy, specific gravity of 1.025, large blood, negative
nitrite, 30 protein, no glucose or ketones, small leukocyte
esterase, greater than 50 red blood cells, greater than 50
white blood cells, few bacteria, few yeast, 21-50 squamous
epithelial cells; glucose 236; sodium 129, potassium 4.3,
chloride 97, bicarb 20, BUN 43, creatinine 2.1; CK 139, CKMB
6, troponin less than 0.3; albumin 3.5, calcium 6.9,
phosphorus 8.1, magnesium 2.4; Dilantin 2.1; initial arterial
blood gas while intubated with a pH of 7.27, pCO2 49, pO2 221
on 100% FI02; lactate 2.1, free calcium 1.04.
HOSPITAL COURSE: 1. Intensive Care Unit course: The
patient's Intensive Care Unit course as outline in above HPI.
To summarize, the patient had acute shortness of breath with
chest pain and anxiety at her rehabilitation facility after
being discharged from the [**Hospital6 **] on p.o.
Levofloxacin after having a loculated pleural effusion and
pneumonia requiring intubation. In the Emergency Department,
she was hypotensive and hypoxic requiring intubation. She
received a significant amount of volume resuscitation. She
was treated with intravenous antibiotics, initially
Ceftriaxone and Flagyl and then switched to Ceftazidime and
Vancomycin given her recent hospital stay.
The patient's chest x-ray showed question of wide mediastinum
but no evidence of PE or dissection by transesophageal
echocardiogram.
Other issues included hyponatremia, acute renal failure with
a creatinine of 2.1 which has since resolved. The patient
was initially treated with steroids for presumed adrenal
insufficiency; however, cortisol stimulation test was fine,
and steroids were discontinued.
The patient was also treated with Bicarbonate for metabolic
acidosis. The patient was treated with Heparin drip for deep
venous thrombosis. The patient had bronchoscopy with
brushings and biopsy on [**2-18**] and was extubated on [**2-19**]. The patient also had labile hypertension controlled with
intravenous antihypertensives. The patient had anemia which
was treated with 1 U of packed red blood cells.
2. Lung cancer: The patient had right lower lobe biopsy
which did not show any definite malignancy. The patient had
bronchial brushings which showed rare atypical cells and
reactive bronchial cells and acute inflammation. She also
had bronchial washings which were positive for malignant
cells consistent with non-small cell carcinoma with features
suggestive of squamous differentiation.
A family meeting with the patient's son, daughter-in-law and
medical team was had to discuss the new diagnosis of lung
cancer.
The patient was with a chest CT revealing a 6.2 x 5.4 cm low
attenuation lesion in the superior segment of the right lower
lobe of the lung. The patient had a large 3.5 cm low density
lesion within the liver with peripheral enhancement, likely
metastatic disease. The patient also has a well
circumscribed small right adrenal lesion and apparently
enhancing nodule with an area of ascites anterior to the
liver. These findings were all consistent with the diagnosis
of metastatic lung cancer.
The patient also had head CT which did not reveal any
evidence of metastatic lesions; however, study was suboptimal
to detect these lesions, as it was done for other purposes.
The overall plan of care was to continue treatment of the
patient's other medical conditions. The patient remained
full code. A discussion was had with Social Work, Case
Management, Palliative Care, Oncology, and Primary Medical
Team with the family given that the patient would be a poor
candidate for therapy.
Oncology saw the patient and deemed that survival in patients
with this diagnosis is eight months, and given co-medical
conditions in this patient, the prognosis is likely much
worse. Goal of treatment is palliative which includes
chemotherapy and radiation therapy, as well as supportive
care.
Her comorbidities would make it difficult for her to tolerate
chemotherapy or radiation. The decision regarding role of
palliative radiation therapy in this patient with a history
of chronic low back pain requiring high doses of MS Contin
for over 10-20 years, make it less likely that palliative
radiation therapy would be of any benefit. This was also
reviewed with the patient's son who agreed.
The patient will likely go back to her nursing home, and if
she has any further decompensations, the family will then
reassess at that time whether to bring her back to the
hospital for more aggressive care or to decide to change the
goal to comfort care.
The hospital course from a cancer view point was otherwise
stable.
3. Deep venous thrombosis: The patient was initially
maintained on Heparin drip. She was then started on Coumadin
and reached therapeutic INR. The goal INR will be between 2
and 3, and the patient is currently on a dose of Coumadin 2.5
mg p.o. q.d.
4. Question stroke: The patient had supratherapeutic PTT
and hematocrit drop, as well as questionable left-sided
weakness and had head CT on [**2-22**] which was negative for
evidence of acute bleed. The patient also had full return of
her neurological status without any focal neurological
deficits.
5. Hypertension: The patient had hypertension that was
difficult to control and required intravenous medications,
initially Hydralazine; however, the patient was gradually
changed over to a p.o. regimen and had good control of her
blood pressure between 130s and 160s systolic on a regimen of
Clonodine 2 patches q.week, Lisinopril 40 mg p.o. q.d.,
Labetalol 200 mg p.o. t.i.d., Norvasc 5 mg p.o. q.d.
6. FEN: The patient has a speech and swallow evaluation
which showed that she would be able to take purees and thin
liquids. She was able to tolerate a reasonable amount of
p.o. intake.
7. Anxiety: The patient is on Klonopin as an outpatient and
had not been restarted on this medication. This was
restarted on [**2160-2-25**]. The patient will also be
restarted on her Celexa.
CONDITION ON DISCHARGE: Stable, but the patient is
definitely below her baseline function and mental status.
The goal is that with supportive care and return to familiar
environment, the patient will have improvement in mental
status, as well as resumption of her Benzodiazepine which she
has been on for many years.
DISCHARGE DIAGNOSIS:
1. Pneumonia.
2. Deep venous thrombosis.
3. Hypertension.
4. Metastatic lung cancer.
FOLLOW-UP: The patient will need her INR followed with a
goal INR between 2 and 3. The patient is currently with an
INR greater than 3 on a dose of Coumadin 2.5 mg p.o. q.d.
The patient can follow-up with her primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] at the nursing home as needed.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Albuterol
metered dose inhalers 2 puffs q.6 hours, Ipotropium Bromide 2
puffs q.4 hours, Clonodine 0.2 mg patch q.week, Clonozapam
0.5 mg p.o. t.i.d. to be titrated to q.i.d., Dulcolax 10 mg
p.o. q.d. p.r.n., Lisinopril 40 mg p.o. q.d., Dilantin 300 mg
p.o. q.d., Labetalol 200 mg p.o. t.i.d., MS Contin 120 mg
p.o. b.i.d., Norvasc 5 mg p.o. q.d., Miconazole patch,
Coumadin 2.5 mg p.o. q.d., Colace 100 mg p.o. b.i.d., Senna 2
tab p.o. b.i.d., Celexa 20 mg p.o. q.d.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2160-2-25**] 15:02
T: [**2160-2-25**] 15:19
JOB#: [**Job Number 39769**]
|
[
"458.9",
"496",
"486",
"197.7",
"584.9",
"162.9",
"453.8",
"518.81",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"88.72",
"96.04",
"33.27",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
11982, 12727
|
11542, 11958
|
3838, 4093
|
5834, 11202
|
4486, 5816
|
113, 3338
|
4119, 4463
|
3361, 3696
|
3713, 3811
|
11227, 11521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,053
| 102,108
|
7715
|
Discharge summary
|
report
|
Admission Date: [**2164-1-24**] Discharge Date: [**2164-1-24**]
Date of Birth: [**2105-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
58M w/ hx Down's who was found to be in respiratory arrest at
home in setting of several days of diarrhea. He has been in his
USOH until the morning of admission when he awoke with N/V and
diarrhea. He was complaining of SOB and chest pain and then
rapidly arrested. He was intubated at the scene and received 7L
IVF. In the ED, he was noted to have a distended abd, to be
profoundly acidotic 6.82/85/151, lactate 12.8, and in PEA
arrest. He was given bicarb, 4 rounds of epi/atropine with
return of pulses and started on a dopamine gtt. He was then
transferred to ICU.
No further history was able to be obtained.
Past Medical History:
Down's Syndrome
Porcelain Gallbladder
Celiac Sprue
Social History:
not obtained
Family History:
not obtained
Physical Exam:
PE in ICU
BP 60/34 P 75 22 27 75% on AC 500X30 Peep 10 100% FiO2
GEN: Intubated, non-responsive
COR: irreg. irreg, distant heart sounds
PULM: [**Last Name (un) 28015**], decrease BS bilat
ABD: soft, distended, guaiac positive (per surgery)
EXT: 2+ edema, oozing from numerous stick sites
Pertinent Results:
[**2164-1-24**] 11:38AM BLOOD Glucose-189* Lactate-12.8* K-4.9
[**2164-1-24**] 12:01PM BLOOD Lactate-12.2*
[**2164-1-24**] 01:16PM BLOOD Lactate-11.9*
[**2164-1-24**] 02:25PM BLOOD Glucose-88 Lactate-12.8*
[**2164-1-24**] 11:38AM BLOOD Type-ART O2 Flow-90 pO2-151* pCO2-85*
pH-6.82* calTCO2-16* Base XS--23 -ASSIST/CON Intubat-INTUBATED
Comment-GREEN
[**2164-1-24**] 12:01PM BLOOD Type-ART pO2-209* pCO2-93* pH-7.00*
calTCO2-25 Base XS--10 -ASSIST/CON Intubat-INTUBATED
[**2164-1-24**] 01:16PM BLOOD Type-ART pO2-168* pCO2-48* pH-7.17*
calTCO2-18* Base XS--10
[**2164-1-24**] 02:25PM BLOOD Type-ART pO2-58* pCO2-62* pH-7.35
calTCO2-36* Base XS-5
[**2164-1-24**] 11:30AM BLOOD CK-MB-5 cTropnT-0.04*
[**2164-1-24**] 01:10PM BLOOD CK-MB-37* MB Indx-2.8 cTropnT-0.12*
[**2164-1-24**] 11:30AM BLOOD Amylase-114*
[**2164-1-24**] 01:10PM BLOOD ALT-623* AST-393* LD(LDH)-893*
CK(CPK)-1322* AlkPhos-46 Amylase-179* TotBili-0.3 DirBili-0.1
IndBili-0.2
[**2164-1-24**] 01:10PM BLOOD Glucose-110* UreaN-24* Creat-2.1* Na-151*
K-4.1 Cl-116* HCO3-17* AnGap-22*
[**2164-1-24**] 01:10PM BLOOD WBC-1.8*# RBC-3.22* Hgb-11.0* Hct-32.4*
MCV-101* MCH-34.1* MCHC-33.9 RDW-14.6 Plt Ct-182
[**2164-1-24**] 01:10PM BLOOD PT-20.4* PTT-150* INR(PT)-2.0*
[**2164-1-24**] 01:10PM BLOOD Fibrino-113* D-Dimer->[**Numeric Identifier 961**]*
Brief Hospital Course:
The hospital course for this 58 y/o M with sudden onset resp
failure and PEA arrest is as follows:
.
# Hemodynamic instability: Patient arrived on the floor
hemodynamically unstable with BP 60/40 while on dopamine gtt. He
was started on levophed and vasopressin gtt as well, but
remained hypotensive despite being on maximum pressors. His
heart rate was between 80-140's with frequent PVCs. Echo
revealed no tamponade, RV or LV dilatation. The decision was
made with the pts sister to continue medical care, but CPR was
felt to be not indicated.
.
# Resp Failure: Pt was intubated at the scene and was intially
oxygenating well; however, over the course of the hosp day, his
sats fell to the 70's despite being on AC 100% FiO2 and 10 PEEP.
He was found on CXR to have severe pulm edema felt to be [**1-13**]
aggressive fluid rescusitation.
.
# Septic Shock/Acidosis: Source remains unclear, but may be GI
in origin. Patient reeived 12 amps of Bicarb to help correct his
acidosis and was started on Vanc/Levo/Flagyl empirically. He was
also given stress dose steroids.
.
# Distended Abd: Pt was noted to have a distended abd on arrival
and there was concern for perforated bowel. Surgery was
consulted and felt that there was no acute GI process to warrant
surgical intervention. It was felt that the guaiac positive
stool could be a component of ischemic bowel compounded by DIC.
.
.
At 4:50PM on [**2164-1-24**], patient was pronounced dead of cardiac
arrest and resp failure. The discussion was made with family,
who felt that they would like an autopsy. The proper
arrangements were made.
Medications on Admission:
Zyprexa
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
n/a
|
[
"038.9",
"785.52",
"276.2",
"995.92",
"427.31",
"584.5",
"286.6",
"410.91",
"557.0",
"758.0",
"507.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4467, 4476
|
2787, 4380
|
325, 349
|
4527, 4536
|
1454, 2764
|
4589, 4595
|
1113, 1127
|
4438, 4444
|
4497, 4506
|
4406, 4415
|
4560, 4566
|
1142, 1435
|
275, 287
|
377, 993
|
1015, 1067
|
1083, 1097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
665
| 170,157
|
16151
|
Discharge summary
|
report
|
Admission Date: [**2119-4-11**] Discharge Date: [**2119-6-3**]
Date of Birth: [**2052-5-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2119-4-17**]: Exploratory laparotomy, lysis of adhesions, ascites,
drainage and open appendectomy.
[**3-28**], [**3-30**], [**5-5**], [**5-15**] [**2118**]: EGD (endoscopy of upper
gastrointestinal tract)
[**2119-5-1**]: EMG (to evaluate foot drop)
[**2119-5-15**]: Sigmoidoscopy
[**2119-5-17**]: Colonoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 66yo man with a history of CAD (s/p RCA DES
[**2113**]), CHF (EF 40%-->60%), HTN, and PUD complaining of several
months of abdominal pain. He describes the pain as generalized
(worst in lower quadrants), constant, severe, exacerbated by
eating, alleviated with burping, and notes associated
significant weight loss (unable to quantify). He denies fever,
chills, nausea, vomiting, diarrhea, melena, hematochezia, and
never had similar pain prior to several months ago.
.
He was admitted [**Date range (1) 46143**]/[**2118**] for this abdominal pain and
underwent a workup including abdominal CT, MRI, MRA, MRCP, EGD,
and EUS with FNA of a pancreatic lesion in the body. The
etiology of his abdominal pain was unclear; the differential at
this time included PUD, pancreatic malignancy, or mesenteric
ischemia. At a followup appointment with his PCP [**Last Name (NamePattern4) **] [**4-11**], he
developed severe [**10-8**] pain and was brought to the ED by
ambulance. Physical exam was concerning for LLQ tenderness
without rebound or guarding and labs were notable for WBC count
of 14.1. CT abdomen revealed mildly distended loops of bowel
without transition point so surgery was consulted concerning
possible SBO, which was refractory to conservative management.
On [**4-17**] he underwent exploratory laparotomy with LOA,
appendectomy, drainage of hemorrhagic ascites. Appendix
pathology is notable for chronic arteritis, and so rheumatology
was consulted and patient was transferred to the medicine
service.
.
On the floor at time of transfer to medicine, the patient
reports mild lower abdominal discomfort (+prior episodes) unlike
the pain that brought him to the hospital (which resolved after
surgery).
.
In the ED, initial VS: 10 97 88 172/97 18 100. He appeared very
uncomfortable, and was very tender to palpation at LLQ, but no
guarding or rebound. Guiac was positive per rectal. He
appeared dry. He received levo, flagyl, morphine, and zofran.
.
Currently, patient reports his pain is about [**3-8**]. He denies
nausea/vomiting. He has no chest pain or shortness of breath.
No fever, chills, no cough.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Hypertension
- Hyperlipidemia, last LDL 55 and HDL 52 ([**1-6**]).
- Coronary artery disease, status post right coronary artery
drug-eluting stent in [**2113**], complicated by VF.
- Left ventricular systolic dysfunction, EF 40%.
- Peripheral vascular disease status post bilateral lower
extremity revascularizations s/p PTA of b/l SFA in [**2113**],
atherectomy of peroneal artery and PTA on the R in [**2116**].
- Ectatic infrarenal aorta, 2.8 cm greatest diameter
- Renal insufficiency
- Peptic ulcer disease (noted on scoping in [**Country 6607**])
- Tobacco abuse, ongoing.
- Pancreatic lesion as above
- History of prostate cancer treated with CyberKnife radiation
therapy.
- History of gout
Social History:
Patient is divorced. Lives alone. Has 5 children but one of
the kids live in [**Location (un) 86**]. Daughter [**Name (NI) 2411**] lives in [**State 531**].
Quit smoking since the last admission a week ago. Denies EtOH
(last drink a year ago) or illicit drug use. Used to work as a
welder.
Family History:
No family history of GI malignancy or GI disease.
Physical Exam:
Vitals: T: 97.7 P: 73 BP: 187/95 R: 22 O2: 99%RA
I/O (24hr): 1310/1350
General: Awake, watching television, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 8cm, no LAD
Lungs: Good air entry throughout, bibasilar crackles, no
wheezes/rhonchi
CV: Regular rate and rhythm, S1, S2, +S4 at apex, 2/6 systolic
ejection murmur at base, no S3 or rub
Abdomen: well healing midline incision with surrounding
ecchymosis, no erythema or drainage, soft, appropriately tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly or masses
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: Alert and oriented x3. Strength 5/5 in upper extremities,
[**5-3**] hip flexion, knee extension bilaterally; 0/5 dorsiflexion,
[**1-3**] plantar flexion on right; [**5-3**] plantar and dorsi-flexion on
left; 2+ patellar reflexes, absent ankle reflexes; sensation to
light touch grossly intact in lower extremities, (sensory defect
to temp/pinprick on lateral aspect of right foot/leg per
neurology).
.
At Discharge:
AVSS/afebrile
GEN: Thin male in NAD.
HEENT: Sclerae anicteric. O-P clear. Poor dentition.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR; s1, S2, +s4, no m/r
ABD: Well healed midline incision. Nondistended, soft, mildly
tender to palpation in LUQ, RLQ.
EXTREM: WWP; no c/c, mild pedal edema
NEURO: A+Ox3. Motor - Normal tone except low in distal RLE.
Strength 5/5 bilat
in IP, quad. Hamstring [**4-3**] R, 5/5 L. Ant tib [**1-3**] R, 5/5 L.
Gastroc [**2-3**] R, 5/5 L. Foot inversion and eversion 0/5 R and 5/5
L. TE [**2-3**] R, 5/5 L. TF [**2-3**] R, 5/5 L. DTRs 2+ bilat knees and
absent bilat ankles. Sensory - Decreased sensation to cold and
pinprick on dorsal and plantar surfaces of R foot, lateral worse
than medial. Also decreased over lateral lower leg up to mid
lower leg. No proprioception of toes on right foot,
proprioception of right ankle intact. Decreased vibratory
sensation on toes of right foot, normal over medial malleolus.
Sensation on left foot normal throughout.
Pertinent Results:
ADMISSION LAB:
[**2119-4-11**] 12:15PM BLOOD WBC-14.1*# RBC-3.92* Hgb-10.9* Hct-33.4*
MCV-85 MCH-27.9 MCHC-32.7 RDW-15.7* Plt Ct-141*
[**2119-4-11**] 12:15PM BLOOD Neuts-90.9* Lymphs-5.1* Monos-3.2 Eos-0.3
Baso-0.6
[**2119-4-11**] 12:15PM BLOOD Plt Ct-141*
[**2119-4-11**] 12:15PM BLOOD PT-13.0 PTT-32.2 INR(PT)-1.1
[**2119-4-11**] 12:15PM BLOOD Glucose-109* UreaN-24* Creat-1.1 Na-137
K-4.3 Cl-95* HCO3-27 AnGap-19
[**2119-4-11**] 12:15PM BLOOD ALT-15 AST-19 AlkPhos-83 Amylase-56
TotBili-0.5
[**2119-4-11**] 12:15PM BLOOD Calcium-9.2 Phos-4.5# Mg-1.9
[**2119-4-11**] 01:22PM BLOOD Lactate-2.6*
[**2119-4-11**] 09:18PM BLOOD Lactate-0.7
-------------------
DISCHARGE LABS:
[**2119-6-3**] WBC 4.5, Hb 8.8, Hct 27.2, Plt 83
[**2119-6-3**] Na 137, K 4.8, Cl 107, HCO3 25, BUN 38, Cr 0.9, Glc 110
-------------------
STUDIES:
MRI/MRCP ([**2119-3-14**]):
1. 0.8 x 1.5 cm lesion in the distal body of the pancreas with
relative enhancement, might correspond to the pancreatic
neoplasm. Short term follow up in 3 months or EUS study is
recommended for further evaluation.
2. Small amount of ascites.
.
EGD ([**2119-3-28**]):
- Erythema, friability, granularity and congestion in the
pylorus (biopsy)
- A few scattered polypoid lesions were noted in the second part
of duodenum. (biopsy)
Otherwise normal EGD to third part of the duodenum
- bx:
A. Antrum "hilar":
Chronic inactive gastritis; focal intestinal metaplasia; [**Doctor Last Name 6311**]
stains for H. pylori will be sent as an addendum..
B. Duodenum, polyp:
Duodenal mucosa, no diagnostic abnormalities recognized;
multiple levels have been examined.
.
EUS ([**2119-3-30**]):
- Submucosal mass with overlying hemorrhagic mucosa was noted in
the second part of the duodenum - unclear clinical significance.
- EUS: A 1.5 cm poorly-localized abnormal area was noted in the
pancreas body - this showed features of focal chronic
pancreatitis, however, a neoplasm could not be ruled out - FNA
was performed.
Otherwise normal appearing pancreas.
- CYTOLOGY [**2119-3-30**]: pancreatic FNA: ATYPICAL.
Many isolated and small groups of columnar mucinous-type
benign-appearing epithelial cells; these may represent low-grade
PanIN (mucinous metaplasia) in association with chronic
pancreatitis or a mucinous cystic neoplasm.
Degenerated and reactive glandular cells.
Benign-appearing squamous cells consistent with esophageal
contamination.
.
MRA abd ([**2119-3-31**]):
1. Stable fusiform aneurysm of the abdominal aorta. Widely
patent SMA and celiac arteries. The inferior mesenteric artery
shows narrowing at its orgin, however remains patent.
2. Stable T1 hypointense lesion in the body of the pancreas
which remains indeterminate.
.
CT Abd/pelvis ([**2119-4-11**]):
- A few mildly distended loops of small bowel with no definite
transition point. A paralytic ileus is favored; however, partial
small-bowel obstruction cannot be entirely excluded.
- Cachexia.
- Severe atherosclerotic calcifications of the aorta and iliac
arteries and SMA and celiac arteries with stable fusiform
aneurysmal dilatation of the aorta and focal aneurysmal
dilatation of the iliac arteries as compared to CT from [**Month (only) 958**]
[**2118**].
.
MR enterography ([**2119-4-14**]):
1. Partial bowel obstruction likely explained by adhesions which
could be due to prior prostate radiotherapy.
2. Bilateral renal cysts.
3. Atherosclerosis with 3.5 cm infrarenal aortic aneurysm.
.
MR L SPINE W/O CONTRAST ([**2119-4-20**]):
1. Multilevel degenerative changes of the lumbar spine as
described above,
most pronounced at L4-5, without evidence of high-grade spinal
canal narrowing at any level. Additional multifactorial
multilevel neural foraminal narrowing as described above.
2. No evidence of metastatic disease to the lumbar spine on this
noncontrast MRI examination.
.
MR lumbar spine (with contrast [**2119-4-21**]):
Multilevel degenerative changes of the lumbar spine, most
pronounced at L4-5, without evidence of high-grade spinal canal
narrowing at any level. No evidence of metastatic disease to the
lumbar spine.
.
EGD ([**2119-4-29**]): Abnormal mucosa in the stomach and duodenum.
Polyp in the second part of the duodenum. Abnormal mucosa in
the duodenum (biopsy showed mildly active duodenitis). Duodenal
ulcer.
.
EMG ([**2119-4-30**]): Complex, abnormal study. There is
electrophysiologic evidence for a severe, subacute and ongoing
right sciatic neuropathy with axonal features. Peroneal-
innervated muscles are affected more than tibial-innervated
muscles, and no axonal continuity was observed to tibialis
anterior or extensor hallucis longus. The abnormal nerve
conduction studies in the left lower extremity may reflect a
concurrent, length-dependent polyneuropathy with axonal
features, or, less likely, a polyradiculopathy. Incidental note
is made of a moderate median neuropathy at the right wrist. The
myopathic units noted in short head of biceps femoris were not
seen in any other muscle, and are a finding of uncertain
clinical significance. The weakness noted in the right upper
extremity does not appear to be due to an acute neurogenic
process.
.
EGD ([**2119-5-5**]):
Impression:
-Abnormal mucosa in the stomach
- Abnormal mucosa in the duodenum
- Polyp in the second part of the duodenum
- Abnormal mucosa in the duodenum (biopsy)
- Duodenal ulcer
.
TTE ([**2119-5-8**]): Mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Pulmonary artery systolic hypertension. Compared with
the prior study (images reviewed) of [**2119-3-8**], the findings are
similar.
.
Persantine-MIBI ([**2119-5-9**]): No evidence of ischemia, continued
mild global hypokinesis and LV dilation.
.
ECG ([**2119-5-9**]): Normal sinus rhythm. ST-T wave abnormalities
that are most marked with T wave inversions in leads II, III,
aVF and V3-V6.
.
CTA Abd/pelvis ([**2119-5-14**]):
1. No evidence of bowel ischemia.
2. Stable infrarenal AAA and bilateral iliac aneurysms.
.
EGD ([**2119-5-15**]):
- Friability, granularity and nodularity in the whole stomach
compatible with gastritis
- The pyloric channel was edematous and friable.
- Friability and nodularity in the whole examined duodenum
compatible with duodenitis or ? vasculitis
- There was no active bleeding. There was no blood or
coffee-ground liquid.
- Erythema and congestion in the antrum compatible with
gastritis
- Otherwise normal EGD to third part of the duodenum
.
Sigmoidoscopy ([**2119-5-16**]):
- Angioectasias in the rectum
- There was dark red blood coating along the mucosa of colon,
which precluded us from examining the mucosa of colon. A large
amount of dark red blood was also seen beyond the splenic
flexure. However, we did not see bright red blood.
- Otherwise normal sigmoidoscopy to splenic flexure
.
Colonoscopy ([**2119-5-17**]):
- The terminal ileum was easily entered and appeared normal.
- Polyp in the descending colon
- Ulcers in the rectum (biopsy)
- Ulcers in the sigmoid colon, descending colon and distal
transverse colon (endoclip, biopsy)
- There was old blood throughout the colon.
- Otherwise normal colonoscopy to cecum and terminal ileum
.
GI Bleeding Study ([**2119-5-16**]):
report pending
.
LE Dopplers ([**2119-5-16**]):
1. No evidence of DVT in either lower extremities.
2. Left [**Hospital Ward Name 4675**] cyst.
.
CXR [**5-16**]:
1. Right lower lobe pneumonia.
2. Kinking of proximal aspect of right internal jugular approach
central
venous catheter, recommend clinical correlation for function.
.
[**5-17**] CXR:
1. Worsening right lower lobe pneumonia.
2. Kink at the proximal aspect of right internal jugular
approach central
venous catheter, recommend clinical correlation for function.
.
[**5-17**] portable abdomen:
1. Worsening right lower lobe pneumonia.
2. Kink at the proximal aspect of right internal jugular
approach central
venous catheter, recommend clinical correlation for function.
.
[**5-18**] CXR:
As compared to the previous radiograph, there is no relevant
change. The subtle right lower lobe opacity has not increased in
extent or
severity. Unchanged course and position of the monitoring and
support
devices.
.
[**5-19**] CXR:
Status post extubation with otherwise no significant change.
.
[**5-22**] CXR: As compared to the previous radiograph, the
pre-existing right
basal parenchymal opacity is unchanged in extent and appearance.
No newly
appeared focal parenchymal opacity. Unchanged size of the
cardiac silhouette.
Minimal tortuosity of the thoracic aorta.
.
Unchanged course and position of the left-sided PICC line. The
right venous
introduction sheath has been removed in the interval.
.
MICROBIOLOGY:
[**2119-4-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST: NEGATIVE.
[**2119-4-11**] Blood Culture, Routine (Final [**2119-4-17**]):
CORYNEBACTERIUM SPECIES
All other blood/urine cxs negative
.
PATHOLOGY:
Pathology:
Appendix: Arteritis, predominantly chronic (transmural
inflammation) with organizing thrombi, but focally acute and
necrotizing.
Duodenum:
Mildly active duodenitis
Descending colon and rectum biopsies:
Colonic mucosa with focal ischemic colitis and extensive
ulceration.
Brief Hospital Course:
Assessment:
66yo man with a history of CAD (s/p RCA DES [**2113**]), PVD, AAA,
HTN, hyperlipidemia, and PUD admitted [**2119-4-11**] with acute
worsening of chronic abdominal pain, right foot drop, and small
bowel obstruction diagnosed with polyarteritis nodosa. Course
was complicated by acute GI bleeding and ECG changes.
.
Course reviewed by problem:
.
#. Polyarteritis nodosa. After presenting with abdominal pain
and small bowel obstruction that did not respond to conservative
management, the patient was taken to the OR on [**2119-4-17**].
Appendectomy revealed arteritis. Rheumatology was consulted,
and given the findings of GI symptoms and weight loss,
pathologic arteritis, and sciatic neuropathy (see below),
polyarteritis nodosa was diagnosed. Pertinent labs included
negative ANCA, negative viral hepatitis serologies (B&C), CRP of
25.4 that came down to 3.1, ESR of 102 that came down to 19,
negative cryoglobulin, urine protein/creatinine of 0.2.
Starting [**4-28**], he was treated with IV steroids for three days,
followed by po prednisone 50 mg po daily, and cyclophosphamide
75 mg po was started [**2119-5-5**] and titrated up to 100mg PO daily,
then dc'd due to decreasing white count, restarted on [**6-2**] at 75
mg daily given stable CBC [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. The cyclophosphomide
whould be taken with 1-2L of fluids; he should receive IV fluids
if unable to tolerate po. Usual course is 6 months but may be
adjusted based on ability to tolerate. He was switched to IV
steroids while having GI bleeding, which was tapered to
methylprednisolone 16 mg IV q 12h on discharge; could consider
change to prednisone 40mg if unable to give IV steroids. He
will continue on this dose of steroids and cyclophosphamide on
discharge, with weekly monitoring of CBC for evidence of
toxicity and further GI blood losses. Weekly CBC should be
faxed to rheumatologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 44524**] for
review and recommendation regarding course of cyclophosphamide
and steroids. He will follow up with rhematology on [**2119-6-19**] at
9am. While on steroids, he required an insulin sliding scale
and was also started on atovaquone for PCP prophylaxis, both of
which were continued on discharge. He was also started on
calcium and vitamin D and will need a DEXA scan and
consideration of bisphosphonate as an outpatient.
.
#. Acute gastrointestinal bleeding. On [**2119-5-5**], the patient
had two episodes of melena overnight and a hematocrit drop from
27.5 to 22.9 over 24 hours; he was transfused 2 units with
appropriate response in hematocrit to 30.7. He never became
hypotensive. EGD revealed diffuse gastritis and duodenitis and
a nonbleeding duodenal ulcer, but nothing to explain the acute
drop in hematocrit. He continued to have bloody stools/melena
and his hematocrit trended down, requiring the transfusion of
one more unit pRBCs. The patient was transferred to the ICU on
[**2119-5-14**] for hypotension in the setting of GIB. He was electively
intubated for procedures. He had a colonoscopy, which showed
multiple ulcerations in the left colon and rectum. Biopsy
revealed focal ischemic colitis. No source of overt bleeding was
noted, however the patient continued to ooze slowly and required
[**12-31**] units of pRBCs per day, nearly 40 units total during the
stay. He also required several platelet transfusions. Hct was
stable in the high 20s (27.2 on discharge) and plts in the 80s
(83 on discharge) in the days prior to discharge and he was
having no evidence of active bleeding. He will require further
monitoring of his crit and PRN transfusions for Hct <25 and plt
<50 at rehab; would recommend [**Hospital1 **] Hct for several days until
stable, then decrease to daily Hct for several days, then
frequency further decreased if also stable. He will continue
[**Hospital1 **] pantoprazole po.
.
#. Nutrition. The patient has had significant weight loss over
the last six months, largely due to decreased intake and food
fear secondary to postprandial pain. This pain has improved
during the admission, but patient continues to require TPN to
meet nutritional recommendations, especially as he has been NPO
in the setting of GIB. His diet was advanced and pt was able to
tolerate some POs prior to discharge.
.
#. Leukocytosis: WBC 14.1 on admission. Patient was afebrile,
without localizing symptoms or signs of infection, negative
chest radiograph, negative UA, urine culture, and blood cultures
were negative. He received levo and flagyl in the ED, and was
continued with IV cipro/flagyl for 10 days given concern of
mesenteric ischemia. He remained afebrile throughout the
hospitalization and WBC count trended down. In the ICU, the
patient had e/o RLL infiltrate while intubated - he was
initially started on Vanc/Zosyn/Cipro for possible VAP. However,
as the pt improved quickly and it was more likely to be
aspiration pneumonitis, the Abx were discontinued on the 4th
day.
.
#. Hypertension: Blood pressure was well controled on Metoprolol
IV when NPO. Pt maintained on Metoprolol and Captopril while in
the ICU - BP 130s-180s. On transfer to the floor, metoprolol
was held to prevent blunting of HR response to GI bleed, and pt
was switched to lisinopril and amlodipine for BP control.
.
#. Hyperlipidemia: Home dose simvastatin was restarted when able
to tolerate oral intake.
.
#. Coronary artery disease: Patient is s/p right coronary artery
drug-eluting stent in [**2113**]. Home dose metoprolol and aspirin
were restarted when tolerating POs, however then held in the
setting of GI bleed. Would recommend restarting as an outpt
when stable.
.
#. Left ventricular systolic dysfunction: EF 40% in [**2111**], 45% in
[**2113**] and >55% on [**2119-2-27**]. Patient had no heart failure symptoms
during this hospital stay.
.
#. Right Foot Drop: Experienced tingle of right foot two days
after suregery with subsequent worsening right lower extremity
weakness and numbness. Neurology consulted. Found severe
sensory/motor deficits in (R) L5 and moderate deficits in S1
territories on examination. L-spine MRI demonstrated multilevel
degenerative changes of the lumbar spine, most pronounced at
L4-5, without evidence of high-grade spinal canal narrowing at
any level. Additional multifactorial multilevel neural foraminal
narrowing. No evidence of metastatic disease to the lumbar spine
on this noncontrast MRI examination. As recommended, a specific
lumbo-sacral plexus MRI following the sciatic nerve with and
without contrast was performed, which was unchanged from the MRI
perfomed the day before. A review of the studies by Neurology
and Radiology attendings determined that the spine imaging was
unremarkable. His presentation was felt to likely represents
compressive neuropathy in distal sciatic or proximal pernoneal.
It was recommended to continue agressive PT, and, if not
improved in [**3-2**] weeks, to perform EMG/NC. He was scheduled for
Neurology follow-up after discharge. Physical and Occupational
Therapy were consulted. The patient was fitted with a orthotic
splint boot which should be used on discharge. Neurology follow
up should be scheduled on dc.
.
#. Post-Operative Course: On [**2119-4-17**], the patient underwent
exploratory laparotomy, lysis of adhesions, ascites, drainage
and open appendectomy, which went well without complication
(reader referred to the Operative Note for details). The
etiology of the small bowel obstruction was found to be due to
pelvic adhesions. After a brief, uneventful stay in the PACU,
the patient arrived on the floor NPO with an NG tube, on IV
fluids and antibiotics, with a foley catheter in place, and a
Dilaudid PCA for pain control. He was continued on TPN. The
patient was hemodynamically stable.
.
Post-operative pain was initially well controlled with the PCA,
which was converted to oral pain medication when tolerating
clear liquids. After a clamping trial, the NG tube was
discontinued on POD#4, and the patient was started on sips of
clears on POD#5. Diet was progressively advanced as tolerated to
a regular diet with Ensure Plus by POD#7. He was restarted on
his home medications on POD#6. He was weaned off TPN on POD#8.
The foley catheter was discontinued at midnight of POD#2. The
patient subsequently voided without problem. The midline
incision with staples experienced sigificant serosanginous
drainage for the first two post-operative days, which was scant
by POD#2. The patient's hematocrit remained stable. The incison
otherwise remained clean and intact.
.
# Deconditioning: pt experienced difficulty ambulating due to
weakness and abd pain. After working with PT for several days
on the general medicine floor, pt able to ambulate to the door.
Morphine was used for pain control PRN. He will require further
PT in rehab for maximum recovery
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation: Over-the-counter.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for loose stools.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
9. Cyclophosphamide 50 mg Tablet Sig: 1.5 Tablets PO qAM: Pt
should drink 1-2 L of fluid with dose. If unable to tolerate
this volume of fluid, please give IVF. Please continue taking
until your rheumatologist tells you to stop. .
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
four times a day: Please take according to inpatient sliding
scale while on steroids.
15. morphine
2-4 mg IV q 6 hrs PRN pain
16. Methylprednisolone Sodium Succ 500 mg Recon Soln Sig:
Sixteen (16) mg Intravenous twice a day: Please continue taking
until your rheumatologist tells you to stop.
17. Outpatient Lab Work
Please check [**Hospital1 **] CBC x 3 days. Can decrease frequency to daily
once stable.
18. Outpatient Lab Work
Please check CBC once weekly (Monday) and forward to
Rheumatologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (fax [**Telephone/Fax (1) 44524**]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Polyarteritis nodosa
.
Secondary:
1. Small-bowel obstruction secondary to pelvic adhesions.
2. Hypertension
3. Coronary artery disease
4. Right foot drop due to sciatic neuropathy
5. Malnutrition
6. Acute gastrointestinal bleed
Discharge Condition:
The patient is hemodynamically stable, without respiratory
distress or uncontrolled pain. Hematocrit stable for several
days with no evidence of active bleed.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] to
evaluate your abdominal pain. You were found to have a small
bowel obstruction and were taken to surgery to lyse these
adhesions and take out your appendix. The pathology from the
appendix showed that you have arteritis (inflammation of blood
vessels). You also developed right foot drop, also thought to
be from the arteritis. We are treating you with prednisone and
cyclophosphamide for the arteritis. While you were in the
hospital you were bleeding from your gastrointestinal tract,
which is why you had endoscopy. The source of the bleeding was
likely due to the arteritis in your small bowel. You received
blood transfusions to keep your blood counts within normal
limits while you were bleeding. Your blood counts were stable
for several days prior to discharge and you tolerated an oral
diet.
.
Please take all medications as prescribed and follow up with the
doctors listed below. The following changes have been made to
your medications:
-STOP taking metoprolol given your recent GI bleed. This should
be slowly restarted as an outpatient given that you have
coronary artery disease
-INCREASE your lisinopril to 40 mg daily
-STOP taking terazosin
-STOP taking ferrous sulfate as it may make it difficult to
detect if you are having a GI bleed. You can restart this when
you are stable
-STOP taking aspirin in the setting of your GI bleeding
-STOP taking simethicone
-Your nicotine patch was held while you were in the hospital as
you didn??????t seem to need it. You may restart it as needed
-START taking methylprednisone 16 mg IV q 12 hrs until
rheumatology tells you to stop
-START taking cyclophosphamide 75 q AM for planned 6 month
course if tolerated or until rheumatologist tells you to stop
-START taking vitamin D and calcium
-START taking insulin and atovaquone while you are on steroids
-START taking amlodipine 5 mg for blood pressure
-START taking morphine as needed for pain
.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-8**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please schedule the following follow-up appointments prior to
discharge from rehab:
- with your primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH
([**Telephone/Fax (1) 7976**])
- [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD ([**Telephone/Fax (1) 2359**]) in general surgery
- [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD ([**Telephone/Fax (1) 463**]) in gastroenterology
.
Please go to the following follow up appointments:
.
Department: RHEUMATOLOGY
When: MONDAY [**2119-6-19**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: NEUROLOGY
When: THURSDAY [**2119-7-27**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"272.4",
"533.90",
"560.81",
"789.59",
"263.9",
"V58.66",
"443.9",
"414.01",
"285.1",
"428.22",
"578.9",
"V45.82",
"401.9",
"428.0",
"486",
"736.79",
"446.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.09",
"54.59",
"45.24",
"88.47",
"54.11",
"45.16",
"45.25",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
27462, 27535
|
15407, 24322
|
330, 648
|
27816, 27976
|
6253, 6912
|
30645, 31154
|
4123, 4174
|
25434, 27439
|
27556, 27795
|
24348, 25411
|
28152, 30372
|
6928, 15384
|
30387, 30622
|
4189, 5239
|
5253, 6234
|
276, 292
|
31178, 31866
|
676, 3073
|
27991, 28128
|
3095, 3796
|
3812, 4107
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,389
| 111,153
|
39034
|
Discharge summary
|
report
|
Admission Date: [**2170-4-3**] Discharge Date: [**2170-4-16**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2170-4-15**] Right Thoracentesis
[**2170-4-4**] Emergernt coronary artery bypass graft x 3 with left
internal mammary artery to left anterior descending coronary
artery; reversed saphenous vein single graft from the aorta to
the first diagonal coronary artery; and reversed saphenous vein
single graft from the aorta to the first obtuse marginal
coronary artery. Mitral valve replacement with 31mm St. [**Male First Name (un) 923**]
epic porcine valve
[**2170-4-4**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 23**] is an 89 year old male who presented with shortness
of breath for a few days. He noticed it started Sunday evening,
over the next two days it progressed to at rest. Family noted
him to have dyspnea and he was brought to emergency for
evaluation.
Past Medical History:
Coronary artery disease
History of Myocardial Infarction in [**2146**]
Hypertension
Peripheral neuropathy of [**Last Name (un) 5487**] etiology
Chronic renal insufficiency
Hiatal hernia
PTSD after war
s/p TURP > 10 years ago
History of Osteomyelitis right heel > 5 years ago
Social History:
Lives at an [**Hospital3 **] facility. Has a girlfriend. [**Name (NI) **]
drinks wine occasionally. No current tobacco but has a [**6-4**] pack
year history remotely. He was a [**Location (un) 7349**] cab driver in the past. He
moved to the [**Location (un) 86**] area 1 year ago. All his medical care is in
[**State 108**].
Family History:
Noncontributory
Physical Exam:
Pulse: 85 SR Resp: 24 O2 sat: 90% 100% NRB
B/P 117/68 on nipride 0.3mg/kg/min
Height: 5'[**71**]" Weight: 88.5
General: respiratory distress on 100% NRB unable to complete
sentences with use of excessory muscles
Skin: Dry [x] intact [x]
Neck: Supple [x] Full ROM [x]
Chest: Diminished throughout
Heart: RRR [x] Irregular [] Murmur [**3-31**] holosystolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema + 1
Neuro: alert and oriented x3 non focal - limited activity
tolerance due to shortness of breath
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
PREOP WORKUP:
[**2170-4-3**] WBC-15.9* RBC-4.66 Hgb-14.9 Hct-43.2 RDW-14.0 Plt
Ct-234
[**2170-4-3**] PT-13.5* PTT-23.8 INR(PT)-1.2*
[**2170-4-3**] UreaN-39* Creat-1.7*
[**2170-4-4**] Cardiac Catheterization:
1. Coronary angiography in this right dominant system
demonstrated two
vessel disease. The LMCA had a distal 60% stenosis. The LAD was
subtotally occluded in the proximal segment with TIMI 2 flow.
The LCx
had an 80% proximal stenosis. The RCA had mild disease.
2. Resting hemodynamics revealed elevated right and left heart
filling
pressures with RVEDP 15 mmHg and PCWP 25 mmHg. There were
accentuated V
waves in the PCW pressure tracing. The pulmonary artery systolic
pressure was elevated at 50 mmHg. The cardiac index was
preserved at 2.5
L/min/m2. The systemic vascular resistance was normal. The
pulmonary
vascular resistance was elevated at 323 dyn-sec/cm5. There was
systemic
arterial normotension.
[**2170-4-4**] Intraop Echocardiogram:
PRE Bypass: Image quality is very poor. No transgastric views
could be obtained. The left atrium is moderately dilated.
Overall left ventricular systolic function is grossly normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. There are complex (>4mm) atheroma in the
[**Month/Day/Year 8813**] arch. The study is inadequate to exclude significant
[**Month/Day/Year 8813**] valve stenosis. No [**Month/Day/Year 8813**] regurgitation is seen. The
mitral valve leaflets are moderately thickened. An eccentric,
anteriorly directed jet of Moderate to severe (3+) mitral
regurgitation is seen. There is P2 flail of the posterior mitral
leaflet with a torn chordae visible.
POST Bypass: Patient is a-paced on phenylepherine and
epinepheine infusions. Image quality remains poor. No
transgastric views could be obtained. Biventircular appears
unchanged. There is a tissue valve in the mitral position. There
is no perivalvular leaks, no MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**First Name (Titles) **] [**Last Name (Titles) 86554**] intact.
Remaining exam is limited, but appears unchanged.
POSTOP LABS:
[**2170-4-16**] WBC-11.8* RBC-3.49* Hgb-11.0* Hct-33.2* RDW-14.3 Plt
Ct-566*#
[**2170-4-12**] WBC-11.0 RBC-3.76* Hgb-11.5* Hct-34.6* RDW-14.6 Plt
Ct-339
[**2170-4-11**] WBC-11.1* RBC-3.65* Hgb-10.9* Hct-33.4* RDW-14.5 Plt
Ct-261
[**2170-4-10**] WBC-12.1* RBC-3.60* Hgb-11.1* Hct-33.1* RDW-14.7 Plt
Ct-201
[**2170-4-16**] PT-20.5* INR(PT)-1.9*
[**2170-4-15**] PT-18.5* PTT-26.2 INR(PT)-1.7*
[**2170-4-14**] PT-18.4* PTT-26.4 INR(PT)-1.7*
[**2170-4-13**] PT-18.9* PTT-29.1 INR(PT)-1.7*
[**2170-4-12**] PT-23.4* PTT-33.3 INR(PT)-2.2*
[**2170-4-16**] Glucose-128* UreaN-64* Creat-2.6* Na-141 K-4.1 Cl-101
HCO3-26
[**2170-4-15**] UreaN-70* Creat-2.8*
[**2170-4-14**] Glucose-107* UreaN-83* Creat-3.1* Na-142 K-3.7 Cl-104
HCO3-27
[**2170-4-13**] Glucose-129* UreaN-93* Creat-3.4* Na-143 K-3.5 Cl-104
HCO3-29
[**2170-4-12**] Glucose-114* UreaN-106* Creat-4.0* Na-143 K-3.6 Cl-103
HCO3-26
[**2170-4-11**] Glucose-112* UreaN-105* Creat-4.6* Na-139 K-3.5 Cl-99
HCO3-27
[**2170-4-10**] UreaN-106* Creat-4.7* Na-139 K-3.5 Cl-99 HCO3-26
AnGap-18
[**2170-4-10**] UreaN-106* Creat-4.7* Na-139 K-3.5 Cl-99 HCO3-26
AnGap-18
[**2170-4-10**] Glucose-93 UreaN-107* Creat-5.2* Na-138 K-3.5 Cl-97
HCO3-25
[**2170-4-9**] Glucose-257* UreaN-91* Creat-5.0* Na-132* K-3.9 Cl-94*
HCO3-25
[**2170-4-8**] Glucose-101* UreaN-73* Creat-4.3* Na-135 K-4.1 Cl-101
HCO3-20*
[**2170-4-7**] Glucose-91 UreaN-54* Creat-3.3* Na-136 K-3.7 Cl-101
HCO3-21*
[**2170-4-16**] 05:45AM BLOOD Mg-2.0
[**2170-4-15**] Discharge Chest X-ray:
As compared to the previous examination, there is status post
thoracocentesis on the right. There is marked decrease in extent
of the right pleural effusion. No pneumothorax can be seen on
the right. On the left, a basal air-fluid level suggests the
presence of minimal intrapleural air, despite the absence of
visibility of a left pneumothorax. No newly appeared focal
parenchymal opacities. Unchanged large hiatal hernia. Mild
cardiomegaly.
Brief Hospital Course:
Presented with shortness of breath and found to be hypoxic in
the setting of heart failure. He was rapidly worked up where an
echo revealed severe mitral valve regurgitation with partial
flail leaflet and torn chordae. He was then brought for a
cardiac catheterization which also revealed severe mitral
regurgitation along with coronary artery disease. In the setting
of respiratory failure and hemodynamic instability, it was
decided to bring him emergently to the operating room where he
underwent a mitral valve replacement with coronary artery bypass
graft. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring. Remained on inotropes and pressors that were weaned
off over the first few days postoperatively, additionally had
episodes of atrial fibrillation and flutter treated with
coumadin and amiodarone. On post operative day two he was
successfully weaned from the ventilator and extubated.
Additionally renal was consulted due to acute kidney injury post
operatively. He remained in the intensive care unit an
extended stay for hemodynamic management, pulmonary monitoring,
and renal management. He progressively improved and was weaned
down to nasal cannula and hemodynamically stable off all
vasoactive medications. Coumadin was held due to increased INR
and allowed to correct back on its own. Renal function slowly
improved and he was transferred to the floor for the remainder
of his care. His renal function continued to improve. On
postoperative day 11, he underwent successful right sided
thoracentesis of approximately 400cc of fluid. He tolerated the
procedure well, and followup chest x-ray showing improvement
with no signs of pneumothorax. He continued make clinical
improvements and was eventually discharged to rehab on
postoperative day 12. Following thoracentesis, Coumadin was
resumed for atrial fibrillation and should be adjusted for goal
INR between 2.0 - 2.5. Following discharge, his renal function
should be monitored weekly to ensure recovery back to baseline.
Medications on Admission:
ASA 325mg daily
Atenolol 25mg po bid
Allopurinol
Zantac 150mg po bid
Xanax 0.25mg po bid prn
Neurontin 300mg po bid
Norvasc 5mg dialy
Zocor 20mg po daily
Omega 3
MVI daily
Triamterene 37.5 / HCTZ 25 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please hold Warfarin today [**4-16**] - please check INR [**4-17**] prior to
giving dose - titrate for goal INR between 2.0 - 2.5.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold if HR less than 60.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute Congestive Heart Failure
Coronary artery disease, Mitral regurgitation - s/p MVR/CABG
Atrial fibrillation
Acute on Chronic Renal Insufficiency
Postop Pleural Effusions
Acute respiratory failure
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
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 -[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2170-5-8**] 1:30
Cardiologist - [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2170-5-1**] 3:20
Please call to schedule appointments
Primary Care Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7730**] [**Last Name (un) **] in [**1-27**] weeks
[**Telephone/Fax (1) 27593**]
Completed by:[**2170-4-16**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"35.23",
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"37.22",
"36.15",
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] |
icd9pcs
|
[
[
[]
]
] |
10471, 10537
|
6766, 8843
|
286, 781
|
10794, 10854
|
2588, 6743
|
11394, 11908
|
1742, 1759
|
9101, 10448
|
10558, 10773
|
8869, 9078
|
10878, 11371
|
1774, 2569
|
227, 248
|
809, 1086
|
1108, 1384
|
1400, 1726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,927
| 179,339
|
3042
|
Discharge summary
|
report
|
Admission Date: [**2198-5-4**] Discharge Date: [**2198-5-8**]
Date of Birth: [**2151-11-20**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8739**]
Chief Complaint:
headaches x5 days, clumsiness in his L-arm
Major Surgical or Invasive Procedure:
[**2198-5-4**]: R parietal craniotomy for metastic lesion
History of Present Illness:
The patient is a 46 yo R-handed man with a history of HTN
who presents to the ED with a 5 day history of headaches,
clumsiness in his L-arm and walking into objects on the L.
The Pt was in his USOH until last Saturday ([**4-28**]), when he noted
that when he tried to grasp his T-shirt with his L-arm, this arm
"wasn't doing it properly". He says he could feel well and that
the arm didn't feel weak, but that his arm didn't exactly do
what
he wanted it to do. He continued to drop items, especially small
ones, during the rest of the week. No numbness or tingling.
At the time he first noted the clumsiness, he also felt
lightheaded. A few after the first event, he noted a headache,
bifrontal, squeezing. The headache is not affected by position,
light makes it worse. It has been associated with nausea, but no
vomiting. No nightly awakenings. Typically, during the rest of
the week, the headaches would last about 30 min. At baseline he
never has any headaches like these; no migraines.
In addition, he has noted that he has been walking into
doorposts/objects at the left side only. He has not noted any
problems with his vision. He attributed this to problems in his
leg. Finally, he has been getting more forgetful, which is
unusual for him.
He contact[**Name (NI) **] his PCP with the above story, who refered him to
the
ED. He is accompanied by a good friend.
ROS:
denies any fever, chills,visual changes, hearing changes,
neckpain/backpain, vomiting, dysphagia, weakness, tingling,
numbness, bowel-bladder dysfunction, chest pain, shortness of
breath, abdominal pain, dysuria, hematuria, or bright red blood
per rectum. Weightloss 5pounds over the last months, no
intention.
Past Medical History:
-hypertension since [**2-16**] yrs
-L-inguinal hernia, s/p surgery
Social History:
Occupation: works as a DJ as well as in a digital photolab
Smoking: no, but has been exposed to second hand smoke (as a
DJ);
EthOH: 6pack on Fridays; drug abuse: no.
Single, takes care of mom; has had one unsafe sexual
relationship
Family History:
-positive for DM and HTN; sister has seizures since childhood;
no
cancers; no migraines
Physical Exam:
VITALS: T99.4 HR108 BP173/74 RR16 sO2 100%
GEN: NAD
HEENT: mmm, anicteric
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, II/VI murmur,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date (although it takes him a
while to come up with [**2198**], first says [**2188**]), person.
Attention: MOYbw: gets into trouble [**Month (only) 547**]-[**Month (only) 116**] (keeps reversing),
finally makes it to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 14489**]: Registration: [**3-16**] items; Recall [**3-16**] at 5 min.
Language: fluent; repetition: intact; Naming intact, including
colors; Comprehension intact; no dysarthria, no paraphasic
errors. Writing: intact. [**Location (un) **]: intact; Prosody: normal. Fund
of knowledge normal; No Apraxia. No Neglect.
CRANIAL NERVES:
II: Visual acquity intact. Visual fields: L-upperquadrantanopia,
pupils equally round and reactive to light both directly and
consensually, 2-->1 mm bilaterally. Disc margins sharp, no
pappilledema.
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; no facial droop.
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. No adventitious
movements, no tremor, no asterixis.
Strength is full. No pronator drift, but a clear parietal drift
on the L. No rebound.
SENSORY SYSTEM: Sensation intact to light touch, pin prick,
temperature (cold), vibration, and proprioception in all
extremities. agraphestesia in both hands; proposagnosia on the
L-arm
REFLEXES:
B T Br Pa Pl
Right 2 2 2 2 2
Left 3 3 3 3 3 (few beats clonus in ankle; crossed adductor)
Toes: mute bilaterally.
COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. No dysmetria or
pastpointing.
GAIT: narrow based, normal arm swing, normal initiation.
Romberg:
negative. Able to do tandem gait, walk on toes, walk on heels.
Pertinent Results:
[**2198-5-4**] 01:00AM BLOOD WBC-7.3 RBC-4.30* Hgb-9.4* Hct-29.4*
MCV-68* MCH-21.8* MCHC-31.8 RDW-15.4 Plt Ct-436
[**2198-5-4**] 01:00AM BLOOD Neuts-75.5* Lymphs-18.3 Monos-4.9 Eos-0.6
Baso-0.7
[**2198-5-8**] 07:10AM BLOOD WBC-6.2 RBC-4.88 Hgb-11.4* Hct-35.5*
MCV-73* MCH-23.3* MCHC-32.0 RDW-16.5* Plt Ct-302
[**2198-5-4**] 01:00AM BLOOD PT-13.9* PTT-26.5 INR(PT)-1.2*
[**2198-5-4**] 01:00AM BLOOD Glucose-122* UreaN-15 Creat-1.4* Na-138
K-5.1 Cl-97 HCO3-26 AnGap-20
[**2198-5-8**] 07:10AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-145
K-3.5 Cl-102 HCO3-30 AnGap-17
[**2198-5-4**] 10:35AM BLOOD ALT-34 AST-27 LD(LDH)-244 AlkPhos-92
Amylase-50 TotBili-0.3
[**2198-5-4**] 10:35AM BLOOD Lipase-24
[**2198-5-4**] 10:35AM BLOOD Albumin-3.7 Calcium-9.5 Phos-4.4 Mg-1.9
[**2198-5-5**] 09:20AM BLOOD Phenyto-10.6
-----
Head CT [**5-3**]:IMPRESSION: 1.4-cm round mass lesion with
peripheral hemorrhage and surrounding extensive vasogenic edema.
There is minimal subfalcine herniation without evidence of
transtentorial or uncal herniation.
-----
Head CT [**5-4**]:IMPRESSION: Post-operative appearance to the brain
without evidence of transtentorial or uncal herniation, and with
minimal leftward subfalcine herniation, that was also present on
the prior study.
-----
Head MR 4/21:1. 1.8-cm enhancing mass in the right
frontoparietal lesion with hemorrhagic component, with edema
that partially enters into right side of the splenium of corpus
callosum, corresponding to the finding on CT scan. The finding
is most likely representing metastatic disease; however, other
differential diagnoses include lymphoma and PNET.
2. Normal MR angiography.
-----
Brain pathology:
METASTATIC CLEAR CELL CARCINOMA most consistent with METASTATIC
RENAL CELL CARCINOMA.
-----
MRI post-op:IMPRESSION: Status post resection of right parietal
enhancing lesion. Blood products are seen at the surgical site
with a small area of residual enhancement suspected at the
anterior margin of the surgical cavity. Surrounding edema is
again noted, unchanged. No interval new abnormalities are seen.
-----
CT torso:Large, heterogeneously-enhancing, necrotic left renal
neoplasm, likely renal cell carcinoma. Pulmonary metastases as
well as a single probable hepatic metastasis are seen. Filling
defect within the left renal vein may represent non- occlusive
bland or tumor thrombus.
Brief Hospital Course:
46 yo R-handed man with a history of HTN who presented to the ED
with a 5 day history of headaches, clumsiness in his L-arm, and
walking into objects on the left. These symptoms had been
fluctuating since onset. On exam, he was very mildly
inattentive, had a L-upper quadrantanopia, a L-parietal drift,
and agraphesthesia in the L-arm. CT head in the ED showed a
round mass in the R-parietal region ([**Doctor Last Name 352**]/white junction) with
extensive edema. In addition, he had anemia.
An MRI with contrast was ordered which showed the mass in more
detail. It was radiographically consistent with a metastasis.
He was started on Decadron 4 mg q6h due to the edema. He was
then taken to surgery for tumor resection. This went well
without complication. His exam remained essentially unchanged
afterwards. His decadron was slowly weaned after surgery. The
preliminary path was renal cell carcinoma.
He then had a torso CT which showed a large 11.1 x 18.3 x 13.1
cm renal mass on the left. This did not compress any major
vessels. It also showed evidence of bilateral lung metastases
and probable liver metastases.
The oncology service was consulted and saw him here. They
arranged for him to follow-up quickly as an outpatient. He will
also follow-up in brain tumor clinic. The treatment course is
not fully clear at this time and will be determined at his
outpatient oncology appointments.
He was seen by social work here for assistance with coping and
his new cancer diagnosis. He is clearly upset, but does accept
the diagnosis.
For seizure prophylaxis, he was started on Keppra 500 mg [**Hospital1 **].
He will continue this and may need to increase it as an
outpatient. He will see multiple neurologists
in the near future and this can be managed as well. His
dexamethasone will continue at 2 mg [**Hospital1 **] for now. Again, this
may be decreased in the future depending on how he does as an
outpatient.
CV: Continued atenolol, but his creatinine was initially
[**Last Name (LF) 14490**], [**First Name3 (LF) **] we stopped his HCTZ.
He will follow-up in brain tumor clinic and with oncology.
Medications on Admission:
1. Atenolol 37.5 mg p.o. daily.
2. Hydrochlorothiazide 25 mg p.o. daily.
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
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:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Metastatic renal cell carcinoma s/p resection of brain met
Discharge Condition:
neurologically stable
Discharge Instructions:
Please continue to work with physical therapy to improve your
mobility and attend all out patient appointments.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1729**] heme/oncologist in 1 week from
discharge. Please call ([**2198**] to schedule an
appointment. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] referred you to his office.
Also follow-up with Dr. [**Last Name (STitle) 724**] on [**5-21**] at 3pm, call [**Telephone/Fax (1) 1844**]
for directions to the Brain [**Hospital 341**] Clinic.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2198-5-21**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4406**] MD, [**MD Number(3) 8740**]
|
[
"280.9",
"197.0",
"198.3",
"189.0",
"197.7",
"401.9",
"790.01",
"280.0",
"781.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"93.59",
"01.59",
"40.19"
] |
icd9pcs
|
[
[
[]
]
] |
10362, 10420
|
7449, 9583
|
359, 419
|
10523, 10547
|
5081, 7426
|
10707, 11405
|
2499, 2588
|
9709, 10339
|
10441, 10502
|
9609, 9686
|
10571, 10684
|
2603, 2978
|
276, 321
|
447, 2140
|
3693, 5062
|
2993, 3677
|
2162, 2230
|
2246, 2483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,921
| 136,594
|
31260
|
Discharge summary
|
report
|
Admission Date: [**2113-8-11**] Discharge Date: [**2113-8-23**]
Service: CARDIOTHORACIC
Allergies:
Cephradine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
off pump cabg x4 [**2113-8-15**] (LIMA to LAD, SVG to RAMUS with Y
grafts to SVG to OM and SVG to PDA)
History of Present Illness:
87 yo male with NSTEMI, angina and DOE originally seen [**7-25**] by
Dr. [**Last Name (STitle) **]. Refused CABG at that time. Readmitted [**8-11**] with
recurrent angina and IV heparin started.
Past Medical History:
- CAD s/p cath w/ no interventions
- pacemaker
- COPD
- HTN
- hyperlipidemia
- paroxysmal a-fib (refused coumadin in past)
- sleep apnea not on C-PAP
- IBS
- depression
- TIA
Social History:
no tob since [**2066**]'s, no alcohol. lives in [**Location **]
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
66" 77 kg
96.5 T HR 71 RR 18 102/65 97% 2L
NAD
non-icteric
neck supple, no carotid bruits
lungs clear
RRR
abd soft, NT, ND
extrems. warm, well-perfused
Pertinent Results:
[**2113-8-21**] 06:40AM BLOOD WBC-12.8* RBC-3.39* Hgb-9.8* Hct-29.3*
MCV-86 MCH-29.0 MCHC-33.6 RDW-17.5* Plt Ct-233#
[**2113-8-21**] 06:40AM BLOOD Plt Ct-233#
[**2113-8-21**] 06:40AM BLOOD Glucose-96 UreaN-62* Creat-2.8* Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2113-8-15**] 04:37AM BLOOD ALT-20 AST-23 AlkPhos-110 TotBili-0.4
No spontaneous echo contrast is seen in the body of the left
atrium or left
atrial appendage. A left-to-right shunt across the interatrial
septum is seen
at rest. A secundum type atrial septal defect is present. Left
ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately
dilated. There is severe regional left ventricular systolic
dysfunction with
severe septal, apical, and mid to lateral anterior and
anterolateral
hypokinesis/akinesis. The inferior, lateral and inferolateral
walls are
moserately hypokinetic in the basal to mid segement but are
severely depressed
apically. The ejection fraction is in the 15-20% range. An
apical left
ventricular thrombus is not seen but can not be completely ruled
out. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta
is moderately dilated. There are complex (>4mm) atheroma in the
aortic arch.
The descending thoracic aorta is moderately dilated and sverely
tortuous.
Spontaneous echo contrast, indicative of decreased blood flow,
is seen in the
descending thoracic aorta. There are complex (>4mm) atheroma in
the descending
thoracic aorta. The wall of the descending aorta is quite thick
- this may be
complex atheroma but an intramural hematoma or an old dissection
can not be
completely ruled out. 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 a trivial/physiologic pericardial effusion.
After completion of bypass grafting, the right ventricle
continues to display
normal function. The focal abnormalities in the left ventricle
persist. The
function of the lateral, inferior, and inferolateral walls is
slightly
improved. The ejection fraction is around 20%. No other change
from pre-CPB
findings.
[**2113-8-21**] 06:40AM BLOOD WBC-12.8* RBC-3.39* Hgb-9.8* Hct-29.3*
MCV-86 MCH-29.0 MCHC-33.6 RDW-17.5* Plt Ct-233#
[**2113-8-21**] 06:40AM BLOOD Plt Ct-233#
[**2113-8-15**] 01:38PM BLOOD PT-15.6* PTT-39.4* INR(PT)-1.4*
[**2113-8-22**] 07:00AM BLOOD Glucose-100 UreaN-57* Creat-2.7* Na-141
K-3.9 Cl-106 HCO3-24 AnGap-15
[**2113-8-21**] 06:40AM BLOOD Glucose-96 UreaN-62* Creat-2.8* Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2113-8-20**] 05:40AM BLOOD Creat-2.8* K-3.8
[**2113-8-19**] 05:20AM BLOOD Glucose-95 UreaN-47* Creat-2.5* Na-137
K-3.6 Cl-104 HCO3-21* AnGap-16
[**2113-8-23**] 06:50AM BLOOD WBC-11.5* RBC-3.47* Hgb-9.9* Hct-30.5*
MCV-88 MCH-28.6 MCHC-32.6 RDW-17.4* Plt Ct-340
[**2113-8-23**] 06:50AM BLOOD Plt Ct-340
[**2113-8-23**] 06:50AM BLOOD Glucose-80 UreaN-54* Creat-2.5* Na-140
K-4.2 Cl-106 HCO3-25 AnGap-13
Brief Hospital Course:
Admitted for recurrent angina on [**8-11**] and heparin started.
Further eval. revealed a calcified aorta on chest CT. Eight beat
run of NSVT on [**8-14**]. OPCABG x4 performed by Dr. [**First Name (STitle) **] on [**8-15**].
Transferred to the CSRU in stable condition on phenylephrine and
propofol drips. Extubated on the morning of POD #2 and pacer
interrogated by EP service. Transferred to the floor on POD #3
to begin increasing his activity level. Went into A fib and oral
amiodarone started. Gentle diuresis continued. Pacing wires and
chest tubes removed without incident. He continued to refuse to
take any medication. He had an 8 beat run of VTach and was seen
by electrophysiology given his EF of 15%. He will follow up as
an outpatient. He was also seen by psychiatry, after which he
agreed to take some of his cardiac medication. He was ready for
discharge to rehab on [**8-23**].
Medications on Admission:
plavix 75 mg daily
ASA 325 mg daily
lasix 30 mg daily
prilosec 20 mg daily
metoprolol 75 mg [**Hospital1 **]
zocor 80 mg daily
ativan
nitro
MVI
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400 mg daily x 1 week, then 200 mg daily ongoing.
10. 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*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
CAD s/p OPCABG x4
TIAs
COPD
elev. lipids
PA Fib
CHF
sleep apnea
IBS
diverticulitis
CRI
depression
epistaxis
Discharge Condition:
stable
Discharge Instructions:
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 100.5, redness or drainage
no lotions creams, powders or ointments on any incision
SHOWER daily and pat incisions dry
Followup Instructions:
see Dr. [**Last Name (STitle) 27542**] in [**1-17**] weeks
see Dr. [**Last Name (STitle) 11493**] in [**2-18**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-8-23**]
|
[
"272.4",
"276.2",
"V43.65",
"410.72",
"311",
"327.23",
"403.90",
"564.1",
"V12.59",
"585.9",
"427.1",
"414.01",
"997.1",
"V43.64",
"428.0",
"427.31",
"496",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"36.15",
"36.13",
"89.45"
] |
icd9pcs
|
[
[
[]
]
] |
6414, 6485
|
4198, 5094
|
230, 338
|
6637, 6646
|
1134, 4175
|
6920, 7235
|
857, 939
|
5288, 6391
|
6506, 6616
|
5120, 5265
|
6670, 6897
|
954, 1115
|
184, 192
|
366, 562
|
584, 760
|
776, 841
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,936
| 102,376
|
45578
|
Discharge summary
|
report
|
Admission Date: [**2157-10-15**] Discharge Date: [**2157-10-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fall/Confusion
Major Surgical or Invasive Procedure:
Thoracocentesis
History of Present Illness:
89-year-old gentleman who has a past medical history
of known CAD s/p CABG (LIMA-LAD; SVG-OM1; SVG-PDA) in [**2149**],
multiple prior PCI's, recent NSTEMI in [**9-16**] thought to be [**2-8**]
demand, on plavix and ASA, Afib no longer on coumadin,
hypertension, hyperlipidemia, and diet controlled diabetes, who
presents s/p unwitnessed fall. He was admitted to the MICU 1 day
ago. Patient does not recall fall or whether there was LOC. He
feel in his home from a standing position and hit his head. He
was noted to have a scalp laceration that was bleeding badly on
arrival to ED. He was estimated to have lost approx 1 unit of
blood and so was given one in the ED. The scalp lesion was
stapled by trauma [**Doctor First Name **]. He was hypotensive to SBP 50s in the ED.
In total he has received 2 PRBCS and 3L IVF over the past 24
hours. His BP stabilizied and so a lower dose of his lasix was
started this morning. CT head was negative.
In addition, he was hypoxic in the ED, requiring at NRB for a
short period of time. CT torson found a right sided non-diplaced
rib fracture and a fairly large left sided pleural effusion
which increased over the past 24 hours. A thoracentesis was
performed and removed 1500 cc of blood fluid. It was felt that
the effusion was secondary to rib fractures.
He reported that he had been feeling unwell all week. He was
found to have a UTI; cutlure is postive for GNRs. He was
initally given broad spectrum antibiotics but narrowed to
ceftriaxone for UTI. He currently feels well. He denies pain,
SOB, lightheadedness or dizziness.
.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
CAD h/o MI s/p CABG s/p PCI
DM, diet controlled
Afib following CABG not anticoagulated
HTN
hyperlipidemia
Anemia
OA
BPH s/p TURP
h/o scrotal hydrocele
spinal stenosis
carotid stenosis
diverticulosis
GERD
h/o hernia repair
h/o stroke
h/o colon polyps
labyrinthitis
s/p detatched retina
s/p tonsillectomy
Social History:
Non smoker. No EtOH. Married with 5 adult children. He is
retired. Prior to retiring he sold life insurance.
Family History:
noncontributory
Physical Exam:
Physical Exam:
Vitals: Tm: 98.8 Tc: 96.8 BP: 100/58 P: 69 R: 19 18 O2: 99% RA.
LOS 2 L positive. good UOP 1.8 over last 24 hrs.
General: Alert, oriented x3, no acute distress
HEENT: Right scalp lac with staples in place, no oozing. Sclera
anicteric, OP with Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Dullness to percussion and decrease breath sounds on
right LL. Dressing from [**First Name5 (NamePattern1) 576**] [**Last Name (NamePattern1) 1830**].
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, + colostomy
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN grossly intact, MAE. sensation grossly intact.
Pertinent Results:
GENERAL LABS (CBC/LFT'S/CMP/COAGS)
.
[**2157-10-15**] 09:15AM BLOOD WBC-8.8 RBC-3.55* Hgb-11.0* Hct-31.8*
MCV-90 MCH-30.9 MCHC-34.5 RDW-14.4 Plt Ct-340
[**2157-10-18**] 09:05AM BLOOD WBC-6.7 RBC-3.43* Hgb-10.4* Hct-30.3*
MCV-88 MCH-30.3 MCHC-34.4 RDW-14.5 Plt Ct-265
[**2157-10-15**] 12:00PM BLOOD Neuts-81.3* Lymphs-12.8* Monos-5.0
Eos-0.5 Baso-0.3
[**2157-10-18**] 09:05AM BLOOD PT-14.2* PTT-34.2 INR(PT)-1.2*
[**2157-10-15**] 09:15AM BLOOD Glucose-144* UreaN-19 Creat-0.8 Na-126*
K-4.3 Cl-91* HCO3-27 AnGap-12
[**2157-10-18**] 09:05AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-130*
K-4.1 Cl-98 HCO3-28 AnGap-8
[**2157-10-16**] 03:31AM BLOOD ALT-7 AST-18 LD(LDH)-185 CK(CPK)-52
AlkPhos-81 TotBili-1.3
[**2157-10-15**] 09:15AM BLOOD proBNP-5063*
[**2157-10-18**] 09:05AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
.
..
Thoracentesis Fluid Analysis
.
PLEURAL ANALYSIS WBC RBC Hct,Fl Polys Lymphs Monos
[**2157-10-16**] 17:58 2.0*1
PLEURAL FLUID
[**2157-10-16**] 17:58 [**2147**]* [**Numeric Identifier 71296**]* 82*2 12* 6*
PLEURAL FLUID
.
.
LESS THAN
SPUN HEMATOCRIT PERFORMED
DIFFERENTIAL REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 85107**] [**2157-10-18**]
.
.
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin
[**2157-10-16**] 17:58 3.4 122 186 2.5
PLEURAL FLUID
.
.
.
URINE CULTURE
**FINAL REPORT [**2157-10-18**]**
URINE CULTURE (Final [**2157-10-18**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
.
.
.
EKG- [**2157-10-15**]
Ectopic atrial rhythm and increase in rate compared to the
previous tracing of [**2157-10-3**]. Left ventricular hypertrophy with
ST-T wave change.
Intraventricular conduction delay. There is scooping of the ST
segments
consistent with use of digitalis. Clinical correlation is
suggested.
TRACING #1
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 170 118 442/[**Medical Record Number 97199**] 122
.
.
.
IMAGING
.
CXR [**2157-10-15**]
CHEST, AP SEMI-UPRIGHT: Again seen is a moderate right pleural
effusion, with partial redistribution along the lateral right
hemithorax and lung apex, likely due to positioning. Chronic
loculated effusion and pleural thickening along the left lateral
hemithorax and lung base are unchanged. There is continued
moderate vascular congestion and interstitial edema. Moderate
cardiomegaly is present, with median sternotomy wires,
mediastinal clips, and coronary bypass grafts. There is no
pneumothorax. Evaluation of the right middle and lower lobes is
limited by superimposed effusion. Mild retrocardiac atelectasis
persists. Diffuse skeletal demineralization persists, with
S-shaped thoracolumbar scoliosis and severe degenerative
changes. Vascular calcification are seen in the upper left
abdomen. Multiple punctate calcifications in the left upper
quadrant of the abdomen are compatible with splenic granulomas
as seen on prior CT.
.
.
CXR [**2157-10-17**]
COMPARISON: [**2157-10-16**].
.
FINDINGS: Moderate right and small partially loculated left
pleural effusions appear unchanged. No visible pneumothorax.
Acute right rib fracture is again demonstrated. No new or
progressive abnormalities.
.
IMPRESSION:
1. Stable moderate right effusion with compressive atelectsis.
2. Continued cardiomegaly and interstitial edema.
3. Chronic loculated left effusion and pleural thickening.
.
.
.
CT HEAD- [**2157-10-15**]
FINDINGS: There is no evidence of acute hemorrhage, large acute
territorial
infarction, or large masses. There is evidence of
periventricular white
matter hypodensities, in keeping with chronic vessel ischemic
changes.
Hypodensity along the subcortical white matter in the right
frontal lobe,
appears unchanged, 2B:26. Ventricles and sulci are prominent,
stable. There
is no hydrocephalus. There is no shift of midline structures.
Moderate
calcification in the carotid arteries, 3B:27, bilaterally.
Minimal mucosal
thickening is seen in the left maxillary sinus. There is no
evidence of
fracture. There is device in the right globe, 3B:33, correlate
with history.
.
IMPRESSION: No acute intracranial process. No fracture.
.
.
CT NECK [**2157-10-15**]
FINDINGS: Hypodensities in the thyroid gland could be further
evaluated with thyroid ultrasound in a nonurgent setting.
Complete opacification of the visualized portion of the right
lung apex.
.
No prevertebral soft tissue edema. The alignment of the cervical
spine is
grossly preserved. There are moderate-to-severe multilevel
degenerative
changes, and bones are diffusely osteopenic. With this
limitation in mind, no definite fracture is seen.
At level C6 posteriorly, there are osteophytes, impinging on
thecal sac, and in a patient with mechanism of injury, these
could put the patient at more risk for cord injury. Multilevel
narrowing of the cervical canal due to multilevel osteophytes.
There is multilevel narrowing of the neural foramina; however,
appears similar compared to MRI, and incompletely evaluated.
Moderate calcifications along bilateral carotid arteries; cannot
exclude a high-grade stenosis.
.
IMPRESSION:
1. Diffuse osteopenia with severe multilevel degenerative
changes through the
cervical spine. Suboptimal evaluation of the cervical spine for
fractures;
however, no definite fracture is seen.Incidental hemangioma of
C6 vertebra.
2. No prevertebral soft tissue edema.
3. Hypodensities in the thyroid gland, could be further
evaluated with
thyroid ultrasound in a non-emergent setting.
4. Complete opacification over the imaged portion of the right
lung apex.
5. Moderate calcification at the cerotids, cannot exclude high
grade
stenosis.
.
.
.
CT CHEST/ABDOMEN/PELVIS [**2157-10-15**]
CT CHEST: The airways are patent up to subsegmental level. There
is a large right pleural effusion, with adjacent atelectasis.
There is a small left pleural effusion with minimal atelectasis
at the left lung base. There is minimal atelectasis in the
lingula and left anterior lung, (3A:43). There is no evidence of
pneumothorax. There are no pathologically enlarged lymph nodes i
n the mediastinum, hilum, or axilla. There are scattered
prominent lymph nodes in the mediastinum, however, do not meet
the CT criteria for pathologic enlargement.
.
CTA: There is no filling defect in the pulmonary arteries to
suggest
pulmonary embolus. Patient is s/p remote CABG. There are severe
calcifications in the coronary arteries. There is no pericardial
effusion. The ascending aorta is slightly prominent, measuring
3.4 cm in diameter.
.
CT ABDOMEN: The liver enhances homogeneously. There is a
hypodensity in the right liver lobe, (3B:127), too small to be
characterized. There is no evidence of liver laceration. There
is no extra- or intra-hepatic biliary duct dilatation. The
gallbladder appears normal. Multiple small
calcifications are seen in the spleen, likely suggesting old
granulomatous infection. The adrenal glands and visualized loops
of small and large bowel appear within normal limits. There is
no evidence of bowel obstruction. Pancreas is atrophic. There
are moderate calcifications in the splenic vessels.
.
The kidneys enhance symmetrically and excrete contrast
symmetrically with no evidence of hydronephrosis. There are
bilateral hypodensities in the kidneys, too small to be
characterized. Stable small hyperdense cystic lesion in the
interpolar region of the left kidney. There is no perinephric
stranding. No free fluid or free air in the abdomen. There are
no pathologically enlarged lymph nodes in the retroperitoneum or
mesentery. There are moderate calcifications in the abdominal
aorta and iliac vessels.
.
CT PELVIS: The urinary bladder, prostate, and seminal vesicles
appear within normal limits. There is a small fat-containing
inguinal hernia, with a small amount of soft tissue as seen on
prior, (3B:162). There is no free fluid in the pelvis. There is
Foley catheter in the urinary bladder.
.
OSSEOUS STRUCTURES: There are similar fractures through the
right eighth and ninth ribs, comminuted as seen on most recent
CT. Nondisplaced rib fracture in the postero-superior rib on the
right, unable to compare to prior since that part of the chest
was not included on prior CT. Multilevel degenerative changes in
the spine.
.
IMPRESSION:
1. No filling defect in the pulmonary artery to suggest
pulmonary embolus.
.
2. Large right pleural effusion with adjacent atelectasis.
.
3. Small left pleural effusion with minimal atelectasis at the
left lung
base, in the lingula, and in the left anterior lung.
.
4. Segmental right eighth and ninth comminuted rib fractures,
similar to
prior. Nondisplaced rib fracture in the upper left posterior
chest wall,
uncertain if it is new since we do have prior CT chest to
compare.
.
5. Additional incidental findings are described in the report,
unchanged.
.
.
.
Fluid analysis (pleural fluid) [**2157-10-18**]
DIAGNOSIS: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
.
Brief Hospital Course:
This is an 89-year-old gentleman with a history of CAD s/p CABG
in [**2149**], multiple prior PCI's, recent NSTEMI in [**9-16**], on plavix
and ASA, Afib no longer on coumadin, HTN, HL, DM2, BPH, s/p
unwitnessed fall.
.
.
# s/p Fall: Unclear etiology based on history. [**Month (only) 116**] be secondary
to dehydration. Does not appear orthostatic. No vertigo. History
of carotid artery stenosis and CAD, but no changes on EKG s/o
cardiac etiology. Was mildly dehydrated and found to have a UTI,
which may have caused confusion and falls. Patient has a
history of falls. Ruled out for MI. Improved with minimal
intervention. Evaluated by PT, who suggested inpatient
rehabilitation.
.
# Hypotension: Initially hypotensive in the ED, most likely
secondary to blood loss, dehydration, and hypertensive
medications. Resuscitated with 3 L NS and 2 U PRBC's to
maintain blood pressures in the 110's-130's. Asymptomatic in
this range. BP medications initially held on the floors due to
concern of recurrent hypotension/blood loss status post fall.
HCT trended and stabalizaed around 30. Was stable throughout
hospital course. Continued sotalol as well as furosemide 20 mg
po daily upon discharge. Valsartan was held because blood
pressures were in the low hundreds range. FUROSEMIDE DOSE
DECREASED FROM 40 TO 20MG IN HOUSE AND PT LEFT ON THIS DOSE.
VALSARTAN HELD ON DISCHARGE for potential low BP in the presence
of acute fall.. PRIMARY CARE DOCTOR TO DECIDE WHEN TO
RESTART/CHANGE DOSING OF THESE MEDICATIONS.
.
# Pleural Effusion: found to ahve significant right sided
pleural effusion on admission xray. Tapped effusion, drained
1.5 L of bloody fluid. No malignant cells present. Thought to
be potential hemothorax from broken rib. Possible
reaccumulation seen by HD3, but interventional pulmonology
hesistant to tap given pt. is asymptomatic, breathing well on
room air, and on continual clopidogrel administration. Will
re-evaluate as an outpatient as necessary, but did not re-tap
patient during hospital stay. No further intervention pursued.
MR. [**Known lastname **] SHOULD HAVE A FOLLOW UP CXR IN [**1-9**] WEEKS.
.
# Rib fracutre: found to have non-displaced rib fracture on
right. Asymptomatic during stay. No further intervention
pursued.
.
# UTI: patient with GNRs in urine found to be pansensitive
(except to TMP/SMX) K. pneumoniae. Pt. received 5 days worth of
ceftriaxone, and will continue to receive 5 days worth of
cefpodoxime out of hospital for complicated UTI. Asymptomatic
during hospital course.
.
# Hyponatremia: Initially 126. Improved to 130s with IV
hydration. Likely initially hypovolemic hyponatremia. Encouraged
PO intake with minimal IVF supplementation. Ranged from 127-132
in house. Pt. discharged at 128. Encouraged not to drink free
water but rather diluted juices. Fluid intake limited to 2L per
day.
.
# CAD: s/p CABG and recent NSTEMI in [**2157-9-7**]. Currently
CP free and ruled out for MI by enzymes on this admission. Last
echo in [**9-/2157**] showed EF 30%. Held Valsartan for several days
due to BP 100-110's. Had Sotalol held a few times due to
hypotension. Continued on ASA, Plavix, and Simvastatin for
entire stay. Lasix was given at 20 mg dose, but held for 2 days
as pt appeared dry. Discharged on all original cardiac meds
(ASA, Plavix, Sotalol, SImvastatin, Valsartan, Furosemide),
except furosemide and valsartan given at lesser dose of 20 mg
and 160 mg qday respectively given possible overdiuresis that
caused his dehydration/fall and relatively low blood pressures.
.
# Systolic Heart Failure: Pt. has prolonged cardiac hx as well
as hx of HF flares. Recently hospitalized in [**9-/2157**] with HF
exacerbation. Last documeneted EF in [**9-/2157**] was 30%. Was
maintained on BB, [**Last Name (un) **], with diuresis PRN furosemide. Did not
have issues with being fluid overloaded while in the hospital.
Effusions felt to be [**2-8**] traumatic injury rather than pulmonary
congestion. Discharged on home regimen with f/u with his
cardiologist within the month. Lasix was decreased to 20 mg
daily and valsartan was held due to hypotension/low normal BP.
PCP'S DECISION TO CHANGE FUROSEMIDE DOSE AND RESTART VALSARTAN.
Pt encouraged to have PO intake of fluids, but to limit intake
to <2L / day and to weigh himself daily based on hx. of sHF.
.
# Afib: Was initially in NSR. Not on coumadin because of history
of falls. Was removed from tele 2nd day on the general medical
floors, as he was not symptomatic/having fib waves. He was
managed with sotalol and ASA 325mg and Plavix 75mg daily without
issues.
.
#BPH- history of difficulty urination, s/p TURP. Wife requested
in house urology evaluation, but based on the lack of acuity of
pt's symptoms, was deferred for outpatient management. Had
foley in place to manage UOP, which was borderline on HD3/4 in
the range of 400-500 cc's per day. Bolused sparingly, 500 cc's
NS once a day toward the end of hospital stay. UOP normalized,
and foley removed. Pt encouraged to have PO intake of fluids,
but to limit intake to <2L / day and to weigh himself daily
based on hx. of sHF.
.
# Diet controlled DM: managed with qid fingersticks, SSI, and
diabetic diet without issues.
.
Comm: [**Name (NI) **] [**Name (NI) 97194**] (wife) [**Telephone/Fax (1) 97200**]
Code: FULL -confirmed with HCP
.
.
.
Medications on Admission:
1. Sotalol 20 mg po bid
2. Simvastatin 40 mg po daily
3. Nitroglycerin 0.3 mg SL PRN chest pain
4. Tamsulosin 0.4 mg po qhs
5. Omeprazole 20 mg po daily
6. Multivitamin po daily
7. Furosemide 80 mg po daily
8. Valsartan 320 mg po daily
9. Aspirin 325 mg po daily
10. Clopidogrel 75 mg po daily
11. Docusate Sodium 100 mg po bid
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. sotalol 80 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day).
9. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day:
Please continue to take until [**2157-10-26**] for a total of 10 days
worth of antibiotics.
Disp:*12 Tablet(s)* Refills:*0*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary:
Traumatic Rib Fracture
Pulmonary Effusion (Hemothorax)
Urinary Tract Infection
.
Secondary:
Coronary Artery Disease status post coronary artery
stents/angioplasty/bypass grafting
History of myocardial infection
Diabetes Mellitus
Atrial fibrillation
Hypertension
hyperlipidemia
hyponatremia
Anemia
Osteoarthritis
Benign Prostatic Hyperplasia
Spinal stenosis
Carotid stenosis
Diverticulosis
Gastroesophageal Reflux Disease
Stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall in your
home. Prior to the fall, you were feeling confused which may
have caused you to fall. You were found to be dehydrated and
also have a urinary tract infection when you came to the
hospital, which may have been contributing to your feelings of
confusion. You had imaging done in the emergency department,
which was negative for a bleed in your brain. Images of your
chest showed an old rib fracture on the right and an old
collection of fluid around your right lung (most likely from
your previous fall 1 month ago).
You were taken to the intensive care unit because you were
having difficulty maintaining oxygenation and keeping your blood
pressure up. You had the fluid around your lung drained, which
was mostly blood likely from your old rib fracture. You
received 2 blood transfusions as you also had a cut on your head
which bled a significant amount. These interventions helped
stabilize your blood pressure and oxygenation.
You were transferred to the general medical service, where
your UTI was treated. You remained stable for several days, and
were transferred to a rehabilitation facility for further
strengthing prior to going home.
.
.
.
While in the hospital, some of your medications were adjusted or
even stopped briefly. The following changes have been made to
your daily medications.
.
.
STOP TAKING : Furosemide 40 mg by mouth daily
START TAKING: Furosemide 20 mg by mouth daily
.
STOP TAKING: Valsartan 320 mg by mouth daily (to be resumed by
your PCP)
.
START TAKING: Cefpodoxime 200 mg by mouth daily (antibiotic for
UTI)
.
.
Since you have a diagnosis of systolic heart failure, you should
weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs, as you may need to increase your fursoemide.
.
It has been a pleasure taking care of you [**Known firstname **]!
Followup Instructions:
You have an appointment with your primary care [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97201**] on [**2157-10-27**] at 2:30 PM. Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 97202**]
Phone: [**Telephone/Fax (1) 53711**]
.
Other Appointments
.
Department: CARDIAC SERVICES
When: [**Telephone/Fax (1) **] [**2157-10-31**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: THURSDAY [**2157-11-10**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,832
| 103,049
|
18504+56962
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-1-5**] Discharge Date: [**2168-1-15**]
Date of Birth: [**2097-2-20**] Sex: F
Service: [**Location (un) 259**] M
CHIEF COMPLAINT: Nausea, vomiting, fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
female with a history of coronary artery disease and chronic
obstructive pulmonary disease recently admitted status post
fall with surgical resection of damaged lung parenchyma,
multiple compound rib fractures. Her course was complicated
by acute abdominal infections. She was found to have a
gangrenous right colon status post colectomy with end
ileostomy, second look on [**10-23**] small bowel resection and end
ileostomy preceded by third look, found to have small bowel
perforations times two. She had multiple bowel resections
with end jejunostomy. She was placed on a tracheostomy on
[**11-9**] and was noted to have positive Klebsiella sputum
Methicillin resistant Staphylococcus aureus and Pseudomonas
at that time; she was discharged on [**11-21**] to rehabilitation
on TPN via PICC line.
She presents this evening after two day history of fever,
temperature around 103.0 F., mild abdominal pain, nausea,
vomiting. No diarrhea and no bright red blood per ostomy.
She was cultured on [**2167-11-4**], and found to have GPCs in
blood and was sent to [**Hospital1 69**].
In the Emergency Room, the patient was noted to be
hypotensive at 80/47, was given Solu-Medrol 125 intravenously
times one, started on Linezolid, Ciprofloxacin and
Ceftazidime with aggressive intravenous volume resuscitation.
Temperature at that time was 103.0 F., heart rate 92;
respiratory rate 23, 92% on three liters nasal cannula.
The patient was admitted to the Medical Intensive Care Unit
Service for septic shock physiology.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease status post myocardial infarction
and percutaneous transluminal coronary angioplasty with stent
in [**2162**].
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Status post fall with multiple rib fractures, spontaneous
pneumothorax and hemothorax requiring Intensive Care Unit
level care.
6. Post care complications with gangrenous colon resection,
small bowel perforation status post multiple bowel
resections.
7. Diabetes mellitus type 2.
8. Nutritionally compromised secondary to short gut.
ALLERGIES: Rash to penicillin; codeine with nausea and
vomiting.
MEDICATIONS ON ADMISSION:
1. Lopressor 12.5 p.o. twice a day.
2. Levothyroxine 100 micrograms p.o. q. day.
3. Regular insulin sliding scale.
4. Ceftazidime which was started in the Emergency Room, one
gram q. eight.
5. Micronidasol cream.
6. Klobesterol.
7. Atrovent.
8. Octreotide 0.1 mg subcutaneously twice a day.
9. B12 shots.
10. Ativan 1 mg p.r.n.
11. Lasix 40 mg p.o. q. day.
12. Hydroxyzine 25 q. four p.r.n.
13. Tylenol p.r.n.
14. Albuterol.
15. Linezolid 600 mg intravenously q. 12.
SOCIAL HISTORY: Positive for tobacco, smoking one pack per
day, 100 pack years; occasional alcohol.
LABORATORY: She was anemic with a hematocrit of 27.5, white
blood cell count of 13.5 without left shift, hyponatremic at
122. Potassium 3.8, chloride 86, bicarbonate 27, BUN 15,
creatinine 0.8, glucose 159, lactate 2.3, ALT 27, AST 35,
alkaline phosphatase 110, amylase 52, lipase 19, total
bilirubin 0.7.
Sinus tachycardia on EKG at a rate of 130. Reciprocal S
waves leads I, II, AVL, V5, V6, right bundle branch block.
Echocardiogram on [**2167-10-20**] revealed an ejection fraction of
greater than 55%, left atrial mild dilatation.
HOSPITAL COURSE: This is a 70 year old female with coronary
artery disease, chronic obstructive pulmonary disease status
post lengthy surgical admission requiring multiple bowel
resections, who presented from a rehabilitation facility on
TPN via PICC. The patient was admitted for a sepsis
protocol.
1. Started on Dopamine a.d., weaned off [**First Name8 (NamePattern2) **] [**Last Name (un) **] of greater
than 70; started on Vancomycin to cover Methicillin resistant
Staphylococcus aureus possible line infection. Outside
hospital microdata revealed six out of six enterococcus
species; later speciated to be pan sensitive as well as three
cultures positive for fungal, later speciated to be C.
albicans. Repeat blood cultures were drawn on [**12-2**]
and [**1-10**], of which only [**1-5**] revealed C. albicans moderate
growth.
The PICC line was discontinued and culture of tip grown again
positive for fungemia and bacteremia. In light of high grade
sepsis, the patient was continued on Linezolid initially and
transitioned to Vancomycin to cover enterococcus species.
She was initially started on a dose of amphotericin
transitioned to intravenous fluconazole. Transthoracic
echocardiogram and transesophageal echocardiogram revealed no
presence of endocarditis or vegetations.
An ophthalmology consultation was obtained to rule out fungal
retinopathy which was negative. The patient was weaned off
pressors on hospital day one and stabilized. She was
afebrile on hospital day one with a decreasing white count
and no true evidence of leukocytosis or intra-abdominal
process. A CT scan of the abdomen was obtained given
patient's multiple anastomoses with concern for abdominal
abscess and/or free fluid collection. CT scan of the abdomen
revealed no abscess, no fluid collection and no
intra-abdominal process. Empiric antibiotic coverage was
discontinued at that time.
The patient was weaned off pressors and successfully volume
resuscitated and given one unit of packed red blood cells as
well as normal saline boluses to maintain MAP. The patient
remained afebrile throughout hospital days two through ten
with no leukocytosis, no physical examination findings
suggestive of intra-abdominal process. Culture data remained
no growth to date after [**1-6**]. A PICC line was placed on
[**2168-1-12**] via Interventional Radiology.
The patient has per report a history of a penicillin allergy.
On questioning, the patient's allergies were small facial
rash. Given lack of anaphylactic reaction or hives, a trial
of Ampicillin was performed with 250 mg intravenously times
once. The patient did not have pruritus, rash, hives or any
evidence of hemodynamic compromise. Transition from
Vancomycin to Ampicillin 2 grams three times a day was made.
The patient to continue on Intravenous Ampicillin times two
weeks and transition to amoxicillin for an additional two
more weeks at rehabilitation facility.
Anti-fungal [**Doctor Last Name 360**], fluconazole was transitioned from
intravenous to p.o. without sequelae. Will continue on
fluconazole for remaining four week course as well to be
terminated at same time as amoxicillin.
Note: In rehabilitation facility, PICC line may be removed
once completion of Ampicillin therapy.
2. Cardiac: The patient has a history of percutaneous
transluminal coronary angioplasty with stent. At outside
hospital EKG with deep S waves and tachycardia. Cycled
enzymes revealed small troponin leak of 0.04. In light of
sepsis, likely due to demand ischemia without significant EKG
changes. Continued on a beta blocker titrated up, metoprolol
and an addition, Lisinopril once blood pressure stabilized
was made. Hemodynamics remained stable throughout remaining
hospital course. One event on Telemetry in the Medical
Intensive Care Unit pertinent for a 25 beat of nonsustained
ventricular tachycardia. Electrolytes were repleted
appropriately. No further events were recorded on Telemetry.
The patient would benefit from outpatient stress test once
intravenous antibiotics are complete.
3. Gastrointestinal: Status post multiple bowel surgeries.
The surgical team is following. No significant findings on
examination, although in light of extent of resection, the
patient was unable to meet p.o. nutrition requirements on her
own. The decision to place a G-tube was made on hospital day
seven. G-tube was placed by General Surgery. The patient
tolerated the procedure well and began continued tube feeds
with goal of cycle tube feeds at night to meet 100% of
nutritional requirements. The patient will be able to eat
during the day for additional caloric needs.
4. Pulmonary: Initially with hypoxia on admission. Chest
x-ray with no clear indication of pneumonia nor aspiration
pneumonia. The patient remained on nebulizers and aggressive
pulmonary toilet, appropriately diuresing once hypotension
resolved and mobilization of extra vascular fluid was
achieved. At time of discharge, the patient was saturating
97% on two liters nasal cannula with a goal of weaning per O2
saturations greater than 92%. The patient to continue on
nebulizers and appropriate respiratory Physical Therapy,
incentive spirometry, at outpatient rehabilitation.
5. Endocrine: The patient was noted to be hypothyroid.
Continued on Synthroid.
Diabetes per patient; the patient was non-diabetic in the
[**Month (only) **] admission after her fall. Blood sugar is
consistently in the 100s, not requiring regular insulin
sliding scale coverage. Insulin sliding scale was continued
during hospital course in concern for insulin resistance
secondary to hypercortisol state during sepsis, currently
resolved. No requirements for insulin.
DISCHARGE MEDICATIONS:
1. Ampicillin two grams intravenously q. eight hours times
two weeks.
2. At completion of #1, amoxicillin 875 mg p.o. twice a day
times an additional two weeks.
3. Fluconazole 400 mg p.o. q. day times four weeks.
4. Captopril 6.25 mg p.o. three times a day.
5. Albuterol nebulizers, one nebulizer inhaler q. two p.r.n.
6. Metoprolol 12.5 mg p.o. twice a day.
7. Fentanyl patch 50 micrograms an hour transdermal q. 72
hours.
8. Micronidasol powder, 2%, one application topical four
times a day p.r.n.
9. Albuterol Ipratropium one to two puffs inhaler q. four
hours.
10. Tylenol 650 mg q. four to six p.r.n.
11. Zofran 2 mg intravenously q. six p.r.n. nausea.
12. Pantoprazole 40 mg p.o. q. day.
13. Heparin 5000 units subcutaneously q. hour until
ambulating.
14. Aspirin 325 mg p.o. q. day.
15. Octreotide acetate 100 micrograms subcutaneously twice a
day.
16. Levothyroxine 100 micrograms p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to continue with rehabilitation and
Physical Therapy as well as Respiratory Therapy with goal to
wean O2 to oximetry saturation of greater than 92%.
2. Will continue course of intravenous antibiotics times two
weeks; at that point, PICC line will be discontinued and
transitioned to oral for a total of one month of therapy.
3. Per recommendations of Rehabilitation facility, the
patient will be returning to primary care physician in
[**Name9 (PRE) 108**] for remainder of care and rehabilitation.
4. As caloric goals are met via G-tube, if patient is able
to tolerate increased p.o., discontinuation of G-tube can be
made at that time.
5. Recommend follow-up closely per General Surgery in
[**State 108**] and/or sooner.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**]
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2168-1-13**] 14:02
T: [**2168-1-13**] 14:03
JOB#: [**Job Number 50869**]
(cclist)
Name: [**Known lastname 9474**],[**Known firstname **] Unit No: [**Unit Number 9475**]
Admission Date: [**2168-1-5**] Discharge Date: [**2168-1-20**]
Date of Birth: Sex:
Service:
ADDENDUM: The patient's anticipated for [**2168-1-15**]
was postponed due to an increase in erythema and nausea at
the site of the gastrojejunostomy tube. At this time,
vancomycin was continued over ampicillin for better
Staphylococcus coverage. A computed tomography of the
abdomen was obtained with contrast which was negative for
abscesses and revealed good placement of gastrojejunostomy
tube site. No intra-abdominal process. Tube feeds were
slowed down to 25 cc per hour with resolution of nausea.
On [**1-18**], the patient developed 5/10 chest pain that
she described as her typical anginal pain. An
electrocardiogram was obtained which showed no significant
abnormalities.
Given the patient's prior cardiac history of cardiac
stenting, the Cardiology team was consulted. The patient's
troponin levels remained mildly elevated, but this was felt
secondary to her prior troponin leak in the setting of demand
ischemia during her sepsis. Troponin and CK/MB levels
remained flat.
A pharmacologic MIBI stress test was obtained which revealed
normal wall motion. No hypokinesis or akinesis. Left
ventricular ejection fraction was greater than 60%. There
was a small basilar inferior wall reversible defect.
In discussion with Cardiology, it was felt that this was best
managed with medical management with proper followup with her
cardiologist as soon as she returns to [**State 675**], titration up
of her ACE inhibitor and beta blocker, and continue on
aspirin and initiation of statin.
On [**2168-1-19**] the peripherally inserted central
catheter line was discontinued after completion of her 14-day
course of intravenous vancomycin. The patient was discharged
to rehabilitation for the remaining two weeks of amoxicillin
and four weeks of fluconazole.
The Nutrition Service amended tube feeding recommendations to
be cycled at night to meet her caloric needs. Appropriate
complete blood count for monitoring the patient's chronic
anemia should be obtained. A Chemistry-7 should be monitored
for her hyponatremia, as well as possible contraction
alkalosis should be obtained every week. Liver function
tests should be monitored every week as well while the
patient is on fluconazole.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with her primary
care physician as soon as she returns to [**State 675**].
2. The patient was instructed to have appropriate followup
with the general surgeon to assess her ostomy site and manage
her gastrojejunostomy tube.
3. The patient was instructed to be in touch with a
cardiologist as well.
MEDICATIONS ON DISCHARGE:
1. Levothyroxine 100 mcg by mouth every day.
2. Pantoprazole 40 mg by mouth once per day.
3. Albuterol/ipratropium nebulizers 1 to 2 puffs q.4h. as
needed.
4. Heparin 5000 units subcutaneously q.8h. (while in bed).
5. Aspirin 325 mg by mouth once per day.
6. Ipratropium nebulizer q.6h. as needed.
7. Tylenol as needed.
8. Albuterol nebulizer q.2h. as needed.
9. Amoxicillin 500 mg by mouth twice per day (for two
weeks).
10. Captopril 12.5 mg by mouth three times per day.
11. Metoprolol tartrate 50-mg tablets 0.75 tablet by mouth
twice per day (to be titrated to heart rate and blood
pressure).
12. Zofran 2 mg intravenously q.6h. as needed (for nausea).
13. Lorazepam 0.5-mg tablets one to two tablets by mouth
q.4-6h. as needed (for anxiety and nausea).
14. Fluconazole 400 mg by mouth every day (times four
weeks).
15. Fentanyl 50-mcg patch transdermally for 72 hours every
three days.
16. Miconazole powder four times per day as needed.
17. Lipitor 10 mg by mouth once per day.
18. Oxygen may be titrated for oxygen saturations of greater
than 92%
19. Calcium carbonate by mouth every day.
20. Vitamin D by mouth every day.
21. Multivitamin by mouth every day.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DISPOSITION: The patient to be discharged to
rehabilitation.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The
1. patient to have appropriate followup with her
cardiologist, general surgery, and her primary care
physician.
2. The patient was given a packet of recent computerized
axial tomography scans of the abdomen, prior echocardiograms,
as well as Persantine MIBI stress test.
3. The patient was also given house officer pager number to
be contact[**Name (NI) **] once she arrives in [**Name (NI) 675**] for appropriate
transition of care to her primary care physician.
Dictated By:[**Last Name (NamePattern1) 3036**]
MEDQUIST36
D: [**2168-1-20**] 11:32
T: [**2168-1-20**] 12:22
JOB#: [**Job Number 9476**]
|
[
"038.0",
"996.62",
"785.52",
"276.1",
"496",
"995.91",
"117.9",
"579.3",
"362.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"43.11",
"88.72",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15404, 15453
|
9314, 10226
|
14121, 15329
|
2465, 2942
|
3604, 9291
|
10250, 13716
|
15487, 16109
|
15344, 15380
|
176, 203
|
232, 1780
|
1802, 2439
|
2959, 3586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,563
| 169,341
|
37204
|
Discharge summary
|
report
|
Admission Date: [**2175-1-17**] Discharge Date: [**2175-1-20**]
Date of Birth: [**2094-3-13**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Ischemic bowel
Major Surgical or Invasive Procedure:
[**2175-1-17**] Exploratory laparotomy and small bowel
resection.
[**2174-1-19**] Exploratory lapartomy
History of Present Illness:
80year old female who presents to [**Hospital3 26615**] with 2 days of
vomiting and diarrhea. She has had epigastric pain for one week
which has gotten progressively worse and constant for the last
day. She also felt week and tired. Denies fever, chills or
night sweats. Emesis was nonbloody, nonbilious. Denies bright
red blood per rectum or melena. CT scan at [**Hospital3 26615**] showed
pneumatosis of the small bowel and portal venous air. She was
emergently transferred to [**Hospital3 **] by med flight. She has
received 4 liters of LR and has made approximately 30 cc of
urine.
Past Medical History:
Past Medical History: Anxiety and hypertension
.
Past Surgery History: Does not know. Has had cataract surgery
Social History:
Social History: Lives with husband and daughter. Denies tobacco
and ETOH.
Family History:
Family History: Noncontributory
Physical Exam:
Physical Exam
Vital Signs: Temp 97.9 HR 151 BP 118/66 RR 44 O2 Sat 91 % on 6
L
NC
General: Tachypneic
Cardiovascular: Tachycardiac
Lung: Clear to auscultation bilateral
Abdomen: Distended, guarding, tender in the upper abdomen
Pertinent Results:
On admission
EKG: Sinus Tachycardia
.
CT Scan Abdomen/Pelvis: Dilated Jejunum is present with
extensive
pneumatosis. Extensive portal venous air is also present. Small
bowel infarction with air in the mesenteric veins extending into
the portal venous system. Severe pancreatitis. Cholelithiasis.
Small amount of ascites.
.
Labs:
138 107 42 187 AGap=18
3.9 17 2.1
CK: 136 MB: Pnd
Ca: 5.6 Mg: 1.5 P: 3.4
ALT: 116 AP: 54 Tbili: 0.5 Alb:
AST: 77 LDH: Dbili: TProt:
Lipase 1402
12.4 13.6 247
41.9
N:89.5 L:6.3 M:3.6 E:0.3 Bas:0.3
PT: 16.5 PTT: 30.6 INR: 1.5
Brief Hospital Course:
[**1-17**]: TICU admission s/p exploratory laparotomy and small bowel
resection, aggressive fluid resuscitation
[**1-18**]: continued massive fluid resuscitation. Pt's tachycardia
and hypotension very fluid responsive. New right subclavian
line placed and left subclavian removed. Plateau pressures
increased from ~ 27 to 30-35; decreasd tidal volumes. Started
TPN.
[**1-19**]: Pancytopenic. Requiring pressors prior to OR. Return TO
OR for eval of bowel with large segments of compromised bowel.
After family meeting patient made CMO.
Medications on Admission:
[**Last Name (un) 1724**]: Lisinopril 30 mg PO Daily, Celexa 20 mg
PO Daily, Xanax 0.25 mg PO TID, Metoprolol 50 mg PO Daily,
Depakote 250 mg PO BID, Cosopt left eye [**Hospital1 **], Zocor 80 mg PO
QHS, Lumigan both eyes daily, Ambien as needed for sleep
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Pancreatits
Ischemic Bowel
Death
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2175-1-20**]
|
[
"401.9",
"518.5",
"574.20",
"284.1",
"276.2",
"300.00",
"567.89",
"557.0",
"577.0",
"568.89",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"54.12",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3079, 3088
|
2205, 2746
|
330, 436
|
3164, 3173
|
1602, 2182
|
3224, 3257
|
1320, 1338
|
3052, 3056
|
3109, 3143
|
2772, 3029
|
3197, 3201
|
1353, 1583
|
275, 292
|
464, 1060
|
1104, 1195
|
1227, 1288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,286
| 198,584
|
33008
|
Discharge summary
|
report
|
Admission Date: [**2173-3-17**] Discharge Date: [**2173-3-21**]
Date of Birth: [**2114-6-30**] Sex: M
Service: MEDICINE
Allergies:
AVASTIN
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Cough, shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
58 M h/o NSCLC stage III s/p chemo, RUL lobectomy and no
residual thoracic/abd/pelvic disease on CT with brain mets s/p
cyberknife x 3, CAD, COPD fev1 of 69% p/w cough and shortness of
breath. Patient started feeling poorly after his last radiation
treatment with cyberknife on [**2173-3-11**]. Started having URI
symptoms with mild cough, congestion. Since last night he felt
very short of breath and was unable to get a ride to the ED
until today, worsening shrotness of breath over this period of
time and worsening cough prodcutive of yellow/white sputum. He
uses 2-3L of nasal cannula O2 per chart nightly, but per pt and
family he only uses this abourt "one hour per week." Denies any
fevers. Does have pain in his lower chest/upper abdomen with
coughing, no vomiting, nausea, diarrhea, constipation or other
complaints. Brought to ED by wife and daughter in law. Pt
Polish speaking only so interview was conducted with
interpreter.
.
On presentation to the ED, vital signs were t99.5, hr150s,
sbp90s, with sats 95% on room air but breathing 40bpm. On exam
he had increased work of breathing with use of intercostal
muscles, rhonchi and exp wheezes bilaterally, othwerise
nonfocal. CXR appeared unchanged from baseline but temp to
100.3 and appeared toxic, so he was given levofloxacin. He had a
CTA since he had tachycardia, hypoxia which showed no PE but LLL
not visualized well due to motion artifact, and mult ground
glass opacities suggestive of multifocal pneumonia. He was given
vancomycin and cefepime in addition to the levofloxacin dose, 1L
of fluid, and albuterol x 3, atrovent x 3, and started bipap
which helped with decreased work of breathing. Abg was
7.4/31/170/28 while on bipap. He was taken off bipap and
tolerated NRB on transfer to the unit.
.
On arrival to the ICU, pt feels much better and is comfortable
on NRB. Denies any complaints currently.
Past Medical History:
Past Medical History:
CAD with h/o remote MI per results of recent echocardiogram and
s/p cardiac cath on [**2171-2-4**] with totally occluded RCA and slow
flow through LAD
Hypertension.
Hyperlipidemia.
COPD, FEV1 69% 1/10
CVA on Avastin [**7-/2172**]
seizure disorder secondary to metastatic brain lesions
.
ONCOLOGIC HISTORY:
- presented to [**Hospital1 2177**] [**3-/2170**] with shortness of breath, CT showed
RUL lung mass, bronchoscopy was done but pt was lost to f/u
until
[**10-19**]
- [**10-19**] presented to Dr. [**Last Name (STitle) 58318**] at [**Hospital1 18**], CT [**2170-10-31**] showed
2.7cm x 2.7 cm spiculated irregular nodule in the posterior RUL
with associated 1.3 cm precarinal lymph node
- [**2170-12-14**]: bronchoscopy and mediastinoscopy with sampling of 4L,
4R, level 7 lymph nodes. Lymph node biopsies negative
- [**2170-12-21**]: CT-guided lung biopsy showed carcinoma with clear
cell features consistent with renal origin. Because the
specimen was CK7 positive, TTF-1 positive and CK20 negative, it
was felt to be most consistent with a primary lung tumor. No
renal
lesion was seen.
- [**2170-12-22**]: PET again revealing the 2.7 x 2.7 cm right upper
lobe mass, which was markedly FDG avid (SUV 12.7). The
previously
noted precarinal lymph node of 1.8 x 0.5 cm was also FDG avid
(SUV 10.5). A paratracheal lymph node of 0.6 cm had an SUV of
3.6.
- [**2170-12-26**] MRI Brain: no evidence of metastatic disease.
- [**2171-2-4**]: repeat bronchoscopy with endobronchial ultrasound was
done due to the markedly FDG-avid precarinal lymph node seen on
PET scan. The 4R lymph node station was again sampled, which
revealed the presence of malignant cells, consistent with
adenocarcinoma.
- [**2171-3-4**] XRT with concurrent cisplatin and etoposide for 2
cycles
- [**2171-4-17**]: repeat bronchoscopy and mediastinoscopy to assess for
residual lymph node disease revealed malignant cells in the 4R
lymph node, making him not a surgical candidate
- continued XRT only, completed [**2171-5-1**]
- [**2171-6-18**]: resumed chemotherapy with cisplatin-pemetrexed at
doses of cisplatin 75 mg/m2 day 1 and pemetrexed 500 mg/m2 day
1, given on [**2171-6-18**] and [**2171-7-9**].
- [**2171-7-25**]: CT Chest showed reduction in size of RUL mass
[**7-/2171**]/[**2172**]: Stable disease on imaging without treatment.
- [**2172-6-24**]: PET scan showed new right hilar mass and increased
avidity of RUL nodule. Brain MRI negative for metastatic
disease.
- [**2172-7-6**]: Carboplatin (AUC 6), Taxol (200mg/m2), Bevacizumab.
Course complicated by CVA on [**2172-7-18**] which subsequently resolved.
- [**2172-7-28**]- [**2172-9-8**]: Received 3 additional cycles of [**Doctor Last Name **]/Taxol
with Bevacizumab omitted. CT with stable disease.
- RUL lobectomy on [**2172-11-6**] and RML lobectomy for atelectatic
lung on [**2172-11-22**]
- [**Date range (3) 76763**]- presentes with new onset seizures with
discovery of new brain metastases, started on decadron and
keppra
- [**Date range (2) 76764**]: 3 single fraction treatments with Cyberknife
for brain metastases from NSC lung cancer
Social History:
Immigrated from Poland 8 years ago. Unemployed, used to work
helping blind children. Quit tobacco recently, 40 pack year
history. No etoh or illicits.
Family History:
No FHx of lung cancer, relative with throat cancer.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: inspiratory and expiratory wheezes bilaterally, no rales
or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION EXAM:
[**2173-3-17**] 04:19PM BLOOD WBC-15.3* RBC-4.18* Hgb-12.5* Hct-36.8*
MCV-88 MCH-30.0 MCHC-34.1 RDW-17.8* Plt Ct-341
[**2173-3-17**] 04:19PM BLOOD Neuts-77* Bands-4 Lymphs-13* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2173-3-17**] 04:19PM BLOOD PT-31.8* PTT-45.7* INR(PT)-3.1*
[**2173-3-17**] 04:19PM BLOOD Glucose-124* UreaN-35* Creat-1.3* Na-131*
K-7.7* Cl-98 HCO3-20* AnGap-21*
[**2173-3-17**] 04:19PM BLOOD Glucose-128* UreaN-35* Creat-1.3* Na-133
K-5.6* Cl-99 HCO3-23 AnGap-17
[**2173-3-17**] 04:19PM BLOOD proBNP-393*
[**2173-3-17**] 04:48PM BLOOD Type-ART pO2-170* pCO2-31* pH-7.48*
calTCO2-24 Base XS-1
[**2173-3-17**] 04:25PM BLOOD Lactate-1.7
.
[**2173-3-17**] CTA CHEST: IMPRESSION:
1. Evaluation for pulmonary embolism is limited secondary to
patient motion.
No definite pulmonary embolism to the segmental levels
bilaterally.
2. Diffuse ground-glass ground-glass opacities throughout the
right lung and minimally within the left upper lobe and lingula
raise concern for a multifocal infectious process.
3. Uncomplicated cholelithiasis.
.
[**2173-3-17**] CXR: IMPRESSION:
1. No acute cardiac or pulmonary process.
2. Post-surgical changes in the right hemithorax, consistent
with prior right upper lobectomy. The degree of pleural
thickening and/or loculated pleural effusion at the right apex
is decreased.
.
DISCHARGE LABS:
[**2173-3-21**] 06:25AM BLOOD WBC-8.4 RBC-4.03* Hgb-11.4* Hct-34.6*
MCV-86 MCH-28.3 MCHC-33.0 RDW-17.4* Plt Ct-316
[**2173-3-21**] 06:25AM BLOOD PT-24.9* INR(PT)-2.4*
[**2173-3-21**] 06:25AM BLOOD Glucose-152* UreaN-34* Creat-1.1 Na-133
K-4.9 Cl-98 HCO3-25 AnGap-15
[**2173-3-20**] 06:10AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.6
[**2173-3-21**] 06:25AM BLOOD Albumin-3.5
[**2173-3-21**] 06:25AM BLOOD ALT-60* AST-16 LD(LDH)-220 AlkPhos-95
TotBili-0.2
[**2173-3-17**] 04:19PM BLOOD proBNP-393*
[**2173-3-18**] 02:06PM BLOOD B-GLUCAN-Negative
Brief Hospital Course:
58yo man with CAD, COPD FEV1 69%, metastatic NSCLC to brain s/p
chemo, RUL lobectomy, and cyberknife presenting with cough and
dyspnea consistent with COPD exacerbation. He started feeling
poorly after his last cyberknife [**2173-3-11**], then cough and
congestion since night PTA. Tachypnea and tachycardia in ED,
required NRB and BIPAP briefly. CTA neg for PE and was started
on empiric treatment for possibly HAP due to temp 100.3F.
Started on standing nebs, IVFs, and dexamethasone. Respiratory
status has improved to the point he does not require oxygen
anymore.
.
# Acute respiratory distress: Due to COPD exacerbation, with
possible bronchitis vs. pneumonia. Sputum negative for PCP.
[**Name10 (NameIs) **] screen negative. Legionella Ag and beta glucan negative.
Now off oxygen even while ambulating, doing well clinically.
Nebs and fluticasone/salmeterol (Advair). Plan for levofloxacin
x7 days. Dexamethasone taking for brain mets. Guaifenesin for
cough.
.
# Tachycardia: Sinus to 150s in ED, improved after hydration.
.
# Hyperkalemia: Lisinopril recently restarted, but held this
admission. Possible causes of hyperkalemia include lisinopril,
metabolic acidosis, and RTA type IV. Hyperkalemia corrected
with Kayexalate and low K+ diet. Avoid NSAIDs for possible RTA
type IV and consider furosemide as outpatient. F/U with PCP
within one week.
.
# Hx of embolic CVA: Continued warfarin, goal INR [**2-12**].
.
# Stage III NSCLC with brain mets: Continued levetiracetam,
dexamethasone, PRN oxycodone. Continued TMP-SMX prophylaxis.
.
# HTN: Continued amlodipine. Lisinopril stopped due to
hyperkalemia.
.
# Depression: Continued mirtazapine.
.
# Anxiety: Continued PRN lorazepam.
.
# CAD: Continued atorvastatin.
.
# FEN: Regular cardiac diet.
.
# GI prophylaxis: Bowel regimen.
.
# DVT prophylaxis: Warfarin for embolic CVA hx.
.
# Access: Peripheral IV.
.
# Code: Full code confirmed with patient.
.
TRANSITION OF CARE ISSUES:
-monitoring of INR given abx (levofloxacin and bactrim) started
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of breath,
wheeze
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Amlodipine 10 mg PO/NG DAILY hold for SBP <100
Atorvastatin 80 mg PO/NG DAILY
Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever
Dexamethasone 4 mg PO/NG Q8H
Docusate Sodium 100 mg PO BID:PRN constipatoni
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
Guaifenesin [**5-20**] mL PO/NG Q6H:PRN cough
Ipratropium Bromide Neb 1 NEB IH Q6H
Levofloxacin 750 mg PO/NG DAILY
LeVETiracetam 1000 mg PO/NG [**Hospital1 **]
Lorazepam 0.5 mg PO/NG Q6H:PRN anxiety
OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
Ranitidine 150 mg PO/NG [**Hospital1 **]
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
Warfarin 5 mg PO/NG DAILY16
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Sig: 1
Nebulizer Inh Q2H PRN shortness of breath, wheeze.
2. amlodipine 10mg PO DAILY.
3. atorvastatin 80 mg PO DAILY.
4. acetaminophen 325-650mg PO Q6H PRN pain.
5. dexamethasone 4mg PO Q8H.
6. docusate sodium 100 mg PO BID PRN constipation.
7. fluticasone-salmeterol 500-50mcg/dose Sig: 1 Disk with Device
Inh [**Hospital1 **].
8. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H PRN cough.
Disp:*100 mL* Refills:*0*
9. ipratropium bromide 0.02% Solution Sig: 1 Nebulizer Inh Q6H
Dyspnea, wheeze.
10. levofloxacin 750mg PO DAILY x3 days.
Disp:*9 Tablet(s)* Refills:*0*
11. levetiracetam 1000mg PO BID.
12. lorazepam 0.5 mg PO Q6H PRN anxiety.
13. nitroglycerin 0.3 mg Sublingual PRN chest pain: [**Month (only) 116**] repeat
q5min up to 3x.
14. oxycodone 5 mg PO Q6H PRN pain.
15. senna 8.6 mg PO BID PRN constipation.
16. warfarin 5 mg PO Once Daily at 4 PM.
17. sulfamethoxazole-trimethoprim 800-160 mg PO qM/W/F.
Disp:*12 Tablet(s)* Refills:*3*
18. ranitidine HCl 150 mg PO BID.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Shortness of breath.
2. Cough.
3. COPD (emphysema) exacerbation.
4. Pneumonia.
5. Hyperkalemia (high potassium).
6. Lung cancer.
7. Hypertension (high blood presure).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for shortness of breath and
cough. This was likely due to a COPD (emphysema) exacerbation
and pneumonia. You were treated with antibiotics, nebulizers,
oxygen, and steroids. You will need to complete a course of
antibiotics at home. Your potassium levels were also elevated,
so your lisinopril was stopped and you were placed on a low
potassium diet.
.
MEDICATION CHANGES:
1. Levofloxacin daily x7 days total.
2. Trimethoprim-sulfamethoxazole (Bactrim) DS 1 tab every
Monday, Wednesday, and Friday to prevent lung infections.
3. Stop lisinopril.
Followup Instructions:
PLEASE CALL YOU PRIMARY CARE PHYSICIAN FOR AN APPOINTMENT THIS
WEEK. YOU NEED TO HAVE YOUR POTASSIUM LEVEL CHECKED THIS WEEK.
.
Department: RADIOLOGY
When: MONDAY [**2173-4-12**] at 8:35 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NEUROLOGY
When: MONDAY [**2173-4-12**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2173-4-20**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"300.00",
"V10.11",
"276.7",
"414.01",
"412",
"486",
"401.9",
"272.4",
"V12.54",
"311",
"491.21",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11966, 11972
|
8040, 10059
|
296, 303
|
12185, 12185
|
6118, 7464
|
12943, 13950
|
5542, 5595
|
10903, 11943
|
11993, 12164
|
10085, 10880
|
12335, 12726
|
7480, 8017
|
5610, 6099
|
12746, 12920
|
229, 258
|
331, 2218
|
12200, 12311
|
2262, 5358
|
5374, 5526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,402
| 113,544
|
31388
|
Discharge summary
|
report
|
Admission Date: [**2185-9-11**] Discharge Date: [**2185-9-19**]
Date of Birth: [**2120-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 yo male recently admitted to neurosurgery service at [**Hospital1 18**]
from [**Date range (1) 9154**] after sustaining an unexplained fall after
prolonged standing at work, who returned to [**Location **] today with
persistent nausea, vomiting, and vertigo. The patient had been
admitted for observation after a head CT showed a small
longitudinal mastoid fracture and a small traumatic SAH along
the lateral lining of the R. lower temporal bone. No surgical
intervention was deemed necessary. The pt was also evaluated by
ENT during that admission, noted to have fluid seen within the
left middle ear cavity, possibly representing blood, on CT of
temporal bones. Pt given Floxicin drops for 10 days with ENT
follow-up in two weeks.
.
In the ED the patient was found to be hypertensive to the 200's
systolic, improved with 20 mg IV labetalol. A CXR was thought to
be concerning for a new infiltrate, and he was given a dose of
levofloxacin. The patient underwent a repeat head CT which
showed interval resolution of small subarachnoid hemorrhage,
unchanged left temporal bone fracture. Neurosurgery was
consulted and felt no surgical intervention necessary at this
time. The patient was planned for admission to medicine for
syncope workup, however his blood pressure became difficult to
control and remained elevated despite 40 mg IV labetalol, 1 inch
of nitropaste, and SL nitro. The patient was then started on a
nitro drip with improvement of his blood pressure to 140's
systolic and was admitted to the [**Hospital Unit Name 153**] for close monitoring and
BP control.
.
On arrival to the floor patient states that he feels improved.
Denies headaches, changes in vision, chest pain or SOB. Denies
numbness or tingling in his extremities. No dysarthria. Denies
orthopnea, no LE edema, no recent change in exercise tolerance.
Has not had a history of syncope or falls in the past. Wife
notes that he has been unable to keep down his medications, also
notes "unsteady" on his feet, rises very slowly from sitting
position. Repeat head ct is negative. he was converted to po
anti-hypertensive medication and bp has been stable.
Past Medical History:
hypertension
SAH s/p fall/syncope after prolonged standing at work
Chronic gout- no flare for over a year
Leg weakness NOS
Pancreatic obstruction NOS 25 years ago, endoscopically released
Social History:
Lives with his wife, son, and daughter. [**Name (NI) 1403**] as a mechanic.
Quit smoking over 30 years ago, no ETOH for 20+ years. Denies
illicits.
Family History:
mother deceased age [**Age over 90 **], father died at age 55 of unknown cause,
heavy drinker
Physical Exam:
vitals: 96.7 bp 150/72 hr 62/min RR 17/min sats 97% on RA
GEN: comfortable at rest
HEENT: PERLAA, oropharynx clear
NECK: no LAD, no JVD, no carotid bruits
CV: RRR, no murmurs or rubs, PMI non-displaced,
LUNGS: CTA B/L w/ good inspiratory effort, no crackles or wheeze
ABDOMEN: soft, nt, nd, hypoactive BS
EXT: no [**Location (un) **], DP pulses palpable B/L
SKIN: dry, no rash
NEURO:CN II-XII grossly intact, A/O X3, normal finger-to-nose
and heel to shin testing, no nystagmus
Pertinent Results:
[**9-11**] Head CT: 1. Interval resolution of blood products in the
sulci of the anterior left temporal lobe, and occipital horns of
the lateral ventricles.
2. Left temporal bone fracture, with persistent fluid/blood in
that middle ear cavity, more completely evaluated and described
on temporal bone CT from [**2185-9-9**].
.
[**9-11**] CXR: FINDINGS: Two views are compared with the limited
bedside AP examination labeled "trauma" dated [**2185-9-7**]. There is
linear atelectasis at the left lung base with slight elevation
of that hemidiaphragm, new. However, no evidence of focal
consolidation is seen. The cardiomediastinal silhouette and
pulmonary vessels are within normal limits, with no evidence of
CHF. There are atherosclerotic changes involving the thoracic
aorta.
SEMI-UPRIGHT PORTABLE VIEW OF THE CHEST: Cardiac and mediastinal
contours are normal. Left lower lobe atelectasis has decreased.
There is interval development of pulmonary vascular engorgement
without interstitial or alveolar edema.
IMPRESSION:
1. New pulmonary vascular congestion without overt edema.
2. Interval improvement in left basilar atelectasis.
.
EKG: (not done in ED) sinus, Left bundle branch bloack, LAD,
borderline PR interval
.
TTE [**2185-9-12**]: Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right
atrial pressure is 0-5mmHg. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and regional/global systolic
function
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber
size and free wall motion are normal. The aortic root is
moderately 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. There is borderline pulmonary
artery systolic
hypertension. There is no pericardial effusion.
.
Head CT [**2185-9-13**]: FINDINGS: At this time, it is extremely
difficult to identify any intracranial hemorrhage. There has
been no change in ventricular size since the prior examination
nor evidence for new brain abnormality, including an infarct.
There is re-demonstration of what is likely a 2-mm Virchow [**Doctor First Name **]
space or sublenticular cyst, left-sided in locale. As the
present examination is a head CT scan, the left temporal bone
fracture is not clearly delineated at this time, compared to the
high-resolution temporal bone study from [**9-9**].
CONCLUSION: No new intracranial pathology is defined
[**2185-9-16**] 07:30AM BLOOD WBC-8.4 RBC-4.03* Hgb-13.3* Hct-35.7*
MCV-89 MCH-33.1* MCHC-37.3* RDW-13.3 Plt Ct-216
[**2185-9-11**] 03:15PM BLOOD WBC-8.2 RBC-3.81* Hgb-12.7* Hct-33.6*
MCV-88 MCH-33.4* MCHC-37.8* RDW-13.1 Plt Ct-194
[**2185-9-11**] 03:15PM BLOOD Neuts-81.9* Lymphs-13.8* Monos-3.3
Eos-0.6 Baso-0.4
[**2185-9-13**] 04:11AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-2+ Ovalocy-1+
Schisto-OCCASIONAL
[**2185-9-15**] 07:50AM BLOOD PT-12.1 PTT-30.0 INR(PT)-1.0
[**2185-9-19**] 07:40AM BLOOD UreaN-16 Creat-0.6 Na-130* K-3.9 Cl-96
HCO3-25 AnGap-13
[**2185-9-15**] 07:50AM BLOOD Glucose-113* UreaN-15 Creat-0.6 Na-125*
K-3.9 Cl-92* HCO3-23 AnGap-14
[**2185-9-11**] 03:15PM BLOOD Glucose-139* UreaN-9 Creat-0.6 Na-131*
K-3.5 Cl-96 HCO3-26 AnGap-13
[**2185-9-11**] 03:15PM BLOOD ALT-21 AST-21 LD(LDH)-177 CK(CPK)-34*
AlkPhos-60 Amylase-35 TotBili-0.6
[**2185-9-11**] 03:15PM BLOOD Lipase-19
[**2185-9-18**] 07:35AM BLOOD Mg-2.0 UricAcd-3.9
[**2185-9-16**] 07:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 Cholest-187
[**2185-9-12**] 04:36AM BLOOD %HbA1c-8.5*
[**2185-9-16**] 07:30AM BLOOD Triglyc-126 HDL-35 CHOL/HD-5.3
LDLcalc-127
[**2185-9-19**] 07:40AM BLOOD Osmolal-268*
[**2185-9-13**] 06:12PM BLOOD Osmolal-273*
[**2185-9-18**] 07:35AM BLOOD TSH-0.51
[**2185-9-18**] 07:35AM BLOOD Free T4-1.9*
[**2185-9-18**] 07:35AM BLOOD Cortsol-12.0
[**2185-9-11**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2185-9-11**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-150 Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2185-9-19**] 09:57AM URINE Osmolal-687
[**2185-9-13**] 02:20PM URINE Osmolal-717
[**2185-9-16**] 08:07PM URINE Osmolal-396
[**2185-9-18**] 05:22PM URINE Osmolal-617
[**2185-9-19**] 09:57AM URINE Hours-RANDOM UreaN-1205 Creat-124 Na-58
K-20
[**2185-9-13**] 02:20PM URINE Hours-RANDOM UreaN-605 Creat-93 Na-175
K-46 Cl-122 HCO3-LESS THAN
[**2185-9-11**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-150 Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2185-9-11**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
Brief Hospital Course:
Hypertension- Initially controlled with IV labetolol and ntg in
the ICU, transitioned to oral medications on floor. Eventually
BP was fairly controlled on 40 mg lisinopril daily, 12.5 mg of
metoprolol [**Hospital1 **] and amlodipine 5 mg daily. These may need to be
further titrated with PCP. [**Name10 (NameIs) **] morning of discharge, he
accidentally got a dose of 25 mg metoprolol po x1 instead of
12.5 mg by the RN. He was asymptomatic at discharge. He denied
dizziness or any other symptoms. He was monitored for many hours
after this dose and was stable in terms of the vital signs.
Vitals at discharge were: T -98.8 BP - 136/76, P - 59, RR -18,
O2 sats 98% RA. He was advised to not take the metoprolol at
home for tonight i.e. day of discharge. However, he was advised
to start taking it on Tuesday [**2185-9-20**]. Nursing visits were set
up at home for BP monitoring.
SAH - repeat CT head did not show worsening of bleed. Cleared by
neurosurgery. Occasionally complained of headache, and was
treated with prn dosing of tylenol and oxycodone with good
control of symptoms.
Nausea/Vomiting- Had significant n/v initially and was not
tolerating PO's. Slowly improved to regular POs and
significant. Symptoms completely resolved at discharge and he
was tolerating po diet well. Continued with ear drops as
directed by ENT. ENT follow up arranged at discharge with Dr
[**Last Name (STitle) 3878**] (as recommended by the receptionist it Dr[**Name (NI) 18353**] office
- [**Doctor First Name 2411**])
SIADH, Hyponatremia was likely related to the intracranial
process. Renal was consulted as despite fluid restriction,
sodium remained low. Patient however, was asymptomatic. However,
without any other treatment other than fluid restriction to 1
lit / 24 hours, sodium improved to 130. An urgent care appt was
scheduled for this week at [**Company 191**] for rechecking Na levels and well
as BP check.
Anemia- hct stable, no signs of active bleeding seen. Will need
further evaluation by PCP as outpatient.
Impaired glucose tolerance - HbA1c was high but blood sugars
were not very high. Mainly < 150. Not started on treatment.
patient to discuss this with new PCP.
Syncope - in past. Etiology unclear. It is not known if the SAH
preceeded the syncope or was the cause of syncope. No
recurrence. No arrythmias noted. ECG at the prior admission
showed left bundle branch block. Repeat ECG this admit showed
same. Per Dr [**Last Name (STitle) **] who saw patient at admit to floor, no older
ECG at [**Hospital 1263**] hospital(where pt got prior care). Patient advised
to discuss this with new PCP for further [**Name9 (PRE) 8019**].
Chronic gout- stable on allopurinol .
PT consult given fall - initially tried to work with him on
medical floor, but BP increased with SBP greater than 200mm Hg
with any activity. With better BP control with oral meds, he was
able to walk with PT. An out-patient stres evaluation is
recommended. PT cleared patient for discharge home.
Should also get follow up F T4 (mildly high) in [**5-13**] weeks with
new PCP.
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN
HydrALAzine 10 mg IV Q6H PRN SBP > 175
Allopurinol 200 mg PO DAILY
Insulin SC (per Insulin Flowsheet)Sliding Scale
Captopril 37.5 mg PO TID
Labetalol 0.5-2 mg/min IV DRIP TITRATE TO SBP < 160
Ciprofloxacin 0.3% Ophth Soln 3 DROP BOTH EARS TID
Metoprolol 12.5 mg PO BID
HYDROmorphone (Dilaudid) 0.5 mg SC Q4-6H:PRN
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Prochlorperazine 10 mg PO/IV Q6H:PRN nausea
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Ciprofloxacin 0.3 % Drops Sig: Three (3) Drop Ophthalmic TID
(3 times a day) for 5 days: to both ears .
Disp:*1 bottle* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Start taking this medicine [**2185-9-20**].
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*90 Capsule(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*45 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Sodium level. To be checked on [**2185-9-21**] by Dr [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**] in
urgent care - [**Company 191**]. [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home With Service
Facility:
Caregroup home Care
Discharge Diagnosis:
Subarachnoid hemorrhage and skull fracture
Hypertension
SIADH
Syncope
Left bundle branch block
Impaired glucose tolerance
Gout
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Your have requested a new primary care physician at our
hospital. An appointment has been made for you as below. Please
keep your appointments. Your new primary care doctor will be Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The appointment for this doctor is in [**Month (only) **]
[**2185**], but we have also made another appointment for this week
for a follow up on the blood test.
Call your doctor or return to the ED if you experience any:
Worsening headache
Lightheadedness
Dizziness, pass out
Nausea and vomiting
Visual changes (double vision, blurred vision)
Numbness or weakness of the arms or legs
Your sodium level has been low and it is recommended that you
follow up with the doctor on [**2185-9-21**] for monitoring blood tests
for sodium level.
You should also take less than 1 liter of fluids a day to
maintain the sodium levels in your blood.
Your blood sugars were ocassionally reported to be mildly high.
Please adhere to the diet the nurse has discussed with you. You
shoudl discuss these high blood sugars with your primary doctor,
Dr [**First Name (STitle) **]. Also, your ECG was abnormal and has a 'left bundle
branch block'. It is recommended that you discuss this with your
Dr [**First Name (STitle) **] as well. You may need a stress test for your heart.
This can arranged by your primary doctor.
Do not take the evening dose of metoprolol (a BP pill) today
i.e. [**2185-9-19**]. You should resume the prescribed dosing starting
[**2185-9-20**].
Followup Instructions:
[**Hospital1 18**], [**Location (un) 86**] - [**Hospital6 **] [**2185-10-25**] at 1330hrs,
[**Hospital Ward Name 23**] 6 with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your new primary care doctor.
The tel number to his clinic is [**Telephone/Fax (1) 250**].
It is also recommended that you go for a urgent care visit at
the [**Hospital6 **] ([**Hospital Ward Name 23**] 1) with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
on Tuesday [**2185-9-21**] at 1330hrs This is to check blood work for
sodium levels.
ENT - Dr. [**Last Name (STitle) 3878**] - [**2185-9-30**] at 3pm. ([**Location (un) **], [**Location (un) **], MA ([**Telephone/Fax (1) 7767**]
|
[
"285.9",
"253.6",
"276.52",
"274.9",
"971.3",
"780.2",
"E855.6",
"401.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13034, 13084
|
8371, 11437
|
328, 334
|
13255, 13264
|
3502, 3513
|
14854, 15566
|
2892, 2987
|
11937, 13011
|
13105, 13234
|
11463, 11914
|
13288, 14831
|
3002, 3483
|
276, 290
|
362, 2496
|
3522, 8348
|
2518, 2709
|
2725, 2876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,932
| 181,286
|
37097
|
Discharge summary
|
report
|
Admission Date: [**2177-1-1**] Discharge Date: [**2177-1-24**]
Date of Birth: [**2131-9-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of life
Major Surgical or Invasive Procedure:
Placement of External Ventricular Drain
Cerebral Angiogram with embolization / multistaged
Sub-Occipital Decompressive Craniotomy
tracheostomy
peg placement
History of Present Illness:
45 year old male, with no significant past medical
history, who presented to the ED s/p acute onset of "Worst
Headache of Life" at 1330 [**2177-1-1**]. Immediately felt diaphoretic
and
[**10-12**] pain. Was seen at [**Hospital **] Hospital where a CT demonstrated
a possible SAH vs Cerebellar hemorrhage. Transferred to [**Hospital1 18**]
for
further management. Upon arrival, is very lethargic and
somnolent, but following commands. Continues to have [**10-12**]
headache.
Past Medical History:
New DM
Social History:
Married, 2 children ages 7 and 10, speaks Khmer and English.
Works as a machine operator. No ETOH and tobacco
Family History:
Unknown
Physical Exam:
On admission:
O: T:96.4 BP: 144/83 HR:84 R:15 O2Sats: 100%
Gen: WD/WN, pain from HA. Notably lethargic/sleepy
HEENT: Normocephalic, Atraumatic. Pupils [**5-6**], brisk EOMs
intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake but lethargic, cooperative with exam,
normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-5**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 4
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-7**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally
Toes downgoing bilaterally
On Discharge:
Pt awake, makes eye contact and tracks readily. Oriented to
self and year - slight prompting for Month and hospital. But
seems to recongnize / remeber facts when prompted. Able to make
needs known via Yes/No nodding. Pupils L 4MM reactive. R 3mm
reactive. EOMI, No facial, tongue ML. + clonus/sustained. non
verbal [**2-4**] trach.
bicep tricep grip ileopsoas AT [**Last Name (un) 938**] [**Last Name (un) **]
right 4 4 5 4- 5 5 4
left 4 4 5 4- 5 5 4
Incision:
subaoccipital crani site is intact without erythema....small mid
incisional scab without exudate
staples to right frontal region intact and can be removed on
[**2177-1-30**]
Pertinent Results:
CTA head [**2177-1-1**]
1. Large arteriovenous malformation centered within the right
middle
cerebellar peduncle with multiple venous aneurysms.
2. Subarachnoid, subdural, and intraparenchymal blood products
predominantly within the posterior fossa with effacement of the
basilar cisterns and diffuse cerebral edema.
CT Head [**2177-1-1**]
1. Marked interval worsening of diffuse subarachnoid hemorrhage
with
intraventricular extension in the frontal and occipital horns of
the lateral ventricle with downward transtentorial herniation
and uncal herniation.
2. Large intraparenchymal hemorrhage centered within the right
cerebellum,
markedly worse than the prior study.
[**2177-1-3**] CT head:
Unchanged appearance of diffuse subarachnoid hemorrhage, right
cerebellar
hemorrhage, transtentorial and uncal herniation, with effacement
of frontal and temporal sulci and compression of the anterior
right lateral ventricle
[**2177-1-5**] CT Head:
Status post occipital craniectomy and evacuation of underlying
cerebellar hematoma. Residual pneumocephalus and hyperdense clot
in the
surgical bed, with surrounding cerebellar edema. Additionally,
there is
diffuse supratentorial subarachnoid hemorrhage, associated
sulcal and
ventricular effacement, and complete effacement of the basilar
cisterns with bilateral transtentorial herniation.
[**2177-1-5**] CXR findings
FINDINGS: Indwelling devices are unchanged in position, and
cardiomediastinal contours appear stable. Improving opacities at
lung bases with residual patchy right basilar and linear left
basilar opacities remaining. Decrease in left effusion with
residual small effusion remaining.
[**2177-1-7**] CTA BRAIN findings
INDICATION: AVM, on the right side, status post suboccipital
craniotomy and
embolization of venous aneurysms, followup evaluation to
evaluate for
vasospasm.
COMPARISON: Non-contrast CT head done on [**2177-1-5**] and CTA done
on [**2177-1-1**].
FINDINGS:
NON-CONTRAST CT HEAD:
Scout image is not available due to technical reasons.
Post-surgical changes are noted in the posterior fossa, with
right-sided and midline suboccipital craniotomy, with small
amount of air in the posterior fossa. There is evidence of edema
in the areas of cerebellar hemisphere, noted in the medial
aspect as well as anteriorly. There are blood products noted in
the subarachnoid spaces, in the supra- and infratentorial
compartments, not significantly changed compared to the most
recent non-contrast CT head. Intraventricular catheter is noted,
with the tip in the region of the third ventricle, with
decreased size of the lateral ventricles, unchanged compared to
the initial study. Overshunting cannot be excluded. The fourth
ventricle is not clearly visualized and is likely filled with
hemorrhage (series 2, image 12).
CT CEREBRAL PERFUSION: While there is some increase in the MTT,
at the site of the surgery, there are no areas of increased MTT,
to suggest an area of increased perfusion related to ischemia in
the imaged portions of the brain.
CT ANGIOGRAM OF THE HEAD: There is redemonstration of the
previously noted
large AV malformation/AV fistula with multiple venous aneurysms
within.
Please see the details on the prior CTA and the cerebral
angiogram for
additional details.
Mass effect on the right side of the pons and the mid brain from
the largest aneurysm noted is unchanged.
There is no obvious evidence of vasospasm on the images
available.
IMPRESSION:
1. Post-surgical changes as described above, with no obvious
evidence of
increased MTT in the imaged portions of the brain, to suggest
ischemia;
increased density noted in the site of the surgery, which may
relate to
post-surgical changes or mild ischemia in this location.
2. Redemonstration of the large AV malformation, in the right
side of the
posterior fossa, with large venous aneurysms within. Please see
the details on the prior CTA and angiogram, performed earlier.
[**2177-1-9**] ABDOMINAL ULTRASOUND - IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. No source of infection identified.
The study and the report were reviewed by the staff radiologist.
[**2177-1-10**] US LOWER EXTREMITIES
BILATERAL LOWER EXTREMITY DVT STUDY: Grayscale and Doppler
son[**Name (NI) 1417**] of the right and left common femoral, superficial
femoral and popliteal veins
demonstrate normal venous flow, compressibility and
augmentation. The left
and right tibial veins and left peroneal veins demonstrate
normal color flow. The left peroneal veins are not visualized.
IMPRESSION: No son[**Name (NI) 493**] evidence of right or left lower
extremity DVT.
[**2177-1-17**] CT BRAIN
Final Report
FINDINGS: High-density material in the posterior fossa and
within dural
venous sinuses is increased compared to the prior study, likely
residual
contrast from the preceding angiogram. The configuration of the
posterior
fossa is unchanged, with persistent cerebellar edema and
evolving
encephalomalacia. Small foci of hyperdense material in the
subarachnoid
space, particularly at the vertex, have decreased in conspicuity
from the
[**1-9**] study.
A right frontal approach ventriculostomy catheter is in
unchanged
configuration. The ventricles remain slit-like. There has been
no change in ventricular size or sulcal effacement posteriorly.
There is no new area of intracranial hemorrhage. There is no
shift of midline structures.
Suboccipital craniotomy is unchanged. Fluid levels are noted in
the mastoid air cells bilaterally. There is dense mucosal
thickening of the sphenoid air cells and ethmoid air cells
bilaterally. Mild mucosal thickening is noted in the maxillary
sinuses bilaterally. Surgical material is seen in the right
maxillary sinus and right orbit.
IMPRESSIONS:
1. Increase in high-density material in the posterior fossa and
dural venous sinuses following angiography, likely related to
the procedure, and residual contrast rather than new hemorrhage.
2. No other area of new intracranial hemorrhage.
3. Decreased conspicuity of subarachnoid hemorrhage.
4. Stable appearance of ventricles and sulci.
[**2177-1-22**] CEREBRAL ANGIOGRAM - RESULTS PENDING
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] ICU on [**1-1**]. His headache
worsened and he experienced respiratory arrest. HE was intubated
and a STAT CT showed increase in cerebellar hemorrhage. Dr.
[**First Name (STitle) **] placed an EVD and performed and angiogram. He found a
dural AV fistula and one branch was embolized. On [**1-2**] he had a
fever to 101.8 and a fever work up was initiated. He had ICP
elevation overnight into [**2177-1-3**]. HE also had an episode of
hypotension to SBP 60 and pentobarbital initiation ceased.
Mannitol was repeated, but ICPs remained in the low 30s. He was
on hypertonic NSS. CT on [**2177-1-3**] showed increase edema in the
posterior fossa. He was exhibiting left sided weakness. A
pentobarbital coma was initiated. EEG was ordered after the
loading dose. He was started on pressor agents for Goals of SBP
100-140 and CPP 0-70. At 1830 his ICP became persistently
elevated to >30. Neurology interpreted his EEG to be partial
burst suppression. The pentobarbital was increased to 4
mg/kg/hr. Mannitol was given. His ICP's remained above 20. At
this time, surgical decompression was discussed with the family.
On [**2177-1-4**] he had ICP's in the 40's which decreased with
hyperventilation to 10. Also on this date a CT Chest was
obtained which showed bilateral lower lobe opacities with a 2mm
pulmonary nodule in the right upper lobe. At that time it was
decided that he would undergo suboccipital decompressive
craniotomy which he received that day. On [**2176-1-6**] his
pentobarbital drip was stopped, he had slight improvement of
Head CT, and his ICP's were in the mid 20's. on [**2177-1-6**] his
sedation lightened slightly and his right pupil began to be
briskly reactive while his left continued to be sluggish. At
this time he had no gag, corneal, or cough however later in the
day he did develop a cough. His mannitol was changed from
scheduled dosing to PRN, and his decadron was discontinued.
Also on this day he continued to spike fevers so he was
pancultured and CSF was sent for evaluation. CSF studies were
within normal limits and urine cultures were negative. Blood and
CSF cultures were negative.
On [**2177-1-7**] his sedation continued to slightly lighten and he had
isolated facial grimacing while NG tube care was being
performed, as well as triple flexion in bilateral lower
extremities, however he still was without a gag or corneal. His
EVD continued to work well, having xanthochromic drainage and
putting out a satisfactory amount. Also on the 5th a CTA was
obtained which showed no evidence of stroke. His mental status
improved over the next few days. He was opening eyes, follows
commands, and MAE.
He continued to spike fevers without an identified source and
then on [**1-12**] Klebsiella was found in his sputum and Cipro was
started. His CSF remained negative. He was then trached and PEG
on [**1-16**] after failing extubation. He then Had a cerebral
angiogram and complete embolization.
He is cleared for discharge by PT OT to rehab and will return
for radiosurgery to complete treatment of AVM. This has been
communicated by case management to his wife who agrees with the
plan.
Medications on Admission:
advil
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Ibuprofen 100 mg/5 mL Suspension Sig: Two (2) PO Q8H (every
8 hours) as needed for fever.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for fever/pain.
5. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection Q6h.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
9. Oxycodone 5 mg/5 mL Solution Sig: [**1-4**] PO Q4H (every 4 hours)
as needed for pain/agitation.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
12. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subarachnoid hemorrhage
Subdural Hematoma
Intraparenchymal Hemorrhage
Arteriovenous Malformation
Diabetic Ketoacidosis
Cerebral Edema
Obstructive Hydrocephalus
Ventilator Acquired Pneumonia
Fever
Respiratory arrest with failure
Dysphagia
Discharge Condition:
Neurologically improved.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
PLEASE HAVE THE REHAB FACILITY REMOVE YOUR STAPLES (2) IN YOUR
SCALP IN THE RIGHT FRONTAL REGION ON [**2177-1-30**]
Follow up with PCP regarding pulmonary nodules noted on CT
Chest, may require additional outpatient work-up
YOU NEED TO BE SEEN IN THE BRAIN [**Hospital **] CLINIC ON [**Hospital Ward Name **] /
[**Hospital Ward Name **] / [**Location (un) **] [**Telephone/Fax (1) **]
YOU WILL BE CONTACT[**Name (NI) **] BY DR. [**Last Name (STitle) **] / RADIATION ONCOLOGY FOR
YOUR FOLLOW UP APPOINTMENT. IF YOU DO NOT RECIEVE A PHONE CALL
PLEASE CALL THE ABOVE NUMBER.
Please follow up with Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) **] to be seen in
the office
Completed by:[**2177-1-24**]
|
[
"787.20",
"999.9",
"250.12",
"430",
"432.1",
"331.4",
"E947.8",
"041.3",
"799.1",
"997.31",
"518.81",
"458.29",
"560.1",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"02.2",
"88.41",
"43.11",
"38.93",
"01.39",
"96.6",
"96.04",
"31.1",
"33.23",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
14149, 14219
|
9454, 12651
|
293, 452
|
14501, 14528
|
3145, 3832
|
16461, 17173
|
1130, 1139
|
12707, 14126
|
14240, 14480
|
12677, 12684
|
14552, 15517
|
15543, 16436
|
1154, 1154
|
2403, 3126
|
231, 255
|
480, 957
|
1686, 2388
|
5109, 9431
|
1168, 1390
|
1405, 1670
|
979, 987
|
1003, 1114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,296
| 143,945
|
13133
|
Discharge summary
|
report
|
Admission Date: [**2102-4-21**] Discharge Date: [**2102-5-2**]
Date of Birth: [**2031-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Jaundice, abdominal pain; low UOP
Major Surgical or Invasive Procedure:
# Cholecystostomy with percutaneous drain placement
# Fine needle aspiration of pancreatic mass via endoscopic
ultrasound
# Stenting of common bile duct via endoscopic retrograde
cholangiopancreatography
# IR-guided placement of right internal jugular temporary
hemodialysis catheter
# IR-guided placement of permanent hemodialysis catheter
# Hemodialysis
# Punch biopsy of atypical nevus at midback
History of Present Illness:
70M h/o DM1 c/b gastroparesis, HTN, presented RUQ intermittent
abdominal pain, nausea, vomiting, anorexia (no fever) x several
months (starting [**2-21**]); jaundice x1wk; and dark urine, light
stools (no melena, hematochezia). EGD and colonoscopy by Dr.
[**Last Name (STitle) **] (GI) were normal, and sx were therefore initially
felt to be [**3-18**] gastroparesis. Metoclopromide was added but did
not improve symptoms. Pt later presented to the ED after his
outpatient endocrinologist noted jaundice. Of note, pt had
continued taking his home medications, including furosemide.
.
ROS:
(+) 15 lbs weight loss in [**4-18**] months, (+) L shoulder pain c/w
rotator cuff injury, periodic numbness in fingers, nausea,
epigastric pain.
(-) CP, SOB, fevers, chills, night sweats, orthopnea, rash.
.
ED course:
# Vitals T 99.8, HR 74, BP 103/63, RR 15, O2 sat 100%RA.
# Imaging:
--Abdominal US: Pancreatic mass, portal vein thrombosis, hepatic
lesions, splenomegaly.
--CT abdomen: Acute cholecystitis, pancreatic mass.
# Consults:
--Surgery: Percutaneous GB drain, placed by IR.
--GI: CT abd, broad spectrum abx, ERCP aware.
# Meds: Pip-taz 3g.
.
MICU course:
After arriving to the floor, pt triggered for < 20 cc UOP/8h,
although VSS, and was therefore transferred to MICU for closer
monitoring. Pt received gentle IVF hydration. Renal was
consulted, felt that low UOP may be [**3-18**] ATN (renal u/s negative
for hydronephrosis), and that pt may need HD. Portal vein
thrombosis was not treated. Percutaneous drain was placed with
scheduled IR-guided bx of the pancreatic mass.
.
Upon transfer to floor, vitals were T 95.5 (oral), BP 137/57, HR
71, RR 20, O2 sat 98% RA, UOP 134 cc.
Past Medical History:
# DM1 c/b gastroparesis
# Hypertension
# Hyperlipidemia
# Ureteral stent ([**2101**] Dr. [**First Name (STitle) **], [**Hospital3 **], [**Location (un) 5503**])
# GERD
# L rotator cuff injury
# h/o melanoma s/p [**2098**] resection
# s/p toe amputation
Social History:
# Personal: Married, 4 children
# Professional: Retired from government
# Tobacco: Smoked from age 14 - 45, maximum 1ppd.
# Alcohol: Quit [**2097**], maximum ~5 drinks per day
# Recreational drugs: None
Family History:
# Father, died [**3-18**] MI
# Mother, died [**3-18**] natural causes
# Brother: [**Name (NI) 11398**]
Physical Exam:
VS: T 95.5 (oral), BP 137/57, HR 71, RR 20, O2 sat 98% RA, UOP
134 cc
Gen: NAD, jaundiced
HEENT: NCAT, MM dry, OP clear, PERRL
Neck: Supple, ?JVD, no LAD
CV: RRR, S1, S2, no m/r/g
Chest: CTAB
Abd: Soft, tender to palpation at epigastrium and RUQ near
percutaneous drain, no guarding or rebound. BS+.
Ext: No edema, toe amputations.
Neuro: A&Ox3. CN II-XII intact. 5/5 strength BUE, BLE.
Skin: Jaundice.
Pertinent Results:
# EGD [**3-16**]: Normal
.
# Colonoscopy [**3-16**]: Normal
.
# ABDOMEN U.S. (COMPLETE STUDY) [**2102-4-21**] 11:47 AM
1. Portal vein thrombosis.
2. Likely pancreatic masses, or lymphoma with sparing of
portions of pancreas for which further characterization by CT or
MR is recommended.
3. Right hepatic lesion that could be characterized by CT or MR.
4. Splenomegaly.
.
# CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2102-4-21**] 4:19
PM
1. Distended galbladder with moderate pericholecystic stranding
suggesting acute cholecystitis. A nuclear medicine gallbladder
scan could be performed to confirm the diagnosis.
2. Pancreatic body mass partially evaluated on this non-contrast
study. There is suggestion of complete portal vein thrombosis,
as demonstrated on previous ultrasound. Further evaluation of
the pancreatic mass, mesenteric vasculature and possible hepatic
metastasis could be performed with MRI with contrast.
3. Splenomegaly and varices consistent with portal hypertension.
.
# RENAL U.S. PORT [**2102-4-22**] 2:33 PM
1. Grayscale ultrasound demonstrates mild increased echogenicity
of the kidneys consistent with medical renal disease. No
evidence of stone, hydronephrosis, or mass.
2. Elevated resistive indices within both kidneys with
absent/reversed diastolic flow in the intraparenchymal renal
arterial waveforms. Findings may be related to medical renal
disease.
3. Patent main renal veins with appropriate direction of flow.
.
# CHEST (PORTABLE AP) [**2102-4-22**] 8:54 AM
No signs for overt pulmonary edema or focal consolidation.
.
# MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS [**2102-4-23**]
12:48 PM
1. Large pancreatic mass consistent with pancreatic carcinoma
with local invasion and vascular encasement.
2. Portal vein thrombosis.
3. Intra and extrahepatic biliary dilatation.
4. Splenomegaly.
5. Ascites.
6. Two liver lesions, which are nonspecific in appearance but
concerning for metastases.
.
# FNA Cytology Report PANCREAS [**2102-4-24**]
POSITIVE FOR MALIGNANT CELLS, consistent with poorly
differentiated adenocarcinoma.
.
# Pathology R. OF MIDLINE CENTRAL BACK [**2102-4-26**]
Lentiginous compound dysplastic nevus with moderate atypia and
numerous dermal melanophages, extending to a peripheral specimen
margin.
.
# ERCP BILIARY&PANCREAS BY GI UNIT [**2102-4-27**] 7:55 AM
Successful plastic stenting across a distal common bile duct
stricture secondary to known pancreatic cancer. Irregular
dilatation noted proximal to the stricture.
.
# ABDOMEN (SUPINE ONLY) [**2102-5-1**] 3:41 PM
No evidence of catheter obstruction.
Brief Hospital Course:
70M h/o DM1, gastroparesis, admitted with N/V, anorexia,
unintentional weight loss, found to have poorly differentiated
metastatic pancreatic adenocarcinoma, cholangitis, and ATN.
.
# Pancreatic head mass: After undergoing fine needle aspiration
via endoscopic ultrasound, pt was found to have poorly
differentiated pancreatic adenocarcinoma, metastatic to the
liver and encasing major vessels. Hematology/oncology was
consulted, and pt arranged for oncology treatment as an
outpatient. Because the mass impinged on the biliary tree, pt
also underwent percutaneous cholecystostomy and ERCP-placed
common bile duct stent. Pt was discharged with capped drain in
place, with instructions to uncap if he developed abdominal
discomfort, fevers, or chills. On discharge, pt was tolerating
PO intake, with no nausea or vomiting.
.
# Cholangitis [**3-18**] pancreatic head mass: After undergoing
percutaneous cholecystostomy drainage, pt completed a course of
piperacillin-tazobactam for cholangitis.
.
# Portal vein thrombosis: Pt was noted to have portal vein
thrombosis, probably subacute, likely related either to invasion
or extrinsic compression by the pancreatic mass, as pt had no
evidence of chronic liver disease. Because of the subacute
nature of the thrombosis, anticoagulation was held.
.
# ATN: Pt developed ATN with significantly decreased urine
output in the setting of ARF, which initially was [**3-18**] prerenal
failure due to dehydration with nausea, vomiting, and continued
furosemide use. (CT abdomen demonstrated only an exophytic cyst
@ L kidney, as well as pt's existing collecting system stent.)
Pt was started on hemodialysis after having an HD catheter
placed by IR, and was administered sevelamer and nephrocaps. Pt
was discharged with outpatient HD.
.
# Enterococcus UTI: Pt's urine culture was positive for
enterococcus, sensitive to ampicillin. Pt completed a 10 day
course of piperacillin-tazobactam for a hospital acquired UTI.
.
# Atypical nevus: Pt was noted to have an atypical nevus at
midback, which was biopsied and found to be a lentiginous
compound dysplastic nevus with moderate atypia and numerous
dermal melanophages. Pt was provided an outpatient dermatology
appointment to review these pathology results and to remove his
stitches.
.
# [**Doctor Last Name 21078**] syndrome: Pt was noted to have a papular rash on his
back, diagnosed as [**Doctor Last Name 21078**] syndrome; steroid creams were
applied with good effect.
.
# R foot stage II pressure ulcer: On day of discharge, pt was
noted to have a stage II pressure ulcer on his R foot. Pt was
discharged with mupirocin and instructed to follow up with his
primary care doctor.
.
# Anemia: Pt's hematocrit was noted to be stable, although his
historical baseline was unclear. [**Name2 (NI) **] received 1 unit PRBC.
Anemia was considered likely [**3-18**] chronic disease and CRI.
.
# Nausea: Pt was treated with ondansetron and prochlorperazine
for nausea.
.
# Hypertension: Pt's home regimen of antihypertensives were held
given his low SBP; he was discharged with no continuing
antihypertensives.
.
# Hyperlipidemia: Pt's atorvastatin was held given LFT
abnormalities, but was restarted on discharge given
normalization of AST and ALT.
.
# DM1: Pt was continued on his Novocor insulin pump, and [**Last Name (un) **]
was consulted to help manage his pump.
.
# Glaucoma: Pt was continued on his home regimen of latanoprost
and timolol eye drops.
.
# Full code
Medications on Admission:
Home meds:
Novacor insulin pump
Furosemide 20mg [**Hospital1 **]-TID
Simvastatin (Zocor) 80mg daily
Diltiazem 300 [**Hospital1 **]
ASA 81mg
Esomeprazole 40mg
.
Meds on MICU transfer:
Heparin 5000units SC TID
Pantoprazole 40 mg PO Q24H
Piperacillin-Tazobactam Na 2.25 g IV Q6H
Acetaminophen 325-650 mg PO Q6H:PRN
.
Meds on floor transfer:
Piperacillin-Tazobactam Na 2.25 g IV Q8H
Simvastatin 80 mg PO DAILY
Heparin 5000 UNIT SC TID
Ondansetron 4 mg IV Q8H:PRN
Prochlorperazine 10 mg IV Q6H:PRN
Pantoprazole 40 mg IV Q24H
.
Allergies: NKDA
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Novocor Insulin Pump
Use as directed.
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
6. 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*
7. Percutaneous drain bag
Please provide drain bag for percutaneous drain. Refills x 10.
8. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) for 14 days.
Disp:*1 tube* Refills:*0*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day as needed for constipation.
Disp:*1800 ML(s)* Refills:*2*
10. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO POST HD
().
Disp:*30 Capsule(s)* Refills:*2*
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
13. Mupirocin 2 % Ointment Sig: One (1) application Topical
three times a day for 10 days: Apply to stage II sore at right
foot.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Primary diagnosis
.
Poorly differentiated adenocarcinoma of the pancreas
Cholecystitis
Portal vein thrombosis
Acute tubular necrosis
Enterococcus urinary tract infection
[**Doctor Last Name 21078**] disease
Atypical nevus NOS, question melanoma
Stage II right foot ulcer
Glaucoma
.
Secondary diagnosis
.
Diabetes mellitus type I
Hypertension
Hyperlipidemia
GERD
Discharge Condition:
Stable, tolerating PO intake
Discharge Instructions:
You were admitted to the hospital because you were nauseous,
vomiting, and were jaundiced. We found that you had a poorly
differentiated adenocarcinoma (cancer) of the pancreas, which
had blocked your gallbladder and led to cholangitis (infection
of the bile ducts). This cancer had also spread to the liver,
and wrapped around the major vessels near the pancreas.
.
We performed several procedures:
.
# We performed a cholecystostomy, where we placed a tube through
your skin and into the gallbladder to open and drain it. You
still have the tube on your left side.
.
# Using endoscopic ultrasound, we performed a fine needle
aspiration of the pancreatic mass, in order to determine what
kind of cells were there.
.
# Because the tumor had closed off the common bile duct, we used
endoscopic retrograde cholangiopancreatography to place a stent
into the common bile duct to drain the liver and the
gallbladder.
.
# Because we found that your kidneys were failing, we placed a
temporary hemodialysis catheter, which we later changed to a
permanent hemodialysis catheter, so that we could start you on
hemodialysis.
.
# We performed several sessions of hemodialysis for you.
.
We also started you on antibiotics for your gallbladder
infection (cholecystitis) and the urinary tract infection that
you developed while you were here. You completed this course of
antibiotics (piperacillin-tazobactam).
.
Finally, for your pancreatic cancer, we consulted
hematology-oncology, which will be working with you for the
future.
.
Also, we found that you had a rash on your back that dermatology
diagnosed as [**Doctor Last Name 21078**] Disease. Dermatology was also concerned
about an abnormal mole on your back, which was concerning for
melanoma. The dermatologist took a punch biopsy of this mole,
and we set up an appointment to have your sutures removed and to
follow up on the pathology. (It is your choice to have your
sutures removed by Dr. [**Last Name (STitle) 24642**] or by the [**Hospital1 18**] dermatologist,
Dr. [**Last Name (STitle) **].)
.
Finally, on the day we discharged you, we found a small blister
on your right foot. We prescribed mupirocin ointment and
instructed you to follow up with your primary care doctor.
.
We have started some new medications for you, and changed some
medications:
.
# For your kidneys:
--Take 1 nephrocap daily
--Take Sevelamer three times daily with meals
.
# For nausea:
--Take ondansetron 4mg by mouth every 8 hours as needed for
nausea
.
# For [**Doctor Last Name 21078**] Disease:
--Apply triamcinolone acetonide 0.1 % Ointment twice daily for
14 days.
.
# For constipation:
--Take lactulose 30ml twice daily as needed for constipation.
.
# For pain:
--Take gabapentin 200mg by mouth after hemodialysis.
.
# For your hypertension: Because you are receiving
hemodialysis, you do not need to take furosemide or diltiazem
anymore for your hypertension. Please stop taking these drugs.
.
# For your Stage II right foot sore:
--Apply mupirocin 1 application three times daily for 10 days.
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 40087**] for
your feet.
.
Otherwise, we have not changed your medications.
.
If you have any extremely concerning symptoms, call your primary
care doctor and go immediately to the emergency room.
Followup Instructions:
You have the following appointments:
.
HEMODIALYSIS: Wednesday, [**5-3**], [**Location (un) **] [**Location (un) 5503**] Dialysis
Center at 2:30pm.
--In the future, your regular hemodialysis schedule will be
every Monday, Wednesday & Friday at 3:15pm.
.
CANCER: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**],
Date/Time:[**2102-5-3**] 3:00
.
PRIMARY CARE: You have an appointment with Dr.[**Name (NI) 40088**]
nurse practitioner to remove your stitches on your back on [**5-10**] at 11:30 am. Please also ask your doctor to examine your
feet for sores.
.
DERMATOLOGY: [**Doctor Last Name 3833**] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2102-5-10**] 10:00.
Please call if you wish to cancel this appointment. This
dermatology office has the pathology results of your skin
biopsy.
Completed by:[**2102-5-4**]
|
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"576.2",
"576.1",
"216.5",
"285.21",
"536.3",
"707.07",
"157.0",
"250.61",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"39.95",
"51.87",
"38.95",
"86.11",
"51.02",
"52.11",
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] |
icd9pcs
|
[
[
[]
]
] |
11655, 11763
|
6130, 9601
|
348, 750
|
12169, 12200
|
3523, 6107
|
15581, 16473
|
2980, 3084
|
10189, 11632
|
11784, 12148
|
9627, 10166
|
12224, 15558
|
3099, 3504
|
275, 310
|
778, 2468
|
2490, 2744
|
2760, 2964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,984
| 124,661
|
3926
|
Discharge summary
|
report
|
Admission Date: [**2187-3-5**] Discharge Date: [**2187-3-10**]
Date of Birth: [**2127-9-2**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine / Robaxin / Lomotil / Metoprolol Tartrate /
Linezolid / Synercid / Rifampin / Optiray 300 / Percodan
Attending:[**Last Name (NamePattern1) 2499**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 F h/o breast ca currently being treated with carboplatin,
taxotere (last [**2187-2-7**]), and herceptin (last [**2187-2-21**]) was in her
USOH until ~5d PTA, when she notes 3d of diarrhea (x2-3/day,
x1-2/night) while returning from a trip to [**State **], these
symptoms resolved 2d PTA. On the morning of her admission, she
awoke and notes nasea, vomitting x 1, and diffuse crampy
abdominal pain. last BM 1d ago, well formed. no change in abd
pain with food, had not had BM, but pain resolved after
vomitting x 1. pt also noted to have fever (100.5 vs 105, but
then up to 102 per call in).
.
pt also notes sharp pain in her right foot from diabetic
neuropathy. ROS otherwise negative for chills, cp, sob, ha, neck
stiffness, join pain, rash, port-site irritation.
.
Upon arrival to ED VS 102.6 117 151/70 20 100%RA. WBC 14,
pt given vanco/cefepime. BCx, UCx sent, CXR unremarkable, CT
ABD/PELVIS unremarakble. Abdominal pain resolved. No chills,
diarrhea, CP or SOB. Plan was to admit to OMED, however pt then
78/34, given 5L IVF with modest response to 80s-90s. Pt
mentating throughout, asx.
.
Pt transferred to [**Hospital Unit Name 153**] given ongoing hypotension.
.
Past Medical History:
1) Type I Diabetes mellitus
2) CAD
- [**1-29**] cardiac cath: 50% mid LAD, 80% distal LCx; stents placed
to LAD and LCx
- [**5-30**] PMIBI: SOB w/o ischemic changes. Nl myocardial perfusion
- [**12-30**] TTE: mild LA enlargement, mildly dilated RA, LVEF >55%,
trivial MR, trace AR
3) Hypothyroidism [**2184-3-2**] TSH 0.78
4) Depression/anxiety
5) Breast cancer: Stage II infiltrating ductal carcinoma dx [**2182**]
- s/p right lumpectomy followed by 4 cycles of
Adriamycin/Cytoxan and 7 weekly Taxotere treatments. Arimidex
since [**1-29**]
- right mastectomy [**2183-3-26**] when mammogram showed new
calcifications
6) GERD
7) Low back pain s/p placement of neural stimulator
8) Right shoulder osteomyelitis:
- Right humeral fracture [**5-30**] s/p ORIF
- [**2183-7-27**] MRSA bacteremia from chemo port -> right septic
shoulder/osteomyelitis
- initially tx with linezolid, stopped due to thrombocytopenia,
changed to daptomycin changed to synercid/rifampin due to
daptomycin resistance. Synercid/rifampin caused pancytopenia, so
she was changed to PO minocycline.
- [**3-31**] right shoulder joint and upper humerus removed by Dr.
[**First Name (STitle) **] at [**Hospital1 2025**] and antibiotic spacer inserted. Intra-op cultures
grew 1 colony of MRSA
--> desensitized to vancomycin and d/c [**2184-3-26**] on planned 6 week
course of vancomycin prior to shoulder replacement, which would
be followed by an additional 4-6 weeks of vancomycin
Social History:
Lives with her husband in [**Name (NI) 17448**], MA. Smoked 20 pack-years,
quit 20 years ago; drinks [**12-27**] cocktails per week; no illicit
drug use. Retired, previously worked with troubled young
adults.
Family History:
1. DM type 1: 2 Siblings, both deceased
2. Mother d. Ovarian CA
Physical Exam:
99.5 BP 87/49 HR 58 RR 16 Sats 100% on RA
GEN: NAD,
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, no
carotid bruits. No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: CTA B, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL, no femoral bruits.
NEURO: alert & oriented x 3, CN II-XII grossly intact. [**4-30**]
strength symmetric @ triceps, biceps, delts, hip flexion,
dorsoflexion, plantarflexion. sensation grossly intact.
Pertinent Results:
[**2187-3-4**] CXR: The lungs appear clear bilaterally, demonstrating
no evidence of pneumonia or CHF.
.
[**2187-3-5**] CT ABD/PELVIS:
1. No evidence for obstruction.
2. Two benign-appearing hepatic lesions, unchanged.
3. Tiny cholelithiasis.
4. Stable T12 compression fracture.
5. Tiny 2-mm non-obstructing left renal stone.
.
Bone Scan [**3-7**]
IMPRESSION: 1. Mild focal increased tracer uptake outlining the
right humeral prosthesis has decreased in intensity compared
with the prior study and likely reflects sequelae of healing. 2.
Interval development of intense tracer uptake in the sternum is
suspicious for metastatic disease. 3. A linear focus of tracer
uptake in the sacrum is suspicious for a sacral insufficiency
fracture. 4. There is a nodule in the right upper lobe on the
SPECT images. This study is limited, however, and further
evaluation with diagnostic CT is suggested.
.
[**2187-3-4**] 06:30PM BLOOD WBC-14.5* RBC-2.95* Hgb-10.0* Hct-29.6*
MCV-101* MCH-33.9* MCHC-33.7 RDW-19.2* Plt Ct-101*
[**2187-3-5**] 05:22AM BLOOD WBC-19.9* RBC-2.65* Hgb-9.5* Hct-27.4*
MCV-103* MCH-35.8* MCHC-34.7 RDW-19.2* Plt Ct-105*
[**2187-3-6**] 03:55AM BLOOD WBC-20.3* RBC-2.29* Hgb-8.1* Hct-24.1*
MCV-105* MCH-35.1* MCHC-33.4 RDW-19.5* Plt Ct-91*
[**2187-3-4**] 06:30PM BLOOD Glucose-241* UreaN-18 Creat-1.0 Na-135
K-3.9 Cl-97 HCO3-29 AnGap-13
[**2187-3-5**] 05:22AM BLOOD Glucose-69* UreaN-20 Creat-1.1 Na-138
K-3.6 Cl-105 HCO3-25 AnGap-12
[**2187-3-5**] 04:39PM BLOOD Glucose-208* UreaN-17 Creat-1.1 Na-132*
K-4.6 Cl-104 HCO3-21* AnGap-12
[**2187-3-4**] 06:30PM BLOOD ALT-28 AST-25 AlkPhos-106 Amylase-16
TotBili-0.6
[**2187-3-4**] 06:30PM BLOOD Lipase-12
[**2187-3-5**] 09:09PM BLOOD CK-MB-3 cTropnT-<0.01
[**2187-3-5**] 04:39PM BLOOD CK-MB-3 cTropnT-<0.01
[**2187-3-5**] 05:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-3-6**] 03:55AM BLOOD Calcium-7.5* Phos-2.4* Mg-2.5
[**2187-3-4**] 06:51PM BLOOD Lactate-1.0
Brief Hospital Course:
59F with PMHx of Breast cancer on carboplatin, taxotere (last
dose [**2187-2-7**]), and herceptin (last dose [**2187-2-21**]), admitted to
the ICU with fever, n/v & hypotension, weaned from pressors
[**3-5**].
.
Hypotension: Patient hypotensive in the ED and admitted to the
[**Hospital Ward Name 332**] ICU. The etiology was most likely sepsis given wbc
elevation and fever, although no source was identified. Bcx,
Ucx, CXR and ct abd/pelvis unremarkable throughout admission.
She was levophed for less than 24 hours. She was also ruled out
for MI, ECHO normal- cardiogenic causes unlikely.
.
Leukocytosis/Fevers: patient treated for sepsis in the [**Hospital Unit Name 153**]. The
differential for source of infection includes MRSA
osteomyelitis, port line, neural stimulator, c diff,
gastroenteritis. Patients fever has resolved before she was
transferred to the medical oncology floor.Leukocytosis may also
have been secondary to neulesta patient recieved last week.
Leukocytosis resolved while on the floor. She was on cefepime
from admission to [**2187-3-8**], and vanco from admission to [**2187-3-7**].
Her Cultures remianed negative. Stool C diff negative as well.
Bone scan done to check shoulder, site of previous
osteomyelitis, and it was negative. Bone scan did show new lytic
lesion on sternum, which was not discussed with patient, and
will be addressed as an outpatient with Dr. [**Last Name (STitle) **].
.
ABD pain: Prior to admission, resolved, etiology unclear, LFTs
unremarkable, no evidence of typlitis/colitis on CT ABD/PELVIS.
Pt ruled out for MI and LFTs all WNL.
.
Diabetes Mellitus Type I: Patient had insulin [**Last Name (STitle) 4581**] and manages
her own diabetes. While she was on the floor, however, her [**Last Name (STitle) 4581**]
accidentally because dislodged. She was put on lantus 9 units
qHS and insulin sliding scale until her husband brought in the
supplies needed to reinstall it.
.
Anemia: Hct dropping from 27 to 24 in setting of aggressive
fluid recussitation. was also likely dry on admission and
recently had chemotherapy. hemolysis labs show unlikely
hemolysis and patient transfused 2 units pRBCs on [**2187-3-7**]. TIBC
low and iron low, likely anemia of chronic disease, and also
chemo related, will start on iron supplements.
.
Breast Cancer: Pt due for chemotherapy this week, taxol and
carboplatin (4th cycle pending). It is being held off on
chemotherapy until resolution of illness. As mentioned above,
bone scan shows new lytic lesion on sternum. Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) **] to f/u with the patient regarding this, it was not
discussed with her during this admission.
.
back pain: Patient has has longstanding chronic back pain, has
neuro-stimulator.
.
depression/anxiety: stable, continue wellbutrin, effexor. She
was seen by social work while here.
.
Diabetic Neuropathy: neuropathy may also be exacerbated by taxol
chemotherapy.
- continue gabapentin
.
hypothyroid: continue home synthroid.
.
GERD: continue PPI
.
C diff: questionable incompletely treated in the past. She was
continued on PO flagyl 500 TID while here. Had formed stools and
2 negative stool cultures. she was discharged off antibiotics.
Medications on Admission:
aromasin 25mg po qdaily
aspirin 325mg po qdaily
atenolol 25mg po qdaily
clonazepam 1mg po qhs
colace 100mg po bid
diovan 40mg po qdaily
effexor xr 150mg po bid
fosamax plus d 70-2,800 qweekly
lasix 40mg po qdaily
lactulose 30cc qd prn
ativan 1mg po tid
levoxyl 150mcg qdaily
lipitor 10mg po qdaily
neurontin 600mg po tid
novofine insulin [**Name5 (PTitle) 4581**]
omeprazole 20mg po tid
wellbutrin sr 150mg po tid
Discharge Medications:
1. Aromasin 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
8. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lactulose 10 gram/15 mL Solution Sig: One (1) PO four times
a day as needed for constipation.
11. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
12. Levoxyl 150 mcg Tablet Sig: One (1) Tablet PO once a day.
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
16. Insulin [**Name5 (PTitle) **] Reservoir 3 mL 22 x [**12-27**] Misc Sig: One (1)
Miscellaneous once a day: Self administered.
17. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Sepsis
Breast CA
Diabetes Type I
Secondary:
CAD
Hypothyroidism
GERD
sinus tachycardia
Discharge Condition:
stable, afebrile.
Discharge Instructions:
You were admitted to the hospital with a fever, nausea and
vomiting. You were intially in the ICU and on Iv medications to
keep your blood pressure from dropping too low. You then came to
the Oncology floor and remained without a fever.
.
Please take your medications as prescribed.
.
Please keep your scheduled appointments as below.
.
Please call your doctor or return to the hospital if you have
fevers, chills, cough, increasing diarrhea and vomiting, or any
other concerning symptoms.
Followup Instructions:
Please schedule an appointment with Dr. [**Last Name (STitle) **] for the next [**12-27**]
weeks.
.
Please schedule an appointment with your [**Last Name (un) **] diabetes doctor,
since you missed the appointment while you were in the hospital.
Unfortunately Dr. [**Last Name (STitle) 14116**] does not officially have any
appointments available until [**Month (only) 116**], but she requested that you
call the office on Tuesday [**3-13**] to be seen on Wednesday or
Thursday. If there are no openings, then please ask the
scheduler to contact Dr. [**Last Name (STitle) 14116**] to allow an appointment time.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2187-3-12**] 12:45
.
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-4-13**] 11:50
.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-4-26**] 10:55
Completed by:[**2187-3-12**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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405, 411
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11196, 11216
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,201
| 190,733
|
54782
|
Discharge summary
|
report
|
Admission Date: [**2200-8-31**] Discharge Date: [**2200-9-11**]
Date of Birth: [**2133-10-7**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
[**2200-8-31**] Exlap, splenectomy, gastrotomy with oversewing of ucler
[**2200-9-2**] Exploratory laparotomy; Abdominal Washout;drainage of
left upper quadrant Abdominal Closure.
History of Present Illness:
Ms. [**Known lastname 111976**] is a 66 yo F w/ PMH of two previous upper GI
bleeds, the most recent a dulifeloy's lesion s/p oversewing in
[**2192**], and hypertension who presented to OSH on [**8-25**] after an
episode of hematemesis and near syncope. Pt reports she had
switched her protonix from daily to prn and had taken an
ibuprofen that day for some knee pain. She denied any preceding
abdominal pain, nausea or vomiting. She reports vomiting large
clots. She was hypotensive and brought to an OSH where her HCT
was 28. She had a repeat episode of hematemsis and underwent EGD
on [**8-25**] which just showed large clots of blood but no obvious
sources of bleeding. She had repeat EGD on [**8-26**] which showed
areas that appeared to be varices with red spots which were
concering for areas of bleeding. per report, these areas were
cauterized. She was stablized and reports one additional episode
of hematemesis and had repeat scope which report is not
available at this time. She underwent a CTA which showed a large
AVM in the LUQ and she was scheduled to have an IR procedure on
[**9-1**]. However on [**8-30**] at 9:30pm the pt had BRBPR, and she then
became quessy and vomited large amounts of bright red blood. She
was hypotensive and started on levo and neo and she had a Right
Fem Aline and TLC placed and the massive transfusion protocol
was activated and she received 4 units of PRBC and 2 of FFP Per
discussions with the OSH, GI felt that there were no other
endoscopic interventions, and surgery felt that she was not a
good candidate for surgery,and was transferred here to [**Hospital1 18**] for
IR intervention. En route with med flight her VS were stable and
she was titrated down on her pressors to 0.15 of levo and had
her 5th unite of blood started, she was given zofran and
midazolam.
On arrival, patient has no complaints. She denies nausea, recent
vomiting, abdominal pain, chest pain, shortness of breath or
dizziness. She is anxious about how this is going to be fixed.
Past Medical History:
Dulefloy's lesion
HTN
Social History:
Works as a psychotherapist, is active doing [**Last Name (un) 91633**]. Has 5 grown
children and 7 grandchildren. She denies any alcohol use,
smoking or other drugs
Family History:
Noncontributory
Physical Exam:
Admission Exam:
General: Pale appearing elderly woman in NAD, lying comfortably
in bed
HEENT: PEERLA, Conjunctival palor
Cardiac: RRR, 2/6 systolic murmur at LUSB nonradiating
Lungs: CTAB
Abd:soft, nontender, flat, hyperactive normal pitched bowel
sounds,
Extremities: No peripheral edema
Pertinent Results:
HCT Trend
[**8-31**] at 3am 28.9
[**8-31**] at 4:40am 27.5
[**8-31**] at 6:25am 33.3
[**8-31**] at 8:43 29.2
8.19 at 931 am 18.4
[**8-31**] at 10:05am 14.7
[**8-31**] at 342 am 37.1
[**2200-8-31**] 03:05AM BLOOD WBC-13.1* RBC-3.25* Hgb-9.8* Hct-28.9*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.7 Plt Ct-65*
[**2200-8-31**] 03:05AM BLOOD Neuts-87.9* Lymphs-8.5* Monos-3.3 Eos-0.2
Baso-0.2
[**2200-8-31**] 03:05AM BLOOD PT-14.0* PTT-21.4* INR(PT)-1.3*
[**2200-8-31**] 06:25AM BLOOD Fibrino-100*
[**2200-8-31**] 10:05AM BLOOD Fibrino-87*
[**2200-8-31**] 03:42PM BLOOD Fibrino-161*#
[**2200-8-31**] 03:05AM BLOOD Glucose-146* UreaN-10 Creat-0.7 Na-144
K-3.6 Cl-115* HCO3-21* AnGap-12
[**2200-8-31**] 08:43AM BLOOD ALT-17 AST-19 AlkPhos-33* TotBili-1.2
[**2200-8-31**] 03:05AM BLOOD CK-MB-3 cTropnT-0.21*
[**2200-8-31**] 03:05AM BLOOD Calcium-7.3* Phos-4.0 Mg-1.5*
[**2200-9-11**] 05:59AM BLOOD WBC-15.5* RBC-3.30* Hgb-10.0* Hct-31.4*
MCV-95 MCH-30.4 MCHC-31.9 RDW-16.8* Plt Ct-580*#
[**8-31**] EGD report:
Impression: Blood in the gastroesophageal junction and lower
third of the esophagusThere was no clear bleeding lesion and the
blood appeared to be refluxing from the stomach.
There was a large (5cm) clot in the fundus obscuring the view of
the gastric side of the GE junction. There was red blood oozing
from underneath the clot although no clear site of bleeding
could be seen. Multiple attempts were made to wash the fundus
but the clot could not be dislodged.
The entire stomach appeared abnormal with inflammed mucosa and
some supercifial non bleeding ulcerations in the body and
antrum.
Blood in the whole examined duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Ms. [**Known lastname 111976**] is a 66 yo F w/ PMH significant for UGIB in the
setting of a Dulefloys lesion in [**2192**] s/p oversewing. Patient
had a bled on [**8-25**] that led her to be admitted to an OSH where
she underwent 3 EGDs which showed an area concerning for a
possible gastric varix and multiple AVMs that were cauterized.
She underwent a CTA which showed an area of splenic artery
aneurysm and possible LUQ AVM. She had a repeat massive
hematemesis at the OSH on the evening of [**8-30**] and she was
transfused 5u pRBC and 2 of FFP. On arrival to [**Hospital1 18**] MICU she
was on 0.15 of Levophed and mentating well with no complaints.
She acutely decompensated requiring 3 pressors and was taken
emergently to IR. In IR, they were able to visualize some
arterial extravasation in the area of the gastric branches off
of the splenic artery so her splenic artery was embolized and
she was transferred back to the ICU. In the ICU she was noted
to have abdominal distension without free air on KUB. GI and
surgery were consulted. She underwent NG suctioning where 7L of
blood was removed from her stomach. Her hematocrit had dropped
down to 14 despite having received 17 U of pRBC, and was oozing
blood from her puncture sites and nose. She was maxed out of 3
pressors, GI scoped her and saw clotted blood and no obvious
source. She was taken emergently to the OR where they performed
who was transferred from OSH for UGIB with unclear source who
became hemodynamically unstable with massive GIB and underwent
splenic artery embolization with continued bleeding and was
taken emergently to the OR for exploratory laparotomy,
splenectomy and gastrostomy with oversewing of arteriovenous
malformations. Patient was transferred to the ICU intubated
ICU course- patient has a history of a Dulefloys' lesion. Pt had
a bled on [**8-25**] that led her to be admitted to the OSH where she
underwent 3 EGDs which showed an area concerning for a possible
gastric varix and multiple AVMs that were cauterized. She
underwent a CTA which showed an area of splenic artery aneurysm
and possible LUQ AVM. She had a repeat massive hematemesis at
the OSH on the evening of [**8-30**] and she was transfused 5u pRBC
there, and 2 [**Location 16678**]. On arrival to [**Hospital1 18**] MICU she was on .15
of Levophed and mentating well with no complaints. She acutely
decompensated requiring 3 pressors and was taken emergently to
IR. In IR, they were able to visualize some arterial
extravasation in the area of the gastric branches off of the
splenic artery so her splenic artery was embolized and she was
transferred back to the ICU. In the ICU she was noted to have
abdominal distension without free air on KUB. GI and surgery
were consulted. She underwent NG suctioning where 7L of blood
was removed from her stomach. Her hematocrit had dropped down to
14 despite having received 17 U of pRBC, and was oozing blood
from her puncture sites and nose. She was maxed out of 3
pressors, GI scoped her and saw clotted blood and no obvious
source. She was taken emergently to the OR where they performed
a splenectomy and oversewing of a dulefoy's lesion.
Patient remained intubated and transferred to the TSICU for
resuscitation not on pressors.
On POD1 she had low urine output but stable BP and HR, so gave
5% albumin x1L instead of blood. She was kept in the icu for
diuresis and monitoring. On [**9-2**] she was taken for washout and
abdomen closure and returned to [**Location **] intubated. Subcutaneous
heparin was restarted.
On [**9-3**] her left IJ cordis was exchanged to triple lumen and her
femoral CVL was discontinued. She was started on clears and
advanced to a regular diet on [**9-4**].
On [**9-5**] she was transferred back to the TICU because of new Afib
with RVR in the setting of presumed melena on the floor. On
arrival she converted to sinus after adenosine. She had an a
-line and right IJ [**Location (un) 109**] placed, blood cultures sent, and a
pantoprazole drip started Her hematocrits were trended and were
stable.
On [**9-6**] her PPI drip was discontinued and [**Hospital1 **] dosing resumed.
i
She did have increasing tachypnea and hypoxia (PaO2 62) for
which she was placed briefly on CPAP then transitioned back to
shovel mask.
During her second ICU stay she alternated between intermittent
Lasix and a Lasix drip for diuresis. She had no recurrence of
melena while in the ICU. She was transitioned to a regular diet
on [**9-6**].
That same day she was started on Cipro for a positive UA. Her
Foley was also changed.
[**9-7**]: increasing bicarb -> Lasix drip d/c'd. repleted
potassium, restarted Lasix gtt.
On [**9-9**] she was in good condition and was transferred back to
the floor.
_
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_
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_
________________________________________________________________
Upon transfer back to the floor she continued to progress. She
was monitored on telemetry and her heart rate remained stable.
She continued to require aggressive diuresis with Lasix for her
fluid volume overload secondary to the aggressive fluid
resuscitation required during her initial acute phase. She had
favorable response to IV Lasix 20 tid initially that was changed
to [**Hospital1 **] dosing; she will be discharged on Lasix 20 mg IV daily
with the goal of transitioning her to oral Lasix for ongoing
diuresis. Because of poor peripheral access she will be
discharged with a right IJ triple lumen central line.
She continues to tolerate a regular diet and her pain is well
controlled on oral narcotics.
Her abdominal staples remain in place and will be removed next
week when she returns to clinic. There were 2 abdominal JP
drains in place that were removed.
She will require repeat EGD in about 6-8 weeks per
recommendation of Gastroenterology with Dr. [**First Name (STitle) **] [**Name (STitle) **].
His contact information was provided to patient and her family
so that they can arrange for an appointment.
She received her spleen vaccines (Pneumococcal, Meningiococcal
and Haemophilus B) on day of her discharge.
Physical and Occupational evaluations were obtained and because
of her deconditioned status she will require rehab after her
acute hospital stay.
Medications on Admission:
Tylenol prn
HCTZ 25mg po qday
Ibuprofen prn
Zantac 150po qday prn
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Heparin 5000 UNIT SC TID
3. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
4. Pantoprazole 40 mg PO Q24H
5. Spironolactone 25 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Furosemide 20 mg IV DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Senna 1 TAB PO BID:PRN constipation
11. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] [**Hospital 731**] Rehabilitation and Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Upper gastrointestinal bleed
Dulefloy's lesion
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with bleeding in your
gastrointestinal tract from an ulcer requiring a radiologic
procedure and an operation to stop the bleeding. You required a
prolonged stay in the ICU for close monitoring. During your
hospital stay you were noted with periods of increased heart
rate requiring medications to slow your heart rate down. You
also required multiple blod transfusions because of the
bleeding. Becasue of your prolonged hopsital stay you were
evlauted by the Physical therapists and are being recommended
for rehab after your acute hopsital stay.
You will be discharged with a tube called a JP drain in your
abdomen that allows for drainage of excess fluid. In addition to
this you will also receive intermittent doses of a diuretic
called Lasix to help your body to get rid ofthe remaining excess
fluid.
Followup Instructions:
Follow up in 6 weeks with Dr. [**First Name (STitle) **] [**Name (STitle) **], Gastroenterology
for scheduling a possible endoscopy and/or colonoscopy. The
telephone number is([**Telephone/Fax (1) 35096**].
Name: [**Name6 (MD) **] [**Name8 (MD) **], MD
Specialty: Primary Care
Location: [**Hospital **] MEDICAL ASSOCATIES-[**Location (un) **]
Address: 56 NEW DRIFTWAY [**Apartment Address(1) 31103**], [**Location (un) **],[**Numeric Identifier 78142**]
Phone: [**Telephone/Fax (1) 85257**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**], MD
When: FRIDAY [**2200-9-19**] at 1:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2200-9-17**]
|
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[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,638
| 163,217
|
51716
|
Discharge summary
|
report
|
Admission Date: [**2175-3-12**] Discharge Date: [**2175-4-4**]
Date of Birth: [**2107-8-23**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Facial Pain
Major Surgical or Invasive Procedure:
Trigeminal nerve block
Trigeminal nerve decompression with craniotomy
History of Present Illness:
67 yo female with recurrent episodes of severe pain from
trigeminal neuralgia excerbation; most recently discharged on
[**2-26**] on standing methadone, dilaudid po prn and dilantin. She
noted Thurs/Fri AM she was developing an acute flare with
unbearable left nasal, cheek and temporal & upper lip pain with
worsening trismus, and inability to eat and chew. She notes no
dysphagia or odynophagia and no difficulty clearing secretions.
She is able to ambulate. Patient has been treated in the past
with IV Dilaudid, Methadone, Dilantin for pain control. Followed
in pain clinic by Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 86416**]) and treated by Dr.
[**First Name (STitle) **] from Neurology/HMVA. Patient is legally blind and has
sensorineural hearing loss in right ear managed at [**Hospital1 2025**].
Past Medical History:
-Trigeminal neuralgia (diagnosed in [**2171**])
-PNA in [**2168**] s/p L thoracentesis x 2 with fluid c/w exudate, and
s/p VATS with reinflation of the lung
-Hypertension
-Grave??????s Disease s/p ablation ([**6-/2163**])
-H/o atrial fibrillation - when she had [**Doctor Last Name 933**] disease and
during hospitalization for PNA and it has never recurred. She
only took coumadin while she was hyperthyroid with [**Doctor Last Name 933**]
disease and then iwas stopped.
-Neural hearing loss (mother had rubella when pregnant with Ms.
[**Known lastname 107126**])
-R eye blindness (s/p cataract surgery & scarring)
-S/p hemorrhagic liver cyst removal
-Diverticulosis of colon
-S/p rectal polyp removal
-s/p cleft palate repair
Social History:
Lives alone in [**Location (un) **] in senior housing apartment. She worked
as a home health aide x 21 years but retired in [**2168**]. She worked
17 years in college food service. She denies any tobacco or drug
use. She rarely drinks alcohol. No children. Independent of
ADLs, IADLs. Indepedent of food preparation, bills, medication
administration.Walks without walker/cane. She uses a walking
stick if its very icy outside. + visual aides. No dentures. +
hearing aide.
Family History:
Father died of heart disease at 74yo. Mother died of metastatic
melanoma at 52 yo. Brother is healthy. One sister has DM,
another sister has thyroid disease.
Physical Exam:
Admission Exam:
VS: 96.4 150/70 60 16 97%RA
GA: Alert, unable to assess orientation as patient states that
she cannot speak [**3-1**] pain, NAD
HEENT: NC/AT, R eye w/cataract & scarring, L pupil RRL, neck
supple, no JVD, sclerae anicteric
NECK: supple, no thyromegaly
LUNGS: CTAB, no W/R/R
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN: face with L>R diffuse erythema, otherwiseno rashes or
lesions
NEURO: alert, SNHL, blind in R eye, otherwise nonfocal
.
Notable Changes at Discharge:
BP 132/85
GENERAL: comfortable appearing, speaks easily
HEENT: 6 cm incision along left occiput c/d/i
Pertinent Results:
Admission Labs:
[**2175-3-12**] 07:43PM BLOOD WBC-7.0 RBC-4.56 Hgb-12.7 Hct-37.8 MCV-83
MCH-27.9 MCHC-33.7 RDW-15.8* Plt Ct-195
[**2175-3-12**] 07:43PM BLOOD Neuts-78.5* Lymphs-15.0* Monos-4.2
Eos-1.9 Baso-0.4
[**2175-3-12**] 07:43PM BLOOD Glucose-77 UreaN-21* Creat-0.9 Na-139
K-4.2 Cl-105 HCO3-24 AnGap-14
[**2175-3-14**] 05:30AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8
.
Discharge Labs:
[**2175-4-4**] 06:20AM BLOOD WBC-6.3 RBC-3.80* Hgb-11.5* Hct-34.4*
MCV-90 MCH-30.3 MCHC-33.6 RDW-17.0* Plt Ct-159
[**2175-4-4**] 06:20AM BLOOD Glucose-84 UreaN-14 Creat-0.6 Na-141
K-3.3 Cl-99 HCO3-33* AnGap-12
[**2175-4-2**] 05:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
Brief Hospital Course:
67 year old female with trigeminal neuralgia who presented with
a third trigeminal neuralgia exacerbation, preventing, talking,
eating, drinking. Patient received trigeminal nerve block and
subsequent microvascular decompression with significant
improvement in her symptoms.
.
#. Trigeminal Neuralgia (TN) Exacerbation: Patient presented
with third excerbation and in severe pain preventing eating,
drinking, or speaking for 3 days prior to admission and getting
progressively worse. Patient has long history of TN, which had
been previously controlled with Oxycontin and Phenytoin. Patient
had tried Carbamazepine, Baclofen, Neurontin, Lamotrigine, and
Topiramate in the past without success. Patient was treated with
Methadone, Pregabalin and Phenytoin during her admission, with
the Pregabalin started during her stay. Patient also received
Dexamethasone for any associated inflammation. A trigeminal
nerve block was performed on [**3-16**] by the pain service which was
unsuccessful. The patient subsequently had craniotomy with
microvascular decompression by the Neurosurgery service on [**3-31**]
with almost immediate pain relief. Patient remained pain free
following surgery until the time of discharge. An MRI with
Fiesta sequence was performed and was consistent with
post-operative changes and detected no concerning pathology.
Patient was cleared for discharge by the Neurosurgical service.
Patient was to taper Dexamethasone and Pregabalin following
discharge. The patient's chronic pain medications, particularly
Methadone and Phenytoin, were not adjusted at the time of
discharge. The patient was instructed to follow up with her PCP
and [**Name9 (PRE) 1194**] [**Name9 (PRE) 4869**] for further management of her pain medications.
.
#. Hypertension: Patient was intially continued on her home
Metoprolol but was found to be bradycardic. Metoprolol was
stopped and HCTZ was started. Electrolytes were stable on HCTZ.
Patient on Captopril briefly post-operatively for prevention of
intracranial hypertension. Patient was discharged on HCTZ and
instructed to follow up closely with her PCP regarding blood
pressure management.
.
#. Graves' Disease s/p Ablation: Patient with long-standing
hypothyroidism following ablation. Patient was continued on her
Levothyroxine throughout admission.
Medications on Admission:
- prednisolone acetate 1 % Drops (1) Drop Ophthalmic HS
- levothyroxine 112 mcg PO DAILY
- phenytoin sodium extended 100 mg Capsule Sig: [**1-29**] Capsules PO
three times a day: take 2 tabs in the morning, and 1 tab at 4pm
and midnight.
- aspirin 81 mg PO DAILY
- metoprolol succinate 100 mg Tablet SR (1) Tablet PO DAILY
- hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H
- methadone 10 mg Tablet (1) Tablet PO three times a day
Discharge Medications:
1. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic HS (at bedtime).
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. phenytoin sodium extended 100 mg Capsule Sig: AS DIRECTED
Capsule PO 200mg in the morning, 100mg in the afternoon, 100mg
in the evening.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
10. dexamethasone 2 mg Tablet Sig: ASDIR Tablet PO ASDIR: Take
two tablets twice a day on [**3-25**] and [**4-7**]. Take two tablets
once a day on [**4-2**] and [**4-10**]. Take 1.5 tablets on [**2-13**] and [**4-13**]. Take one tablet daily on [**2-16**] and [**4-16**].
Take .5 tablets on [**4-22**] and [**4-19**]. Then stop. .
Disp:*27 Tablet(s)* Refills:*0*
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 15 days:
Take one capsule daily while on Dexamethasone. .
Disp:*15 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. pregabalin 75 mg Capsule Sig: One (1) Capsule PO once a day
for 4 days.
Disp:*4 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Trigeminal Neuralgia Exacerbation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 107126**]:
You were admitted to the hospital for a trigeminal neuralgia
exacerbation. You had a trigeminal nerve block with little
relief of your pain. You subsequently had a decompression of
your nerve that improved your pain significantly. You will need
to follow up with, Dr. [**Last Name (STitle) **], your neurosurgeon after
discharge.
.
While you were in the hospital we noticed that your heart rate
was slow on telemetry. Metoprolol can make your heart rate slow,
so it was stopped and you were switched to hydrochlorothiazide
(HCTZ) for blood pressure control. You were started on a small
dose, so you should follow up with your PCP to determine what
the appropriate dose is to control your blood pressure.
.
The following changes you were made to your medications:
1. Your Metoprolol was stopped as your heart rate was slow.
2. You were started on Hydrochlorothiazide 12.5 mg by mouth once
a day. This medication is for your blood pressure. Your
outpatient physician will make changes to this medication as
needed.
3. You were started on Docusate sodium (Colace) 100 mg by mouth
twice a day. This medication will help soften your stool.
4. You were started on Senna 1 tab by mouth twice a day as
needed for constipation.
5. You were started on Dexamethasone (steroids) during this
hospitalization. You can slowly stop taking these as an
outpatient. You have been given a prescription for 2 mg tablets.
Take two tablets twice a day on [**3-25**] and [**4-7**]. Take two
tablets once a day on [**4-2**] and [**4-10**]. Take 1.5 tablets on
[**2-13**] and [**4-13**]. Take one tablet daily on [**2-16**] and
[**4-16**]. Take .5 tablets on [**4-22**] and [**4-19**]. Then stop.
6. You were started on Omeprazole 20 mg. Take one capsule daily
while on Dexamethasone to protect your stomach.
7. You were started on Pregabalin (Lyrica) during this
hospitalization. You will no longer need this medication after
discharge but will need to taper if off over several days. Take
one pill daily starting on [**4-5**] until all pills have been taken.
Followup Instructions:
Please keep all follow-up appointments as below:
.
Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
When: Wednesday, [**4-5**], 9AM
.
Department: NEUROSURGERY
When: TUESDAY [**2175-4-11**] at 9:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2175-4-10**]
|
[
"401.9",
"791.9",
"389.15",
"530.81",
"369.4",
"350.1",
"780.62",
"562.10",
"V58.65",
"244.1",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.89",
"04.81",
"99.23",
"04.41"
] |
icd9pcs
|
[
[
[]
]
] |
8439, 8445
|
4042, 6346
|
289, 361
|
8536, 8536
|
3367, 3367
|
10780, 11387
|
2464, 2626
|
6828, 8416
|
8466, 8515
|
6372, 6805
|
8687, 10757
|
3751, 4019
|
2641, 3230
|
3244, 3348
|
238, 251
|
389, 1206
|
3383, 3735
|
8551, 8663
|
1228, 1958
|
1974, 2448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,083
| 159,662
|
26349+57496
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-7-9**] Discharge Date: [**2177-7-16**]
Date of Birth: [**2108-12-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
68F with DOE, s/p prolonged recent prolonged hospitalization.
Major Surgical or Invasive Procedure:
[**2177-7-9**] AVR (#21 magna pericardial), CABG x 1(SVG->Diag)
History of Present Illness:
68F with c/o DOE/fatigue over past year. Echo c/w severe AS.
Past Medical History:
hx of SBO [**6-25**] s/p small bowel resection in [**Month (only) 205**], ex-lap with
extensive lysis of adhesions [**7-26**] c/b intraabd abscess treated
with zosyn/fluc (grew yeast) - d/c'd in [**8-26**] from [**Hospital1 **].
CAD
Aortic stenosis [**7-26**]- [**Location (un) 109**] 0.6
Depression
Anxiety D/O
Asthma
s/p TAH/BSO
Social History:
nonsmoker, no EtOH, no IVDA, divorced, lives with son
Family History:
NC
Physical Exam:
Elderly WF in NAD
T: 99.6 BP: 114/61 HR:80 RR:20 O2 sat 98% on RA
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromgaly, carotids
2+=bilat w/ radiating murmur.
Lungs: diffuse wheezes bilat.
CV: RRR without R/G, [**3-27**] harsh systolic murmur
Abd: well-healed midline incisional scar without surrounding
errythema, NABS, soft, mild tenderness without guarding,
rebound, or tenderness.
Ext: no C/C/E, pulses 2+=bilat. throughout.
Neuro: nonfocal
Pertinent Results:
[**2177-7-14**] 01:16PM BLOOD WBC-5.3 RBC-3.34* Hgb-10.0* Hct-29.1*
MCV-87 MCH-29.8 MCHC-34.2 RDW-14.1 Plt Ct-232
[**2177-7-13**] 04:30AM BLOOD Glucose-107* UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-31 AnGap-9
RADIOLOGY Final Report
CHEST (PA & LAT) [**2177-7-15**] 8:55 AM
CHEST (PA & LAT)
Reason: eval effusions
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman7/19 CABGx2, AVR s/p
REASON FOR THIS EXAMINATION:
eval effusions
REASON FOR THE STUDY: Evaluation for effusion in a 68-year-old
woman with a status post CABG and aortic valve replacement.
TECHNIQUE: PA and lateral view of the chest.
COMPARISON: This study is compared to the previous one done on
[**7-11**].
FINDINGS: There is improving mild bilateral atelectasis, more
dominant on the right. The left small pleural effusion is
improved compared to previous study. Heart size, mediastinal and
hilar contours are normal. The synthetic aortic valve is stable.
IMPRESSION: Improving mild bilateral basilar atelectasis, more
dominant on the right . Small left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2177-7-15**] 1:09 PM
Cardiology Report ECHO Study Date of [**2177-7-9**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Intraop for AVR CABG
Status: Inpatient
Date/Time: [**2177-7-9**] at 13:15
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW3-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.5 cm (nl <= 5.0 cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.52 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg (nl <= 10
mm Hg)
Aorta - Valve Level: 2.1 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm)
Aortic Valve - Peak Gradient: 43 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
Mitral Valve - Peak Velocity: 0.8 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.88
Mitral Valve - E Wave Deceleration Time: 150 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV
systolic function.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Complex (>4mm) atheroma in
aortic root.
Normal ascending aorta diameter. Simple atheroma in ascending
aorta. Normal
aortic arch diameter. There are complex (>4mm) atheroma in the
aortic arch.
Normal descending aorta diameter. There are complex (>4mm)
atheroma in the
descending thoracic aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS.
Mild to moderate ([**12-23**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. No MS. The MR vena contracta is <0.3cm. Mild (1+)
MR. Eccentric
MR jet.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No 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. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
Pre bypass: The left atrium is moderately dilated. T 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.
Regional left
ventricular wall motion is normal; LVEF > 55%.. Right
ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the
aortic root, aortic arch, and the descending thoracic aorta. The
ascending
aorta has moderate nonmobile plaques. There is severe aortic
valve stenosis
with a severely calcified aortic valve; [**Location (un) 109**] 0.6 cm2. Mild to
moderate ([**12-23**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Mild (1+) mitral regurgitation is seen. The mitral regurgitation
jet is
eccentric. There is no pericardial effusion.
Post bypass: Perserved biventricular function. LVEF > 55%. A
bioprosthetic #21
aortic valve is insitu. There is no Aortic insufficiency,
stenosis, or
perivalvular leaks. Peak gradient on the aortic valve prosthesis
ranges from
5-10 mm hg. Mitral regurgitation is now trace. Aortic contours
are unchanged.
Remaining exam is unchanged. All findings discussed with
surgeons at the time
of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2177-7-9**] 17:59.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 65202**])
Brief Hospital Course:
Ms. [**Known lastname 27363**] was taken to the operating room on [**2177-7-9**] where
she underwent an AVR with a #21 CE magna pericardial valve and a
CABG x 1 (SVG->Diag). She was transferred to the SICU in
critical but stable condition. She was extubated and weaned from
her phenylephrine by POD #1. She as transferred to the floor the
same day. She was seen in consultation by infectious diseases
for a question of a small vegeatation on the noncoronary cusp of
her native aortic valve, and she remains on vancomycin until the
OR pathology is final. A PICC line was placed to allow for long
term antibiotics. She was also placed on levofloxacin for one
week (end [**7-19**]) for a question of pneumonia post op.
The aerobic and anaerobic cultures of the valve were negative,
but final pathology is pending. Unless the pathology is
absolutely conclusive that there was not a vegetation on the
valve, the patient will have a 4 week course of Vancomycin. The
patient was discharged to rehab in stable condition on POD#7.
Dr. [**First Name (STitle) **] of infectious disease will notify the rehab if the
patient can stop the vanco prior to 4 weeks.
Medications on Admission:
doxepin
klonopin
neurontin
lopressor
protonix
lomotil
loperamide
ambien
MVI
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Doxepin 25 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).
8. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)) as needed.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): end [**2176-7-19**]. Tablet(s)
10. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) as needed.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
13. Vancomycin HCl 1000 mg IV Q 12H
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
AS
CAD
h/o SBO with multiple abdominal abscessess
h/o viral meningitis
h/o pna
hital hernia
HTN
CVA
depression
anxiety
multiple pulmonary nodules
asthma
s/p LOA/partial small bowel resection
s/p appy
s/p TAH/BSO
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.
Followup Instructions:
Dr. [**Last Name (STitle) 65203**] 4 weeks
Dr. [**Last Name (STitle) 37742**] 2 weeks
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2177-8-11**] 4:00
Make an appointment with Dr. [**First Name (STitle) **](Infectious Disease) for 4
weeks. [**Telephone/Fax (1) **]
Completed by:[**2177-7-16**] Name: [**Known lastname 11488**],[**Known firstname 3650**] Unit No: [**Numeric Identifier 11489**]
Admission Date: [**2177-7-9**] Discharge Date: [**2177-7-16**]
Date of Birth: [**2108-12-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Prior to the patient's discharge, the pathology of the valve was
negative for endocarditis. The PICC and vanco were d/c'd and
the patient was discharged to rehab. This was discussed with
the patient and Dr. [**First Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 2075**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2177-7-16**]
|
[
"530.81",
"396.8",
"997.3",
"486",
"414.01",
"300.4",
"401.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.11",
"99.04",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
11843, 12068
|
7569, 8721
|
382, 448
|
10524, 10532
|
1511, 1833
|
10801, 11820
|
981, 985
|
8847, 10178
|
1870, 1908
|
10289, 10503
|
8747, 8824
|
10556, 10778
|
2900, 7470
|
1000, 1492
|
281, 344
|
1937, 2874
|
476, 538
|
7504, 7546
|
560, 893
|
909, 965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,442
| 136,323
|
19950+57101
|
Discharge summary
|
report+addendum
|
Admission Date: [**2198-11-30**] Discharge Date: [**2198-12-3**]
Date of Birth: [**2153-11-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 45-year-old man with a
history of chronic alcohol use status post Whipple in [**2196**]
for chronic pancreatitis with a questionable history of
ascites and encephalopathy in the past per the patient, who
presents to an outside hospital after episode of hematemesis.
Patient states that he was feeling unwell when he stopped off
at a local bar and proceeded to vomit up a large amount of
dark red blood with a questionable syncopal episode. EMS was
activated and patient was taken to an outside ED, where he
was found to have postural changes. His hematocrit was 22
and platelets 150,000.
He was transfused 1 unit of packed red blood cells and
octreotide drip and taken for EGD. EGD demonstrated grade 2
esophageal varices with oozing bleeding, stigmata of recent
bleed and red signs. Esophageal varices were banded.
Laboratories here remained hemodynamically stable and had no
further episodes of hematemesis. He was transferred to the
[**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] monitoring. The patient denies
lightheadedness or dizziness, abdominal pain. He states that
he has had melena x1, but no history in the past, no history
of jaundice, blood transfusion, trave outside of the state
except for a trip to [**Country 4754**] last year.
Family history of liver disease.
PAST MEDICAL HISTORY:
1. Hypertension.
2. GERD.
3. Chronic pancreatitis status post Whipple.
4. Alcohol abuse.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Afebrile, blood pressure
109/51, pulse 86, respirations 20, and satting 99% on 2
liters. General: Well-developed and well-nourished, alert
and oriented times three in no apparent distress. HEENT:
atraumatic, normocephalic. Pupils are equal, round, and
reactive to light. Extraocular movements are intact.
Sclerae are anicteric. Oropharynx is clear. Mucous
membranes moist. Chest was clear to auscultation
bilaterally. Cor: Regular rate, [**3-15**] holosystolic murmur
heard best at the right upper sternal border, no rub or
gallop. Abdomen is soft, nontender, nondistended. Liver
edge palpated 5 cm below the right costal margin, spleen
palpated 2 cm below the left costal margin, no fluid wave,
and positive bowel sounds. Extremities were warm and well
perfused, no clubbing, cyanosis, or edema. Skin: Spider
angiomas and telangiectasias from the upper shoulders.
Psoriatic changes upper and lower extremities. Neurologic:
cranial nerves II through XII intact. No asterixis.
LABORATORY: White count 5.8, hematocrit 26.1, platelets 113,
INR of 1.6, PT 15.7, PTT 36.4. Sodium 141, potassium 4.8,
chloride 113, bicarb 19, BUN 15, creatinine 0.5, glucose 100,
calcium 7.4, magnesium 1.5, phosphorus 4.3, AST 74, ALT 27,
alkaline phosphatase 92, total bilirubin 2.5, albumin 2.6.
EKG: Normal sinus rhythm with rate of 99, normal axis. P-R
and QRS intervals are normal. Q-T 466/598. Left atrial
enlargement, question of right atrial enlargement by V1.
HOSPITAL COURSE:
1. Esophageal varices: Patient with grade 2 varices status
post banding outside hospital. Patient transferred on
octreotide drip. Patient was admitted to the MICU for
monitoring and patient had no evidence of rebleed and
required a total of six units of packed red blood cells to
maintain his hematocrit. Patient was continued on octreotide
for a total of five days on empiric ciprofloxacin for
spontaneous bacterial peritonitis prophylaxis. Patient was
eventually called up to the Floor.
2. Chronic liver disease: Ultrasound demonstrated diffuse
increased echogenicity. No focal masses. Hepatitis
serologies, AFB are pending at the time of dictation.
Patient has Child's Class B ............ discrimination
function of 10.9. He has patent portal hepatic venous blood
flow on ultrasound and will need Hepatology followup and
probable long-term nadolol.
3. Alcohol abuse: The patient was put on CIWA scale, but
demonstrated no evidence of withdrawal. He was seen by
Social Work, who reiterated need for the patient to stop
drinking alcohol.
4. Heart murmur: This is likely a flow murmur secondary to
patient's hemodynamic state. This may be followed up with an
echocardiogram if it remains after the patient was further
stabilized.
5. History of Whipple: Patient endorses multiple bowel
movements per day. A fecal ............ was sent and is
pending at the time of dictation. Patient may need pancreas
enzymes in the future.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Home.
This dictation will have an addendum when the patient is
discharged from the floor.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF
Dictated By:[**Name8 (MD) 7583**]
MEDQUIST36
D: [**2198-12-3**] 13:09
T: [**2198-12-4**] 07:41
JOB#: [**Job Number 53801**]
Name: [**Known lastname 9996**],[**Known firstname 126**] Unit No: [**Unit Number 9997**]
Admission Date: [**2198-12-4**] Discharge Date: [**2198-12-5**]
Date of Birth: Sex:
Service:
ADDENDUM: This Discharge Summary Addendum will cover the
dates [**2198-12-4**] to [**2198-12-5**].
On hospital day five, the patient went out from the Medical
Intensive Care Unit to the floor. He remained
hemodynamically stable. He was afebrile. His heart rate was
within the normal range.
CONDITION AT DISCHARGE: He was discharged on hospital day
six in stable condition.
MEDICATIONS ON DISCHARGE:
1. Ultram 50 mg by mouth q.6-8h. as needed (for pain).
2. Thiamine 100 mg by mouth once per day.
3. Folic acid 1 mg by mouth once per day.
4. Lactulose 30 mL by mouth three times per day (for 14
days).
5. Tylenol.
6. Protonix 40 mg by mouth once per day.
7. Ciprofloxacin one tablet by mouth q.12h. (for 14 days).
8. Nadolol 20 mg by mouth once per day.
9. Spironolactone 50 mg by mouth once per day.
10. Sucralfate 1 gram by mouth four times per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician on that Tuesday ([**2198-12-11**]) to have his
spironolactone checked.
2. The patient was to have an esophagogastroduodenoscopy
performed on that Wednesday ([**2198-12-12**]).
[**First Name8 (NamePattern2) 77**] [**First Name4 (NamePattern1) 1495**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8396**]
Dictated By:[**Last Name (NamePattern1) 1061**]
MEDQUIST36
D: [**2199-2-14**] 10:40
T: [**2199-2-14**] 16:51
JOB#: [**Job Number 9998**]
|
[
"530.81",
"571.2",
"401.9",
"285.1",
"456.20",
"572.3",
"577.1",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4625, 5485
|
5587, 6058
|
3157, 4603
|
6091, 6657
|
1653, 3140
|
5500, 5560
|
158, 1480
|
1502, 1630
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,742
| 172,634
|
28487
|
Discharge summary
|
report
|
Admission Date: [**2134-6-13**] Discharge Date: [**2134-6-17**]
Date of Birth: [**2057-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
VAC changed
History of Present Illness:
76M with ESRD on HD, CAD s/p cabg, afib, copd, dm2 presents from
rehab on the day after being discharged from [**Hospital1 18**] on cardiac
[**Doctor First Name **] service. The patient underwent elective cabg/MVR by Dr.
[**Last Name (STitle) **] on [**5-12**]. He had a complicated course developing sepsis on
[**5-19**] and found to have mesenteric ischemia requiring exploratory
laparotomy and right colectomy by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He also
developed a PNA and c.diff. He was discharged to [**Hospital1 9494**] on [**6-11**] with a plan to continue 7 days of vanc/CTX for PNA
and 10 days of flaygyl for c diff. At the rehab, the patient was
evaluated by a moonlighter who noted reddish output from g-tube
that was found to be guaiac+. The patient's wife was [**Name (NI) 653**]
regarding concern for an intestinal bleed and the patient was
transferred to [**Hospital1 18**] for further evaluation.
In [**Hospital1 18**] ED the hct was found to be 33.9, up from 30.2 at
discharge on [**6-11**]. VS p 90 132/66 12 100% on vent. He was
evaluated by gen [**Doctor First Name **] and cardiac [**Doctor First Name **] in the ED in whose
assessment the patient, aside from the concern for bleeding,
appeared with similar clinical status to the point where he was
discharged to rehab.
Past Medical History:
ESRD on HD
HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-16**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH
Social History:
Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.2 BP: 93/52 HR: 80 RR: 16 O2sat 100% on vent
AC 500 x 12 5 0.4
GEN: eyes open spontaneously, attends to stimuli, nods to
questions
HEENT: pupils reactive, edentulous
CHEST: R HD line, midline substernal incision well healing,
clear to auscultation
CV: RR, S1 and S2 wnl, no m/r/g
ABD: soft, NT, ileostomy with some black eschar and pink tissue
as well, midline abd wound with packing, thick yellow secretions
in wound, pink tissue
EXT: no c/c/e
Pertinent Results:
[**2134-6-13**] 01:15AM BLOOD WBC-12.6* RBC-3.34* Hgb-10.3* Hct-33.9*
MCV-102* MCH-31.0 MCHC-30.5* RDW-20.2*
[**2134-6-13**] 01:15AM BLOOD Neuts-70.4* Lymphs-22.7 Monos-6.1 Eos-0.6
Baso-0.2
[**2134-6-13**] 08:36AM BLOOD WBC-13.0* RBC-3.40* Hgb-10.3* Hct-34.6*
MCV-102* MCH-30.4 MCHC-29.9* RDW-20.2* Plt Ct-420
[**2134-6-14**] 08:38AM BLOOD WBC-14.1* RBC-3.17* Hgb-10.0* Hct-32.3*
MCV-102* MCH-31.6 MCHC-30.9* RDW-21.3* Plt Ct-386
[**2134-6-13**] 08:36AM BLOOD PT-16.3* PTT-28.0 INR(PT)-1.5*
[**2134-6-14**] 12:15PM BLOOD PT-19.2* PTT-41.0* INR(PT)-1.8*
[**2134-6-13**] 01:15AM BLOOD [**Month/Day/Year **]-92 UreaN-58* Creat-2.9* Na-141
K-4.5 Cl-110* HCO3-21* AnGap-15
[**2134-6-13**] 08:36AM BLOOD [**Month/Day/Year **]-72 UreaN-64* Creat-3.1* Na-144
K-4.3 Cl-112* HCO3-19* AnGap-17
[**2134-6-14**] 08:38AM BLOOD [**Month/Day/Year **]-242* UreaN-82* Creat-3.9* Na-145
K-4.8 Cl-115* HCO3-15* AnGap-20
[**2134-6-14**] 08:38AM BLOOD Albumin-2.4* Calcium-8.8 Phos-4.4 Mg-2.4
[**2134-6-14**] 08:38AM BLOOD Vanco-6.7*
.
CHEST (PORTABLE AP) [**2134-6-13**] 12:18 AM
AP SEMI-UPRIGHT CHEST: The extreme left costophrenic angle is
excluded from the radiograph. The tracheostomy tip terminates 5
cm above the carina. Median sternotomy wires and right central
venous catheter are unchanged in position. The heart size,
mediastinal and hilar contours are stable. There is interval
decrease in perihilar interstitial opacity consistent with
improving pulmonary venous pressure. Small bilateral pleural
effusions persist. Mild retrocardiac opacity likely reflects a
combination of atelectasis and effusion, although underlying
infectious process is not excluded.
IMPRESSION:
1. Improving pulmonary interstitial edema.
2. Unchanged small pleural effusions and retrocardiac opacity
representing atelectasis or pneumonia.
.
CHEST (PORTABLE AP) [**2134-6-14**] 2:44 AM
SINGLE BEDSIDE AP RADIOGRAPH OF THE CHEST: Prominent
interstitial markings may represent chronic vascular congestion.
Overall, these are unchanged since multiple prior studies dating
back to [**2132-9-13**]. There is no obvious pleural effusion.
There is no pneumothorax. The cardiomediastinal silhouette is
normal. There are no focal consolidations. Triple lumen tunneled
dialysis catheter terminating in the mid SVC is noted.
Tracheostomy tube is in unchanged location.
IMPRESSION: Prominent bilateral interstitial markings may
represent chronic vascular congestion. No acute cardiopulmonary
process identified.
[**2134-6-17**] 03:21AM BLOOD WBC-12.1* RBC-3.11* Hgb-9.6* Hct-31.0*
MCV-100* MCH-31.0 MCHC-31.1 RDW-20.1* Plt Ct-275
[**2134-6-13**] 01:15AM BLOOD Neuts-70.4* Lymphs-22.7 Monos-6.1 Eos-0.6
Baso-0.2
[**2134-6-17**] 03:21AM BLOOD Plt Ct-275
[**2134-6-17**] 03:21AM BLOOD PT-18.9* PTT-32.0 INR(PT)-1.7*
[**2134-6-17**] 03:21AM BLOOD [**Month/Day/Year **]-191* UreaN-33* Creat-2.3*# Na-138
K-3.9 Cl-104 HCO3-23 AnGap-15
[**2134-6-16**] 04:24PM BLOOD [**Month/Day/Year **]-214* UreaN-64* Creat-3.6* Na-137
K-4.2 Cl-108 HCO3-16* AnGap-17
[**2134-6-15**] 03:55PM BLOOD [**Month/Day/Year **]-213* UreaN-53* Creat-3.0* Na-139
K-4.1 Cl-109* HCO3-18* AnGap-16
[**2134-6-14**] 10:02PM BLOOD ALT-34 AST-48* LD(LDH)-381* AlkPhos-221*
TotBili-0.8
[**2134-6-17**] 03:21AM BLOOD Calcium-7.5* Phos-1.7* Mg-1.6
.
.
Upper extremity US:
IMPRESSION:
1. Right internal jugular vein not clearly visualized. No
evidence of deep venous thrombosis seen
.
Gastrograffin G-tube study:
IMPRESSION: Tube with contrast injection indicative of gastric
placement.
Brief Hospital Course:
# GI Bleed:
HCT on admission was stable from previous and remained stable.
G-tube was examined by medical and surgical teams and no
evidence of bleed was observed. The G-tube was changed. A PPI
was started for gastritis prevention. The patient should have
daily hematocrit checks.
# Respiratory failure:
The patient was at the rehab facility with a trach for vent
weaning. His vent settings were weaned to CPAP w/ & w/o PS with
pressure support level: 14 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %.
# PNA:
Sputum grew MRSA and E. Coli. Plan was to continue
vanc/ceftriaxone for 7 days at discharge [**6-11**]. The patient
developed a fever and had an infiltrate on CXR. He was switched
to vancomycin/piperacillin-tazobactam/metronidazole and will be
treated for a seven day course ending on [**2134-6-22**].
# Gastric Tube Placement:
The patient has his gastric tube replaced during this
hospitalization. The location of the tube was confirmed
radiographically. The patient had bleeding around the site of
his gastric tube, with no bleeding from within the G tube, the
day prior to discharge that resolved with pressure.
# Abdominal Wound:
The patient had a vacuum dressing applied by surgery. The
dressing needs to be changed every four days.
# C. Diff infection: The patient was continued on flagyl.
Given the extended duration of abx therapy he will need to
continue taking Flagyl though [**2134-7-2**].
# CAD/CABG:
No evidence of active ischemia. He was continued on [**Month/Day/Year **], BB,
statin.
# ESRD on HD:
Renal team aware, he was continued on HD by renal team. His HD
line was clotted for which he received TPA multiple times with
improvement in line function.
# Afib/ ?history of DVT
Now in sinus rhythm. He was continued on coumadin and BB for
rate control. His coumadin was increased for subtherapeutic
INR. He should have his INR checked on a daily basis and his
medications titrated appropriately.
# mouth sore:
The patient has irritation of the upper gum in the tooth line
(ofcourse he has no teeth). The plan is for nursing to check
this area frequently and keep it clean
# Code Status: FULL CODE
Medications on Admission:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q24H (every 24 hours).
7. Warfarin 1 mg Tablet Sig: adjust dose to INR Tablet PO DAILY
(Daily) as needed for afib: Target INR 2-2.5
last dose 5/26-1mg.
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for nose.
11. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 days.
12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous HD PROTOCOL (HD Protochol) for 7 days.
13. Ceftriaxone 1 gram Recon Soln Sig: One (1) gm Intravenous
Q24H (every 24 hours) for 7 days.
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: as directed
below ML Intravenous PRN (as needed) as needed for line flush:
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 10 UNIT/ML .
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10
days.
16. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
once a day.
17. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection Q AC&HS.
18. Maalox/Diphenhydramine/Lidocaine Sig: Five (5) cc every
six (6) hours as needed.
19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic PRN (as needed).
20. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**6-20**]
Puffs Inhalation Q4H (every 4 hours) as needed for when on vent.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
units Injection ASDIR (AS DIRECTED): at breakfast, lunch, dinner
and HS, give 4 oz juice for [**Hospital1 **] 0-50, nothing for 51-150, 2
units for 151-200, 4 units for 201-250, 6 units for 251-300, 8
units for 301-350, 10 units for 351-400, [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) **]
>400.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days: complete course on [**7-2**].
8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous HD PROTOCOL (HD Protochol) for 3 days: complete
course [**6-22**].
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**6-20**]
puffs Inhalation every four (4) hours as needed: while on vent.
12. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 gram
Recon Solns Intravenous Q12H (every 12 hours) for 4 days: end
date [**6-22**].
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: adjust [**Name8 (MD) **] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary
1. non-bleeding G-tube
2. temporarily clotted dialysis line
Secondary
1. hospital acquire pneumonia
2. history of c. difficile infection
3. respiratory failure with tracheostomy tube
4. end stage renal disease on dialysis
5. coronary artery disease status post CABG
6. atrial fibrillation
7. history of mesenteric ischemia with post-laparotomy scar
Discharge Condition:
Afebrile, VSS, awake and nods head in response to questions
Discharge Instructions:
You were admitted to the hospital because of concern that there
might be bleeding from your G-tube. You were evaluated by
medical and surgical doctors who [**Name5 (PTitle) 2985**] there was no bleeding from
your G-tube, and your G-tube was changed. Your blood levels were
followed and remained stable. While you were here you were
followed by renal specialists who oversaw your hemodialysis.
Your hemodialysis line was felt to be clotted, for which you
received TPA and the clot resolved. Your wound vac was changed
by the surgery team.
.
You also developed a fever so one of your antibiotics was
changed from ceftriaxone to zosyn to provide broader coverage
for hospital acquired infections. You had a CXR which showed a
possible new LLL infiltrate which could suggest a new PNA. You
should continue to to take the vancomycin with dialysis and the
zosyn to complete a 7 day course on [**6-20**]. You should continue to
take the flagyl for c. diff infection until [**6-27**].
.
Please take all medications as prescribed. Please go to all
follow up appointments. You should follow up with surgery for
evaluation of your abdominal wound. You should have a repeat CXR
after completion of antibiotics. If you have fevers, bleeding,
or any other concerning symptoms, please call the doctor or come
to the hospital.
Followup Instructions:
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] [**2-14**] wks after discharge from rehab
[**Telephone/Fax (1) 26190**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2 wks after discharge from rehab [**Telephone/Fax (1) 170**]
Dr. [**First Name (STitle) **] [**Name (STitle) **] [**2-14**] wks after discharge from rehab
Pt has numerous actinic keratoses (precancerous lesions) which
will need to be treated as an outpatient. He agrees to follow up
with his new primary dermatologist as scheduled in [**Month (only) **].
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (General Surgery Clinic) in [**2-14**] weeks.
Dr.[**Name (NI) 670**] nurse will contact you regarding an appointment.
You can call ([**Telephone/Fax (1) 3618**] if you have further questions.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2134-6-23**]
|
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icd9cm
|
[
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[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,141
| 161,651
|
26585+57506
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-1-17**] Discharge Date: [**2138-1-27**]
Date of Birth: [**2057-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Stent Removal
History of Present Illness:
81M c tracheomalacia stent placed 1 month ago w/ cough, on
azithromax, s/p stent removal [**2138-1-17**]
Past Medical History:
Tracheomalacia s/p stent [**2137-11-13**], then stent removal [**2137-11-27**]
CAD s/p CABG
Chronic atrial fibrillation: had been on coumadin prior to
[**11-11**], but stopped for procedures.
Hypertension
Hyperlipidemia
COPD
s/p L thoracoplasty for recurrent pleural effusion in [**2081**]'s
Social History:
Lives alone. Used to work as a mechanical drafter. He does not
drink and used to smoke cigars, 2 cigars a day for 2 years and
quit 15 years ago. He reports exposure to asbestos (cutting a
board in his basement).
Family History:
NC
Physical Exam:
GEN: NAD
CV: RRR
PULM: Clear
ABD: SOFT, NT
EXT: + PULSES
Brief Hospital Course:
Patient tolerated stent removal
Pt's pain controlled.
Pt tol po, afebrile, ambulating
Medications on Admission:
prednisone taper [30' through [**1-14**], 20' through [**1-17**], 10' through
[**1-20**], 5' through [**1-23**]], prilosec 20', toprol 150', robitussin,
valsartan 160', coumadin 2.5 [stopped [**1-10**]]
[**1-17**] - afib / brady , pred taper
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
2 days.
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: after completing 2 days of 10 mg dose.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 22201**] VNA
Discharge Diagnosis:
Tracheomalacia s/p stent removal
Discharge Condition:
Stable
Discharge Instructions:
Call or go to ED for SOB, Fever temp > 101.4,N/V ,
Followup Instructions:
Call Dr[**Name (NI) 1816**] clinic on Monday [**2138-1-20**]
Completed by:[**2138-1-18**] Name: [**Known lastname 7410**],[**Known firstname **] J Unit No: [**Numeric Identifier 11525**]
Admission Date: [**2138-1-17**] Discharge Date: [**2138-1-27**]
Date of Birth: [**2057-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 10570**]
Addendum:
This is an addendum to previously dictated discharged summary.
The patient was not discharged on [**2138-1-17**] in lieu of the plan
for an operation the next week.
Chief Complaint:
Tracheomalacia
Major Surgical or Invasive Procedure:
Tracheoplasty via Right thoracotomy
History of Present Illness:
This is an 80 year old gentleman with a history of
tracheomalacia who now presents for elective repair. He has a
several year history of this disease as characterized by
shortness of breath and productive cough. He also has known left
main bronchus disease. He has had stents placed inthe past but
they have been complicated by dyspnea and obstruction requiring
removal. He also charaies a diagnosis of COPD and has had a left
thoracoplasty for recurrent infectious effusions.
Past Medical History:
Tracheomalacia s/p stent [**2137-11-13**], then stent removal [**2137-11-27**]
CAD s/p CABG
Chronic atrial fibrillation: had been on coumadin prior to
[**11-11**], but stopped for procedures.
Hypertension
Hyperlipidemia
COPD
s/p L thoracoplasty for recurrent pleural effusion in [**2081**]'s
Social History:
The patient lives alone but is cared for by his daughter. Used
to work as a mechanical drafter. He does not drink and used to
smoke cigars, 2 cigars a day for 2 years and quit 15 years ago.
He reports exposure to asbestos (cutting a board in his
basement).
Family History:
noncontributory
Physical Exam:
On admission:
Afebrile, vital signs stable, respiratory rate 20 and O2 Sat 98%
on room air
Gen: no acute distress, pleasant,
HEENT: moist mucous membranes
Neck: no lymphadenopathy, no masses
CV: regular rate and rhythm
Pulm: CTAB
Abd: soft, NT/ND
Extr: warm, well-perfused
Pertinent Results:
[**2138-1-18**] 07:38PM BLOOD WBC-12.3* RBC-4.35* Hgb-14.3 Hct-41.9
MCV-96 MCH-32.9* MCHC-34.2 RDW-14.5 Plt Ct-263
[**2138-1-19**] 06:00AM BLOOD WBC-10.1 RBC-4.30* Hgb-14.2 Hct-40.9
MCV-95 MCH-32.9* MCHC-34.6 RDW-14.5 Plt Ct-253
[**2138-1-20**] 03:49PM BLOOD WBC-24.1*# RBC-4.29* Hgb-14.1 Hct-40.9
MCV-95 MCH-32.8* MCHC-34.5 RDW-14.3 Plt Ct-276
[**2138-1-21**] 03:15AM BLOOD WBC-25.0* RBC-3.88* Hgb-13.0* Hct-37.0*
MCV-96 MCH-33.6* MCHC-35.2* RDW-14.5 Plt Ct-265
[**2138-1-22**] 06:00AM BLOOD WBC-18.5* RBC-4.03* Hgb-13.0* Hct-38.3*
MCV-95 MCH-32.2* MCHC-33.8 RDW-14.7 Plt Ct-259
[**2138-1-23**] 05:26PM BLOOD WBC-16.6* RBC-3.87* Hgb-13.0* Hct-36.9*
MCV-95 MCH-33.6* MCHC-35.3* RDW-14.6 Plt Ct-226
[**2138-1-26**] 05:00AM BLOOD PT-17.6* INR(PT)-1.6*
[**2138-1-27**] 06:20AM BLOOD PT-17.3* INR(PT)-1.6*
[**2138-1-18**] 07:38PM BLOOD Glucose-202* UreaN-23* Creat-0.9 Na-136
K-4.8 Cl-99 HCO3-25 AnGap-17
[**2138-1-20**] 03:49PM BLOOD Glucose-220* UreaN-19 Creat-0.8 Na-135
K-4.4 Cl-101 HCO3-24 AnGap-14
[**2138-1-21**] 03:15AM BLOOD Glucose-166* UreaN-19 Creat-0.9 Na-133
K-4.9 Cl-101 HCO3-26 AnGap-11
[**2138-1-23**] 05:26PM BLOOD Glucose-134* UreaN-18 Creat-1.1 Na-133
K-4.4 Cl-94* HCO3-29 AnGap-14
[**2138-1-18**] 07:38PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.7
[**2138-1-22**] 06:00AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9
[**2138-1-23**] 05:26PM BLOOD Calcium-8.7 Phos-3.4
RADIOLOGY:
[**2138-1-21**] CXR: AP single view obtained with patient in
semi-upright position is analyzed in direct comparison with a
similar previous study of [**2138-1-20**]. Again, the patient
is slightly rotated towards the right which
exaggerates the on previous examination existing up to 2 cm wide
pneumothorax between the right lateral chest wall and the
visceral pleura has now practically disappeared. In the apical
area where the previously described three chest tubes
terminate, expansion of the pulmonary tissue is not complete.
Thus, again approximately 2-3 cm wide apical pneumothorax
remaining. In comparison with the previous study, however, even
this gap has diminished slightly. Within the pulmonary
parenchyma, no new infiltrates are identified. The cutaneous
emphysema in the right chest wall persists and may even have
progressed slightly. The left hemithorax as well as signs of
previous bypass surgery are unchanged.
[**2138-1-26**] CXR: There has been no significant change since the
previous film of [**2138-1-25**]. Specifically, the right
pneumothorax is unchanged. There is persistent extensive
subcutaneous emphysema in the right chest wall and neck and the
chronic bilateral parenchymal/pleural changes and left upper
thoracoplasty are again demonstrated.
MICRO:
[**2138-1-20**] Bronchoalveolar Lavage: GRAM STAIN (Final [**2138-1-20**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): COLUMNAR EPITHELIAL CELLS.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2138-1-22**]):
~1000/ML OROPHARYNGEAL FLORA.
MOLD. 1 COLONY ON 1 PLATE.
Brief Hospital Course:
This is an 80 year old gentleman who was admitted for tracheal
stent removal and then tracheoplasty on [**2138-1-20**] (please see the
operative report of Dr. [**Last Name (STitle) 384**] for full details). He had a good
post-operative course. Initially he was in the intensive care
unit where he was extubated immediately post-operatively and had
no post-op shortness of breath. He was started on a clear
liquids diet on post-op day 1 which was eventually advanced to a
soft and then regular diet. He had his chest tubes placed to
water seal on post-op day 1 but they were placed back on wall
suction when he developed a pneumothorax; they were subsequently
placed on water seal on post-op day 2 and then removed on
post-op day 3 without subsequent pneumothorax. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain
left in place was then removed on post-op day 5. He worked with
physical therapy and was cleared for home discharge. He was
discharged to home on post-operative day 7 with planned
follow-up with thoracic surgery. With regards to his
anticoagulation for known chronic atrial fibrillation, this was
initially held (the patient hadn't taken coumadin for weeks
prior to admission) and he was eventually resumed on his daily
coumadin regimen with planned follow-up with his primary care
physician for INR checks. All questions were answered to his
satisfaction upon discharge.
Medications on Admission:
Prednisone taper (through [**2138-1-23**])
Prilosec 20 mg po qdaily
Toprol 150 mg po qdaily
Robitussin
valsartan 160 mg po qdialy
Coumadin 2.5 mg po qdaily.
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: through [**2138-1-31**].
Disp:*8 Tablet(s)* Refills:*0*
2. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: You
should have your levels checked twice/week.
Disp:*20 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
You should have an INR checked with your primary care physician
on Wednesday [**2138-1-29**]
4. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*2*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*10 Capsule(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily):
(this is different from pre-admission dose).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Protonix 40 mg po BID
Robitussin
valsartan 160 mg po qdialy
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 11526**] VNA
Discharge Diagnosis:
Primary: Tracheomalacia
Secondary: Atrial Fibrillation, hypertension, copd,
hyperlipidemia
Discharge Condition:
Good pain control, tolerating POs, no shortness of breath
Discharge Instructions:
Call or go to ED for SOB, Fever temp > 101.4,N/V. Take all
medications as prescribed. You may continue a regular diet. You
should
Followup Instructions:
You should follow-up in the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 384**] in [**12-9**]
weeks (call for an appointment at [**Telephone/Fax (1) 1477**]).
You should follow-up wiht Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11527**] in 1 week for a
Coumadin level check [**Telephone/Fax (1) 11528**])
[**First Name4 (NamePattern1) 904**] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(1) 1370**]
Completed by:[**2138-1-27**]
|
[
"496",
"511.0",
"272.4",
"427.31",
"V45.81",
"401.9",
"V58.61",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51",
"98.15",
"33.22",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
9873, 9933
|
7335, 8741
|
2802, 2840
|
10068, 10128
|
4282, 7312
|
10307, 10841
|
3954, 3971
|
8948, 9850
|
9954, 10047
|
8767, 8925
|
10152, 10284
|
3986, 3986
|
2748, 2764
|
2868, 3347
|
4001, 4263
|
3369, 3662
|
3678, 3938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,032
| 116,396
|
40379
|
Discharge summary
|
report
|
Admission Date: [**2174-6-6**] Discharge Date: [**2174-6-10**]
Date of Birth: [**2108-5-10**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization status post percutaneous intervention (2
bare metal stents)
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 88506**] is a 66 year old M
w/ h/o pancreatic CA s/p sphincterotomy [**12-15**] and chemotherapy
with gemcitabine and erlotinib, DM type 2, and CAD s/p MI and
PCI/stent [**2167**] who is transferred from OSH with acute inferior
STEMI. Patient presented to [**Hospital3 8544**] the afternoon of
admission with chest pain, onset around noon and radiation to
neck and left arm. Pain occurred at rest and was worse with
inspiration. Associated with SOB, no nausea or vomiting. Of
note, reported some pleuritic symptoms several days prior to
this episode, though not as intense. Pain was [**9-14**] at its worst.
Presented to OSH where EKGs were remarkable for STE and small q
waves in II, III, aVF with reciprocal ST depressions in I and
aVL. Patient was given asa, plavix 300, and started on a heparin
drip. He was given nitro x 3 without relief of his symptoms and
subsequently started on a nitro drip. He was transferred to
[**Hospital1 18**] for further management.
.
On arrival at [**Hospital1 18**] patient was taken straight to cath lab.
Vitals at that time were HR 109, BP 128/68 RR 19 O2 sat 99%.
Cardiac catheterization showed a right dominant system with
total occlusion of RCA, minimal disease in the remaining
vessels. The lesion was apparently difficult to cross and
behaved more like a chronic TO than an acute lesion. He
underwent balloon dilation and then two bare metal stents were
placed in the proximal and mid RCA.
.
In the CCU, patient reported pain improved, but continued
pleuritic pain in his upper chest/neck with inspiration and
burping. [**3-10**] in intensity. Denied cough, hemoptysis,
hematemesis, nausea, vomiting, abdominal pain, rashes. Reports
has been active at home, walking around and driving more than in
recent times. ROS is negative for diarrhea, black stools, bloody
stools, and fevers. +Chills.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
CAD s/p PCI in [**2167**]
3. OTHER PAST MEDICAL HISTORY:
Metastatic Pancreatic cancer (currently on gemcitabine qOweek
and erlotinib daily)
Embolic cerebral infarcts
Status post left MCA stroke with left carotid artery stenosis
S/p upper and lower GI bleed [**12-15**]
Thrombocytopenia
Diabetic retinopathy
Cataracts
Glaucoma
Social History:
- Tobacco: currently smokes 1ppd x 40 years
- EtOH: previously was a heavy drinker, quit 20 years ago.
Denies current EtOH use
- Illicits: denies
Lives with his wife. [**Name (NI) **] 3 children, numerous grandchildren.
Family History:
The patient's father died of asbestosis and
mesothelioma at 75 years. His mother is alive at [**Age over 90 **] years. He
has three children and two brothers without health concerns.
.
Physical Exam:
On Admission:
VS: T= 99.4 BP= 118/65 HR=99 RR=16 O2 sat=99% on 2L
GENERAL: thin elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm, positive hepatojugular reflex.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Rub appreciated at LLSB. No m/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 anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits. Dopplerable DPs.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
On Discharge
VSS
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Rub appreciated at LLSB. No m/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 anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits. Dopplerable DPs.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
On Admission:
[**2174-6-6**] 09:50PM WBC-9.2 RBC-3.02* HGB-9.2* HCT-27.3* MCV-90
MCH-30.4 MCHC-33.6 RDW-16.9*
[**2174-6-6**] 09:50PM NEUTS-78* BANDS-3 LYMPHS-8* MONOS-10 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2174-6-6**] 09:50PM GLUCOSE-347* UREA N-24* CREAT-0.9 SODIUM-134
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15
[**2174-6-6**] 09:50PM ALT(SGPT)-55* AST(SGOT)-79* CK(CPK)-363* ALK
PHOS-223* TOT BILI-0.6
[**2174-6-6**] 09:50PM PT-14.1* PTT-46.1* INR(PT)-1.2*
.
On Discharge: [**2174-6-10**] 06:45
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
12.8* 2.96* 9.1* 27.5* 93 30.9 33.2 17.6* 120*
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
109 27* 1.1 138 4.1 106 22 14
.
Cardiac Markers:
CK-MB MB Indx cTropnT
[**2174-6-7**] 12:00 20* 7.8* 3.53*1
[**2174-6-7**] 04:15 23* 6.4* 5.22*1
.
HgA1c: 8.3
.
Lipid Panel: [**2174-6-7**] 04:15
Cholest Triglyc HDL CHOL/HD LDLcalc
136 111 11 12.4 103
.
Cardiac Catheerization:
PROCEDURE:
Percutaneous coronary revascularization was performed using
placement of
bare-metal stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
11) INTERMEDIUS NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
17) LEFT PDA NORMAL
17A) POSTERIOR LV NORMAL
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
1 vessel coronary artery disease. The LM, LAD and LCx had
minimal
disease. The RCA was totally occluded proximally.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressure of 133/53mmHg.
FINAL DIAGNOSIS:
1. Bare metal stents placed in a patient with presumed STEMI
with ST
elevation in 3 and F.
2. He is still c/o of pleuritic chest pain. A spiral CT must be
obtained
to r/o PE as this may have been a chronic TO.
3. ASA and clopidogrel for as long as a year if he can tolerate
it, but
no less than a month.
.
TTE:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with inferior and
inferolateral akinesis, c/w RCA disease. The remaining segments
contract normally (LVEF = 40%). The right ventricular cavity is
mildly dilated with focal basal free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. 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: Mild regional left ventricular systolic dysfunction,
c/w CAD. Dilated and hypokinetic RV in a pattern, consistent
with either proximal RCA disease or acute pulmonary hypertension
(e.g., PE). Normal estimated pulmonary pressures argue in favor
of CAD as a cause of RV dysfunction.
.
CTA Chest:
The pulmonary arterial tree is well opacified and there is no
embolic filling defect. The aorta is normal in caliber, and
there is no evidence of dissection.
Airways are patent to subsegmental levels bilaterally. Note is
made of small bilateral pleural effusions with overlying
subsegmental atelectasis. In addition, there is more focal
consolidation in the left lower lobe (4:67) with the possibility
of pneumonia not excluded. The lungs are otherwise clear.
The heart and great vessels are notable for extensive coronary
arterial
calcification as well as coronary arterial stenting. Though
there is no
hilar, mediastinal or axillary lymphadenopathy by size criteria,
note is made of many borderline sized hilar nodes as well as
multiple mediastinal nodes, notable in number.
The study is not tailored for precise characterization of
subdiaphragmatic
contents. Nevertheless those included are notable for
pneumobilia as well as a metallic common bile duct stent seen on
the scout imaging. Osseous
structures reveal no suspicious sclerotic or lytic lesions.
IMPRESSION:
1. No pulmonary embolism.
2. Small bilateral pleural effusions with overlying atelectasis
as well as
more confluent opacity at the left lung base. For the latter,
the possibility of pneumonia is not excluded and should be
correlated to the clinical presentation of the patient.
3. Extensive coronary arterial calcification
.
RUQ ultrasound [**6-9**]:
IMPRESSION:
1. No intrahepatic biliary ductal dilatation. Small pneumobilia
in the CBD, likely introduced by the known biliary stent.
2. Extensive metastatic disease in the liver, better assessed by
the prior CT torso on [**2174-2-21**].
3. Cholelithiasis without acute cholecystitis. Splenomegaly. No
ascites.
.
Brief Hospital Course:
Mr. [**Known lastname 88506**] is a 66 year old M w/ h/o pancreatic CA s/p
sphincterotomy [**12-15**] and chemotherapy with gemcitabine and
erlotinib, DM type 2, and CAD s/p MI and
PCI/stent [**2167**] who was transferred from OSH with acute inferior
STEMI.
.
# STEMI: Patient presented with chest pain to OSH that was
severe and sharp in quality and acute in onset at rest. EKG
consistent with inferior MI. Total occlusion of RCA on cath, but
some suggestion of chronic state. Now s/p PCI with 2 BMS to RCA.
Given findings on cath and history of intermittent pleuritic
pain prior to today's episode cannot be entirely sure about the
timing of the MI. ASA 325mg and clopidogrel 75mg needs to be
taken daily for as long as a year if he can tolerate, but no
less than one month. No statin was given history of
rhabdomyolysis. Pt has f/u appt wtih Dr. [**Last Name (STitle) **] at [**Hospital1 18**] and
will f/u with his PCP [**Last Name (NamePattern4) **] 1 week.
.
# Pleuritic chest pain: Thought [**3-9**] MI related pericardial
irritation. Resolved over hospital stay. No pericardial
effusion, small pleural effusions noted. Chest CTA showed no
evidence of PE. He does have a friction rub noted on exam that
persisted.
.
# Acute Systolic Dysfunction: As of [**2174-2-5**], intact EF with
no evidence of systolic or diastolic dysfunction. ECHO after MI
showed EF of 40%, no pericardial effusion. Pt did not have
symptoms of CHF during his hospital stay but teaching regarding
daily weights, low Na diet and adherance to medicines done at
discharge. He was not on diuretics in the past. ACEi was started
as an inpatient and should be uptitrated if BP tolerate.
.
# RHYTHM: Currently in sinus. No history of arrhythmias or
syncope. No arrythmias noted on telemetry during hospital stay.
.
# Pancreatic CA: Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**]. Currently on
gemcitabine 1000 mg/m2 days one and 15 of a 28-day cycle in
combination with erlotinib 100 mg p.o. daily. This is his off
week for gemcitabine. Dr. [**Last Name (STitle) 1852**] was consulted during pts
hospital stay and recommended continuing Tarceva for now with
close f/u after discharge to discuss further chemotherapy
options. Home dose of Lovenox was continued.
.
# Hypertension: Currently normotensive. No hypotensive episodes
at OSH or in hospital. Lisinopril continued and metoprolol
uptitrated to goal HR in 70's. Amlodipine was not continued.
.
# Diabetes mellitus: On metformin and glipizide at home. Last
A1c 8.3. No medication changes were made.
.
# Bacteremia: Pt developed fevers and found to have Klebsiella
in his blood cultures. Urine culture was negative. ID was
consulted given pts history of pancreatic CA and recommended a
12 day course of IV Ceftriaxone. This was continued at discharge
via new PICC line. The source of bacteremia is unclear with no
evidence of secondary infection via CT or ultrasound testing.
His leukocytosis resolved and pt remained hemodynamically
stable. He will f/u closely wtih ID and his outpatient
oncologist. There are 3 more sets of blood cultures pending at
the time of his discharge.
Medications on Admission:
Amlodipine 10 mg daily
Lovenox 100 mg SC qHS
Erlotinib 100 mg daily
Lisinopril 5 mg daily
Metoprolol Succinate 200 mg daily
Omeprazole 20 mg daily
Prochlorperazine maleate 10 mg q6h prn for nausea/vomiting
Terazosin 1 mg qHS
Zolpidem 5 mg qhs prn for sleep
MVI daily
Glyburide 5 mg [**Hospital1 **]
Metformin 1000 mg [**Hospital1 **]
Discharge Medications:
1. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
once a day.
2. glyburide-metformin 5-500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
5. ceftriaxone 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 12 days.
Disp:*12 bags* Refills:*0*
6. Outpatient Lab Work
Check Chem-7, LFT's and CBC on Wed [**6-15**] and Wed [**6-22**] and
call results to Dr. [**Last Name (STitle) **] [**Name (STitle) **] at Infectious disease
clinic: ([**Telephone/Fax (1) 4170**] or at 617-632-page #[**Numeric Identifier 38654**]
7. 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.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. terazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime.
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
14. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
15. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain: take no
more than 2 tablets, call Dr. [**Last Name (STitle) **] or 911 for any chest
pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
ST Elevation myocardial infarction
Diabetes Mellitus
Hypertension
Dyslipidemia
Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 88506**],
You were admitted to the hospital because you had a heart
attack. You underwent cardiac catheterization and two stents
were placed in one of your coronary arteries. You were found to
have bacteria in your blood and you were seen by the infectious
disease team and started on an antibiotic called ceftriaxone.
You will need to get this antibiotic for a total of 2 weeks. As
of this time, we do not know why you developed this infection in
your blood. You will need to have your blood drawn weekly to
check your liver and kidney function on this antibiotic. You
will see the infectious disease doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] [**6-13**].
No lifting more than 10 poounds for one week, no pools or baths
for one week. You may shower as usual. No driving for 3 days
after you go home.
.
We made the following changes to your medicines:
1. STOP taking amlodipine and omeprazole
2. START taking clopidogrel (Plavix) every day and aspirin 325
mg for at least one month and possibly longer. Do not stop
taking Plavix with aspirin or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **]
tells you to.
3. Decrease Metoprolol to 100 mg daily
4. Start Ceftriaxone intravenously for 2 weeks to treat the
bacteria in your blood
5. Start famotidine twice daily instead of omprazole to decrease
the acid in your stomach.
6. Stop taking your Tarceva, you can discuss this with Dr.
[**Last Name (STitle) 1852**] at your next appt. Per Dr. [**Last Name (STitle) 1852**], you will not get
your intravenous chemotherapy on [**Last Name (STitle) 766**] while you are on
antibiotics.
Followup Instructions:
Name: [**Last Name (LF) 313**],[**First Name3 (LF) **] N
Location: [**Hospital **] HEALTH CENTER
Address: 200 [**Last Name (un) 12504**] DR, [**Location (un) **],[**Numeric Identifier 18464**]
Phone: [**Telephone/Fax (1) 18462**]
Appointment: Tuesday [**2174-6-14**] 1:30pm
Department: INFECTIOUS DISEASE
When: [**Year (4 digits) **] [**2174-6-13**] at 10:00 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: [**Hospital Ward Name **] [**2174-6-13**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: [**Hospital Ward Name **] [**2174-6-13**] at 12:00 PM
With: [**Name6 (MD) 8111**] [**Name8 (MD) 8112**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: Friday [**8-12**] at 10:30am
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
The cardiology office will call you in a few days with an
earlier appt.
Completed by:[**2174-9-14**]
|
[
"197.7",
"401.9",
"272.4",
"E947.8",
"041.3",
"790.7",
"427.31",
"362.01",
"157.8",
"486",
"250.50",
"584.9",
"414.2",
"410.41",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.53",
"00.46",
"00.66",
"36.06",
"88.56",
"37.22",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15582, 15634
|
10286, 13431
|
282, 368
|
15775, 15775
|
4919, 4919
|
17628, 19273
|
3149, 3338
|
13816, 15559
|
15655, 15754
|
13457, 13793
|
7168, 10263
|
15926, 17605
|
3353, 3353
|
2566, 2592
|
5423, 7151
|
232, 244
|
397, 2456
|
4934, 5409
|
15790, 15902
|
2623, 2893
|
2478, 2546
|
2909, 3133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,655
| 159,513
|
46756
|
Discharge summary
|
report
|
Admission Date: [**2192-4-19**] Discharge Date: [**2192-4-25**]
Date of Birth: [**2128-8-24**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 62-year-old female,
with end-stage severe COPD, who had been recently admitted to
the [**Hospital Unit Name 153**] [**4-1**] through [**4-12**]. Briefly, she was discharged to
[**Hospital6 13846**] and was there for
approximately a week when she was found to be lethargic but
arousable with an ABG of 7.09, 130, 104. She was brought to
the [**Hospital1 18**] Emergency Department where she was intubated, and
she was transferred to the [**Hospital Unit Name 153**].
PAST MEDICAL HISTORY: The patient's past medical history is
adequately documented in previous discharge summaries.
MEDICATIONS ON ADMISSION:
1. Diltiazem.
2. Metoprolol.
3. Aspirin.
4. Prednisone taper.
5. Klonopin.
6. Vitamin D.
7. Protonix.
8. Calcium carbonate.
9. Fosamax.
10.Folate.
11.Robitussin.
12.Lispro sliding scale.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, the blood pressure was
122/48, heart rate 88-113. The patient was on ventilation
400x14, PEEP 5. Her exam was notable for decreased breath
sounds, poor air movement, but no wheezes. A chest x-ray
showed no infiltrates. Her white count was 7.5, hematocrit
27. Her Chem-7 was within normal limits for her.
BRIEF SUMMARY OF HER HOSPITAL COURSE: This 62-year-old
female was admitted with a COPD exacerbation from [**Hospital3 **] Hospital. She was intubated in the Emergency
Department. The patient's arterial blood gases corrected
with intubation, but she was clearly quite uncomfortable and
distressed to be on the ventilator and made it clear that she
did not want to continue on the ventilator. Her [**Last Name (LF) 802**], [**Name (NI) **]
[**Name (NI) **], confirmed that the patient's wishes were not to
continue on the ventilator at this time. In keeping with the
patient's and closest involved relative, [**Name (NI) **] [**Last Name (NamePattern1) **], wishes
the patient was extubated on [**2192-4-24**] and made comfort
measures only. Morphine was used prn to keep the patient
comfortable. The patient's time of death from cardiac
arrest, a minute after the primary cause being her
respiratory failure, was 9:22 pm on [**2192-4-25**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 20173**]
MEDQUIST36
D: [**2192-4-25**] 21:56:23
T: [**2192-4-26**] 12:08:43
Job#: [**Job Number 99231**]
|
[
"518.81",
"428.32",
"428.0",
"054.9",
"251.8",
"458.9",
"305.00",
"E932.0",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
787, 1013
|
1399, 2603
|
1036, 1381
|
165, 644
|
667, 761
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,894
| 106,711
|
53517
|
Discharge summary
|
report
|
Admission Date: [**2104-3-18**] Discharge Date: [**2104-5-1**]
Date of Birth: [**2035-7-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
fatigue, malaise, APML
Major Surgical or Invasive Procedure:
Endotracheal intubation
Tracheostomy
CVL placement
Pericardial drain
Bone marrow biopsy
History of Present Illness:
Pt is a 68 Y M with Hx of HTN who is transferred from
[**Hospital3 **] with DVT, PE, and a new diagnosis of
APML. History is obtained from the patient without the current
availability of all previous records. On [**2104-1-25**], he
went to see his PCP for [**Name Initial (PRE) **] routine visit and because he had
conjunctivitis. There he was found to have Hgb of 10 and WBC
2.2 whose values were the same a week later. His PCP referred
him to a hematologist who sent him for a CXR because he had a
chronic, dry cough. The CXR showed bilateral patchy infiltrate,
but he had a chest CT to characterize it further. He was
started on Avelox for PNA, and referred to a pulmonologist. His
pulmonologist noted peripheral eosinophilia and started him on a
course of prednisone 80mg PO daily x 3 days with a 20mg taper
every 3 days which ended about a week ago. The prednisone
improved his breathing and dry cough somewhat. Repeat CBC
approximately one week prior to admission showed WBC of 22K with
immature cells in the periphery. He underwent a BMBx and
afterwards complained of right leg pain and swelling. His
pulmonologist referred him for LE ultrasound which showed a RLE
DVT; he was admitted to [**Hospital1 **] where CTPA also
revealed PE. He was started on IV heparin. His BMBx and
peripheral flow cytometry returned which was consistent with
APML. He was transferred to [**Hospital1 18**] for further evaluation. On
arrival, he states that he has had fatigue, anorexia, insomnia,
and 25 lb weight loss for the past 1-2 months. He also has a
mild global HA and RLE swelling and soreness but no other acute
concerns.
.
Review of Systems:
(+) Per HPI; Tmax 100.7 this past week; + night sweats for 2
weeks, DOE for the past week
(-) Denies chills Denies blurry vision, diplopia, loss of
vision, photophobia. Denies sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, melena, hematemesis,
hematochezia. Denies dysuria. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
.
Past Medical History:
.
PMH:
HTN
s/p T&A at age 4
.
Social History:
Lives alone and is a widower; has 1 son, 4 daughters, and 10
grandchildren. He is retired from working in Telecom at [**University/College **],
quit smoking 40 years ago, occasional EtOH but quit for Lent, no
illegal drugs
Family History:
Mother had breast CA in her 40s, father's side of family had
Alcoholism; no other blood or oncologic disorders
Physical Exam:
VS: T 100.7 bp 118/60 HR 114 RR 17 SaO2 96 RA Wt 176.3 lbs
GEN: Elderly man in NAD, awake, alert, making jokes
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg tachycardia, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, 2+ DP/PT bilaterally; RLE has ankle swelling and
red, non-puritic rash on anterior shin. Bilateral sock-line
edema
SKIN: warm skin
NEURO: oriented x 3, normal attention, CN II-XII intact, [**4-12**]
strength throughout, intact sensation to light touch
PSYCH: appropriate
.
Pertinent Results:
[**2104-3-18**] 07:39PM GLUCOSE-96 UREA N-21* CREAT-0.8 SODIUM-132*
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-27 ANION GAP-11
[**2104-3-18**] 07:39PM ALT(SGPT)-16 AST(SGOT)-18 LD(LDH)-210 ALK
PHOS-52 TOT BILI-0.3
[**2104-3-18**] 07:39PM CALCIUM-7.8* PHOSPHATE-2.6* MAGNESIUM-2.1
URIC ACID-4.3
[**2104-3-18**] 07:39PM WBC-28.9* RBC-2.15* HGB-7.7* HCT-22.6*
MCV-105* MCH-35.6* MCHC-33.9 RDW-15.8*
[**2104-3-18**] 07:39PM NEUTS-1* BANDS-0 LYMPHS-19 MONOS-15* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* OTHER-65*
[**2104-3-18**] 07:39PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
TEARDROP-OCCASIONAL
[**2104-3-18**] 07:39PM PLT COUNT-119*
[**2104-3-18**] 07:39PM PT-16.4* PTT-28.6 INR(PT)-1.5*
[**2104-3-18**] 07:39PM FIBRINOGE-429*
Portable TTE ([**2104-3-20**]) - Post STEMI
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Mild tricuspid regurgitation. Mild pulmonary
artery systolic hypertension.
Portable TTE ([**2104-3-21**]) - Acute onset of pulmonary edema
Overall left ventricular systolic function is probably
moderately depressed (LVEF= 30-35 %). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. No mitral regurgitation is seen. There is no
pericardial effusion.
Portable TTE ([**2104-3-22**]) - Hypotensive episode
The estimated right atrial pressure is 5-10 mmHg. Overall left
ventricular systolic function is moderately depressed (LVEF=
30-35 %) secondary to hypo- to akinesis of the mid-distal
anterior septum, apex, and distal lateral wall
(anterior/inferior walls not well visualized). Right ventricular
chamber size is normal. with ? focal hypokinesis of the apical
free wall (clip [**Clip Number (Radiology) **]). The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial pericardial effusion.
IMPRESSION: Poor image quality. Moderate regional and global
left ventricular systolic dysfunction. Possible focal
hypokinesis of the RV apex. Mild mitral regurgitation. Moderate
tricuspid regurgitation with mild pulmonary artery systolic
hypertension.
Compared with the prior study dated [**2104-3-21**] (images reviewed),
regional and global biventricular systolic function are similar.
Mitral regurgitation is slightly worse but still in the mild
range. Pulmonary pressures were measured but not reported on the
prior echo (also mildly elevated then).
Portable TTE ([**2104-3-26**]) - Persistently tachycardic
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with hypokinesis of the anterior septum and anterior
walls, distal inferior wall, and apex. The remaining segments
contract normally (LVEF = 30-35%). No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened (?#). No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a very small pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (LAD distribution). Compared with
the prior study (images reviewed) of [**2104-3-22**], left ventricular
systolic function is similar.
Cardiac catheterization ([**2104-3-19**])-
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary disease. The LMCA was
patent. The LAD had a 70% proximal lesion with extensive
thrombosis. The LCX and RCA were patent.
2. Limited resting hemodynamics revealed normotension.
3. Successful Export thrombectomy and PTCA only of proximal LAD
thrombotic lesion.
4. Successful hemostasis of right radial arteriotomy with TR
band.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Anterior STEMI
3. Successful export thrombectomy and PTCA only of proximal LAD.
3. ASA while ok with heme/onc; integrilin for 12 hours; restart
heparin per CCU team.
ECHO POST-DRAINAGE [**4-25**]: There is a very small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
Mr. [**Known lastname **] is a 68M with a h/o HTN who was admittedon [**3-18**] to
the BMT service with newly diagnosed AML and DVT/PE on heparin.
He was transferred to the CCU after patient developed an acute
STEMI; cath demonstrated an acute thrombous in the LAD and he
underwent PTCA and thrombectomy; no stents were deployed. His
CCU course was notable for tachycardia, volume overload
(requiring IV lasix prn), several fevers with an episode of
hypotension prompting the initiation of Abx in the setting of
neutropenia, and initiation of chemo with etoposide and
cytarabine for his AML. He was called out to the BMT floor on
4/18pm. He was later admitted to the MICU because of hypotension
and tachypnea in the setting of diuresis. His course was c/b
ARDS and hypoxic respiratory failure, renal failure and volume
overload requiring CVVH, and pericardial tamponade. After the pt
had been intubated for several weeks, he was transitioned to
tracheostomy. His respiratory status waxed and waned but then
progressively declined; he also had a persistent pressor
requirement to maintain his pressures while on CVVH. After
multiple discussions with the family, the pt was transitioned to
CMO status, and he passed away o/n on [**2104-5-1**].
.
ACTIVE HOSPITALIZATION ISSUES:
.
#AML: pt was transferred from OSH with labs initially concerning
for AML vs APML, was briefly treated with ATRA prior to Dx of
AML. No e/o TLS. We d/c'd Allopurinol 300mg PO daily given uric
acid levels <4 for about 2 days. Pt was treated with etoposide
and cytarabine given cardiotoxicity from anthracyclines
(Etoposide 100 [**12-13**]/cytarabine 200 [**12-15**]). Due to complicated ICU
course, further chemo was not undertaken.
.
#s/p STEMI: On BMT floor on day after admission, pt developed an
acute STEMI. In the cath lab he was found to have an acute
thrombous in the LAD and underwent PTCA and thrombectomy; no
stents were deployed. Currently has depressed EF ~30-35%. Had
intermittent episodes of being volume-up in CCU, has been
intermittently diuresed. Has o/w been asymptomatic. A small
pericardial effusion seen on [**3-26**] TTE; no tamponade or
physiologic changes; thought by cards to be clinically
insignificant. He had tachycardia to 120-130s for several days
in the CCU, but after call-out had a HR in the 80-90s. On BMT,
we stopped atorvastatin on [**3-27**] given possibility of drug-drug
interaction with chemo drugs after consulting with cards. Pt was
not given heparin and ASA given falling PLTs.
.
#Pericardial tamponade: The patient was transferred to the CCU
on [**2104-4-24**] in the setting of decreased blood pressures and
echocardiographic evidence of pericardial effusion with
tamponade physiology. A pericardial drain was placed on [**4-24**]
and 500cc of bloody fluid was removed and drain left in place.
Opening pressure was 28. No right heart cath was done. Drain put
out 150mL bloody fluid overnight and then stopped draining the
morning after it was placed. Repeat echo on [**4-25**] AM showed very
small pericardial effusion. Drain was pulled and pt was
transferred back to [**Hospital Unit Name 153**]. Pt tolerated procedure well with no
complications. He remained stable on 2 pressors, which were not
able to be weaned while in the CCU.
.
# Hypoxic respiratory failure: Secondary to multifocal
PNA/ARDS. Mini- BAL from [**4-19**] showed Pseudomonas fluorescens
resistant to cefepime, sensitive to zosyn, intermediate to
meropenem. CT chest [**4-16**] showed worsening of bilateral diffuse
opacifications compared to prior, possibly due to further volume
overload. Pt received tracheostomy. Prior to CMO status, the pt
was being treated with amikacin, ambisome, Zosyn, linezolid.
.
# Hypotension, persistent pressor requirement: likely related
to prolonged shock/sepsis. Pt required pressors especially
during CVVH volume removal.
.
# [**Last Name (un) **]. Creatinine was up to 3.6 from baseline 0.8 in the context
of ATN from hypotension; it improved down to the 1??????s with CVVH.
Although CVVH was able to remove volume occasionally, volume
removal was limited due to tenuous BP's.
.
# Apical hypokinesis and PAF: He was s/p DCCV x3 on [**4-9**] for
atrial tachyarrhythmia. He was maintained on a heparin drip.
.
#DVT and PE: Dx'd at OSH, initially was on heparin upon
admission, until PLT's started to drop.
.
Medications on Admission:
HCTZ 25mg PO daily
ASA 81 mg PO daily
Discharge Medications:
Pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
AML
PNA
[**Last Name (un) **]
STEMI
Pericardial tamponade
PE/DVT
Discharge Condition:
Pt passed away
Discharge Instructions:
Pt passed away
Followup Instructions:
Pt passed away
Completed by:[**2104-5-3**]
|
[
"285.22",
"276.0",
"427.31",
"428.41",
"038.9",
"997.31",
"578.1",
"584.5",
"414.01",
"276.1",
"423.3",
"205.00",
"518.84",
"276.3",
"933.1",
"423.9",
"E879.8",
"560.1",
"288.00",
"284.19",
"780.61",
"453.41",
"410.01",
"415.19",
"782.4",
"276.8",
"V49.86",
"558.9",
"286.9",
"041.7",
"427.32",
"428.0",
"112.0",
"486",
"348.30",
"995.92",
"785.52",
"401.9",
"528.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.6",
"88.51",
"00.66",
"96.72",
"38.7",
"00.40",
"99.25",
"33.23",
"33.24",
"99.62",
"37.22",
"31.1",
"39.95",
"37.0",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
13550, 13559
|
9081, 13422
|
326, 415
|
13667, 13683
|
3829, 8611
|
13746, 13790
|
2965, 3078
|
13511, 13527
|
13580, 13646
|
13448, 13488
|
8628, 9058
|
13707, 13723
|
3093, 3810
|
2097, 2653
|
264, 288
|
443, 2078
|
2675, 2706
|
2722, 2948
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,509
| 142,906
|
11520
|
Discharge summary
|
report
|
Admission Date: [**2103-12-18**] Date of Death: [**2103-12-23**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with past medical history significant for metastatic
renal cell carcinoma, status post match-related donor,
Mini-Allogeneic Peripheral blood cell transplantation who was
transferred from [**Hospital 33316**] Hospital in [**Doctor Last Name 5602**], [**State 2748**]
with tachypnea, shortness of breath, productive cough and a
temperature of 100.2. The patient is hypoxic, oxygen at 95%
on 4 liters with sputum cultures growing 4+ pseudomonas.
Chest x-ray revealed rapidly progressed tumor and planned to
transfer to [**Hospital1 18**] for further management. On arrival,
patient decision to transition to comfort care measures with
request of continuation of antibiotic. The patient was
managed with a morphine sulfate drip to be titrated for
discomfort, Scopolamine patch and ............ sublingual
0.125 mg three times a day p.r.n. secretions. The patients
family was present throughout as well as palliative care team
on [**2103-12-19**] with the arrival of his son from [**Name2 (NI) **]. The
patient was transitioned to CMO. The patient expired on
[**2103-12-23**] in the surroundings of his entire family, wife. [**Name (NI) 6**]
autopsy was declined.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-830
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2104-2-20**] 15:55
T: [**2104-2-21**] 09:54
JOB#: [**Job Number 36704**]
|
[
"197.0",
"197.2",
"V10.52",
"198.89",
"996.85",
"518.84",
"482.1",
"584.9",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
152, 1583
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,217
| 128,746
|
39739
|
Discharge summary
|
report
|
Admission Date: [**2192-8-1**] Discharge Date: [**2192-8-2**]
Date of Birth: [**2143-7-5**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
[**Last Name (un) **] placement
Central line placement
History of Present Illness:
Briefly, pt is a 49yo man with h/o EtOH abuse who was found down
in cardiac arrest by his wife at home. EMS was called, who noted
PEA and initiated CPR. He was unable to be intubated in the
field, so he was taken to the closest ED. There CPR was
continued and after a fourth round of epinephrine, cardiac
rhythm became VT/VF, for which he was shocked into sinus
tachycardia with a pulse. He was intubated, and when OG tube was
placed 6+ liters of bright red blood were suctioned from his
upper GI tract. Labs there were significant for anemia and
thrombocytopenia, acute renal failure, metabolic acidosis (pH
6.80), elevated CK with evidence of myocardial infarction, liver
failure, and coagulopathy. He was resuscitated with blood
products including PRBCs and FFP, in addition to IV fluids with
lactated ringers and normal saline, as well as vasopressor
support with Levophed. He developed hyperkalemia and required
calcium gluconate and bicarbonate. Once he was stabilized,
transfer to [**Hospital1 18**] MICU was arranged, and we were consulted for
possible upper endoscopy to assess variceal hemorrhage and for
probable placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube.
.
On arrival to the floor, SBP dropped to the 60s, requiring
additional vasopressor support, blood products, and IV fluid
resuscitation.
Past Medical History:
EtOH Abuse
prior acute variceal hemorrhage
Social History:
unknown
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: hypothermic, HR 86, NBP 69/35, ABP 81/48, R 14, SaO2 100%
Vent: AC - 500 x 14 / peep 5 / 100% FiO2
General: intubated
HEENT: pupils dilated and non-responsive, sclerae anicteric,
blood pooling in oropharynx
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no murmurs
Abdomen: decreased BS, soft/NT/ND, no HSM
Extrem: no edema
Skin: no jaundice
Neuro: GCS 3
Pertinent Results:
ADMISSION LABS
[**2192-8-1**] 09:46PM BLOOD WBC-6.0 RBC-2.58* Hgb-8.3* Hct-26.8*
MCV-104* MCH-32.0 MCHC-30.8* RDW-14.7 Plt Ct-48*
[**2192-8-1**] 09:46PM BLOOD Plt Ct-48*
[**2192-8-1**] 09:46PM BLOOD PT-27.1* PTT-150* INR(PT)-2.6*
[**2192-8-1**] 09:46PM BLOOD Fibrino-54*
[**2192-8-1**] 09:46PM BLOOD Glucose-347* UreaN-37* Creat-2.9* Na-137
K-7.6* Cl-100 HCO3-10* AnGap-35*
[**2192-8-1**] 09:46PM BLOOD Fibrino-54*
[**2192-8-1**] 09:46PM BLOOD ALT-435* AST-1587* LD(LDH)-2640*
CK(CPK)-5515* AlkPhos-87 TotBili-1.7*
[**2192-8-1**] 09:46PM BLOOD CK-MB-95* MB Indx-1.7 cTropnT-0.36*
[**2192-8-1**] 09:46PM BLOOD Albumin-1.6* Calcium-7.5* Phos-16.9*
Mg-3.4*
[**2192-8-1**] 10:09PM BLOOD Type-ART pO2-454* pCO2-51* pH-6.79*
calTCO2-9* Base XS--29
[**2192-8-1**] 09:55PM BLOOD Lactate-18.0*
[**2192-8-1**] 10:09PM BLOOD O2 Sat-98
[**2192-8-1**] 10:09PM BLOOD freeCa-0.47*
Brief Hospital Course:
#) GI Bleed/Hypovolemic Shock: Upon arriving to the MICU, the
patient was started on a massive transfusion protocol.
Including the pt's time at the OSH and on transport, the patient
received a total of 15 units of pRBCs (7 here), 10 units of FFP
(4 here), and 2 units of cryoprecipitate here. The patient also
received Vitamin K on transfer, and received 1 unit of platelets
here at [**Hospital1 18**]. His blood pressure was supported with maximum
doses of levophed, neosynephrine, and vasopressin. He was also
bolused with NS to help support his pressure.
#) Hyperkalemia: This was secondary to the profound time he was
down and his acidosis. He was treated with insulin and D50 x 2
at [**Hospital1 18**], and x 2 during transport. He was also given 2 amps of
CaCl, had 4g of Calcium gluconate, and also received CaCl on
transport. His tele was monitored which showed QRS widening,
however no peaked T waves.
#) Metabolic acidosis: Pt had a profound lactic acidosis [**1-24**]
down time. His lactate was in the 50s at the OSH, and this came
down to the upper teens with hydration here.
#) Renal failure: Pt had a Cr of 2.9 upon admission to the MICU.
Medications on Admission:
Unknown
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2192-8-2**]
|
[
"276.2",
"584.9",
"305.00",
"456.0",
"785.59",
"285.1",
"286.9",
"V12.53",
"276.7",
"348.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4410, 4419
|
3160, 4324
|
302, 358
|
4471, 4481
|
2270, 3137
|
4533, 4566
|
1838, 1847
|
4382, 4387
|
4440, 4450
|
4350, 4359
|
4505, 4510
|
1862, 2251
|
254, 264
|
386, 1731
|
1753, 1797
|
1813, 1822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,216
| 139,360
|
31299
|
Discharge summary
|
report
|
Admission Date: [**2156-5-27**] Discharge Date: [**2156-5-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal discomfort
Major Surgical or Invasive Procedure:
Nasogastric tube placement
History of Present Illness:
[**Age over 90 **] year old woman presented with abdominal pain and was found to
have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2432**]-stomach on CT that appeared consistent with gastric
outlet obstruction. Surgery was consulted; however, the patient
refused surgery. Shortly thereafter the patient became
unresponsive and was emergently intubated. ABG prior to
intubation: 7.28/23/172. Lactate 6.2 which came down to 4.3 with
fluids and neosynephrine. WBC 2.8 with 23 bands. Head CT
revealed GI consult was called with plans to place NG tube via
upper endoscopy. In the interim a central line was placed and
levofloxacin and flagyl were given.
An NG tube was placed, two liters of brownish fluid/material
came out. At that time it was learned the pt had presented to an
OSH similarly and that she did not want any interventions. The
PCP and family were notified and they believed she would not
want further care. Pressors were stopped and morphine drip was
started, pt made CMO and transferred to MICU for eventual
extubation
Past Medical History:
Gastro-intestinal obstruction of unkown etiology
Lower extremity edema
Status post bilateral hip replacements
Social History:
Widowed, supportive son and dtr-in-law
Family History:
Unknown
Physical Exam:
Skin-pale, no obvious rashes
Abdomen-distended, tympanitic, NGT in place & draining
LE-trace edema
Pertinent Results:
[**2156-5-27**] 12:35PM WBC-2.8* RBC-5.73* HGB-18.1* HCT-53.9* MCV-94
MCH-31.6 MCHC-33.6 RDW-14.3
[**2156-5-27**] 12:35PM NEUTS-50 BANDS-26* LYMPHS-18 MONOS-3 EOS-0
BASOS-0 ATYPS-1* METAS-2* MYELOS-0
[**2156-5-27**] 12:47PM LACTATE-6.2*
[**2156-5-27**] 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
CT OF THE ABDOMEN WITHOUT CONTRAST: The lung bases demonstrate
atelectatic changes in the dependent portions, bilaterally. On
the left lung base, there is a small opacity that could
represent airspace consolidation versus atelectasis. No evidence
of pleural effusions.
The liver is small with slightly irregular contours could
represent cirrhotic changes. Gallbladder demonstrates a
gallstone. No evidence of intra- or extra-hepatic biliary ductal
dilatation. The spleen, pancreas, and adrenal glands are normal.
The kidneys appear normal without evidence of hydronephrosis.
Free fluid within the abdomen is noted which could be related to
liver disease.
There is severe dilatation of the stomach which appears to be a
tapering area at the distal antrum or prepyloric. No discrete
mass is noted, the esophagus is not dilated. Despite this severe
distention, the stomach maintains the J shape. This process is
likely chronic in nature. Small pockets of free air are noted
within the abdomen. No evidence of lymphadenopathy.
CT OF THE PELVIS WITHOUT CONTRAST: Severe streak artifact from
hip prosthesis is noted limiting the exam. A Foley catheter is
seen within the bladder. Free fluid is noted within the pelvis.
Atherosclerotic changes are noted.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. Bilateral hip prostheses. Degenerative changes of
the thoracic and lumbar spine. Compression deformity of T11.
Thoracolumbar scoliosis is noted.
IMPRESSION:
1. Severe dilatation of the stomach with an apparent transition
point in the distal antrum or prepyloric area. No discrete mass
is identified. The esophagus is not dilated.
2. Left lung base small opacity that could represent atelectasis
or early pneumonia.
3. Small pockets of free air within the abdomen.
4. Ascites.
Brief Hospital Course:
Pt admitted to the MICU. She was CMO. She died shortly after
arrival to the unit. She was not responsive. Pupils sluggish,
no reflexes. The family requested an autopsy.
Medications on Admission:
lasix
protonix
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Complications due to Gastro-intestinal obstruction of unknown
etiology
Discharge Condition:
Deceased
Discharge Instructions:
na
Followup Instructions:
na
|
[
"789.5",
"560.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4208, 4217
|
3939, 4115
|
283, 311
|
4331, 4341
|
1735, 3916
|
4392, 4397
|
1591, 1600
|
4180, 4185
|
4238, 4310
|
4141, 4157
|
4365, 4369
|
1615, 1716
|
223, 245
|
339, 1386
|
1408, 1519
|
1535, 1575
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,969
| 118,492
|
9442
|
Discharge summary
|
report
|
Admission Date: [**2193-5-20**] Discharge Date: [**2193-5-23**]
Date of Birth: [**2117-8-20**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman
with past medical history significant for hypertension, GERD,
COPD, long tobacco history who initially presented to
[**Hospital 1474**] Hospital on [**2193-5-15**] with chief complaint of left
jaw and arm pain. The patient was seen in the ER, but left
due to lack of bed availability. Apparently, the patient was
pain free over the next few days, but on [**2193-5-18**], he
developed similar left arm and jaw pain. He represented to
the Emergency Room. He was given sublingual nitroglycerin
and morphine. An EKG showed sinus bradycardia at 39, normal
axis, PR prolongation, Q wave in I, aVL, V4-V6, T-wave
inversions in II, III, aVF, and scoopy ST segments in V5-V6.
His creatinine kinases were flat, but his troponin was 2.3.
The patient was started on Norvasc and Imdur, his beta-
blocker was held. The patient was transferred to the CMI
Service for cardiac catheterization. The patient had a
complicated cardiac catheterization with ST elevations in V1-
V3, hypertension, bradycardia and was transferred to the CCU
for closer monitoring.
PAST MEDICAL HISTORY: Hypertension.
GERD.
COPD.
Status post appendectomy.
Right eye surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS AS AN OUTPATIENT:
1. Aspirin.
2. Lopressor.
MEDICATIONS ON TRANSFER:
1. Imdur 30 mg every day.
2. Aspirin 325 mg every day.
3. Norvasc 5 mg every day.
4. Lopressor 25 mg 2 times a day.
FAMILY HISTORY: No CAD, dyslipidemia or diabetes mellitus.
SOCIAL HISTORY: Two packs per day of tobacco.
PHYSICAL EXAMINATION: He is afebrile. Heart rate 79, up
from the low of 39; blood pressure 171/68, oxygen saturation
95-100 percent on 2 liters nasal cannula. In general, he is
lying in bed in no apparent distress. HEENT: Extraocular
muscles intact. His neck is supple. The patient is lying
completely flat without elevated JVP. Chest clear to
auscultation in anterior lung fields. Cardiovascular,
regular rate and rhythm without murmurs, rubs, or gallops.
Abdomen soft, normoactive bowel sounds, audible bruit.
Extremities, no clubbing, cyanosis, or edema. Bilateral
femoral bruits right greater than left starting at the level
of umbilicus.
LABORATORY DATA ON ADMISSION: Hematocrit 33.9. His cardiac
catheterization on [**2193-5-20**] showed severe LAD and RCA
disease, moderate left circumflex and diagonal disease. He
had successful PTCA and stenting of the RCA with a 2.5 mm
Taxus stent. Specifically, his LMCA was not obstructed. His
LAD showed long severe diffuse disease, apical LAD filled by
collaterals from the OMB. His diagonal was proximally
occluded 70 percent in the large branching vessel. Left
circumflex was not obstructed. His OM-1 with 70 percent
diffuse mid-stenosis and RCA with 95 percent mid-vessel
stenosis in the large dominant vessel.
HOSPITAL COURSE: This 75-year-old man with hypertension,
GERD, COPD, status post stent to RCA, LAD, diagonal with
cardiac catheterization complicated by episodes of jaw pain,
ST elevations, hypertension, and bradycardia was admitted to
CCU for closer observation.
Cardiac. Ischemia: He was continued on aspirin, Plavix,
Integrilin. His CK and troponins were trended. His troponin
was noted to go up to 0.24 the day after cardiac
catheterization. His troponin actually continued to rise.
His troponin peaked at 0.79. His CKs peaked at 373. The
patient was started on low-dose beta-blockers, Lopressor 12.5
mg 2 times a day, which he tolerated without significant
bradycardia. Over the next several days, his [**Last Name (un) **] was
restarted and was titrated up, and it was felt that the
creatinine kinase and troponin leak after his cardiac
catheterization was due to jailing of acute marginal branch
when the stent was placed in the RCA.
Pump: The patient had a repeat echocardiogram, which showed
preserved ejection fraction of 60-70 percent. He had no
evidence of congestive heart failure throughout the remainder
of his hospitalization.
Rhythm: Initially, the patient was noted to have
hypertension and bradycardia, was concerning for vagal
episodes versus right coronary artery ischemia with decreased
blood flow to the SA node. He was followed throughout the
remainder of his hospitalization, and his heart rate remained
between the high 40s and 60s even with the addition of the
beta-blocker. It was felt that this may have been just a
vagal episode related to the cardiac catheterization.
COPD: Given the recent event, the patient's beta-agonists
were held. He was given ipratropium for wheezing as needed.
Neurologic: The patient was noted to have altered mental
status, was described as agitated, disoriented, and
combative. The patient had received opioids and possibly
benzodiazepines, given he had been written for these on as
needed basis. In addition, he received atropine for his
bradycardia in the cardiac catheterization lab. It was felt
that the atropine may be contributing to the delirium. In
addition, it was felt that the patient may have some baseline
dementia, which was exacerbated by the ICU setting. The
patient was started on Haldol, which was then changed to
olanzapine given the olanzapine has less anticholinergic
effects. The patient was monitored continually by the
nursing staff, and his mental status slowly improved and was
significantly back to baseline prior to discharge.
Hypertension: The patient's blood pressure was initially
quite elevated. He was started on a nitroglycerin drip in
the Intensive Care Unit. The nitroglycerin drip was slowly
titrated off, and he was started on hydrochlorothiazide. His
Avapro was slowly increased. He was continued on Lopressor
12.5 mg, which was started for his CAD. In addition, the
patient's amlodipine was increased up to 10 mg every day, and
he was started on hydralazine 25 mg 3 times a day prior to
discharge. The patient was to follow up with his
cardiologist Dr. [**Last Name (STitle) 7047**] in 2 weeks for further titration of
his blood pressure.
Hematocrit: The patient had blood count of 33.9 on admission
in the ICU. His MCV was in the low 80s. He had iron studies
sent, which showed a low B12, low ferritin, low iron but high
TIBC, which was consistent with a mixed picture of possibly
both iron deficiency and B12 deficiency anemia. The
patient's B12 was repleted, and he was started on iron with
vitamin C to improve absorption. He was guaiac negative
throughout this hospital stay, however, given his iron
deficiency anemia, we recommended an outpatient colonoscopy
on discharge.
Tobacco use: The patient has a history of 2 packs per day.
He was started on nicotine patch and did well throughout the
hospital stay without craving. We continued to encourage him
to try to quit smoking on discharge.
DISCHARGE CONDITION: Stable, ambulating without difficulty,
alert, and oriented times 3.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
stent to right coronary artery, left anterior descending,
diagonal 1.
Chronic obstructive pulmonary disease.
Hypertension, severe.
Gastroesophageal reflux disease.
Delirium.
Bladder diverticulum.
Iron-deficiency anemia.
B12 deficiency.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg by mouth every day.
2. Plavix 75 mg by mouth every day. The patient was advised
not to stop this without seeking with the cardiologist.
3. Toprol XL 25 mg by mouth at bedtime.
4. Hydralazine 25 mg by mouth 3 times a day.
5. Nitroglycerin 0.2 mg sublingual as needed for chest pain.
6. Nicotine 14 mg patch, 1 patch transdermal every day;
advised not to use if smoking.
7. Iron sulfate 325 mg by mouth 2 times a day.
8. Vitamin C 500 mg by mouth 2 times a day.
9. Lipitor 40 mg by mouth at bedtime.
10. Vitamin B12 50 mcg by mouth every day.
11. Irbesartan 150 mg 2 tablets by mouth every morning.
12. Amlodipine 10 mg at bedtime.
13. Hydrochlorothiazide 25 mg every morning.
DISCHARGE FOLLOW-UP: The patient is to follow up with his
primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Thursday [**2193-5-30**]
at 11 a.m. to recheck his blood pressure. He is advised that
if his blood pressure is still high, he may need further
tests to rule out renal artery stenosis or pulmonary
hypertension. The patient is also advised he will need to
have an outpatient colonoscopy arranged by Dr. [**Last Name (STitle) **]. In
addition, he is to follow up with his cardiologist Dr.
[**Last Name (STitle) 7047**] in 2 weeks after discharge. He has an appointment
for Tuesday [**2193-6-4**] at 9:30 a.m. In addition, he is to
follow up with the [**Hospital 159**] Clinic for the bladder
diverticulum noted on imaging during this hospitalization.
He has an appointment on Wednesday [**2193-7-10**] at 10 a.m. with
[**Hospital 159**] Clinic. He is advised that if he preferred, he can
make an appointment with a urologist closer to home, but then he
should
cancel this appointment here at [**Hospital1 18**].
MAJOR SURGICAL INTERVENTIONS: He is status post cardiac
catheterization with stent placement.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 10641**]
MEDQUIST36
D: [**2193-7-2**] 14:44:37
T: [**2193-7-3**] 01:56:43
Job#: [**Job Number 32204**]
|
[
"414.01",
"401.9",
"410.71",
"293.0",
"496",
"530.81",
"458.29",
"280.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.07",
"99.20",
"36.05",
"36.06",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6940, 7052
|
1602, 1646
|
7074, 7355
|
7378, 9601
|
2994, 6918
|
1717, 2364
|
165, 1246
|
2379, 2976
|
1467, 1585
|
1269, 1442
|
1663, 1694
|
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